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Differential
Diagnosis
Mnemonics
Differential
Diagnosis
Mnemonics
Thomas J. Donnelly, MD
Pulmonary and Critical Care Consultants
Dayton, Ohio
Christopher C. Giza, MD
Assistant Researcher
Division of Neurosurgery
University of California
Los Angeles, California
HANLEY BELFUS, INC.
/
Philadelphia
Hcolshe
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library of Congress Cotologing-in-Publ icotion Dota
Donnelly, Thomos J 1962-
Differential Di ognosi s Mnemonics / Thomas J. Donnelly, Christopher C. Gizo.
p. ; cm.
Includes bi bl iographical references and index.
ISBN 1-56053- 31 10 lalk paper)
1. Diagnosis, Di fferential. 2. Mnemonics. I. Gi za, Christopher ., 1965-
II. Ti tle.
[DNlM: ! Diagnosi s, Di fferential-Termi nol ogy-English. 2. Association
Learni ng-Terminology-English. WB 15 D685d 2000J
RC71.5.D66 2001
616 07'5'014-dc21
99-088120
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CONTENTS
I . I ntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ov|o Jse ! s Hoo\ . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ce^e|o Appooc |o ||ee^| o' og^os s . . . . . . . . . : + . + +
! ^ ^gAooc| ||e|e^| o og^oses . . . . . . . . . .
|ese^| ^go^d sccss ^g Coses . . . . . . . . . . . . . . . . . . . . . . .
I I . Pulmonary and Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Ce^e|o' Co^s de|o| o^s
Ce^e|o'App|ooc|oc' ~o^o|y^ed c ^e . . . . . . . . . . . . . .
Ce^eo' Appooc |o C |co Coe ^ed c ^e . . . . . . . . . . . . . . .
Ces|/<oy ^|e|pe|o|o^ . . . . . . . . . . . . . . . . . . . . . . . .
C' ^co oy~p|o~so^do g^s
C|o^ cCocg . . . . . . . . . . . . . . . . . . . . . . . . . . +
C' coo ^g . . . . . . . . . . . . . . . . . . +
ysp^eo . . . . . . . . . . . . . . . . . . . . . . . . . . .
e~op|yss . . . . . . . . . . . . . . . . . . . . . . . .
o|do| . . . + , + . . + . + . + + . . . . . . + . . . . . . . . .
\eez ^g . . . . . . . . . . . . . . . . . . . . . . . . . .
C' ^ co Co^d | o^so og^oses
A<o||cse c' ~o^o|y ^| '||o|es . . . . . . . . . . . . . . . .
Acc|e <esp o|o|yo ce . . . . . . . . . + . . + . + + . +
H|o^c ec|os s . . . . . . . . . . . . . . . . . . . . . .
Cov|oyo^dCys|c .c^g seose . . . . . . . . . . . . .
' ^|e|s| | o 'c^g seose . . . . . . . . . . . . . . .
^ed os| ^o' ^oss . . + . + . . + . + + . . . + . . + + + . . + . +
' eco' c||cs o^
^ec~o|oox . . . . . . ' . . . . . + + + . . + . + + . + . + + + + .
c' ~o^oy ype||e^s o^ . . . . . . . . . . . . . . .
c' ~o^oy ' ^| '||o|e . . . . . . . . . . . . . . . . .
c' ~o^oy 'odc' e . . . . . , + . + . + + . . + + + + + + + + . . + . . + . +
<e|oc|o|yypo|e^s o^ . . . . . . . . . . . . + + + + . . +
oocodoss . . . . . . . . . . . . . . . . . . . . . . . . . . . .
III. HematolOgy and Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ce^e|o Co^s de|o| o^s
C ^co' oy~p|o~sond b g^s
A^e~ o . . . . . . . . . . . . . . . . . . . . . . . . . . . +
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Con|en|s v
o eed g o|~eses
Sp eo~ego y .
C ~ co Co~d | o~so og~oses
.os ~op~ o
.y|~ocy|os s
ypecoog.oo eS|o|es
.y~p~ope~ o
^oocy|os s . . .
`ec|ope~ o . . . .
`e.|op~ o
. . .
ocy|ope o . . . . . .
!~o~oo|c!~o~oocy|ope~ c.p.o
'~o~oocy|ope~ o . . .
!~.o~oocy|os s . . +
!o~s|cs o~ <eoc|os
'V. I nfecti ous Di sease = = = = = = + + + + + + = + + =
C ~ co Sy~p|o~so~d S g~s
eveo|U~s~ov g ~ . ..
' |ec|o~sCo.s g Sp eo~ego y .
!e~peo|ce/.se'ssoc o| o~
C ~ co Co~d ' o~so og~oses
Ac.|e^e~ g |s
. . . .
A S/ c~o~ ~~c~ode|ce~cy\ .s .
~~c~ode|cecyS|o|es
<~e.~o| c eve
Sexco y!o~s~ ||ed ' seoses
V. Cardiol ogy
C ~ co' Sy~p|o~s o~d S g~s
Sy~cope .
C co' Cod | o~so ' ogoses
A~y|~~ o
A|o ' o o|o~
Co~ges|ve eo|'o ce
ypo|e~s o~
ecod|s
<es|c|veCod oc 'seose
V' . Endocri nology . . . . . . .
Ce~eo Co~s deo|o~s
|. |oy/ypo|~o o~cs
C ~ co Sy~p|o~so~dS g~s
A~e~o~eo .
Cy~eco~os|o
s.| s~ . .
v| Con|en|S
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C ~ co Cod | o~so og~oses
Adeo ~s.||cecy . . . .
Coc o d!.~os . . . . . . . . . . . . . .
ypeco ce~ o . . . . .
ypep~osp~o|e~ o
ypepooc| ~e~ o . . . .
ype|~yo d s~ . . . . . . . . . . . . .
ypoco ce~ o . . . . + . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ypog yce~o . . . . . . .
ypop~osp~o|e~ o . . . .
Sydo~eo| oppopo|eA| d ce|c o~oesece|o~
V' ' . Nephrology . . . . . . . . .
Ceeo Co~s deo|os
C ~ co Sy~p|o~s o~d S gs
.de~o . . . . . . . . .
e~o|c o . + .
ype|es o .
C ~ co Co~d | oso og~oses
ypeo e~ o . . .
ype~o|e~o
ypooe~ o . .
ypo~o|e~o . .
'epo|c Sy~do~e .
<e~o 'o .e . . . .
<e~o S|o~es
V' | ' . Acid-Base
Ce~eo Cosdeo| o~s
A|eo o oodCos' |epe|o|o . . . . . . . . . .
C ~ co Co~d | o~sod ogoses
^e|ooo cAcdos sv|~ o g~A~ oc Cop
^e|ooo cAcdossv|~o 'o~o A~ o Cop . . .
.ovA o Cop . . . . . . . . . . + . +
^e|ooo cA so oss . . . . . . . . . .
<esp o|oyAcdos s
<esp o|oyA o oss
IX. Gastroenterology .
C co Sy~p|o~so~dS g~s
Aodo~ ~o 'o ~ . . . . .
o~eo . . . . . . . . . . .
ysp~og o . . . . . .
epo|o~egoy . . . . . . . . . . . + .
|oc~d ce
'ocseo od\o~ | g . . . .
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Contents v||
C|inico' Condi|ions o|Diognoses
'onceo|||s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 82
X. Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C' n co Sy~p|o~sond S gns
Acc|e^onoo|| | s . . . . . . . . . . . . . . . . . . . .
'n|' o~~o|oy'o'yo|| | s .
C' n co' Cond | onso| ognoses
Co c c~ 'yopospo|e ydo|e epos | on seose . . .
C<:S! Syndo~e . . . . . .
s|eoo|| | s . . . . . . . . . . . . . . . . . . . . . . . . . . .
<ec~o|o dA| | s . . . . . . . . . . . . . . . . .
Sys|e~ c Sc eoss,Sc' eode|~o| . .
Sys|e~ c'cpcs:y|e~o|oscs . . . . . . . . .
\oscc' | s . . . . . . . . . . . . . . . . . .
\egenesC|onc'o~o|oss . . . .
XI . Neurology . . . . . . . . . . . . .
Ceneo Consdeo|ons
ov!o ^o\eo oood ||e|en|o' ognos s . .
ov!o ^oe o \o ng ||e|en| o' ognoss . . .
ov!o o o Cood 'eco' og c :xo~no|on . .
'eco og c :xo~no|onSc~~oy . . . . . . . . . . . . . . . . .
C' n co| Sy~p|o~sond S gns
A|e|ed^en|o' S|o|cs
A|ox o . . . . . . . . . . . . . . . . . .
Ac|ono~ c so|de|s . .
p' op o . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
zzness . . . . . . . . . . . . . . . . . . . . .
eodoc~e . . . . . . . . . . . . . . . . . . . . . . . .
'oss o|Consc ocsness

^onocc' o\ sco' 'oss

'|oss . . . . . . . . .
< g d |y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
!|e~o . . . . . . . . . . . . . . . . . . . . . . . . . . . .
\eo\ness .
C n co Cond|onso| ognoses
e~en|o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
^ye opo|y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
'ec|opo|y . . . . . . . . . . . . . . . . . . . . . . .
Sezc|e . . .
S|o\e . . . . . . . . . .
'ec|o'ogyC'osso|y . . . . . . . . . . . . . . . . . . . . . . . . . . .
X|l. Appendi x . . . . . . . . . . . . . . . . . . .
Ac|ony~ Dc|ono|y
V/|/ Con|en|s
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W
PREFACE
Ce~e|o| ~go cse'c' o~dco~p'e|ed ||e|e~| o' d og~oss s o \eys|o~eo|c' ~ co'
~ed c ~e ^o~y|ex|s exs|v~ c~ p|ovdeex~ocs|.ve s|s o|poss o ed og~oses
|oo po| cc o co~p o ~| . ' | s e| ~ ~g scc~ s|s ~|o cse|c' d ||ee~| o s|~o| s
po||o| | ~eo|o| ~edc ~e ^e~o|z ~g ' s|so| d og~osesco~ oeo doc~| ~g
|os\, o~do dy o~eo||~o| oycs ~g ~~e~ocs oso ||o~evo\, vev s~|o
~oe eo| ~ ~g d ||ee~| o' d og~oses ~oe po o|oo eo~deve~ e~ oyoo e. '~ od
d | o~, ve pese~| o~ o|go~ zo| o~o opp|ooc~ |o d ||e|e~| o' d og~os s |~o| s
p|oc| co' o~deos y' eo~ed 1~e~~e~o~cspese~|ed ~ee|o~ge|o~co~c se
' s|s |~o|~oyoeco~~ ||ed|o~e~oyo|e|~e| |s||eod, |o~o|e ' e~g|~y, co~
p|e~e~s ve s| ~gs|~o|co~ oe 'ooed cpv~e~ ~eeded ' ~ o ~os| o coses, |~e
~~e~o~ cs|~e~seves spe oc|so~e|~~g|~o||e|es|o|~esy~p|o~ o|d og~o
ss, ~ceos ~g |~e e' ~ood o| e~e~oe| ~g |I.
!~ocg~oc|o s|cde~|s ~ed co' edcco| o~, ~eo|s~e ecevescoc~|'ess ' ||' e
| pso| peo|' s |~o|oe o| ~~e~se p|oc| co' vo||~oc|o|eo|e~ d || cc ||o oo
cp ~ |~e |yp co' ~ed co' |ex|ooo\ A||eeoc~ ~~e~o~ c, ve ~ove ~c' cded
~o~ypeos|~o|e|e|o|~esy~p|o~o|co~d| o~ desc| oed. So~eo||~ese|ps
o|e cs|o~e' ~e|s, o|~e|s o|e s~o' |oo' esooc|' ~es |~o| ~e' pogo~ ze co~
~o~ y|e|ee~ced ~|o|~o|o~ .
\e ~opeyoc | ~d|~ s|o oeo cse|c ~o~dooo|~o| povdeso soc~d o|go~
zo| o~o' ||o~evo |o opp|ooc~ ~g d ||e|e~| o' d og~oses. !~e ~~e~o~ c

|o~o|~ecesso| y ed |o so~e ceo|ve s| ~gs, v~ c~s~oc' d oeeos y |e~e~

oeed osve ' oso~cs ~g. \eve' co~e o~y scgges| o~so| ~ev ~~e~o~ cs
||o~ oceode|s
!o~ o~ ~e' ' y
C~| sC zo
Preface. /X
W
a
INTRODUCTION
!~e pcposeo|| sooo s|o ~e p~ed co|s|cde~|so~dc' ~ c o~s|o~ co~pe
~e~s ve d ||ee~| o' d og~oses |o| co~~o~ ~|e ~o ~ed c ~eo~d ~e.o ogy
poo e~s | s o~ od |oogo~ z ~g d og~os|c poss o |es qc c y o~d e'|ec
|vey ~ c' ~ co s |co| o~s
A ~.~oeo|exce ' e~|e|ee~ces povde co~pe~e~s ve s|s o|d ||ee~| o
d og~oses ! sooovos ceo|ed v| o s ~ o pcpose ~ ~ ~d, oc|ve pe
se~| o~ oppooc~ oosed o~ ~~e~o~ cs !e ~~e~o~ cs o|e ~|e~ded |o po
v de s ~p e|o~evo|s o~ v~ c~ |o co~s|.c|d ||ee~| o d og~oses 'eyoe
~o| ~|e~ded |o oe |~e so eso.ce o| ~|o|~o| o~, o~d p ~oy |ex|s so. d oe
eod |o |c y c~de|s|o~d d seose po|oge~es s | sdo.o||.' |o| o~yo~e co~ e
~e~oe|eve|y ~~e~o~ c ~ |~ s ooo \e ~ope |o||~ose|o co~~o~'y e~
co.~|eed poo e~sv ' oe e|o ~ed, |~e o|es co~ oe e|ee~ced so. do
po| c. opoo e~o se.
^os| s|cde~|s o~d es de~|s o|e|o~ o| v | ~.~eocsd seose pocesses,
o.| oved ||c.|yg v ~g o~ ex~ocs|ved ||ee~l o' d og~oss |o~ ~e~oy|oo
po| cc o|c ~ co' e~| |y !~ s p|oo e~ o||e~ s|e~s ||o~ |e ' oco| o~ogo~ zo
|o~o |o~evo ~ced ||ee~| o d og~oses oe co~sdeed ~ |e~s o| co|e
go es o| ' ' ~ess, |eyoe ~cc eos e|o co~p e|e \e ~ove o||e~p|ed |o
de~| o v devo e|y o| c ~ co sce~ooso~do|go~ zeo d ||ee~| o d og~o
ss |oeoc~ So~e e~| | esoe co~~o~, s.c~ os o~e~ o o e~o' |o 'ce, v~ e
o|~eso|e~o|espec o zed, s.c~os|e|oc|o|y~ypo|e~s o~ ov ~goco~p e|e
s|o|poss o ed og~oses o| |~eoc|se|v ' 'eod |o |ecoec|d og~osseve~ ~
|~e ~os|co~p excoses ! soppooc e~coc|oges |~o|o.g~~ess ~ evo' .o
| o~s, so|o|d og~osesoe ~o|~ ssed
!e ~~e~o~ cs o~ge ~ ' e~g|depe~d ~go~ |~e c' ~ co' e~||y So~e|~es
~oe|o~o~eosoee~ ~c .ded|ooev|yo|o|go~ zo| o~o |eoso~s !~eoes|
~~e~o~ cs oe co~c se, pe| ~e~| vods o p oses co~s|.c|ed |o e|ec||~e
po|~oge~es so||~epoo'e~ |~esoe ~o~oe|o~s ~p evods|o|~e p ~
e~e~oe ~g o s|o|poss o |es A~exp' o~o|oysec|o~ s ~c' .dedv| eoc
~~e~o~ c|o evev po|oge~es so| p|ovde e' p|.' ~|o|~o| o~ So~e co~
~o~'y .sed ~~e~o~ cs , o.|~o|s ge~eo' y .~~ov~j o|e ~c cded ~ de|ee~ce
|o | e |~ s|oyo||o| ' oc\o|o oe||e |ep oce~e~| ' ~o' 'y, peose |ogveo~y
o|s|c ' ce~se|oe~ ~ |~e c|eo|o~ o||~ese~~e~o~ cs
Introduction l '
H ow to Use This Book
!ecop|e|soed v ded oyo|goc sys|e~ ocd pesec|ed v|o co~~o^ o|go^
zo| oco |e~e A Ce^e|o' Cocs de|o| ocssec|oc s|o||s so~e cop|e|s|op|o
v deo^ ove|vevo|d||e|ec| o d ogcos socdc' c co' ossess~e^|pe|ce^||o|o|
po|| cc' o|sys|e~. Spec|c~^e~oc cs,v co|ed v ded ^|o |vosec|o^s,|o|'ov
!e | |s|sec| oc , C c co Sy~p|o~socd S gcs, ' s|s ~ce~oc cs |o| e|e| |o
spec | cc' cco' co~p' o c|s oy|epo|e^|,e g , cocg, eodocel, o||opo||cc'o|
c ^ co' s g^sde|ec|ooeo^co|e|c pysco exo~ ^o|o^ ,e g. , oc^d ce, o|ox ol
!e seco^d ~ce~o^ csec|o^, C' ^ co Co^d | ocso^d ' og^oses, s|s d||e|
e^| o d og^oses |oc ^ co' co^d | o^sde|ec|ed |ocg|ecseo|voocsd og
cos|c |es|s ,scc os|o~oocy|ope^ o, ype|^o||e~ ol , gece|o' ~^e~o^ cs |o|
o|oodd ogcoses, e g , sexco' ' y|o^s~||edd seose, p^ec~o|o|oxl, o^dspec|c
~ce~o^cs|o|e|e|oo po| cc' od so|de, sccos|ec~o|o do|| | s,A' Sl .
!cs, |e| |s|sec|oc s ^|ecded|oe p c~o\ ^go d ||ee^| o' d ogcos s' s|
oosed p| ~o ' yo^|ece|co~p' o c|oo s g^ | co^|c' ^co' sgc, o|e||e ^ |o'
s|o|yocd pysco' !e seco^d sec|o^ s o ~ed o| ge^e|o| cg ~oe spec | c
d ||e|ec| o soosed cpo^ ^ | o d ogcos|c|es| ^gocdcoe|c' co^s deo|o^o||e
ove|o' c' ^co'sy^do~e :ocsec|oc s' s|ed o' pooe|co''y|o|eoseo|e|ee^ce.
General Approach to Di ferenti al Diagnoses
!ed||e|e^| o' d og^oss|oocy~ed co' poo e~co^oe|ocg|o| ^|e|~so|
co|ego| eso|d seose !e ~^e~oc c"McDl Cl Mc DCC" ~oy oe csed os o
ge^e|o oppooc |o o^y po| ec|
Me|ooo cd seose ,e g , ^c|| | o^o de|ceccy, dys p de~ os, po|pyol
ccdoc ^ed seose ,|y|odd seose, d ooe|esl
D|cgs/~ed c ^es , o||ogec c, occ de^|o , se|od~ c s|e|edl
l ^|ec| o^s , e g , ooc|e o' , v o' , |ccgo , ~ycoooc|e| o , p|o|ozoo' ,
e ~ ^| cl
Cocgec |o' ooco~o' | es , ^e |ed oco|o~ c, ~~c^o' og c ocd ~e|ooo' c
d so|desl
l ~~c^o' og cd seose ,co''ogecvoscc' o|d seoses, os||o, ocqc ed ~~c^o
de|ceccyl
Meop' os~s,e g. , p| ~o|y, ~e|os|o| c, po|o^eop os| cl
cxo| c, s||o^ged seoseso|cc\^ovce|oogysccossocod, s| ocy|os s/
Dege^e|o|ve p|ocesses ,e. g. , A' ze ~e|s, o~yo||op c'o|e|o' sc'e|ossl
Ccccpo| o^o' / ecv |o^~e^|o' exposces , e. g , osoes|os, ype|se^s | v |y,
||oc~ol
Co|d ovoscc' o|d seoses , e. g. , o||y|~ os, o|e|osc'e|os s, pc' ~o^o|y e~
oo' cs, co^ges|ve eo|||o ' cel
Z Introduction
! s ' |s| nc cdes |e p ~o|ye|o|oges|o| ~os| ~ed|co' p|oo'e~s. !e|e s,
o|coc|se, so~eove|'op oe|veec co|ego|es: o|e|osc'e|os s s oo| o co|d|o
voscc' o|ocd~e|ooo' cd seose, oo|~ c|ec| ocsocdco' ' ogecvoscc' o|d seoses
~oycocsecodovoscc o|dseose, ~ocyo||~e exo|c dseoses ~oy oveoc
~~cco' og coos s, ocd~ocy ~~cco og c d seoses ore exo|c !~e edcc
doccy s cecessoy, ~oveve, s cceso~eec| | esoe d || cc' ||oc' oss |yo ~oy
oe|ogo||ec |o ||o~evo\oosedso e yocpo|ogeces s scsed oexo~pe,
ve|edoesocec oss |y o~y|~~ oso pc ~ocoy e~oo cs- oo| oe co~~oc
ec| | es |~o| ~ove ~ocy cocses !e cod ovoscc oco|ego|y~e ps yoc |o e
~e~oe||~eseco~~oc poo e~s c cccsco pesec|o| ocs
\~ec |ocedv |~ ocyc c co poo' e~, yoc coc cse e |~e||~e ^: C' `:
C~ce~oc co oco|~e, ~oe spec| c ~ce~oc c| odeve' opo d||eec| o'
d ogcos s o|exo~p' e, |o po| ec|os eco |o ce, yoccoccocs|cc|o d ||e
ec| o oosedoc |~e co|egoes c ^: C `:Co cse |e spec | c "| CA5c
A k' 5| MCBUM, "v c s|s spec|ccocses o||eco |o c|e
Pre-renal
| c||ovoscc o|vo c~e depe|oc ,de~ydo| oc, |~ dspoc cgl
Co|d occocses , C', ^' , |o~pocodel
epo|oeco'sycdo~e
A|e o dseose, eco o||ey s|ecoss|
5ocs
cc' o~ps o/oos|e| co co~p co| ocs
Pre-renalRenal
Acc|e|coc o|cecoss, A!` c o secse, oo| pe ocdeco e|oogy|
Renal
kod og|op ccoc|os| ocd o|e|ox cs , dcgs, ~oodo~yoys s, ~e~o ys s|
' c|o|eco e~oo , c~o'es|eo , C|
5c e|ode~o
|c|es||o' cep~ | s
Meco| z cgvoscc | s , po yo||e|scodoso, \egeces|
C' o~e|c' ocep~| | s
Post-renal
B' odde|oos|cc|oc , csco ypos|o| s~, so~e| ~eso'ood, pcs, co cc' |
U|e|e|o' oos||cc|oc , co' cc , |e|ope|oceo' | o|os s, cocce|l
Mec|oss o| |eco pop oe , d ooe|es, s cs e ce' ' oce~ o, `SA oocse,
c|ec| oc|
!~e|vo oppooc~es povde |o||yco~pe~ecs ve ' s|s o|poss o ' | es, ocd
|e|eoe s||ecg|s ocdveoscesses |o oo|~ ^:' C|': Co' ovs o|ood
c' oss | co| oc o| d seose p|ocesses, v e CAS:A <' S' 'C oJ' s|s spe
c | c cocses o| eco |o ce ocdo|goc zes |~e~ c peeco , eco , ocdpos|
eco' co|ego es | s ~e p|c |o oos o| ~ed co poo e~s cs cg oo|~ |ypes o|
opp|ooc~
////OOuC//O/ U
,.. -.. .,..
!wo|~ocg~|p|ocesses oe ~e p|.' ~opp|ooc~ ~gd ||ee~| o d og~oses
l \~o| s|~e ~os| e' yd og~os s-!~ sges|o| opp|ooc~ ~vo ves oo
~go||~e e~| e p c|.e |s| o~d |o|~c o| ~go ~ypo|~ess |o exp'o~ | A||e e
v ev ~g o |~e do|o |o| o cose, dec de v~ c~ d og~os s s ~os| \e y !~e
|~ ~ ~g pocess |o~ |~ s po ~| |occseso~ p|ov ~god spov ~g|~e~ypo|~es s
!~ soppooc~ s~e p|c |o| ~oes ~p ecoses, o' |~ocg~ ~os|c ~ c o~s.se | |o
so~eex|e~| ~o coses oy co|e|c o||e~| o~ |o o~y ospec|s |~o|oe ~co~s s
|e~|v|~ |~e pesc~p|ved og~osso~d oe oo|e |o occo.~||o|~e~ Avoid be
comi ng fix,ated on a di agnosi s and i gnori ng data that do not support it,
z \~o|o|e|~epo|e~|s p|ooe~s-!~ soppooc~|occseso~|~epo|s o
~d v d.o ospec|so||~e cose .s|o o||~e po|e~|s pooe~so~dco~sdeod|
|e|e~| o dog~os s|oeoc~ !~e~, o||e~p||o |o ~c o|eo c~|y~g d og~oss|~o|
exp'o ~s|~edo|o, ceo| ~gov~o e|o~|~epo|s. !~ s|ec~~ q.e s~e p|c v~e~
|ocedv |~co~p'excoses|eo|. ~g ~.| p esy~p|o~so~d ogeo~o.~|so|do|o.
!~e ~~e~o~ coppooc~ |od ||ee~| o' d og~oss e~p~os zes s|o| ~g v |~
o co~pe|e s|o| poss o |es. Ce|o ~e~||eso~ |~e s|v ' oeveyc~co~~o~
o~d .~' ey ~ ~os|c cc~s|o~ces. Co~~o~e~||esoeco~sdeed ~ |~e ~| o'
d ||e|e~| o d og~os s o| o poo e~, o.|o|~eospec|s o| opo| cc' o po| e~|s
cose ~oyd ec||~evo.p |o ~oe c~.s.o e~| | es !~ soppooc~ soppop
o|eos ' o~gosyo. do ~o| g~o|e|eo|.es|~o|~oy oe ~co~ss|e~|v |~ |~e pe
sc~ed d og~os s.
A~o|~e|opp|ooc~|ode| ~ ~g o o~g s|o|d og~os|c poss o |es s|ode
ve'op o seco~d ope~opseve~ o |~ |d ' s|oosed o~ o seco~d s g~o|sy~p|o~
o||~e po| e~|. |yo. oss.~e |~o| |~e ~o~|es|o| os o||~e d seose ~ qces|o~
o|eseco~doy|oo~epocess, |~e~yoc co~ ' ~ | |~e ~c~oe|o| poss o |es oy
o~'y pc|sc ~g d og~oses |~o|oe o~ oo|~ s|s He co|e|c .s ~g |~s opp|ooc~,
oecocsepo|e~|s ~oy~ove ~o|e| ~o~o~ed seose pocess o|vo, o~d ~po
|o~|d og~os|cco~s deo| o~s ~oy oe e' ~ ~o|ed pe~o|ce'y Ago ~, | sc |
co |o o'voys e|e ooc|o |~eco~pe|e' s|o|d ||ee~| o d og~os|cposs o |es
v~e~o ' |~e|eo|ceso|o cosedo~o|odd cp|oo co~ee~|p c|c|e
Sources of Error in Differential Diagnosis
'ec s o~o~oyss so p|ocess |~o| o||e~p|s |o c' oss |yeos ~ ~ed co eo
so~ ~g, v|~ |~e goo o| ~pov ~g|~e occcocyo|d ||e|e~| o d og~osso~de~
sc ~g | ~o| o c | co d og~os s s ~o| ~ ssed. A |~ocg~ co~|ovesy ex s|s ~
opp y ~g dec s o~ o~oyss |o c ~ co' se|| ~gs, | s vo|~v~ ' e|o c~des|o~d |~e
socces o|eo| ~eopp|ooc~|occseso~ | s| oc| ~ ~gthe basic steps in ar
ri vi ng at a presumptive di agnosi s o~d |~e~ c oss |y ~g eos occod ~g|o
v~ee|~eyoccc ~ |~ose ooscs|eps !~e ooscs|eps oe
I . Tri ggeri ngde|e|~ ~ ~g o dog~os|c poss o |yoosed o~ po|e~| ~|o|
~o|o~
4 Introduction
-
z |oo cges|oo s~ ~g|~eco~|ex|v |~ ~v~ c~|~epooe~v oesoved
J Co|he|| ng ocd p|ccess cg ev ev ~g o~d ~|epe| ~g d og~os| c
do|o, se ec| ~go~dd scod ~g poss o ed og~oses
^ Ve| l| co| cc eoc~ ~go | ~o d og~oss, |~e o~e |~o|oes| ||s o ' o||~e
do|o
. osoccco| eoc~ o||~ese s|eps
T| gge| cg e||c|s ~oy esc | |o~ o oco| ~ov' edge o~d ossocio| o~s
Co~s de' ~eexo~p eo| o e~o |o ce po|e~| ~ v~o~ ~ypo|e~s o~ deve'ops
s~o|'yo||e oeg ~~ ~gd oys s So~ec ~ c o~s ~oyco~s desepsso ~e~o
~oge , v~ c~ oe p ocs o e| , oc|~os| ~ep~oog s|s voc d ~~ed o|e y|~ ~o|
o pecod

o e||cso~ o~d|o~po~odeos oe ~g ~cc~ ~oe e y ! gge ~g s

o associative process |~o| co~esv|~ expe e~ce
||oo cge||c|socccv~e~yoc do~o||~ ~oood'ye~ocg~ ~co~s de ~g
|~ecocseo|o po|e~|s poo e~ oexo~p e, o po| e~|v |~ ecce~|oodo~
~o po ~seco~doy|o ~ypeco ce~ o ~oy c~degoo~ex|e~svegos|o ~|es| ~o
vocp oecocse|~e d ||ee~| o d og~os so'oodo~ ~o d sco~|o|vos ~o|
|o~ed oood ye~ocg~|o ~c' cde~e|ooo' cosys|e~ cd sodes !~ sjpeo|
eode~o~s|o|es|~e ~po|o~ceo|~ov ~go co~p'e|e s|o|d og~os|c poss o
|esprior to e~oo ~go~ o~ ex|e~sve vocp ' |o' sos~ovs|~evo'ceo||o~ ~g
|~e d ||ee~| o d og~os s ~|vo o~oe co~|ex|s , e. , ^. C `. C o~do
~~e~o~ c|ooodo~ ~o po ~| o~d|~e~ oo ~go||~e ~|esec| o~ o| |~e se|s
oood |o~ ~go~d |o~ ~g ~ ~c | p eco~|ex|s ~oy deceose|o~ ~g eos
Co|he|| cg ocd p|ccess nge||c|s esc||o~ ~ s ~|epe|~g|es|esc'|s, ~o|
c~des|o~d ~g |~e se~s | v jospec | c |yo|o |es|, o ~o| ~ov ~g o po| cc o
d seose pevo e~ceo e|~ood ~o g ve~ po| e~| oexo~p e, o s' g~| yee
vo|ed c ~oy co|ec~o o~ ~e ~ o oyeood po| e~|v|~ sevee ~ype|e~so~
~oy eod o c ~ c o~|o pcsceo d og~os so|p~eoc~o~ocy|o~o, eve~|~ocg~
|~ s so oe d seose | s ~cc~ ~oe ' ey|~o||~e co|ec~o o~ ~e esc | s|o'se
pos|ve, o~d |~e|es|pooooys~oc d ~o|~oveoee~odeed ~ |~e ~ | o evo' c
o|o~o||~ s po|e~| ' ~| ~s ce~o d seoseoe~ovoscc' od seoses~oc' d oe ~
ves|go|ed | s| ~ |~ sjpe o| po|e~|oe|oe oo ~g|o ~oe c~csco d og~oses
,See |~eSocces o| og~os|c :o o~ |~e~ex|poge|oodd | o~o d sccs
so~ o| poooo s|c| ~ ~. ~g |
Ve| l| co|| cce||c|socccv~e~so~edo|o scppo| ~go po| cc' od og~os s
oeoo'o ~ed, o~d|~e po|e~|s|~e~ ossc~ed|o~ove|~o|d og~oss,eve~v~e~
o|~e, co~|od c|oydo|oscoseqce~|'yoeco~eovo oo e o ~g|ooccoc~||oo '
ospec|so|o cose o~d ~oppopo|e yod~e ~g| oo pesc~p|ve d og~os s e
sc|s ~premature closure. Co~s deo vo~o~v |~ |eve, os~ , o~e~ o, e~o' ~
sc|| c e~cy, o~d o pos|ve o~| ~cc eo o~| oody |es| scgges| ~g |~e d og~os so|
sys|e~ c cpcsey|~e~o|oscs , S..| ' ||~ spo| e~|o so ~od o ~eo|~c ~c o~do
~ego|vedoco es|o~ded 'A|es|, |~ese |eo|ces oe esseos yexp o ~ed oy o
s ~p edog~osso| S'. , o |~ocg~ ~o| ~poss o' e| esc~p|ve ~~c~oscppessve
|~eopy o| |~ s po| e~||o o d og~oss o| S.: coc d oe ~ozodocs | |~e po| e~|
eo y ~osscoocc|eooc|e o e~docod | sos|~ecocseo|~e~c | p epoo e~s
!~eeo sooe "nc

lou'|"e||c|s !~eseocccv~e~|~epo|e~|s| ~d ~gsoe

~ g~yo|yp co' |o|~ec~de y ~gd seose, o|~ed seose sex|e~e'yc~co~~o~.
////OOuC//O/ O
An example o|thi s type o| error occurred when a young woman on bi rth con
||o' pi l l s presented wi th dyspnea, chest pai n, and a hi gh
-
probabi l ity V/Q
sco ^os|c' c osvoc d poooo' y' | o|eo| coogco| o , as was done i n
| ~ scose, g ve | o scos|e' ' o| oo| | d gs Scoseqce|'y, ~oveve|, |~e po
||e| deve oped co|d oc |o~poode dce |o ~e~o ~og c pe| co|d | s , ~e
oc|co' poo e~| od~odo po oged |es ve coe cocseos o esc | o| |~e
o| coogc o| o A o|e ogo~ de~os|o|ed o coge | o ys|eosed pc'
~ooy o|ey scoseg~e| , v~ c~ exp o ed |~e ~ g~poooo ' |y \/ sco
!~ s |ype o| e||o s c|o||co|e oc|, so~e coses, covo doo' e `o~o||e
~ov ve ve pe|o~ oc dc| es, eos v ' occc !~ sexo~p e po |s |o |~e
|oc| |~o| you must continue to be vigilant even when a diagnosis seems as
sured. 'o|e |~o| pe~o| ce c osce, o | ~ocg~ cde|s|odoo e | ~ scose,
vos| o|~e po| e|s de|| ~e|
The Importance of Probability i n Diferential Diagnosis
\~e evo co| g |~e do|o os|~eyopp y|o o |s|o|d ogos|c poss o |es,
| s~e p|c' |ocos dep|oooo ' | es A'voysqces| o
1. ovco~~o s |~ed seose
z ov co~~o s |~e d seose |~e e evo|popc' o||o , e |~e po
|cc opo| e|oe gevo co|ed-
J ov co~~o s o po|cc o sy~p|o~, s g, o oooo|oy esc | |~e
d seose oe gcos deed
As yoc pogess ~ed co edcco|o od go |o~ o|yv|~d ||ee|d s
eoses, |~eseqces| os oeco~e eos e|o osve| ooyes|~eoe~ so ~o|~e~o|
co e o|os~ p|~o' co oe ~e p|c ossess g |~e poooo |y o| oe d|seose
vescs oo|~e, g ve o po| cc o| d g |oooo ' |esco oeco' cc'o|ed oosed
o ooyes c e, v~ c~s|o|es |~o| |~e se ~ood o| o d seose o po|e| v|~ o
g ve se| o| |d gsco oe es| ~o|ed os |~e popo| o o| po| e|sv |~ |~e
so~e| d gsv~oo so ~ove |~e d seose oexo~p e, |~e \e' ~ood o| pec
~o o o peso v|~ |eve, cocg~, od spc|c~ ses| ~o|ed oy d v d g |~e
c~oeo|peop ev|~ |eve, cocg~, spc|c~, od pec~o o oy |~e c~oeo|
peop ev |~ |eve, cocg~ , od spc|c~ !~e oc|co ~o|~e~o' co co cc o| o s
co~p' ex, od|~eeoe ~oyc | c s~s o| |~ s|ypeo| ooy|co opp|ooc~, oc|
o |ev s ~p eod cse|c' po |s co oe o||e|ed
Have a general idea of the preval ence and common symptoms o|o
pc|| cc od|seose 'o exo~p e, o yocgvo~o v |~|eve|, sveo| g, ox|e|y,
|oc~ycod o, od ~ype|es o ~oy ~ove o p~eoc~o~ocy|o~o, oc| ~ype|~y
o d s~o'so sposs o'e !~eooovesy~p|o~so|ec~ooc|es|co|oo|~d sodes,
~oveve, ~ype|~yo d s~ s ~cc~ ~oe sey|o oe|~ecocseoecocse | s~oe
co~~o !~e| d go|exop~| ~o' ~os ~oy oe see Coves d seose, oc|
voc d o| oec~ooc|es|co| p~eoc~o~ocy|o~o, ogo po | g|ovod ~y
e|~yo d s~ os|~e ~oe' seycocse Aevo' co|oo ~ed o|~ype|~yo d s~,
v~ eseep g p~eoc~o~ocy|o~o o|~eoocs oce, voc d oeoppop| o|e
'~ s s|oce A so, |~e ooove se|| g, yoc s~oc dcosdeo oxe|yd so
de,eve ~oe co~~o| oso possoecocseo||~e po|e|s sy~p|o~s
///lOOuC//O/
'~e ~oe s,e.|.o | d g s, |~e ~oe ~e ,|c |v oe es|oo s~ cga
s|o| se yd ogoses Sel ect one or two pivotal fi ndi ngs , ,vo|s | o| o ,o
| e|s.ose|o.osdeo|oo|'ed ||ee|o d ogos s y,e.o .e~ o, |oex
o~, e, s o good , vo| oe.ocse | ~os o |o y ve de| ed s| o| .ocses
C ..o g o so ~ g~| .e ~e ,|c os |s s' o| d ogos|. ,oss o ' es s o|~e ~
|ed :| | es sc.~ os .~es| ,o o|o| gce oe ~oe ,oo e~o| . oe.o.se'~ey
oe os,e.|. od .o o..c o oge.~oeo|d seoses
\~e .os de g d ogos|. ,oss o '|es, | s ,eo,s oes| |o compare
one symptom or fi ndi ng (pivot) across mul ti pl e di seases, s|eod o|see| g
seveo sy~,'o~s o| d gs |o o s g e d seose ~ s s'e,vse ~ |o| o o|
do'o ooyss ee,s |~e ,ooo. |es o| o s,e. | . | d g o s,e.|. d seose
|~e|oe|o' !~ed ||..|y o| '~s o,,ou.~ s '~e o.so|s,e. |.do|o |o|~e
. de.eod ,evo e.eo|s gs od sy~,|o~s s,e. | .d seoses A'so, |~e
~os| ,ooo. ed ogos s oosed o oe sy~,|o~ ~oy o' .e |e ~os' se y
o||eo |~edo|ooe .osdeed !~es|e,vse .osdeo|o o|s g e , vo|s s
~eo||oe'o.e, o'~e|~o e, o.e, good . .o .dg~e'
Other Sources of Diagnostic Error
Gi vi ng equal wei ght to pdsitive and negative fi ndi ngs. ||e ve |o.cs
o o ,os|ve oooo|o|y|es| |esc'| od ,cs.eo d ogos s .osed o | oe|oe
g v g|oo~c.~ve g||o o ,os|veesc ', ,oyo||e|o |ooose|sc,,o|vee
e~e's !~ sos,e.|o|,oooo s|. eoso go||e s eg e.|ed
Usi ng the first i nformatian that comes to mi nd. !~ ssoc.e o| eo os
.ee |e~ed |~e ovo oo |y ~ec s| . A exo~, e s|~e ~~ed o|e.os deo
|o o| ~yo.od o |o.' o os o ,oss . ed ogos sv~e o ,o' e| ,ese|s
v|~.~es|,o |o|~ee~ege.y oo~, ,e .od | so,c ~ooye~oo s~ ~oy
o|.o~e|o~ d os eod y!~ese o||ed ogoses ~oy o| oe .os deed
|o y od |~e evo co| ood|eo'~e| ~oy .e ~ sd e.|ed
Laoki ng for evi dence that supports an earl y worki ng hypothesi s and
i gnori ng contradictory data. Aexo~,'e o| |~ s so.o ed .o| ~o' o . os s
sees g s.~e~..ogeso| ~e.Co| o ,o|e|v|~ .~es|,o , v~ e go
g ~oed ||.se.~ogesv~ . ~oyoe scgges|veo| ,e .od | s
Bel ievi ng i n the chosen course of acti on and favor i ng evidence that
supports i t. ys . os ~oy oe.o~e |oo ves|ed o d ogos sod .o' .e
dov |~evog ,o|~voy ,csc |oe.o.seo|ove.o| de.e
Summary ofTypes of Errors
! gge geos
o~ g eos
Co|~e g od ,o.ess geos
\e|.o|o eos
`o|oc |eos
e~o|ce. os.e
`o|g v g e.o ve g~||o
,os'veoJ ego|ve| d gs
'~eovo oo 'y ~e. s| .
Co| ~o| o o os
ve.o|de.e/ ovee o.e
o o ~e|~ododog~o
|/l/OOucl|O/ 7
Ways to Avoid Errors
l Coe|. yco~p e ~|o~o| o~
z co~eo|vo pvo|s
J ove o co~p e|e d ||ee~| o d og~os s|o eoc~ pvo|
^

oveo| eos|o ge~eo se~seo||~epevo e~ceo||~ed seose ~ogve~

pop.o'o o~d ~|~eeevo~|pop.o|o~ |o|~e po|e~| oe~g co~sdeed
o oveoge~eodeoo||~epevoe~ceo|os,~p|o~ ~ opo|c.odseose
o ~o|d scod co~|odc|oydo|ov~e~ | oeco~esovo oo e Acoe|.
occo.~'~g o| c~exp o ~edospec|s o||~ecose sesse~| o
oyo||e~' o~|ov~o|s ~o| pese~|, e , ~ego|ve | ~d ~gs
o ~ov| ~o| d ||ee~| o d og~oss s o~ ~pe|ec|sc e~ce o. are fallible.
1~e c~expec|ed, .~ ey, oop co| ~oy occc
f..,......,...
A |ev vods oe ~o de ego d ~gcosepese~|o| o~ o~d d sc.ss o~ Cose
co~|ee~ces oe ~vo coo e |eoc~ ~g exec ses .eo ~ ~g |o pese~|coses ~ o
co~c se o~d ode y ~o~ ~e |eoc~es '~e p ~c p es o d.||ee~| o d og~os s
Cose pese~'o| o e~p~os zes ogo~ zo|o~o| do|o Cose d sccss o~ e~p oys
c | co '~ ~ ~g od ogo~ zo| o~o|d og~os|c poss o | es
Case Presentation
1~e ey |o cose pese~|o|o~ s oev|y '~e |od | o~o o~d , ~s|oyo~d
p~ysco , 'o~o| s'~eoes||o~evo|od sc.ss o~ oeg ~v|~ o c~e|co~p o ~|
,v~y'~epo'e|co~e'o~ed co o||e~'o~|o~d| ~e~poceedv '~o~ogo~ zed
~ s|oy o~d p~ys co exo~ 1~e ~ s|oy s~o. d oe d sccssed ~ c~o~o og co
o.de |o ovo d co~|.s o. o| e|s v~o~oveoee~ |oo o~g | ~eo ~ove
oee~|o~s|eed|o~o~o'~e~osp |o |yp co y ~oveex|e~sveo~dco~p ex ~ s
|oes | s '~e d.|yo| |~e pese~|e|o ovod ovey o~g d sccss o~so| pevo.s
vo.psopes.~p|ved og~oses oc.so~|~eessential features o'|~ecose
Tips on Presentation
oe o e' and .e'|oo.g~ oc s~o. d oe oo e|o pese~|~os' coses co~
pe'ey o ~ ~.|es o ess .ve~ '~e ~os' co~pex coses co oe s.~~o
zed e'|ec|vey ~o oe|pese~|o' o~
ese|| ~ecose ~c~oo og co ode
Avod c .|'e ~g |~e ~ s|oy v|~ oooo|oy esc 's, pevo.s vocps, o
o|~e p~ys c o~s pes.~p|ved og~oses
o ov'~e| od | o~o o~d 'o~o|
o C~ e|co~p o ~|
o s|oyo|pese~' ~ess
o |/llOOucl|O/
-
c os|~ed co' ~ s|oy
d ^ed co| os
e o~ y ~ s|oy
1. Soc o ~ s|oy
g <evev o|sys|e~s, oe||
~ ~ysco exo~
oc.so~ pe||~e~|pos|veand ~ego|vee e~e|s
| .s.o' 'y soes|, |o|esoseo||eoc~ g, |o o~ | ooo|o|oy es. |s||o~|~e
' o pese~|o| o~ !~ so~ ss o~ e~p~oszes |~e ~po|o~ce o|o coe|. c
co evo .o| o~ |o g. de|~e ode~g o| oooo|oy|es|s So~e|~es |~e c .s o~
o| ooo|o|oy|es|s s .ovo doo es ce |~oyoe|~eeoso|ood~ ss oo e
|eo ,e g , oe~ o| ~~os|coses, ~oveve, | s oes||o | s| cosded og~os
'c poss o |es o~d '~e ooyze oppopo|ey|oc.sed d og~os| c|es| g
`o|e|~o|o |~oo.g~ ~ s|o.yo~dp~ysco exo~ o|os~o. d oe pe|o~ed
oeve|ypo|e~|, od|~e pese~|e|so. d oe pepoed |o povdeo~y ~|o~o
| o~ | | s eq.es|ed oveve, oex~o.s've s' o' o ego've| d gs s .~
ecessoy
Describing a Symptom
\~e~ co: de g |~e d ||ee~| o d ogo: :o| o po|e|: :y~p|o~ o.c~ e|
co~p o | , || sesse| o |o oo|o ~o |oo.g~~ s|oyodocc.o|eydescoe|~e
poo e~ ^oyco~p' o ~|s, s.c~ os c~es|o oodo~ ~o' po , ~ove ~.~eo.s
co.ses, o~d o ~oe spec | c desc p| o s eq. ed 'o d ec' |'e vos.p
o~sde|~e ~e~o cCCMH|A' '5 .
Co~p o | v~o| s|~e poo e~-
Cse| v~e~ dd |oeg -
Mog | .de~ovsevee s|-
Ho||e ep sod c-cescedo, dec.escedo- cos|o~|-
|oco| o v~ee s |-does |od o'e-
Assoc o|ed sy~p|o~s o|e oy o|~e sy~p'o~s 'e~poo y eo'ed |o '~e
co~p o |-
|~pove~e|sv~o|~oses |oe||e-
'ego|ves| ~. v~o|~oses |vose-
5 ~ o ep sodes |~e pos| ~os |eve ~oppe~ed oe|oe-
o|o ~g|~esedesc p|ve|eo|.|es ~oyeveo |e co.se o|o sy~p|o~
o~sde'~eco~p o |o|c~es|po
Co~p o | c~es| po
Cse' oego~z ~o.sogo
Mog |.de1O/l J
Ho||e~cesce~do, c.s~ g
'oco' o s.os|eo oco'o od o| g |o|e ovod e||o~
Assoc o|ed sy~p|o~ss~o|~esso| oeo|~, d op~oess, oxe|y
|~pove~e's es|, |ogyce ~
'ego|ve s| ~. exe|o~
5 ~ oepsodes |~epos| oyeosogooe|oecoo~oyo|eyoypossgo|
l/l|OOucl/O/
C~es|po ~os ~y|od co.ses, o.| |~e ooove ~ s|oys|ogy po|s|o og o
Cos deo d ||ee|se|o||eo|.es |o c~es|po
Co~p' o | c~es|po
Cse| oego ~o.sogo
Mog |.de l J/ l J
o||e cos|o|, s~op
|oco|os.os|eo oco| o, ood o| g
Assoc o|ed sy~p|o~s oo |y|o|oseo deepoeo|~
| ~pove~e|s s|| g.p, eo g |ovod
Mego|ve s| ~. 'y g|o|
5 ~ o ep sodes |~epos| o p o~ s|oy
|~ s s|oce, |~ec~es|po |eo|.esoe s.gges|veo|pecod|o po , od o
d ||ee| s|o|d ogos|c poss o |es s~o. d oecosdeed
Case Discussion
1. oeg v |~ o summary statement. A||e s|e g |o |~e cose, g ve o
oese|ece s.~~oy o| |~e cose 'o exo~p e !~e cose coces o ^^
yeoo d ~o ev | ~ o ~ s|oy o| poo yco|o ed d ooe|es od |oveo.s
d.g oo.sev~o pese|sv |~ o zdoy~ s|oyo||eve|, os~, od deceos g
. eo.|p.| !~es.~~o|y s|o|e~e| so ges|o | , o oveo ~pess o , o|
|~e cose | s ~e p|. oeco.se o pese|o| o o||e s.gges|s o se yd ogo

s s, od |~ed sc.ss o co |oc.s o pov g o d spov g | ~ s pes.~p| ve

d ogos s
z `ex|, ~ose o probl em l i st o| | ~e~o o c.e|od pos| poo e~s
|~eooove exo~p e, o poo e~ s|co. d c .de
eve|
<os~
.eceos g . eo.|p.|
s|oyo|d ooe|es
s|oyo| |oveo.sd.goo.se
J Cos|.c||~edi fferenti al di agnosi s framework oosedo|~eco|egoes
o'd seoseooy .s g ~e~o cs|o spec|c e|'es o|~epoo e~ s|
4. `oov |~ed ogos| c posso | | es oosed o |~e ~ s|oy od p~ys co
exo~
o <eq.es|spec|c o.oo|oyo ~og g |es|s| o|.|~e oov dov |~e
d ogos|c poss o | es Spec |c ~e~ocs ~oyoe .sed |o cosde |~ed ||e
e| o d ogos s |o ce|o oooo|oyooo ~o | es v|eo oe oo|o : oo|
coo::|eo| || ||e o:eo:e: oeog coo:oeeo, o|oy: e|.o |o ||e ogoo|,
coop|e|e o||eeo|o| |o e.oo:oe oogoo:|. po::o||e:.
S.~~oze |~e do|o od p o |zed ogos|c poss o | es
1 0 l/llOOuc//O/
W
II
PULMONARY AND
CRITICAL CARE
General Considerations
G. ...-. .,...
^oyd sodes ~ove p.|~ooy ~o |es|o| os, od c~es|sy~p|o~s oe |e
q.e| y |~e | s| o| ced oy |~e po| e|, e g , co.g~, v~eez g, s~o||ess o|
oeo|~| !~e .g so co~~o |oge| o|go|o |ec| o, d.g|ox c |y, co|d o
vosc. o co~po~ se, ~~.o og cd seose, od eop os| c pocesses op
pooc~ g|~epo|e|v|~ |~ooccd seose, | ~ so||~e ~oe co~~oco|ego|es
o| ess, s.c~ os |ec| o, eopos~, |oxc expos.es, od co|d ovosc.' od s
eose Aso ~po|o|, o.| essco~~o, oe |~e ~~.o' og cod exo|c co|e
goeso|d seose, o~ogv~ c~ |~ee scosdeoo eoveop |~eco|ego|es
o| ' esss.c~osedoc|eo~e|ooo cd seoses ~ove'essd ec|p. ~ooy
vo've~e| \e co opp y|~e ~e~o c "McD| C| Mc DCC":
Me|ooo' c , e g , o~y' o dos s, o p~o l o| ||ypsde|cecy|
cdoc e,po|oeop'os|csydo~es, e.oedoc|ece' ' ~ypep os o|
D.gs/~ed c es , e g , |o|.o|o , o~odo|oe, c~e~o|~eopy|ox c |y|
| |ec|o , e g , '\|e' o|ed, !o, ooc|e o' pe.~o o|
Coge |o ,e g , ooc~oge ccys|s, o|ogee|s, cys|c|oos s|
| ~~.o' og c,e g , Coodpos|.es, ~e.~o|o d .g, os|~~o, o, :|
Meop'os|c , p ~oy .g, p e.o od~ed os| o |.~os, ~e|os|o|cd seose|
cxo| c d seoses , e g , so|co d, eos op~ ' cg|o. o~o, 'A^, |es| | o
d seoses|
Degeeo|ve , e g , C-, degeeo|ve e.o~.sc. o d seoseA.S]|
Ccc.po| oo' /ev o~e|o , e g. , s~os g, osoes|os s, ~ypeses | v j|
Co|d ovosc.' o,e g , ., ede~o|o~ C, \', p.' ~ooy|ype|es o|
Metabol i c di sorders co.se~.' |sys|e~ d seose, o.||~e' .godc~es| .s.o y
oe o| p|o~ e|y vo'ved A~y o dos s , o so exo|c od ~~.o' og c| ~oy
lulOO/3/y3/OC////C3l C3/0 M l l
o|eypese~|ospoe~c~y~o ovosc. o .~g d seose A p~o l o~|'yps ~de|
c e~cyo|e~ eods |o e~p~yse~o, especo y ~ yo.~g s~oes, o~d o soco.d
oe coss|ed oso~ ~~e||ed d sode '~ odd | o~, |~e c~gs~oyoe o||ec|ed oy
o~go ~g ~e|ooo cpocesses, scc~ospc ~o~oyede~o |o~ ce~ oo'oc~yp
~eo , .ss~o. oeo|~ ~g| |o~ d ooe|c e|ooc dos s
1~e .~g ~os'||e ~ov~ endocri ne |.~c|o~ o~dso|~ sco|egoy .s.o y s
co| ~e|p|. ~|o~c o| cg d ||eec| o|d og~oses |oc~es|d seose .c~g co~ce,
po| c. oy s~o ce coc ~o~o, co~ co.se poo~eop os|c sy~do~es s.c~ os
SA| o~d .s~ ~gssy~do~e ^yxede~o ~oyoe ossoco|ed v|~ p e.o e|
|cs o~s !~e o|e e~| |y o| ~e. oe~doc ~e ce| ~ypep|os o ~oy pese~| os
c~oc coos|.c|ve c~g d seose
Drugs co~ co.se~ypese~s |v |yeoc|o~s .xo~pes ~c .de~ |o|.o~|o ~
o~d ,~ecy|o ~ A so, ce|o ~c~e~o|~eope.| c oge~'s ~oveve ~ov~ p.
~oco y|ox c | es , ~e|~o|exo|e, cy|oxo~ , o eo~yc c , o`U| A~ odooce
co.ses p. ~o~oy | oos s osve| oso|~e|ypeso| .~g ~ . y ~|ove~o.s
d .g oo.se o~d coco ~e oo.se ~oy ~ove oc.|e o~d c~o~ c p. ~o~oy
~o~ |es|o| o~s
I nfectious processes o| ~ocy |ypes co~ ~vove |~e .~gs e|~e p ~o 'y,
os ~ooo ooc|e o p~e.~o~o, o os po|o|o d sse~ ~o|ed ~|ec|o~ , s.c~os
ospeg oss ~ ~~.~oco~po~sed po|e~|s \ .ses, ~ycoooc|e o, ~e ~~|~s,
o~d o|~e poos |es co~ o | cocse pc| ~oco y po|~o|ogy e|o ~ c|ec| o.s
oge~|s ~oyoespec | co y ossoc o|ed v | ~ c~o~ c d seoses, s.c~ os ~
A S, o o.~o deo ~cys|c| oos s
!~eco|egoyo|congeni tal l ung di sorders ~c cdes o~o|o~ c, ~~c~o
og c, o~d ~e|ooo coo~o~o | es A~o|o~ cd sodes ~c cde oo~c~oge~ c
cys|s, seq.es|o|o~ , o~ddys~o| ec osy~do~e ~~.~ode|c e~cysy~do~es
scc~ os ~~c~og oo. ~de|ce~cyo|.~c| o~o ~ec|op~ d sodesc~ooc|es
| co y pese~|v |~ ecc|e~|s ~op. ~o~oy c|ec| o~s A p~o1o~| |yps cde|
c e~cy ped sposes po| e~|s |o po~ oo. o e~p~yse~o Cys|c | oos s s o
co~~o~ ~ ~e |ed d:seose v |~ po~ ~e~| p. ~o~oy ~vo ve~e~| ~c .d ~g
oo~c~ ec|os s, c~oc c ~|ec| ocs, o~d| o|o|cc~ocges
I mmunologi c di sease ~oy o||ec||~e c~gsspec|co y, os ~ os|~~o, op.
~o~oy ~vo ve~e~|~oy oe o~ y o po|o| o ~oev despeod ~~.~o og c
pocessscc~osCoodpos|ceso\ege~es \ |.o yo||co|oge~ vosc. od s
eosesco~ cvo|ve |~e esp o|oysys|e~ .xo~pes cc cdep.|~o~oy| oos s ~
sc'eode~o, .~g~od. es ~ ~ec~o|o d o|~ | s, p e.o e||cs o~s ~ S.., o~d
|oc~eo co|opse ~ eops ~g poyc~o~d | s `eco ~~.~o og cd sodes s.c~
os ~yos|~ec og|ov socd Cc ocoo ~oy eod|oespo|o|y ~.sc e|o .e
!opco eos ~op~ | oepese~|so~ ~~c~o|og cespo~se|o |~e ~|ec| o.soge~|
| o o, o~d s|eo|ed v |~ |~eo~|| o o oge~|d e|~y co oo~oz ~e A eg c
oo~c~opc ~ocoyospeg oss so~o|~eexo~peo|o~ ~|ec|o.soge~|e c|
cg oc ~|e~se c||o~~o|oyespo~se !eo|~e~| s p ~o y d ec|ed o| ~od |y
~g|~e ~os|espocsev |~ s|eo ds
Neopl astic di sease ~oyo se p ~o |y ~|~e .~gso ~e|os|osze |o~ o
d s|o~|cocce| `eop os~s ~ o|~e |~ooccs|cc|.|eso sococo||ec| p.|~o~oy
|.cc| oc , e g , p|ec|o |c~os, co~pessoc o|o voys|o~|y~p~ ~odes|
lZ lu/OO/3ly3/OCll/lC3/ C3l0
W
`.~eo.s exotic condi ti ons o|'ec| 'e .~gs, c .d ~g s|ocy|oss /, so
codos s, y~pog o e o~yo~o'os s, o~d eos ~op c .~g d seose ^o~yo|
|ese dseoses oe |o.g| 'o ove o ~~.o ogc .os s
Degenerative di seases ~oyco.se p. ~ooysy~p|o~o|oogyseco~do y,
os s |e cose v| ~e.o~.sc. od sodes s.c osA.S !esed sodesco~
eod 'osvo ov g dys|. c| o~ od os o| o o es,o'oy|o .e Sevee
yposco ossco eod|oo es|c|veve| o'oyde|ec| .~pyse~oo soco. d
oecos deed dege~eo've ~o~o og ~g, .g|.~c|o~s ovydec ~eso~d
s '.sdege~eo|ve
~ |eco'egoyo| occupati onal and envi ronmental exposures, s~o ge
o|ed .gd seose s vey co~~o~ |eoge|s |o|co~ co.se .g dseose
oe eg o od c .de os.es'os, s co, coo d.s| , o~d oey . ~ y,e
se~s | v |yeoc|o~s c .de|o~es .g, .d|oc es .g, o~d~.~eo.so|e
e~| |es 'o.~o ~oy eod |o e~ooge, p~e.~o|oox, .~gco~' .s o , o
.y|o o'e |o|ooccs|.c|.es
Cardi ovascul ar di seases ~oy vove 'e . gs seco~do y, co.s g p.
~ooy ~| |o|es o~d ,. ~ooy ype'eso A.~o~o | es o||e eo'o~d
oo|o oe ~po|o' cos deo'os |oocc d seose !evosc. | des ,c oss
'ed .de ~~.o og c d seose| o~d p. ~ooy ve~oocc .s ve d seosesoe
~oe oe . ~ooye~.o s~ sveyco~~o~, .ded ogosed, o~d ~oy oe
s do.s The presentati ons of pul monary embol i sm are myri ad, and the di s
order shoul d be consi dered in the di fferential for most thoracic probl ems.
G. ... . .. ..
'ecoeo| c |co y ,o'e~|s sco~p exodeq. esoogozedoppooc
|o ~oog g ~. | sys|e~ dseose os de 'e ~e~o~ c "M| CU 5 |' |c
CCA|5.
Medco|os/,opy oxs
| vos os
Cod ovosc. o
U e/eo
5 / dec.o | scoe
|.gs
' |ec|o.sd seose
' .ds/ e ec|oy'es/.| | o~
cdoc e
Cos'o 'es| o / ve
Ccoog c/e~o|oog c
Ao geso/~e.o og c
|o~g|e~ pog~oss
5oco /|o~ y
/u/OO/3/y3/O C///C3/ C3/0 |U
^o~y o||ese po|e~|soeo~ ~.~eo.s medications v c ~oy co.ses de
e||ec|s s.c os |eve, os, o~d cy|ope os oe|. yevev|e po| e~|s ~ed
c ~es do y, v |o eye |ovod d sco| ~. ~g .~ecessoyoge|s o~s deo
osp |o zed po| e|s|oso~e|ypeo|.\popy ox s, espec o y U po| e~|s
^oypo|e~'sso. doecos deed|os|ess . ce/gos||s popylox s, osve
~vosve poced.es od dve g ~es o~d co|e|es oe co~~o ~|e
U !ese i nvasi ons, v e o||e ecessoy, oe so.ces o| o|oge~ cco~p
co| os, espec o y |ec| o, o~dso. d oe d sco~| ~.edossoo~ os poss o e
A sys|e~o' c oppooc s |e~ .sed |o oddess ' e po' e| s p oo e~s
cardi ac e g , e~ody~o~ cs, d . es s| , u ri nary/renal , e g , | . d oo o~ce,
oU`/ceo| e, d o ys s| , ski n , e g , os, dec.o |.s coe| , l ungs , c .d ~g
ve| o|o ~o~oge~e'| , i nfectious di sease ,oc| veo s.spec|ed ~|ec| o~s, o~
| o o' c |eopy ~c .d ~g|eo|~e~|doy| , fl ui ds/electrolytes/nutri ti on , \'s,
eec|oy|e d sodes o ep oce~e', e|eo o poe'eo ~.| | o| , endocr i ne
,e g , d ooe'es |yo dd seose, s|eod |eopy, , GI /l iver , e. g , gos|o 'es| ~o
oeed ~g, d oeo/cos| po| o, c os s/epo| c dys|.c| o , poceo| cd s
eose| , oncol ogi c/hematol ogi c e g , ~o g~oc es, cy|ope os, coog. opo
|y| , o~d anal gesi a/anxiol ysi s/neurol ogi c status , e g , po ~o~oge~e| ,
co~o, e.o og cde| . |s, psyc o| cd seose|
| s ~po|o|'o eossess| el ong-term prognosi s |eq.e~| ysoos| oovo d
|.| e coe oe|. o||e| o o||e s g ve~ |o o po| e|s ~ed co ss.esv |o.|
co~s deo' o~o||e se ood o| s.v vo o coce o| ~eo~ g|.| ecovey
A og |e so~e ~es, soci al /fami l i al ss.es oe o| poo~o.' ~po|o~ce
o~ y ~e~oes o||e oe .pse|od coceed !ey eq. e eg. o ~ee| ~gs
v | |e U pys c o~|od sc.ss ~ed co poo' e~s, |eo|~e|dec s os, pog
~os s, ode~do| |edec s os
C..-., ....
<eod ~go ces|xoy eq. es oogo zed oppooc o~dco~ oeoseosyos
ABCDc| o~~o~ ~e|ods .sed e~pos zes|o| ~g o~| eo.|s deo~d
vos g os|o| ~g ~|ece~|eo~dvos ~go.| !eAo.. ~e|od* s|o|s
v | o q. csco~| ~o| o~ o| |e | ~s q.o |o| ve ospec|s o~d |e o.| ~eso
cecs s||o ~|epe|o| o
Initial review:
Ao A
Bodypos | o
Co~| ~ o~e
Do|e
cxpos.e
| ' ~s|oco~po so
* Thi s mnemonic was adapted from one proposed by Robert Crauseman, N.
l 4 lulOO/3ly3/OCl///C3l C3l0
-

Interpretation.
A voy/Adeopo|~y
Boes/Beos|s~odovs
Cod ocs ~oce||e/Cos|op~e cog'es
D op~og~/Dges|ve|oc|
cdges/cx|o|~oocc|ssces
| e ds/|o ' c|e
' o y, |~e eodes~oc d oo o| |~e | ' ~s poec|o , AH o HA| , |~e |~e
body posi tion , odo| c, o|o|ed, e|c| , od |~e confi rm |~e o~e o| |~e po
| e|, |~edate o||~e| ~, od|~e|ype o|exposure ,ovepee||o|ed o cde
pee|
o|ed| See | o' d f i l ms oe ovo oo e |o o co~po so . Ago , cs g
AoC.osyocgc de, evev| ~eeevo| s|cc|ceso| ~ec~es|xoy S|o| oy
oo g o| '~e ai rway |o vd|~ od|oco oov g !~e oo |o evdeceo|
~ ' o adenopathy o| e oge~e| os ~ g~| oe see v |~ pc ~ooy o||e|y ~y
pe|es o . `ex|, exo~ e |o breast shadows, v~ c~ ~oy o||ec| |~e des |y
| ~e ove cg| e ds, od coe| c y ev ev|~ebones | o o||oc|ces o ev
deceo| y|cooe es os
!~ecardi ac si l houette osve os|~ecostophreni c angl es s~oc d oeexo~
ed |o ev dece o|cod oce oge~e|o p eco e||cs os .oo o||~e di
aphragm |o see ||~ee s d scepocy |~e ~e g~|o| |~e ~e~d op~og~so
evdeceo||ee o cde||~e d op~og~ !~e digestive tract |~eco oeoo
yzed \ |~ |~ec~es|, oo|oev deceo|esop~ogeo e oge~e|o ~e
o| o o||~es|o~oc~ osve os d ' o|ed oopso| oove oe ov|~ed op~og~
.ooo||~eedges odextra-thoracic tissues. 'o|| cc oy, ooo| |~eopces|o|
| o|oss o op co d seose osve os pec~o|~ooces, v~ c~ ~oy occc o og
|~e edges op co 'y, o|eo y, o o||~e oose o||~e cg ' eco | ~ ce go
p oqces ~oyoepese| `ex|, exo~ e |~eex|o|~ooc c so|| | ssceso oo|~
|~eo|e| ood 'o|e|o p|oec| os
' o' y, ossess |~e cg fi el ds |o| ev dece o| o veo o | g o |es| | o
pocesses .v dece o|co d oc fai l ure ~oy oe see | | ~ee so veo o o
spoce d seosev |~ po~ e|voscc o| |y v |~o| v |~oc|ev deceo| p' ec|o
e||cs os
~
Pulmonary and Critical Care l O
Cl inical Symptoms and Signs
C H R O N I C C O U G H
GASPS AND COU GH
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1 . Cocg soeo||e~os|co~~o~ co~p o ~|se~coc|eed oypys c o~s |
s~os|o||e~ |eo|ed |ocppe espo|oy||oc| ~|ec| o~sod/os~o g A pe
ss|e~|cocg ' os| ~g o~ge|| o z vee\s ~oy ~dco|eo ~o|e se ocsd seose
!e ooove d||ee~| o |oco~ ccocg e|es |ocoses' os| ~gseveo veess ~
v c ces| od og|opsoe ~o|~o
2 . ~o s~o\e, oco ccocg ~oy ~d co|ec|o co|o~c | so | ~oyeo d
|edeve op~e|o|coce, po| cc o' yve~ | voveso~o voy Any change
i n the nature of a chroni c cough i n a smoker warrants i nvesti gati on for pos
si bl e neopl asm.
3 . ' ~|ec|o~s, |e ~os| co~~o~cocseso|cocg , ~oy oe dce|ov o oooc|e
| o po|oge~s, v o oge|s o|e |e csco cc p|s '~ odd' | o~, o pos| ~|ec| ocs
cocg ~oyosedce|oocyc eo| ||o| o~ o~d cocg g, vc |c|e ||o|es

l lulOO/3ly3/O Cl///C3lC3l0
..
|~e|~oo| A pos| |ec|ocs cocg~ ~oy os|seveo vees o|e| |~e eso c| o^o|
|~e occ|e ^|ec| ocs pocess !eo|~e|co^s s's o| cocg~ sc ppesso|s, po
||op| c~, o^d, occos oo 'y, o coc|seo| ^~oed s|eods
4. oo|~ pc ~o^oy poe^c~y~o o^d p eco d seose ~oy pese^|os o cocg~
v | ~ov |~oc|dyspeo A c~es|xoy csco y s|~e| s| |es|oo|o ^ed o||e| ~e
~ s|oyo^d p~ysco ^evo co| ^go c~o^ ccocg~ , e , o cocg~ os| ^g o^ge
|~o^z |oJ vees| . ||~ec~es|xoy s ego|ve, co^sdeo ~oe ~ |ed d ||e|
e| o' d ogos s, os oc| ed oy |~e CASS A`.UC ~^e~o c
5. e|o ~ s'o co |eo|c es ~oy po ^| | o|~e e| o ogyo|o c~o^ c cocg~
Sy~p|o~so|~eo|oc ovo|se^ gcocg~ ^|ecc~oecy, e g , ^ g~|| ~oy ^
d co|e gastroesophageal refl ux. A cocg~ |~o| svose ^ |~e eve^ ^gso o
c~ d~ood ~ s|oyo| |eoc|ve o |voysd seose ~oy scgges|asthma. Smoking-in
duced c~o c oo^c~ | s o^d post-i nfecti on cocg~|o~ c~o c |o| o^ oe
veyco~~oo^ds~oc d oescspec|ed v~e |~ee so ~ s|oyo|s~o goo^
|ecede^| |ec|o^ `oso co^ges| o o seso| o^ o| pos'^oso d p ~oy ^d
co|e si nusi ti s os |~e cocseo|o cocg~ oey, pess|e^|c' eo ~ ^o|~eo ~oy
oeseco^doy|oo S eo, v~ c~s~oc d oecos deed |^oso do ^ogeod
cocg~do^ | espo^d| o||eo|~e^|
ACE i nhi bi tors, scc~ os cop|op , oe o co~~o cocse o| cocg~ ^ po
|e^|so^o^| ~ype||e^s ve|~e|opy A neopl asm ^|~eoveo voy, v~ c~ s^o|
v s o eoxoy, ~oy oe ~ode ~o^ |es| oycocg~ A^esop~ogeo|di verticul um
, e g , /e^es d ve| cc' c~j cocses ~o |os s, egc|g |o| o^ , o^dcocg~ ossoc
o|ed v|~ eo| ^g o|e|sv |~congestive heart fai l ure ~oy~oveoexoceoo
|o^ o| eoc|ve o voys d seosev |~ cocg~o^d/ov~eez ^g, o||e^ vose o|
g~| !~epese^ceo|eopo o|eod seoses~oc d po~p| o^ ves| go| o^o|
|~e outer ear co^o o^d |~e eo d|c~, os ||o|o^ |~ose oeos oy ~o , vox,
o o |o|e g oody ~oy eod |o s| ~c o| o^ o| |~evogcs eve o^d cocg~ !~e
eo co^o s~oc d oe exo~ ^ed o po| e^|s pese^| ^g v |~ cocg~ , os eo|
p|oo e~s ~oy oe osy~p|o~o| c
!~e pese^ce o|s| doo^ p~ys co exo~ ^o| o o|o po pooe ^ec~oss
~oy ^d co|e o^ upper ai rway poo e~os o cocseo|c~|o^ c cocg~ A gas
trOi ntesti nal-ai rway fi stul a, csco y |oc~eoesop~ogeo , c~ooc|e s| co y
cocsescocg~v~ e eo| ^g. A^d| ^o y, | ~eoccce^ceo|| ~ecocg~o||e|vo|\
ovose ^go| |~ecocg~ dc| ^g|~evo|vee ~oy scgges| o^ occcpo| o^o
cocse eod ^g|oo hypersensiti vity p^ec~o^ | so|o^o e|gy
6. S|cd es ~ove s~ov^ |~o| po| e^|sv |~ cocg~ ' os| ^g o^ge| ~o^ J vee\s
v~o co~e |o o pc ~o^oy spec o s||o|evo co| o^ o' ~os| ^vo| oo y~ove o^e
o||occocses o| c~o^ c cocg~ gos|oesop~ogeo e| cx, os|~~o, s~o\ ^g ^
dcced c~|o^ co|o^c~ | s, o s ^cs | s/pos|^oso d| p !~e oc|~o|s o| |~ese s|cd
es~ovescgges|ed |~o|ovo|\cp|o|~ese|oc possoe e^||es od/o|e~p | c
|eo|~e^|o||~e~ v eod |o |eso c| o^ o||~ecocg~ ^ |~e g|eo| ~o o |yo|
coses Add ^g |~eco~~o^e^| | yo| pos| ^|ec|ocs cocg~|o |~ese|oce| | es
c|eo|es|~e~^e~o^ cCAS'S,v~ c~ sogoods|o|||od og^os ^g|~ecocseo|
c~|o^ ccocg~
lu/OO/3ly3/OCl///C3l C3tO l
7. ccos o~o 'y, po| e~|s v |~ pc|~o~oy | oos s pese~| v |~ cocg~o~do
~ego|vexoy !~ese po|e~|s csco' 'y ~ove| ~e, ve'c|o coc eso~ c~es| ocs
cc |o| o~, o^do C!sco~v ' |eveo |~e ~|e|s| | o' d seose
8. ' ~o y, |o po| e~|s ~ v~o~ o o|~e cocses o| cocg~ oe c ed oc|, o psy
c~oge~ ce| o ogy s poss o e !~ sd og~os s eqc es exc' cs o~ o| |~eo|~e
o|o|e~e~|o~eo e|oog es
CL U B
c. .
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C L U B B I N G
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".
C' coo ~g ~os oee~ ooseved ~ossoco|o~ v|~ c~g d seoses s ~ce o~| qc|y,
~oveve, |scocse sc~~ov~ |~oyoesee~ ossoco|edv|~co~ces, po|cc
' o y pc ~o~oy ~eop os~s, o~d v~e~ scc~ o~ossoco|o~ exs|s, |~ee csco y
s ev de~ce o| ~ype|op~ c pc ~o~oy os|eoo|~|opo|~y C coo ~g o so s oo
seved ^so~e coses o|c~o^ c ved seose, os ve os ~ ~| o~~o|oy oove
d seose, espec o' y v|~ c' ceo|ve co' | s C coo ~g s o vey co~~o^ sy~p|o~
~ po| e~|s v|~ cys|c | o|os so~d ~ o|~e po| e^|s v|~ oo~c~ ec|os s |~e|
' c^g d seoses |~o| ~ove oee^ ossoc o|ed v | ~c' coo ^g ^c cde c~gooscess
o~d osoes|os s 'essco~~o~y, |~osoee~ see~ ^ ossoco|o~v|~socodoss
o~d eos ^op~ cgo~c o~o. C' coo ~g s essco~~o^ yossoc o|ed v |~ pc
~o~oy| oos s ' |s oo| ossoco|edv|~C', |~e p|ese~ceo|c' coo ~gs~oc' d
po~p|o~ ~ves| go| o^|oo|~ed og~oses C' coo ~g ~oy egessv |~ |eo|
~e~|o||~e c~dey ^gd seose.
lo lu/OO/3ly3/OCl///C3/ C3l0
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DYS P N E A
S H E PANTS
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1 . .ysp~eo s de| ~ed oso~oo~o~o y c~co~|o|oo eovoe~esso|oeo|
~go~d osd vesecocses o|e~|s ov~ desc|p| o~so|sy~p|o~s~oy ~c cde
|o| gce, eovy oeo| ~g, veos~ess, ces|| g|~ess, veez ~g, o~do|e co~
p o ~|s !e|e oe |oc| p| ~oy o~o|o~ co|eos |o| ~| ce~ce |ese~so| o~ o|
o|eo| ~g Hc ~o~oy/o voys|e|cecep|os, Ao|c/coo|d ce~oecep|o|s,
Meco~edc oy ce~oecep|os o~d !ooc c ~csc e s|e|c |ecep|os
, " HAM!"| ~pc||o~ |ese s|es ~| ce~ces|e oeo| ~g po||e ~. oexo~p' e,
o~occ|e exoceoo|o~o|eods |o c~g ype ~| o| o~ o~dces|vo ' ex
po~s o~, v c ~|c~ s| ~co|es pc ~o~oy o~d |oocc ~csc es|e|c ecep
|os, c | ~o|e' y ' eod ~g |o |e se~so| o~ o|dysp~eo `ec o~cscc o d seose
cocses ypove~| o| o~, o ov ~g |o seo~d |o|o g pC o~d
ov pC s| ~c o|e oo|| c, coo| d, o~d ~edc o|y ce~oecep|os o~d cocse
dysp~eo A |e~o| ve y, ypox o |o~ pc ~o~o|y e~oo s| ~c o|es oo| c,
coo|d, o~d ~edc oyce~oecep|oso~dcocsesdysp~eo
2. !e o~se| o| dysp~eo ,occ|e, scoocc|e, c|o~ c/p|ogessve| osve os ex
oceoo~|s soc d oe es|oo sed `o|e |o| so~e po|e~|s v| s ovy pog|es
s ve pocesses ~oy godco y odop| oy deceos ~g |e pys co oc| v |y, oc|
co~p' o ~o|~o|eocc|e sy~p|o~so|es| os | o~o co~p' o ~|so|dysp~eo ~oy
oe e c |ed, sccos orthopnea ,vose~ ~g ~|escp ~epos | o~ co|d ocd s
eose, cppeo |voyoos|cc| o~, d op|og~o| c po|o yssl

platpnea , so||~ess
o| oeo| ve~ ossc~ ~g o~ cp g'| pos | o~ c |os s po| e~|s v| ~|opc
~o~oysc~|s, p~ec~o~ec|o~ypo|e~|sv| ~|oo| o' sc~|s, po|e~|s v| de
| c e~|oodo~ ~o ~cscc' o|ce|, trepopnea ,dysp~eooccc| ~g ~ |e g|o|'e||
lul/O/3ly3/OCl/l|c3l C3l0 l d
o|eo' decco |cs pos | o^ ~eo|d seose, .^ o|eo pc ~o^oy d seose| , o^d
paroxysmal nocturnal dyspnea , ~os|o||e^ eo|ed |o e||ve^| cc o|o ce, o.|
~oyoesee^v|~oos|.c|ve .cg d seoseoseepdso|deed o|eo|~ ^g|
3. ^ odd | oc| oexe| o^o' o^d pos | o^o pec p |o^|s, q.es| o^ | ~epo| e^|
oooc|occ.po|o^o oe^v o^~e^|o' exposces, oc ~o' expos.|es, ^~o o| o^o
oge^|s, o^d seoso^o vose^ ^g.
4. Stress, anxi ety, and decondi t i on i ng oe co~~oc cocseso| dysp^eo,
o.| o||e^ eqc e o^ex|e^s ve cves| go| o^ |o c e o.| ~oe |e|~ |eo|e^ ^g
e| o og es
5. Scspec|heart di sease ocodoc sc~e~ o ^po|e^|so| ss|oov|~ o ~ s
|oyo|codocd seoseA~ s|oyo'exe| o^o sy~p|o~s, o|~opceo, po|oxys~o'
^oc|c^o dysp^eo, oc~es| po ^~oyoepesec|, osve os p~ysco' exo~ ^o
|o^ | ^d ^gs o| ede~o, .g.ove^o.s d s|ecs o^ , ocod oc ~c| ~cs/go' ops
^|ocod ocs~cc|so sococse~ypoxe~ o, C, ocd dyspceo
6. '.' ~ocoy embol i ~oypesec|v |~ occ|edyspceo, c~es| po c, o v~eez
^g C~oc c, ec.|e^|pc' ~o^oy e~oo ~oy oe e'o|vey s ec| c | o' 'yo^d
pese^|ossovy p|ogessve dysp^eo .v de^ceo|oveex|e~ lyve^o.s oo
s|cc|o^ ~oy ^o|oe pese^|
7. !~eco|egoyo|p ~oypul monary di sease ^c cdeso voy, ^|es| | o o^d
^| |o|ve, p eco , o^d pc ~o^oyvosc. od seoses , e~oo cd seose sco^sd
eed sepoo|e yooove| \~eez ^g, co.g~ , o^d o vose^ ^g o|sy~p|o~s ^
| ~eeve^ ^g ^oyoc^gepe|so^ s.gges|eoc|veo voysd seose,v~ ' egodc
o 'y pogessvedysp^eo o^d ve'c|ococs es co^o depo| ec|scgges| c|e
s| | o' pc ~ocoy| o|os s | ~oyp. ~o^oy ~ype||e^so^ so||e^seec c yo.^g
vo~ec o^d ~oy pese^|os g|odco ' yp|og|essvedysp^eo v |~ o po.c lyo|
p~ysco | ^d ^gs
8. Anemi a s~o. doeco^s deed ^ yoc^g, ~e^s||co| cgvo~e^ocd ^ po
| ec|s v|~ gos|o ^|es| co d seose, c~o^ c |e^o d seose, o~o g^o^cy
9. Neuromuscul ar di seases cc cde ~yopo|~ es, ce.opo|~ es, o^dd op~og
~o|c dys|.^c| o^
1 0. os|.c|o^ o| |~e trachea or upper ai rways, ~oy oesco| e, o^dv~eez
^g ~oy oe o|| oc|ed ^co||ec| y |o os|~ ~o o| C' !.~os o| | ~e cppe
o voy o^d voco co|d dys|ccc| o^ oe poss o' e e| o og es !~e |' ovvo c~e
oop~oys~ovo c~ooc|es| cpo||e|co| oos|cc| o^
1 1 . Sl eep-di sordered breathi ng sco~~o^ cooesepo|ec|s, |~ee de|'y, ocd

| ec|sv |~ c~o^ c~eo|ocd .cgd seose eovysco ^g, esy ~o~ove

~

^|sv~ ' eos eep, ~o^ ^g~eodoc~es, doy| ~e~ypeso~^o e^ce, o^d sexco
dys|ccc|o^ oe c ces|o|~e d ogcos s ' | s ~po|o^||ooo|o ^ c|o~o|oc |o~
|o~ 'y ~e~oes ocd s eep po|ces os ve os |~e po| ec| S' eep d s|.oo^ce
coc cocse|o|gce, execse ^|o eo^ce, o^dco~p o ^|so|dysp^eo
1 2. ^e o||~e ~os| co~~o^ c ^ co coc.^d.~s s|~e di fferentiation of car
di ac from pul monary dyspnea. ^o^y po| e^|s ~ove oo|~ eo| o^d .^g d s
eose, ocd |~e e o|ve co^| oc| o^ o| eoc~ ~oy oe d || cc | |o d sce^ . !~e
~po|o^ceo|o coe|c p~ysco exo~ co| oc coc^o| oe oves|o|ed .ooscoe
|c' ' y|o |~e s g^so|C, ^c cd cg oc SJ oS^go op, |o es, cgcove^ocsd s
|e^s o^ ]\'| , o^d pe p~e|o ede~o S g^s o| p.' ~o^oy ' ~ |o| o^ cc cde
20 lulOO/3ly3/OC///|c3l Cl6
^
v
cee
z g
o edcced o e~|y, ceosed .gvo .~es, od ~ype|eso~o~ce|o
pe
c.ss
o
'o|e |~o||\od pedo ede~o ~oy oe see v|~ co| pc ~oo' e,
o
d |~eyoe ~o|ovoys ~d co|veo|e||sded cod ocdys|c~c| o
'
odd | o
~ |o |~e p~ys co exo~ ~o|o~, o|evs ~pe ~eosce~e~|s ~oy oe
~e'
p|c
!~e peosexp |o|oy|ov, .'| so~ eos yoo|o ~ed ~eos.eo|o |ov
~|o|o~ A ed.c|o ~ .' , zJJ ./~ | ~dco|es oos|.c|o o~d o se ypc'
~ooy e|oogy !~e o,o so |eds|ooe ove ~ p. ~o~oy dysp~eo, o
|~ocg~ |~ee s cosdeoo eove op e go.po| ves| go|o|s ~os scgges|ed
cs ~goco~o o| o~o| oo|~ ~eos.es, './ o / l JJJ, |o d ||ee~| o|e oe
|vee~ cod oc od pc ~o~oydysp~eo !~ey ~ove ~o~ed |~ sqco~||y |~e dys
p~eo d ||ee|io| o dex , | o~d cse o cc|o|| o| l J |o d s| gc s~ oe|vee~
p.' ~ooyo~d co|d oce|oog es A < I J ~dco|eso p|oooo epc ~o~oy
e|oogy, vo.es > l J oe s.gges|veo|o cod oce|oogy oe coe|c |o oo|o
o oo~o | o,o~doocc.|o|e'.,o||e~|oc~ypecpo| e~|sco~o|pe|o~
|~s es| |o y| ||~ese poo~e|e|s oe oe g .sed

A~o|~e s ~p eoeds de po|o~e|e| s |~e bl ood pressure response to the

Valsalva maneuver. !~eo|e o pessce espo~se|o |~e\oso'vo ~o~e.ve s
ooo~o ~e |~esys|o' cod os|o cdyslc~c| o~ ,see C~op|e\, Cod oogy|
`o~o y, '~ee s o deceose ~ |~e p. seo~p |cdeod o ~o||ov g o| pc se
pessce espo~se|os|o ~g ~ C |~ s espose s o' .~|ed, p|odcc ~go
sqcoe vove espose A o~o o||e o' espo~se|o \osovo scgges|s o pc
~ooye|oogy|odysp~eo
H E M 0 P TYS I S
CAVI TATES
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lul/O/3ly3/OCll//C3l C3|0 Zl
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1 . \~e o po| e| co~p o so| o ood |~e spc|c~, | s| de|e ~ e ||~e
socce s|~e cgsoo |voys , ~e~op|ys s|od~o||~e~oc|~, ose, p~oy~x, o|
C' |oc|. !~e ~ex| s|epsoe|oqco||o|e|~eo~oc|o|o ood od|~e~co~s de
poss o e e| o og es !~e d seose p|ocesses cocs g ~e~op|ys s o||e~ cocse
|ssce~ecos s, o~d|~e ' c~gcavitates. Cov| es, cys|c c~o~ges, ooc~ ec|os s,
oo' veo oo spoce | g o c~es|xoy ~oy ~d co|e o soc|ceo| o eed g.
'||cse ~| ' |o|es scgges|o ~oe ' ~|ed d ||ee~| o , e g , voscc | sv |~ d ||cse
o' veo o ~e~o ~oge, coogc opo|~y, ~ ||o s|eos s| A | ~ocg~ o o o ~ ~g
sy~p|o~, ~e~op|yss so||e~ seco~do|y|o o oe~ ge|oogy C|osso| ~ossve
~e~op|ys ss ~os|co~~o~ ycocsed oycoce, !o, o|oo~c~ ec|os s
2. Congestive heart fai l ure o||e cocses p ~s, |o|~yspc|c~, oc|o|ey|o~ s y
ooodyspc|c~ ^|o' s|eoss sspec | co ' yossoco|ed v|~ ~e~op|ys s, oe'y,
~ |o |egcg |o|o ~oy cocseexpec|oo|o~ o|||oso ood
3 . seoses o| |~e ai rways o||e cocse ~e~opjs s, v |~ ||oc~eoo|o~c~ | sos
|~e ~os| co~~o cocseo| o ood| ged spc|c~. C~|o co voy ~| o~~o| o~
eods|oooc~ ec|os s, v~ c~co~~o~ ycocses ~e~opjs s
4. Vascul itides, scc~os\egees g|o~co~o|oss oCoodpos|ces d seose,
oeo||e~ c~ooc|ezed oy|eve|, occ|e ' ' ess, od evdeceo|sys|e~ c vove
~e|, o||e~ eo dys|c~c| o . A|e|ove~ocs ~o |o~o| os ~oycocse ~e~op
|yss od s~oc d oe |c ed oc| oe|oeo ops esoe|ose~
5. Ce||o i nfecti ons, scc~os!o, |cg , odooe|oo c c~gooscess, oe ~oe
se y|ococse ~e~op|ys s e~opjss ~ |~esed seoses so||e~ see~ ~ ossoc
o|o v|~cys|cocov|oy 'c~g d seose S|op~y'ococco |ec|o~ |o ov ~g
| cezo c~ooc|e s| co y cocses cs|y o o oody spc|c~ <oe' y, Serratia
marcescens c~g |ec|o cocses edd s~ spc|c~ |~o|oppeos o oody
6. Trauma |o~ |~o|occ ~ c es, ~o' o| os, pc ~ooyo|e|yco|~e|es, oe
do|oc~eo |coes~oycocsevo oo eo~oc|so|o voyoeed ~g
7. Anticoagul ati on v |~ coc~od ~o ~epo ~, oo oeed ~gd o|~es sscc~ os
|~o~oocy|ope~ o ~oy pec p|o|e o'eed g |o~ |~e esp|o|oy||oc| Ago ,
|~e pese~ceo| oood does ~o|ecesso ' y ~d co|eo ~o' g~o~cy o| spec|c
|ec| ocse| o ogy, oc| oe scsp c ocs, s ce o~| coogc' o| o co c~~oss o
occc'| eso
8. Scspec|tumors o| |~e o |voyo poec~y~o ~ s~oses o po|e~|sv |~ o
s~ov~ ~o' g~o~cy.
9. 'c ~o~oy embol i ~oy cocse| ssce |oc| o od ~e~op|ys s. <oe'y, pc
~oo|ye~oo cocsecov|o| o.
1 0. oe co|e|c | od sc ~ o|e ~e~op|ys s|o~ stomach o|o|~e|gos|o ~|es|
~o o eed ~g. `osop~o|y~geo o eed g ~oy cocse cocg~ od oe ~ s ~|e|
pe|ed os ~e~opjs s !~e p' o| ~e~opjss s csco y o so' ~e, v~ e|~o|||o~
|~es|o~oc~ soc d c
1 1 . !~e ||eo| ~e| o| ~e~op|ys s csco' y ~voves oosevo| o od pe~ops
~o ~|o ~ ~g |~e oeed g socce ~ |~e depede~|pos | o | |~e ~e~op|ys s s
ZZ lul/O/3ly3/OC//l|C3l C3l0
oss ve , oo | o y de| ^ed os > oJJ ~ /z^ ~oc|s| , ^|coo| o^ v |~ o doco' e
cece^do||oc~eo' |coe so||e^ eqc ed, v |~ o^ o||e~p||oso o|e|~e ~e~o|
|~og ^g ' c^g o^d peve^| so ^g o| |~e oo^o' eed ^g ' c^g !~e socce o|
ossve oeed ^g s csco y|~e oo^c~ o o|e o sys|e~, o^d ~e~os|os s ~oy
oeoo|o^ed oo^c~oscop co 'y, scg co y, o|oy ^vosve |od o' og cp|ocedc|e
1 2. Aoeco~pe~e^sve ' s|o|cocseso|~e~op|yss soc|' ^ed oe'ov
TRAC
H EAL
t.. . . . t.. . t... . . t . .
. .,. ....
+.
. .. .,. ., s... +. /. .
... . . .. , +.....

.
..,.
:. .. ,,: , ... .,
.., . . :. ./.. .. .
c..c. .. .. . , . . ... .

c..
...
+. +. . . .. .. .,
+ . . .., .. . .....
s/..,.. ...,. . s .
. .,.. . s . . .
:. .... .. :. . ./..... . .
:,
. .,..... .... . ,. . . .. .
. . .,. , ,... .
Also. penicillamine and arterial bronchial fistula
S T R I D O R
WE TRACH OR TR EAT
u,

.
s , .. . ./..., .. . .
lu/OO/3ly3/OCl///C3/ C3l0 ZJ
t. . .
s .. , , . .
:. .. ,,
c. ... ...... . . ..
+ .. , . .. . . ...
v. .
e.... . ., .../ ,. ..
s

.., . ./s. .. . , ... . .

t../t...,
s . .
t. /. ., ..,. .
:, . .
t... ... ... .
WH E E Z I N G
ASTH MA
:.. .
s. . ..,. ...
t.. .... / . ,. ..,. ...
+. .. .
v...,.. ./.
:., . ./: ,,
"..
1 . A ' |~o|v~eezes s ^o|os|~~o ,s' e| !~e~^e~oc cAS!^A e~p~o
s zes|~e maior cocses o| v~eez ^g \~eez cg scocsed oyo |voy ^o||ov
^g. !~e ^oov ^g ~oy oe c |~e cppe|o |voy , e g. , ' oycgeo |c~os, voco'
co|ddys|c^c| o^| , |~e ogeo |voys , e. g. , ' ccgco^ce|, osp o|ed|o|e gcoody| ,
o |~e s~o' ' o |voys , e. g , oocc~ o | s, os|~ ~o| \~e^ |~ee s cppe|o |voy
co~p|o~ se, |~ev~eez ^g soc^d s~eod oes|ove| |~e|oc~eo ocd s|e|eed
24 lulOO/3(3/OCl/l/C3l C3/0
|o
os
stridor. :x|opc' ~o^o yd sode|s o so ~oycocse oo^c~oc
^s|| c| o^
ocd
v~eez ^g .xo~p' es ^c' cdeede~o ||o~ C, o^op~y ox
/o' ' egy,
oc
d
podcc| o^ o| oo^c~oco^s| c| ^gscos|o^ces os occcs ^ |~e
coc ^o d
syc
do~eo^d ~os|ocy|os s.
2.
Asthma so co~~o^ cocseo| v~eez ^g o^ds~oc d oescspe
|ed v~ec
c~
ooc|e| s| c ~ s|oy, pc ~o^o|y |c ^c| oc |es|s, o^d espocse|o| ~
opy o|e
see^ \~e^ c^csco' |eo|c|esoe eccoc^|eed, co^sde|o|~ecocses
o|v~eez
cg
Ce|o ^os|~~o| cs ~oy oe o| ~ g~ ss|o esp o|o|y |o ce oc
d
deo|~ . A
cc~
oe|o||oc|os scgges| |~o|os|~~o s sevee ocd |~o|c ose|o'
vcpo^d
pe~ops ~oe c|e^sve|~eopyocdedcco|o^oe ^ecessoy.
'ov socoecoco~ cs|o|cs
^oe |~oc |vo~osp|o zo|ocspeyeo
A ~ s|o|yo| ^|coo|o^
g~ ^c~oeo|os|~~o ~ed co|o^s
S g^|coc|d c|^o vo o| o^so|> JJ7c~ocgepedoy co |
o
v
`oc|cco os|~~o
g~o~oc^|o|oe|oogoc s|cse, ~oe|~o^|vo co^ s|e|spe|
oc|~|
Assoco|ed psyc~o|cd seose

|~e||oc|o|s ^c' cd ^goge, degeeo|oos|cc|oc , ocd |oceo soco

\
oe s g^ |
co^| cdco|oso|~ g~ ssos|~~o
3 . Smal l ai rways di seases oe o g|ocpo| pooy ccdes|ood ec| |
es d s| ^c|
||o~ os|~~o. As |~e co~e cd co|es, |~ey cocse coov cg ocd ooz
|cc| o^ o|
|~es~o o voys o^d cocseqce^|v~eez ^g. A eo|veyco~~oc p
ys co ex
o~ co| o^ | ^d cg s o^ e^d ^sp o|oy sqceos, v~c~ poooo' yc
O
espo^ds
|oo|eope^ ^g o|d s|o o voys
4. Tracheal di sease and l arge ai rway obstruction .s.o' ycocses||
o|, v~ c~
~oyoed || cc' || od ||eec|o|e||o~v~eez cg Jppeo voy es ocs
ocoede
|ec|ed oy p~ysco exo~ co| o^ ,s||doove| |~e cppeo voys| oc~
oc|e s| c
| ovvo c~e'oops. A po| cc oyco~~oc cocseo|.ppeo |voyv
eez cg s
voco'coddys|c^c| o^ !~ese po| e^|s,o||e^yoc^g vo~e^, jp co' ' y
ove exe|
|o^o o| e~o| oco y ^dcced v~eez^g o^d s~o|cesso| oeo|~ v~
~ ~oyoe
seve|e.C~o|oc|e|s|co y, |~ev~eezcg occcs v|~ cs,o|oc !~e|Q
vvo' c~e
oop ~oy s~ovvo| oo
(
y ^ |~e ^sp |o|oyp~ose !~ese po|ec|so||q
c oe~ s
d ogcosed ocd |eo|ed ~popey ,o||ec v |~ s|eods| os |e||oc|oy
s|~~o| cs
Speec~ |~eopy o^d edcco|oco|e~e' p|c
5. .x||opc' ~o^oyd sodesco^cocseo|occ~oco+s|c| o^ Heart f
i '
u
r
e
~oy
oe ~ode ~oc |es| oy v~eez ^g o | ~oyexoceco|e co~o yqc
sceo| o
voys ~ype|eoc|v|y c ce|o c po| e^|s A |ev cccsco d seoses ( ma
tocytosi s,
carci noi d syndrome) co^ p|odcce ~ s|o~ ^ cco~occds |~o|cocs
os

, ~y
po|ecs o^, ocdv~eez ^g Co|c co d|c~osco^coasev~eez ^goy
(
vo ~ec~
oc s~s , I | o voyoos|cc|o^ oy o oocc~ o co|c ~od, o^d , z| p|
dcc| o^ o|
o AA, o o|occ~ococs| c|o|, v~ c~ csco ' yo^y coases v~eez cg
v~e^|~e
|c~o ^vo'ves |~e ve, seeC~op|e|\ , :cdoc co ogy, |~eCo|c ^o d
sec|

o^| .
6. Anaphyl axis and al lergy co^cocseoo^c~ospos+o^dv~eez ^
g. | s c |
co' |o dec||ye^v o^~e^|o pec p |o^|s o|v~eez ~g, os scc~ s^ov
' edgeco^
oe |esov ^g. Avo docceo|pec p |o^|s oovo|es |~e ceed |o~ed c
| o^
_

lulOOn3(3/OC///C3l
3l0 Z

7. 'c ~oco|y |ccc| oc |es|s o|e essec| o' c |~ed ogco

_
so| o voyoos|cc| oc
ocdossess cg|~eespocse|o |~eopy ' cspec||~e|' ovvo c~e'oopv |~oo|~ c
sp |o|o|yocdexp |o|o|y' ~os|oevdecceo|o o|geo |voyoos||cc| oc o|o c
ccg vo' c~e~eosc|e~ec|s ocoos|cc|ve ccg d seos s~oc' d s~ov co|~o o|
cc|eosed ' ccgvo' c~es !~ecocossess~ec|o| s ~p' sp |o~e|y , '.\I , '\Cl
de|e ~ ces |oos|cc|oc s p|esec| ccosoco y, o p|ovoco|ve|es||o os|~~o
; ceeded , e , ~e|~oc~o cec~o' ' ecge |es|l v~ec |~ed ogcos ss ccce|o c
8 . oe'ov s o ~oeco~pe~ecsve s|o||~ecocseso| v~eez cg
THE ASTH MATI CS
t ..
+, .. . . .,. . .
t. ...
:.. .
s. . ..,. ...
t.. .... / . ,. ..,. ...
+. .. .
v...,.. ./.
:., . ./ : ,,
t .
. / . .
c,.. . ./ ... .
s ,/-
26 lu/OO/3/y3/OC////C3/ C3/0
Cl inical Conditions or Diagnoses
AC U T E R E S P I R ATO R Y
D I S T R E S S SY N D R O M E
D I F F U S E P U L M O N A R Y
I N F I LT R AT E S
ARDS
:....
+.. -., , 200
a .. . ..
s.. :..,* 1 8 -,
"..
I . !~ec' ^ co' de| c | oco|A<S s , l | acute onset, , z| ratio (Pa02/Fi02) o|
zJJ o| 'ess ,ego|d'esso| '::'eve l , , Jl di ffuse, bi lateral i nfi ltrates oc ||oc|o'
c~es|xoy, ,^| Swan-Ganz wedge p|essce l o ~~g o o c' co' ev
de^ceo| e|o| o' ~ype||e^s oc .

2. !~e deve'op~ec|o|d ||cse pc ~ocoy c| |o|es ~oy op d' yeod |o |espo

|oy|o ' ce ecdev~e|~e|~ee|oogyssecocdoy|oco^ges|ve ~eo||o ' ce
o| dce|o cop ' ' oy ' eo Cop ' oy ' eos ' eods |o |~e occ|e esp |o|oyd s||ess
sycdo~e ||cse pc' ~o^oy c| |o|es ~oy oe co~posed o| o^y o||~e pev
ocs y~e^| oede| o ogesc^depc' ~o^oy ^| '||o|e,see p|evocssec| ocl
3 . oo|~ cocges|ve~eo||o ceocdcop ' o|yeosy^d|o~escocse| c d|o occc
~co|e c |~eo veo' o spoce, oc| |~e p~yso'og c ~ec~o^ s~soe d ||ee^| .e|
~eo|||o ' cecocseso^ ^c|eose ^cop ' ' oy~ydos|o|cpessce, o^d | c d sex||cded
|o |~e oveo , v~ eA<Socccssecocdo|y|o o cop ' ' oy ' eop~e^o~ecoc,
c v~ c~| c dex||ovoso|es ^|o |~eo'veo !~e p~ys co' exo~ co| oc c o po| ec|
c|esp |o|oyd s||esso|v~o so' eodyo o vec|' o|o ~oyoe' ~|ed, od o|~e
d og^os|c|es|s ~oyoe^eeded|o ^d co|e|~e co|c|eo||~epc ~ocoy c| '|o|es
!vo cse|c |es|s o|e |~e echocardi ogr am, v~ c~ coc gve o^ ossess~e^|o|
ove|o g' ooo' co|d oc|c^c| oos ve'' os pc ~oco|ypessc|es
.
ocdpul monary
lu/OO/3/y3/O C////C3/C3/0 27
artery catheterization ,Svo^Co^z| A' |ocg ~o^y po|ees ~oyoe ~eo
sc|edv | |e Svo^Cozco|e|e, |e ~os| ~po||oa| n H ||ee^| o| ^g oe
|veecco|d ogec c pc o^oyede~o o^d ^o^cod oge pu' ~o^o|y ede~o
oe | evedge p|essueo^d pc' ~o^oy d os|o cp|essc|s . o cod oge^ cpc'
~o^oy ede~o, oo||aevedgeo^d A d os|o coee'vo|d |yp co' ' y > zJ
~~g ' ^ ^o^cod oge+ c pc' ~oco|y ede~o, |e pc y cop ' ' o|yvedge
p|essc|e scsco' 'y < 2J~~g
4. !e|eopyo| A<'S sscppo| ve,v |spec o' e~pas| s cc de^| |y ^go^d
|eo| cg|ecocse. !eeos oee^ o g|eo|deo' o| ^|eesr o sIe|od |eopy |o|
A<'S, o^d cc|e^|do|oscgges|s o o e l z veess o|e c^se|, dc ^g |eso
co ' ed | o|op|o' |eo| vepaose ^os| s|cd es ove sow~ o so' c|oy e||ec| o|
s|e|o dsve^ |eyve|es|o|ed eoy ^ |ecoc|seo| AS. 'u||e s|cdes oe
ceeded|o co^| ~ oece| | o|e ^ |e coc|se
5. |ee so ~oeco~|ee^s ve ~^e~o^ c|o|ecoaszso| /<S.
CARDS? H OPE I T' S NOT ARDS
CNo . .
a. .. . . ,,...
a. ..
a.,. . ..... .
s/. ,. . . ..
+,.. /.
O .,
-... . .
t . . ,.. . .
. /.. .
t. . .. ..
s .,, . . ,. .
s. . ,
e... . , . , . . . -- -
t . , . ,/. .
: . ... ..
s. . .
a . . ...... . .,. ..
s,.. ...,. .....
Zo lu/OO/3/y3/OCllllc3l C3/0
AC U T E R E S P I R ATO R Y
FA I L U R E
A P E H I T I NTU BATE D
:. ..
" White " X-Rays
-..
s.
+ .,
. ,
t.
"Black " X-Rays
. . ,. ..
s. , ... .,. . .. . .
:. . -.
t. . . .
e . ..,.... .., . . ,,
.. ..
s ... -... ... .
:,. .
t..
s .. . .,. . . . . .
a ..,.. .. .. ..,,/.. .. . ,
...
"..
1 . ! s ~ce~oc c cd co|es |e ~o ococseso|occ|e esp o|o|y|o ce !~e
| s| po| o||e ~ce~oc c, A .'!, ^dco|es |~eso~e pocesses cocs cg pc
~o^oy c| |o|es !~ese pocesses eod|oopoc|co|o^soc |e c~es|xoy !~e
seco^d o | o|| ~e ~^e~o^ c, ' '!JoA!:', cd co|ese| o' og es c v c| e
c~es|x|oyo||ec does ^o| s~ovocy c| ' |o|es. ' c|~esee^| | es, o spoce d s
eose s ^o| |e cocseo| |esp o|oy|o ' ce, o^dyoc ~cs|cocs deo|ecocses
o| ~ypoxe~ o , e g , ceco og c ~po ~ec| eod cg|o ~ypevec| o| oc , |ecs oc
lulOO/3ly3/OCl///C3l C3l0 Zd
pceco|~o|ox
.
cppeocd veo |voy os|ccc
.
ocd vosc. o|oos||cc| oc|
!ee|oe, ocoocvoy|o dvdecp|ecocses .|occ|eesp o|cy|o ce s oy
|ose |~o|~ove v~ |exoys ,opoc | conccs| ocd|ose|~o|~ove o ocx|oys
,c' eo ' ccg| e' ds| .
2. !ee oe s xp oy e~o+ sso| nypoxeo.
'ov csp ed ||oc|oc |ogec,
yovec| 'o|oc
scc osocccso| ~ g~ o'||ode
'|asoc po |en|
\/C so|c~
.ov xedvecoas oxygec
Scc|
| |ese cocses
. | ~e os| ~po|oc | cnes oe\/C + so|c n, sc c| , ocd
ypovec| ' o| oc
3 . !e cdco|ocs|o|eeQec|ecdo|ocn
eo c|.bo| oco|e
ypoxe c esp o|oy |o o|e , p_ < J rmHg oc > `7 oxygec|
ypecoo c|esp o|o|o ' ce ,|esj o|oycc dos sv|~o pH < ` J|
A voy p|o|ec|oc
cceos cg c|oc|oc o' p|essce
B R O N C H I E C TAS I S
A SI CK AI RWA Y
: ..,/ . / ... ...
s,.....
. ,. ,. .. . ,
., . . -.. .
c,.. . .
s. ..,

.., ,.
-. . . ,., .
:
, . . ,.. , . .( ABPA)
. / ... . , ... . . .... .
. ,., .,..... ...
s . .. .. /s.. , . , . ,..
. ..
w ... . -.. , . . ....
, . . . v.. .h
: . .. .,. . ,
- .. .,. ., C .,
J lu/OO/3ly3/OCll//C3/ L@l0
"..
1 . o|occ~ ec|os s, o d o| o^o||~eo voys, scsco yo esc' |o|co^ ce^do
oo^c o ^| o~~o|oc
2. e~op|ys s ~oy oeo |eqcec||eo|ceo|co^ co|occ~ ec|os s.
3 . oo^c~ ec|os s eods|o d o| o^o|oo^c~ o o||e es o^d ^ceosed o ood
|ov, v~ c~ ped sposespo|e^|s|ooeed cg
4. 'y oocc~ ec|os s e|e|s |o pedo~ ^oc| ycppe ooed seose , e , sec
o^doy|o !o o ~ s|op os~os sl , v~ c csco' y d|o ^s e||ec| ve y

!~e cod co'

sy~p|o~ s e~op|ys s \e| o|occ~ ec|os s |e|es | o' ove| ooe d seose,
v~ c~ sc~ooc|ezed oyc~|o^ ccocg~o^d pcc e^|spc|c~. :xcep|o^s|o | s
ocg~ c oss | co| o^ cc cdecys|c | o|os s, v c~ ~os po~ ce^| cppe' ooed s
eoseo^d|~ c, |e^ococssec|e| o^s
5. A|ev d seosesco~~ocycocseoo^c~ ec|ossv |~oc cppe| ooepedo~
^o^ce !~ese coc oe |e~e~oeed oy |~e ~^e~o^ c 'ACT , ' c^g , AoA,
Cys|c| oos s, !o|
6. A voy ' es o^s cc cde|c~o|s , oec g^o^d ~o' gcoc|| , |o|e gc oody osp |o
|o^ , od oo^c~o ' s !~ese o voy es os ~oy cocsec~o^ co|e'ec|ossocd,
c | ~o|e'y, o|occ~ec|os s
CAV I TA R Y A N D CY S T I C
L U N G D I S E AS E
WE I RD H OLES
u,

.
s . .,..
. ,

... Pneumocvstis carinii, TB)

+ ... . . . . . . .
a. . . ,... , .,.....
+ .. ,.. .
e , ., ...... .
.... . ,.( LAM)
s . .. /... . . . . . ...
s. . .
lulOO/3ly3/OC///C3/ C3l0 M Jl
"..
1 . !ep|ese~ceo|cov|eso|cys|ccogeso~|eces|xoy ~oyoecocsed
oy ~ec|o| z ~g p|ocesses scc~ os ~|ec| o~s, voscc' | des, ~|oc|o ||o~ e~oo ,
o ~o g~o~cy A' soco~s de|ce||o ~ deve' op~e~|o' o~o~o es, occcpo| o~o'
exposc|es, o~d c~csco p ~oy ' c~g d seoses.
2. 'c ~oo|y cov | es p ~o| y |esc' | ||o~ s x sec| os o| |~e "McD| C' Mc
DCC ~~e~o~ c , l j | ~|ec| ocs, ' z, Coge~ |o , , J| ' ~~c~o' og c, , ^| Meo
p'os|c, , o| cxo| c, ,| Ccccpo| o~o /e~v o~e~|o exposces
3 . I nfecti ous etiol ogies ~c cde ~ycoooc|e o' d seose, |c~go d seose, ~ec|o
| z ~g ooc|e| o ~|ec| o~s, po|os | c ~|ec| o~s, o~d sep| c pc ~o~o|y e~oo'
!coeccocscov|es|ypco yoccc| +|ecppe|'ooes, oc|co~ p|ese~| ~ o~y 'o
co| o~ !~eyoe po|o| o c~o~ cd seose p|ocess, so p| o|| ~so|e ~e p|c' ~
o~oyz ~g |e pogess o~ o| |e d seose ~ |~eoose~ceo| scpe ~|ec| o~, o
| c d 'eve's o|e c~co~~o~ ~ |coe|ca ocs cov | es Spc|c~ o~o'ys so||e~ s pos
|ve ~ oc|vecov|o|y|coecc os s, os|~eogo~ s~ ' ood s eo|vey gv |~ ~
|~ecov |y c~go d seoses, scc~ os cocc d o~ycos s, o' os|o~ycos s, o~d~ s|o
p os~os s, o soco~ podccecov | es
Aspe|g oss ~oycocse o~occ|e ~eco| z ~g p~ec~o~ o ~ ~~c~oco~p|o
~ sed po|e~|s, o| | ~oycoo~ ze peexs| ~gcov | es, p|odcc ~gov s o e|c~go'
oo' o~c~es| odogopy. oecocse vosveospeg ' os scooc|e|s|co y ~vo'ves
o ood vesse s, |~o~oos s, ~|oc| o~, odcov|y|o~o| o~o||e~ e~sce. !e co
oc|es|ccesce~| s g~ s podcced oy ~|oc|ed | sscev |~ |~e |c~go cov |y
\ ||co' 'y o ' ooc|e| o ~|ec| o~s co~ cocseo p~ec~o~ o |o| ~oy p|odcce
cov |oy ' c~gco~ges Cov |oy cc~gesoe ~oe |yp co' o| o~oe|ooeso~d
go~~ego| ve o|go~ s~s oveve, Staphylococcus aureus, Streptococcus
pneumonia, o~d 'eg o~e o spec eso co~ p|odcce cov||o|y' c~g co~ges A
|o|e co~p' co| o o| ooc|e o p~ec~o~ o s pc ~o~oy go~g|e~e !~e|od o
og coppeoo~ce co~ oec~o|oc|es|c, v |~ ~|oc|ed c~g| ssce|oo| ~gv | ~
o po|e~cy~o' cov |y Scgeyo||e~ s |eqc ed |oeso' c| o~
'o|os | c ~|ec| o~s soc d oe scspec|ed ~ d v dco sv |~ oppop o|e
||ove od exposc|e ~ s|oy o|ogo ~ os s s seco~doy |o o ve |' ce o~d s
e~de~ c| oSoc|~eos|As o :c~ ococccs sossoco|edv |exposce| os~eep,
dogs, o|v d os|s scc osco| ooco| |e ~dee A cooc|e|s|c |od o og cop
peoo~ce, |~e vo|e| 'y s g~, s p|odccedv~e~ |~e e~cys|ed ogo~ s~s ~e~
o|oesde|oc|o~|~eodve~| | oo~d|' oo|v |~ ~o cov |y
' ~o' y, sep|c pc' ~o~oye~oo ~os|co~~o~' yoccc|os o |esc |o|| ccsp d
e~docod | s oo pe peo socce ^c' | p ecov |o y es o~s ~oyoe pese~|,
o||e~ ~ |~e ove c~g zo~esvee|~eo oodscpp y sg|eo|e|.
4. Co~ge~ |o' o~o~o es ~c cdedevelopmental cysts ,e g. , o|o~coge~ cj os
ve' os pc' ~o~oyseqces||o| o~, o~ds~oc' d oe scsoec|ed ~ yoc~g odc'|s p|e
se| ~gv | osy~p|o~o| ccov |oy' c~g ' es o~s
5. ~~c~o og c pocesses ~c cde|~e voscc d | es o~d |ec~o|o d o| | | s.
Wegener's granulomatosi s s|~e~os|co~~o~ ~~c~oog cd seose|~o|p|ese~|s
oZ lu/OO/3(3/OCll/lC3/ C3l0
M

v | pc' ~o~o|ycov | es Rheumatoid arthri ti s co~ cocse ' c~g ~odc' es |~o||eo
| ce ce~||o ~ecos s o~d eve~|co y cov |o|e A~sy os ~g spo~dy' | s o~d
poy~yos|so' so~oy|eo|ceop co' oc' ' ocsd seose
6. Oncologi c pocessesco~ podccecov|esoy|vo ~ec~o~ s~s , l j oos|cc
| o~o|o oo~c~csv|~d s|o scppco|ve ~|ec| o~, o|, 2| cov|o|o~o| |e|c~o|
~ossseco~do|y|o oc|g|ov ~go||~e o'ood scpp'y Sqco~ocsce' ' co|c ~o~os
~ove o po|| cc o| p|ope~s |y |o oc|gov | ~e o' ood scpp'y o~d cov|o|e
A~g oce~| c ' y~po~o , y~p~o~o|o d g| o~c' o~o|os sl s o~ c~csco' ~o' g
~o~cy|o|co~cocse ~c' | p' e c~g ~ossesv c ~oycov|o|e
7. :xo|cd seosescocs ~gcys|s ~c cdehi stiocytosi s X, JM, o~d sarcoi dosi s.
Yoc~gepo|e~|svop|ese~|v|~c'|pe' c~gcys|ssocdb scspec|edo|ov ~g
|~esed seoses. s|ocy|oss/, o' soco''edeos ~op cg|o~c o~o, so d seose
o|s~ose|s l s eo|ed |o|coeocssc'eosso~docccs ~ yoc~g|e~o es
8. Envi ronmental or occupational exposures ~oy'eod|ocys|c ' c~g d seose
A co~~o~ occcpo| o~o' cocse o| cys|c c~g d seose ss cos s, v c occcs
~ ~od ocs~ ~es A'so, o|e'y, ~c' | p e|oc~opo|e~|sdeve' opocc|ecov|o|y
' c~g d seose o| c~ce|o ~e| o ogy '|esc~oo'y, |e |oc~o eods |o voscc' o|
~ c|y, esc | ~g ~| ~ecov|oyco~gesocxoy.
9. As v|~ ~os| |espo|o|yp|oo' e~s, embol i o|e o poss o' e, o' oe |o|e, cocse
o| cys|c o cov |oyc~o~ges oo|~ pc ~o~oy o~d sep|c e~oo' co~ cocse
~ec|oss, ~|oc| o~, o~dscoseqce~|cov|o| o~ .
I N T E R S T I T I A L L U N G
D I S E AS E
I S I T I P F?
-
s. . .
. .. . . ..
t... .. , .. . . ..
..,
. , .,.... . ....
-.. ..., , . ARDS)
-. .
lulOO/3/y3/OC/lllC3l C3/0 JJ
"..
! . !e cg ~|es|| c~s |eoeo oe|vee~ |egosexco~g ~go' veo oep |e
c~o~d |e cop ' ' oy ~e~oo~e 'o|~o 'y | s spoce s vey | ~o~d o' 'ovs
|oe||ec|vegosexco~ge \e~ d seoses o |ox~s do~oge |e .''| c~, |
~oy oeco~e | ' |o|ed v| ~| o~~o|o|yce ' so~d, c' | ~o|e'y, sco| s:ce !ese
~|e|s| | o ' c~g d seoses podcce o~ ~po ~e~| ~ |ed ||cs o~ o| oxyge~ o~d
eod| o esp o| o| ysy~p|o~o|o' ogy !eces| |od ogop cooc|e| s| co y
sovs vo| s o||e~ co' ' edo e| cc' oo ' ~eopo||e~ o| ~| '|o| o~ .
!e |e|~ d ||cse poe~cy~o ' c~g d seose ~oy oe ~o|e opp|op o|e
s ~ce |ese d seoses ~oy ~vo've |e o |voys o~do spoces ~ odd | o~ |o |e
~|e|s|| c~. !e ~~e~o~ c I S IT ' '-sc~~o zes |e p| ~o|ycocses o| ~|e|
s| | o' d seose
2 . ~e o| |e ~os|co~~o~'y e~coc~|e|ed ~|es| | o ' c~gd seoses s d o
po| c pc ~o~o| y | o|os s, | H| Sarcoi dosi s s o so ve|y co~~o~ o~d os
~y|odsys|e~ c~o~ |es|o| o~s I mmunol ogic/col l agen-vascul ar di seases ove
ve''desc| oed sys|e~ c|eo|c|eso~dpc' ~o~oy ~vo ve~e~|. 'c~g d seose soc
cos o~o ' y |e | o' | ~d ~g ~ po| e~|s v | co' ' oge~voscc o| d seoses
Treatment-related cocses ~cs| oe coe|c' ' yco~s de|ed s ~ce e~ovo' o||e o|
|e~d ~g oge~| s c| | co' Aco~p e|e occcpo| o~o' o~d e~v |o~~e~|o' s|oy s
~o~do|o|y| oexc' cde i nhal ati onal l ung di sease. Avo do~ceo|| e ~c | ~g
oge~| s ~o~do|o|y|o|e po| e~|, o~do|e pe|so~so| ss~oyoe de~|||ed
c' ~o~o|y ~|ec| o~s, A<'S, o~do|e|' c~g ~ c es ~oy esc'| ~post-i nfl amma
tory | o|oss o~d pe|~o~e~| poe~cy~o' co~ges ' ~o' 'y, o ~c~oeo|c~csco
fami l i al d seoses oveossoco|ed ~|es| | o ' c~gd seose
3 . !e s|oyodc' ~ co' exo~ ~o| o~ so~e|~es scgges| o~ e|o'ogy|o| ~|e|
s| | o' d seose, s0coso~exposce o o~ c~de' y ~gd seose !e ces| |od o
gop ~oy sovcooc|e s| cpo||e|~sv c ~oyo' soscgges|o~e| o ogy. 'o|
exo~p' e, ce|o d seoses ~o|e co~~o~'y ovepedo~ ~o~|' y upper l obe ~
vo ve~e~|, ~c' cd ~gA~y os ~g spo~dy | s, PI E , c|o~ ceos ~op ' c p~ec~o
~ o| , | ~|ec| o~s , !H, s|op os~os sj , Coo vo|se|s p~ec~oco~ os s/s cos s,
cos ~op cg o~0' o~o, s| ocy|os s/ , o~d5oco dos s/oe|y' ' os s, AH'Cc5j
Ap|edo~ ~o~| ylower lobe po||e~o| d seose ssee~ ~osoes|os s, o'veo'o|p|o
|e ~os s, ', co' ' oge~voscc o|d seoses, o~dc|o~ cype|se~s|v|yp~ec~o~ | s
`odces scgges| soco dos s, Vege~e|s, | ~o o| o~o exposces , p~ec~oco
~ oses| , |ec~o|o do|| | s, o|y~po~o|odg|o~c' o~o|oss, 5V' k'j !epes
e~ce o| pl eural di sease s c~csco' ~ ~|e|s||o' ' c~g d seose, oc| ~oyb see~ ~
osoes|os s, 'y~pO~g | cco|c ~o~o|oss, o~dco''oge~voscc' od seoses. 'o~o'
o ~ceosed ' cgvo' c~eso~d cys|c co~ges o|e see~ ~ o~' yo |ev d seoses
' ~o' 'y, lymphadenopathy so' soc~csco ~ ~|es| | o' c~g d seose o~d ~oy ~
d co|esoco dos s, o~y' o dos s, 'y~po~g | cco|c ~o~o|oss, o|oey' ' os s
4. ' ||cse poe~cy~o ' c~g d seose~os|o||e~ eods|o ~c|eosed c~g e os| c
|yo~do |edcc| o ~ ' c~gvo' c~es Hc' ~o~o|y |c~c| o~|es|s csco 'y |eveo o e
s| c| veve~| ' o|o|yde|ec| ccos o~o' y ~|es| | o' d seose s see~ ~o po| e~|
34 lu/OO/3/y3/OC/l/lC3/ C3/0
v | normal or i ncreased ' Jng vol umes, o~d | s ~o|ovs |e d ||e|e~| o co~
s de|oo y. !ecocses o| ~|e|s| | o' ' c~g d seosev | ~o~o' o ~ceosed ' c~g
vo' c~esoe sc~~ozed oy|e ~~e~o~ c|cT'5 BkCMC. L, cos ~op c
g|o~c o~o, s| ocy|os sXL To c ~ ec| o~ , ~|ove~ocsd|cgoocse| , 5o|co dos s,
B|o~c ec|o|c d seoses , e g , cys| c| oos sj , kesp o|oy o|o~c o | s, Co |e
o|veoo~c o | s, Meco|oo~o|oss, C+ ., ypese~s | v |y p~ec~o~ | s.
, ! s ~~e~o~ c sodop|ed |o~o~e ~ve~|ed oy<ooe|Sp ~e, ^ l ' ~co~
|os||oo|ecocseso| ~|es| | o c~g d seose, |esed seoses|eo|c|eoos|cc|o~
o~ pc ~o~o|y |c~c| o~ |es|s :xcep| o~s oe ypese~s | v |y p~ec~o~ | so~d
eos ~op c go~c' o~o, v c~os|o||e~ sov es| c| o~ o~ pc' ~o~oy|c~c
|o~ |es| ~gdesp|e ~o|~o o| ~ceosed ' J~gvo' c~es.
5. !e|eo|eoppox ~o|e'y I oJ ~ov~ ~dv dco d seoses|o|~oyoeossoc
o|ed v| ~|es| | o' c~g d seose !e ~os| ||eqce~|' ye~coc~|e|ed oe '', so|
co dos s, o~d ~|e|s||o c~gd seoseossoc o|edv|co oge~voscc o|d seoses
!e |o' ' ov ~g ~~e~o~ c' s|s ~o~yo||e cocseso| ~|e|s| | o' c~gd seose
I HAVE BRONCH E D A N I NTE RSTI TI AL
L U N G
.. ., . . -
+ . .,-. ..,
:RDS .,
. . . ...
t ..., . ...
s . ,. . ... .
s .. . . . ... .,.... .
....
e,. . ,. ... ... . /
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s . - .:.. . . ...
c,.. ....
+ ,. .,
t . ., .... - .,.
a ,. . , . . , .. . .
. .,
:, . .
s ... ,., . . -... . ... ..
. . ,
ulOO/3/y3/O C//llC3l C3/0 35
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3/O Cl/l/C3/ {3/0
:,.. .. . .,
., .,.
: .. ..
s. ... . ,
v...... ...
s . ./.. . ,... .
"..
1 . ceo||e~os|co~~oc d so|de|s o||e ~ed os| cc~ so ~oss !e| s|
s|ep c evo' co| oc s|o de|e|~ ce |eco~po||~ec| o||e ~ed os| cc~ c v c
|e~oss s oco|ed oc|e o, ~ dd e, o pos|e| o !e~os|co~~oc anteri or
masses o|e| e^ !s |y~oco, |yod ~oss, |e|o|o~o, |e| o e ' y~po~o. !e
~os|co~~oc mi ddl e masses oe voscc o| ~osses, y~p codeec oge~ec|s,
o cys|s , pe cod o , ooccogec c| Posteri or masses cc' cde cec|ogec c
|c~os, o|o' e|c os, o| esopogeo' d ve|| cc'
2. AC! scoc, |o''oved oyo opsyvec opp|op o|e, s|e csco oppooc |o
d ogcos s.
3 . Cocses o|o ~ed os| co' ~oss, oyco~po|| ~ec| , o|e sc~~o| zed oy |e
~ce~oc c oe'ov !ee sso~eoveop c|eco|ego|es osso~eec| | escoc
oe|occd c ~o|e|oc oce ~ed os| co co~po||~ec|
N E RVES AND CH EST PARTS
Posterior Mediastinum
s , . .
s..,. .,. ..
s. ... . ,
... . , . ,.. .,.
s. . .,... ./. . .
s .. /. . , ... ..,.
,

Middle Mediastinum
: .. .. ...
s.
a .... .
lu/OO/3ly3/OCl///C3/
C3/0
J/
c,... . . ,
+... , .. .,, ..
s ., .,. . .
s.. ... .
t ...... . ,
Anterior Mediastinum
-... , ...
:. . .,.
s ,. .. . .,.
t. .... .,. ., . ,.
s .. .......
P L E U R A L E F F U S I O N
P E H I T? DE CU B, TAP
- .
s.
+ .,
,
t
a . ,. . ..
s ..,. - ....
c,
e
s
t. . . .. . .
:. ..
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Jo lu/OO/3ly3/OCl//lC3l C3/0
-
"..
1 . !ee oe ~o^y d ||e|e^| |ypes o| |' c d |o| ~oyec|e||e p ec|o' spoce
S ~ 'o| |o pc' ~o^o|y ^| ||o|es, p ec|o |' c d ~oy cocss|o| pus, edema, hemor
rhage, i mmunol ogi c reacti ons, o tumor cel l s , '. ' ! !eseo|e|e~o o|
cocseso||' c d ^| ep' ec|o' spoce. oveve, o|e||ypeso' so~oygo ^occess,
sccosdi alysis fl ui d, ^| o~~o|oy|' c d|o~o |cp|cedesophagus, chyle ||o~
c c|y|o |e |oocc dcc|, uri ne, bi l e, total parenteral nutrition (TPN) , ascitic
fl ui d, o| pancreati c fl ui d , .CUH!A'l !e|eeve^ ove oee^ coses o|CS|
, p' ecodc|o | s|c' ol ocd s|oo' ,|eco|ooxl ^ |e p ec|o' spoce As v | pc|
~o^oy ^| '|o|es, pc ~oco|ye~oo s~~cs|oeco^s de|ed ^|ed ||ee^| o d
ogcosso|o p' ec|o e||cs oc
2. \ec o p ec|o e||cs o^ sd scove|ed, decco|cs| ~ssoc d oe oo|o ^ed |o
see ||e| c d|'ovs||ee'y !o|oce^|ess soc'd |ec oe pe|o|~ed without dely
oc |eey|'ov cg| c d !o|oce^|ess s ^dco|ed ^v ||co' yo' ' ^ev'ydog^osed,
||ee|owcgp'eco'e||cs o^s .xcep|ocs|o|^ s|ce oevec |ec cco' d og^os|s
sce||o c, e g , Cl o||e|e so^yo s~o'' o~oc^|o|| c d c|e p'eco'spoce.
3 . ec|o e||cs o^s o|e o|ood y co|e
9
o zed os |ocscdo|es o excdo|es
!|o^scdo|esoccc|ve^ systemi c factors |o| ^|' cecce |e |o|~o| o^ ocdoo
sop|o^o|p ec|o' | c d oe o' |e|ed !e ~os|co~~o^cocseso|e 'e|vec|| cc|o|
|o ' c|e, pc ~oco|ye~oo' cs, o^d c |os s |e|s ^c' cde cep|o| c sycd|o~e,
pe| |o^eo' d oys s, ~yxede~o, o|e'ec|os s, o^d c| co|o|ox U| ^o|o|ox s|e
oc ycocseo|ococ d c|ocscdo|e
4. .xcdo|es occc|ve^ local factors |o| c|'cecce |e|o|~o|oc ocd ooso|p
|o^ o| p eco' |' c dso|eo' |e|ed !e ~os|co~~o^ cocses o|e ooc|e| o' p^eJ
~o^ o, ~o' g^occy, v |o' ^|ec| oc, o^dpc ~o^o|ye~oo cs 'c' ~o^o|yembolus
~oycocsee |e|o ||ocscdo|e o|oc excdo|edepecd ^go^ ve|e| c|o|c|on
ocd e~o|oge occcs Co^ce|o^dypo|yo d s~ o so ~oy cocse e|e| a
||o^scdo|e o|excdo|e
5. C| |e| o|o|o^excdo|eo|e.
o ' ec|o' |' cd p|o|e ^/se|c~ p|o|e ^ > J o
o ' ec|o' |' c d '/se|c~. > J
c ' eco' | c d . > z/Jo| |e ^o|~o cppe' ~ ||ose|c~
!ocscdo|es ove ^o^eo| |ese|eo|c|es
6. ||e| c d sexcdo|ve, |e|o ow ^g|es|s soc'd oe o|de|ed. g' ccose, amy
' ose, ce' ' coc^| o^d d ||e|e^| o' , cc' |c|es, cy|o'ogy, g|o~ s|o ^, ocd p !vo o|
||eecy|o'og cso~p esv ' ' c' eoc|o ~o g^o^cy ^ ~os|coses
7. A poss o epo|opcec~oc ce||csocsoc' d oe|opped ~~ed o|e'y ' | ssaid
|ooe co~p co|ed |o^yo||e|o' ow cgo|ep|ese^|
o Cosspcs
o |go^ s~sv s o' eo^ g|o~ s|o ^
c C' ccose< oJ
d p < ` J
Co~p co|ed e||csocscsco' yeqc e ces||coed|o coge
lulOO/3(3/OCl///C3l C3l0 39
!op ec | scsco y |eqc |eso p eco o opsy|od og^ossdco|o |~e scoc|y
o|o|go^ s~s ^ |~e| c d !~e|' c d o|e^, oc|^o|o'voysl 'oc\s ~oso|~e' o' ce' s
^o ^g| ~ed og^os so| p| ~o|y |c oe|cc ocs p' ec | s ~oy oed || cc | , oc| |
s~oc d oepc|sced oggessveyos |~e|e s o ~ g~ ^c de^ce o| p|og|esso^ |o
pc' ~o^oy po|e^c~y~o' d seose !~ed og^os s~oyoee' csve seveo ^ev d
og^os| c s|cd es oe ovo ' oo e !~ee s ev de^ce |~o|o^o evo|ed ode^os ^e
deo~ ^ose 'eve' ~oyoe~e' p|c ^es|oo' s~ ^go d og^os so| |aoe|cc'ocs p'ec
| | s A seco^d p|o~ s ^g d og^os|c|es| so po'y~eose c~o ^ eoc|o^ ossoy
spec | c|o ~ycoooc|e o' d seose !~s |es|~oy oe opp' ed |o spc|c~ so~p'es
o^d ~os oee^ csed |o o^o ys so| p' eco' o^d o|~e oody|' c ds ' | ~os o ~ g~
degeeo| se^s | v |y, v |~ poooo'yo 'esse|deg|eeo| spec| c|y
9. A ovg ccose sc~o|oc|e|s| co||~ec~o|odo||~| | se||cs o^s |~e|e^| | es
|~o| ~oy~ove o ve|y ovg ccose ^c cdee~pye~o, ~o' g^o^cy, |coecc os s,
S': , o^desop~ogeo' cp|ce.
I 0. o' oody| c d ~oy oe see^ ^ ~o^yco^d | o^s, oc|o^ oC coc^| geo|e|
| ~o^ I JJ, JJJ scgges|s |oc~o, ~o' g^o^cy, pc' ~o^oye~oo' s~, pos|co
d oc ^ cy sy^do~e, o osoes|os p' ec | s , ' ! B|L D-' ^|ovecocs co|~e|e,
Toc~o, BA': oe^ g^ osoes|os p ec o e||cs o^| , .c^g co^ce, L~oo' s~,
D|ess' essy^do~e.
I I . A p ec|o |' c d o~y'ose eve' occos o^o y s ~e p|c !~e ~^e~o^ c AMY
.A5L UH ,Ade^oco|c ^o~o, Mycoooc|e| o, Yo|\ ^g,esop~ogeo cp|cel, |ve|
d seose, Acc|e po^ceo| | s, 5e|c~ ~ypeo~y ose~ o, Lc|opc peg^o^cy,
U|e|eo' oos||cc| o^, Hsecdocys| co^ ~e' pyoc |e~e~oe |e' o|ed d sodes
yd|oep~osso^d o|~ed seoses|o|es|~o| eod|o o^ e' evo|edsec~o~yose
o' so ^ceose|~e p'ec|o | c do~y'ose eve' !~e ~ g~es| 'evesoe see^ ^ po^
c|eo| c d seose, o^d csco yoe g|eo|e | ~o^ zJ ^ o|~e cocses ^c' cd ^g
co^ce| |~e p eco' | c d/sec~ o~y ose eve s csco 'y oooc| l J 'o^ceo| c
psecdocys|s |yp co' ' y ~ove |~e ~ g~es| o~y ose eve s, o||e^ geo|e| | ~o^
l JJ, JJJ A~yose sozy~e o^oyss~oyoe~e p|c ^p ^po ^| ^g| ~ecocseo|
o ~ g~ p' eco |' c d o~y' ose A ~ g~so' vo|y sozy~e ' eve ^d co|es ~o' g
^o^cy, v~eeoso ~ g~ po^ceo|c sozy~e 'eve ^dco|es po^ceo| cd seose.
!~e ~os|co~~o^ ~o g^o^c escocs ^go ~ g~ p eco | c do~y oseo|e c^g
o| ovo| o^coc ^o~o !~ s|oc|co^oe~e p|c ^d ||ee^| o| ^g' c^gcoc ^o~o
||o~ ~eso|~e' o~o, oecocse~eso|~e o~osdo^o| ~o\eo~y' ose
I 2. A ~ g~pece^|ogeo|eos ^op~ s ^ |~e p' ec|o spoce csco y ^dco|es|~e
p|ese^ceo|o o| oood :os ^op~ s ~oyoccc~c'o|e o|e|o p^ec~o|~ooxo
~e~o|~oge ^|o |~e p'ec|o' spoce |~ecocseso|p' eco | c deos ^op~ ' o ^
c cdece||o ^ dcgs scc~ osdo^||o' e^e, pc' ~o^o|y e~oo' , po|os| c ^|ec| o^s,
|c^go' ^|ec| o^s, o^d ~o g^o^c es oe^ g^ osoes|os p ec|o' e||cs o^ , oA':l s
o co~p co| o^ o| osoes|os exposce |~o|~oyoccc l J l o yeos o||e||~e ^
| o' exposce oecocse|~ep' ec o' e||cs o^ s o'oody, o ~ g~ eos ^op~ coc^|
~oy oesee^ v |~ oA'. osve . !~e ~^e~o^ c BAHL , Bood, A , Ho|os|es,
L~oo l sc~~ozes |~e p| ~oycocso| p eco | c deos op~ o
1 3 . Scspec| |~e pese^ce o| y~p~o| c| c d ^|~e p eco' spoce , c~y'o|~oox
v~e^ e||cs o^s eoccc~c o|e op d' y o| ~ove o ~ y co o !~e |' c d s ^o|
o' voysr , ~oveve|, o^d~oyoe|co doo'oody Co^d | o^s|~o|,o~~o^' y
40 |ulOO/3ly3/OCt/|C3l C3/0
'eod |o |ce occc~c o| oc o| ' y~pco| c |' c d ,ccy e cc' cde||oc~o, ~o gcoccy
,espec o' ' y' y~pco~o , cces|sc|gey, cocgc cg, vo~ | cg, os|o c cg. A geo|
cc~oe|o|o|cecocd | ocs ~oy oeossoco|ed v |c o ccy o|co|ox osve , c
c cd cg 'A^, ye ov co sycdo~e, c|ec| ocs ' eod cg| o|co|oc c ' y~pcode
copo|cy, cc cd cg |coecc os s ocd |ccgo' c|ec| ocs, | ' o| os s, oo| c ocd
pc ~ocoyocecys~s, ocdce|o ccocgec |o sycd|o~es, |o exo~p eovcs
sycd|o~e, `oococssycdo~e, ocd!cces sycdo~e
So~e ~o o e| o og es o| ccy o|cooxoe sc~~o zed oy|ce ~ce~oc c
CY.LS-Cocgc/s|o c/vo~ | cg, eed|oyd seoses, Ye ov co ' sycdo~e,
|y~pco~o/.A^/'y~pc codeec o|ge~ec|, L epcoc|oss, Sc|gey/||oc~o A' o|
|cese cocd | ocs 'eod |o oos||cc|oc o| y~pco| csocd/o| c cy |o |ce|co|oc c
dcc|. A p eco' | cd |g'ycede 'eve' > I l J es|oo sces |ced ogcos so| ccyo
|coox A'eve o|oJl I J s c|e~ed o|e ocd ~oy oe cdco|veo|ccyo|coox
\cec |ce 'eve' s c|e|~ed o|e, |ce p' eco' | c d scoc d oe sco~||ed |o| eec
|opco|ess|o lok |o||cepesecceo| ccyo~c|ocs \cec o ccyo|coox sd og
cosed, es|oo' sc `' |o||ce po|ec|, ocd c|o|e!'` o co|o||e~p|oggessve
cces||coedo coge, os|c s~oy'eod|o cc|| | oco dep'e| oc. !ce |co|oc cdcc|
~oy|cec spoc|oceocs'yceo , | |doesco| , scg co' ' go| oc ~oyoe cdco|ed
1 4. ||cecocseo|o p eco' e||csoc s co|de|e|~ ced o||e||coocec|ess, |cec
p eco oopsy scsco 'y|ce cex|d ogcos|cs|ep ' | peco' o opsy |o ' s|oye' do
d ogcos s, |cec cocs deocopec sc|g co pocedce oocccoscopy ~oy oe
ce p|c' | |cee s oco|ce|coc||~ed pc ~oco|y'esoc oce~opjs s, oc| |cey e d
sqc|e ov|ooc ccd ogcosed p ec|o e||cs ocv|c oco|cev seco~o' xoy
1 5 . A s~o cc~oe|o| excdo| vee||cs ocse cded ogcos s evec o||eopec
p ec|o o opsy .xpeeccescovs |co|oooc||vo|c dso||cesedoco|ecc, ocd
cod ogcoss ses|oo' sced !ceyo|epesc~ed|o oeo esc|o| c|ec|ocoo|ce|
c| o~~o|o|y pocess |co| cos |esoved !ce e~o c cg oce| c d o| coses oe
evec|co y |occd |o cove o spec|c d ogcos s ^o gcoccy, csco' 'y y~pco~o,
s|ce ~os|co~~oc cocse A |ev po| ec|s evec|co' ' yoe d ogcosed v |c co ' o
gec voscc o d seoses oo|ce ~ sce oceocsd ogcoses. c|e|es| cg'y, c |ce
' o|ges| pco sced se es, coce o| |ce po| ec|s v |c c cd ogcosed excdo| ve
p' eco e||cs ocsvco cod scg co oopsyve|eeve|occd|o cove |coe|cc' os s
1 6. ee so ocge' s|o||cecocseso|p eco e||cs ocs.
UH , DOC I ' L L NE E D MY TAP STAT
e ..
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lulOO/3(3/O C/l/lC3l C3/0 4
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P N E U M OT H O R AX
CH EST PAI NS
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4Z lulOO/3/y3/OC/lllC3l C3/0
-
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s .. ..., . ........
s . s. . .
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1 . ~oyo| spo~|oeocs p~ec~o|~ooxco~~o~ yocccs ~|o' , |~ ~dvd
co's o~d scsco ydce|ocp|c|eo|opco o eos S~oesoe o| ceosed s
2. !eo|~e~| o|o ogep~ec~o|~oox | o ' y voves osp o| o~ , o||e |o
'oved oyc~es||coe |eexpos o. ecce| pec~o|~o|oxco~ oe |eo|ed v|~
sc eos ~goge~|s,|e|ocyc eoo'eo~yc | oscg co y As~o pec~o|~oox
co~ oe |o''oved oy se| o c~es|xoys, oecocse | ~oy eso've v|~oc| ~ed co
| o~so|eo|~e~|
3 . !es o o~ec~o|~o|ox s |e |~|eo|e~ ~g od co eod |o cod oc oes| |
~oyoeo co~p co| oo|~ec~o co ve| ' o| o~ | s|eo|ed e~ege| yv|~o
o|geoo|e eed ep'oced |~e p eco spoce
P U L M O N A R Y
H Y P E R T E N S I O N
LVE DP
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1 . !~ed ||ee~| o d o_oos s|opc' ~oooy~ype|ecs oc, A!`S| so p c~o
cg poo e~ !ae ~ s|cy, p~ys co' ex~ o| oc , ocd c~es|x|oy gc de yoc c
de|e ~ cgw~ee |~c o oc\ c |~e p' c~o cg s oco|ed , . e. , oo|o, oo|| c
vo ve, e|| ve~|| c' e, ~| Io vo ve, e|| o|| c~, ' o|ge pc ~ocoy ve s, pc ~ooy
vecc' es, pJ ~co|ycp ' ' o es, pc ~ooo|y o||e| o' es, pc ~ocoy o||e es| A' so
cocs depJ' co|yvc' ved seose, | gn|vec|| cc o dys|ccc| o, | ccsp d vove
d seose, g~| o|| o' d seose, od scoc' v ove c|~o~oos s
2. 'e||vec||cc'o| |o c|e s| ~e~os|co~~occocseo|pc ~oco|y~ype||ecs oc
'e||sded|o ce,| ~e'e|| vec||cco|ecddos|o'cp|essce,'\:l se'evo|ed !~cs,
oc ~po|oc| | s|s|ep s|oossesse||ve| cc o| |ccc|oc |o ceoc|o cod oc
cocseo|pc' ~co|y~yge||es o !~e p~ys co exo~ o| o~oyde|ec|ocSo
pc' ~ooyedeo, sc_ges| g e||vec|| cc o||o ce ~ys co | cd cgs cdco|ve
o|pc ~oo|y~ype||ecs oc o|ocycocse cc cde cgcovecocsd s|es o, o g~|
vec|| cc o~eove, o ' otd _, od o sys|o cpc ~ooy~c ~c|
3 . Cocses o| left-si ded fai l ure , pos| pc ~ocoycop ' oyl c cdesys|o' cod
d os|o' cC',ccogec |o' ~eo|d seose, vo vc' o|~eo||d seose, ocdo| o' |c~o|s
Vascul ar causes o| pJl ~oo|y~ype||ens o c' cdec~oc c|~|o~ooe~oo' , p
~o|ypc' ~oco|y~ype|es oc, ||ovecoosd|cgoocse,co ' ogecvoscc' o|d seoses
scc~ os sc' eode|mo/C:S!, sc~ s|oso~ os s, d e|/ve g~|'oss p ' ' s, s c' ece'
oce~ o, ocdpc' ~oco ~ype|esoossoc o|edv |~c ||~os s c' ~oco|yvecocs
d seose s |oeood, o | |~ocg~voscc' o, | s o pos|pc ~oco|y cop ' 'oy p|ocess
|~o| ~oy 'oo\' \e C'. Extri nsic processes cocs g pc ~ooy~ype||es oc
c' cdeyp~oscc' os s, eco~cscc od seose, ocd| oos cg~ed os| c | s e|od c
oxygec desaturati on cocsed oy oos|cc|ves eepopceo o~ypovec| o| oc syc
d|o~esevec|coycocsepc' ~ooy ~yoe|es o C~|oc ~ypoxo o|ocy cocse
eods |o pc ~coyvscc ocos|| c| c ocd, c | ~o|ey, ~ype|es o ' co' y,
pul monary parenchymal di seases scc~ os Cod c|es| | o cgd seose
des||oy|~ecop ' ' o|y oed, ' eod g|o po ~ocoy~ype|es oc
44 lulOO03Q 3/O Lll/lC3l C3l0
4. Aec~ocod ogo~de~os||o|es oo| .\od\|cc| o, vo' vc' o||cc| o,
od oes| ~o|eo| pc ~ooy o|ey pessces, | so good | o o vos ve
|es|. e| |ve 'oco' zo|oo||~e o oc ~oy|eqc e pc ~ooyo||eyco|e|e|
zo| o |o ~eosce |~e pc ~oo|y cop ' oyvedge pessce , C\ , o e|ec
|o o| 'e||o| o p|essce, od o d co|oo| '\: c' ~ooy og ogopy
~oy oe ecessoy|o |c eoc| c|o c pc ~ooy e~oo o|o|evoscc o oo
s||cc| os !~e ~e~o c oeov s|s |~ecocseso| pc ~ooy ~ype||es ood
dco|es| ~e~e p|c d ogos|c |o~o| o povded oy| ~eA co|e|e|.
I C H ECK PCWPS AND LVE DPS
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lulOO/3/y3/OC//l/C3l C3/0 45
P U L M O N A R Y I N F I LT R AT E
P L H I T?
:. ..
-..
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+ .,
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1 . A pc ~ooy | |o|e so co~~o ~ed co' poo' e~ A|~ocg~ |~epo|e| o
e|oogesoe ~oy, | ~eco~pos|o o| | '|o|es s ~ |ed A pc' ~ooy | ' |o|e
~oyoeco~posed o| , I | aspi rated |oodoo , , zj pus , |ec|ol , , J pc ~ooy
edema ovoscc o eo, ,^| hemorrhage, ,o ce||o i mmunologi c pocesses
c' cd gco ' ogevoscc o d seoses, eos op~ c ' cgd seoses, H, od
o'veo'opo|e os s, od, | tumor | |o| o As|~e~e~o cscgges|s, o'voys
cos de pul monary embol i sm |~e d ||ee| o d ogos so| o ev | |o|e,
po| cc o| yv~e s|oc|os oe pese|o|~ec' co p c|c|e scc eo
2. Apo|e|sspec|cpese| gsy~p|o~s co d co|e|~eo|c|eo||~e | ||o|e
'oexo~p e, |eve od podcc|ve cocg~ ~oy d co|e o |ec| ocse| o ogy.
|~eo|~e ~od, o po| e|v|~ oes od o ~ s|o|yo|coges|ve ~eo| |o ' ce
~os| \ey ~os pc ~ooyede~o e~op|ys s ~oy dco|e o cde'y g pc'
~ooy~e~o~ogesydo~e,v~ 'e |~epeseceo|ce||o sys|e~ csy~p|o~s
~oypo | |ovo|d o ~~co og ccocseo||~e cgd seose. ' o y, so| cg
coce|oc~o|oc|es|c |od og|op~s~oy eod| oo cos deo| oo|eop'os~.
c ~ooyeop os~so||e o oco o voy, 'eod g|oo pos|oos|cc|ve pec
~o o, v~ c~ ~oy oe |ecce| o||o ' |oc eoo||eoppop| o|e |~e|opy. 'ess
co~~o'y, eop' os~sp ~o| 'y vo've|~eo spocesod cocse o | ||o|e ,see
oe'ovl `eop os~s co ~ove |~e so~ee||ec|oy o'eed g |o |~e o spoces
3 . Co~~c|yocqc ed, ooc|e| o pec~o o,CAl s|~e~os|co~~o cocse
o| o pc ~ooy | |o|e !~e lyp co pese| g|eo|c|esoe |eve, cocg~v |~
pcc e| spc|c~, od o 'ooo | ' |o|e /c | oood seose s ~oe se ocsod
essco~~o \ |~ | ~e' yod e||ec|veo| ~ coo o |~eopy, c co' odod o
gop~ c ~pove~e|oeev de| |coc|se, |~e|e o|e excep|os|o |~ese c es
deped g o ~os|spec | c|oc|os ,e g. , |~eede|'yj od |~e po|cc'o| po|~oge
,e g , .eg oe' ' o| , oc||~eypovdevo'coo'egc de es ossess gespose
46 |ulOO/3/y3/OC//llC3l C3/0
4. Aco~~occ c co p|oo e~ s d ||e|ec| o| cg oe|veec CA ocdo|~e|cocses
o|o |spoced seose. \~ec|ocedv |~o pc' ~ocoy c| ||o|e, |~e|eoe|oc p|
~o|y cocs de|o| ocs. C' c co pesec|o| oc , Ucde|'y cgd seoses/ ss, kod o
g|op~ coppeoocce, ocd Lxpec|ed |espocse |o |~eopy , CUkLl !~e cl i ni cal
presentation o|CAcsco y cc' cdes occ|e ocse|o||eve|, cocg~, ocd pcc' ec|
spc|c ~ !~e oosecce o||~ese |eo|c|es o||~e p|esecce o| ess|yp co | cd cgs
, e g. , po'ocged coc|se, ~e~op|ys s, y~p~odecopo|~y, d sp|opo|oco|e ~ypox
e~ ol s~oc d po~p|cocs deo| oc o|o|~e|ec| | es Apo|| cc' o po| ec|s under
lyi ng di seases or ri sk factors ,e g , A S, \covc ~o gcoccy, s~o\ cg/C,
~~oo ' |y/~ype|coogc' oo ' |y, ~ed co| ocs/d|cg csel ped spose |o spec | c
po|~ogecsococd | ocso|~e|| ~ocCA !~eradi ographi c pattern o| | ~e c| '
|o|e ~oyscgges|o spec | cd ogcos s, e g , vo' c~e oss, pe p~eo po||e|c, e
cc||ecce c| ~e so~eoeol Acd, | co' 'y, ~os |~e po| ec| ~od |~e expected
response to therapy, o|~os|~e c| |o|e pe|s s|ed o| cceosed csze
Ac o go |~~ oosed oc |~ese p| cc po cocs de|o| ocs oeg cs v|~ e~p c
|~eopy |oCAv~ec |~e |od ogop~ ocd sy~p|o~soe eosocoo' yscgges
| ve '| |~e po| ec|espocds |o |eo|~ec|ocd od ogop~ cceo cg occc|s, |~ec
co|c||~e cves| go| oc sceeded. ' |o|ypco'|eo|c|esoep|esec|, pog|essoco|
|eccecceocccs, o |~e|e sco ~p|ove~ec|, |~ec cocs de|o|~ee| o og es
5. \~ec o pc' ~ocoy c| ' |o|e pogesses o|o ' s|oeso've o||espec | c|~e|
op es, cocs de |~e cocseso|c~|oc c pc' ~ocoy c| |o|es sc~~o|zed oy |~e
~ce~oc cA|VLC|Ak || S!. Aveo o| ce coc co~o, .y~p~o~o, Voscc' | s,
Los cop~ ' c pcec~oc o, C|goc z cg pcec~oc o, | po d pcec~oc o, Aveo'o|
po|e cos s, ke| cx/osp o| oc, | /' , ' y~p~ocy|c ocd desqco~o| ve c|e|s|
|o pcec~oc | sl , ' c|ec|oc , e g , !o, |ccg l , Soco dos s, ocd Toc~eooocc~ o
oos|cc| oc. !~ s ~ce~oc c e|e|s| o|~e|oc|| ~o| | ~e~o o| |y o||~eseec| | es
s~ow oc al veol ar-fi l l i ng pattern oc c~es|xoys A |ev o|~ee| o' og es ~oy
|oe'ycocse o c~|oc co' veo o c| '|o|e, cc' cd cgo~y' o dos s, o' veo' o~ co
' |~ os s, ocds 'ec| ~ ||o' s|ecos s
6. !~e|o ov cg ~ce~oc co||e|s o ~o ede|o ' ed sc~~oy o||~ecocses o|
pc ~ocoy c| ||o|es.
PN I T L P L
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lulOO/3/y3/OC/ll/C3l C3/0 M 47
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P U L M O N A R Y N O D U L E
P NOD U L E
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I . !~e| d go|o so|o|ypc ~oo|yodc' e scocse|o|coce !~epo|e| o
e|o'ogeso e~oy, odso~e~o o cocsesoesc~~o|zed o|e c~oe| I I
:ve |~ s og s| s o|co~p|e~esve, od soo ~o|e poc|co'oppooc~|o |~e
so'|o|ypc' ~oo|y odc' e soc| ed oy|~e~e~o cA 'U':.
2. !~e~os|c | co qces| os|oosve|oe v~e|~e|o|o||~e odc' e epe
se|s o ~o gocy od |scgey s dco|ed Seveo ~ s|o co' e' e~e|s
c|eose |~e c~oce o| o ~o' gocy, odo s|epvse oppooc~ o so s oc| ed
oy|~e~e~o cooove.
3 . A. age geo|e |~o Jo c|eoses |~e c~oce o| ~o gocy. !~ee|oe, o
~oe ogg|essved ogos|c s||o|egy ~oy oe cde||o\e o o'de|po| e|
4. Ni cotine odd c|s ,s~o\esl~oveo geo|'y c|eosed c deceo| ooc~o
ge ccoc o~o A s~o\ g~ s|oy~odo|eso ~o|e ogg|essveopp|ooc~.
48 lulOO/3(3/OC/l/C3l C3/0
5. ceo||~e| |s||~ cgs|o| cdoc| sv~e|~e|o co| old fi l ms oeovo oo' e, |o
de|e| ~ ce | |~e codc' e so cev| cd cg A ' es oc |~o| vos p|esec| oc oc o d
| ~ s~cc~ ess e'y| ooe~o gcoc|
6. !~edoubl i ng ti me o|o codc' e~oy cdco|ev~e|~e|o co| | s' e' y|ooe
~o' gcoc| ^o gcocc es csco' 'y doco' e c s zeo||e zJdoys oc| oe|o|e ^oJ
doys oec gc es ocs~oygeo|'y cceose cs ze c 'ess| ~oczJdoysocdo||ec
oe dce |o c|ec| ocs A so,ocy' es oc |~o|doesco|doco e c ^oJdoys s ~cc~
ess' e y|ooe~o' gcoc|
7. Cocs de|~epo| ec|s underlyi ng di seases. ' s| ~ spo| ec|o s~oe|v |~e~
p~yse~o ocdo| cc|eosed s|ococce` oes |~epo| ec|~oveo covc ~o
gcoccy :v decce o| pcec~oc o ocd c|ec| oc :v decce o| o co' ' ogec
voscc' o|d seose o|oc ~~ccode| c eccysycdo~e^ocy~ s|o co' |eo|ces
oe cd co| ve o|spec | ce|o ogy|o|~ecodc e
8. ~ysco exo~ co| oc~oyeveo lymphadenopathy cd co|veo|~o gcoccy
o| c|ec| oc . A' so, |o y~p~ code sde|ec|ed, |~ s s~oc d oe |~e | s| s |e o|
o opsy ' |v ' oeeos e||o o opsy|~oc |~e' ccg' es oo ocd v es|oo' s~s|og cg
9. ' co y, d ogcos|c exami nati ons s~oc d oeccde|o\ec !~ec~o ceo| |es|s
depecds, o|cocse, oc |~e po| ec|ocd|~eooove~ec| oced s|oc|o|s, v~ c~
v ' ' de|e ~ ce~ovoggessve|~ep~ys c occoc oe c||y cg|o dec||yv~e|~e
o co||~e ' es oc s ~o gcoc| :xo~ co| ocs cc' cde C!scocs, |ce ceed' eosp
o| oc o||~e ' es oc, oocc~oscopyv |~ o opsy, |~o|oco|o~yv |~ o opsy, o, c
so~ecoses, ~ed os| coscopy ecec|ev decce~ os s~ovc |~o| :!scocc cg
~oyoeoo' e| od ||eec| o|e ~o gcoc|||o~ oec gc | es ocs
I 0. !~e| cd cgo|~c | p' ecodc es cdco|esd ||e|en||ypeso|d seose!~eco|
ego|eso|d seose|o oecocs deed cc' cdedeve'op~ec|o' ooco|~o' | es, c|ec
| ocsd seoses, ~~c co' og cd seoses, ~e|os|o| c ceop os~s, ocd |oc~o| c
c cy, osve ' os d opo|~ ccocses ' c A' .S po| ec| s, ~c' | p' e codc' es ~oy
occcsecocdoy| oC, |coe|cc'os s, cyp|ococos s, C^\, opos s so|co~o,
y~p~o~o, ocd pyogec co|goc s~s,s|op~, s||epl
I I . e|e s o po|| o' s|o|cocseso|pc' ~ooo|y coUc' es
LEAVE THAT C H EST ALO NE P L EASE
. ,.
s .
:. .. ,,
... . .
s .
t ...... .
+. ..
:, .
t. . .
l13/y3/OC/ll/C3l C3/0 4d
c ... .,. ....
+....
s .,. .,. .,
s. . .
t...
:. .... ..
.,.
e,. ,. ./--
s . . . .. . . . .
s. ,. .
-...
.. .. . . .
s . .. ., ,..
:. . .. . .
s,.....
s ,. ,.. ...
R E F R AC TO R Y H Y P OT E N S I O N
CRAS H I NG
c. .... .
s. ..,
: ../: . .
s. ./.
+,. .
..... ,
s. ,
a / .. ,
"..
I . A |~ocg~ |~eeoe ~oycocseso| ~ypo|es o , v~e /e'oc|oq ~ypo|e
s o secoc|eed, yoc ~cs|cosdeo ve|yspec|c s|o|poss o ee|o'oges

50 /ulOO/3(3/OC//llC3l C3/0
!c|c |o| ~ s s|v~eco po| ec|s o'ood pessce|o 's|o cceosedesp|ecse o| c
|ovecocs | c dso| p|esso ogec|s ^ocyo| |~ese cocses o||e|oc|oy ~ypo|ec
soc oe e~egecc es ocd |eqc e cgec|||eo|~ec|
2 . A s ~p esys|e~|o e~e~oe| cg |~e cocseso| e||oc|o|y ~ypo|ecs oc s
sc~~o|zed oy |~e ~ce~oc cCAS 'C, o oy|~e ~ce~oc c!LkM| MA|
Tox c/d|cgs, Lcdoc ce/eec||o'y|es, kesp o|o|y, Myocod' o' /voscc' o, | c|ec
| oc/seps s, Meco'og c, A||oc|, .os cgo'ood.
3 . Cardi ovascul ar cocses cc cde| g~| vec| cc o c|oc| oc , pc ~ocoy e~
oo' s~, co|d oc|o~pocode, oy|~~ o, ocd ~ossve e|vec|| cc'o| c|o|c| oc
Respi ratory cocses o|ec o|e seec 'c po|ec|s oc |~e vec| ' o|oocd cc cde |ec
s oc pcec~o|~o|ox ocdoc|o::, v~ c~ occc|sv~ec po| ec|so|eovevec|
o|ed o ~ovesevee o voyoos||cc| oc :cdoc cecocses cc' cdeAddi son's
d seose, ocdsys|e~ caci dosis ~oycocse~ypo|ecs oc Sepsi s/toxi c cocses c
c cde ooc|e o sep| c s~oc\, |ox c s~oc\, ocop~y ox s, ocddcgove|dose
Hypocalcemi a ~oy cocse ~ypo|ecs oc s cce voscc o |oce ocd pesso|ogec|s
o|e co' c c~depecdec| I naccurate blood pressure readi ngs ~oy |esc' |||o~
poo|o'oodp|essc|ecc||| |, pe p~e|o voscc' od seose, ocd vecocsoos||cc| oc
, e g , scpe| o|vecocovosycd|o~el, eod cg|o o |o'se ~pess oco|e|oc|o|y
~ypo|ecs oc Neurol ogi c cocses cc cdeC\A, sp co' cod c c|y, ocd ep dco'
oces|~es o C| bleedi ng ~oyoeoccc |, o| oood 'oss ~oyoccc c|e |~oox,
e|ope||oceo'o|eo, o|oodo~ec
4. !~e|o' ' ov cg~ce~oc c s|s spec|ccocseso| e|oc|o|y~ypo|ecs oc .
ALARM, BP THAT' S DROP P I NG
:. .. . . ... . ...
. ......,
. ..
:,. .
s ,. .. . . .
v... . ... . ..
s . .. .
- ., .
t..
+,. .
: . .
t. ..
. .
lulOO/3/y3/OC//l/C3l C3/0 M 51
a.,./. . .., . . .,.....
s.. ,,. .
e. . ..
-... . .
- /...
.... .... ,. .. .
s., . . ., .. . -... .
,.. .. .
a... ... . ,
SA R C O I D O S I S
H I LAR NODE S*
+... ,. ,
... . . . . . .,
.,...,
:.. , ./.. . .
s. . ... ... . . . .. .
s. , . .. . .. . . . . ,. .
, . . ... .
e.. , .. . . .. ..,. .. . .
.,
a ... . ../. .. .. , ,
s ,. ... /. . .
s. .. ,, . .,. .. .
* Clinical characteristics
52 lu/OOn3ly3nO C/|llC3/C3/0
-
SARCOI D BL U ES * *
s ..
:. ..,/. . . , ..
s. ..,
c.. ...,..
e. .. . . . .
I .. ,.. .,
a,.,. ./. .,. ..
s . ./.
., .., ,.... .
. . . . ...,
e... . , -. ..,
s. . .. ..
s,. . .,.. . . ,. , ..
,. .
* * Possible presentations
"..
1 . Soco dos s s o ~c' | sys|e~ d seose \ |co ' y o~yogo~ sys|e~ ~oy oe
~voved
c ~o~oy ~|es| | o' ~vo've~e~|, cp|o l JJ7|
'y~p~ode~opo|~y, ~ o/~ed os| ~o ,o-J7|
A|~o g o/o|~ | s, zo-oJ7|
oo~e ~oov , l o^J7| , oc| oe'y sy~p|o~o| c oeyo~d ~ ' d o~e~ o,
~ec|ope~ o, o~deos ~op~ ' o
epo|o~ego'y/ vee~zy~ee'evo| o~ , zJJJ7|
p~|~o ~o'og c , zo7| cve | s,`o-o7o|eyecoses|
:y|~e~o ~odosc~ , zo7| , s ~ es o~s
Uppeesp o|oy|oc|,cp|ozJ7|
So voyg o~d, poo|d e~' oge~e~|, o o|eo , l J7|
Sp e~o~ego y, o lJ7|
'eco og c ~vove~e~| , o7| c~ o|eo |oc o poo ys s , ~os|co~~o~l ,
pop ' ede~o
.
~eo ~g oo~o~o , ~ypo|~o' o~ c/p |c |oy ' es o~ , c~o~ c
~e~ ~g | s
.
~oss es o~ , se zce
Cod ocd seose , o7| o~y|~~ os, ~eo|o oc
.
pe cod | s, C'
e~o coc~~e|ooo s~oo~o~o , ~ep~o |~ os s,oe
.
< o7|
ooees ~s p dcsoo|~e p |c |oyde| c e~cy
lul/O/3|y3/OCtuC3l C3|0 bJ
2 . c' ~o~oy, occ o, y~p~ ode, ods\ ~ c~o~ges oe |~e ~os|co~~o~,
c' ~ co' ' y ~po|o~||eo|ces
3 . ^oycoses o|e |ocd ~c de|o yo~ c~es|xoy |oc|, |~s so~eo|o~' y
o |ev d seoses v~ c~ o po| e|~oy~oveo ~o\edyoo~o~o' c~es|x|oy,
oc|oppeoqc|e ~eo |~y

4. !~ed seosepo|~ogeess~oyoe e'o|ed |oexogge|o|ed ~e pe!ce ' oc|v|y.

5 . ype|co' ce~ o sdce |o o~ c|eose l , zo~ydoxy oseoc| v |y | ~e
go~c'o~os ' |o||e~ |espods|o s|eod |~e|opy.
6. Ce|o ~|oc|os o|e ossoco|ed v |~ pogessved seose ~soco dos s, |~e
p|eseceo|v~ c~ ~oyoe eoso |o| ~oeogg|essve | o | ~eopy. !~ese
|oc|o|s ~c' cdec~o~ c cve | s, c~|o c oo~e d seose, ep~|oco c os s, s\ ~
p' oqces, ' cpcs pe~ o, o~d pc ~oo|y ~| '||o|es v |~oc| ~odces , |ype J pc
~o~oyso|codos sl
54 lulOO/3/y3/O C/lllC3l C3/0
-
I
HEMATO L O G Y
General Considerati ons
!~e d ||e|ec| o d ogcos s|oo ~e~o|oog cd so|de|coc oe deve'oped cs cg
| ~e^:' C' ':Cco|ego|es.
Me|ooo' c, e. g. , o~y' o dos s, Hl z ocd |oo|ede| c ecc esl
Lcdoc ce , e. g. , po|oceop os| csycdo~es, odeco csc|| c eccy, ~ypo

|~y|o. d s~l
Dcgs/~ed c ces, e. g. , oc| o o| cs, o' co~o' , c~e~o|~eopy|ox c |yl
l c|ec|oc , e g. , '' \|e'o|ed, !H, sys|e~ c c|ec|ocsl
Cocgec |o' , e g. , 'occoc s, c~|oc cg| occ o~o|ocsd seose, p|o|e cC
de| c eccyl
I mmunologic , e g. , hemolytic anemia, '!', autoi mmune cec||opec ol
Neoplastic (e. g. , leukemia, lymphoma, metastatic di sease)
Exotic di seases (e. g. , sarcoid, porphyri a, Wegener's)
Degenerative ( ?myelodyspl asia; also premalignantl
Occupational/environmental (e. g. , radiation, hydrocarbons, heavy metal
poisoni ng)
Co|dovoscc o| , e g. , c||oco|d ocs~cc|, ~ype|coogc' oo' es|o|es cocs cg
\I/':l
'oo e~s cocs de|ed i n | ~e ~e~o|o ogy sec| oc p| ~o 'y cvo've | ~e ooce
~o|ov ocdo|ecoe ~ode ~oc |es| oyo deceose o cceose coceo||~e
p| ~oy o ood ce' ' |ypes HCs, \HCs, ocdp' o|e' e|s A so cc' cdedo|eooco|
~o | eso||~esp' eecocdd so|de|so|coogc' o| oc
M0O3lOlOQy 55 ,
Cl i ni cal Symptoms and Si gns
AN E M I A
MCVS
v. .
c.
. /
...
.
.. .
s. /
.
... / . ...
`..
1 . Ace~ o
sde| ced oso dop c |~e ~e~og' oo c coccec|o| oc !~e |oc
oos c ~ec~
_c s~soe ' s|ed ooove
:xo~ co| oco| |~e pe p~eo' s~eo ocd
edce' cd
es , . e , ~eocce' ' vo c~e^C\] , HCd s| oc| ocv d|~l s| ~e|s|
s|ep c evo'
o| oco|oce~ o !~e^C\ s |~e ~os| ~e p|c' e

|o gc de |~e
vocp !~

~ce~oc c ^C\S ~e ps|ocoovdovc|~e

||

c| o' oy c' os
s|y cgoc o
c
e~ oos~ cocy| c, co~ocy| c, o ~ococy| c
2. Marrow
problems oe c~ooc|ezed oyo deceose c podcc|oc o| HCs.
!~ee~oyo
zo de| c eccy cco~pocec|s
ceeded|oco~o HCsyc|~es s, |~e
~oov ~o
1
oe cvoded ocd ep'oced oyoc c| '|o|ve pocess scc~ oso ~o
' gcoccy, ~
y
e' op~|~ s cpocess l , o|~ee~oyoep ~oy~oovdys|ccc|oc
, ~yeodysp

os o l . ^oov pooe~s~oyoe~ cocy|c, . e , pocesses|~o|pe

|co ~e~og'
oo c podcc| oc, scc~ os oc de| c eccyl , co~ocy|c , e. , ~ye'o
dysp os ol ,
o ~ococy| c ,. e , pocesses |~o| c|e|ee v |~ HC ~o| co| oc ,
scc~ os H1 2
de| c eccyl.
3
.
Consum
pti on/destructi on o| ey|~ocy|es occcs c
po| ec|s v |~ oc|o ~
~cce o ce
op' os| c d seoses , ~e~o y| c oce~ ol , ~ec~oc co ~eo| vo' ves,
sevee sys|e
m c ' cesses scc~ osseps s , ' Cl , o |~o~oo| c
|~o~oocy|opec c
pcpco ,
|
`
| HCso edes|oyed e |~e oy oc| oodes , oc|o ~~cced sodesl
ooc c|ov
5scc o cocse , ~ec~oc co ~eo| vove o o' ood vesse' pocessl
c|ovoscc o
c cy s co' ed ~ coocg opo|~ c, ocd|~e
pe p~eo s~eo|eo
|ces do~og
zd HCs co ed sc~ s|ocy|es Cocsc~p|ve/des|cc|ve pocesses
oe occo~p
5ced oy cceosed ooce ~oov oc| v |yocd
~oe e|ccocy|es c
| ~epe p~e
5 s~eo. S cce|~e e| ccocy|e so yoccg
. ' oge HC, |~ee soc
56 M0O3
|
OlOQy
c|eose |~e ^CV !~cs |~ese p|ocesses csco' 'y o|e ~oc|ocy| c, cess |~e|e
scoco~ |o|~o||ov|o ce , e , o de|cecy|o~ c~|o' c~e~o ys' sl
4. Vol ume i ncrease cocses~e~od c|'o od o dec|eose ~e~og' oo co
ce|o| o !~ ss |co| o secoc|e|ed v~ede~ydo|ed po| e|s|eceve ||o
veocs |' cds A'so, occ|e oood 'oss, |oveocs| c ds ~oy ~o\e |~e o'ood
'oss ~o |es| s ce |~e | o ~e~og oo ~oy oe o ~o !~e ^C\ s c o|
|ec|ed oyvo c~e' ceoseod s csco y o|~ocy| c
5. Stool /menstrual/occul t blood losses ||eqce|' yo|e occo~po ed oy |o
de| c ecy od oe co~~o cocses o| ~ c|ocy|c oe~ o Yocgvo~e o|e
o||eoe~ coecocseo|~o|~ y~es||co' oood oss !~eo|~eco~~ococse
o| o' ood ' oss s occc | GI o' eed g ' eod g|o ~e~occc' | pos | ve s|oo s 'ess
co~~o'y, occc'|o'ood ossocccs||o~ o |eo soc|ce, scc~oso |e|ope|
|oeo o' eed e||ope |oeo oeed g~oyoccco||e|o vosvepocedceo|
oso co~p' co| o o|o| coogc' o| o ' odd | o |o o d|op |~e ~e~og oo ,
|~eHU` c|eoses||o~oosooed ~e~e~e|ooo' '|es
6 . !~e ~e~o coe ovdv des|~e oe~ os |o co|ego|esoccod ~g|o |~e
^C\. ~ cocy| c, o|~ocy|c, o~oc|ocy| c
I T' S ANE MI A' S BRAND
I ,
t. ... .
Microcytic
s ... . .
Usually Normocytic
: . ...
s, . . .
s ..
v, . . . . . ...
I V . .
: ... . .
s . .
Usually Macrocytic
s1 2 ,
s. . ,.. ./ ,. .
: / . .
s . . . , . ..
a ,. aNA .,.. . . . a , ..
.... ..
M0O3lOlOQy 57
-
ex|o' | o||ve s\| ^ d| seoses, ceood| o' ys| sj , o^d oo| oosorpli oo. Drugs that | o
c| o||di hydrolate reductase | e. g . , oe|co||exo|e, || oo|e|e^ejo|DNA metab
ol i sm |e g , 5-FU, cyd|oxyc|eo, ozo| c op| ^e, AZT, ocyc| ov| |j o' so cocse o
~oc|ocy| co^e~ o
1 0. !cevo|\cpo| o^e~ o ^c'cdes|c' ^goc|occc'|o'ood 'oss,csco' ' ys|oo'o|
~e^s||co , exo~ ^o| o^ o||cepe pce|o' s~eo|, ccec\ ^g|o| de| c e^c es , |o^,
|o'o|e, o| HI z , o e| cc' ocy|ecoc^|| oossess ~o||ovoc| v |y, o ce~o'yssvo|\
cp , o ' co ^, ', cop|ogoo ^, se|c~ ||ee ce~og oo ^ , o^d posso'yo oo^e
~o||ov o opsy
1 1 . !ce |e|cc'ocy|ecoc^| s o^ ^d co| o^ o||ce ~o||ovs copoc |y |o ~o\e
<HCs e|e s o s gc|'yd ||e|e^|~^e~o^ c|o|o^e~ o,s|' ' oosed o^^C\l|co|
e~pcos zes|ce ~po||o^ceo||cee|cc'ocy|ecoo^|.
I T' S A R ETI CS D E F ECT
,
r. ... .
s ... . .
Microcytic
Usually Normocytic
: ... . .
s. . .
s ..
r./, . . .
../ ... ...
c . . .,....,.. . .. . .
s . .
Usually Macrocytic
a .,. aNA .,. . . . . a , ..
.... ..
s. -
- ..
s ,. . . :., .
c. . ,( 8 1 2)
r-/ ,. .
Hematology
7. N
|
crocy|| c onem|
o:
ore
due |o o
del|
c|encyol one ol lhe
|hree m
o
[
or con

:
||lJ
e
n|>olhemQ
loo| n

|ron,
g
loo|
n, Ond
g
:phyr| n
,
Hem
ogloo| ncom
pr|

>
_9
%
ol
|he prole|n |n lhe b\
, >o
|cr
yl|c cell>Ore >oll ond
pole. | |
on
de
|
c
|
e

y
|>
>==n |n >lole> ol ch:on|c
`
o
lo
c
|o>> [
>loo| , en>lruo| ,
occul|| , b\ de>
l:uc||on
jhe
o|y>| >| , or nul:|l|onOl de
l|c|e
ncy [
vegelO:| On d
|el|
, 1hetho| o:>em|
> oreO
d
|ver
:e g:oup ol d
|>eo>e> :e
>u|||
ng |
n delecl| ve gloo| ncho| np:od
ucl|on
1he
:|
de
|Oo|o:
|iconem|o:
orech
O:oc
ler|

edoy

r|nged>|de:oolo>l>
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Oonorol
po:phy:|n >yn
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e

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ey oy oe hered
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gnonl|
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O>e >
lole>
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|
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ch|on

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> |ong>lond| ng | nl
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'
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e
O
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ed oy l
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copoc
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| evoled or noro| >eru
le::|l|
n
,
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i o |>
cou>ed
oy :e

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el|n |eve|> o
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B L E E D I N G D I AT H E S E S
APTT
:.. . . ., , AVM, .
- .... . . .,
r,. ./,. ... . .. .. . .,
r...
`..
1 . A oeed cgpoo' e~ s~os|co~~oc ye'o|ed|oocanatomi c abnormal ity.
Cocgec |o' ooco|~o' |essccosoc o||e|ovecocs ~o'|o|~o|oc oocqc edde
|ec|s scc~ os pep|c cce d seose oe co~~oc . Pl asma protei n abnormal i ti es
o|e'essco~~ococd~oyoe~ode~oc |es|v |ccexpec|ed e~o~ogeosso
c o|ed v | o ~ co|sc|g co' p|ocedc|e. Thrombocytopeni a os ~ocy cocses
ocd seo|veyco~~oc, oc|qual i tative platelet abnormal ities oe |o|e ' co' 'y,
trauma s o co~~oc cocseo| e~o|ogeocd csco' 'y oov ocs, oc|excessve
o'eed cgo|ocs cgo|e|~ co|oc~o ~oy cd co|e ococcc'|oeed cg d o|es s
2. !~eAPT, !, p'o|e e|cocc|, ocd o eed cg | ~e oe |e p| ~oy ooo|o|o|y
s|cdesoo|o cedvec cves|go| cgo poss o' ep'os~opo|e cooco|~o' |yo|qco'
|o|vepo|ee|de|ec| |e||es|s cccd cg||o~o c| ~e, | o| cogecossoy, c o|soc
o ' |yocd 'ys s, ocd|oc|o|ossoys~oyb e'p|c' c dec||ycgspec|c de|c ecc es.
Pri mary Hemostati c ( Platel et) Di sorders
Platelet adhesion defects:
\oc \ ' eoocdsd seose

e|codSoc e|sycdo~e ,oosecce, dys|ccc|oco|Cp

o/'Xj
Platelet aggregation defects
Cocz~occs|~|o~oos|ec o, oosecce, dys|ccc|oco|Cp

o/' ' ' ol
Pl atelet release defects
ec|eosed cyc'ooxygecose
oc|v|y
|cgsosp | c, cocs|eodo'
oc|c|o~~o|oy
ogec|s
Cocgec|o'
Platelet coagulant defect
Sco||ssycd|o~e
Gp glycoprotei n.
b M0O3lOlOQy
Cocc es|o|ogepoo' de|ec|s
Cocgec|o'
Acqc |ed
Ue~o
'o|ee|coo| cg, e g , pec c ' ' c
or po|op|o|e csl
Rel ati onshi p Between Secondary Hemostati c Di sorders and
Coagul ati on Test Abnormal i ti es
Prolonged partial thrombopl astin time ( PTI)
No cl i ni cal bleedi ng -factors XI I , HMWK, PK
Mil d or rare bleedi ng -factor XI
Frequent, severe bleedi ng-factors VI I I and I X
Prolonged prothrombi n time (PT)
Factor VII deficiency
Vitami n K deficiency-early
Warfar i n anticoagulant i ngestion
Prolonged PTI and PT
Factor ' ' , V, or X deficiency
Vitami n K deficiency-late
Warfari n anticoagul ant i ngestion
Prolonged thrombin time (TI)
Mi l d or rare bleedi ng-afi bri nogenemia
Frequent, severe bleedi ng -dysfi bri nogenemia
Hepari n-l i ke i nhi bi tors or hepar i n admi nistration
Prolonged PT and/or PTI not corrected with normal plasma
Speci fi c or nonspecific i nhi bi tor syndromes
Clot sol ubi l ity i n 5 N urea
Factor XIII deficiency
I nhi bitors or defective cross-l i nki ng
Rapi d clot l ysi s
Al pho2 plasmi n i nhi bi tor
HMWK " hi gh-molecular-wei ght kininogen; PK " prekal l i krei n.
Both tables fram Handi n RI : Bleedi ng and thrombosi s. I n Isselbacher KJ, et al (eds) : Harrison's
Principles of Internal Medicine, 1 3th ed. New York, McGraw-Hi l l , I nc. , 1994, pp 317-322;
with permission.
S P L E N O M E G A LY
BANTI ' S
s .
: ./,. ,.
s ../ . .. . ...
t,. . .
.
s. /s,.. .,. ....
M0O3lOlOQy M l
,.
N..
1 . Banti 's sydo~e s|eepoy~csed|odesc| oecoges|ve sp eo~ego' y
w |~ ypesp e s~ Us g HA'! S os yoc| gc de, |~e cocses o| sp eo
~ego yco oec' oss|ed s xco|ego es. Blood flow probl ems cocsesp eo
~ego yoy ceosedsp e cve p|essc|esodcoseqce|coges| o . Sp e c
ve | ~o~oos s ,o||e secodoy|opoceo| | sl , po|o ve | ~o~oos so|ex
|| s cco~pess o, c os s, epo| cve | ~o~oos s , HcddC~ o sydo~el ,
od C'o' cocsecoges|ve sp' eo~ego' y Anemi as secondary to erythro
cyte abnormal i ti es ,e g , |o osse~ os, s c' ece d seose, eed |oyspe|ocy
|os sl cocsesp' eo~ego' yoecocse|~ee s 'ype|p osoo||~e e| cc oedo|e o
sys|e~ ossoc o|ed v | |edes|cc| o o||~eooo~o HCs !~esed seoses
o' so~oycocsesp' e c |oc|o , e , sc e ce l
Neopl asms and i nfi ltrative di seases d ec|y vove|esp eeod'eod |o
|s e' oge~e| ~ye' op|o' |eo|ve syd|o~esod ~ye' op|~ s c pocesses,
oecocse o| ~o|ov ypo|cc| o, |~ee ~oy oe co~peso|oyex|o~edc oy
~e~o|opo es s cocs g sp' eo~ego y Thyrotoxi cosi s s ossoc o|ed v |~
sp eo~ego' y oecocse o| |~yo d ~o ~oe- dcced y~p~o d ypep' os o
'c~e|ocs i nfecti ons, csco' 'y c~o c, ~oy cocse sp' eo~ego'y sode|s o|
~~c e egc o| o scc~ os sarcoi dosi s and S|L ~oy|eo|ce sp eo~ego y
|~e|exo~p es c cde ec~o|o d o|| | s , 'e' |ys sydo~el, se|c~ s cess,
od ~~ce ~e~o'y|coe~ os.
2. !~e degee o| sp eo~ego' y vo es v | |~e d seose e| |y ^oss ve
sp' eo~ego' yocccs co c~yeocy|c ece~ o, ~ye o|o|ossv|~ ~ye o d
~e|op os o, ~o y ce' ' ece~ o, Cocc~e|s od ' e~o cd seoses, so
co dos s, |o' osse~ o ~o o, co c ~o' o o, coge |o syp~ s, ' e s~~o os s,
odso~ecoseso|po|o ve oos|cc| o !~eseo|eco cd seoses v~ c~
|esp ees ov ye' oges cp|ceo||esp ee ~oy oe see occ|e |ec
| ocspocesses scc~ os :H\ ~oocc eos s, ~o' o| o, od jp~o d |eve
3 . ee so ~o|eco~pe~esve s| go| |e cocseso|sp' eo~ego' y
HI S BI G SP L E NI C MASS
+.. . .... -. .
. .
s . . . . , . .. . .
s, . .
. .. . .... , :. . .,
. ,. ... .
a... ... /,. , .
62 M0O3lOlOQy
S LL/OO| | QOnv8Ou| |O| 8O8O8
-.. . ...
. . ... . .
t ,.,.. . ., , .,.. . .
.. ... .
s .. ,. , .. . ...
......
,
c-- ,.. .. ,. ,
v, .. . ...
:. ,. . .
s. . .
s . ../,..
4. Avoys co~s deo occc |, ~|ec|ocs e|o'ogy|osp' eo~ego' ys ~ce |~ese
d seosesoe ey|o |espod |o oppopo|e|~eopy !~ee oe c~eocs ~|ec
| osossoco|ed v|~ sp e~o~egoy, ~oyo|v~ c~oe s|ed ~ C~op|e| \ ,see
~|ec|o~sCocs gSp e~o~ego'y |
Cl inical Conditions or Di agnoses
E O S I N O P H I L I A
AL L E RG I C
: .. . . . ,
.,./. ,.,
..,..
t./. ....
s. .., .... ... . . ,
.,.., . . PI E .,.
a.... . .
. . .. .,. .
c .,... . ....
M0O3lOlOQy OJ
`..
1 . :os cop o sde| ced os > oJJeos cop s/~ c|o' |e o| o ood .os co
p ' o os dve|sed seose ossoc o| o^s, oc| A'':<C' C |eoc|o^soe poooo y
|e ~os|co~~o^ A' eg c eoc| o^s |o d|cgs, po' ecs, ~ coogo^ s~s, o^d
o|e|o^| ge^sco^s| ~co|eeos ^op o
2. Addi son's d seose |eqcec| y|eo|ces o ~odeo|e eos ^op o |o| esoves
v | od~ ^ s|o| oc o|co| cos|e|o ds Lymphoma s|e ~o' g^occy ~os|co~
~oc y ossoc o|ed v | eos ^op o, o' | ocg ossoc o| o^s v | ~o^y so' d
|c~o|s ove oeec desc| oed !c~oossoco|ed eos cop o s poooo yo esc |
o| c|e|' ec\ co sece|oc ocd o||ec ^d co|es o v de y d sse~ co|ed |c~o
:os cop ' c' ece~ o s o |oe e~o|o' og c ^eop' os~ v | d|o~o| co ' y g
eos ^op coc^|s L-tryptophan p|epo|o| ocs||o~ o s cg' esoc|cevee ~p
co|ed c |e eos ^op o~yo g o sy^do~e, o po|ec| o y |o|o , ~c| sys|e~ d s
eose Eczema o^d seveo' o|e s\ ^ d seoses , e g , pe~p gcs. ~ycos s
|c^go desl ~oyoeossoc o|edv | eos ^op o
Seve|o respi ratory di seases |eo|c|eeos ^op o, cc cd ngos|~ood|e
`' : , pc ~ocoy c| ||o|es v | eos ^op ol sy^do~es !e `' . sy^do~es ^
c' cdeocc|eeos cop c p^ec~o^ o, c|o^ ceos ^op c p^ec~o^ o, Cc|g
S|ocssvoscc' | s, po|os|c c|es|o|oc , e , |opco p^ec~oc o| , ocd o 'eg c
o|occopc ~oco|yospeg ' os s, Ao`A| !eype|eos ^op ' csy^do~e, o ~c'
| sys|e~ d seose, ~oycocse eos ^op ' c c| ||o| oc o| ocy o|go^ ^c' cd ^g |e
ccgs '|cgs o'so co^ cocseeos cop ' ov | pc' ~ocoy ^| ' |o| oc
|os cop c gastroenteri ti s s cooc|e|zed oyeos ^op ' c c| ' |o| oc o|
ocypo|oc o| |e gos||o ^|es| ^o |oc|, pe peo' eos cop ' o , o7o|cosesl,
ocd c| o~~o|o|yd o|eo I nfecti ons v | e ~ ^|s |yp co ' ycocse eos ^o
p ' o, ocd cocc d o des ~ycos s s c^ qce o~ocg | c^go c|ec| ocs ^ |s
p|opecs |y|o e c |eos ^op ' o Col l agen vascul ar di seases scc os ec~o
|o do| | s, eos cop ' c|osc | s, o' ' eg co^g | s, socodos s, o^d \ege^e|s
g|occ' o~o|osso' sooe ossoco|ed v | eos ^op o
3. !eepo^y~Loeffler's osoee^opp' ed| o`' :sy^do~es,| e d opo| cy
pe|eos cop ' csycdo~e, ocd|o eos cop cecdocod | s. .oe||'e| o g ^o 'y
desc| oed |ocs ec| pc' ~oco|y c| ||o|esv | eos cop ' o, v c ~oy ove
oeec |eo|ed |oosco os s c|es|o| o^ . A'|ocg |os cospec | cde| ^ | o^, |e
^o~e s s| ' csed c coses o| d opo| c, oec gc pc ~oco|y c| ' ||o|es v |
eos cop ' o
4. !ecy|o ce' .o so^ ~po||oc|s| ~c o|oo|eos cop so^d spoooo y c
|ego c ~o^y o| o ' cocseso|eos cop ' o !e |o''ov cg ~ce~oc c, e~po
s z ^g |eo' eo|' 'o, ' s|s |ecocseso|eos cop ' o
Hematology
P LASMA I L- F I VE RAGE
-. .. ..
.. ,..
: ..
s. . .
v. ,., , -, . ,... .. .
. , . .. ..
: ,,/:., , ,. ... .. .,.
.. ,. .,
. ., ..../ .
- ,. ( ABPA, .,. .
, ,.. ..,
.... . ./ .,... . ...
s./. ....
s.,. .. .. ..
:, ,./:. .... ..

a.... . .
s,. .
E R YT H R O C YTO S I S
H I RBCS
+, ./,.. ..
. ..,. .
s .. . ,,. . .. .. ,..
s . . .
c. ,, /, .. , .. .
s. ./.,.

M0O3lOlOQy 65
`..
1 . ||y|ocy|os so poycy| e~ o cd co|es o^ cceose c cc~oe|o|ey||o
cy|es ^o so~p' eo| o'ood, v c ~oy o| ~oy co| oeo e|ec||oco||o|o' oody
ed ce s | s ~po|oc||o d s| ^gc s oe|vee^ absolute erythrocytosis, o ||ce ^
ceose ^ |o|o' oody ed ce' ' ~oss, o^d relative erythrocytosis, v c occc|s v |
deyd|o| o^, cceose ^<oCco^ce^|o|oc| ocd s|ess
2. !e oosc~eco^ s~so|ey|ocy|ossoe sc~~o zed oy <oCS
H Y P E R C OAG U L A B L E
STAT E S
PT I NRS
- .. ..
t...
. . /.... .
s ..
s-.
s . .. ,...
"..
I 'c~eocsd sodes ~oy p|ed spose po| e^|s |o||o~oos s '|eqcec|'y, |e
s|oyo^d pysco exo~ ^o| o^ eveo' o ' \eye|o ogy oc|o|s ped spos cg|o
||o~oos s cc cdeooes|y, vo coseve ^s, |oc~o, ge^eo o^es|es o, ~~oo
zo| o^, ~o' gco^cy, C, o|o coc||ocep|ves, ^|ec|oc , p|ego^cy, ^epo|c
sy^do~e, ocd oood po|e ^de|ec|s.
2. 'ede^|oc|o o, o ~c|o|o^ ^ v c|oc|o|o sess|o^||ooc|vo|ed po|e cC,
s| e~os|co~~o^ ce |ed ype|coogc' oo' ecocd | oc ^ov^ o~ozygocs
cd v dco soeo| g |s |o| eccec|||o~ooe~oo' ceve^|s. !e | s\|o| e|
e|ozygo|es s ess c' eo.
OO M0O3lOlOQy
3. Hrole o oe||c eoc|es oy oe d| ll cu' |lo deo| ly
,
Current |es|s oo' y |den|| [
1 0-20
%
ol lhe coses ol |o| ' o' l:ooos| s Seru 'eve's o| prole nsC ood S
w| ' | oe ollecled oy ' o|ge l:oo| ood worlo| ooolcoogu' ol| on. |el c eoc|es
oy oecoogeolo' o| ocqu :ed. An| l:oo o |A1j'' ' , p:ole o C, ood p:ole n S
o:ele os|cooocoogenlo'condlons. 1e oslcoooocqu :ed delecls
oreA1' | ' ood ool pospo' p d oo| oodes.
4. 1e ' upusoolcoogu|oo| s on onl pospo' pd oo|. oody lol p:o'ongs le
'!oy ole:le:og w l pospo' pd nle ' ooo:olo|yossoy ' |doesno|couse
c' oco' o'eed og, oul:ole:p:ed sposeslo|ooossood d|:es|e|ooo|lon.
5. : no:y A1 ' ' ' 'oss p:oooo ycouses ype|coogc' oo ' |y o pol.eols w l |e
nep:olc synd|oe. !ese polenls o|e p|ed sposed lo :eno' ve o l |oooss
ood pu'ono|yeoo' s.
6. ' g 'eve'so|oocyslne p|ed spose polen|s lo o|le:o' oswe'' osveoous
loooss. 'oocysl oe o'so oyoe on po:lonlloclo: nledeve'opeolol
ole:osc'e:os s
7. An po|loo|d:ug:eoled coJseolype:coogu' oo ly s epo: nossoc oled
l:ooocy|opeo o. 1e leo|u:es o:e o||e|o'|:ooosswllo' ' og p o|e'elcounls.
cveo'owdoses o|suoccloneous epo:o coocousels synd:oe. A epo: nog
g:egoloo sludy s ovo oo'elo| ooo|olo:yconl|o|oo n suspec|ed coses.
8. 'e:e so o|ecopeensve ' s|ol ype:coogu oo' esloles.
DVT, P E AND CLOTS
a,. , . .
...... ..
1tum - . j .,
- ... ..
t , .,. . ,,. .
: . /: . . . .
s ., /s ..
a,.. . .. ../a,. , .
c- /c .,... . ... , -,.. SLE)
. ../.. .S
U.. ./e. ... ..
r-/r . , . . ...
s ,/s... .
Also: hyperviscosity (Waldenstrom '5), homocystinuria, ATIII, a/pha- l antiplas
min, heparin cofactor II, plasminogen, plasminogen activator, and factor XII
deficiencies.
M0O3lOlOQy O
LY M P H O P E N I A
NOT A T CE L L
s . .. ../ ...
e. . . .
t-/ . .
AI DS
t . ... .,/, . .
c,.. .,./. .,
s.. , ./. .. .
.,.
.. ../ .,.... . ...
`..
1 . Absolute lymphopenia sde| ^ed os< l JJJ y~pocy|es/~' . Relative lym
phopenia s p|esec|ve^ < I o7 o| ' ecocy|es o|e 'y~pocy|es Aoso c|e y~
pope^ o s~os|o||ec secocdo|y|os|eod |e|opy o|cy|o|ox cd|cgs, oc| |e
|eo|c|escgges|s cc~eocsd seose ossoc o| o^s. ' ^||c|, ocysevee sys|e~ c
' ' ^ess~oy|eo|ce ' y~popec o
2. A' |ocg |e d seoseossoco|ocsoe ~y od, |e | ^d ^go| y~popec o s
~po||o^|oecocse | seo|ve'y oe ' ^oce, p|eA 'Se|o s|cdyo| po|ec|so| o
~o o e|e|o' ce^|e|, |e ^c de^ceo| e |eooso' c|eo| |e' o|ve 'y~popec o
vosoc' yz. ^7, o^d | vos s g^ | co^|' yossoc o|edv | ~o' g^occy C ve^| e
cc|eosed seve|yo| ' cess ^| se|e||o' g|ocpo|po| ec|s, | spoooo' e |o|
|e cc decceo| y~pope^ o c |ege^eo popc' o| oc s~cc ' ess
3. !ecocseqce^ceso|' y~popec o cc cde |e||eo|e^ ^g ^|ec| o^s, espe
c o y|osecocsed oyv cses, |ccg , o^d ~ycoooc|e o S ^ce'y~pocy|es o|e
~po||oc| c ~~c^e scve ' o^ce ocd p|evec| cg ceop' os| cp|o' |eo| o^, ' y~
pope^ o o' so ~oy p|ed spose po|e^|s |o ~o g^occ es As ~ec| o^ed ooove,
|ee so^ ossoc o| oc oe|vee^ 'y~popec o o^d ~o' gcoccy, oc|cocse ocd
e||ec|o e^o|ce|o c
4. .y~pope^ o ~oyoeo c' ce| oo^ c ^de 'y cg sys|e~ c d seose scc os
A' 'S,' cpcs, o| 'y~po~o Co^s de||e poss o ' |yo|A' 'S o^y po|e^|v |
ccexp' o ced ' y~popec o ^ odd | oc |o | ed seoses ' s|ed oe ov, ' y~po
pe^ o os oee^ seec c po| e^|s v | C', dcg o' e|gy, odvocced oge,
68 M0O3lOlOQy
oypepoo|yo d s~, | ge~ ^o' ^eco g o, ~yos|ec o g|ov s ,v |oc||y~ec
|o~yj, pe| od c pooyss, o~yo||op c'o|eo' sc'eoss, o^d ypo|y|o d s~
I ' M H E LPL ESS WI TH OUT
T AND B CE L LS
. ..
v. . .
+... .
s ... /. .
.,,... , . . .,
-... . .
. ...
s....
s. .
s..... , ,
u . ...
. /.. .
t-
+ .. , . .
e. . . .
e .
t,.,
t . ... .,
AI DS
s . .. ../ ...
a ...
s . .. . .,. . ,.. .
c..,/,.. .,.
s... . ..
.,.
. .. .
s. . .
M0O3lOlOQy 69
M O N O CYTO S I S
MONO
v,.. .
e. . .
s .. ......
e. ..., . .
"..
1 . Monocytes are ci rcul ati ng cells with a hal f-life of l zz^ hours. They leave
the bl ood stream and enter t i ssues, di fferenti ati ng i nto macrophages ( " bi g
eaters" ) specific for t he parti cul ar organ ( e. g. , alveol ar macrophages, spl eni c
macrophages, l i ver Kupffer cel l s, brai n mi crogl i al cel i s, dendri ti c cel l s) . They
have di verse functi ons, such as phagocytosi s, l ymphocyte activati on, and other
cytoki ne-medi ated acti vi ti es. Many di sorders affecti ng PMNs, i ncl udi ng toxi ns
and i nfections, al so affect monocytes. Asi gnificant i ncrease i n monocytes, how
ever, should prompt consideration of certai n specific conditions.
2. In the presence of monocytosi s, exami ne for mal i gnancy, tuberculosi s, and a
few other od i nfections.
3. Here i s a more specific di fferenti al for monocytosis, emphasi zi ng the evolu
tion of a pripheral blood monocyte i nto a ti ssue-specific macrophage:
I ' L L B E A MACROP HAGE
...,. ...
. .
. .. .. . . ...
s . .
s . . .
A . . ,. . . ... . . .. . .
M0O3lOlOQy
v, .. . . .
: .... (T8, . ,.. .
c,.,. . .
+,.. ....
e , /e . . ,., .. ,......
...
- .. . . . . .
+ ,. . .
:, . . . ,
,. ... ... .- ,..
a . ... .... .. , . .
s....,
N E U T R O P E N I A
ANCS
:. /:. .
s ../ . .. ./.
c. .,,.../ . ,. .
s. ./. . , .
`..
1 . The normal concentrati on of neutrophi l s i s approxi mately 3650/ml ( range
I oJUzoUl . The absolute neutrophi l count ( nANC) i s determi ned by mul ti ply
i ng the percent neutrophi l s by the total whi te blood cell count . When the ANC
i s l ess than l UUU, i nfectious compl ications i ncrease si gnificantly, and the i nfl am
matory process i s essenti al ly absent when the ANC i s less than zUU Neutro
peni a may resul t from four basic mechani sms: autoi mmune or anti body-medi ated
peripheral destructi on; neopl astic, i nfi l trative, or toxic depression of the marrow;
cardi opul monary bypass and hemodi al ysi s; or sepsi s/overwhel mi ng i nfecti on.
2. Autoi mmune processes may feature anti neutrophi l anti bodi es and/or hy
persl eni sm, causi ng neutropeni a. Exampl es i ncl ude SLE, rheumatoi d arthri ti s,
Fel ty's syndrome, ond Wegener's gr anul omatosi s. Drugs such as di u reti cs,
M0O3lOlOQy l
al pha-methyl dopa, and some phenothi azi nes al so may act as haptens, promot
i ng peri pheral destruction of neutrophi l s.
3. Processes t hat i mpai r marrow producti on of neutrophi l s i ncl ude neopl asti c
i nvasi on, i nfi l trative/i nfectious i nvolvement of the marrow, and the cytotoxi c
effects of drugs. Neutropeni a i s common i n pati ents treated wi t h hi gh doses of
chemotherapy. The duration and severity of neutropeni a can be amel i orated by
admi ni stration of GSF.
4. Cardi opul monary bypass and hemodi al ysi s cause peripheral pool i ng and
a transi ent neutropeni a. Sepsi s/overwhel mi ng i nfecti ons al so may cause a
transi ent neutropeni a, whi ch may be an effect of endotoxi n release. Be careful
not to mi ss sepsi s, especi al ly in elderly pati ents, who may have a pauci ty of
other si gns of i nfection .
5. Neutropeni c patients are predi sposed to i nfecti ons wi th bacteria and fungi
(especi ol ly Candida and Aspergilus) . Some condi ti ons occurri ng predomi nantly
in neutropeni c patients i ncl ude ski n lesions from fungal i nfect i on , ecthyma gan
grenosum (often a resul t of Pseudomonas i nfect i on) . Sweet's syndrome ( neu
trophi l i c dermatosi s) , typhl i ti s ( i nfl ammati on of the cecum) , peri rectal i nfecti ons,
and opportuni stic pneumoni as.
6. Here is a more compl ete di fferenti al for neutropeni a:
MI N I MAL Wh i t e B l ood Ce l i S
v .. ./. . . . ,.. ,
.. ,, .. .
s . . . ( 8 1 2, ..
. , .. . . . . .,
v, . . ./ ... . .
: ... . .
.. .
u, .
s ,, . .
c . - ,.. /c, .. . ..
s ,. ,
Z M0O3lOlOQy
N E U T R O P H I L I A
NNb
- . ., ..
v. . ..
s..,. . .
s,.. .../ . ...
`..
I . Neutrophi l i a, an i ncrease i n " PMNS" (pol ymorphonucl ear neutrophi l s! , re
sults from four pri mary processes: peri pheral demargi nati on of existi ng PMNs,
marrow release of an exi sti ng pool of PMNs, newly synthesi zed PMNs, and
sti mul ation by mi scel l aneous systemi c di seases ( probabl y by a combi nati on of
related processes) .
2 . Peri pheral demargi nati on occurs when neutrophi l s outsi de the bone
marrow are released from thei r si tes of adherence al ong bl ood vessel s ( many
al ong vessel s i n the spl een and l ung) . Thi s process can rapi dl y doubl e the
number of neutrophi ls seen on the peripheral smear. Demargi nati on occurs with
physiologic stress, exercise, exogenous epi nephri ne admi ni strati on, steroid ther
apy, and nonsteroi dal anti -i nfl ammatory agents. The deficiency of the leukocyte
adhesion protei n CR3 causes neutroph i l s to adhere poorly to endothel i al cel l s
and mar gi nat i on i s i nhi bi ted. Pati ents wi th thi s defect have promi nent neu
trophi l i a and recurrent i nfections .
3 . Marrow release of an exi sti ng pool of neutrophi l s occurs with steroid ther
apy, acute i nfections, and i nflammati on (e. g. , thermal i ni ury) .
4. New synt hesi s of PMNs occurs i n response to i nfect i ons, necrosi s of
ti ssue ( e. g. , gangrene, pul monary or myocardi al i nfarcti on, thermal i ni uryl, i n
fl ammatory states ( e. g. , vascul i ti s, hypersensi ti vity reacti ons! , steroid therapy,
and myel oprol i ferati ve di sorders ( e. g . , pol ycythemi a vera, AML, myel oi d
metapl asi a) .
5. Vari ous systemi c di sorders, i ncl udi ng di abeti c ketoaci dosi s, uremi a from
acute renal fai l u re, metastat i c cancers, acute hemor r hage, hemol YSi S, and
ecl ampsi a, can sti mul ate neutrophi l i a. Toxi c exposures such as poisoni ng and
l i t hi um admi n i strati on al so may be associ ated wi th neutrophi l i a. The mecha
ni sm of neutroph i l i a i n these di sorders may be a combi nati on of the above
processes.
6. Persi stent neutroph i l i a of 30, 000 to 50, 000 cel l s/ml i s cal led a l euke
moid reaction (to di sti ngui sh from leukemi a) and may be the result of mal i gnant
M0O3lOlOQy d
i nvasi on of bone marrow, extensive i nfl ammati on, or severe i nfecti on . The neu
trophi ls seen in the ci rcul ati on are usual l y mature.
7. Two more specific di fferenti al s for neutrophi l i a are given below:
H I P MNS
+ .,
.
- ,. , ....
v, .. . .
s . .. ...
s. .
Note: This mnemonic emphasizes the most common etiologies of neutrophilia.
MAD N E UTROP H I LS
v, .. . .
:. . , .,.CR3 .
a .. .. . .
s. . . ...
s .. .
e . ... . . .
t ,..
s... , ../.... . .
e , .... ,......
- ,. , ....
+ .,/+ ,. .
.
. . .
s. .
Note: This mnemonic lists most of the causes of neutrophilia.
74 M0O3lOlOQy
PA N C YTO P E N I A
AI DS?
: ... . .
... .
a,. ... ..
s ,. ,
`..
1 . There are four pr i mary mechan i sms of pancytopeni a: apl ast i c marrow
( hypocel l ul ar ) , i nvaded marrow ( neopl asm, storage di seases) , dyspl ast i c
marrow ( normo or hypercel l ul ar) , and spl enomegaly. As the mnemoni c suggests,
'\ i nfecti on shoul d be considered in any patient with pancytopeni a.
2. Causes of apl astic anemi a i ncl ude congeni tal di sorders ( e. g. , Fanconi 's
anemi a) , chemi cal and other toxic exposures ( e. g. , benzene, al kylat i ng agents,
arsenical s, radi at i on) , i mmunol ogi cal ly medi ated apl asi a ( e. g. , SLE) , i nfections
(e. g. , hepati ti s, parvovi rus) , other mi scel l aneous associ ati ons ( e. g. , pregnancy,
t ransfusi on-associ ated graft versus host di sease) , and i di opath i c apl ast i c
anemi a. Marrow i nvasi on and replacement occurs wi th hematologic mal i gnan
ci es, metastati c cancers, storage cel l di sorders, osteopetrosi s, and myelofi bro
si s. Dysplastic di sorders feature a normal or hypercel l ul ar marrow and i ncl ude
Hl z defi ci ency, fol ate defi ci ency, AI DS, and pr i mary myel odyspl asi a.
Spl enomegal y and consequent hyperspleni sm promote accelerated removal of
cel l s from ci rcul ati on, and marrow cel l ularity i s usual ly normal .
3. In approachi ng pancytopeni a, fi rst rul e out drugs, toxi ns, i nfecti ons ( e. g. ,
AI DS) , and nut ri t i onal defi ci enci es as causes . Exami nat i on of t he per i pheral
smear may provi de cl ues to the di agnosi s, but bone marrow aspi rati on and
bi opsy are t he definitive tests.
4. The following mnemoni c l i sts the pri mary causes of pancytopeni a:
LO P MNS AND RBCS
. .
e.... .
M0O3lOlOQy O
,.
-.,.. .. . , . .
v, ,. ... .,
s ... ... ..
s. . .
: ... .
s.. . . ,( B 1 2, ..
a.,./. .
s. .. , ....
s ,.
c, . . ... . . :. . .
s. ./ . .
T H R O M B OT I C
T H R O M B O C YTO P E N I C
P U R P U R A
R ETI C
s. ,. ..
t .......
r ,. .
...... . ,. .
c.. ....,..
`..
1 . 'i s a di sease of unknown etiol ogy, The di agnosis i s based on the pentad
of: , l | renal dysfuncti on, 2| elevated body temperature, ( 3) thrombocytopeni a,
, ^l i ntravascul ar hemolysis ( " mi croangi opat hi c" ) , and ( 5) central nervous system
dysfunction ( i . e" al tered mental status, seizures) .
2. !may be t he result of endothel i al release of abnormal Von Wi l l ebrand
factor mul ti mers. These multi mers preci pi tate the formation of fi bri n mi crothrombi
/ M0O3lOlOQy
that occl ude blood vessels and damage RBCs and pl atelets. There is al so evi
dence that an i nhi biti on or deficiency of a critical Von Wi l lebrand cl eavi ng factor
is responsi bl e for the microthrombi . The resul t is a mi croangi opathi c process with
severe thrombocytopeni a and anemi a. The pri mary end-organ damage i s seen
in renal and neurol ogi c dysfuncti on. The peripheral smear is the key to maki ng a
prompt di agnosi s and i ni ti ati ng treatment. The smear shows schi stocytes, cel l s
damaged by the mi croangi opath i c process, and a marked reti culocytosi s
( " RETI C) . The reti cul ocytosi s i s evidence that t he marrow i s functi oni ng normal l y
i n response to peripheral destruction of RBCs. The MCV ( see Anemi a secti on) i s
el evated because of the i ncrease i n these l arge, i mmature erythrocytes.
3 . Coagul ati on tests are normal in TIP, whereas i n DI C abnormal i ti es of PT,
PTI, fi bri nogen, fi bri n spl i t products, and Wi mer are the rul e.
4. Treat ment of TIP i nvolves prompt pl asmapheresi s and pl asma exchange.
I ntravenous i mmunoglobul i n, vi ncri sti ne, and gl ucocorti coi ds may be benefi ci al ,
but control l ed studi es are l acki ng. Spl enectomy may have a role i n refractory
cases. Pl atelet transfusions are not i ndicated.
5. Hemolytic uremi c syndrome, a syndrome closely related to TIP, is seen pre
domi nantly i n chi ldren and has more promi nent renal i nvolvement. It may occur
after gastroenteri tis caused by E. coli 01 57: H7
T H R O M B O C YTO P E N I A
P LTS
- . ....
..
r. , ,. .
s,. . . ...
`..
1 . Thrombocytopeni a i s a resul t of one of four probl ems: peri pheral destructi on,
laboratory error, trappi ng i n the spleen, and synthetic problems. Peri pheral de
struction of pl atelets occurs with ITP, DIC TIP, PTP, prosthetic valves, pregnancy
associ ated di sorders, certai n drugs, systemi c i nfecti ons, and collagen vascul ar
di seases. Laboratory error may occur wi t h automated di fferenti al s. Be certai n
to look at the peri pheral smear to rul e out pl atel et cl umpi ng, whi ch wi l l give a
M0O3/OlOgy M
fal sel y low count . Trappi ng i n the spl een (sequestrat i on) reduces ci rcul at i ng
pl atel ets and i s seen i n any of t he processes that cause spl enomegal y ( see
Spl enomegal y secti on) . Synthesi s problems are pri mary bone marrow produc
ti on abnormal i ti es t hat occur wi th i nvasi on of marrow, dr ugs ( those causi ng
marrow suppressi on) , and some i nfections. Synthesis probl ems also may feature
decreased numbers of other cells (see Pancytopeni a section) .
2. Acute thrombocytopeni a i s an emergency, and " I TPS" l i sts the most i mportant
eti ol ogi es. A prompt di agnosi s i s critical , because bl eedi ng can be l i fe-threaten
i ng, and the treatments di ffer.
I TPS
.. . ,. ...( I TP)
t . . ,. ...(TTP)
- ,.,/-... .... ...( PTP)
s. ./ .. .. . ..... . .,. ..
3. ITP or i mmune thrombocytopeni a may occur as an isolated phenomenon or
i n association with mal i gnanci es, col l agen vascul ar di seases, or admi ni stration
of certai n dr ugs. Anti body-medi ated destructi on of pl atel ets may requi re i m
munosuppressive therapy. A careful search for a causati ve drug is cri ti cal , as
smal l amounts of t he offendi ng agent can trigger t he reacti on . Prolonged throm
boytopeni a occurs with drugs that are cleared slowly from the body, such as
gold and phenytoi n. Hepari n causes a specific and potenti al ly catastrophi c syn
drome of thrombocytopeni a and arter i al t hrombosi s cal l ed hepar i n-i nduced
thrombocytopeni a. The hepari n-induced pl atel et anti body test i s di agnosti c. All
hepri n, i ncl udi ng IV flushes, must be di sconti nued.
4. TP and the cl osel y related hemol yti c uremi c syndrome are treated wi t h
plasma exchange (see TIP secti on) .
5. PTP and pregnancy-ssoci ated syndromes shoul d be suspected i n women
wi th acute thrombocytopeni a. PTP i s a rare phenomenon t hat occurs 1 week
after transfusi on in i ndi vi dual s ( al most al ways women) l acki ng certai n pl atelet
antigens (the most common i s PlA 1 ) . Most patients have had a pri or exposure to
Pl 1 anti gens duri ng pregnancy or a prior transfusi on . I ntravenous i mmunogl ob
ul i n or steroids may faci l itate recovery i n 4-5 days. The rel ated pregnancy-as
soiated syndromes of ecl ampsi a, acute fatty l i ver, and HELLP ( hemol ysi s wi th
elevated l iver enzymes and low pl atelets) are l i fe-threateni ng. Microangi opathi c
destructi on lowers pl atelets preci pi tously, and ti mel y del i very of the fetus i s the
only cure.
6. Sersi s/DI C i s a syndrome of anemi a, thrombocytopeni a, and coagulopa
ty often occurri ng in associ ati on with a severe, systemi c i nfection . I t al so occurs
i n assoiation with mal i gnancies and i nfl a

matory conditions such as pancreati ti s.

b M0O3lOlOQy
Pat i ents have rapi dl y fal l i ng hemogl obi ns and pl atel et cou nts, wi t h an el e
vated parti al t hrombopl ast i n t i me. Bl eedi ng and i schemi a from cl otti ng may
be present . There i s a bi gh mortal i t rate, and i mprovements occur wi th treat
ment of the underl yi ng i l l ness . There may be some benefi t i n tryi ng to treat
severe bleedi ng ( pl atel et, R BC, and pl asma transfusi ons) or i schemi a ( hepari n)
i n certai n pat i ent s, but such treatment i s i ndi vi dual i zed. Treat ment of acute
promyelocytic l eukemi a may preci pi tate DI C, and prophyl acti c hepari n is of
benefi t .
7. The approach to thrombocytopeni a i ncl udes a complete hi story wi th a care
ful search for possi ble causati ve drugs, i nfecti ons, or i nflammatory condi ti ons,
and a physi cal exami nat i on focusi ng on the spl een and l i ver. The per i pheral
blood smear i s exami ned for evidence of cl umpi ng, mi croangi opathi c changes,
or other abnormal i ti es. I f the cause i s not certai n, then a prompt bone marrow
biopsy shoul d be performed. Patients with ITP, TIP, PTP, and other causes of pe
ri pheral destruction wi l l have normal or i ncreased numbers of megakaryocytes.
A pri mary marrow di sorder may show decreased megakaryocytes or an i nfi ltra-
oc
.
8. Here is a more complete di fferenti al for thrombocytopeni a:
H E LP ME, I TS Ol e!
+ ,. . .,/-
s .. ./- -/......, .
. . .../. . ,..
- ... .. .
v. ,.,/v. .. .
s ...,. . ..
.. . ,. . ..
r.. .. --
s.., ..../,. .
a.,. , . . . . .
. ./.. .
c .,.... . ... . . , ...
M0O3/OlOgy M
T H R O M B O C YTO S I S
PLATE L ET CRI SI S
- ,,. ...
. .
:. .,
t .
s... . . ,.. .
.,.
s p
t .
c. ...
s ... . . . .
.
s. . .
,
s .,
`..
1 . Pl atelets i ncrease i n response to systemi c processes ( "acute phase reactant ") .
Mast cases of thrombocytosi s are a refl ecti on of an i nfl ammatory condi t i on .
When the platelet count exceeds one mi l l i on, suspect a pri mary myeloprol i fera
tive di sorder such as essent i al t hrombocythemi a, polycyt hemi a vera, or l eu
kemi a. Bone marrow bi opsy i s i ndi cated.
2. The four " I " s of thrombocytosi s are i nfecti on, i nfl ammati on , i ron defici ency,
and i ncreased producti on.
80 M0O8lOlOQy
T R A N S F U S I O N R E AC T I O N S
GOT A BAD U N I T
a... ..... ...
e. . .
t ,. .( PTP)
: ..
s .. ... ., .., ..
:.. ,. ..
a ., ,. ..
e . . . . , . ..
s.
. -I V, .. . . CMV .. . .. .
t.. .. ... .. , ,(TRALI )
`..
1 . H'ood p|odcc||ocs|csoc soc ~po||oc|ocd||eqcec|y ' |esov cg|e|opy
Adve|se|eoc|ocs|o|ocs|cs ocso|e co~~oc, oveve, ocd |cs po|s ~oc ocs
cseo|| s c|e|vec|oc sceeded. !rocs|csoc eoc|ocso|eo|ood'yc' oss | edos
~~cce ocd coc ~~cce I mmune causes cc' cdeg|o||ve|scsos|d seose,
pos|||ocs|cs oc ||o~oocy|opec o, o ' o ~~cc zo| oc, o'ood p|essce cs|oo ' |y
|o~ ocopy'ox s, occ|eocd de'oyed e~o'ys s, c|| co| o, cec||op ' c|eo||'e|e
oc| ocs, ocd!<AJ, o cec||op cdcced ' ccg c cy Noni mmune compl i ca
ti ons o|||ocs|cs oc cc' cdeove|'ood , e |e|occ|evo c~eexpocs oc o| c|oc c
ocove| oodlocd c|ec| ocs.
2. Graft versus host di sease ( GVHD) so oeco~p co| oc o|||ocs|cs oc |e
sc' | cg ||o~ ||ocs|cs oc o| v oo' e, doco| y~pocy|es. !|ocs|cs ocossoc o|ed
GVHD csco' 'y occc |s vec o po| ec| ece ves o' ood ||o~ o c' ose' y |e o|ed
doco| !edoco|s ' y~pocy|es oveco~~ococ| gecsocd oe co||ecogczed
os |o|e gc oy |eec p| ec| !ese 'y~pocy|es, oveve|, see |e |ec p ec|os
|o|e gcocd po' |eo|e, ' eod cg| o|c' ~ coc|~c |o|gocsys|e~ |o c|eocddeo| .
3. Overload states, e |e|vo' c~eo| |oc, o|e co~~oc coc ~~cceco~p co
| ocso| ||ocs|cs oc 'c o de| po| ec|s ocd po| ec|s v| co|d ocd seose, | e
vo' c~eo|| e||ocs|cs oc ~oycocse pc ~oco|yede~o ! sco~p' co| occoc
M0O8lOlOQy M d|
oe ovo ded oy s ov ^|cs o^ o od~ c s|e cg o d c e| c |o^ ove' ood ~oy
occc| ^ po| ec|s eqc | cg c~oc c||ocs|cs o^s !~ s po|e^| o 'y|o|o' co~p co
| occo^ oe pevec|edv|~c~e' o| o^|~e|opy
4. Thrombocytopeni a so o|ecocseqce^ceo||ocs|cs oc | scsco ysee^ ^
vo~e^v|~o spec|cpo|ee|oc| gec|ype, v~o~ove~odo p|o|peg^o^cy !~e
p co pesec|o|oc s ~osed |~|o~oocy|ope^ ooccc|| ^g seveo' doys o||e|o
|ocs|cs oc o|ec|sspo^|oceocs'y|ecove, oc|s|eod |~e|opyo|'\ ~~c^og'oo
c c~oyoe o| oe^e||.
5. Al l oi mmuni zati on |o o'ood ce o^| gecs o HL o^| ges sco~~oc o^d
co~p' co|esscoseqcec|||o^s|csocso^do|goc |ocsp o^|o| on ovocs'y, ~ ^
~ z ^gexposce |o o'ood podcc|s sdes oo' e
6. Bl ood pressure i nstabi l i ty ocds~ococcc c po| ec|sv |~oc| oodes|o
' gA !~ese ^d v dco s eqc e 'gAe| c ec|o ood p|odcc|s |o~ e'o|ves ooe
doco s|s
7. Ac

te hemolytic reactions oe o|eocdo|e^o esc'|o|AH cco~po| o |y

o| o |ev o|~eoc| gecs !~ecocse|eqce^| y sc e co' eo, o^d |~e |esc | s
|op d c|ovoscc' o|~e~o ys s o|e^|s ~oy~ove| cs~ ^g, c~es| ocd ooc po c,
cocseo, do|~eo, do|c| ce, |eve, c~ s, ocds~oc e~og' oo cc o, |eco |o
ce, C, o^ddeo|~~oye^sce A^ ~po||o^|c' ce|oo|o^s|cs o^eoc|o^ s|~o|
|~e ~e~og oo c does co| se |o |~eexpec|ed eve o|e||~e ||ocs|cs oc |~e
~e' p|c ooo|o|o|y s|cd es ^c' cde ~op|og' oo c, c^coc cgo|ed o co c , sec~
ocd c ce |ee ~e~ogoo ^s, ocd o d ec| Coo~os|es| !~e cd ec|Coo~os
|es| ~oyco|oe pos | ve s cceo geo|cc~oeo|oc| ood esoe ooccd|o <HCs
8. Delayed hemolytic reactions oe o |esc'| o|ex|ovoscc'o e~oyss ocd ~ove
o ~oegodco' ocse| !~eseeoc|ocs~os|o|ec oe cocsed oyoc| oodes|o|~e
<~sys|e~, oc|o|~es, e g , e , c||, dd|oeco~~oc ^oose, oc^d ce, o^d
|eve|occc ol J doyso|e||o^s|csoc , oc|~oeseve|eco~p co|ocso|eo|e
9. Urti cari a |o~ o cc|oceocs o ' eg c |eoc| o^ so co~~o^ o^d oec gc e
spocse |o |o^s|cs o^. ' | coc csco y oe ~ocoged oy s ov cg |~e ^|cs oc o^d
od~ ^s|e| cgoc| ~ s|o~ ^es
1 0. Neutrophi l i c reactions csco ycocse|eve ocdoe o esc |o| ~~ccede
s|cc|oc o| ||ocs|csed ' ecocy|es !~ese eoc| ocsoe csco ' y~ ' d ocd |eo|ed
v|~ o^| py|e| cs
1 1 . I nfecti ons ||o~||ocs|cs oc ~oy oe cocsed oyv cses, ooc|e| o, o| p|o|o
zoo^s !~e | so| c|ec|oc s ov, oc| s| ' p|esec| S|e zo| oc s poss o e|o
so~e p os~oco~po^e^|s, oc| co||o|ce' ' c o|podcc|s Coe|c' docosc|ee^ ^g
ocds|ocdod oooo|o|yossoysoe| ~e~os| ~po|o^|p|evec| ve ~eosces
1 2. Transfusi on-associ ated l ung i nj ury so o|e|ypeo| ceJ||op~ ' c|eoc| o^
A^o eg cpc ~oco|yede~o |esc'|s||o~ ' ccgseqces||o|o^ o|oc| oodycoo|ed
cec|op~ s o| e^|s v|~ |~ s ~oe sevee eoc|o^ ~ove o ~ g~||e|o| oc| ood
es|~o|eoc|v|~ do^o|' ecsocy|es. \|~ scppo|ve co|e, ~os| po|e^|s ~oveo
good ecove|y
dZ M0O8lOlOQy
I
INF ECTIOUS DIS E AS E
Cl i nical Symptoms and Si gns
F E V E R O F U N K N OWN
O R I G I N
I GOT T H E F E VE R*
...,. ...
a. . .... ... ,.. . .,..
,.. .... .. . .
e. . . . .
r. . . , ,. .
. ./...
r ./ .. . .,.
+,. . . .../..
s . . .
-.. . ..
s . . . .,
.... . .
s- . . ...
s... , ...
* diferential diagnosis
l/l0Cl/Ou5Ll50850 oJ
`..
1 . !e c' oss c |eve| o| c ^\^ov^ o g ^, 'Ul vos de| ced os |eve|s ge|
| o^Jo J"C o^ seveo occos ocs, dco| oco| ' ' cess > J vee\s, o^d |o ce |o
|eoc o d og^os so|e| 1 vee\o| ^osp|o' ^ves| go| oc. ! sos oee^ ~od
|ed so~evo|os~ocypo| ec|so|e ^o|osp |o' zed, o^dspec o' co^s de|o| o^
sg vec |o ^ec|opec c, ^osoco~ o' , ocd '\ossoco|ed 'Js
2. ^|ec|ocs ^ovcocseo s~o' 'e|o~oc^|o|Usoecocse ~ cooo'ogys|cd
es ove ~poved de|ec| o^ !H, po o^ged ~o^o^cc' eos s sy^do~es v |
cH\, C^\, ocd ' \, ^||ooodo~ co' ooscesses, os|eo~ye| | s, ^|ec|ed p|os
|e|'c devces, o^d ecdoco|d | so|ecocsdeo| o^s. Cc'|c|e^ego|veecdoco|d
| s s|o|e, o | ocg p| o| ||eo|~e^|v | oc| o o| csocd |os| d ocsogo^ s~s
, AC:Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans,
Co|d oooc|e| c~, Eikenella corrodens, Kingella kingae) soc' d oe cocsdeed
3. !c~o|so|e 'ess||eqce^|cocsesdce|o ~p|oved ~og ^g ~odo' | es
4. 'oc| | ocs|eve|soe ~po|oc|cocs deo| o^s. ^ocyoveoccc|ed ^yoc^g
vo~e^ c|eeo | p|o|ess o^s.
5. c~o^yc oss c '3s, |e|e os oeec o^e||o ^|e ^ | o vo\cp | s ~
peo|ve|oco|e|c''y |evev o ' p|evocs d og^os|c s|cdes , ~og cg, po|o' og c
spec ~e^s, ocd ~ coo o'ogylocd ^o|s ~p y|e' yo^ epo||s !epo| ec|soc d
oe o|| o' ' ~ed co| o^s, | poss' o e, ocd ~c' | p' e o'ood cc | c|es , ||ee |o s xl
soc doeoo|o ^edo^d oe\ep||o|o| eos|2vee\s|oecsc|eg|ov| o||os| d
ocs , . e. , ACcogo^ s~s. |espec o' zed cc' |c|e|ecc qces ~oy oe ^d
co|ed |o| | ccg /o|yp co ~ycoooc|e o, o| cc| | | o^o' vo| oc| ooc|e o !e
|e~o' ^de|o||evo|\cp sd c|o|ed oy|e po| cc' o|cose |S<, |eo| ' eogg' c
| ^ ^s, o^d ||es |o|vo| ocs ^|ec|ocscocseso|ec o|e oo|o ced, oc| oe pooo
o'yo| 'ovy e' d 've ocd oo^e ~o|ov o ops es o|e oc| ^e c 'Uvo\cp,
oso|e ~og cgs|cd es , csco y ces|o^d oodo~ co C!sl e odc |evevocd
|eossess~ec| sc | co' A|e|6 ~oc|s, o s gc | coc|po||o^o|'3s ~oy oec^
d og^osed ,> 20x|
o4 l/l0CllOu5 /l50350
I N F E C T I O N S C AU S I N G
S P L E N O M E G A LY
TH E TR EATABL E SP L E NI C MASS
t. . .
+ .. ... .
sBV . .. . . .
t,.. .. . .
s .. ,. . .
s . . .
: s
t . .. .
: ....
|'
3 .. ,.. .
s . . .
. .. .. . . ...
s . .
s. . ., .
-. .... .
., ...
s . ,..
s. , ,. . . . ...
. .... . . . .
CMV
v. . .
:... .. .
s, .
s ... .. .
`.
Avoys cocs deococcc' |, ^|ec|ocse|oogy|o| sp eco~ego' ys ^ce|esed s
eoses o|e e' y|o espo^d |o oppop o|e |e|opy. . s|ed ooove so d ||eec| o'
o||ecc~e|ocs c|ec|ocsossoc o|ed v |~sp eco~egoy
l/l0Cl/Ou5 L/50350 85
T E M P E R AT U R E P U L S E
D I S S O C I AT I O N
BAD TE MPS, LO H R
s . .
:., . . . , ... , .
a,..
r. .. .
E BV
v,.. .
-. .... .
s. .
... . .
U . .. .. .
+.. . .
s ... . ..
Also: yellow fever, "factitious" fever
`.
!ec ^ co' | ^d ^go|o 'ov eo|o|ev |o g|e~peo|c|e~oy cdco|e c
|ec|o^ v | o~ ^||oce' ' c o po|oge^ . ' depo| e^|sv | cod occo^dcc| oc
sys|e~ d seoseoo^ oe|oo'ocse|so' so ~oyoveo lower |o^-expec|ed eo||
|o|ev ||eve|
86 //l0Cl/Ou5L/50350
Cl i ni cal Conditions or Diagnoses
AC U T E M E N I N G I T I S
I N F ECTS A LOT*
.., /..... , .
Neisseria meningitidis
-. ,.
Escherichia coli
c, . . ./ . . ..
t.. ..
Streptococcus pneumoniae
:.. , . . . .
Listeria monocvtogenes
e. . ./... . ./. .. . .
t.. .. ,.
Also: subarachnoid hemorrhage
* diferential diagnosis
`..
Acc|e ~ec cg | s s|~eoo|cp|ocse|o|~ec cgeo' c|'o~~o| oc, |ypco''yossoc
o|edv |~ c|ec| oc
I . C' oss csy~p|o~s o|occ|e ~ec cg | s cc' cde |eve, eodoce, s| || cecs,
ocd o |eo| oc c ~ec|o s|o|cs ' c odd | oc , se zces, po|op~oo o, vo~ | cg,
ocd|oco' ceco og cde|c|s ~oy occ.|.
2 . \o|scpo|scspec|ed ~ec cg | s must cc cde exo~ co| oco|CS'.
//l0Cl/Ou5 L/50350 o/
Asep|c

oc|eo epes S ~pex

/eccg|s,\|o /ec cg | s :ccep~o'|s T

/e^ cg|s
\

C l 02000 l000- I 00, 000 0- I 000 I 00 l 000

||eec| o :oy /`s /os|y/`s /os|yy~p~s :oy. /`s
.o|e y~p~s .o|e yp~s
C ccose `o~o /oyoe ov `o~o /oyoeov
o|e `o~o /oyoe ~ g~ 'oo /oyoe~ g~
' c odd | oc , c~ec CoC ocd d ||eec| o |o ev decce o| sys|e~ c ^|ec| o^
C~ece'ec|o'y|es, g' ccose, oc doU`/ceo| ^ ce, o^doo|o ^ oood cc |ces
Coc o C!scoc s ^dco|ed ^cosesv |~ |oco ^eco og cde| c |so|evdecce
o| ^ceosed c|oco^ o p|essce, o |scoooc~^o d ~e~o~oge s scspec|ed
C~es|ocd s ^csxoys oe ~e p|. dec||y^g po|e^| o socceso| ^|ec|oc
3. ooc|e o ~e^ cg | s s o ~ed co e~e|ge^cy, o^d d ogcos so^d |eo|~e^|
~cs| oe c | o|ed c o |~e y|os~ oc 'deo y, CS s~oc d oe oo|o ced po~p|'y
o^d o' . o|cs s|o|ed os soo^ os |~e ' s co~p e'ed oveve, antibiotics
should not be delayed v~ ' eovo | cg^eco ~og ^go ||~ee oed ||cc' | es ^
oo|o ^ ^gCS
4. Scspec|ed e|o ogcoge^|sd ||ev|~ po|ec|s oge
o `eoco|es/' c|o^|s E. coli, o|~ego~ cego|ves, Cocp o streptococcus,
| monocytogenes, oey 5 pneumoniae
o C~ dec N. meningitidis, 5 pneumoniae. Haemophilus influenzae os o
cocse o| c~ d~ood ~e^ ^g|s ~os deceosed dce |o v despeod cse o| H. in
fluenzae ~~c^zo| oc
c Adc| 5 pneumoniae, N. meningitidis. c o' depopc o| oos, E. coli, o|~e
go~ ^ego|ves, ocd L. monocytogenes occcv|~ ^ceos cg|eqce^cy
5. |~e s|oc|os/c c co | cd cgs |~o| ~oy ~e p|o de|e ~ ce e yogoc
s~s ^c' cde
o <ecec| cecoscg co procedure-Staphylococcus aureus, ' epidermidis,
ocoeooes, go~ ^ego|ves
o oo c/ep dco ooscess, ~eod |oc~o ocoeooes, go~cego| ves, '
pneumoniae
c :^docod | s/' \dcg cse'. aureus
d Sp e^ec|o~y, s c ece d seose' pneumoniae
e ' ~~c^oco~po~ sed secocdoy|o c~e~o|~eopy, s|e|o ds'. pneumo
niae, | monocytogenes, |ccg , Mycobacterium tuberculosis, cy|o~ego ov |cs,
epes
| '\/A' SToxoplasma gondii Cryptococcus neoformans, M tuberculosis,
cy|o~ego ov cs, ~epes
g C~o^ co co~o s ~' pneumonaie, L. monocytogenes
~ Cocge^ |o de|ec|/de~o ||oc| ' aureus, ' epidermidis, E. co/i, go~
^ego|ves
||s/~os|o d| s/s ccs | s' pneumoniae, H. influenzae
i . <os~/pcpcoN. meningitidis
88 l/l0Cl|Ou5 /l50350
6. ^e^ ^g s~cs, s| || ^ecs, ^cc~o' g d |y| s oe ysee^ ^ ^eo^o|eso^d c
|o^|s. ' evse, | ~oy ^o| oe po~ ^e^| ^ e' de'y, deo ' |o|ed po|e^|s
7. Scoooc~^o d ~e~o~oge ~oy pese^|v |~ o |eo|o^ ^ ~e^|o' s|o|cs, s| |l
^ecs, ~eodoc~e, o^d eve^|eve.
8. !eo|~e^|s d ec|ed o|' eyc^de| y ^gogo^ s~s. :~p c|eo|~e^|s~oc d
oe ^ | o|ed ossoo^ os posso eo^d ~oyoec~o^ged ' o|eosCS'o^dcc' |ce
esc' |s oeco~eovo ' oo' e ' ^ ^eo^o|es, e~p c| ~eopy ge^e o ' yco^s s|s o|
o~p c ' ^ o^d ge^|o~ c ^ ' ^c~ ' d e^, ce|o|ox ~eoce|| oxo^eoe csed ^
| o y, ^ odc|s, pe^ c ' ^C
A I D S/ H u MA N
1 M M U N O 0 E F I C l E N C Y
V I R U S
STOP CATCH I NG I T*
Sa l monel l a ( sepsi s, di a r r hea)
Thrombocytopeni a
Oncol ogi c di sease ( Kaposi 's, l ymphoma)
Pneumocystis carinii
Cytomega l ovl ru:, ryptococcosi s, Candi di asi s,
C ryptospor i di um
Avium intracellulare, mycobacterium
Toxopl asmosi s
Consti tuti onal symptoms
Herpes si mpl ex/zoster
I at rogeni c
sode enl argement/l ymphadenopathy
aui l l ai n Barre syndrome/neuropathy
I sospora
Tu bercul osi s
Also: dementia
* clinical manifestations/opportunistic infections
l/l0CllOu5 Ll50350 89
`..
1 . ppo||cc s| c c|ec|ocs ~oyoec' oss | edocco|d cg|o|eogoc sys|e~, sl
cvo'ved
o Agec|s ossoc o|ed v | pneumoni a/pneumoni ti s cc' cde Pneumocystis
carinii cy|o~ego ov cs, Mycobacterium tuberculosis, e|pess ~p' ex.
o Di ssemi nated i nfecti ons o|eseec v | Mycobacterium avium introcel/u
lore, Mycobacterium tuberculosis, c|yp|ococcoss, epess ~p' ex
c. `eco' og c c|ec|ocssccosencephal i tis ocd meni ngi ti s o|ecocsed oy
cy|o~ego' ov cs, M. tuberculosis, c|yp|ococcos s, |oxop' os~os s, ocd d |ec|
C`S c|ec|oc oy\
d Ocul ar i nfecti ons csco 'y o|e ossoc o|ed v | cy|o~ego ov cs o |oxo
p os~os s.
e Cos|o c|es| co' ( esophagi ti s, di arrhea) ~oc |es|o| ocso|e seec v |
cy|o~ego ov |cs , esopog | sl , cocd d os s,esopog | s, o o' ||csl , e|pes
s ~p ex,esophog | s| , c|yp|ospo| d c~, d o|eo| , sospo|o , d o||eol , ocd so'
~oce' o , d oeo|
| Cutaneous i nfecti ons oe csco' ' y dce| o epes s ~p' ex ocd e|pes
zos|e|
2. cco' og c ~oc |es|o| ocso|A S o|e p| ~o 'y dce|o opos s soco~o
ocd' y~po d~o' gcocc es.
3 . !e|eoe o ~y| od o| cec|o og c ~oc |es|o| ocso|A' S v c coe' o|e
|e~po|o' ' yv ||es|ogeo||e ccde|' y cgd seose.
Asy~p|o~o|c
Asep|c~ec cg | s, csco yeo y ccoc|se
Acc|ede~ye co| cg poycec|opo|y, Cc ' o cHo|l, csco' 'yeo|'y
C|oc c po'ycec|opo|y, 'o|e|
^ye'opo|y, o|e|
^ec cg | s/eccepo | s, oppo||cc s| c c|ec|oc o|e ccocse
Ceeo|o' ceop'os~ , p ~o|yceeo|o' y~po~ol , 'o|e c coc|se
Sezc|es, vo| oo' e
S||ose/ sce~ o, vo oo e
e~ec| o, ' o|e ccoc|se
4. e~o|o'og c~oc |es|o| ocso|A S/ \
o. !o~oocy|opec o
o Ace~ o
c ec|eosed!^' y~pocy|ecocc|
5. Cocs| |c| oco' /sys|e~ csy~p|o~so|e ve|yco~~oc ocd ~oy oe cocspe
c | c, po| cc o' y c|e eo|' ys|oges o||e d seose. oveve, |eyo' so ~oy
e|o' d |eocse|o|oc oppo|cc s|c c|ec| oc, ocd|cs ~cs|oe|osecse|ocs'y
!ese s gcs ocd sy~p|o~s cc cde|eves, o|| |o' g o, | go|s, ~yo g os, os,
d o|eo, oodo~ co po c, eodoce, |o| gce, ocdve g|' oss
//l0Cl/Ou5 L/50350
I M M U N O D E F I C I E N C Y
S TAT E S
SCANT DI SEASE B LOCKS
Ski n di sease
Compl ement defi ci ency
A nt i body defi ci ency
Neutrophi l di sorders/neutropeni a
T-cel l abnor mal i t i es
Di abetes
ntravenous drug abusers
Spl enectomi zed pat i ents
E l der l y
AI DS
Steroi ds and ot her i mmu nosuppressi ve drugs
ETOH abusers
Babi es
Li ver fai l u re
Organ transpl ant
Cancer
Ki dney fa i l ure
S ta rvat i on/ma I n utr i ti on
"otes
1 . !~eSCA`1po|o||~ s ~^e~o^ ce~p~os zes|~e|ve ~o o|co~poce^|s
o| |~e ~~ccesys|e~ cc|o^eocso^d ~cccs~e~ooce oo| es, co~p e~ec|,
o^| oody, p~ogocy|es, o^dce ~ed o|ed ~~c^ |y
2. o| e^|sv |~oc| oodyde| c ecc es ~oveecc|e^|o c~oc cs ^opc' ~o^oy
c|ec| o^, ~e^ cg | s, ocd ooc|ee~ o, o' ' o|v~ c~ o|e ~os| co~~ocycocsed
oypyogec cooc|e| o
3. | e^|sv |~ co~p e~ec|de| c ecc es o|e p|ed sposed |o pyogec c ooc|e|
o' ^|ec| oc, ocd |~ose v |~ |e ~ ^o' co~p' e~e^| co~po^e^| de| c e^c es
,CoC-j~oy~ove |ecc||e^|`e sse| o c|ec|o^s
l/l0Cl/Ou5 L/50850 l
4. A.~o~o |eso|!ce sp|ed spose|od sse~ ~o|edv o' ~|ec| o~sosve os
|.~g o~d o|~eoppo||.~ s| cogo~ s~s
5. `e.|ope~ c po|e~|soe ped sposed |o .oc|e o o~d|c~go ~|ec| o~s
6. Sp e~ec|o~zed po| e~|soe o| ~ g~ | s|o sevee ~|ec| o~s .y e~cops.
o|edogo~ s~sd.e|o S. pneumoniae, H. influenzae, o~d N. meningitidis. The
z .oc .s ( Capnocytophaga canimorsusj s o |os| d ocs go~~ego| veo
go~ s~ |~o|~oyco.se|c ~ ~o~| ~|ec|o~ o||e|o dog . |e Sp e~ec|o~ zed po
| e~|s o so ~oy ~ove ~o|e sevee ' ~esses |o~ p|o|ozoo s.c~ os Plasmodium
malariae o~d Ho.es o
R H E U M AT I C F E V E R
J ONES *
J oi nt s ( pol yart h r i ti s)
Over l oad/openi ng snap ( car di ti s, val ve di sease)
Neu rol og i c ( chorea)
E rythema mar gi natum
Subcuta neous nodul es
* maior manifestations
`otes
1 . <~e.~o| c|eve so~ ~| ' o~~o|o|yd seose |~o| occ.|s oso de oyed se
q.e' o|ogo.pA s||ep|ococco p~oy~geo ~|ec| o~ !~e d og~os s s ~ode.y
spec | c ~o o|o~d ~ ~o| ~o~|es|o| o~so| |~e d seoses. !~e ~o o~o~ |es|o
| o~so| ~ec~o| c|eve o|e sc~~ozed .y |~e ~~e~o~ c|':S, v~ c~ e|e|s
|o |~e|o~esc |e o
2. !~ej oi nt i nvolvement o| ~e.~o| c |eve s oc oc.|e ~ g|o|oy po'yo|~| | s
~os|co~~o~' yo||ec| ~g |~e ' o ge o ~|s o|| ~eex|e~ | es, ..| | ~oyo||ec|
o' ~os|o~y o~| ~|~e.ody
3 . Overl oad/openi ng snap e|es |o |~e co|d oc ~vo ve~e~| o| |~e.~o| c
|eve!~ s s| ~e~os| ~po||o~|~o~|es|o|o~ .eco.se|~oy.e|o|o ~| ~eocc|e
s|ogeso 'eod |o pe~o~e~|vo'vedo~oge o~d o~g|e~ cod ocdys|c~c| o~ .
4. !~e neurologi c mani festati ons o| ~ec~o| c|eve ~ove .ee~ co ed Syde~
~o~s c~oeo o S| \ |.s do~ce, o~d |~ese ~o~es e|e |o |~e c~ooc|e s| c
Z //l0Cl/Ou5 L/50350
scdde , o ~ ess, egc o ~ove~e|sv~ c~ ~oy oe occo~po ed oy ~csc' e
veoessod e~o| oo s'oo |y !~ec~oeo so||e o deoyed ~o |es|o| o
o|~e.~o| c'eve
5. Erythema margi natum s o evoesce| p os~ |~o| s c~ooc|e s| c o|
~e.~o| c|eve !~eey|~e~o s'os e|, ~ go'oy, od ~oyoe oo.g~|ooy
'~e opp co| o o| eo|
6. Subcutaneous nodul es oe s~o' , peoszed, po ess sve' gs|~o|occc|
oveooypo~ eces od|edos
`. ^ o ~o |es|o' os |~o| co oe csed es|oo s~ g |~e d ogos s o|
~ec~o| c|eve c cde|~ec co' | d gso|o|~o g ood|eveosve''os|e
oooo|oy| d gs o| o e evo|ed ey|~ocy|e sed ~e|o| o o|e, o e evo|ed
Ceoc|ve po'e eve , odo po oged < |evo o |~e :C
8. .v decescppo| goo|ecede|g|ocpAs||ep|ococco |ec| o c .des
o pos | ve |~oo|cc |.e, o pos | ve op d s|ep|ococco o| ge|es|, o o e e
vo|edo s g s|ep|ococco o| oody | |e !~ed ogos s o| ~ec~o| c|eve s
~ode oy ~o ood~ o ~o|es|o| os, osve' oss.ppo| g ev deceo| o
gocpA s|ep|ococco |ec' o | |~ee s ev dece o|o peced g gocpA
s|ep|o.occo |ec| o od |vo ~o o ~o |es|o| os, o oe ~o o od|vo
~ o ~o |es|o| os, |~e |~ee .s o ~ g~ poooo ' |y |~o||~e po| e| ~os occ|e
~e.~o| c|eve
9. '~e| d gs|~o| ~oy oe pese| o po| e|v |~ ~ec~o| c|eve c cde
oodo~ o po , |oc~ycod o, od ep s|ox s, o.||~ese | d gsoe ospec | c
odo| ~ od ogos|cvo .e
S E X U A L LY T R A N S M I TT E D
D I S E AS E S
NO WRAP, U G ETS CLAP*
NOngonococca l u rethr i ti s
Warts, geni t al
Rei ter 's syndrome
AI DS
P rocti ti s, i nfect i ous
U l cerati ve geni t al l esi ons ( herpes si mpl ex)
l/l0Cl/Ou5 //50350 do
W
Gonorrhea
E pi di dymi t i s
Tr i chomonas
Syph i l i s
Cytomega l ovi rus, Cervi ca l ca ncer
L i ce
A rth r i t i s
Pel vi c i nf l ammatory di sease
* o|eeo|o' oogoo::
`otes
1 . C .o sy~p|o~s |o' o g sexco y |o~s~ '|ed d seoses ,S's| |oo pys
. o~s o|'e~| o~ . cdege |o d s.oge, po / d s.o~|o|, ov s o e es o~s
^oypo'e~|sv |S'soeosy~p|o~o|.oddoo|see ~ed .o .oe
2. ope ~ooge~e'o|o po'e~|v ' o~ S' ~.s| ~. cde de~||.o|o~ od
|eo|~e~|o||e |e.|ed po|~e
3 . | se p|. |o. oss |yS!s |o.o~~o .' .o pese|o| o~sosydo~es
o Je| | s, ~oes | o.| | s/ oveC ~|e.|o~s
o :p d dy~ | s g. A.c|eo|~ | s
. Ue|~ |s/.ys||s ,|e~o es| \o|s
d \cvovog ~ | s

e v. ~|o~~o'oyd seose ,|e~o es

e J .eo|ve esos
4. Je| ' s|yp .o ypese~|sos o .e|o d s.ogeod/odysc o o sex.
o y o.|ve ~o e 'e ~os| e yoge|s oe N gooo|eoe, C|'ooyoo |oc|o
oo|:, Jeop|o:oo .eo'y|c.o, o~d epes s ~p exv cs A |e~o|ed og~oses
|o oe.os deed . cde oo.|e o .ys| ' soos|o|| s
5. :p ddy~ ' s ~oypese|os c~ o'eo |es| .c o po !ed ||ee| o d og
\
~os s . .des|es| .. o|os o~, |o.~o, |es| .. o .o.e, o |e.|o As ~ .|e
|~| | s, N gooo/|eoe o~d C |oc|ooo |: oe |~e pedo~ ~o~| oge~|s Co~
~ego|ves ~oy .ocseep d dy~ | s ~ o de~e~o|ole . oy|o.| po.ed.es
6. .ovege|oc ~oy ~|e.|o~s |e~o espese|v |vog ~o d s.oge, dy
sc o, po ~|. |e.ocse, o~d/o ge |o d s.o~|o| Je| | s/.ys||s ge~eo y
.o.sesdyscoo~dsdce|o N gooo|eoe, C |oc|ooo|:, o oo.|e o .ys| |s
\cvovog ~ ' s |yp .o y ~o~ |es|s v ' vog ~o d s.oge, vog o po ~/d s.o~
|o|, o~d dysc odce|o.o|o.|o| c ~ev | ~| o~ed oo o ~oy e|o og.
oge~|s oe yeos|s ' Cooooo o'ocoo:| , c|ooooo: vogoo':, o~d oo.|e o
, Coooee''o vogoo':, ~y.op os~o, e|.
7. Ce |o . .esoe.o.sed oy|e|o' ov ~gogo~ s~s
o |epooeoo po''o.o ,syp s|
94 l/l0C//Ou5 //50350
>
. .es o~ , c~o~ce| c ceo|ed, po ~ ess, | ~, ~d.o|ed popc' e ~c.
oo| o~ l J-Jdoys
Ade~opo|~y | ~, d sce|e, ~ovoo' e, po ~ess, occ.| ~g 1 veeso||e
c~o~ce
o |e/pe: geo/|o'/:
.es o~ ~c | p' e, po ~|.' , ey|~e~o|ocsves c' es ' ~c.oo|o~ zdoys
Ade~opo|~y |e~de, so||, ~o|po~ ~e~|v|~ ecce~| eso~s
c |oeoop|'.: o.c/ey c~o~co d|
.es o so||, ~o| ~dco|ed, vey po ~|c ves c e/popc e |o c ce
~ccoo|o~ Jo doys
Ade~opo|~y po ~|c , J~ o|eo , scppco| ve, occc ~g l vees o||e
p ~oy
d. C|'ooyoo |/oc|ooo|: , y~p~ogo~.'o~ove~eec~|
.es o~ po ~ ess, o||e~ c~~o| ced pop. e/.' ce| ' ~ccoo| o~ oz I
doys
Ade~opo|~y |e~de, o o|eo , JJ7| , ~o||ed, s.pp.o| ve, occ. ~g
oz l doyso||e
e Co'yooo|oooc|e/.o g/oo.'ooo|: , go~c o~o ~gc ~o e|
| . 'es o~ po ~ ess, egc o, |~ c'e~ed popc e/. ce ` ~ccoo| o~ -'J
doys
Ade~opo|~y ~o~e ^oydeveop go~ ooscesses, ~oveve
o. Ac.|e o|~ | s s ~os| co~~o~'ycocsed oy N. gooo//|eoe ~ yo.~g od. |s
<e |essy~do~e sseco~d ||ee~| o d og~oss ~c .deso|~e ~|ec|o.so|~
|des , oeoogococc.:, e:/o/o, syp~ s| , cys|o' ~d.ced o|~ | s, <A, S'., o~d
soco d See| ~ed ||ee~| o |oocc|e ~o~oo|~ | s ~| ~e<~e.~o|o'ogyc~op|e
|o| ~oe ~|o~o| o~
9. Ce~ |o vo|s ,co~dy o~o oc.~ ~o|o| oe co.sed oy ~c~o~ pop o~ov cs
o~d oe ossoco|ed v|~ cevco dysp os o '~ed ||ee~|o d og~oss o|vo|s
~c cdesco~dy o~o o|o ,seco~doysyp~ s| o~d ~o' cscc~co~|ogosc~
1 0. e v c | o~~o|oyd seose s |yp co y co.sed oy N. gooo//|eoe o C
|oc|ooo|: Sy~p|o~o|o'ogy c' cdes oveoodo~~o/pevcpo ~, o||e~ dc ~g
~e~ses, o~dso~e| ~escev co d sc~oge, pe v c~oss, o~d/o e.socy|os s
l/l0Cl/Ou5 L/50350 95

ACLS
Anxi ety
I
CARDIOLOG Y
Cl i nical Symptoms and Si gns
SY N C O P E
Ca rdi ovascul ar causes
Loss of vol ume/ort host asi s
Sei zure/neurol ogi c causes
Also: see "Loss of consciousness " in the Neurology chapter.
`otes
1 . Syccope so geceo' zed veoscess o|~csc esv | osso| pos|c|o'|oce, c
oo ' |y|o s|ocd cp| g~|, ocd o ss o|cocsc ocscess !~ee o|e ~ocycocses o|
syccope, ocd | ~cs|oed ||e|ec| o|ed |o~ |ee cgso|d zz cess o|o c|cess os
ve' ' ossezces S ccepo| ec|s o||ec pesec|v | o oss o|cocsc ocscessv |
oc|o c' eo ~ s|o|y0; oc|ecede|evec|s, ve cccdese zces c|ed ||eec| o
d ogcos so|syccopeevec |ocgs|c|'yspeos cg|eydoco|cocsesyccope.
2. !e ~ce~oc cAC'S g ves o s ~p' e g|ocp cg |o |e cocses o|oppo|ec|
syccope. Anxi et o| e~o| oco s||ess ~oy cocse o oss o| cocsc ocscessocd
suoseqcec|syccope Cardiovascul ar causes cc cdecocges|ve ~eo||o ' ce,
vo vc o ~eo|d seose, ~po ed vecocs e|c c, ocd o~y|~os. Loss of vol ume
cocses ~ypo|es oc ocd scoseqcec|o||~os|os s cxo~p es cc' cde o ood ' oss
|o~gos|o c|es| co ~e~o||oge, deyd|o| oc, ocdAdd socsd seose. Seizures
C3/O/OlOQy dZ
or neurologi c di sorders o so co~ cocseo oss o|co~sc ocsess Ago ~, |~e d |
|ee~| o| o~ oe|vee sezces o~d |~e |ce cocses o|sycope so c | co ospec|
o| |~e evo co| o A ~oe co~pe~es ve od ~ec~o~ s| c oppooc~ |o | ~e
p|oo e~o|sy~cope ssc~~ozed oy| ~e|o' ov ~g ~e~o~ c.
VASOVAGALS
Vol ume l oss
Anxi ety attack
Sei zure/eVA
Obstructi on of venous retu rn ( mi ctu r i ti on, Va l sal va,
cou-gh, myxoma)
Vasodepr essor/Vasoconstri ctor defect
Arrhyt hmi a
Gl ucose drop
Aort i c di ssecti on
Low ca rdi ac out put
Shy- Drager/Sympatheti c dysf uncti on
3. \AS\ACA'S oc| ~es |~ecocseso| sycope occod ~g| o|~e p~ys o og c
~ec~o~ s~s Vol ume loss, anxi ety attacks, and seizures/CVA oeogo ~po
|o~|cos deo| o~s Obstruction of venous return ~oy occc|v |~ ~ c|c | o~,
\o'sovo ~oecves, cocg~, o, oe'y, o oo vovee||ec|o| o o|o ~yxo~o
Vasodepressor/vasoconstrictor defects ~oy p|ec p |o|e ~ecocod oge~ c
sy~cope Sycope ~ |~ s se|| ~g |yp co y occcs v~e~ |~ee so d ~ ~ s~ed
ve~ocs e|c|o|~e~eo|cpos|od ~g !~ sd ~ ~ s~edveocs e|c~ eods |o o
edcc|o~ ~ s|oevo c~eod o e|'ex ~ceose sy~po|~e|coc|v|y scscep
|o'e ~d v dco s, |~e ~ceosed sy~po|~e|coc|v|ycocseso co~p ex |eoc|o
oe|vee |~e ~eo|o~d|~eoc|oo~ c~e|vocssys|e~ !~e e||esc'|s oppop|
o|e pe p~eo vosod o| o~ o~d oodyco|d o, v~c~ pec p |o|e ~ypo|e~s o~ o~d
sycope !~edog~oss s ~ode oy| ||oo e|es| g, o|e~ cs g sopo|e|e~o
|cs o~ `ecocod oge csy~copeo|e |espo~dsve |o oe|ooocse||~eopy
Co|d oc arrhythmi as, e |~e|oc~yo~y|~~ os o o|odyoy|~~ os, oe ~
po|o~| ~ po|e| o y |e|~eo|e~ ~gcocses o|sycope A~y|~~ oso||e d
co|e |~e peseceo| sc~e~ co~ec~o~ co cod ocdseose
4. A o ood gl ucose drop o' so co cocse|o ~|ess o~d o sy~copo eve~| ' ~
sevee coses, ovg ccose eves~oy ~dccesezc|es. ~sc ~depe~de~|d ooe|
cs o~de de ypo|e|so~oo ~ypog'yce~ coge~|soe o| ss
5. Aortic di ssection so ess co~~o~cocseo|sy~cope, o~d|~ed og~os s s
o||e~ c~scspec|ed Ao| c d ssec| o co~ oe |op d y|o|o' , od | ~esy~p|o~s
~oyoee'o|ve'y~o~spec |c !~ed ssec|o~ ~oycocseo osso| o'oodvo' c~e
o pe|cod o |o~poodeo~d|esc' | ~gsy~cope A low cardi ac output ~oyoe
98 C3/O/OlOQy
secodoy|o co^ges|ve ~eo| |o ce, vo vc o~eo|d seose, espec o' ' yoo| c
s|eos s, ~oss ve p. ~o^oye~oo s~, o cod oc |o~po^ode A ~ g~ eve o|
scsp c o^ o^d po~p|d ogoss ~oy.e ' |esov ^g
6. ^o y, Shy-Drager/sympathetic dysfunction e|es |o ,e p~eo o.|oo~ c
dys|.^c| o |~o|cocses o vosocos| c|o de|ec' S~yogesydo~e s o
d opo|~ coc|o^o~ cd sode SJg co' sy~,o|~ec|o~yo ,~o~oco og c sy~
po|~ec|o~y dce |o o| ~ype|es ve ~ed co| os co^ co.se odeq.o|e voso
cos|c|ov~e ossc~ go^ cp g~|pos|ce o.e|c^ecopo|~yo ^| |o|ve
d seoses scc~ os o~y o dos soe co~~o cocses Ce.e.o ~y,ope|cs o e
sc|sv|~o s..seqce^|sycopo ep sode
7. Differentiating syncope from seizure is critical. Se zce po|e|s ~oe o||e
~ove o ~e~oyo| |~e eve|s peced g |~e eve^| o^d de~os|o|e pos|eve|
, pos|c|o | co^|.s o^ A so, sevee cy |o~ |o ^g, |ogce . | g, o^d ^co|
^eceoe ^dco|veo|o se zce
8 . A co~pe~esve s| o| |~e d v d.o e^| | es co.s g sycope ss.~~o
zed .y |~e ~e~o^ c! S^A.: ^: A^` \ACA.
THI S MAD E ME DAMN VAGAL
Tamponade
Hy p e r t e n s i ve cr t st s
I nt racrani al hemorr hage/CVA
Sei zure
Myocardi al i nfarcti on
Aorti c di ssect i on
Drugs
E moti on/anxi ety attack
Mi ctur i ti on/tussi ve
E mbol us ( PE)
Dysrhyt hmi a
Addi son's
Mi grai ne ( basi l ar)
N eu rocar di ogeni c
Vol ume l oss
Aort i c stenosi s/obstructi on
G l ucose drop
A utonomi c dysfu ncti on
Low cardi ac out put ( CH
C3/OlOlOQy 99
W
Clinical Conditions or Diagnoses
AR R H YT H M I A
AI CD ME ?
Adrenergi c sti mu l i
I schemi a
Conducti on system di sease
D rugs
Mecha ni cal sti mu l i ( e . g . , st retch, '/ catheter)
E l ect rol ytes
`otes
1 . Cod oc o~y|~ ~ oco^ oe s.od v ded ^|o tachyarrhythmi as obrady
arrhythmi as. A | ~ocg~ |~e e ec|op~ys o og c ~ec~o^ s~s o|o~y|~ ~ o oe
co~p ex, o |ev oosc e|o ogess~oc d oe co^s deed ^ evey po|e^|v|~ o^
o~y|~~ o !~ese ~ec~o^ s~soe sc~~ozed oy'~e ~^e~o^ c A C ^:-
!~e ~^e~o^ co sooss|~ec ^ co qces|o^ o|v~e|~eo^oc|o~o| c ~p o^|
oo ecod ocde| o o|o ,AC| s ^dco|ed !~ s |o~ o| |~eopy s oeco~ ^g
^ceos ^g yco~~o^ , po| cc o' y|o po|e^|sv | ve^| cc o o~y| ~~ oso^d
co^ges|ve ~eo||o ce
2. Adrenergic sti mul i ~oy pec p|o|e co|d oc|oc~yo~y|~~ os cxo~pes ^
c cdeexcessveco||e ^e ^|ose, oe|oode^eg cogo^ s|s, o^d p~eoc~o~o
cy|o~o Co d oc i schemi a o' so s o^ ~po|o^|co^s de|o| o^ ^ o|~y|~ ~ o
sc~e~ c do~oge|o |~e co^d.c| o^ sys|e~ ~oyse| .p|~es.os|o|e |oo~y|~
~ o, oes. |o^|co^ges|ve ~eo| |o ce ~oyco.se ~yocod o s|e|c~ o^do so
p|ec p |o|e o~y|~~ os Conducti on system di sease co^ oe co^ge^ |o o sec
o^do|y |o sc~e~ o o ~ec~o^ co s| ~c Drugs oe o co~~o^ pec p|o^|o|
cod oco~y|~~ os ^ odd|o^|o adrenergi c sti mul i , oge^|s scc~osc sop de
o^d|e|e^od ^e ^co~o ^o| o^v |~ ~oco deo^| oo|cs~oveoee^ ~p' co|ed
ose|o' og eso|cod oco~y|~~ o ^o^y oge^|s csed |o |eo|cod oc o~y|~
~ os ~oy ~ove p|oo~y|~~ ce||ec|s Mechani cal sti mu l i co^ p|ec p |o|e
100 C3/O/OlOQy
cod ocoy|~ o ' ~o y, electrolyte ooo~o' | es, espec o ype|coo|os ~
po|oss c~, ~oges c~, odco' c c~, oe ~po|o|co~s deo| os ~o po| e|
v|cod ocoy|~ os
AT R I A L F I B R I L L AT I O N
I HAVE A F I B
I schemi a
Hyperthyroi di sm
Acute per i car di ti s
Val vul ar heart di sease ( especi al l y mi t ra l stenosi s)
E mbol us ( PE)
A tr i a l septa l defect
Fa i l u re -
I nfect i on
Booze
`otes
I . A| o | o o| o s o co~~oc oy|~ o|o|co~ oe |e ~ ||e~| , pooxys
~o | o pes s|e~| | s cooc|e zed oy d sogozed o| o' oc| v |y v | o
egc o'y egc o ve| cc oespo~se !e~o o~oo d |eso|o| o' | o o
| ooe
o !ocycod o |o| ~oy pec p |o|e ypo|es o~, sycope, pc' ~oo y
ede~o, oo~g o
o 'osso|o| o c|o||oc |o|es 'e||ve~| cc o| ' god oc|p.|
c Sys|e~ ce~oo ~os| o||e~ cocs g s|ose ^os| po| e~|s v| co~ c
o| o | o o| o~soc d oecos deed|ovo|o o| coog. o|o ,|oge| '<o|
z JJ J| |o edcce|e so|ceeoovosc.' oocc de~|.
2. A||e | o o|eco|o o|sy~p|o~o| co| o' | o o| o, seoc|ooe|o'
ogy ^os| o||e , cde y ~g cod opc ~ooy d seose scc os peri cardi ti s,
val vul ar heart di sease, atri al septal defect, o fai l ure , e||s dedo g| s ded|
spese| ^yocod o |oc|o~ so oecocseo| so|o|edo|o | o ' ' o| o, oc|
po|'e|sv | sce~ ceo|d seose ~oydeveopo| o | o ' ' o| oove| ~e.
C3/OlOlOQy M
3 . cves|go|eo|~e| p ~oycocseso|oc|os |~o|~oy c~osso| o | o o| o
o scscep| o e cd v dco A|| o | o o| o ~oyoe|~e| s| s g o| hyperthy
roi di sm o pul monary embol i sm. Sys|e~ cd so|de|sscc~ os i nfecti on o so co
pec p |o|e o| o | o ' o| oc Booze ges| o ~oy p|ec p |o|e o vo e|y o|o
y|~~ os, c cd go|| o | o o| o !e soco edo doy~eo|'yp co' ' yocc.s
o||eo oge d gepsodeooveeed
4. <oey, o| o | o ' o| o occcs v |~oc| ossoc o|ed eo| d seose o |~e
ooove s|ed p|ec p |o|s ! s oeo| o | o o|ogeeo y ~osogood og
|e~ pogos sod ~oyoeo ~o |es|o|oo| cdey g|ocycod ooodyco
d osydo~e
C O N G E S T I V E H E A R T
FA I L U R E
I SCH E MI A? PA CATH S
Low output
I schemi a
S ubacute bacter i al endoca rdi t i s
Ca rdi omyopathy
Hypertensi on
Eff usi on/tamponade
Mi t ra l val ve di sease
I nfect i ous myocar di ti s
Aorti c va l ve di sease
High output
Paget/myel oma
A-V fi stu l a
Cardi ac s h u nt
Anemi a
Th i ami ne defi ci ency ( beri -ber i )
Hyperthyroi di sm
Sepsi s
Z C3lO/OlOQy
`..
1 . Coges|ve ~eo||o .e , C'| s o cl i ni cal di agnosi s. |o coe|c p~ys co
exo~ ~o|o eveos|~e| d ~gso|C ,ede~o, .gc oveocsd s|e~| o, o g~|
oe|sded ~eove, o~o.scc |o|oyJoS^, o es, p e.o e||cs o~s| , |~eegod
esso|o|~ed og~os|c|es| ges. |s,|~epo|e|s c co C. !~e ~po|oce
o| |~e p~ys co exo~ co| oc | d ~gs coo| oe ovee~p~os zed |~ee oe
~o~y|o~so| C ~ v~ c~cod oc|ccc| o ~oy oppeo ~o~o o ~og ~g
s|cd es ~ce o coe|. c co exo~ o| o~ s doce, od| ~epo|e| ~os oee~
de|e~ ed|o oec co y ~ C, c co ~og g s|.des scc~ os o~ ec~oco
d ogo~ ~oy oe .sed |o co~| ~ |'ed ogos sod|o e .c do|e |~e e|oogy
2. !~e~ce~o~ c SC:^ A-ACA!Sd vdesco~ges|ve ~eo||o .e c|o
|vo~o |ypes |~ose ossoco|ed v|~ ovcod oco.|p.|, o~d |~oseossoco|ed
v|~ ~ g~ cod oc o.|p.| \~e~ o coe|c exo~ ~o| o eveos |~ec co |eo
|.es o|C', oc| |~e ec~ocodgo~s~ovs o ~o~o e ec| o~ |oc| o, co~
s deoeo||~ee poss o | es
o. !~eec~ocod ogo~ sscoop| ~o .
o g~oc|pc|C' s pese~|
c Ad os|o' c, es|c|veocos|c|vede|ec|s pese|
3. .ovoc|p.|s|o|es oe |~e ~os| co~~o cocses o|C I schemia v'~ scose
qcec|e|ve| c. odys|.~c|o s |~e ~os|co~~o cocseo|Cocd po|e~|o' y
eves o e Subacute bacterial endocardi ti s ~oyco.se|oc~ycodo o~d vosod
' o| o, s|ess~g|~e ~eo| '|osococo.sevovco .yo~d scoseqce~|s|e~oss
oegcg|o|o~ ' dopo|~ccardiomyopathy, o'socoed d o|edcodo~yopo|~y,
co.sesC ~ |~e oosecceo|coo~oyo|eyd seose 'ocgs|od ghyperten
sion ~oycocsecodocdys|cc|o o ovo.|p.|s|o|e. ype|es o~ oso co~
co.seo es|c|vecod o~yopo|~y 'ecod o' effusi on otamponade ~oyco.se
sy~p|o~s o|C, o~d s~o. d oe de|ec|ed oy ec~ocodogop~y Mitral od
aortic vo v. od seosesoe essco~~o~|odoy, o.| s| ~po|o|cocseso|C
Ago ~, ec~ocod ogop~y s .se|J | o . eo.| |~ese e~| | es o y, i nfecti on,
.s.o' ' yv o , ~oycocse~yocod | so~do s.oseq.e|d o|ed cod o~yopo|~y
4. g~o.|p.||o ce s ess co~~o~ |~o~ |~e 'ovo.|p.|s|o|es A CA!S
s.~~ozes|~ecocseso|~ g~o.|p.||o ' .e | o so dco|es|~e~os| ~po|o|
|es||ope|o~v~eco po|e| s cC, o.||~eec~ocodogo~scgges|s co~o
sys|o' c|.~c|o p.' ~ooyo|eyco|~e|ezo| o~ !~eoo~o~o' p~ysoogyo||~e
~ g~o.|p.|s|o|e~oyoe secodoy|o o sys|e~ cs~.~|, osocccs v|~ Paget's
di sease ocd multi pl e myel oma. ~ |~esed seoses|~eeoe oo~y, ~|o~edc ' oy
s~.|s !~ee s ceosed oood |ov |~o.g~|~eses~.~|sv |~o.||ssceoxygec
de' vey !~e es.|s o~ ceose S\C,o~d ~ceosed de~ocdoc |~e~eo||o
~o ~|o o ~ g~ecod oco.|pc||o ~ee| |~e oxygec de~o~dso||~e o|~e|ssces
|~eoodyA ' ogearteriovenous fistula o cardi ac shunt ~oy ~ove|~eso~e
e||ec| Seveeanemia ed.ces|~eoxyge~ coyg copoc|yo||~eoood, |oc ~g
|~e~eo||o~o c|o o ~ g~ecod oco.|p.| Thi amine deficiency cocsesd ||.se
vosod'o|o|oc v~ c~ c |.c eods |o oc cceosed vo' c~e o|c c.' o| o~ |~o| |~e
C3/O/OlOQy M o

eo| ~cs| ~o 'o A c~ooc|es|c ~ypedyo~ cc cc o| o s see Hyper

thyroi di sm, v|~ |s~e g~|eed ~e|ooo cde~ods, o so co cocseo ~ g~o.|p.|
s|o|e Sepsis eods |o o ~ g~oc|pc|s|o|e v|~ sys|e~ cvosod o|o| o Ago ,
|esecod | os| eeo|| s cdes|ess, od |o ce ~oyesce Seps s o so
~oy~oveo d ec|cod ocdepesso|e||ec|, od |~ s co exoceoo|e c c. o
|oy|o .e es|c|ved seoses, |~ecod ococ|pc|~oyoeo|~o' o~ g~
5. o po| e|v | ~ ov C, deco~peso| o ~oyoccc, eod g| oo
edematous s|o|ev|~ ,edo ede~o, o"edema toes . " '~e |o ov g ~e~o c
sc~~ozes |~e ~po|o| cos deo| os deco~peso'ed C A o''~ese
e||ess~oc d .ecos deedv~ede|e~ g |~eco.seo|Cexoceoo' o
E DE MA TOES
E mbol us
Dysrhyth mi a
E cl ampsi a/pregna ncy
Myoca rdi al i nfa rct i on
Anemi a
Thyroi d di sease
Overexerti on/excessi ve f l ui d or sal t
E l evated bl ood press u re
Sepsi s/i nfect i on
6. A |~ocg~ ~os|C sd.e |o sys|o c dys|.c| o , ce|o cod ' os ~oy
~pede| ~e~eo|s oo |y |o e ox !~ s d os|o cdys|.c' o ~pedes cod oc
| ' ' g od eods 'o '~e c co s|o'e o| C !~e d s| g. s~ g |eo'. e s o
o~o e|| ve' cc oeec|o |oc|o o o ec~ocod ogo~ oo'~e ~og g
|es| <e~e~oe| ~o| | ~ee||ve| cc o e ec| o |oc|o so ~eos.eo| :y:!o|.
|cc| o, oc| does o| ossess |~e ~eo|sd os|o c|cc| o

H Y P OT E N S I O N
BP D ECLI N E D
Bl ood l oss
Poor PO i nt ake
1 04 C3/O/OlOQy

D i a rrhea/Dehydrat i on
E ndocr i ne ( e. g . , Addi son's)
Ca rd i ac di sease
L i ver fa i l u re
I nfect i on/sepsi s
Neuropathy ( autonomi c)
E mbol us ( pul monary)
D rugs
"otes
\
. !~ sd ||ee| o s~oes ~oyo||~e |eo|.eso|sycope
2. Add sos dseose ~oy oovey ~cc~ e sepssv |~ |eve, o |eed ~e~|o'
s|o|.s, od e|oc|oy ~ypo|es o ' | s op d y ~poved , ~ ~c|es| v|~ ~|o
ve~o.sg ccoco|co ds
P E R I C A R D I T I S
PR DI P, ST U P
P ost -pe r i ca rd i oto my
R heu mati c fever
D rugs
I nfect i on
|'
3, vi ra l , pyogeni c)
P u l monary embol us
S LE
Thyroi d di sease
U remi a
Post-M I ( acute, Dressl er)
C3/O/OlOQy M 1 05

"otes
I e cod | s s o sydo~ecocsed .y | o~~o| o o||~e pe cod c~ !~e
es. |so||~. s | o~~o| o c .dec~es| po , o pe cod o |c|o c., pe co
d o e||.s o, odc~ooc|es|c .C c~oges
2. C~es|po ' o||e sevee| so co~~osy~p|o~o|occ|e pecod | s |~oy
.e o.se| ~oe sc.oc.|e d seose, s.c~ os | ..ecc os s o ~yxede~o
Cooc|e s| co y, | e po s e eved .y s || g cp od eo g |ovod
Svo ov g ~oyexoce.o|e |~e po
J. e cod o | c| o c . s |~e ~os| ~po|o| p~ys co s gc | s o ~ g~
p |c~ed, sco|c~ g socd od ~oy ~ove |~ ee co~poe|scoespod g|o
|~e cod occyc e
4. 's' , S! up" desc.es|ec~ooc|es|c .C c~oges c po cod | s de
pesso o|'~e < |evo s od vdespeod e evo|o o| S! seg~e|s ! vove
veso o so ~oy .e see ||ee|o|o o||~ese .C c~oges |o~ |~ose o|
oc.'e ~yocod o sc~e~ o s ~po|o'
5. ee so ~e~o c|o |~ed ||ee| o d ogos so| pecod | s
I T CAUSE D P E RI CARDI TI S
I nfect i on ( vi ral , bacter i al , mycobacteri al , f u ngal ,
par asi ti c)
Tumor ( pr i ma ry, metastat i c)
Col l agen-vascu l ar di seases ( e. g. , SLE, RA, scl eroder ma)
Acute
U remi a
Sarcoi dosi s
Embol us
D ressl er 's
Post-peri ca rdi otomy
Exter nal trauma
Rheu mati c fever
I nheri ted (fa mi l i a l ,
C hol esterol/C hyl operi cardi um
A tri -a l septa l defect
Ru ptu red aort i c aneurysm
D rugs ( procai nami de, hydra l azi ne, and others)
I di opath i c
7 06 C3lO|O/OQy
Thyroi d di sease ( myxedema)
I rradi ati on
Severe, ch roni c anemi a
6. ' | o~~o| o o| |~e pecod c~ ~oy .e secodoy |o o i nfecti on, csco' 'y
v o , ..| .oc|e o , ~yco.oc|e o , od o|~ee| o og es oe poss . e ' | o~
~o| o o so ~oyoccc os o esu | o|d ec| .y |o |~e pe cod . ~, s.c~ os
post-cardiac surgery, o|o~ chest trauma. Adoce| |o~~o| oo'|~e .g,
osocccsv | ~ pc ~ooy embol i sm, o | ~e ~eo|, osoccc s v | acute my
ocardi al i nfarcti on, o so co co.se pe cod | s ^yocod o |oc| o ~oy
cocse oocc|e pe cod o e||cs o oo o|e, oc|o ~~ce p~eo~eo co ed
Dressler's sydo
'
e ess es sydo~eo so co occ.o||e cod oc scgey
|~ecol l agen-scul ar di seases scc~ os ~e.~o|od o|~ | sosys|e~ c .pcs
ey|~e~o|oscs co~~oy cocse pecod o d seose ecod | s s o so oeo|
|~ecod oc~o |es|o|oso|rheumati c fever . Sys|e~ c essesscc~osuremi a
od hypothyroi di sm cococse pe cod o | o~~o| o od e||.s o o y,
ce|o drugs ~oy cocse pe cod o d seose od/o e||cs o c .d g ~y
do oz e, poco o~ de, od ~ ox d
R E S T R I C T I V E CA R D I AC
D I S E AS E
A STI F F E R CH F
Amyl oi d
Sa rcoi dosi s
Tu mor i nf i l trat i on
I di opat hi c
F i brosi s ( endomyocardi al )
Fabry's
Eosi noph i l i c
Radi ati on
Constr i cti ve peri ca rdi ti s
Hypertensi on/Hypertr ophy
Fe over l oad ( hemoch romotosi s)
C3lO|O/OQy M 107
W
".
!~s ~~e~o~ c s|s |~ose ~| |o|ve o~d | oo| cd seoses |~o| eod |o d os|o c
dys|c~c| o . A' so ~c cded ~ |~ s s| s|~e e~||y o|constri cti ve peri cardi ti s,
v~ c~ ~oyoed || cc || od s| ~gc s~|o~ es|c|ve d seose eve~ o||e ec~oco
d ogop~yo~d pc ~o~oy o|eyco|~e|ezo| o~ !~e d ||ee| o| o~ o| co~s|c
' ve pe cod | s |o~ es' c| ve d seose s c | co , oecocse co~s| c|ve
pecod |s sscg co ycoec|oo e
1 08 C3lO/OlOQy

I
ENDOCRINOLOGY
General Considerations
.cdoc ^ed sodes pese^| ^~y od voys ocd oe o co|egoy c |~e ^.
C '.C ~ce~oc c C | co | o| ~eccdes|ocd cgo||~esed sodes s| ~ecoc
cep|o|o s|| ~c' o|oy s gco' ( "trophi c" hormone) |o~ o e~o|esocce ocd o
|oge|g o^d |~o| podcces |~e "effector" hormone. eedooc|o~ |~e |oge|
ogo^o|o~o ~e|ooo' cpodcc||c|~edovcs|eo~ so|ecespocs o' e|o|e
scoseqce^| ^~ o | oc o||~e|op c ~o~o^e oecocseo||~ segc' o|oysys|e~,
ecdoc ced sodes ~oy esc ||o~ dys|ccc|oc o||es| ~co|oyo |~e e||ec|o
o|go^s \~e^ co^s de cg ecdoc ced seose, |~ ^soooc||e co^seqceccesol
hyper- o^d hypo-function o|eoc~e||ec|og' o^d ocd |ss| ~c o|oyg ocd.
`o|e|o|s|o^dode^doc ^o ogc|es| cg soes|doce ^ oc oc|po|ec|se|| cg
v~e^|~epo|ec| s cos|oo'es|o|eo|eo |~. Acc|e ' cesses c~osp|o' zed po|ec|s
coc ccped c|oo yo |e~o~o^o |es| cg o^d ~ose |es| c|epe|o|oc c^e oo e
.. ..,/-,.. ...
!~ep |c |oy s |e~os|e, o "TCHGLND, " ,seecex|poge| oecocse | podcces
sx ~o o~o~oces ,!S, pooc| c, gov|~ ~o~oce, |egocodo|op cs 'o^d
'S, ocd AC!l , o^ds|oes|vo o|es , Aocdoxy|oc ^l !e p |c |oy~ypo
|o o~ cox s so| po||esys|e~ co^s s|^go||~e o^|eop|c|oy , !'CJ | ,
|~epos|e op |c |oyo^ecoypop~yss, ' l ocd |~e~ypo|~o o~cs , l . !~e
pos|e op |c|oy sessec| o ' yo^ex|e^s oco|o^oeo o||~e ~ypo|o o~cs. !~e
optic chiasm eso^|eoo^dscpe o|o|ep|c|oyg ocdo^d sco~pessedoy
oc|e op|c|oy^eop os~scocs cgv sco' | e dde|ec|s \ sco sy~p|o~s ~oyoe
|~e| s|s gco|o p |c |oy|c~o !e o^|eop |c |oy so ~o opodcceo|e^
doge^ocsopiates, ^c' cd ^gecdop cs, e^sep~o cs, o^ddy^op cs
TS
Cp| cc os~/Cp o ds
Ho'oc|c
t/OOC//OlOQy M 109
Cov| o~o~e
|/'S
AC!
Mec|oypopyss ,A, oxy|oc j
Dopo~ e/ypo|o o~ ceeos g|oc|os
Anteri or Pi tui tary: Hypo- and Hyper-Functi on
TSH. Sy~p|o~so|ypo|c~c|o~ oe |ose o| ypo|yo d s~, ~c cd g|o
| gce, e|ogy, co~s| po| o, cod |o' eo~ce, ~csc' eco~ps, copo |c~e sy~
do~e, ~e~oog o, ede~o, ve g| oss, s ov ~go| ~|e ' ec|co |cc| o~, dy
s ~ od o , deepe~ ~g o| |e vo ce, od co~o S gso| ype|c~c| o~ oe
|ose o| ype||y|o d s~ ,see ype|yo d s~sec| o~l
Opti c chi asm. A |ocg ~o|o o~o~esece| ~g e| |y, o|e o p | c |oy
|c~os

~p ~gecpo| ss|cc|ce odcocsev sco | e' dd s|c|oo~ces.

Prolacti n. g' eve so| p|o oc|~ ~oycocse ypogood s~o~dgo oc|o
|eo, v eoveve's oe cooc|ezed oy |e oo |y|o 'oc|o|e
Growth hormone. :xcess gov| o ~oe cocses oco~egoy, o sy~
d|o~e |o| ~oy c cde|o| gce, ceosed sveo| g, eo| |o' eo~ce, e~ og
cg ods od |ee|, coose~ ~g o| |oc o' |eo|c es, eodoce, v s o~ oss,
~ocog' oss o, C', ~po|ece, d~ey s|o~es, ypeso~o e~ce, o~d oos||cc
||ves'eepopeo
LH and FSH. e|ce~cyo||e go~odo|op sesc'|s ~ ypogo~od s~od
| c|e|| ' |y Coodo||op ~ excess s csco y d ogosed ~e~v | deceosed
' o do, o~d ~oyoe~ sd ogosed os p ~o|y ypogo~od s~ |o p |c |o|y|c~o
sco|scspec|ed
ACTH. AC! excess esc |s ~ Ccs ~gs syd|o~e, cooc|e| zed oy
~csc eveos~ess, ype|e~s o~ , o~e~oeo, g ccose |o eoce, os|eopoo
s s, s| oe, odce|o d s|| oc| o o| |o| AC! de| c e~cy cocses seco~doy
od|eo' ~sc||c e~cy ,see Ad|e~o' sc||cecysec|ol
Neurohypophysi s ( Posteri or Pi tui tary) :
Hypo- and Hyper-Functi on
AD. A excess s eveved ~| eS' A sec| o 'oss o|Acocses
d ooe|es ~s p dcs,see ype~o|e~ o sec|o ~ |e `epo' ogycop|e|l
Oxytoci n. xy|oc s| ~c o|es c|e ~eco|oc| o o~d co|oc| o o| ~y
oep |e o ce so| |e oeos|, cocs g ~ e ec| o~ xy|oc os o~ A e
e||ec|, v c ~oy oe c ~ co y s g | co~|ve | s g ve ~ ogedoses |o
oos|e|| co cses ` |o so os o vosod o|oye||ec|, v c ~oycocse ypo|e
s|o od co|d ovoscc o co~po~ se, po| cc' o'y ~ po|e~|sv| eo|d seose
ocd veoes|e|cso|ecood~ s|eed
Hypothal amus: Hypo- and Hyper-Functi on
opo~ ~e, p|o oc| ~e'eos g |oc|ol o~d| eypopys o|op c o~oes
, !< , C< , . < , C< , o~d C' so~o|os|o| | l oe podcced oy | e
1 1 0 L/OOC/l/OlOQy

~ypo|~o o~cso~d egc o|e po' oc| ~ e'eose, |~yod |c~c| o~, |~e ode^o' ox s,
go~odo|op ^s, o^d gov|~ ~o|ro~e eeose ^ cy|o|~e~ypo|~o' o~csop |c
|oys|o |esc' |s ~ o edcc|o^ ~ eve so| C, ., 'S, !S, o~d AC!, v |~
o se ~ po oc| ~, v~ c~ s ~o|~o ' y ~~ o |ed oy |o^ ce eoseo|dopo~ ~e
Ag ^ ~evosopess ~o~doxy|oc ~ eves|o' ' | |~e~eco~ypop~yss s ~ ced
Cl i ni cal Symptoms and Si gns
AM E N O R R H E A
WHAT S EX? *
Wei ght l oss
Hypot hal ami c ( pi tui tar y dysf unct i on)
A natomi c anoma l i es of t he vagi na and uterus
Testi cul ar femi ni zat i on
St ress ( systemi c i l l ness)
Exerci se
XO (Turner 's)
Also: Gonadal dysgenesis, Kallman's syndrome, physiologic delay
* primary amenorrhea
P E RI OD GAP*
Pol ycysti c ova ry di sease/i nsu l i n resi stance
E ndometr i a l fa i l u re (Asherman's)
Resi stant ovary syndrome
I l l ness ( severe systemi c di sease)
Ovar i an fa i l u re ( autoi mmune, ear l y menopause)
Di eti ng/exerci se
t/OOC///OlOQy M 1 1 1
&
Gravi d
Adrenal dysf uncti on ( congen i t al adrenal hyperpl asi a,
Addi son's)
P i tu i ta ry di sease
* secondary amenorrhea
`otes
1 . A~e~o~eo sd vded ~|o p| ~oy , ~o ~ | o| o~ o| ~e~ses| o~d seco~doy
,cesso|o~ o|es|oo' s~ed ~e~ses|co|egoes
2. |eg~o~cy ~cs| oe c ed o.| | |s| ~ o~y po| e~| v|~ o~e~o|~eo c|~e
evo' co| o~ sge~eo y.~de|oe~ ~|~e|o ov ~g ~s|o~ces
o `o ~e~ses ~ove occc|ed oy oge I ^, o~d deve op~e~|o|seco~doy
sexc~ooc|es|cs soose~|o|e|oded
o `o ~e~ses ~ove occ.|ed oy oge l
c Avo~o~v|~ es|oo s~ed ~e~ses ~os ~o oeed ~g |o |~ee cyces o
~o~|~s
3. !~eoos c co'ego eso| poo e~s oe o.|| ov poo e~s , o~o|o~ c o oc| ,
ovo o~d sodes, o~|eop |c |oyd sodes, o~d C`Sd sode,~ypo|~o o~.s|
4. :vo .o| o~after pregnancy is ruled out ~c .deso ~ s|oyo~dp~ysco exo~,
v |~ o c' ~ co ossess~e~|o|es|oge~ s|o|.s ~ pe v cexo~ o| o~, ~o|~o' es
|oge~s| ~.o|ed vog ~o' ~.coso s ~o s|o~d cgo|ed 'o~o' ce|v co' ~cccs
s|e|c~eso~dde~o~s|o|es|e~ ~gv~e~ poced o~ o s de
5. |c ~co exo~ ~o| o~ s~o|~o , o!So~d po oc'~oe oo|o ~ed, o~d|~e
po| e~| s g ve~ o poges|o| o~o' c~o ' e~ge|o c~ec|ov |~oovo ~e~ses ' |
v |~dovo oeed ~g occ.|s o~d po oc|~ o~d !S oe ~o~o , |~e~ |~ed og
~os s s o~ovc o'oy o eed ~g po ycys|c ovo o~ d seose| ' | ~ov |~dovo
oeed ~gocc.s, |~e~ evo' .o| o~depe~dscpo~|~e po oc|~ eve | po oc| ~ s
e' evo|ed o~d/ogo oc|o~eo s p|ese~|, |~e~ p |c |oy ~og ~g s ~dco|ed ' |
p|o oc| ~ s ovo|~o~o , |~e~.o~dSs~o. doe~eosced. |'o~d S
oe eevo|ed, |~e~|~ed og~os s sovo o~ |o ce |go~odo||op ~soe ovo
~o~o , |~e~ |~ed og~os s so ~ypo|~o' o~cp |. |oy d so|deoo~o~o|o~ c
c|e ~ede|ec| , e g , As~e~o~s| Cyc ces|oge~ o~d p|oges|eo~es~o. d
co.se~e~s|co| o~ | | ~ec|ecs s~o~o
Z L/OOCl//OlOQy
G Y N E C O M AS T I A
TEST ME
Testoster one def i ci ency
Estrogen excess
Sen i l i ty
Teenagers/i nfa nts
Medi cati ons
Eti ol ogy u n known
`otes
1 . Cy^eco~os' o does ^o| ^d co|e ooso .|e ~o~o^e eve s, oc| o|~e| o
c~o^ge ^ '~e o|o o| ~o e|o |e~o esex ~o~o^es Cy^eco~os|o ~oy oe ^
d co' ve o| c^de y ^g e^doc ^opo|~y o ~oy oe |~e es. | o| ooes |y o o
^o~o p~yso ogcp~e^o~e^o^ , ^evoo^ , odo esce^ce, og ^gl
2. Co.seso| gy^eco~os| ocoooec' oss | ed os e |~e po|o og c o p~ys o
og c o|~o ogcco.ses~oyoed vded ^|o|~osev~c eod|oo decrease i n
testosterone eve , o^ i ncrease i n estrogen eve , o oe seco^doy | o| ~e
e||ec' o| o medi cati on . A deceosed |es|os|eo^e eve ~oyoe| ~eesc | o| o
co^ge^ |o d sodeo|es| cc o |o ce seco^doy |o e^o |o .e, |oc~o, o
oc~ | s ^ceosed es'oge^ e||ec| ~oyoeseco^doy|oo p ~oy ^ceose ^
es|oge^ , s.c~ os occ.s v |~ | . ~os o| |~e |es|es, |.e ~e ~op~od |es, o
~CCpod.c ^g |.~os A^ ^ceosed es|oge^ e||ec| o so ~oy oesee^v~e^
|~ee s ^ceosed s.os|o|e ovo ' oo e|oex||og o^dc o oo~o|ose, s.c~ os
occcs ^ode^o d seose, ' ved seose, ~o ^c|| | o^ , o~ype||~yo d s~ Ap|
~oy ^ceose ^ ex|og' o^dc o oo~o|oseo so co^ eod |o ^ceosed es|o
ge^ e||ec| ~ys o og ccocses o|e |~ose c~o^ges|o|occc|dc| ^g |e ^o~o
~.~o^ |e| ~escc os ^ newborns, teenagers, o^d |~e el derl y. ^os|coses
oe d opo|~ c ( eti ol ogy unknown) . A de| ^ | ve d og^os s co^ oe eoc~ed ^
ess|~o^ o^e~o |o| po| e^|s
3 . ys co exo~ ^o| o^ s~o. d ^c cde |es| cc o exo~ ^o| o^ ||es|esoe
s~o , oo|o ^o oyo|ype ||es|es oe osy~~e|c, o |c~o ~oy oe pese^|
4. l ^ ' o oooo|oy'es|s ^c cde veo^d e^o |c^c|o^ |es|s :^doc^e evo co
| o^ ^c .des ~eosce~e^|s o| sec~ o^dos|e^ed o^eo z^~o.c ^oy I
e|os|eo ds, p os~o es|od o , ~CC, ., o^d|es|os|eo^e
5. cgs ~oy cocse gy^eco~os| o oy pro-estrogeni c or anti-testosterone
mechani sms. !~ey~oyoc|d ec|yos es||oge^s, e^o^ce es|oge^ sec|e| o^,
t/OOC/l/OlOQy M 1 13
-
&
^~ o | |es|os|eo^e oc| o^ o|sy^|~es s, o|oc| oy o^ c^\^ov^ ~ec~o^ s ~ A
coe|c d|cg ~ s|o|y s esse^| o' cgs|~o|cocse gy^eco~os|o ^c cdees||o
ge^s, e'oco^ozo e, ~e|o^ dozo e, vo ocsc~e~o|~e|opec| c oge^|s, sp |o^o
oc|o^e, c ~e| d e, | c|o~ de, so^ oz d, ~e|~y' dopo, |cyc co^| depesso^|s,
o~epozoe, AC. ^~ o|os, coc c~c~o^^e ooce|s, ~o co^o, o^d ~e|o ^
6. ^e^ v |~ ^e|e |es sy^do~e ~ove o ~ g~ ^c de^ce o| oeos|co^ce
Scee^ ^g~o~~ogop~y sesse^| o'
7. e|e so ~oeco~pe~e^s ve s|o| | ~ecocseso| gy^eco~os|o
N U DE TESTAME NT
Newborn/teenager
U remi a/renal fa i l u re
D rugs
E st rogens
Testosterone i nhi bi tors
E l der l y
Starvati on/n utri ti onal defi ci ency
Test i cul ar fa i l ure
Adr enal di sease
Mor bi d obesi ty ( hi gh a romatase)
E nd-stage l i ver di sease
Neopl asm ( test i cul ar or other HCG-produci ng t umor)
Thyr oi d di sease
H I R S U T I S M
peOD HAI RS
P rol acti noma
Congeni t al adrenal hyper pl asi a
Ovar i an tu mors ( ar r henobl astoma, hi l us cel l tu mor)
D rugs
l l 4 t/OOc///OlOQy
H i l us cel l hyperpl asi a
Adrenal t umors
di opathi c (fami l i al )
Resi sta nce to i n s u l i n ( syndrome pol ycysti c ovary
di sease)
Steroi ds ( exogenous, Cushi ng's)
Also: idiopathic (familial)
`otes
1 . s.| s~ sde| ^edosmale-patern ~o gov|~ ^vo~e^, ^co^|os||o~y
pe| c~os s, v~ c~ s excess ve ~o gov|~ ^ o ^o ~o' oody d s| o.| o^
s.| s~ s d.e|o o ~o~o^o ~oo' o^ce , e , excessveo^doge^ pod.c| o^| ,
v~ e~ype|c~osses.'|s|o~ s| ~. o| o^o|exs|^g ~o , o||e^ oy ~ed co| o^s
, e g , cyc ospo ^ o ~ ^oxd ' l . !~ee sco^s deoo evo oo |y ^ ~o gov|~
^ ^o~o' ~e^ o^dvo~e^, |~.soo^o~o ~o gov|~ sd || c. ||ode| ^e
2. !~ec ^ co sce^o od c|o|es|~ed og^os| c evo .o| o^ o|~ s.| s~ o y
cys|c ovoy d seose , Cl s o^e o||~e ~os| co~~o^co.ses o| po|~o og c
~ s.| s~o^d s s.ooc.|e ^ o^se| <op do^se|o^d |o^v ' zo|o^ oe c~ooc
|es|co|~o g^o^ceso^d ~o^do|e co~p e|e evo .o| o^ .
3 . !~e ~ s|oys~o.' d |oc.so^ d.g ^ges| o^, |o~ y ~ s|oy, o^d ~e^s|.o ~ s
|oy ~ysco exo~ ^o| o^s g^so|v ' zo|o^ ^c' .dedeepe^ ^go|voce , ' oy^
geo' e^ oge~e^| | , |e~poo' oo d ^g, c |oo~egoy, ~o' e esc.|c~eo^, o^d
^ceosed ~.sc e ~oss S g^so|C.s~ ^gs sy^do~e ,s| o, ~oo^ |oce, |.^co'
ooes|y, o^d o.||o o~.~p l s~o. d oeso.g~|
4. o|o ^p' os~o|es|os|eo^e, po oc| ^, o^d :AS eve s, posso y|o oved
oy ode^o o^dovo o^ ~og ^g
5. ^os|po|e^|so^s|eod |~eopydo^o|~ove~ s.|s~, oeco.ses|eodss.ppess
ode^o o^doge^ pod.c| o^ A^doge^ pod.c|o^ s s| ~. o|ed oyAC!, so
o^yco^d | o^s|eo|. ^gexcessve AC! sece|o^ |yp co' ' yco.se ~ s.| s~
6. .gs , o^d poycys|c ovoyd seose o S|e ^'eve^| ~o sy^do~el oe | ~e
~os| co~~o^ co.seso| ^o^|o~ ' o ~ s.| s~ !.e d.g ^d.ced ~ s.| s~ , ^
co^|os||o ~ype| c~os s| es.|s|o~ o d ec|o^doge^ ce||ec|o s| ~. o| o^o|
o^doge^ sece| o^

7. Co^ge^ |o ode^o ~ypep os o , o|e z l ~ydoxyose de| c e^cyl ~oy oe

c ^ co y ^d s| ^g. s~oo' e|o~ 'C o|e^|sv|~ |~ sd sode ~ove o de|ec|
^ co|so' sy^|~ess eod ^g|o e evo|ed AC! 'eves, v~ c~ ^ |.^ co.se exces
s ve o^doge^ pod.c| o^ : evo|ed :AS o^d dexo~e|~eso^es.ppess o' e
~ypeo^doge^ s~ oe s|o^g s.ppo|s|o|~ sd og^os s
8. 'o|e^|sv|~C.s~ ^gssy^do~e~oy^o|o'voys~ove~ s.| s~ C .coco|cods
s.ppessode^o o^doge^ pod.c| o^ AC! s| ~.'o|eso^doge^ pod.c| o^
L/OOC///OlOQy M 1 1 5
-
Cl inical Conditions or Di agnoses
AD R E N A L I N S U F F I C I E N C Y
LACKS ADR E NAL *
Low sodi u m
Aci dosi s
Ca l ci um el evat i on
K el evat i on
Ski n hyper pi gmentati on
A I ter ed menta l status
Depressi on
Ref ractory hypotensi on
Eosi nophi l i a
Na u sea/abdomi nal pa i n/anorexi a
Ast heni a
Loss of wei ght
* c|ooc|e:|c: o| ooeoo| o:.||ceocy
`otes
1 . ~oyodeoco|co de|cecy soe, o.| seco~doy, d.e|os|eod |~e
opyl seo|veyco~~o~ Adeo sc|| c e^cy~oyoec~osed oys|essd.e
|o, |oexo~p e, sys|e~ c ess o |ec|o~
2. Causes of adrenal i nsufici ency c cdeoo|o~cdes|cc|o~ o||~e ode^
o s , oc|o ~~ce des|.c| o, s. g co e~ovo , ~|ec| o, ~e~o~oge, o
~e|os|o| c vos o| , ~e|ooo c |o .e , co~ge |o od e~o ype p os o o
e^zy~e ~ o |os scc~ os ~e|opyo~eo se|oco~ozo el , AC!ooc ~g o|
ood es, scppess o o| |~e ~ypo|~o o~ cp |c |oyox s dce |o s|eod |eopy,
o~d ~ypop |. |o s~ secodoy|o ypo|~o o~cp '. |oyd seose
3 . ' ~oy ode^o ~s.|| c e^cy ~oy oe po| o|o po'yg odc' o o.|o ~~c~e
sydo~e Assoco|edcod | o~s ~c .dey~pocy|c|~yo d | s, pe~o|ceovo
o^ |o ce, d ooe|es, o^d ype|~yo d s~ Add | o~o d sodes ~c cde pe ~
c ocso~e~ o, v | go, o opec o, sp.e, od ~yos|~eo gov s
O L/OOC///O/OQy
4. Laboratory di agnosi s o| ode~o s.|| c e~cy eq. es AC! s| ~c o| o~
|es| g |o ossessodeo esevecopoc |y|o s|eod pod.c| o~ Sec~od c
~oys|eod eve's ~oyoe | ~e~o~o o~ge ~ ~ d ode~o sc|| c e~cy, o~d
|~ee|oe oe ~o|e oo' e|od og~os s ooso 'eves o|co|so' o~do'dos|eo~e
~oyoe sco~o~o' , oc|de| ~ | ve d og~os s s oo|o ~ed ve |ey|o |o ~
ceose o||e AC! s| ~c o|o~
5. Co~s deode~o ~s.|| c e~cy ~ oy po|e~|o~ s|eod |~eopy, s ~ced.o
| o~ o| |eopy co~~o| e oo y ped c|v~ c~ po| e~|sv ~ove scppess o~ o|
|e odeo ox s o|e|s o~ s|eod |eopy vo ove s g~ |co~| ~|ec.e~|
essso. d oe g ve~ s|essdose s|eodse~p co yv eoc.|ey
6. So .~edo od ped~ soe ~|e|ee v | | e AC! s| ~c o| o |es|
ydoco|soe|eopy ~oes ~|epe|o|o~ o||e|es|d || c. |, osve ' o po
| e|v|~s.spec|ed ode~o ~sJ||ce~cy, dexo~e|~osoe~oy oeg ve~oc.|e'y,
os |v ' ' ~o| |e|ee v|~ |~eAC! s| ~.' o| o~ |es| oo|~ so c~edo o~d ped
~ so~eoe c | ~o|e' yco~ve|ed |o ped~ so' o~e, v~ c~d ec|y |e|ees v |
|~eco|so ossoy ydoco|sooe o so d ec|y ~|e|eesv| |eco|so ossoy
exo~e|~osoedoes ~o| ~|e|ee, oc| ||sg ve oveseveo doys |co scp
pess |e odeo ox s exo~e|~oso~e o so os vey || e ~ ~eo oco| co d
e||ec|o~d ~oyo| ~pove ypo|es o~osdo~o|co yos ~ydoco| so~e
7. ~c|co y po' e|s, |epe|o|o o||eAC! s| ~. o|o |es| s d || c. |,
o~d|eeco| so evesvoygeo| y

A|| s| ~e, |~ee s~oco~v ~c ~gevdece

|~o| s|eo d scpp e~e~|o| o s oe~e| c o ~ |ese po| e~|s |e oosece o|
c eo yde~os|oo eode~o sc|| cecy
CA R C I N O I D T U M O R S
5 - H I AAS
Heart
I ntest i ne
Ai r way
Ast hma
Ski n
"otes
I . Coc o d |c~osoe |~o.g~| |oose|o~ ~ecoe~doc ~ece s '~ey

sy~
|~eszeovo e|y o|o~o~eso~d o oge~ co~ ~es, |e ~os|po~ ~ec| o||ese
t/OOC///OlOQy M 1 1 7
-
scos|o~ces s serotoni n . Seo|o~ s ~e|ooo zed ~ |~e oody |o o~yd|oxy~
do eoce|c ocd , o AA| , v~ c~ s |~e exc|e|ed ~ |~e c e Se|o|o~ s|~e
~o o| ~ed o|o espo~s o e|ocod o' ~o~ |es|o| oso| |~e coc ~o dsy
do~e, o~d |~ese|ve ~o |es|o|o~soe cove~ e~|'yoc| ~ed oy|~e~e~o~ c
o'AAS
2. Coc o d|.~osco~ oe|ocd ~o ~c~oeo|oco|o~s. !e cgs, oo~c~ ,
o~d ||oc~eo oe |~e ~os|co~~o s |es |o o co|c o d |~es |es c' .de|~e
s|o~oc~ , dcode.~, e cc~, ec~, oppe~d x, cecc~, co oo, o~d ec|.~ `
ge~eo , |~ecoc ~o d sydo~e, v|~ o |s sys|e~ c ~o~ |es|o| o~s, ssee
po|e|sv|~ ~e|os|o|c d seose|o |~e ve !~ s s |~ocg~| |o occ.oecocse|~e
e~|eopo| ~ c c cc' o| o~ o ~o' ' y ~e|ooo zes |~e podcc|s o| |~e coc ~o d
|c~o, | ~cspeve~| ~gsys|e~ csy~p|o~s ce~epo| c~e|os|oseso|epese|,
|~e podcc|s podcced oy|~ecoc ~o d |c~ooe eeosed |ee'y ~|o |~ec cc
o| o~, ovo d g ~epo|cc' eoo~ce
3. Carci noi d heart di sease occcs ~|vo|~ dso| po|e~|s v~o~ove|~eco
c ~o d syd o~e 1 ccsp d eg.g |o| o~ o~d | ccsp d s|e~os s oe |~e ~os|
co~~o~ ~o~ |es|o| o~s, oc|o' so pc ~oo|ys|eos s~oyoccJ 'e||sded ~eo|
d seoseocccs ~||eqce~| y ~ ess|~o~ I J7o|po| e~|s.!~ep|epodeoceo|
esos o|~e g~|sde o| |~e ~eo|scgges|s |~o||~e ~eo|d seose se o|ed |o
|oc|os sece|ed |o |~e ~epo| cve oy ve ~e|os|oses '~ s co~cep| s s.p
po|ed oy |~e |oc| |~o| |~e o~oec| c d.gs|e~| c o~ ~eod dex|e~| co~ e
oppeo|o |e|eev|~ ~o|~o seo|o~ ~~e|ooo s~o~d ~ove oee ossoco|ed
v |~ s ~ ' o cod ocvo vc o ' es o~s A secod ~o|es|o| o~ o| |~e coc o d
sydo~e s hypotension.
4. I ntesti nal mani festations c cde gos|o ~|es| ~o oeed ~g, oos|.c| o , o,
v|~ |~e coc ~o dsy~do~e, po|e~|s ~oydeveopd o~eo !~e ~os|co~~o~
|ypeo|d o~eo s~ xed sece|oyo~d~ype~o| ' |y ~dcced, podcc ~gvo|ey
s|oos c~esposve|o|os| ~g.
5. Ai rway obstruction |o~ o coc o d |c~ov|~ oco' zed v~eez ~g so~e
o||~e ~o|e co~~o~ pese|o| oso| |~ s |.~o !~eseo voy|c~os oevey
vosc. ood ~oy pese~|v|~ ~e~op|yss ~odd | o |o oco zedv~eez ~g
6. Asthma, v|~ s g |co~|v~eez g, so~o|~e~o~ |es|o| oo|~ g~ eveso|
seo|o |e eose ~ odd | o~ |o |~e ooove~e| oed 'oco zedv~eez~g |o~
o o voy es o, d ||csev~eez~g ~oyoccc dce |o ooc~ o ~ypeeoc|v|y
s| ~co|ed oy|~e ooge~ co~ es podcced oy|~eco|c o d|c~o|
7. Ski n mani festations oe po|o| |~e c oss c ~o |es|o| os o| |~e co|c ~o d
|c~o| 'o| e|s ~ove ~|e~secc|o~eocs| cs~ ~g os| ~g .p|oseveo ~ocs. !~ s
~vo'ves ~os| po~ ~e~| y|~e|oceo~d cppepo| o~so||~e oody A o|e s
~o |es|o| o o|o coc ~o d | c~o| vo' v ~g| ~e po~ceos o| go o' odde s
ec|oy|cey|~e~o. :||ec|ve||eo|~e|o| coc o d|c~osdepedso~| ~e o
co| o~ o~d sy~p|o~s .oco zed d seose o~d o voy ~oy espod |o s.g co'
esec| o~ ^e|os|o| c d seose, ~oveve, p ~o y ~voves |eo|~e|o|seve|e
sy~p|o~s ossoc o|ed v |~ |~e coc ~o d sydo~e c||eo| de s o po|e|
~ o |oo| ~o|~o~esece|o oy co|c ~o dce' s, o~d| ~ soge| co~ povdee|
|ec| ve co~|o o| d o~eo, |' cs~ ~g, od v~eez ~g ~ os ~o~y os o7 o|
coses
l l L/OOC///OlOQy
H Y P E R C A L C E M I A
Hy p e r CALCE MI AS
Hype fpa rathyroi di sm
Ca ncer
Acute renal fai l u re
L i th i um
Congeni t al (fa mi l i al hypocal ci u r i c hypercal cemi a)
E ndocr i ne di seases ( Addi son's, pheoch romocytoma,
thyrotoxi cosi s)
Mi l k a l kal ai syndrome
I mmobi l i zati on ( exacerbates another u nderl yi ng
di sor der)
A and D hypervi tami nosi s
Sa rcoi d and other gra n ul omatous di seases
^|so thiazide diuretics
`otes
1 . S g~so~dsy~p|o~so|~ypeco ce~ o ~c' cde~eco~cscc oveosess, oo
do~ o' po ~ , psyc~ o|| c d s| c|ooce, e~o s|o~es , ocd ||oc|ces , oo~es,
goo~s, s|o~es, o~d psyc~ c~oocs|
2. \~e~ ~ype|co ce~ o s coc| |~ed , csco' y oy o~ zed co c c~ ~eosc|e
~e|| , |~e o de||e d og~oss ~cs| oe es|oo' s~ed.
3. ~oy ~ypepoo|~yo d s~ s |~e ~os|co~~o~cocseo|osy~p|o~o|c ~y
peco ce~o ~ o odc | !~eopy|o|~ se~||ydepe~dscpoc |~e oge o| |e po
| e|od |~e pese~ceo| co~p co| o~s o|e~|s cde oJ yeos od |oc| e' y
c~degoscgey |~e| ~d co| os ~c cde
o : evo|o~o|se|c~co c c~~oe|~o J zoJ. ^J~~o /.ove|~ecppe
~ |o|~o|~o
o s|o|yo|o |e|~eo|e~ ~gepsodescc~osde~yd|o|o
c eceos g eo |c~c|o
d <eo s|oe;
e : evo|o~ o| coyco c c~ > ^JJ ~g/z^ ~oc|s
| S g| co| edco|o o| ooe ~ossoy~o vosve ~eosc|e~e|s
4. ^o g~occyossoc o|ed ~ype|co ce~ o ~oyoe dce|oseve|o ~ec~o~ s~s
o oo~y cvoso~ ,e g. , p|os|o|e, oeos||
L/OOC///OlOQy M 1 19
-
o Sece| o~ o| !|e' o|ed po|e ~ , e. , sq.o~o.sce o~d .oep |~e o'
coces|
c od.c|o~ o|os|eocos| oc|vo| ~g |oc|o, v~ c~ s poooo y ~|e e. l
, e , ~ye o~o|
5. !~ oz de d .e| cs ~c|eose co c .~ e.p|ose, v~eeos ' oop d .e| cs
,|.ose~ de| , o||e pope e~ydo| o~, p|o~o|eco c .~exce| o~
6. ~~oo zo|o~does o|co.se~ypeco ce~ oo' oe, o.| ~oy ~oeo occ.'|
co.se ~o~ |es|, s.c~osoge|s d seose, ~ypepoo|~yo d s~, o ~o g~o~cy
H Y P E R P H O S P H AT E M I A
H I GH P04 PARAS
Hypopa rathyroi di sm
I ntest i nal absor pti on ( vi ta mi n D)
G raves' di sease
Hemol ysi s
Parentera l P04
Oncol ogi c/or gan i nfarcti on
Paraprotei n
Addi son's
Renal fa i l u re
Aci dosi s
Sa rcoi dosi s/gra n ul omatous di sease
`otes
1 . ypep~osp~o|e~o ~os~o~yco.ses, v~ c~o|eo.| ~ed oy|~e~e~o~ c
CC A<AS C~ooc|ezed oyo ~ g~ eve'o|p~osp~o.s, ' C Cj ,
oeo|| ~ep ~oyco.ses s ~ypopoo|~yo d s~
2" S ~ce poo|~yod ~o~o~es p~osp~o|.|c, ~ypep~osp~o|e~ o so cod ~o'
|eo|.eo| hypoparathyroi di sm. Asecod ~po|o~| ~ed o|o| p~osp~o|.s
~o~eos|oss sv |o~ ~ \|o~~ e~oces i ntesti nal absorption o| p~osp~o
.s, o~d ~ypep~osp~o|e~ o ~oyoesee~v|~ove~edco|oo|v |o~ o ~
go~.o~o|o.sd seoses, ~v~ c~|~ee se~~o~cedcoveso~o| v |o~ ~D |o |s
120 L/OOC//OlOQy
oc|ve |o~ S ces|eods e~o~ce|~eexce|o~ o| p~osp~ocs ~|o |~e . ~e,
o| cc oy ~ eo oco| co ds, Add so~s d seosev | ~|s de| c e~cyo| s|eods
co esc| ~ypep~osp~o|e~o Graves' di sease o~d o|~eco.seso|~ype|~y
o d s~o so oc||odeceose eo exce|o o| p~osp~o.s :~~o~ced ce . oe
eose o| p~osp~o.s ~oy occcv|~ tumor lysis syndrome, organ i nfarction, o
hemolysi s. ype|~yo d s~ o so ~oyoc||o ~ceosece ' c o e'eoseo|p~osp~o
cs Aocc|e ~e|ooo coespo|oyoc dosscocseso ce' . os~ ||o|p~osp~o
cso.|o| ce s, eod ~g|o ~ype p~osp~o|e~ o Parenteral admi ni strati on o|
|oveocs p~osp~o|e so|s o p~osp~o' p d ~|cs o~s co ~ceose sec~ p~os
,~o.s eve s Ao~o~o , pos | ve yc~oged sec~ po|e ~s, v~ c~ ~oy occc
v|~ ~c'| p' e~ye o~o, ~oycocseo ~oed e'evo| o~o|p~osp~o.s !~esepo
|e~s see~ |o ove o vey~ g~o d ~go||~ |y|o p~osp~ocs ' ~o' 'y, renal fail
ure s pe~ops |~e ~os|co~~o od ~po|o|cocse o| ~ypep~osp~o|e~ o.
!~ s sco~~o~' y~o~oged v |~ ~|es| ~o p~osp~o|eo d ~g es ~so~dd e|oy
es|c| o~s ~osp~ocs co~ oe e~oved oyd oyss oy|oo ~|ed ex|e~|
H Y P E R P R O L AC T I N E M I A
PROLACTI NS
P regnancy
Renal fa i l ure
Ora l cont racept i ves and other medi cat i ons
Li ver fa i l ure
Adenoma ( prol act i n-secret i ng tumor)
Chest wal l di sease ( i ncl udi ng herpes zoster, surgery)
Thyroi dal di sease ( hypothyroi di sm)
I nf i l trati ve di sease of t he pi tu i ta ry ( sar coi dosi s,
hi sti ocytosi s
N u rsi ng/n i ppl e sti mu l ati on
St a l k effect
`otes
1 . `o~o 'y, po oc| ~sece|o~ oy|~e p |c|oy s es|o ed oy~ypo|~o' o~c
dopo~ ~esece| o !~cs, oy pocess |~o|d s.p|s ~ypo| ~o o~ csece|o o|
dopo~ eooocs |soc|v|y co~ co.se~ypepooc| e~ o
t/OOC///OlOQy M Z
-
2. ypepo' oc| ce~ o cocses ypogo^od s~ ^ ~ec o^d, oey, gyceco~os
| o ocd go' oc|o eo | co~~o^ yco.ses ypogo^od s~, o~ecoeo, ocd
go'oc|oeo ^vo~ec, sc| s~ soe
3 . o|o ^o coe|.' dcg s|oy cgs|o|o'ocsdopo~ esy^|es s, eeose,
ocd oc|o^ cc cde peco| oz ces, oc|yope^oces, ~e|oc opo~ de, ~e|y'
dopo, ocd esep ^e. :s|oge^s| ~c o| o^oveco~es^o~o dopo~ ceg c c
o | oc ! se||ec| s o^ ysee^ c gdosees|oge^ pepoo| o^s :s|oge^ o so
o'ocss po oc| ^ oc|o^ o||eoeos|, pevec| cg oc|o| o^
4. '^ odd | o^ |o sec~ po oc| ^ eve s, ' oooo|oyevo' .o| oc ^c .des |yod
|.^c|o^ |es|s o^d, c|eoppop o|e se|| ^g, e^o' ocd 've |.^c|o^ |es|s ^os|
po|e^|s eqc ecoc o' ~og ^g, ^<' l
5. Acypocess|o|o||ec|s|ep|. |oys|o s, s|o se||ec|l oocssdopo~ cese
ce|oc , e' eos ^g |e p |. |oy |o~ dopo~ ^eg c ^ o | o o^d esc | ^g ^ y
pepooc|^e~ o
H Y P E R T H Y R O I D I S M
TH E TSH
JoH excess
Hamburger thyrotoxi cosi s ( occul t hormone i ntake)
Ectopi c thyroi d t i ssue
Thyr oi d gl and hyperf uncti on
St i mu l ator of the thyroi d gl and
Hashi moto's ( r el ease of prefor med hor mone)
`otes
1 . !c!S e|es |o |e|s||es| |o ode ve^ evo' .o| ^g |yo d |.^c| o^
!eeoe s x ~o o ~eco^ s~so| ype|yo d s~ , I | !S excess, , z| o~
ocge |yo|oxcoss/occ. |socce o| o~o^e, , J| ec|op c|c^c| o^ ^g|yod
|ssce, ,^| |yod g' o^d ype|ccc| oc, , o| .cegco|ed s| ~co|os o| |e|yod
go^d, o^d(6) os ~o|os/eeoseo|pe|o~ed o~oce ||ese~eco^ s~s,
|e' o||e|ee, !S, oe |e ~os| co~~o^ !S seevo|ed c |e| s|cose
ocd scppessed c |eo|e|ve ' ^ odd | o^|o !S, ossoys|o!J ocd !^ |.^c
|oc , oc|oo^| oody||es, ocd poss oysc c| ' ' o| o^scoc^ ^goe o||ec ^d co|ed
122 t/OOC///OlOQy
'~ occ|e'y ' ' , ~osp |o zed po|e|s, !S 'eves ~oy o| e|ec| |~yod |c~c|ococ
cco|ey o~d co~o| oe e' edo~

2. TSH excess sqc|e oeod s cocsed oy!Ssece| ~g |c~os o~d sceoos

v~ c~ |~e p |. |oy s ess|o| |o |eedoocs ~ o | o Hamburger thyrotoxi
cosis , ~ges|o~o|o ~o |~yod |ssce| od scep|| ocs.seo||~yod ~o~o~e
, |~yo|ox cos s|oc| ' o| oe seco~doy |o o~ exoge~ocs socce o| |~yo d ~o
~o~e Ectopi c thyroid tissue s o oeco~d | o v~ c~ovo o~| ssce, s||.~o
ovo | oo ~e|os|o|c |o' ' cc o|~y|o dcoc o~o pod.ces excess|~y|o d ~o|
~o~e Thyroid gl and hyperfuncti on occcs v|~ o ~ype|.~c| o~ ~godeo~o
od |oxc ~c | od. ogo |e Sti mul ators of the thyroid gl and oc| e !S,
od |~e ~os| co~~o~ s |~e ' o~goc|g |~yod s| ~co|o , J!S| o| Coves d s
eose !|op~oo' os| c|.~o|s ~oyo' so podcceo~oo~o~o |~y|o d s| ~.' o|o
Hashi moto's thyroi di ti s osve os od o| o~, s.oocc|e, odc~o~ c|yod|s
cocse ~ype|~yo d s~ oyexcessve eoogeo| pe|o|~ed |~yod ~o|~o~e |o
|~ec |c.' o|o !~yod scppessve|~e|opy s.se' ess ~ |~ese po|e~|s, o~d |eo|
~e| so ~ed o|o~e oo| g |~e sy~p|o~so||~yo|ox cos s
3 . ^o~ |es|o|o~s o| ~ype|~y|o d| s~ c cde~evo.s~ess,e~o| oo oo |y,
oo |y|o s' eep, ||e~os, |eqce~|oove ~ove~e~|s, sveo| g, ve g~| oss, od
~eo| ~|o eo~ce |ox ~o' ~csc eveoess, |e~o, ~ypee|'ex o, |oc~ycod o,
~ype||es o v|~vde~ed p. se pessce, o~d o|~es g~so|sy~po|~e|cove
s| ~c o| o~ oe c~ooc|e s| c Coves d seose po| e~|s ~oy o so de~o~s|o|e
d s| c|ve | |o| veop~|~o ~opo|~y od de~opo|~y ~ o |ev, .sco' 'y o' de|
po| e~|s, o c' co p c|.eo|opo|~y, ve g~| oss, od~ype~e|ooo' s~poss o' y
co~p co|ed oy ~eo| |o ce o~d o| o o~y|~~ os , opo|~e|c|~y|o|ox cos s |
~oyoe pese~| A |oe sy~d|o~e o| ~yposo e~ cpe od c poo' yss ~oy occ.
~ |~y|o|oxc po| e~|s, espec o' y Aso od .o|~A~e co~ ~e~
4. !~e|o ov ~g ~~e~o~ c s|s ~os|o| | ~eco.seso| ~ype|~yo d s~
I G ET A TSH
I rradi at i on
G raves' di sease
Exogenous hyperthyroi di sm ( i odi ne, i atrogeni c,
fact i t i ous)
Toxi c mu l t i nodul ar goi ter
Adenoma
TSH-produci ng t umor
Su bacute thyroi di ti s
Hashi moto's
Also: "TSH" (Trophoblastic disease, Struma ovarii, Heparin-all very rare)
L/OOC/l/OlOQy M 123
h
H Y P O C A L C E M I A
I S PTH OK?
I atrogeni c
Sepsi s
P a rathyroi dectomy/P seudohypopa r athyr oi di sm
Tu mor l ysi s/Tra u ma
Hypopa rathyroi di sm/Hypomagnesemi a
Ustfoma l aci a ( r i ckets)
K i dney d i sease
`otes
1 . ypoco ce~ o ~oy oe o |o~s e~| p~e~o~e~o o o c~o~ c co~d | o~
C | co' |o de|e~ ~ ~g |~e co.se o| o ov ~eos.ed se c~co c c~ s c~de
s|o~d ~g |~e|.~c| o~o s|o|e o| poo|~yo d ~o~o~e , !, ' S !- | '
oc|s|o ~ceosesec~co c c~, o~d ~ ~ypoco ce~ cs|o|es ~oyoepese~|, o.|
|o~s e~| ydysegc o|ed, oose~|, pese~|o~d ~e||ec|ve, oovev~e ~ed
2. \~e~ ~|epe| ~g |~e sec~ co' c c~, e~e~oe |~o|o 'ov se.~ o o.~ ~
es. |s ~ o ov~eosce~e~|o| se .~co' c c ~ A~ o~ zed co c .~ ~eosce
~e~|v ' oe ~o~o
3 . Iatrogeni c causes ~c cde|o~s|cs o~so| c |o|ed o ood pod.c's, p os~o
exc~o~ge|~eopy, o~d~ed co| o~sscc~os~epo ~, po|o~ ~e, o~dg .cogo~
!~esee||ec|s oe .s.o' y|o~s e~|o~d ~oy ~o|eq. e |eo|~e~|
4. Sepsi s o~d c | co ~ess o||e~ oe occo~po~ed oyo ovsec~ co c .~,
o.|o||e~ ~ove ~o ~o o~ zed co' c c~leve' s o~ceo| | s cocses o pes s|e~|
' ovco' c c~ eve dc ~g|~eocc|es|oge|o.~ceoeoso~s !eo|~e~| s poo
oo y~o| ~dco|ed ~ ~os|po| e~|s, s ~ce |~e s g~so~dsy~p|o~s o| ~ypoco
ce~ o oe oose~| e~e~oe |~o| ' \co c .~ o~d ~ypeco' ce~ c s|o|es ~oy
pec p |o|e po~ceo| | s
5. Parathyroidectomy, e |~e ~|e~| o~o y o os o esc |o| |~yod s.gey, e
sc' |s ~ |~e oose~ceo|! !~e ~~edo|e pos|opeo|vepe od pese~|s po|c
c| o poo' e~s | sevee oo~e d seose s pese~| s|e | s | oos s es.' |s |o~
o~gs|o~d ~g ~ypepoo|~yo d s~, o~d oo~e ~ ~eo de| c |soe oge, esc |
cg ~ |~e ~oo |y |o espo~d |o ovsec~ co c c~ eve's
6. Pseudohypoparathyroi di sm s o ~eed |oyd seose c~ooc|ezed oye~d
ogo~c~espo~sve~ess|o'! ! spese~|, ~ ~ceosed o~oc~|s| o~d ~e|
le||ve 'oo|~yod go~d~ype|op~y s pese~|
124 L/OOC///OlOQy
l
7. Tumor lysi s syndrome od trauma causi ng rhabdomyol ysi s oe occ|e
cocseso'~ypep~osp~o|e~ o, odco c c~ eves |o pec p|o.s'y Coco~ |o|
eo' |o ce exoceoo|es|~e ~ypep~osp~o|e~ o, od '! s ovev~e ~ed
!eo|~e|sd ec|ed |ovod ove g p~osp~oo.s od ~pov g eo '.c| o
o. Hypoparathyroi di sm co occ.ososo' o|ed coge|o de|ec|o osso
c o| o v |~ o|~eoo~o es Acq. ed ~ypopoo|~yo d s~ ~oyoccc o||e
scgey ,d sccssed ooove| oos o o.|o ~~.ep~eo~eo ! s oose|o
sc|| c e|o~oc|s
9. Hypomagnesemi a, v~e sevee, s ossoco|ed v|~ ~ypococe~ o d.e |o
~po ed ! e eose ! s oose|o oppopo|e yov
1 0. Osteomal aci a , ce|s| occ.sv~e v |o~ s oose|, d e|oy, ' oco|
sc g~|, |es| o ~o oosop| o, de|ec|vey ~e'ooo zed o| covc so'|~e
opy, v |o~ depede| ce|s |ype '| o e||ec|ve , ve d seose, eo d s
eose, v 'o~ depede| ce|s |ype ' | \ |~o.'v|o~ , ! s e||ec|ve
1 1 . Ki dney di sease es.|s p~osp~o|e e|e| o, v~ c~ ovesco c .~od
|e|eesv |~coves o o| zoCv |o~ |o |soc|ve l , zo|o~ ' o
sese, |ovev~e ~s! od ~oes | e||ec|ve <edcc gd e'oyp~osp~o|e
od cs g p~osp~o|e o des od co c | o | ~eopy oe |~e co es|oes o|
|eo|~e|
H Y P O G LYC E M I A
I NS U L I NOMAS
I ns u l i noma
Neopl asm ( e. g . , l arge retroperi toneal t umors)
S ul fonyl ureas
U remi a/renal fai l u re
L i ver fa i l u re
I nsu l i n ant i body synd rome
N ut r i t i on ( " reacti ve hypogl ycemi a " )
Other drugs ( ethanol , pr opra nol ol , aspi r i n)
M unchausen's syndr ome ( sel f-admi ni stered i nsu l i n)
Adrenal i nsuff i ci ency ( i ncl udi ng pa nhypopi tu i tar i sm)
Starvat i on
^|:o /o/e |e/eo||oq eo,oo|c oe|ec|:
L/OOCl//O/OQy M Zb
-
`..
1 . I nsul i n o~d sul fonyl urea therapy cocse|~egeo| ~o o|yo|~ypogyce~ c
ep sodes A coe|c ossess~e~|o|~ed co| o~s s esse~| o , os ~ s|oes ~ ~ed
co' o~s ~oyco.se ~ypog yce~ o , e g , oce'y ~exo~ de s.cs| |c| o~ |ooce|o
zo'o~ de| Other medi cati ons co~ co.se sy~p|o~o| c ~ypog yce~ o scc~ os
~|oveo.s pe|o~od ~e ~ AS po| e|s So~edcgs ~oy~oveoc|v|ys ~ o
' osc |o~y ceo oge~|s , e g , ooc| ~| , co.s ~g~ypogyce~ o ~e de yo ~o
~oc s~ed po|e~|s
2. Sy~p'o~so| ~ypogyce~ o oe eo|ed |oepi nephri ne secretion o~d CNS
gl ucose depri vation . A op d dop ~g .cose eve eods |o sy~p|o~sossoc
o|edv|~ excess ep ~ep~ ~esece'o~ scc~ os |oc~ycod o, sveo' ~g, |e~o,
ox e|y, u~d ~cge \ |~ ~oe godco dops, C`Ssy~p|o~s pedo~ o|e,
s.c~osd zz~ess, ~eodoc~e, c ocd ~go|v s o~, co~|cs o~, o~d se z.es
J . sc o~o so oe '.~o .eve so| ~s. ~, po ~s. ~o~dCpep|des~oc d
ce oc|o ~ed dc ~g ~ypogyce~ o e~o~s|o| o~ o| ovg .cose o~d ~ g~ ~
sc ~eves dc ~g |~e~ypogyce~ cepsode so|s.||ce~|evde~ce|o|~ed
ogos s o| s. ~o~o oc' | ocs ~ypog yce~ o 'o~ ~s. ~ ec| o~ o
sc |o~y ceo d.gs spococ y|~e~os|co~~o~cocseo| ~ypogyce~ o ~ ~o~
d oce| cs ~sc ~ ~ ec|o~ cocses o se ~ sc eve s, cc| ovCpep|de o~d
po ~sc ~ eve s ^os| po' e~'s v |~ ~sc ~o~os ~ove eevo|ed po ~s. ~ |oc
|o~s ,> Zo7o||~e|o|o se.~ ~s. ~| C~o~ c ~sc ~ ~ ec| o~o so ~oy ~d.ce
'~edeveop~e|o|o~| ~sc ~o| cod es
4. Pseudohypogl ycemi a so |e~ gve~|o po|e~|sv~o ~ove sy~p|o~s z |oo
~ocs o|'e ~eo s, cc'do ' ~ove o~ ossoc o|ed ov g .cose eve '~ese po
| e's ~oy ce e|eed |oevo .o| o~ cecocse o|o sp. ocs y ov ~eosce~e~'
|s~oc d ce e~e~ceed |~o|opp|ox ~o|e'y zo7o| ~o~o ~d v dco s~oveo
ovsec~ g .cose eve z |o o ~ocs o|'e o ~eo , so |~ so o~e s ~sc||ce~||o
d og~ose |.e ~ypog yce~ o 'ce ~ypogyce~ o s~oc d cocse sy~p|o~so~d
e c | o ~ypo|~o' o~ cp|.|oyespo~seo| ~ceos ~g sec~ co|so
5. |~e i nsul i n anti body syndrome, ~sc s coc~dcy|~eo~' codeso||eo
~eo Seveo ~ocs o|e, |~e ~sc ~ s e eosed o~do ~ypog yce~ cep sode
occ.s
6. <eoc've ~ypog yce~ o ~oyced || c. ''o d og~ose, o~doo g ccose |oe
o~ce |es| ~g s~o| ~e p|. A ~ g~ pece~|oge o| ~o|~o peope de~o~s||o|e o
deceose ~ sec~ g .cose, s ~ce ~sc ~eves ~o~o' y se o||e o ~eo

7. !c ~os oe o oe cocse o| ~ypogyce~ o, o~d ~s. ~o~o s |~e ~os|

co~~o~ `o~s e|ce |.~os co.se ~ypogyce~ o cyseveo ~ec~o~ s~s , l |
eeose o| ~sc ~ egov|~ |oc|o , C' | o|s ~ g~ ~o ecc o ve g~| pec.
so , o g C , , z| ~oss ve |c~o ccde~ v |~ ~ g~g .cose c| ' zo|o~, , Jj ~e
po| c ~| |o|o~ cy |c~o, o~d , ^| ,odcc| o~ o| oc|oo~| cod es|o ~sc ~ o |s
|ecep|o
126 c/OOc//O/OQy
D
H Y P O P H O S P H AT E M I A
P H OSP HORS
Pa rathyroi dectomy
Hypervent i l at i on
Oncogeni c
S ta rvati on-refeedi ng
P hosphate bi nders
Hypert her mi a
Osteoma l aci a
Recovery f r om di abeti c ketoaci dosi s
Steroi ds
P HOS FATE
Pa rathyroi dectomy
Hyperpa rathyroi di sm
Oncogeni c
Steroi ds
Feedi ng
Al ka l osi s
Ther mal i nj u ry/hypert her mi a
E nter i c ( P04 bi nders, di et ary def i ci ency)
1 . ypop~osp~o|e~ oco oe~odeo|e o|seve|e Sevee ~ypop~osp~o|e~ o
sde| ~edos p~osp~o.s 'eves c |~ese.~ oe ovJ. J ~^/' !~e e||ec|s o|
p~osp~o.s dep' e| o~ cc .de ~oodo~yo yss, cod o~yopo|~y, esp o|oy |o
.e, ey|~ocy|e dys|.~c| o, e.ocy|e dys|.~c| o~ , se e|o de~ ceo zo| o
odoo~ed seose, ~evo.ssys|e~ dys|.c| o~ , o~d~e|ooo coc dos s
2. ypepoo|~yo d s~sossoco|edv|~ p~osp~o.sdep e| o~, ~oveve, o||e
parathyroidectomy |o ogs|o~d ~g ~ypepoo|yo d s~, ~.gy oo~e sy~
do~e ~oy occ., od ogeo~o.~|s o| p~osp~o.s ~oy go op d y ~|o |~e
ooe, pod.c g c co ~ypop~osp~o|e~ o Hyperventil ation es.|s ~ o es
p o|oyo o os s !~e e evo| o~ ~ p ~ceoses |~e o|e o| gycoyss ocd s.o
seq.e|p~osp~o|y o|o~ o|g' .cose !~ s es.|s o ~~ed o|e ce ' . o.p|oe
o| p~osp~o.socd ~ypop~osp~o|e~ o Soco' ' ed oncogeni c os|eo~o oc o so
t/OOC//OlOQy M 127
eco' p~osp~o|e vos| cg sycdo~e ossoc o|ed v |~ ce|o c ~esecc~y~o
|c~os ' | s|~ocg~||~o|ocosye| cc dec| | ed ~edo|o po~o|es excessve c
coy p~osp~ocs oss Starvation v |~ scoseqcec| e|eed ug o so ~oy esc'| c
s gc | coc| ~ypop~osp~o|e~o c|~e c | o doyso| co o e ep e|oc !~eso~e
e||ec|coc oeseecv|~ ~ype|o ~ec|o| oc.
c c~oc cal cohol i cs, p~osp~o|cs coc|ec| sedcced cse e|o' ~csc es,
poooo y oecocseo|eco' p~osp~o|e osses \~ec c~|oc co' co~o cs go c|o
v|~dovo |o~ o' co~o , p~osp~ocs~oyoe |op dy|osec cp c|o|~ese'e|oc,
~csc e, o ve, esc | cg csevee ~ypop~osp~o|e~ o, v~ c~ ~oy | c cpe
c p|o|e occ|e ~oodo~yo ys s ~osp~o|eo cd cgoc|oc ds ~oydec|eose c
|es| co ooso|p|oc o|p~osp~ocsocd eod |o ~ypop~osp~o|e~ o |ovecsed
'c coses o| hyperthermi a, po|| cc' o y |~e ceco ep|c ~o' gcoc|sycd|o~e,
p~osp~o|e' eve s~oy|o' ' occ|e y A s ~ o p~eco~ecoc coc oeseec c |~e e
covey |o~ ex~ocs|ed execse o v|~

evee |~e~o o.|cs Osteomal aci a o

eco

ce|s |esc|s ceco |coc oosses o| p~osp~ocs !~ sesc|s|o~o de|

c eccy o|v |o~ c , v~ c~ co~o y po~o|es p~osp~ocsooso|p| oc c po
| ec|s v | ~ di abetic ketoaci dosi s, ~e|ooo' c oc dos socd csc cde| c eccy
~oo ze c|oce c' o p~osp~o|e s|oes ocd eod |o |~e |exce|oc c |~e c| ce
!~ese po| ec|so so ~oy~ove ~od poo cc| | oco c|oe, eod cg| oo ove
eve o| p~osp~o|e s|oes \~ec csc c s |~ec od~ c s|e|ed ocd |~ee s c
ceosed g ccose ec||y c|~ece' ' s, p~osp~ocso so ec|es | ~ece' ' s, ocd sec~
~ypop~osp~o|e~ o~oy|esc' | co' 'y, steroid therapy, po| cc' o|' yo'dos|eoce,
oc|o so g' ccoco| co ds, |ecds|opo~o|e p~osp~o|e exc|e| oc c|o |~ec ce
ocd ~oy eod| oo dep' e|oco| |o|o' oody p~osp~ocs
3 . !eo|~ec|o| ~ypop~osp~o|e~ o depecdsoc |~ec c co sceco o c occ|e
sy~p|o~o|c ~ypop~osp~o|e~ o, p~osp~o|csso|s ~oy oegvec oy c|ovecocs
cec|oc c cosesv |~coexs|ec|~yposo e~ o, po|oss c~ so'| ~oy oeod~ cs
|eed. c ||eo|cg o' co~o' cs v~oo||ec o|e p~osp~o|e, po|oss c~, ocd ~og
ces c~de| c ec|po|oss c~so' |ocd ~ogces c~sc|o|e ~oyoecood~ c s|e|ed
o ocg v|~ g' ccose
128 L/OOC/l/OlOQy
SY N D R O M E O F
I N A P P R O P R I AT E
AN T I D I U R E T I C H O R M O N E
S E C R E T I O N
SI ADH
S mal l cel l carci noma and other ca ncers ( pancreati c,
Hodgki n's di sease, thyroi d, duodenal )
I nfect i ons ( tubercul osi s, pneumoni a, l ung abscess)
A RDS/mecha ni cal venti l at i on/pul monary di sease
D rugs
Head t rauma/neurol ogi c di sease
`otes
1 . S A s|~e|e~opp ed |oexcessvevosopess eeose ossoco|ed v |~
~ypoo|e~ o v |~oc|ede~o J| e s opp|op o|e ycoce|o|ed , csco y
> JJJ ~~o /'j desp |e o 'ov p' os~o os~o o |y od sec ~ sod c~ co
ce|o| o Sod c~exce|o |~e c e s ~o |o ed , csco' y > zJ ~~o /.j
oy ~ypevo' e~ o, scppesso o| |~e e ogo|es odos|eoe sys|e~, od
ceosed eves o|o| o o|c e|c pep|de o3` od ceo| e ~oydeceose
dce|o d c| o .
2. S A ~oy oesecodoy|o ~o goc es, pc ~ooyd seoses, dcgs, od
ce||o e|vocs sys|e~ d sode|s Mal i gnanci es cocs g S A c cde s~o
ce' ' coc o~o, poceo|c co|c o~o, odg s d seose, |~y|od coc o~o,
oddcodeo co|c o~o Pul monary di seases cocs gSA c cde|coecc
oss, pec~o o, od cg ooscess, os ve osc~|o coos||cc|ve pc ~ooy
d seose, A<S, od ~ec~o co ve| ' o| o Drugs |~o| ~oy cocse S' A
c' cde ~ypog yce~ coge|s, psyc~o|op cs, oco| cs, odc~e~o|~eopec| c
oge|s Central nervous system di sorders cocs g S A c cde ~eod
|oc~o, ~e~o|~oge, ecep~o' | s, ~e g | s, Cc o oo|, od pop~y o
|~e|cocseso| ecvo e~ c ~ypoo||e~ o c cdepsyc~oge c poyd ps o, ~y
po|~yo d s~, odeo sc|| c ecy, po , scgey, odoes|~es o
3. S' A s~oc d oe scspec|ed v~e po|e|s ~ove ~ypoo|e~ o od o co
cec|o|ed c e ,> JJJ ~~o /sgj |~e oosece o|de~yd|o| o ' ~po|oc|
L/OOCl//OlOQy M 129
-
co~d | o~s|o . eo.| ~c .ded .| o~o' ~ypo~o|e~ o,s.c~osocc.s ~ ode~o
co||cos|eod ~s.|| c e~cyj, ede~o|o.ss|o|es , C, ~ypo|~yo d s~j , ~ype|e~
sve s|o|es , e~o o|eys|e~os s| , d .e|c .se, pse.do~ypo~o|e~ o ,excessve
p os~o | g yce des o po|e ~s| , o~d p ~oy po yd ps o , o|voys ossoc o|ed
v|~ o d .|e . ~e, os~o' o |y < l oJ ~~o /g|
4. A vo|e| ' ood |es|osve ' os. ~oy o p os~o A\ eve soe .se|.' ~|~e
evo .o| o~ ' ~ |~evo|e ood |es|, o po| e~|d ~s o oge vo .~eo| |' . d o~d
| ~e~ .| ~e s co ec|ed ~ ~o.| yso~p es 'o~o' y, o| eos|o7o|| ~evo|e
s~o.d oe exce|ed oy^ ~o.s, o oJ7 oy o ~o.s, o~d |~e oves| . ~eos~o
o |y , .s.o' y |eoc~ed ~ |~eseco~d ~o.| s~o.' d oe ess | ~o~ I JJ ~~o /g
' os~o A\ s ~~eos.|oo e ~ ~ypo~o|e~ c s|o|es, o.| S A | s de
|ec|oo eeve~o||eovo|e| ood
5. !|eo|~e~|o| S A ~voves e ev~g|~e.~de' y ~gco.seo~d| . des||c|o~
!~ed.gde~ecocyc ~e ~~ o |s A o~d ~oy oe o .se|. |eo|~e~| So~e po
| e~|sv|~ c~o~ cS' Aco~ oe |eo|ed v |~ o ~ g~so |o~d po|e ~d e|. !~e
~ g~os~o o |yv ~ceose|eevo|e|exce| o~
130 t/OOC/l/OlOQy
m
N E P HROLOGY
General Consi derations
!~eeoe |vo voys o| oppooc~ g |eo d seose , l | oosed o e| o ogy, os
oc| ed |~e ^: C ': C ~e~o c, od, z| oosed o po|~o'ogy||o~ o
|eo' o opsy | s ~po|o| |o |ecog ze | ~o| | ~eso~ed seose pocessco
cocsed ||ee|po|~o' ogco p|ocesses | ~e dey,|oexo~pe, sys|e~ c cpcs
e|y|~e~o|oscs ~oycocseo vo e|yo|eo' ' es os|
Me|ooo ce g , o~y o dos s, ~ypec| ce~ o
cdoc e-e. g , ~ypeco ce~ o, ~ype|od ~ypo|~yo d s~, S A od
d ooe|es s p dcs
Dcgs/~ed c es e g , c~e~o|~eopec| coge|s, o| o o| cs, |od oco
||os|dye
' |ec|oe g , \|e o|ed, |coecc os s, pye oep~ | s
Coge |o -po'ycys|c deydseose, A'po|ssyd|o~e, |e|'cxep~opo|~y
' ~~co og ce g , Coodpos|ces, \egee|sg|oc'o~o|os s, S.:
Meop' os| c e g , eo ce coc o~o, |os | oo ce coc o~o, | c~o|
ysssydo~e
cxo|cd seoses e g , socodoss, !', cyogooc' e~ o
Degeeo|veogg, -~ype||eso
Ccccpo| oo' / ev |o~e|o' ||oc~o
Cod ovoscc o| e g , o| ~eosc' eos s, ~ype|es ve ep~|opo|~y, c~o'es
|eo e~oo
A ~c | |cdeo|metabolic di sorders ~oycocse eo d seose !~ese c cde
o~y o dos s, ~ypeco ce~ o, odo|~ed seoses|~o| eod|oooo~o ceoses
~e|ooo'c p|odcc|s |~e oood s|eo~ ype|' pde~ o eod g|oo|~eosce
ossoso cocd oecosde|ed o ~e|ooo cd seose'eod g|o eo sc||cecy
Endocri ne di seases ~oy oe ~ode ~o|es| oy eo sc|| c ecy Ago ,
~ypeco ce~ o, secodoy| o~ypepoo|~yo d s~, co eod | oeo |o ce
od/o| ep~|o | ~ os s ooe|es co cocse po|e c o o pogessve eo
sc|Lc ecy od, c' | ~o|e'y, |eo' |o ' ce |~eedoc| esyd|o~es vo v g
|~e dey c cdeS Aod~ypo od~ype||~y|o d s~ ' odd | o, eo' ce'
coc o~o ~oy~oveseveo' ossoco|ed pooeop os|csydo~es.
N0/lO/OQy M 1 31
.. .

Drugs oeo |eq.e|co.seo|eo' sc|| c ecy, odv |co yoydcgco

co.se eo d seose. A co~~o poo e~ s eo sc|| cecy dcced oy o|
~ype| es ve oge|s, espec o' y AC: ~ o |os. |~e|o~s o| d.g dcced
eo d seose c .de |es| | o ep~ | s od |o~s secodoy |oc~e~o|~eo
pe.|coge|s, |oveo.sod oco|os|,o |oveo.sdcgoo.se
^oy|ypes o| i nfecti ons cocse eo' d seose \d seose co ' eod |o
sevee po'e . o od eo |o ce !c.ecc os s ~oy p ~o y vove |~e d
eysod |~ec oy|oc| ye oep~ | s so soo co~~o |ec|ocsd seose
vo v g|~e deys
Congenital di seases coco.se eo ~o |es|o| os Ao~o es o| |~e .
oy |oc| od c~o c e| cx ep~opo|~y ~oy eod |o eo |o .e oycys|c
deyd seoseod ~edc oyspoge deyd seoseoe|o~ o cocseso|eo
|o .e |~e ~e|ed ~e|ooo cd seoses scc~ os 'ooys d seose od vo ocs
s|ooged seoses co eod |o eo s.|| c ecy A vo e|y o| coge |o d so
des ~oycocseeo s|oes, c .d gcys| os sod .esc~'y~osydo~e
I mmunologi c di seases o||e o||ec||~e deys, od eo d seose ~oy oe
|~e| s|~o |es|o| o o|o ~~co og c d seose \ |co 'y o ' o| |~e co oge
vosc.' od seoses , e g , S.:| ~ove eo ~o|es|o| os !~e voscc | des, c .d
g \egees , Coodpos|.es, od po' yo|e | s odoso, ~oy eod |o eo'
|o .e
Neoplastic di sease ~oyose p ~o ' y | ~e deyso vove| ~e deys
secodo y <eo' ce coc o~o co oev de y~e|os|o|cod o||e ~ososso
c o|ed pooeop os|c sydo~es ^e|os|o|c |c~os o oco y vosve ' .~os,
o||e gyeco' og c, ~oyco.se co~pess o o||~e .e|es od eo |o ' .e
ypeco ce~ o secodoy|o ~o go| d seoseco eod |o eo |o ce, os
co ~c | p e~ye' o~o
'c~eo.s exotic d seoses o||ec| |~e deys, c cd gsoco dos s, |o~ o'
^ed|eoeo|eve, od ! So~eo| |~esed seosesoe|~o.g~| | o~oveo ~
~co og c oos s
e~ops|~e ~os| ~po|o|ospec|o|degenerative d seose|ocos de s
|~e e||ec'o|og go eo |.c| o !~e g o~e c o | |o| o o|edeceoses
s|eod yv |~ oge, odo ovsec~ ceo| e ~oy o| e|ec|oc|.o' eo |cc
| o oe de ypo|e|
Occupati onal and envi ronmental exposures ~oy ' eod |o eo dys|cc
| o :x| s c|oc~o co co.se deydo~oge, ~e~o|. o, o |osoeed g
ydocooo expos.e ~oycocseCoodpos|.essydo~e
Cardiovascul ar di seases ~oy vove|~e s deys secodo y. C~o c~y
pe|es o co eod |o eo s.|| c ecy od, c | ~o|e y, eo |o .e
C~o es|eo e~oo ~oyoccc v |~ sevee o|~eosc eo|c d seoseo||e o od
ogop~ cdye pocedc e A so, coges|ve ~eo||o ce so vey co~~oco.se
o| peeo ozo|e~ o
132 N0j//OlOQy
Cl i n i cal Symptoms and Si gns
E D E M A
TH E LEAK OF VE I NS or VALVES
Venous di sease ( obstruct i on, i nsuff i ci ency)
Al bumi nuri a/al bumi n l oss i n stool
Lymphati c obstructi on ( congeni t al , acqu i red)
Vol ume over l oad
E l ectrol yte/n utri ti onal def i ci ency
Sepsi s/capi l l ary l eak
or
Tumor
Heart fa i l u re
Enteropathy ( protei n- l os i ng)
L i ver fa i l ure
E ndocr i ne ( hypothyroi di sm, al dosteroni sm, di abetes)
A I ti tude si ckness
Ki dney di sease ( renal fa i l u re, nephroti c syndrome)
Obstruct i on of l ymphat i cs
Fi l ar i asi s
Venous th rombosi s
Ecl ampsi a/pregna ncy
I at rogeni c
Nutr i t i onal def i ci ency
Sepsi s/capi l l ary l eak
Note
\A.\:S e'es |o |~e oss o| veocs vo vc o co~,e|ece v|~ og ~g, o
co~~o~ cocseo|ede~o :de~o ~oy esc | |o~ veocsd seose , |~|o~oos s,
N0//O/OQy M lJJ
ex| ~s cco~pess o~, |oc~o, ve~ocsvo vc o ~sc|| c e~cy| , oss o| o oc~ ~
( ~ep~os s, po|e ~ os ~ge~|eopo|~y| , ' y~p~o| c oos|cc|o ,co~ge~ |o , ~o g
~o~|, | o os s| , vo c~eove ood , C, e~o |o ' ce, c ~os sj , e' ec|oy|e/~c|
| o~o' de| c e~c es |~o|cocse o oss o|ve~ocs ~|eg |y, ocd seps s o~d o|~e
sys|e~ cco~d | o~scocs ~gcop ' ' oy eo
H E MAT U R I A
UA RBCS
U ret h ra
Arti factua l ( e. g. , dar k ur i ne, menses, medi cat i ons)
Renal ( e. g. , tra u ma, cysts, pyel onephr i t i s)
B l adder
Col l ect i ng system
Systemi c di sorder ( e. g. , vascul i t i s, coagu l opathy)
`otes
1 . e~o|c o s de| ~ed os |~e pese~ceo|goss o ood o oCs , > I z pe
~p|| ~|~espc~ c ~oysed ~e~| | s ~po|o~| ~ | o y|o ooo||~esed ~e~| |o
c eoc||o se ~e~o|c o Ce|o ~ ~ed co| o~s , |o~p ~, pe~ozopy d ~e| o~d
d seoses , pop~y o| ~oyo |e c ~eco o. Aso, oo|~ ~yog oo ~c o o~d ~e~o
g' oo ~c o cocse o pos | ve d ps| c |es' v|~ o ~ego| ve c ~oy sed ~e~|
^e~s|co|o~o' soco~oe~ s|oe~ |o ~e~o|c o
2. e~o|c o~oyo g ~o|eo| o~ys|e|o~ g o~ec' cs |o | ~ece|~o. !~epes
e~ce o|ce~o|ed oCs, oCcos|s, po|e ~co, oeevo|ed oJ' o~d ceo| ~ ~e
scppo|o g o~ec osocce. ' so' o|ed ~e~o|c o, v | ~oc| cos|s o po|e ~c oj
scgges|s o eed ~g | o~ o s |e ~ |~e co ec| ~g sys|e~, o odde, o c e|~ o
'oss o | es ~c cde ~eop os~s, !o, e~o s|o~es, |oc~o, pop oy ~ecos s,
o~o gesc ~eopo|~y, pos|o| | s, cys| | s, o ce|~ | s
3 . ~ | o y, exc cdeJ! , coogc o| o~ d sodes, o~d'o !~e po|e~|s ogeo~d
pese~'o| o~ de|e ~ ~e ' ~e d ec| o~ o| |~e voc p o exo~p e, o yoc~g
|e~o ev|~dyscovoc d ~os| e yoe|eo|ed v'~ o | o' o| o~| oo|cs, v~ e
o~o de ~o~ v ' ~ ece~|o~se|o| goss ~e~o| c o ~oy oe ~ves| go|ed v |~
e~o ~og ~g o~d/ocys|oscopy '~ yoc~ge po' e~|sv |~oc|ev de~ceo| ~
|ec| o~, o~ \ s o||e~ |~e | s| ~og ~g|es|odeed
134 N0j//lOQy
4. A co~~o~ e~o d seose |~o||eo|.es ~e~o| . o s gA ~ep~opo|~y ' gA
ep~opo|~y sc~ooc|e|zed oygoss o ~ coscopc ~e~o|. ov |~o.|o|~e
sy~p|o~s !~e pogoss s vo oo e, o.|d seose pogesso~ |ypco y ss ov,
v | oppox ~o|e y'J7 o| po|e|s deve op g eo |o ce v | zJ yeos o|
d og~os s Se| ~ |ed oc.|e e~o 'o .e ~oydeveop 'o ov~g on .ppeesp
|o|oy ~|ec| o~ !~ee s ~o ~ovc e||ec|ve |eo|~e||o gA ep~opo|~y, od
|eo eo|e~o o opsy ~|~ sd sode sco~|oveso
5. So~eo| |~e ~oe co~~o~ co.ses o| ~e~o|. o oe s.~~o zed oy |~e|o
ovg ~~e~o c
I P E E RBCS
I nfecti on
Pseudohematur i a ( menses, dar k ur i ne)
Exerci se
Exter na l trauma
Renal di sease ( gl omeru l ar sou rce)
B eni gn prostati c hypertr ophy
Ca ncer
Stones
6. ee s o ~oeco~p e|ed ||ee~| o' |o e~o|. o
I ' D PASS H E MATU RI A
I gA nephropathy
Dr ugs/da rk u ri ne ( pseudohematu r i a) _
Pol ycysti c ki dney di sease
A na l gesi c nephropathy
Si ckl e cel l
Stones
N0j/lO/OQy M l Jb
H emogl obi n u ri a, myogl obi n u ri a, porphyr i a
Exerci se
Ma l i gnancy
Acute gl omerul oneph r i ti s
Trauma
U reth r i ti s
Renal i nfa rct i on
I nfect i on
A I port 's syndrome and other i n heri ted di seases
( e. g . , si ckl e cel l , pol ycysti c ki dney di sease)
H Y P E R T E N S I O N
I C H ECK A BP
I di opat hi c ( essent i al )
C NS d i sor ders
H i gh out put states
E ndocr i ne di seases
Coa rctat i on
Ki dney di sease
Acute stress
Bi rth control pi l l s and other drugs
P regnancy
Note
:ssec| o ~ype|ecs oc occo.c|s |ogeo|e| ~oc -J7o| ~ype|ecs oc coses
!e p ~o| ycocses o|oce'evo|ed o ood pessc|e oe oc| ced oy " 1 C:C
A BP. "
oO N0j//OlOQy
S E C O N DA R Y H Y P E R T E N S I O N
R E NALS
Renal
E ndocr i ne
Neurol ogi c
Aort i c coarctati on
L i cori ce gl uttony
Scl eroder ma
`otes
1 . ype|e~s o~ s d opo| c, esse' o , o secodoy'o oe o| |e cocses
o.| ~ed oy .`A.S
2. Renal di seases |o| cocse ype|es o~ c cde ~o~y 'ypes o| eo
poecy~o d seoseosve os e~ovosc. o ype|es o~
3 . Endocrine causes o| seco~doyype|es ooeoco~egoy, o dos|eo s~,
| ce |.~o, Ccs gs sydo~e, peoco~ocy|o~o, od ypeco ce~ o
eoco~ocy|o~osoe cooc|ezed oy pooxys~o os.s|o ed epsodeso|
sevee ype|e~s o eodoce, po p |o| o~s, o~d/o po|.se d opoes s oe
o ~os|ovoys ossoco|ed v| |e ype'eso~ !e|c~os ~oysece|eep ep
~e, oep ep e, seo|o~ , o ~o| ~g !e |e~ pece|.e e|es 'o |eoo
sevo|o |o' l J7oe ~o g~o~|, l J7oe o o|eo , o~d ' J7oeex|oodeo
.x|oode~o s |es ~c .desy~po:e|c go~g o ,ogo o|/cceo~de | o~d|e
o odde, ~c|c|oossoc o|ed sy~p|o~s| A|ce |c~opod.ces e~ eod ~g
|o ype|es o~ |~oy ese~o eCo~ssy~do~e, p ~oyypeo dos|eo s~| ,
excep||o|e eves oe deceosed Co~~s sydo~e o co~|ocep'ves
cocd oe co~sdeed oexogeo.se~doceco.seo|secodoyype|e~s o~
.s|ogess| ~c o|e o~go|es oge podcc|o oy| e ve, |eeoy ceos g
ogo|e~s o~do dos|eoe 'eve s S|eod |eopyosooses o ood pessce
4. Neurol ogi c di sorders co.s g ype|es o~ c cde ceosed ~|oco o
pessce, occ|esp ~o cod ~ cy, dysoc|o~o~ o, poy~ec | s ,occ|e popy o,
eod poso ~g| , o~d psycoge c|oc|os.
5. Aortic coarctation ~oy oe d ogosed oyo oood pess.eod pc sed ||e
e| o oe|vee .ppeo~d ove ex|e~ |esod cooc|es|c oo|c ~g ,|o~
~ceosed |ov|o.g ~|ecos|o' o|ees| see oxoy
6. Licorice co~|o ~sgycy z coc d, v c ~ceoses |e ~ eo oco' code|
|ec|s o|e~dogeocsco|so
7
.
Scleroderma eo c s s s o do~o| c od |e|eo|e~ g ~o 'es|o'o~ o|
|e d seose AC: ~ o|osoe |e |eo'~e|o|co ce
N0j//OlOQy M 137

Cl inical Condi tions or Diagnoses
H Y P E R KA L E M I A
A H I K
Aci dosi s
Hypoa l dosteroni sm
I atrogeni c/I naccurate measu rement ( LAB error, dr ugs,
I V potassi um)
Ki dney di sease ( renal fai l u re, r enal t ubul ar di sease)
`otes
1 . !~ep ~oycocseso|o ~ g~ sec~ po|oss c~oesc~~o zed oyA
Aci dosi s cocses po|oss c~|o s~||oc|o| ce ' s Hypoaldosteroni sm cocses ~y
peo' e~ o oecocse o' dos|eoe o~o' 'y po~o|es eo po|oss c~exce| o
I atrogeni c cocseso| ~ype|o' e~ o c cded cg|~eopy , ~epo , po|oss c~
spo g d ce|csj od ' \so' c| osco|o g po|oss c ~ I naccurate measure
ments ~oy oe oo|o ed v~e ~e~o' ys so| |~e spec ~eoccc|s o |o~ poo
o' ood dov g|ec~ qce,ove| | o| o o| o' ood pesscecc||j ' o' 'y, ki dney
di sease ~ o|s o~o' po|oss c~exce|o od eods|o ~ype|o e~ o
2. !|ce~ypeo' e~ oocccsoyoeo| |~|ee ~ec~o s~s i nadequate excretion
, eo d seose, ~ypovo e~ o, ~ypoo dos|eo s~, po|oss c~spo g d c|e| cs| ,
potassi um shi ft |o~|ssces,| sscedo~oge, dcgs, oc dos s, ype|os~o' o |y,
sc de|c ecy, ~ype|o e~ cpe od c poo ys s| , o|excessive i ntake. 'secdo
~ype|o' e~ oocccsv|~|~|o~oocy|os s, ecocy|os s, o v||o ~e~o ys s
3 . eo ~ec~o s~so| ~ypeo e~ o vove o deceose | |e|ed o ood o
|coc o| d seose Acc|e|eo |o ' c|e s ~o|e e y|ococsesevee ~ype|o e~ o
|~o c~o c eo' sc|| c ecy, c es: o' gc o scpevees ypoe e~ c ~y
poo dos|eo s~ ~oy oe see po| e|sv |~ ~odeo|e |eo' dys|cc| o !ype
\ eo | coc ooc dos s, |eqce| ysee d ooe|cs os ve os o|~e |es| | o
ep~| | des, s ossoc o|ed v |~ o ~ypec~' o|e~ c ~e|ooo c oc dos s `o
s|eo do' o| | o~~o|oydcgs, cove||g ezy~e ~ o|os, od oe|oooc
es ~oy dcce~ypope e~ c ~ypoodos|e|o s~
138 N0j//OlOQy
4. |cgs |o| ~oy dcce ype|o e~ o ~c cde epo , o |s o dos|e|oce
sece| o~| , po|oss c~spo g d c|e| cs, sccc y' co' e, d g |o' s, o~d og ~ ~e,
osve os `SA' s, AC: o |os, od oe|oo'oces
5. A||oc|.oeevo|o~o|po|oss c~~oyoccc |oood sdov~o||eepeo|ed
c ec go| |e |s| od |oc~ qce| opp co|o o | s eoso~, ovoys ~~ed
o|e yececoe evo|ed po|oss .~ eve
6. ^ooge~e~|soc d vove o ~~ed o|e . |o oo |o gpeoed !
voves, po' o~go|o o||e PR |e|vo' , o|co~pe|e eo|o oc og|essve y
peo e~ o eods|oo s ~evove .co| g.|o| o~, ve|| c. o| o ' o| o~, od
s|o~ds| Acc|e ~|eve~| o~s c cdeod~ s|o|o o| \co c c~ , v c sco
d opo|ec|ve|osve os \ s. , g .cose, ocooo~o|e, od possoyep ep
~e, o o| v c s || po|oss c~ ~|oce c' o'y o|oss .~o d g es s,
d ce| cs, od/od oyss ~oyoe ~dco|ed| o|e~ove po|oss c~|o~ |e oody
7. ee so ~oe co~p e|e s|o||ecocses o|ypeoe~ o
A BAD K PLI GHT
A I dosterone defi ci ency (Addi son's congeni t al adrenal
hyper pl asi a, hyporeni nemi a, hepar i n)
B l ood di seases ( th rombocytosi s, l eukocytosi s,
l eukemi a)
Aci dosi s
D rugs
Ki dney di sease ( rena l fai l u re, renal tubul ar di sease)
Per i odi c par al ysi s ( hyperkal emi c)
La boratory error
I ntravenous potassi um admi ni st rat i on, ant i bi oti cs
Geophagi a/excessi ve i nta ke
Hyper osmol al i ty
Ti ssue necrosi s
N0j//lOQy M 139

H Y P E R N AT R E M I A
AVP
Al tered ment al status/abnormal t hi rst/access to water
i mpa i red
Vol ume l oss ( renal , ext ra-renal )
P r i mary sodi u m ga i n ( r ar e, i atrogen i c)
`otes
Ag ^ ^evosopess ^ , A\| s o so co ed o| d ce| c o ~o^e, o^d |s ~o o
oc|o s| oco^seve vo|e oy co^ce^|o| ^g| ec e A\ eeose sp ~o y
|egc' o|ed oyco^ges co^ce^|o|o^o|p os~oso c|es As p os~o os~o' o |y
ses, so do |e eve so|A\ !o o esse ex|e^|, deceoses ^ p os~o vo c~e
o sos| ~co|e| eeeoseo| A\. \o|edep| vo| o^cocses oo| ype|os~o o j
o^d vo c~edep e| o, o^d|cs s o po|e|s| ~c cs |o A\ e eose A\ |e
oc|s|o ~ox ~o y co^ce^|o|e |e c| e, |csde|e^d ^gvo c~e !e osso|e|
|ec|ve A\ eods|ovo .~e oss od ypeo|e~ o.
1 . ypeo|e~ o sde| ed os o se c~sod c~o| geo|e| |o^ l ^o ~^/'
S ^cesod c~o^d |socco~poy go^ osoe|e~o oe||ec|veos~o so||e
ex||oce c o | c d, hypernatremi a i s by defi ni tion a state of hyperosmol al i ly.
!e|ee~o o~eco s~so|ype|o|e~ oo|eoc|' ^edoy|eA\~^e~o c
, l j o' |eed ~e|o s|o|cso ~po ed occess|o|eevo|e|, , z| vo c~eoss, , J| p
~o|ysod c~go '^ |es| c|es|sese, e|e|eevo|e s'os|, vc s|e~os|
co~~o^ sceo o, o, ~o|e oey, |o|o sod c~ sgo ed !eoppop o|e e
spo^se|o ypovo' e~ oo^dype^o|e~ o s ^ceos g vo|e| ^|oe ,s| ~co|ed
oy| s|| o^d exce| ^go ~ox ~o ycoce|o|ed c e,co^|oed oyA\ eeose|
2. ^os| coseso| ype|^o|e~ o o|e seco^doy |o o e| oss o| |ee vo|e
Altered mental status occ|e y o pos|opeo|ve po|e^|s, ~|ed access
^|o^|s, odcopped po| e|so^d ~eco^ co yve^| ' o|ed po| e|s, o^d abnor
mal thi rst mechani sm ^ po| e^|sv | o ypo|o o~ c ^ cyo cocseo ^e| oss
o|||eevo|e| ypo|o' o~ c ~po |~e^| ~oy oedce |o g|o^J o~o|ocsd seose,
|c~o|s, ceeoovoscc o occ de|, o, |oey, esse|o' ypeo|e~ o :sse^| o'
ype|^o|e~ o|epese|soos~o|ecep|o|de|ec| A\e eose ' | sco|oc|e|
zed oyo oco| espo^se|o |oced vo|e |oe
3. Vol ume depletion |o~|eevo|e osses~oy oe e |e| eo o|ex|oe^o
<e^o' ||eevo|e| osses oe ~os|co~~o'y secodo|y|o d|cgs, sccos ' oop
140 N0j//lOQy
h
d ce|cs, v~ c~ ^|e|eev |~ coJ^|ecce^|eoosop| o^ A^ os~o| cd c|es s
o' so~oyesc | ^^e||eevo|e oss ypegyce~ o|o~c^co^|o edd ooe|es
s |~e ~os| co~~o^ cocse, oveve, ^o^ ^ |o' od~ ^ s|o| o^ os |e so~e
esc ' ^ceosed ceo eves|o~ o ~ g~po|e ^d e|os|eod |~eopyco^ |esc |
^o^os~o|cd cesso^d e||eevo'e oss.
\~e^ '~ee s o osso|A\ 'c^c| o^, |~esy^do~eo|d ooe|es ^s p dcs |e
sc |s !~eeoe'vo p ~o|yco|ego eso|d ooe|es ^s p dcs ce^|od ooe|es c
s p dcs, v~ c~ esc |s |o~ des|cc| o^ o| |~e ^eco~ypop~ys s o^d | ~cs | e
^eco^sv~ c~ sece|eA\, o^d ep~oge^ c d ooe|es, v~ c e^|o so oco|
espo^s ve^esso||~e d^ey| oA\ !~ s ~oy oee |~eo p ~oy co^ge^ |o'
de|ec|o seco^do y|o | ~ c~ od~ ^ s|o' o^ , ~ypeco ce~ o, ~ypoo' e~ o,
pop oy^ecoss,o| peg^o^cy eg^o^cy so^ ^|e|es| ^g p~yso og co s|o|e,
^ |~o||~e p' oce^|osece|esovosopess ^ose,v~ c~deceoses|~ee||ec|veoc
|v|yo|A\
4. .os|y, pri mary sodi um gai n ~oy eod |o ~ype^o|e~ o oveve, |~ s s
oe o^d o|oge^ c ^os' co~~o^y, ' ~ s es. |s |o~ od~ s|o| o^ o| ~ype
|o^ cso ^eosod c~ ocooo^o|eso c| o^s ^ ~osp|o zed po|e^|s
5. . e ~ypo^o|e~ o, po| e^|s v|~ ~ype|^o|e~ o co^ oe d v ded ^|o ypo
vo e~ c, ecvo e~ c, o^d ~ype|vo e~ c co|ego es Hypavol emi c hyperna
tremi a occcs ^ |~e vey yoc^g od vey o d, o^d s see^ ^ s |co| o^s o|
ex|e~e ex|oce . o | c d osses od/oo^ ^oo |y|o|oe ^|eevo|e ode
qco|ey,'eo e ^esses, vo~ | ^g, d o~eo, o^dseveee^o osses| Euvol emi c
hypernatremi a o so co^ oedce| oex|oce' ' c o| | c d ' ossv |~oc|odeqco|e
occess|ovo|e, o|o~ |~e 'oss o|co^|o o|vo|e ~o~eos|os s ooe|es ^
s p dcs, e '~e ce^|o o ^ep~oge^ c, cocses o^ ^oo |y |o eoosoo| |eed
vo|e, esc | ^g ^ sys|e~ c ~ype|o^ c |y o.| o ~ypeos~o o c ^e Hyper
vol emi c hypernatremi a, o |~ocg~ c^co~~o^, s o|oge^ c, o^d | ~oy occc|
o||esod c~ ocooo^o|e ^ ec|o ood~ ^ s|o|o^ o| ~ype|o^ cso ^e.
6. o|egeo| ~o o||yo|po| e^|s, |e|eo|~e^|o| ~ype^o|e~ o ^ | o' 'y ^
voves vo c~e ep e|o^ v |~ ~ypo|o^ c| c ds `o~o' so ^e s e o|ve y~ypo
|o c, oc|s~oc d oy oe csed |o es|oo s~ c cc o|oys|oo |y ^ce c cc o|oy
s|oo |y s o||o ^ed, po| e^|s co^ |~e^ oe e~ydo|ed e | ~e ^|ove^ocs y o
, pe|eoo y| oo y v|~ ~oe ~ypo|o^ c| c ds oe coe|c |o :|o|y coec||~e
vo|ede| c | ^o ~oe |~o^ l z ~'q/. ove z^ ocs Ceeoo' ede~o ~oy
esc ||o~ |oo op dcoec| o
7. c~oos ^g|~eoppop o|e | c ds|ocoec| o^, | sc | co |o ^ov|~epo
| e^|s c ^oy co^ce^|o| ^g copoc|y So~e po| e|s, espec o y |~ose v|~ d o
oe|es ^s p dcs, ~ovec ^oyos~o o |esos'ovos^J|oJ ~~o' /' A^ ^|cso^
o|~o'|^o~o' so ^e, os~o o' |y I o^ ~~o /.| v esc | ^o |c||~e|se ^se c~
sod c~, o^dso~oe~ypo|o^ c| c ds, o7dex|ose ^vo|e| soc doeod~ ^ s
|eed ^ so~e coses o| ce^|o d ooe|es ^s p dcs, o sy^|~e|c o^o og o|o^| d
ce|c ~o|~o^e, A\', co^ oeod~ ^s|eed e |~e ^|ove^ocs yo ^|o^oso 'y
8 . e p|c |o ~c os |o coec| ^g |o|o oody sod c~o^d vo|e de| c|s o|e
ovo ' oo e ^ |~e |e |og|ono]ou/oo| o| ^eoc|oe, \o J^z, zJ| I ^-, zJJJ.
!oes| ~o|e |~e e||ec|o| I ' o| oy ^|cso|e o^ |~e sec~ os~o' o' |y, cse |e |o'
ov ^g|o~c o
N0j/lOlOQy M 4|
-
. + ~|.so|e 'o sec~ `o'|
Coge sec~
`o

|o|o
oody
vo|e , |e|s| + ]
!o|o oodyvo|e s.sco y es| ~o|ed os ^JJ7 o||e oodyve g|, J ^J
X v| ~ g| ! s|o ~c o o ovsyo.|o pedc||e e||ec|o| l .o|o po| c. o ~
||ove~o.s| c d o~ |esec~ sod .~ !o dec deov~cc| . d |ogve, s ~p y
d v de|e des ed co|ec|o , e g , I z ~:q/z^ s| oy | ecoge sec~
'oco' c. o|ed oy|eeqco| o~ A'soodd|o| so~o.| ex||ovo .~e|oogo
~g osses dc ~g |e ~|cs o| ~e ! soppoocvosve ' |o ~os| cocseso|
||eevo|e ossos og os|eco~ge ~ e' ec|oy|ecoce||o|o~s od ogo ~g
||eevo|eoe coe|c y~o |oed As~e~| o~edooove, |e dv d.o po|e|s
c| o|ycocce~|o| goo |y~cs|oe ~ov~ , c ~eos~o' o |y|
9. A\'co~sevesvo|eoyco~ce|o| g|e . e. ' | ~ceoses|e pe~eoo |y
o|| ed s|o co' ec| ~g dcc|, | eeoy|oc |o| ~g |ee vo| e ecp|oe ~|o |e
~edc' ' oy |e|s| | . ~ |eoose~ce o|A\, |eevo|e s os|o~d ype |o
||e~ o e~s.es !e cocses o| ype~o|e~ oo|e ogo zed oy |e |o ov g
~e~o c. ! !C.':C!< e|es |o o ~pe~eoo eco' ec| ~gd.c|, ' oc
o|e||ec|veA\oc|v|y| o~ds.oseqce~||eevo|e osses, o~d AS!U ^
e|es|o|eo||e o|oge~ cco.seso|p ~oysod c~go ~.
TI GHT COL L ECTOR VS. A STU P I D MD
Low AVP 2 to eNS disease
Trauma
nfect i on ( meni ngi t i s, encephal i t i s, etc. )
G ui l l ai n- Barre
Hemorrhage
Tu mor/mass
Ineffective AVP 2 to renal impairment
Congeni ta l nephrogeni c d i abetes i nsi pi dus
Osmoti c di uresi s
Li thi u m/dr ugs
Loop di u reti cs
Ea rl y phase of ATN ( pol yu ri c)
Cal ci um el evati on
Tubul ar defect ( especi al l y medul l ary cysti c ki dney)
Ot her i ntr i nsi c renal di seases
Rel i ef of u ri nary obstruct i on
Nonrenal free water losses
Vomi ti ng/di a rrhea/NG suct i on
Ski n/sweat i ng'
4Z N0j//OlOQy
Inadequate intake
A I tered menta l status/a l tered t hi rst/access i mpai rment
Primary sodium gain
Sa l i n e i nf usi on ( hyperton i c r el ati ve to concentrati ng
abi l i ty)
T'N
Uter i ne i nj ect i on wi th hypertoni c sa l i ne
PO sal t
I V bi ca rbonate
D i a l ysate ( hypertoni c)
M i neral ocort i coi ds ( Cushi ng's, Conn's)
D rown i ng, dr i nki ng sea water
H Y P O KA L E M I A
L ESS K
Lasi x/di u ret i cs
E nter i c l osses ( e. g . , di arr hea, f i st ul as)
Steroi ds ( Cushi ng's, al dosteroni sm, exogenous steroi ds)
Shi ft ( a l ka l osi s, treatment of DKA, peri odi c paral ysi s)
Ki dney di sease ( renal t ubul ar aci dosi s [ RTAI , Li ddl e's
syndr ome)
A MEGA K DROP
Al ka l osi s
Magnesi um depl eti on
E nter i c l osses ( di arr hea)
Gl ucocorti coi d excess ( Cushi ng's, exogenous steroi ds,
ectopi c ACTH)
Al dosteroni sm
N0j//OlOQy M 143
-
Ketoaci dosi s
D i uret i cs ( th i azi des, f u r osemi de, ethacryni c aci d)
Renta l tu bul ar di seases ( RTA, Li ddl e's, l eukemi a,
ant i bi ot i cs)
Osmoti c di u resi s
Per i odi c par al ysi s
`otes
1 . !~e p ~c p e ~ec~o s~so|~ypoo e~ ooe
o :~|ecosses
o d~ey osses , <!A, d c|e| cs, os~o| cd c es s, ~ ~eo oco| co ds od
g ccoco||codexcess, ~oges c~de|ce~cy|
c S~ ||o|ce c o po|oss c ~ , o o os s, pe od c poo ys s, ~sc ~ e||ec|,
co|ec~o o~ es|
2. Enteric l osses oe csco 'ydce|od o~eo, o |~ocg~vo~ | ~g, v ocsode~o
~os, | s| c os, o~d ce|os g~o dos|o~y ~oy eod |o excessve po|oss .~ oss
\ |~vo~ | g, osso|gos||coc d eods|o~e|ooo co o os s, v~ c~ ceoses
|coc oo cooo~o|e coce~|o|o ~ceoses ~ o coooo|e o~ oseve|co|e ~
~c|eosed |coc o po|oss c~co~ce~|o| o~ o~dscoseqce~| exce| o ' ~odd
| o~, secodoy~ype|o dos|eo~ s~ |o~ vo' c~edep e| o~ co~| oc|es| opo|os
s c~'osses
3 . Ki dney losses co~occcv|~vo' c~eco~ce~|o|o~ o~d ~e|ooo co o' os s,
d c|e| c cse o~dos~o| cd ces s, excess ~ ~eo oco|| co d oc| v |y, o ~ e~o'
|coc od seose ce|cs ocg~e~|sod c~od| c dde' ve|y| o| ~ed s|o |coc e
po|oss c~ sece|oys |e, |~eeoye~~oc ~g po|oss c~ osses os~o| cd ce
s s, scc~ os ~d ooe|ce|ooc dos s, excessvepo|oss c~ossesoccc|dce|o c
~oy osses o| ~ego| ve y c~oged e|o oc ds !~e se|c~ po|oss c~ ~oy oe
~o~o ~|o y dce |oce' c' os~||, oc|||o spec p |ocsyv|~ co|ec|o~ o||~e
oc dos s
:xcess ve ~ ~eo oco| co d oc| v |y co~ oesee~v |~ p|
,
~o yo dos|eo
~ s~, o|v|~ seco~do|yo dos|eo~ s~ ~ co~ c~c| o~ v|~ ~o g~o~| ~ype|e~
s o~, oo||es sy~do~e, o~d cx|og' o~e c' o| ce' | c~os ' co ceco~|o ~s
g' yce| ~ z c oc d, v~ c~ ~ ~ o |s I I o~yd|oxys|eo d deyd|oge~ose ! s
e~zy~eco~ve|s co|so | oo~ ~oc|ve |o~ v |~ o ~ ~eo' oco| co d oc| v |y
~~ o | o~ o||~e e~zy~e ~ceoses|~e ~ ~eo oco| co d oc|v|y o|e~doge~ocs
co|so
ccoco| co ds s| ~c o|e e~o' po|oss c ~ sece| o~, eod ~g |o ~ypo
o e~ o o~d o o os s <eo | coc o po|oss c~ vos| ~g occcs ~ |ypes o~d
' ' |e~o | coc o oc dos s, . dd es sydo~e, ece~ oossoc o|ed e~o' | coc o
d seose, o~d ~ | coc o dys|c~c| o~ seco~doy | odcg | ~eopy , pe~ c ' ' ~s ,
o~p~o|e c ~ o|
144 N0j//lOQy
J
4. yposo e~ oo so s see co~d | o~s|o|cocse o i ntracel l ul ar shi ft o|
po|oss c~, scc~ os o o os s, pe od c po|o ys s, ~sc' od~ s|o| o~ , o| ~
ceosed oe|oodeeg coc| v |y !~ s s || s |e pe~ se |o |eo| ~g ~ype
o e~ o v|~ ~sc ~, g ccose, o cooo~o|e, od oe|oode~eg coge~|s.
5. o||oge~ccocsesscc~os l asix-di uretic admi nistration od steroid therapy
oeco~~o~ e~o po|oss c~oss
6. !~e pese~ce o| ype|es o~ scgges|s ypeo dos|eo s~ o g ccoco|
co d excess ' oo||es syd| o~e, | ee s seco~do|y ype|o dos|eo s~,
oc| o ~o' o ood pessc e A g~ e ~ ' eve sc ppo||s | e d og~os so| o
e~ ~sece| ~g ' c ~o o ~o|e~s ve po| e| s, c ~oy po|oss c ~ eve' s
soc d oe ossessed 'ov c oy po|oss c~ exce| o~ scgges's C osses o
p| od c|e| ccse g c ~oy po|oss c~, > zo ~~o' /.| scgges|s e~o | coc
' o| oc dos s, d ooe| c e|ooc dos s, vo~ | ~g, cc|e~| d ce| c cse, o| oo ||e|s
sy~do~e
lower Gl losses Diuretics
Deficient (prior use)
intake
Renal tubular
acidosis
Diabetic
acidosis
Hypokalemio
Cosde ce() shifts
(a(kaiosis, insulin, fadrenergic
aganists, periodic paralysis)
Blood Pressure
Vomiting
Diuretics
(current use)
8orfer's
Malignant
hypertension
Renin-secreting
fumor
Hyperaldoster
onism
Glucocorticoid
excess
licorice
'ovc~o||o ~ypoo e o evo co|o , 'o~ .ev sy `C . ds od eec||oy|es
` 'sse ooc~e, oocvo d, \ sec, e| 01 ,eds| o sos c pes o| ' |e|o
/ed c e, l J|ed `evo, /cC|ov ' , 1 994; v |~pesso |
N0j//OlOQy M 145
b
H Y P O N AT R E M I A
OSM
Osmoti ca l l y act i ve sol ute
Sodi um di sor der
Measurement er r or
`otes
1 . !esec~osmolal ity o^d|~epo|e|svol ume status oe|~e|vo eyee~e^|s
evo' .o| ^g |e cocse o|o ov se.~ sod c~ ypo^o|e~ o ,sod c~ < I Jo
~:q/.| does ^o| s ~p y ^d co|e o s|o|e o| ov |o|o oody sod .~ !o|o oody
sod c~ ~oy oe ed.ced, o ~o , o ^ceosed !~e ~eosJed se.~ sod .~
co^ce'o|o^ sdepede|o^|~esec~ os~o o |y , C5M | , v~ c~ de|e~ es
v~e|~eo po|~o og csod c~ d sode s p|ese| A se.~ os~o o |y d ||ee^|
o|es oe|vee |~e | ee co|ego es o| ~ypo^o|e~ o , l | Cs~o| co y oc| ve
soc|es, , z| 5od c~d sodes, od , J| Meosc|e~e|e|os
2 . A g~sec~os~o o' |y, >zoo| ^dco|es|ep|ese^ceo|os~o|co' yoc|ve
o c|es s.c os ~o^ |o o g .cose .cose o^d ~o^ |o oe osmoti cal l y
:ctive sol utes, v c co.sevo|e ~ove~e|o.|o|ce ' sodo d ' c| o o|| ~e
p' os~o. ypo^o|e~ oesceso.| , s cep os~oos~o o |y s ^ceosed, c co
~o^ |es|o| oso| ~ypo|o^ c|yoeoose| !~e ovsec~sod c~ s, o sese,
oppop| o|e, s ce o o|~o sod c~ eve voc d 'eod|oo^eve geos~o
o |y !~ s sceo o sco~~o yeco.|e|ed po|e|sv|~ ~ype|gyce~ o,
v~o~coec|oo||~e g~g ccose evesv|~ sc' ^ socco~po^ ed oyo se
sec~sod .~ Aos~o| cd cessco.ses|eevo|e oss, od ~ypeo|e~ o
~oyesc |o||ec'eo ^g| ~eos~o|co yoc|veso c|e
3. A po| o' og c sodi um di sorder sde| ed oy o 'ov se c~ os~o' o |y ,
z oJ| , |~ecocses o|v c~ ~oy oedv ded ^|o ypovo' e~ c, e.vo e~ c, od
~ype|vo e~ ce| o' og esos s|ed o^poges I ^oI ^-
4. Ao~o sec~os~o o |y, zoJzoo| scgges|s pse.do~ypo^o|e~ od.e|o
o measurement error, v c~ co occc seve|e ~ype p de~ o o ~ype|po
|e e~ o !~ s|ype o|e|o s essco~~ov|~ ^eve oooo|oy|ec~^ q.es
5. ce pse.do~ypo^o|e~ o |o~ ~eosce~e^|eoso^d occ.~c o| o o|
os~o|co yoc|veso c|es s c ed oc|, |~eo |ce, po|~oog csod c~d sode s
pese| !~e po| e|s vo' c~e s|o|cs s |~e^ .sed |o e cc do|e |~e cocse
:de~o|o.s s|o|es od po|o.d vo c~edep e| o oe cs.o y oov ocs, oc|
so~ecoses | ~oyoed || cc' ||ods| ^gc s oe|vee ~odeo|evo c~edepe| o,
^o~ovo e~ o, o^d ~odes|vo c~eexpos o^oyp~ysco exo~ o| oo oe
146 N0j/lOlOQy
6. ypovo e~ c~ypoo|e~ o d co|esso | 'osses excess o|vo|e osses ' |
o ~ypoo|e~ cpo| e|oppeos|ooec' co yvo c~edep e|ed, |~e | s~oc d
oede|e~ edv~e|~e|~eosseso|eextra-renal ,seqces|o|o oss | o renal
,os~o| co yoc|ve soc|es, d ce| c|~e|opy, c oyso | vos| g, dopo~ e |c
s o o~ eo oco|cod de|cecy| ^eosc|e~e|o||~ec| o|ysod c~es|oo
s~es |~e cocse, v |~ o ~ g~ c | e sod c~ ,> zJ ~~o' /.| d co| g eo'
osses, odo ' ovc esod c~ , IJ ~~o' /'| d co| g eo sod c~cose
vo|oodex|o|eo osses
`. .cvo e~ c~ypoo'e~ o sesse| o yo esc|o|excessive free water i ntake
,v|~ odeqco|esoc|e |ose|, oexcessive ADH activit. :xcessve, scep||ocs,
|eevo|e |oeocccsv|~ psyc| o| c esses !~ scod | o~oyoed|| cc ||o
d s| gc s~ ||o~ S' A, s ce po|e|s do o|ocsov'edge |~e poo' e~ |~e
|o~so||~ s |oe ~oo oceoe oeepo|o~o o, oexcessve |oeo|~ypo
|o c| c dsv|~ ||ed e|oyso c|e, od |~e |eo od|oos| sydo~e, v~ c~
e de ypo|e|s odve||e|'y~oveo s ~ o d e|oy ~oo oce !~eo||ep|ooe~
~oyoe ~ode~o|es|v~eo d ce|c spesc|oed|o o edey po| e|v |~o
pood e| :evo|ed A 'eves ~ o | |~e dey |o~ exce| g |ee vo|e !~e
esc'| s~odes|vo c~eexpos o ,o|ec' co' y oppoe|| od ~ypoo|e~ o
!~e ey |eo|ceo| S A s o oppop o|e ycoce|o|ed c e | ~e
|oce o| se c~ ~ypoos~o o |y od o|~ovo e~ o !~eeoe ~oy cocses o|
S' A, c cd gd| cgs, eop os~s, od C`Sd so|des So~eo|~e| s|o|es
scc~ os po , e~o| o, od |~e pos|opeo|ves|o|e~oyo'so |e~poo y ~po
vo|e|exc|e| o , poooo yos o esc |o| oA~ed o|ed ~ec~o s~ A s
p|oooo' y ~po|o| edoc e cocses o| ~ypoo|e~ o scc~ os ~ypo|~y
o d s~od pce co|so de| c ecy,Add sos d seose csco 'y esc |s ~ypov
o' e~ o od|eo|ces so |vos| g S A, c e sod c~ csco' y exceeds zJ
~~o /'cess| c d |oe ~osoee es||c|ed
8. A ~po||o|d s| c| o|o ~oe ecosc|g co po|e|s s oe|vee S' A
od ceeoo so |vos| g , o ~ypovo e~ cs|o|e| . Ceeoo' so | vos| g s e o
|ve'y oe od ~oy oe e o|ed |o e evo|ed eve so| o| o o| ce| c pep| de
, A`| . !~ed ogos sdepedsoes|oo s~ go |edcc|o ooodvo c~eod
opp|op| o|e o| ces s \o' c~e es| c| o ,os s opp|op o|e S A| ~oy oe
~ozo|docs ce|eoo' so |vos| g s ce | co eod |o ceeoo sc~e~ o ||o~
vosospos~ !~e pope|eo|~e| s|o ~o |o |ovoscc' o|vo' c~eod coec|
~ypoo|e~ o v|~ o~o so e |cs o opo~ e o so s| ~c o|esA`e
eoseod po~o|es o| c|es s
9. Aessve'cdes|ood ecvo e~ cs|o|e sesse| o ~ypoo|e~ oo|| ~es c
ce ' sydo~e '| s~ypo|~eszed|~o||~esepo|e|s~oveo reset serum "osmostat"
, zoJ~~o /.| od ~o |o o ove sec~ sod c~dce|o ees|oo s~ g |~e
o~o ogeo|os~oo |, A|eo|vey, |~oyosoepese|os|o|eo|eevo|ed
A oc|v|ysecodoy|o o cov oos~o| cs| ~c cs \~eos~o o |y s
ove|ed sc||ce|y, os~o|c ~ o | oo|Aoveco~es|~eoos~o|cs| ~c cs
1 0. ypevo' e~ c ~ypoo||e~ o occcs v | ~ ede~o|ocs s|o|es ^ec~o s
| co' 'y, |~ese cod | osoe s ~ o |o |~e ~ypovo e~ cs|o|es |~o||~e e||ec|ve
c cc' o| gvo c~e s edcced od|~e dey coseves sod c~ , c e sod c~
< l J ~~o /.| C' s|~e ~os|co~~o cocseo| ~ypevo e~ c~ypoo|e~ o,
N0j//OlOQy M 1 47

od ~ypoo'e~ o sossoco|ed v|~o poo| p|ogoss .oss o| p os~o po|e s

, o oc~ .| o, po|e os ge|eopo|~y| co.ses |~ d spoc go| | c ds, |ovos
c.' o dep' e| o, od ~ypoo|e~ o :ds|oge ' ve d seose ~po s c cc o| o
od p' os~o po|e sy|~essv|~ coseq.e|ede~ood ~ypoo|e~ o <eo
'o .e ~po s|~eoo |y|oexce|e o o~o vo .~eo|d c|e c eodesc|s
~ypoo||e~ o odede~o :o y |~eco.seo| eo |o ' c|e, |~evo c~eexpo
so ~oyoe ~odes|, od po|e|s ~oyoppeo||o ~oveecvo e~ c~ypoo|e~o
1 1 . !eo|~e| geeo , oy sevee, sy~p|o~o| c ypoo|e~ o od ~ypo
o|e~ o deve' op g ove z^ ~ocs o ess , e g , po| e|s v |~ psyc~oge c
po'yd ps o, s.g co odoos|e||c po|e|s|s~o. doe|eo|ed v|~ ~ype|o cso
' .| o od ~oe po~p| coec| o |~e ~o o |, o| po| e|s, rapid correction
of hyponatremi a i s hazardous and may l ead to central nervous system
damage ,. e , ce|o po| e ~ye o ys s| A s|odod . e s| ~o||~e sec~
sod c~s~o. do|oe|o sed oy~oe |~o J o|o l J ~~o /.pe~o.|odno
more than 1 2 mmol /L over 24 hours . Ao|~e ~ox ~o| ~ypoo|e~ o |eo|
~e| s |~o| |~e | ~e|o coec|o s~o. d oppox ~o|e |~e | ~eco.se o| deve
op~e|, e , |op d'y occ.| g ~ypoo||e~ os~o.' d oe coec|ed |op d'y, od
~oe c~o ccod | oss~o. doeco|ec|ed god.o' y|
1 2 . !~e |o ovg ~e~o csepoo|es ~ypoo|e~ccod | os |o |occo|e
go es pseudohyponatremi a, od hypovol emi c, euvolemi c, odhypervol emi c
,ede~o|ocs|s|o|es
A SOD I UM WATE R CAP E R
Pseudohyponatremia
Arti factua l
Hypovolemic
Sequestrat i on, S ki n l osses ( burns and sweat i ng)
Osmoti c di uresi s
Di ureti cs
I ntest i nal l osses ( di arr hea, vomi t i ng)
U ri nary sal t wast i ng
Mi neral ocorti coi d def i ci ency
Wat er i ntoxi cati on
ADH excess ( SI ADH)
Euvolemic
Temporary i mpai rment of water excr eti on ( pai n,
emot i on, drugs, post-operat i ve)
E ndocri ne ( hypothyroi di sm, pure corti col def i ci ency)
Reset osmostat ( " si ck cel l " )
148 N0//O/OQy
l
Hypervo/emic
Congesti ve heart fa i l ure
Al bumi n uri a
P rotei n- l osi ng enteropathy
E nd-st age l i ver di sease ( ci rr hosi s)
Renal fai l u re
N E P H R OT I C SY N D R O M E
MAD NE P H ROTI CS
Medi cat i ons/toxi ns/dr ugs
Amyl oi dosi s
Di abetes
Neopl asm
E ndoca rdi t i s/i nfect i ons
P ri ma ry g l omeru l ar di sease
H eredi ta ry di seases
Renal vei n t hrombosi s
Obesi ty ( morbi d)
Thyroi d di sease ( myxedema and thyroi di t i s)
I nter sti ti a I neph r i ti s
C h ron i c ref l ux/obst ruct i on
S LE, col l agen vascu l ar di seases
`otes
I . `ep~ o|c sy~do~e s c~ooc|e zed oyo oc~ ~c o , > J og/d| , ~ypo
o oc~ e~ o, od ede~o J ~oy oss o|c | co p os~o po'e ~s ped sposes
po| e|s |o |o~ooe~oo ceve|s , e~o ve | ~o~oos s, pc ~ooy e~oo cs| ,
~ype p de~ oodocce eo|ed o|~eosceos s, v |o~ de| c ecy, o~d po
|e ~ ~o c|| o, osve osdcg|oxc|y|o~ deceosed p os~o po|e o ~d ~g
2. !~e ~o o |y o| coses oe dce|o g' o~ec od seose , o7| , c cd ~g ~e~
oo~ocs , ^J7| , ~ ~ ~o' c~o~ged seose, |oco' g' o~ec osc eos s, ~e~oo~e
po |eo|veg c~ec o~ep | s , `| , o~d ~esog opo' |eo| ve '
N0j/lOlOQy M 149
3 . Sys|e~ c d seoses, ~c .d ~g d ooe|es ~e |.s, S.:, o~y' o dos s, d.g eoc
| o~s, '~yod d seose, ~|ec| o~s, o~d ~o g~o~cy, osve os ooes |y, occo.~|
|o ooo.|zo7o|coses
4. ^o g~o~c es |~o| ~oy oe ossoc o|ed v|~ ~ep~os s ~c .de ~ye o~o,
odg ~s o~d~o~odg ~s y~p~o~os, e.e~ o, o~doeos|o~d |oc|
coc ~o~os
5. .gs |~o| co.se '~e ~ep~o| c sy~do~e ~c .de go d, ~eo ~, pe~ c
o~ ~e, pooe~ c d, cop|op , o~d `SA s
6. ~'ec|o~sossoc o|ed v |'~e~ep~o|csy~do~e ~c .dee~docod | s, ~epo
'|s o, s~.~| ~|ec| o~s, syp~ s, o~d ~ooo
7. :vo .o' o~ o'~ep~o|csy~do~e ~c .des z^~o.. ~e|o po|e ~ o~d ce
o' ~e, se.~ o o.~ ~, c~o es|eo , o~d co~p e~e~| <. eo.|d ooe|es o~d S.:,
os ve.' os d.g expos.e, .~de y ~g ~o g~o~cy, o~d ~|ec|o~ ' | ~osys|e~ c
d seoseoexpos.eco~oed scoveed, | ~e~o e~o o opsy s ~dco|ed
R E N A L FA I L U R E
B I G B UNS
B l ood f l ow probl em ( pre-renal )
I ntr i nsi c renal di sease ( renal )
G I /i nter nal bl eedi ng ( meta bol i sm of heme)
B l adder out l et obstr uct i on ( post-rena l )
U retera l /col l ect i ng system obstruct i on ( post-renal )
Nephrotoxi ns ( e. g. , drugs, r habdomyol ysi s, u ri c aci d)
Steroi ds ( catabol i c states)
`otes
I . A~ e evo|ed o ood .eo~ |oge~ , oJ`| eve ~oy ~d co|ee~o ~s.||ce~cy
, ed.ced <| o~oyocc.seco~doy|o ~ceosedco|ooo' s~o|po|e ~s, e. g ,
s|eod |~eopy|o v|~ ~ceosed ~e|ooo s~o| ~e~epodJc|s, e g , ' oo|~e
~|e~o oeed ~g| o oJ`Spovdeso q. c s|o|co.seso|o s ~g oJ`
\~e~ e~o' ~s.|| ce~cy s|~eco.seo| o s ~g oJ`, | s~e p|.' |oco|egoze
e| o oges os pre-renal , renal , o post-renal . ee~o ozo|e~ o occ..s v~e~
e~o o' ood s ed.ced o~d, oso co~seq.e~ce, e~o' | |o| o~ , <| ee~o
co.ses ~c .devo' .~edepe|o~, ~eo|'o .e,vosc. od seose, o~ds~oc <e~o
150 N0j//lOQy
cocseso|ovc eoc|pc|esc | ||o~do~ogeod seoseo||e|e^o' poec~y~o,
^c cd ^g |~e g o~ec , |es| | c ~, od | coc es !ox s, voscc |des, ^|es| | o'
d seoses, o^d p ~o|y g o~ec o^ep| |des oe o~o^g | ~ecocses os|e^o
co^d |os|o| eod|oovc| eoc|pc|oeco|oc|ezed oyooo|o~ coos|cc
|o^ |o c eoc|pc| !~e ~os|co~~o^o||ese sp.os|o|ee^ oge~e^|, o |~ocg
pop oy^ec|os s, o o|eo' ce|eo'oos||cc| o, od oodde|oc|e|oos|cc|o^o|e
poss o' ecocses !ee s, o|cocse, ove op ^ e| o og es , e g , C' ~oy p.e
c p|o|eA!` , oc|| sc oss|co|oc s cse|c' ogoz gd og^os| cposs o | es
2. !~e|o ov g ~e~o^ c s|s ~os|o||~ecocseso|eo |o ' ceoccod g|o
peeo , eo' , o^d pos||eo ~eco^ s~s
I CHASE A RI S I NG B U N
Pre-renal
ntravascu l ar vol u me depl et i on ( dehydrat i on, t hi rd
spaci ng)
Ca rdi ac ca uses ( CHF MI , t amponade)
H epatorena l syndrome
A rteri a l di sease ( r enal a rtery stenosi s)
Shock
Ecl ampsi a/obstetri cal compl i cat i ons
/l6-tna//HOna/
Ou!81uOu| |D8C|O88
HOna/
Radi ographi c contrast and other toxi ns ( dr ugs,
r habdomyol ysi s, hemol ysi s)
ntrarenal embol i ( chol esterol , DI C)
Scl eroder ma
I ntersti ti a l nephri t i s
Necroti zi ng vascul i ti s ( pol yarter i ti s, nodosa, Wegener 's)
G l omeru l onephri ti s
Post-renal
B l adder obstruct i on ( usua l l y prostat i sm, somet i mes
bl ood, pus, ca l cul i )
U reteral obstruct i on ( cal cul i , retroperi toneal fi brosi s,
ca ncer)
Necr osi s of renal papi l l ae ( di abetes, si ckl e cel l anemi a,
NSAI D abuse, i nfect i on)
N0j/lOlOQy M 1 51
b
3 . !~e .sco oppooc~ ogo depeds o |~e ~ s|oy od ~ysco evo co| o
eqce|y, p|e|eo' co.sesoe oov o.s, scc~ os Cod c ~os s os|eo
cocses co oe exc .ded oppop| o|e po| e|s oy p' oce~e| o| o o' ey
co|~e|e oU' od ceo| e ~oy|.|~e ~e p |o de| |y |e po|~ogees s
peeo' cocses, oU` ses d spopo||oo|e y| oceo| e ,o||e o o|oo|
zJ l ogeo|e| , v~ ' e eo cocses, c|eo| ee'evo|o .sco y s ~o|e po
occed 'eex s| g eo d seose ~oy co|o.d |~ese poo~e|es od s o
co~~o |oc|o ovc| eoc|pc|
4. \~e|~ee| o ogyss| q.es| o, o eo c |oso.d s ~e p|c |oevo .o|e
|~e co ec| g sys|e~ |o peseceo|oos|cc|o od|oossess eo sze S~o ,
s~c\e \ deys dco|e 'ogs|od gd seose| ~o| s c' \e y| ooeeves o e
`o~o' o oge deys ~oyoe dco|veo|~oeoc.|ed seose Ce|o seo
ogc|es|s od eo oopsy ~oyoeoppopo|e o~p| eo o opsysespec o y
~po|o| coses o| pogessve eo sc|| c ecyv~e ~~.oscppessve
|~e|oy ~oypeseveeo |cc| o , e g , voscc | s|
5. ypoco~p' e~e|e~ ceo' |o ' ce "CCMH5"
Cyog ooc e~ o
Ccc. | |ec|o ,edocod | s, s~c| ep~| | s|
Me~o|oopo |eo|veg' o~ec oep~ | s
Hos|s||ep|ococco g o~e|. oep~ | s
5ys|e~ c cpcsey|~e~o|os.s
'ovco~p e~e|'eve's oe occos oo ' y~e' p|c' |~ed ||ee| o' d ogos s o|
g o~ec oep~ | s, s g|co| yoov g|~e' s|o|d ogos|c poss o |es !~e
|o'eo|co~p' e~e| g' o~e|.' o| c|yod p|ogesso o| |eo' sc||cecy s
o| ceo ' dopo|~ c ~e~ooop|o |e|o|ve g o~ec' oep~ | s, o o| oody
co ed C
,
ep~ | c|oc|o| s copoo eo| d.c gC
,
c eovogeod poooo y
cocses|~epess|e|depess oo|C
,
eve' s !~ se||yo||e ssee ossoco
| o v|~ ~epo||s o |ec| o
.
R E N A L S TO N E S
OUCHS
Oxal ate
U rate
Cyst i ne
Hyperca l cemi a
St ruvi te
1 52 N0j/lO/OQy
"..
1 . d~eys|oesoeo~og|~e~os|po |. o|o|| c| o~s, ~ece|~e~~e~o~c
UCS
2. Oxal ate s o co~~o~ co~po~e~|o| dey s|oes ypeoxo . o co~
occ. ~ ~o oosop|ve gos|o ~|es| o d sodes, s.c~ osCo~~s d seoseo~d
. ceo|veco | s `o~o y, |ee oxo o'e s oo.d oy co c . ~ ~|~e g.| od s
o|oosooed ^o oosooed |o| o ~ds co c .~, eod ~g |o |ee .~ ~o oxo o|e
ee oxo o|e s eod y oosooed od |~e exce'ed ~|~e . e g~ eve so|
oxo'o|e ~ |~e. e pec p |o|e co c .~o-o o|es|o~e|o|~o| o~
3 . Uri c oc d s|o~es occ. v |~ 'ov po~ ds.pe|so|. o| o~ o| |~e . ~e v |
.dssoc o|ed . c oc d ^ye opo |eo|ve d seose, c~e~o|~eopy, od 'esc~
`y~o sy~do~e co.se ~ossve pod.c| o~ o~d exce|o~ o| . coc d ~ go.|,
de~ydo| o~, o~d d opo'~ c.coc d |~ os s, . ~e p s .s.o y ov Jcoc d
|oc |o|es ~e|eogeo.s ~.c eo| o o| co c .~oxo o|e, | .s, ~ype . cos. o
co.ses co' c .~oxo'o|es|o~es
4. Cysti ne s|oesoe oe o~d oe see~ ~ po|e~|sv|~ ~eed|oycys| ~os s
5. Hypercal cemi a , e g , ~ypepoo|~yo d s~, ~eop os| c ~ypeco ce~ o| ~
ceoses . ~oyco c .~coce~|o|o od pec p|o|es co c .~s'o~e|o~o| o~
ypeco c . o ~oyoe dopo|~ co es. ||o~ eo |.o. od seose ~d s|o
|e~o |.o. o|oc dos s, o~o o' ~e .| ~eo~d ov .| ~oyc |o|e eves|ovo||o
~o| o~o|co c .~ p~osp~o|es|o~es.
6. Struvite s|o~es,^g`C| occ.~o y ~ vo~e~ o~d es. ||o~ . ~oy
'oc| |ec|os v|~ .eosepod.c gogo~ s~s, .s.o y o|e.s| S|.v|e s|oes
~oy_ovq. |e ogeo~d| |~e eo pevs , s|og~o co c. .s|
/0j/lOlOQy M l bJ
m
ACID- BASE
General Considerations
Arteri al Bl ood Gas I nterpretati on
!~e ~|epe|o| o o o~o|e o o' ood gos co oes ~p | ed oy| ~es|eps oc|
ed ~ |~e ~~e~o c "ABC kLAD" .
Accco|e Ao- , e~de|soosse'oo' c~|
Bos cooc d c- , p ~oyd sode|
Cop/de|o go, , o o~ gop|
kesp o|o|yo~e|ooo' c-
Lx|e~ed s|cooce-
Appopo|eco~pe~so|o-
Doco eo| p' ed sode-
s|, de|e ~ ~e ||~egos s accurate oy de|e ~ ~ ~g |~e ~ydoge o coce~
|o|o '| cs g|~eedesoosse oo c~ eqco| o~
As ~p evoy|o eco |~ se o| os~ p s|o e~e~oe|~o| | ceosesos
|~e pCC, ceosesoCC|deceoses !~e | |oo g ve~ p co oede
|e~ ~ed oy e |~e|o||~e |o' ' ov ~g ~e|~ods [ I | <e~e~oe|~o|o|p z o,
eveyJ I c~ | c~o~ge p c~oges '| co~ce~|o|o~ oy . 1 0 ~:q/. |~e
oppos|ed ec| o~ So, |] |o p ^ s^J ~.q/., |~e | |o p .o s
JJ ~:q/. od ] |o| p . J soJ~:q/' [2| \ |~eveyJ I c~ | | se
p, ~c' | p y|~e peced g '] oyJ o, e g , |oo c~o~ge p|o~ ^|o
o, ^J ~.q/.x J. o Jz~:q/'| . Covesey, |o eve|yJ I c~ | |o p,
~c | p y| ~ep|eced g | oy l zo , e g. , |oo c~o~ge p|o~ ^| o J,
^J ~.q/.x I zo oJ|
!~esecod ~e|~od s s g~| y ~oe occco|e, oc| e | ~e ~e| ~od s csc
o ' y sc| | c e| |o co| ~ g occc ocy !~e | o ov g ' s|s | ~e | |o| o
g ve~ p
-C/O350 bb
:
p o, | " l ^
p , | zJ- o
p , | zo
p. o, | Jz
p. ^, | ^J
p J, | " oJ
p z, ] * z o
p l , '] o o
p J, |" -
p -, ]* l zz.
!~e co~po~e~|s o| |e o cooo~o|e/cooo~ coc d sys|e~ oe o' voys ~
eqc o c~ ~|~eo ood,o~ dso p, pCC,, o~d CC
,
| ~eosc|ed oyve~ocs
o' ood c~e~ s|ysoc dod~ee |o |eco~s|o ~|s o| e~deso~osse oo' c~ ' |
|ee sd sogee~e~|, |~e~ o oooo|oyo co ec| o~ e|o ~osoccced o~d
epeo|de|e~ ~o| o~s~oc doeoo|o ~ed
!o ossess |~eocccocyo|oxyge~o| o~, odd|~epCo~ dpCC | |e|o|o
s geo|e |~o~ l ^J !<< , o' seo eve | , |~e~ |e po| e~| vos o~ scpp e~e~|o'
oxyge~ o| o ' oooo|oyeovos ~ode !~e oxyge~ eve deceosesv |~ oge,
v~ c~co~ oe es| ~o|ed oysco||oc| ~g l !<<|o~ oJ|oeveyyeo o|oge
ooove J So, o~ oJyeoo d po| e~|soc' d oveo pC ~o ess|o~ J o|
seo 'eve'
A|'ees|oo s~. ~g|~eco~s s|e~cyo| | ~evo ces|op, pCC, o~d CC
,
],
' oo o| |~e p |o es|oo' s~ | | e p ~o|y o do~ ~o~| d sode s basi c or
aci di c. S ~ce |~ee s ~ooveco~pe~so| o~ |o| o~oc doosed so|de, | ep|
~oy d s|coo~ce sde|e~ ~ed oy|~e p ccos o~o y, o c~|o~ c |esp o|o|y
oc dos so|o so oss ~oyoveo ~o~o p ~ |~eoose~ceo|o ~ xed d sode|
`ex|, |~e serum anion gap, `o] , C| + CC
,
| , sco' cc o|ed |o oos
|o| | ~e pese~ce o| c~~eosced o~ o~s, os occcs v |~ |e odd | o~ o| o~y
s|o~g oc d |o oody|' c ds !~e o~ o~ gop co~ oeo |e|ed ~|eoose~ce o| o~
ocdoosed sode A ov sec~ o oc~ ~ o o~ ~c|eose ~c ~~eosced co| o~,
scc~osoccc|sv|~ | c~ ~ges|o~o|ve~ce|o ~po|opo|e ~so|e p|ese~| ~
~c | p e ~ye' o~o, ~oydec|eose|~egop,see 'ovA~ o~opsec|o~| . ~|e
o|e ~o~d, ,e|ooo co o os s ~oy~odes|'y ~c|eose| ~eo~ o~ gop A~ ~
c|eose ~ |eo~ o~gopcsco' 'y ~dco|es |~e p|ese~ceo|o ~e|ooo coc dos s,
oc| |~e ~o| ~o o~ o~ gop vo es v dey, v | ~ o~ ove|ogevo ce o| I J I z
~:q/. ve~|~e oge~c~oe|o||oc|os|~o|co~ o||ec||eo~o~gop, p|evocs
e' ec||o'y|es ~eosc|e~e~|s||o~ |epo| e~|~oyoe~e p|c |oco~po| so~
\ |~o ~ g~o~ o~gop~e|ooo coc dos s, |~ees~oc d oeo c'ose ec p|o
co e' o| o~s~ poe|vee~ | e se ~ o~ o~ gop o~d |e dec|eose o| se|c~
CC
,
| , co ed| ~edelta gap. !~ede' |o gop sde| ~ed os, o~ o~ gop l z|
' ~s ~p egopoc dos s, o edcc| o~ ~se|c~ CC
,
] oy l J s ossoco|edv |~
o~ ~ceose ~ o~ o~gopo| I J Add |'o~o||~evo ce|ode' |o gop|o|e~eo
sced CC
,
| o ovs yoc |ode|e~ ~e |~e CC
,
] eve|~o|ex s|ed p o||o
| ~edeve op~e~|o||~e gopoc dos s !cs, | de |o gop+ CC
,
] s ~ |~e
~o~o o~ge|ose c~ CC
,
], |e~ o s ~p eo~ o~ gop oc dos s sp|ese~|
|OO -ClO350
, e , |eoddedoc d os cocsed |e expec|ed dop ~ CC| | ||e vo ce s
oc|sde|e~o~o o~ge, |e~o~o|ed sode ~cs|oveoee~pese~|p o|o
|e deve op~e~|o||e gopoc dos s
!e|o ov~gc' essc~~o ze|ecseo|de |ogopo||e|o g o~ o~gop s
de|ec|ed
zo de|o gop+ CC| zJ, s ~p e ggopoc dos s
e |o gop+ CC| < zJ, o ~o~o~ o~ gopoc dos so so spese~|
e |o gop + CC| zo, o ~e|ooo co o osso so s pese~|
`ex|, de|e~ ~e|espec|c |ype o|oc d coooscd sode| Acdoosed s
o|des co~ oe c oss | ed os e |e respi ratory or metabol i c. <esp o|oy d so
des oe ~|o|ed oyo co~ge ~ 'oCC v e~e|ooo' cd sodesoe ~|o|ed
oy o co~ge ~ CC] !ese p ~oy d s|coo~ces ~ | o|e ped c|oo e co~
pe~so|o|y co~ges ,see oe'ov| .
'oo| osee ||ee so~ex|e~eco~ge ~p, pCC, o CC], os| s
o||e~ ~dco|es o~occ|e pocess o||vo pocesses |o|cocse| ep |o co~ge
~ |eso~ed ec| o~ , e g , o ~e|ooo co o os so~d esp o|oy o o os s os
occc s ~ o peg~o~| po| e~| vo os sevee vo~ | ~g |o~ ypee~e

gov do, o C'v | C, e|e~| o~ o~d ypox o cocs ~g oc| c oc dos s|

Acdoose d s|coo~ces ~v c |eespo~se|oo p ~oy d s|coo~ce s oov
ocsy ~opp|op o|e , e g , ~ceose pCC v| ~e|ooo coc dos s| oe ~ xed
o~d do ~o| eqc e |e cse o| ped c|ve|o~c os :x|e~ed s|coo~ces eqc e
op d|eopy
'| |e co~ges ~p, pCC, o~d CC| o|e ~o|ex||e~eo~ddo ~o| |ep
|ese~| o~ ~opp|op o|e d ec|o~ o|co~pe~so| o~, |e~ ossess ve|eappro
pri ate compensation os occced oy cs ~gspec|c pedc|ve|o|~c oe !ese
|o|~c oeo|e cse|c' ~ pedc| ~g |eoppopo|edegee o| espo~se, oc|eep
~ ~ ~d |o| o~ opp|op o|e ve~| o|oy espo~se |o o ~e|ooo cd s|coo~ce
~oy |oe l z ocs|ooccc, o~dodeqco|e e~o co~pe~so| o~|oo |esp o|o|y
d sode ~oy |o\e seve|o' doys |o occc '| s o so ~po||o~||o c~des|o~d |o|
|eco~pe~so|oyespo~ses do ~o| ~o~o ze |e p :xcep|o~ occos o~o y,
co~ cesp o|o|yoc dos so|o' \o oss ~oy oveo ~o~o p.
Summary of the Pri mary Di sturbances and Compensatory
Responses for Aci d-Base Di sorders
Compen-
Pri mary satory
Disorder Disturbance Response
Respiratory I ncreased I ncreased
acidosis pC02 HC03
Type
Acute
Appropri ate
Response for a
Si ngl e Disorder Comments
For each change pH i s lower
in pC02 of than chroni c
1 0 TORR Ifrom aci dosi s
normal pC02 Uncompl icated
of 40 TORR) , acute respi-
expected change ratory aci dosi s
Table continued on next page.
-C/O350 1 57

Summary of the Pri mary Di sturbances and Compensatory
Responses for Aci d-Base Di sorders (Continued)
Compen- Appropriate
Primary sa tory Response for a
.
Disorder Disturbance Response Type Si ngl e Disorder
Respi ratory I ncreased I ncreased Acute in pH is 0. 08 wi l l not el evate
aci dosi s pC02 HC03 {cont i units (patient wi th [HC03 -] over
(conti {cant } {cont.} pC02 of 60 32 unl ess
shoul d have pH superi mposed
of 20/ 1 0 x metabol ic
0. 08 0 1 6, so al kal osi s is
predicted pH is present
7.4 0. 1 6 " 7 24)
HC03 i ncreases
1 mmal /L for each
1 0 mmHg i n-
crease i n pC02
Chronic For each change i n pH less than
pC02 of 1 0 TORR normal , but
from normal pC02 may be normal .
of 40 TORR, ex- Unusual for pa-
pected change i n tients with
pH is 0. 03 units pC02 > 60
(patient with pC02 TORR to have
of 60 shoul d have normal pH.
pH of 20/ 1 0 x
0. 03 " 0. 06_ so
predicted pH i s 7. 4 -
0. 06 7 34)
HC03 i ncreases 3-
3. 5 mmol /L for each
1 0 mmHg i ncrease
i n pC02.
Respi ratory Decreased Decreased Acute Same rule as acute pH is higher
alkalosis pC02 HC03 respiratory aci dosi s than chroni c
(pati ent wi th pC02 al kal osi s
of 20 shoul d have
pH of 7 56)
HC03 decreases
2 mmal /L for each
1 0 mmHg decrease
in pC02.
Chronic Same rule as chronic Unusual for
respi ratory acidosis HC03- to fal l
(patient with pC02 to less than
of 20 shoul d have 1 5 mEq/L i n
pH of 7 46) absence of
Table continued on next page.
1 58 -ClO350
Summary of the Pri mary Di sturbances and Compensatory
Responses for Aci d-Base Di sorders (Continued)
Compen- Appropriate
Pri mary satory Response for a
Disorder Disturbance Response Type Si ngl e Disorder
Respi ratory Decreased Decreased Chroni c HC03 decreases accompanying
al kalosis pC02 HC03 lcont.) 4-5 mmol /L for metabolic
Icont ) lcont. ) Icont.) each 1 0 mmHg aci dosi s.
decrease i n pC02. The pH is often
normal .
Metabol i c Decreased Decreased pC02 [ 1 5( HC03) Ful l compensation
acidosis HC03 pC02 + 8) Z (patient ( hyperventi l a-
with metabol ic ti on) may take
aci dosi s and HC03 1 2-24 hours
of 1 0 should have
pC02 of [ 1 . 5( 1 0) +
8) 2 23 2
2 1 -25 TORR.
pC02 last 2 di gi ts
of pH x 1 00.
Metabol i c I ncreased I ncreased pC02 0. 9* Compensation
al kal osi s HC03 pC02 ( HC03) + 9 less consistent
(patient with meta- than for meta-
bol i c al kal osi s and bol ic aci dosi s.
HC03 of 40 pC02 > 45
shoul d have pC02 occurs in 25%
of 0. 9* (40) + of cases. Rare
9 45 TORR) to see pC02
> 55 TORR
* range 0. 6-0. 9 except i n severe
al kal osi s or
superi mposed
respi ratory
al kal osi s.
A||e| c~ec g |o| oppop o|e co~pe~so| o~ , dec de | |~e d sode| s
s ~p' eo| |o doubl e or tripl e d s|cooce s p|esec| !ypes o| ~xed d sodes
o~d c'ces |o|~e peseceoeos |o'ovs
I Metabol i c al kal osi s + respi ratory al kal osi s -Both p|ocesses
ceose | ~e p A deceosed pCC, s see~ v | ~ ~ceosed CC
,
A ve|y
~ g~ p sposs o' eoecocse|~eo' o' oses sc~~o|e !~e|e so ~ d e' evo| o
o| o o~ gop ypoo e~ o|eq ce| y s pese~| :xo~p e peg~ocy v |~
vo~ | cg
z Respi ratory aci dosi s + metabol ic al kal osi s-Both pocesses ~c|eose
|~e CC. ||ec |~ee so co|~o pocdo ve|y~ g~CC
,
pCC s ~ g~e|
|~o ped c|ed o |~eoos so| ~e|ooo co o os so oe. :xo~p e C''+ d
c|e| c|~eopy
\
-C/O350 Od

J Metabol ic aci dosi s + respi ratory aci dosi s-Both pocesses deceose
|e p p sve|y ov oecocse|eoc doses s.~~o|e :xo~p e deco~pe~
so|edC+ 'oc|coc dos s
^ Metabol ic acidosis + metabolic al kal osi s-!e|vo pocessescoge
|eCCod|epCC ~oppos |ed ec| os !ep ~oyoe ~ceosed, de
ceosed, o ~o~o , depe~d ~g o~ |e e o| ve seve|yo| |e |vo pocesses
Co~s de' sd og~os sve~ |e o o~ gop s ~ceosed, oc||e CC s o'
deceosed :xo~p' e A+ vo~ | g
o Metabolic acidosis + respi ratory al ka'osisoo| pocessesdeceose|e
CC Cosde| sd ogossve o ~e|ooo cocdosssocco~po~edoyo
pCC,|o| sove|o~pedc|ed, ove esp o|oyo oosssossoco|edv|
o~ CC ~eosce~e~|'ove|o~ p|edc|ed :xo~p' e so' cyo|eove|dose
Tri pl e acid-base di sturbance-tripl e d s|coo~cesocccve~ o ~ xed
~e|ooo' coc dos s + ~e|ooo co' so os s s co~p' co|ed oy e |e|o esp |o|o|y
oc dos s o o esp |o|o|yo so os s \ ' e ~ x|ces o| ~e|ooo cd s|c|ooces
~oyocc., ~xed esp|o|oyd s|.oo~cesco~~o|occcoyde| ~ | o~, oecocseo
peso co ~eve co~cce|'yove od.deexce|e C !e d og~os so|o
|p ed s|coo~ce sgeeo ' y~ode ~ o po|e~|v| ~e|ooo' co' o os so~des
p o|oyoc dos so|o o' os s ~vo~ |e o o~ gop s |ocd |o oes g~ | co~| y
ceosed , > I | . :xo~p e A+ vo~ | ~g + oo|.~do| o~/ypove~| o| o
Cl i nical Conditions and Diagnoses
M E TA B O L I C AC I D O S I S
KL U ES
I Ketoaci doses
WI T H A
AN I O N
Lacti c aci doses
U remi a ( orga ni c aci ds)
H I G H
GA P
Ethyl ene gl ycol and the al cohol s
Sal i cyl ates
160 -C/O350
`..
1 . ! s~~e~o~ c s|s |~ep ~oyco^d | o~s ~v c~|eo~ o~ gop, |'o| ~
, C' | + CC| | }, ~ceoses oecocseo| el ectroneutral i ty, c^~eosc|ed o^ o~s
~cs| ~c|eose os o cooo^o|e |o ' s, ' eod ~g|o o v de^ ~go||~e o~ o^ gop
.3:S|o|~ecocseo| o~ ^c|eosed o^ o^gopco~e|o~ |~e ~ s|oyo^d oo
o|o|oy|es|s, ^c .d ~g oJ`, ceo| ~ ~e, g' ccose, oc|o|e, sec~ e|o^es, sec~
os~o o' |y, o^do |ox ^ sc|ee^
2. Ketoaci dosi s occcs ~|~eese|| ~gs di abetes, al cohol i sm, o~d mal nutri
ti on ( "DAM! " ) . ^ d ooe| c e|ooc dos s, oce|ooce|c o^d oe|o~ydoxyoc|y c
oc dso|e p|odcced ~oe op dy |~o^ |~eyco^ oe ~e|ooo zed. !eyoccc~c
' o| e, cocs ^g o dop ^ p' os~o o co oo~o|e o^d o se ^ |e o^ o^ gop
A' co~o' cs ~oy ~ove poo |ood ^|oe o~d vo~ | ~g ossoc o|ed v | g
e|~o~o' ~|oe, cocs ^g e|ooc dos s o^d o~e evo|ed o~ o~ gop. !ese|ooc
dos s~oyoe~ ssed oecocse|~e |op|.ss de|es||o e|o^eso~ yde|ec|soce
|ooce|c oc d o^d ^o| oe|o~ydoxyoc|y c oc d, v~ c |e~ds|o p|edo~ ^o|e
^o ^c| | o^ o' o~e ~oycocseo ~odes| se|ooc dos s <ed.ced cooo~ydo|e
evescocse ov ^sc ~o~d ~ gg ccogo~ !ese~o|~o^o' c~o~ges ,o' so|ee
vo~| |o 'Ao^d o' co~o c e|os s| |ovogycoyss o^d se|oge^es s
3. Uremia sco|oc|ezedoy| ~eoccc~c'o|o~o|organic aci ds, v c^o~o'y
oeexce|ed oy|es d^ey ~occ|e |e~o'|o ' c|e, p'os~o ocooo~o|e|osoy I |o
z ~~o /'pe|doy | ~po |ed |e^ooc dexce|o~ s |~e soecocseo|~e|ooococ
dos s. Ceo|e|o|eso|dec ~e scgges||~ep|ese^ceo|o^ odd | o^o cocseo|
oc dpodcc|o~ ' ^co^ce~o' |o'ce,|eocooo~o|e|e~ds|os|oozeo|eveso
lzlo ~~o' /'o^d oe'y|o''s oeov I J ~~o/'c~ esso^o|e|dso|de spese~|
4. Lactic aci dosi s occcsve |~e|e s o^ ~oo o~ce oe|vee^ 'oc|o|epodcc
| o~ o^d e' ~ ~o| o~ ("LCTIC") . 'c ^go^oe|oo cco^d | o^s, gycoyss s oc
ce e|o|ed o^d pycvo|e ^ceoses 'y|cvo|e s ~ eqc o| c~ v| oc|o|e, | ~cs,
'oc|o|e eve's ~c|eose S ~ceo^epo|o^ sge~e|o|ed|o|eoc~ oc|o|e ~o' ecc' e
podcced, oc dos s s|~e|esc'|o|' oc|o|e podcc| o~
oecocse|~e ve s |e ~o o o|go~ |o| ~e|ooo' z ^g oc|o|e, seve|eliver
di sease cocses ' oc| c oc dos s 'oc|o|e podcc| o~ s^o~o , oc|~e|ooo' s~ s
~po |ed \ |~ s g~ | co~|' ve| dys|c~c| o^, |e ^o~o' oc|o|e' ood p|odcced
oy|eoody s ^o|~e|ooo zed, 'oc|o|eoccc~c'o|es, o~d oc dos se~sces
Se'ec|ve dys|.^c| o~ o| ~ |oc~o^d o , e g , co~ge~ |o' d seose, o gco^ de
|ox c |y| cocses' oc| coc dos s |eoose^ceo|o|~e|evde~ceo| ve|dys|c~c
| o^ 'oc|o|e ovep|odcc| o~ esc |s |o~ c| cc' o|oy|o ce ! ssce ~ypox o, os
occcs v| cardi opul monary grrest, arbon monoxi de poso~ ~g o~d sevee
o~e~ o, eods|o oc| coc dos s. \ go|ocsexecseo|~cscc' o tetany osoccc|s
v | se zc|es ~oy cocseo | o^s e~| se ~ ' oc|o|e. Sys|e~ c infecti on/sepsi s
cocses c cc o|oys~oc, o
9
o^ ~ypope||cs o^, o^dscoseqce~| 'oc|o|e podcc
| o~ 'oc|coc dos s~oyco~p co|eancers, scc~ os ' ecse~ oo^d y~po~o,
v~e^| ssceypoxo s^o| ~ev de~ce vep|odcc| o^o|'oc|o|eoy|e ~o g
^o^|| ssce~oyoeo |oc|o|
-C/0850 M l Ol

`o|e|~o| ' oc| coc dos so so ~oyco^| o.|e|o |e seveeoc dos ssee^
v |so cy o|e, ~e|o^o' , oe|~ye^eg'yco' poso^ ^gs
5. Ethylene glycol o^d methanol oe co^ve||ed |ooc d c ~e|ooo |es, v~ c
occ.~. o|e ^|e o oed A^ ^ceose ^os~o o gop scooc|e s| c, o^d
p|o~p| ^|eve^|o^ sc| | co' sopopyo co~o co.ses o ~oe~odes| ^ceose
^ o^ o^ gop o^d se.~ os~o' o |y
6. Sal icylates co.seoc~ooc|es|c ^|o esp|o|oyo so ossoys| ~.' o| ^gce^
||o' |esp o|o^ !~epese^ceo| esp|o|oyo o'ossco~o^edv| o^ ^ceosed
o^o^ gop |eq.e^|'y occ.sv|~ so cyo|e ^|oxco|o^ o^d s~o.' d ^o|oe ~ ssed.
7. Ce|o ^gos|o ^|es| ^o d sodes ~oveoee^ epo|ed |oco.seo gopocdoss
seco^doy|o occ.~.' o| o^ o| D-Iactate. | s|~o.g~| |~o|ce|o ^ ooc|e o po
d.ceoc|o|e ^ |~eg.| |~o| ssys|e~co yoosooed Aspec o' se.~ossoy|o
'oc|o|esovo oo' e, os | s^o|de|ec|edoy|~eco^ve^| o^o' ossoy.
8. |~ed|.gsoveoee^ossoco|ed v| o gopoc dos s. so^ oz d co.ses e
|oc|oysez.es o^d o s.oseq.e^| oc| coc dos s 'o|o de~yde s oey .sed,
o^d |s o e ^ co.s ^g gopoc dos s s ^o| ve' doc.~e^|ed, o.| | s e~e~
oeed oeco.se o| | ~e |o~ o| "MUD PI LES" ~^e~o^ c , oe|o^oJ , J|e~ o,
DK, poo de~yde, |sopopy' oco~o , |oc|coc d, e|~y e^eg'yco , so cyo|es|
Propylene glycol , o d .e^|.sed ^so~e ^|ove^o.s ~ed co| o^s , e g , ^ ||o
gyce ^e| , ~oy oeyco.seo seco^doy oc| coc dos s.
9. \~e^ ~eos.ed p os~o os~o ol |yexceeds |eco c.' o|ed os~o' o' |y [( 2 x
pl asma No) + gl ucose/1 8 + BUN/2. 81 , s.spec|e|ye^e g'yco' o| ~e|~o^o
|oxc|y :|~o^o ^|oxco|o^o^dso~ecoseso| oc|coc dos so o co~o cse|o
s so' so ~oy |eo|.eo s~o' ' os~o' o' gop , .p|o I JI o ~s~/g| .
DAM U LACTI C GAPS
Ketoacidoses
Di abeti c ketoaci doses
Al cohol i c ketosi s
Mal nutri ti on
Organic acids
U remi a
Lactic acidoses
Li ver di sease
Arrest
Ca rbon monoxi de poi soni ng
Tetany/sei zures ( rhabdomyol ysi s)
I nfect i on/sepsi s
Ca ncer
1 62 -ClO350
Other unmeasured anions
Ga stroi ntest i nal di sease ( D- I actate)
Al cohol s/ant i -f reeze
P ropyl ene gl ycol /pa ral dehyde
Sa l i cyl ates
M E TA B O L I C AC I D O S E S
WI T H A N O R MA L
AN I O N G A P
GUT
Ga stroi ntesti nal l osses ( di ar r hea, pancreati c fi stu l a)
U ri nary l osses
Tota l par entera l n utri t i on
Notes
! . 'o|~o' oc oc gopo| hype|c|' o|e~ coc doseso| ~os|o|voys esc' | lo~
HC03 loss from the GI tract or from the ki dney. As |~e ooove ~~e~o~ cscg
ges|s, C3! osses||o~ d oeo o|e |~e ~os| co~~o~ cocse 3 ~o|y 'osses
||o~ |e~o |coc o|d seoseoe ess co~~o~
2 . '~ oo|~ C o~d |eo d so|de|s, sod c~ o cooo~o|e s|oes oe ov, o~d
sod c~c~ o de s|e|o ~ed ~ excessveo~oc~|s|o p|esevevo' c~es|o| cs !e
c e~e|c~oge ouri nary ani on gap, { ( [Na] +[K] - [CI] }, s cse|c ~d ||e
e~| o| ~g oe|vee~ e~o o~dgos|o |es| ~o cocses o|CC
,
oss. 3| oy oc d
| co| o~ esc |s |o~ |~eexce| oc o|o~~o~ c~, ` !~e pese~ce o| |~e
pos | ve o~, `', ~dco|es |~o|o|~e~o o|co| o~s, [Na] +[K] , oe pese~| ~
'ove|o~oc~|sv~e~co~poed|o|~e ~o o|o o~, [Cl] . Aego|vec eo~ o~
gop ~p es |~e p|ese~ce o| `_ ~ |~e c ~e, d co| ~g oppop| o|e e~o
oc d | co| o~ espo~se| ooc dos s, os C osses| A pos|vevo ce d co|es
o e~o oc d | co| o~ de|ec| , ~o `' ~ |~e c| ~e| | |e cocseoppeos |o oe
e~o dys|cc|o , pos|vec oyo o~gop| , |~e~|~e sec~ po|oss c~ s~e p
| c .ov po|oss c~scgges|s o ' sece|o~ de|ec|, v~e|eos ~ gvo ceso|e
cos s|e|v|~ de|ce~|o dos|eo~eoc|o,!ype \e~o |coc o|o: do '<!A| |
-ClO-U350 1 63

3 . oe coses, o|oge c o|~o' gopoc dos s |esc' |s |o~ |oveocs od

~ s||o|o o|!'' o oc d co~ ooc d so c| os, o~~o c ~c o de oy
doc o coc d Aoppoe|, o~o gopoc dos s soccos oo 'ysee veo
gopoc dos s s occo~po ed oy o peexs|g cod | o |o| oves |e o o
gop, scc os ypoo' oc~ e~ o oo co| o cpoopo|e , see.ov A o op
sec|o|
4. Respi ratory al kal osi s v| edcced pCC, eve' s eods |o o oss o| o co
ooo|e \ | rapid correction , e , deceosed espo|oy o|e|, pCC e|c|s
|o o|~o' , oc|o coooo|e cosevo| o od ec o~o| o oy|e dey |oes
z^|o^o oc|s|o e|ceves|oo~o A|os e|ogopoc dos socccs
5. ' DKA, | s co~~o |o see o c de|o ypec' oe~ coc dos s |e
recovery pose ! speo~eo occcsoecocsesod c~c o de se|o ed
v |vo c~e ep e| o 1e e|oes , osocce|o egeeo| g o coooo|e| oe
' os| |e c e, od o coooo|e egee|o| o s s oved S ~ ' oy, v goocs
vo c~eep' oce~e| o deydo|ed po| e|scpp|esses o dos|eoesece| o
S ce o' dos|eoe ceoses o coooo|e egeeo| o ocd oosop| o, |e
'ove eve s|ed|o ~o |o |e ypec oe~ cs|o|e ! s expos o oc do
s s s |e covese o| |e co|oc| o o' o' os s see v | vo c~edep e| o,
| e' o||e| so g o dos|eoe s|o|e !eoc dos s |o~ vo c~e ep oce~e|
soe' yo|c co s g | coce
6. A~oeco~peesve s| go|cocseso|ogopocdoses s s|ed oeov
!e ~e~o ce~pos zes |e ~po|oce o|co' cc' o| g |e c egopve
|ecocsescce|o .
U RI NE GAP: NA+K-CL
U reterosi gmoi dostomy
RTA
I ntest i nal di sease ( di arr hea)
N H4+/PN
Ea rl y renal fai l u re
Gl ue sn i ff i ng ( tol uene)
A I dosterone defi ci ency
Pancreat i c fi stu l a
NaCI i nf usi on ( "expa nsi on" aci dosi s)
After DKA or respi ratory a l ka l osi s
K+spar i ng di ureti cs
Carboni c anhydrase i nhi bi tors ( i mpai rs ur i ne aci di fi cati on)
Laxati ve abuse ( GI l osses)
1 64 -C/O350
L ow AN I O N G A P
ALB U MI N
Al bumi n l oss
L i t hi um
B romi ne
U n measu red cati ons ( K, Mg, Cal
Myel oma ( cati oni c pa raprotei n)
I odi de
Na + underesti mati on/a rti fact
`otes
1 . A ovsec ~ al bumi n s |e ~os|co~~o~cocseo| ovo~ o~ gop !e
~o~o o o~gop soppox~o|e'yol z oecocseo|| sv deogeo|~o~o
o~d |e ~oy|oc|os o||ec| ~g ||e o~ o~ gop, |ec co' cse|c' esso|o ov
~eosced o o gop os oee~ qces| oed ~ov g |e|oc|os |o|o||ec| |e
o~ o gop s peops ~os| cse|c ve |y ~g|o de|e ~ e|e s g~ | coceo|
~odes|co~ges ~ |eo~ o~gop, e g , o~ o o~ gop o| I ~oyoes g~ | co~|
~o po|e~|v|ovey' ovo oc~ ~| A edcc| o~ ~|eo~ o~gop~oyo so oe
dce|o ooo|o|oye|o.
2. A ove sec~ o o gop ~oy oe ooseved ~ cod | o~sv| o~ c|eose
~ unmeasured cati ons, scc os occc|s v| ypeo e~o, ype|co ce~ o, o
ype|~og~ese~ o |~oyo sooeseeve |ee so~ ceose ~c~eosced
co|o~s|o|oe ~o| ~o~o ypese~|, scc os v| mul tipl e myeloma, poyco~o'
go~~opo|y, o l i thi um. A ov gop s see~ v | o dec|eose c ~eosced
o os, csco ' yypoo' oc~ e~ o| Sodi um underestimation s~cc ess' se y|o
occcgve ~evd ec| o~se'ec|ve |ec~ qces , o ov gop vos ~oe co~~o
p|evocs' y ~coseso|ypevscos|yod sevee ype~o|e~ o| . C odeove|es
| ~o| o~vos|o~o' ysee~ ~coseso|ype|gyce| de~ o, oc|| so'so s ess o|
o p|oo e~ ov oveve, bromi ne o~d i odi de ~oy'eod |o c o deovees|
~o| o od |cs edcce |e o~ ogop oo~ eo~d od de oves g|' yove
eo' c' eo|o~ces |oc' o de :' ec|oy|e ~eosce~e~|sdo ~o|d s| ~gc s oe
|vee~ oo~ eo| od de od c o de, so o se oo~ ~eo od de s|ose'y
~eosced os o~ eve| geo|e| se c o de |e oey epo|ed cocses o|o
ovse|c~o~ ogop ~c cdee~o' |osp o~|o| o~o~d ypo~o||e~ o
3. C eo y, |e|eo|e ~oyco~s deo| o~s ~co cc o| g |e o~ o~goppo| c
c oy o po| e~|v | ~c' | p e ~ed co p|oo' e~s !ose o o||ese|oc|o|s c|o
occoc|vce |e|pe|~g |e o~o gop
-C/O-350 1 65
M E TA B O L I C AL K A L O S I S
AL OOS
Al dosterone
Lasi x
Dehydrati on
Over-venti l ati on
S t6mach l osses
`otes
1 . /e|ooo co o oss s~o|ospec | cd seose, | scsco' ' yo espo~se|o'oC'
o~dde| c | U~des|o~d ~g|eo~o~eodos|eo~es|eey|oc~des|o~d ~g
~os| coseso|~e|ooo co o os s, e~ce, |e ~~e~o~ cA'.S A dos|eo~e
po~o|es:eno|oc d | co| o~ o~d co~co~ |o~| o cooo~o|e ege~eo| o~ o~d oo
sop| o~ ~oy ypeo dos|eo~ s~ o~d o|e ype ~ ~eo oco| co d s|o|es
cocse ~e|ooo co' o' os s S ~ ' oy, vo c~edep e| o~ cocses o seco~doy ~
c:eose |n o|dosle|one, o' so po~o| ~g elooo| |c o'
r
o' os| s. \|| vo' c~econ

lrocl| on, lhe:e |s on | nc:eose |n sod u ov| d| l due lo o| dosleone ocl| v| l

becou>eo|e|ecl:oneul:o| | l, on|ons usl oe :eooso:oed w|lh sod| u, lhe:e|ore,
chlo:ide |sox|o||:eooso:oed, |eov|ngve:| | ll|ech|o:|de |n lhe u:|ne, |o:lh|s
reoson, lhe eosureenlo|ur| nech|o:|de|see mneon|c ne
,
l pogej | s he|p|u|
| ndeler| n| ng lhecouseo| elooo||c o| ro| os| s
2 . !e o o: | l o| ~e| ooo' c o o' os s coses oe dce |o ex|oce' ' c o | ' o d
vo' c~eco~|oc|o~ o~d espo~d| oso ~eod~ ~s|o| o~ !esesoco ' ed >o| i ne-
>en>if|ve |ypes co~~o~' y esc' | |o~ vo~ | ~g o~d d ce| c cse ~ |ese ~
s|o~ces, vo c~e oss eods |o e~o' sod c~co~sevo| o~, ~ecess |o|~g ~ox ~o'
eoosop|o~o|c o deoso~oo go|eo~ o~ U ~ec o de scsco y ess|o~
l J ~~o'es/. ~ so' ~ese~s |ve ~e|ooo' co' so' os s <ep' oce~e~|o||evo' c~e
de| c |coec|s| eo' o os s
3. ype~ ~eooco|co d s~, p ~oy, Ccs ~gssy~do~e, e~o o|eys|e~os s,
~o g~o~|ype|e~s o~, |ce' |c~o, oo||essy~do~e,o~d ' coceg c||o~y| s
|eo|e ~o o ~eco~ s~|o|co~ ~o ~|o ~ ~e|ooo' co o os s !eseco~d
| o~soeso| | ne

sens|l|veo~d|yp co' ' yoveo c ~ec o deco~ce~|o|o~ > zJ

~~o'es/' !epo|e~|svo c~es|o|cse ps|od ||ee~|o|e oe|vee~ o so ~ese~
s |ve cocse , ov vo c~e| o~do so' ~e ~se~s | vecocse , ~o ~o' o ~ceosed
vo c ~e| <oe y, po| e~|s v| ex|oce' c o |' c d vo c~edep e| o~ ove o|e
cocses|o~e|ooo'co ooss, ~og~es c~dep e| o~, oo||es sy~do~e| .dd es
sy~do~e so oed sode ~ v c po|e~|soppeo|o ove ypeodos|eo~ s~,
1 66 -C/O-350
J
oc|o dos|eoce eve's o|e 'ov. | s p|oooo ydce|o oc c|| ~s c| coc' o|de|ec|
ocd coc oe|eo|edv | |o ~|eeeoo~ o de, oc|co|sp |oco oc|oce
4. !e|o ov^g ~~e~o^ c s|s |espec|ccocseso| ~e|ooo' co' so os s
R E NAL CL- EVAL
Recovery from hypercapni a, orga ni c aci dosi s
E mesi s
Nasogastr i c suct i on
Al dosteroni sm
Lasi x/l oop di ureti cs
Cysti c fi br osi s
Low K+, Mg++
Exsangui nat i on/massi ve t ra n sf usi on ( ci trate)
Vol ume depl et i on
Al kal ai i nt ake ( I V bi carb, mi l k-a l ka l a i )
L i ddl e's synd rome
R E S P I R ATO R Y AC I D O S I S
COPOS
Ca rdi ac a rrest
Ubtu ndati on
P ul monary di sease/a i r way obstruct i on
D rugs/over dose
Skel eta l /neuromuscul ar di sease
`otes
I . <esp o|oyoc dos s epese~|s o |o ce o|ve~| o| o^ os|cc|ve cg d s
eose s|e ~os| co~~o^ cocseo| oo| occ|e o^dc|oc c|esp |o|oyoc dos s,
~ece|e~ce~o~ cC''S
/C/O-350 1 67
2 . Co~~o^cocses o| ~ypove^| ' o| o^ o^dscoseqce^| |esp |o|oyoc dos s ^
c' cdeco|d oc oes|, oo|c^do| o^, pc ~o^oyd seose o| oge o voyoos||cc
| o, C`Sdepess gdcgs/ovedose, o^d se e|o /^eco~cscc o d seose
, e g , A.S, ~yos|~e^o gov s, odvo^ced yp~osco' os s|
R E S P I R ATO R Y AL KA L O S I S
peo2 VE NTS
P regnancy
Ci rrhosi s
O2 def i ci t
`otes
Vent i l ator
E mbol us
Neu rol ogi c di sease
Temperature (fever, heat)
Sa l i cyl ates/drugs
1 . co^||os||o esp o|oyoc dos s, esp o|o|y o' o os s ssecodoy| o~y
peve^| o| o^ veexce|o^ o|co|oo^ d ox de, CC, \:`!S, occoc|s |o|
|~e o o os s
2. <esp o|oyce^|es| ~. o| o^ ^ pregnancy s dce|o ceosed podcc|o
o| p|oges|eo^e, v~ e ^ci rrhosi s |~ee poooo y sdeceosed ~e|ooo s~o|
scos|o^ces|~o|s| ~co|e|~eespo|oyce^|e ypoxo (02 deficit) o sococses
~ypeve^| o| o^. o|e^|s o^ ~ec~o^ co' venti l ators ~oy ~ove |espo|oyo o
ossv~e|~e~ c|e ve^| o| o s ^oppopo|e y~ g~ !oc~ypeo o^d esp |o
|oy o o os s s o veyses |ve o oe |^o^spec | cs g^ o| c ~o^oy embol us.
C`S ^ cy o neurol ogi c di seases o so ~oycocse~ypeve^| ' o| o Temper
ature e evo|o^s v|~ |eve o ~eo| ex~ocs| o^ s| ~c o|e oeo|~ ^g, o^d espo
|o|yo o' os s s|~e ^ | o ocdooseooo~o' |y ^sal icylate overdose.
1 68 -C/O-350
1
GASTROENTEROLOGY
Cl inical Symptoms and Si gns
AB D O M I N A L PA I N
MEAN GUT
Meta bol i c
E ndocri ne
Abdomi nal
Neurogeni c
Gynecol ogi c/geni ta l i a
U ri nary/r enal system
Thoraci c
`otes
1 . ^:A`C3! povdes o s ~p' eo.| ~e|oopp|ooc~ ~g oodo~ ~o' po .
!~e ~os| ~po|o~| | o dec s o sv~e|~e cge|s.g co |eve~| o o d
ogos|c|es| g s ~dco|ed 1~e ~ s|oyod p~ys co exo~ o| o o~do |ev
s ~p' e|es|s gc de|~e dec s o~~o ~g | sesse~| o |o exc cdeex|ooodo~ o'
cocseso|po , e , ~e|ooo c, e~doc ~o og c, eco og c, gyecoog c, co
og c, o~d |~oocc|oe|oee~oo|s g o~expesve od ~vos ve |es| ~g.
2. Metabol ic co.seso|oodo~ o po ~ c .de.e~ o, pop~yo, Cl es|eose
de|cecy, o~ o ^ed|eo~eo 'eve, o~d posos , e g , ~eovy ~e|o s, e
ve~o~o| o~, c~e~o|eopy| Endocri ne co.ses ~c' cdeodeo ~sc|| c ecy, ~y
peco ce~ o, od d ooe|c e|ooc dos s ^os| o| |~e ~|oobdo~| co' e'o oges
55//O0/l0/OlOQy M 1 69
o|po ^oe s|ed |e '<: '< S3<C' CA.A:`':C!^- ~e~o^ c
o^ poge l z Neurogeni c cocses o| po ^ ^c cde epeszos|e, |ooes do
so' s, psycoge^ c po , |cc| oo' oove' d seose, od sp o' od cc | s
Gynecologic cocses o| po ^ ~po|o| o^y|e~o' e po| e|od espec o ' y
|oseo|~es|co| ^g ogeo^d urologic cocses o|po , sJc os eo s|oes,
pye oep | s, od c oy e|e| o, o' sooe ^c' cded ^ |ed ||ee^| o' |oop
ped c | s o y, po ~oy oe e|eed |o~ thoracic poo e~s scc os p^ec
~o o o^d ~yocod o sce~ o :sopogeo' d seose csco y cocses ces|
d sco~|o|, o |ocgpo| e|s~oyco~p o o|oodo~ o' sy~p|o~s
3 . !e | o d ogos| c evo co| o o|o po| e|v | occ|e oodo~ o' po
o||e ^c cdesCoC, c ^o yss, o~y oseo^d/o ' pose, ' vee^zy~es, odoo
do~ ^o' xoys, |oe^ v | |e po| e| ^ |e cp g| pos | oo |o evo co|e |o d
o|ed oops o| oove' o |ee o |e |es|s ~oyoeoppop o|e ^ se' ec|ed
po| e|s, scc ossec~ e ec|oy|es, o3`, ceo| ^e, co'c cr, cosy^|op s| ~
c o| oc|es| g |oode^o' sc|| c ecy, o o ces|od ogop
4. I mportant tips for internists:
o oecoe|c |oexc cde ~e|ooo' cdeo^ge~e|s, sys| e~ cd seosesod
ex|ooodo~ o' pocesses, v c~oypese|w| oodo~ ^o po
o <c eoc|ec|opc peg^ocy ^oy|e~o eo| ~es|co| ^g oge. 'e'vcex
o~ o| o^ soc d oe pe|o~ed o^ v | co' yo' vo~e v | occ|e oodo~ ^o'
po ^ :veyvo~o^o| epodcc|veoge~cs| oveo peg^o^cy|es|
c :' de' y po| e|s v| occ|e oodo~ ^o pocesses ~oy ove o|yp co pe
se^|o|o^sodsoc' d oe ~o^ogedv | geo|ecoc| o^. Nese|e c sce~ o,
| o exo~p e, ~oypese^|v|sevee po ^ odoc^ ~pessve pys co' exo~
^o| o^, e , po oc|o|popo|o|o|ec' ^ co' | ^d ^gs| . A' so, po|e|so^co
| cos|eo d |eopy ~oy ove o| yp co' pese^|o| os, os s|eo ds ~oy ~os\
c' ^ co' | d gs

5. !e ' oco| o , dco| o, pogess o^, odo^se|o| po ^ ,see |oo e co oe

e' p|c' d||ee| o| g oe|vee^ cocseso|oodo~ ^o po ^ !ee s cos de
oo eove' op, oc| o ge^eo | ~ecocse s o||e e' p|c ^ d sce^ ^g|ecocse
o|oodo~ o' po <e' ev g o^d oggovo| ^g|oc|osoe e' p|c 'oco' z ^g
|esocce. oexo~p e, po e' eved oy|e possoge o| oove ~ove~e^|s
scgges|s|eco ooso ' e'ysocce. o ^ | o|edoysvo' ' ov g ~p' co|es|e
esopogcs,v 'e po oggovo|ed oyo^yoc| o^|o|~oves|eoodo~escg
ges|s pe |o | s,|e po| e^|csco' 'y pe|es|o e s| | ^|eo|e o^d, v |
oos|cc|o o|o o' ' ovv sccs, po| e^|s csco' 'y~oveoooc| ooo||e~p||osee\
e' e|, od ~ove~e|does o|~o\e |e po vose
1 70 55//O0//0/OlOQy
Pai n Accordi ng to the Acui ty of Onset
Abrupt-Gnset Pai n ( i nstant)
Gastrointestinal Causes
Perforated ulcer
Ruptured abscess or hematoma
I ntesti nal i nfarct
Ruptured esophagus
Nongastrointestinal Causes
Ruptured or di ssecti ng aneurysm
Ruptured ectopi c pregnancy
Pneumothorax
Myocardi al i nfarction
Pul monary i nfarction
Di ssecting aneurysm
Rapi d-Onset Pai n ( mi nutes)
Gastrointestinal Causes
Perforated viscus
Strangulated viscus
Vol vul us
Pancreati ti s
Bi l i ary colic
Mesenteri c i nfarct
Diverti cul i ti s
Penetrati ng peptic ul cer
Hi gh i ntesti nal obstruction
Appendi ci ti s (gradual onset more common)
Nongastrointestinal Causes
Ureteral colic
Renal colic
EctopiC pregnancy
Gradual-Gnset Pai n (hours)
Gastrointestinal Causes
Appendi ci ti s
Strangulated hernia
Low i ntesti nal obstruction
Chol ecystitis
Pancreatitis
Gastritis
Peptic ul cer
Col oni c diverti cul i ti s
Meckel's di verti cul i ti s
Crohn's di sease
Ul cerative col i ti s
Mesenteric l ymphadeni ti s
Abscess
I ntesti nal i nfarct
Mesenteri c cyst
Nongastrointestinal Causes
Cysti ti s
Pyel i ti s
Sal pi ngi ti s
Prostatitis
Threatened abortion
Uri nary retention
Pneumoni ti s
35/lO0//0lOlOQy M | |

6. ee so ~e~o~ cde ^eo| g |~e d ||ee| o d og^oss|ooppe~d c | s

P RE P F OR SUR GI CAL
AP P E NDECTOMY?
Pyel oneph r i ti s
Renal stone
Ectopi c pregnancy
Pel vi c i nf l ammatory di sease
Fol l i cl e ru pture ( mi ttel schmerz)
Ovar i an cyst torsi on
R upt ure of cor pus l uteal cyst
Spl eni c ruptu re
U ri nary retenti on
R u ptured aneu rysm
Ga str oenter i ti s
I nfarcted/i schemi c gut
Crhn's/ul cerat i ve col i t i s
Abscess
L i ver capsul e di st ensi on/i rri tat i on
Appendi ci t i s
Pa ncreati t i s
Perforated ul cer
E s o p h a g ea I rupture
No di sease
Di vert i cu l i t i s
E ndometr i osi s
Chol ecysti ti s
Twi sted bowel
Obstructed bowel
M eckel 's di vert i cu l um
Yersi n i a/l ymphadeni t i s
1 72 35//O0//0/OlOQy
t
D I A R R H E A
SOI L I NG
Secretory
Osmot i c
I nf l ammatory
Laxati ves ( fact i t i ous)
I schemi c
Neurogen i c
Ga st roi ntesti nal bl eedi n g
`otes
1 . !e p ~oy ~eco^ s~so|d oeo , ooppoe^|doeo| oe sc~~ozed
oy |e ~^e~o^ cS' '' ' ' o|eo s de| ^ed os oc ^ceose ^ do 'y s|oo
ve g|ooove zJJg|o~s pedoy S ^ce| s s^o|ove|yeos yoo|o ^ed ~eo
sce, d oeo seede|^ed |o~ |epo|e^|s pe|spec|ve o^ ^ceose ^ s|oo
|eqce^cyo^d/o qc d|y ! soe| ^ | o^ ^c' cdesype|de|eco| o^, v c so^
^ceose ^|eqce^cyv |oc|o ^ceose ^s|oo' veg| os occcs ^ |oo e
oove sy^d|o~e, ype||y|o d s~, o^d|eco' ^co^| ^e^ce A'so ^c' cded sgos
'o ^|es| ^o' o'eed ^gcocs ^g ~e' e^o, vc po|e^|s ~oydescoeosd oeo
2. Secretory ,vo|e|y| d o|eo s cooc|e|zed oyvo'c~ ^ocs|eco oc|pc| ^o|
^ecesso y e o|ed |o|ood ^|ose, v c|o ' s |o ~pove v| |os| ^g !e|e s
pe|coo|o^ o| ^o~o | c d o^d e ec|oy|e ||o^spo| ^ |egc|, o^d |e |esc | s
vo|eys|oosv | ^o~o' e'ec|oy|e co^ce^|o|o^s o^d ^o ^ceose ^ s|ooos
~o' o' |y !e c' oss c exo~p'es o| sece|oyd o|eos o|e o~o^o' , ^c cd ^g
coc ^o d sy^do~e, /o ^ge. so^ , \' 'o~o, ~edc ' oy |yo d co|c ^o~o,
o^dsys|e~c ~os|ocy|os s A^excep|o^ sso~o| s|o| ^o~o, ^v c| ed o|
eo s os~o|c v| s|eo|oeo seco^doy|o ^ o | o^o|po^ceo|c sece|o^s
o^d go oodde~o| |y o eso |ss| ~co|eco o^ csece| o^, o^d p|ocesses|o|
^ceose o eso' |de vey|o|eco o^o sococsesec|e|oyd o|eo :xo~p es
^c cde eo' oyposs o esec|o , edcced |eooso|p| o^| , |c^co vogo|o~y , oo
^o|~o |o^s || , o^do||e|coecys|ec|o~y,|edcceds|o|ogecopoc |y|
3. Osmotic d oeos , scc os po^ceo| | s, spce, ooc|e| o' ovegov| , o^d
\ pp es d seose| oe co|oc|e| zed oyoc y, geosy, |oc' s~e ^g s|oo s,
ve g|'oss, o^d ~pove~e^| ^d o|eo v| |os| ^g ! s|o~o| d o|eo e
sc |s Lo~ o^ ^ges|ed so' c|e |o| s ^o| oosooed oy |e s~o ^|es|^e !e c^
oosooedso'c|eexe|so^os~o| c|oceo^ddovs|' c d ^|o|e ^|es| ^o c~e^
!e esc|o^| ^c|eosed s|oo' vo c~eexceeds |eco' o^s eoosop|ve copoc|y,
35//O0//0/OlOQ
Y
M 1 73
M
b
ocd d oeo ecsces S|oo oco'ys ss~ovs o gop oe|vee e'ec|oy|e coccec
|o|ocsocd |o|os|ooos~o' o' |ydce |o|eccoosooed so c|e
4. I nfl ammatory cocses , c|' o~~o|o|yoove d seose, od o| oc ec|e|oco' | s,
eos cop~ cgos|oec|ee|socd ce|o cA' Sossoc o|ed c|ec|ocs| oe co|oc
|e|zed oy |eve|, oodo~ co' po c, ocd oood ocd/o ecocy|es c |e s|oo' c
|ese d sode|s|~ee s c| o~~o| oc ocd c cy| o|~e c|es| co ~ccoso. !e
~ec~oc s~o| d oeo ~oy cc' cde ~o ooso|p|oc o sec|e|oc dce| od s cp
|oco|co~o ~ccoso'|ccc| ocs
5. 'oc| | ocsd o~eo||o~laxative abuse sos~o| cocdsoc' d oe scspec|ed
c vo~ec v |~ c~oc c d o|~eo, ypoo e~ o, ocdo s|oyo| psyc~ o| c
cess Ce||o c p|esc oed ~ed co| ocs o' so coc cocse d o|eo, scc os
oc|oc ds, |~eop~y ce, co c~ c ce, d g |o s, ocd oc| o o| cs.
6. I schemi a s no| o co~~oc cocse o|d o~eo, ocd |ec' c co' p c|c|e de
pecdsoc |edegeeo|voscc' oco~po~ se Acc|e, |c ~ coc| sce~ cco | s s
dce|oco~p e|evesse' occ cs oc ocd |eo|ces sevee oodo~ co po c, o oody
d o~eo, ocd |op d deco~pecso| oc 'ococc csve sce~ o ~oso 'esssevee
coc|seocd csco' yesoves v |~oc| c|evec| oc 'o|ec|sv | cococc' cs ve s
ce~ o ove essedeg|ees o| po c ocd o eed cg, occc cg ove o ocge|
peodo|| ~e Acoex o, vo~ | cg, ocd d oeo~oyoe| ep| ~o|yco~p o c|s
7. Neurogenic d sode|s oe d s|coocces o| c|es| co' ~o| |y|~o|o||eccocse
ype|de|eco| oc o ccoc| cecce os opposed |o |ce d o||eo !e |oo' e
oove sycdo~e , oS| so co~~oc ocd cceos cgy ecog zed |o~o|cec|o
gec cd o|~eo ' oS s c~o|oc|e zed oy o' |eco| cg cocs| po| oc ocdd o|~eo,
as ve osd ||cse oodo~ co po c ' oSoeg cs oy eo' yodc'|ood ocds~oc' d
co|oeoccep|ed oso d ogcos s coco de po|ec|v |~ ecec|ocse|d o|~eo.
C|ecec|o og cd seoses , d ooe|es, cocdoeqc cosycdo~e, S~yoge|| o' so
coccocseo |eed c|es| co' ~o| ' jocd d o~eo
8. Gastroi ntesti nal bleedi ng, vecscoocc|e, ~oycocse||eqcec|oose, o oc\
s|oo' s A | ocg~ co|s|| c| yd oeo, po| ec|s ~oy c|ep|e| | osscc A so,
so~eo||eo|~e| ~ec~oc s~so|d o|~eo ~oy|eo|c|e o'eed cg, espec o' 'y|e
| c|'o~~o|oye| o' ogesocd sc~e~ o
9. !e ~o o|yo|coses o|acute di arrhea , I ^ doys c dco| oc| oe c
|ec| ocs, |~e d ogcosso|v~ c~coc oe scspec|ed oyo ~ s|o|yo| ecec||ove' ,
| cges| oco|cccsco' |ood ,|ovseo|oodoccde|cooed poc' |yp|odcc|so ~o~
oc|ge|l, o| ecec|coc|oc|v |~ peop'ev~o ove oeec s c ' c|ec|ocs oy cvo
s ve ooc|e o , Coopy|oooc|e/, '||ge||o, 'o|oone||o, ^e/ooono:, ce||o c
|sc|e||c||o co||| oeo||ec ossoc o|edv|~ ooodyd oeo | s ~po|oc||oex
c' cdeo|ecocses o| ooodyd o~eo scc~ os ~esec|e c sce~ o ocd c| o~
~o|o|y oove d seose c|ec|ocs oy coc cvosve ooc|e| o ocd po|ozoo , \|o/|o
c|o|e|oe, ec|eo|ox gec c E. co||, K|eo:|e||o, o|d o, Cyp|ospo| d o| |ypco' ' y
p|odccevo|eyd o|~eo v |oc| oood C o|||c||e |o|e'ycocses o oodyd o
|eo Ye|:|n|o, v~ c~co~~oc y c|ec|s |~e |e~ co' ' ec~ocdcecc~, o||ec pe
sec|s v | vo|e|yd o~eo ocd | g~| oveqcod|oc| po c , v~ c coc ~ ~ c
oppecd c | socd C|ocsd seose
1 0. A ~oe co~p|eecs ve ' s|o||ecocseso|chroni c di arrhea, ogoczed
po|opyso' og co' y, |o''ovs
| 4 35l/0/l0/OlOQy
d

I RACE TO PASS LOTS OF WI LD 8M,

FI N D A CUR E !
Ischemia
I schemi a
Secretory
Recta l vi l l ous adenoma
A fter chol ecystectomy ( chol err hei c)
Col l agenous col i t i s ( l ymphocyt i c or mi croscopi c
col i t i s)
E ndocr i ne (Zol l i nger- El l i son, VI Poma, carci noi d,
medul l ary thyr oi d ca rci noma, mastocytosi s)
Tru nca l vagotomy
Obesi ty surgery ( i l eal bypass or resect i on)
Osmotic
Pancreat i t i s ( ch roni c pancreati ti s wi th steator r hea)
Abeta l i poprotei nemi a
Somatostati noma
Short-bowel syndrome
Lymphangi ectasi a
Overgrowth of bacter i a
Tropi cal spr ue
Spr ue ( gl uten-sensi ti ve)
Ul estra/di etet i c foods
F ru i ts/ca ndy ( fructose, sor bi ta l )
Wh i ppl e's di sease
I nfect i ons ca usi ng steator r hea ( I sospora, Gi ardi a,
Strongyl oi des)
Lactose i ntol er ance
Dr ugs causi ng steator r hea ( e. g . , col ch i ci ne, neomyci n)
Factitious or "pseudo " diarrhea
B l eedi ng ( mel ena)
M uncha usen's/mal i nger i ng ( l axati ve abuse)
35//O0//0/O/OQy M 1 75
Neurogenic or altered motility
Feca l i nconti nence or i mpacti on ( obsti pati on)
I rri tabl e bowel
Neu rol ogi c di seases ( e. g . , autonomi c neuropat hi es,
ca uda equi na syndrome)
.
Di abetes mel l i tus
Inflammatory
A I DS-associ ated i nfect i ons ( ch roni c i nfecti ons)
C rohn's di sease
U l cerati ve col i t i s
Radi at i on enterocol i t i s
Eosi nophi l i c gastroenter i t i s
DYS P H AG I A
BI TES
B l ocked esophageal l umen
I ntr i nsi c narrowi ng of t he esophagus
Th roat/mout h di sease ( oropharyngeal dysphagi a)
E xtri nsi c compressi on of t he esophagus
Smoot h/Str i ated muscl e di sorders
`otes
1 . !~ee oe |ve p ~o|y ~eco~ s~so|dysp~og o Blockage of the esopha
geal l umen esc |s||o~ ~poc|ed |o|e g~ ood es o~d svo ' ov ~g|oo ' ogeo
|ood oo cs ocesses |~o|cocse i ntri nsi c narrowi ng of the esophagus ^c' cde
~epes v cs o~d o|~eoppo||c~ s| c ~|ec| o^s, esop~ogeo' veos o~d ~gs,
pep| c s||c|ces o~d cocs| coc ~s, oe~ g^ o~d ~o g~o~| |u~os, o~d Co~~ s
d seose Ao~o~o |eso||~ethroat and mouth cocseo|op~oy~geo' dysp~og o
o~d ^c cde p~oy^geo veo~ess |o~ s|oe, oco|so' vo|o~ S oge^ssy^
do~eo^d es o^so||ec| ~g|~e|o^gce Extri nsi c compression of the esophagus
~oyoecocsedoyo |~yod ~oss, /e^ses d ve||cc c~, voscc oo^o~o es, o|
7 76 35/lO0//0lO/OQy
~ed os| o |c~o|s. o|o e os ped spose po| e|s |o oo| ^|| s c oov
g , s| c|c|es ||o~ C: <'| od ex| s c co~pess o , ^co|ceo| o^ o| o
pooesopogeo os d g e o| sodeso| smooth muscl e ,sc eode~o,
oco os o, Cogos d seose, d ||cseesopogeo spos~o ^c|coce esopo
gcs| od striated muscl e , ^eco~csc. od seoses, ooes, |e|o^.s| co.se ~o'o
dyspog o
2. !esy~p|o~ o| dyspog o ~oyoeoopoygeo' o|esopogeo Oro
pharyngeal dysphagi a , ||oo| od ~o.| e|ooges| s s.gges|ed oyo s|oy
o| o|e|oopoy^geo sy~p|o~s c .d g ^oso egcg|o| o , cocg go^ o|
'e~p| ^g |osvo ov o^d coco~ |o|speec~ d s|coo^ces o| e's v| ece|
s|oeo|epo| cc o y e' y|o ~oveoopoygeo dyspogo
3 . Esophageal dysphagi a s cocsed oy |e o|e |oc e| o og co g|ocps
, o' ocoge, | s c, ex| s c, o^d s~oo|/s| o|ed ~.sc e| o' ocogeo| |e
esopogeo c~e, || s c ^o |ov g, o^d ex| s cco~pess o cocse oe
.|oo.o oos|.c| o, v ed seoseso|s~oo| ods|o|ed ~.sc ecocseoeuo
ou:cu|o| dyspog o ^eco co od e.|o~csc.' o|ypes o|dyspog o co
csco y oed s| g. sed oyo o|| e|, oc|coe|c , s|o|y |oc.s g o|e|ype o|
|ood d.c gdyspog o ,so' ds, ' q. ds| , |e po||e| o|dyspog o , ^|e|~||e^|,
cos|o|od/opog|essve|, odve|eeo|o. s pese|
3 . Dysphagi a for sol i d foods onl y: ! ssy~p|o~ s.gges|s ~eco co oo
s|.c| o, os| c ds oe oo e|o ||ovese|e po| o yoos|.c|ed esopog.s ~oe
eosy| o^ sods ' |dyspog o|o|so d|ood s ^|e~||e|, | ~oyoe dce|oo
esopogeo' ,Sco|z | | ^g \ |esopogeo' | ^gs, |eoos|.c|o^ s~ d, od
o^ y oge|ood oo .sesoe oos|.c|ed, ece |e |e ~ ||e| o|ce o| sy~p
|o~s |ogess ve dyspog o v | o s|oy o| eo|| o. s.gges|s pep| c
esopog | sv | o v |oc|o pep| cs| c|.|e. |ogess vedyspog o|oso ds
v |o.|o s|oyo|eo||oc scooc|es|co|esopogeo' |.~os
5. Dysphagi a for both sol i ds and l i qui ds: ! ssy~p|o~ scooc|e s| co|
ec o~.sc.' o dyspog o , ~o| ' |y d so de | , o odvoced ~eco co oo
s||cc| o peve^| ^g |' c ds||o~ poss g ogess ve ~o| |y|ype dyspog o s
.s.o' y d.e|o oco os o secdooco os o, d.e|o |.~o | ||o| g| e ~ye
|e c p excs, so o|eco.seo|| ssy~p|o~. |e ~ ||e|, ep sod c ~o| |y|ype
dyspog o v | ossoc o|ed ces| po ~oy d co|e d ||cse esopogeo'
spos~ ^ po| e|s|o~ So.| A~e| co, cogos coco os o so.' d oeco^s d
e|ed |og|ess ve dyspog o v | seveeossoc o|ed eo | oc ssee v |
sc e|ode~o
6. ys co' exo~ o| o so. d c cdeo seoc |o|cev co o^dscpoc ov cc
' o y~p odes od |eo|.|es o|co^ec|ve | ss.e d seose A oo| .~ esopo
g|o~ |ypco' ' y s|e| s|d ogos|c|es|oo|o ed ' |o ~o| ' |yd sode| s ey,
esopogeo ~o^o~e|y s oo|o ed od, poss oy, o cppeC' e^doscopy|o
ce oc|pse.dooco os o |~ec|o co' oos||.c|o ssee^ o|eoo| c~s|.dy,
o cppeC' edoscopyv| o opsy s dco|ed !o|occC! s cse|. |od og
^os ^g|ecocseo|ex|| ^s cco~p|ess oo||eesopogcs.
7 ee so co~p|ees ve s| o||eco.seso|dyspogo
35l/O0/l0/OlOQy M
-
OH WH E N EATI NG BI TES
Oropharyngeal dysphagi a ( stroke, Sj ogren' s, tongue
par al ysi s/i nj ury)
H erpes si mpl ex/opport uni st i c i nfect i ons ( CMV,
Ca ndi da)
Web
H i atal her ni a ( i nca rcerated)
E sophageal spasm
N utcracker esophagus
Extr i' nsi c compressi on ( thyroi d mass, Zen ker 's
di verti cul um, aneurysm)
Achal asi a
Trypanasomi asi s ( Chagas' di sease)
I nfl ammatory bowel di sease ( Croh n's)
N eu romuscul ar di seases ( myastheni a gravi s,
pol i omyel i t i s, ALS, pol ymyosi t i s)
G E R D/pept i c str i ct ure
B u rn ( caust i c i ngesti on)
I mpacted forei gn body
Tu mor
E sophageal r i ng
Scl eroder ma
H E PATO M E G A LY
BI G H E PATI C MASS
B udd-Chi ari syndrome
I nfect i ons ( vi r al hepati ti s, E BV, Wei l 's di sease, TB,
amebi c abscess, hydati d cyst)
Gaucher 's di sease/G I ycog
e
n storage di seases
1 78 85llO0/l0lOlOQy
,
&
H epati c cysts ( pol ycysti c di sease)
Ext ramedul l ary hematopoi esi s ( i . e. , myel oprol i ferati ve
di seases)
Pri mary bi l i ary ci rr hosi s
Amyl oi dosi s
Toxi ns
I ron over l oad ( e. g . , hemoch romatosi s)
Congesti ve heart fa i l u re
Ma l i gnancy ( e. g. , hepatoma, metastat i c tu mors,
I ymphoprol i ferat i ve di seases, adenoma)
Al cohol
Sa rcoi dosi s/gra n u l omatous hepati ti s
Sch i stosomi asi s (vascu l ar obstructi on)
Notes
1 . A po poo e ' ve|, epo|o~egoy, ~oy cd co|e occ|e c|ec| oc, |ox c
do~oge, c| ' ||o| oc, ~e|ooo cd seose, oos||cc|oc |o o edo coge, o|voscc
o| cocges| oc/oos||cc| oc. A po' poo' e ' ve ~oyo' so oede|ec|ed c po| ec|s
v | COPD ve|e |ee sdovcvo|d d sp' oce~ec|o||e ve|ocd, o|e' y,
vec|e|e sococo|o~ coco~o'y , < ede' s ooel.
2. !eevo' co| oc o|epo|o~ego' ydepecds cpoc |e |op d|yo|ec o|ge~ec|
ocd p|esec| cg s|o|co' ocd c' c co' |eo|c|es. ' cgece|o' , ossess ' ve|eczy~es,
o ' co c, ocd epo|c syc|e|c |Jcc|oc ,p|o||o~o c| ~e, o oc~ cl , ocd |o''ov
cp v|~ ~og cgs|cd es.
J U N D I C E
BI L E
B i l i ary obstruct i on
I nheri ted di sorders of bi l e metabol i sm
L i ver par enchymal damage ( i nfect i on, toxi ns)
E ryth rocyte destruct i on
35l/O0/l0/OlOQy M 1 79
b
"otes
1 . !~e po|~op~ys o og c ~ec~o~ s~so|~ypeo .o ~e~ ooe o.| ~ed oy|~e
o .. ~~e~o~ c , l | bi l i ary obstruction , e , c~o e |~ os s| , , z| i nherited di sor
ders o| o eco~ .go| o~ o| exce| o~ , e , ' oe| s, .o ~|o~~so~ , C g e
`o o o~d <o|o| sy~do~e|, , J| liver parenchymal damage , ~|ec| o~, |ox ~s| ,
o~d , ^| erythrocyte destruction , ~e~o' ys s, ~e||ec|veey|opoes s|
2 . o. ~dce es. |s |o~ ~ypeo .o ~e~ oo~doppeos os ye ' ov ~g o||~e
s ~o~dsce|o |~eco~d | o~s~oyco.seye ov ~g ,co|o|e~e~ o| o|doe~
~g , Add so~s| o| |~e s ~ , o.| do ~o|co.se sc eo c|eJs. A||e| oo|o ~ ~go
se.~ o .o eve o~d co~| ~ ~g |~o|s ~ p g~e~|o| o~ c~o~ges o|e d.e|o
o.~d ce, |~e ~ex| s|ep s |o |oc| o~o|e |~e o ' | .o ~ ~|o J~co~ .go|ed , ~d
|ec| |o~dco~ .go|ed, d |ec|||oc| o~s
3. Jocoojugo|eo ~ypeo ' .o ~e~ o oe yco.ses o .o ' eve sgeo|e|~o~
o ~g/d , ode~e~o ys s oos , ~op|og oo ~, e| c. ocy|e co.~|, d ec|o~d ~d
|ec| o~| g oo. ~ |es|s, e|c | | o~o|~eco.se s ~o| oppo|e~| so|de|s | ~o|
co.seo pedo~ ~o~|y.~co~ .go|ed ~ypeo .o ~e~ o ~c .deey|~ocy|eoo
~omo' | es, sepss ,deceosed ~epo| c .p|oe| , C, o~d ce|o ~ ~~e |ed co~
d |o~s , oe|s, C g'e`o o |ypes ' o~d I I ) .
4. ' || ~epo| e~|~oso pedo~ ~o~|' y coojugo|eo ~ypeo ' |.o ~e~ o, |~e ~ex|
s|ep s |o d ||ee~| o|eoe|vee~ ve poe~c~y~o do~oge o~d o ' oy oos.c
| o~ . ve poe~c~y~o ~ .y co.ses ve|y ~ g~ eves o| |o~so~ ~oses AS!
, S!| o~dA'!, S'!| o ' oy oos|.c| o~ ~os o esse cc|eose | |o~so~
~oses o~do ~oe e~o|soo' e e evo| o~ o|o' o ~e p~osp~o|ose , o~d o ~.
c' eo| dose, |oo|o ~ed| | o ' o yoos||.c| o~ ss.spec|ed, | ~e~ d ||ee~| o|e
oe|vee~ ~|o~epo|c o~d ex|o~epo|c o oy oos|.c| o~ oy ~og ~g s|.d es,
o||e~ .' ||oso~og|op~y so|des |~o|co.seo p|edo~ ~o~| yco~ .go|ed ~ype|
o ' .o ~e~ o ~c .de~epo|oce .' o|des|.c|o~ , ~|ec|o~, d|.gs| , o ' oyoos|.c
|o~ ,s|o~es, o~o~o eso| |~e o ed.c|, co~ce|, sc eos ~g c~o' o~g | s| , o~d o
|ev ~~e| |ed d sodeso|o e exce|o~ , .o ~]o~~so~, <o|o||
5. ee s o ~oeco~pe|e s|o|e|o' og eso| o.~d ce
I ' M PAGI NG MRS WHI PPL E STAT
I nfecti on ( e. g . , vi ra l hepati t i s, sepsi s, l eptospi rosi s,
Clonorchis, Ascariasis)
Medi cati ons/dr ugs
Postoperat i ve chol estasi s
Al pha-1 anti -trypsi n defi ci ency
Gal l stones
180 35//0//0/lOQy
I nj u ry/tra uma ( hemobi l i a)
Neopl asms ( e. g. , chol angi ocarci noma, per i a mpul l ar y
carci noma, carci noma head of pa ncr eas)
Gra n u l omatous/i nf i l t rati ve di sease ( e. g . , sarcoi dosi s)
Mal formati on of t he bi l i ar y t r ee ( atresi a, str i ct ure,
chol edochal cyst, etc. )
Reye's syndr ome
Scl erosi ng chol angi t i s
Wi l son's di sease
H eredi t ary di seases ( Gi l bert 's, Dubi n-Joh nson, Rotor
syndrome, Cr i gl er- Naj j ar)
I ron over l oad
Pregnancy-rel ated ( chol estasi s of pregnancy,
pre-ecl ampsi a, acute fatty l i ver of pregnancy)
Pri mary bi l i ary ci rr hosi s
Laen nec's ci r rhosi s (a l cohol i c)
E ryth rocyte destruct i on
.
S tarvat i on/fasti ng
TPN
A utoi mmune hepati ti s
Toxi ns
N AU S E A A N D VO M I T I N G
I VOMI T
I ncreased i ntr acra n i a l pr essure/CNS di sease
Vascul ar
Obstructi ve
Metabol i c/toxi c
I nfect i ous
Trau mati c
35l/O/l0/OlOQy M 181
`otes
1 . `ocseo ocdvo~ | cgoeveyco~~oc sy~p|o~socd ~oy oeossoc o|ed
v| ocyo||e cocses o|oodo~ co' po c,seeAodo~ co o csec| oc| 'c |oc|,
|ese sy~p|o~so||ec occc |oge|e \ec cocseo ocd vo~ | cg o|e |e p
~oysy~p|o~s, oveve, o d ||e|ec| p o | zo| oc o|d ogcos|c poss o ' | es
sc~~o zed oy |e ~ce~oc c ' \^' ! , see o so 'occeo| | s sec| oc| s
oppopo|e. I ncreased i ntracrani al pressure, osocccsv | c|oce.eoo e~
o|oge, coc cocse cocseo ocd vo~ | cg Vascul ar e| o oges cc cde ~esec
|ec sce~ o, ~yocod o sce~ o, ocd ~ g|o ce eodoce Obstruction o|
|e GI |oc| , e g , odes ocs, vovc cs, c|csscscep| oc| ocd psecdooos|.cc| oc
, e g , sc' eode|~o, gos||opo|es s| oe co~~occocseso|cocseo ocdvo~ | cg
Metabol i c/toxic cocses cc cde pegcoccy, ype|co' ce~ o, odeco csc||
c eccy, sdcey|o c|e, dcgs, ocdd ooe|c se|ooc dos s I nfectious e| o oges c
c' cdegos||oec|e| | s, oppecd c | s, ooscess, |e||coooc|e| py|o/|, seps s, ocd
~ec cg | s. ' co y, trauma |o|eoodo~ec, e |eex| cs co eo|ed|oscge|y,
oe eos ' y|ecogc zed cocseso|cocseo ocdvo~ | cg
2 . Sees o s|o|yo|eodoces o ceco' og co sy~p|o~s, os|ese ~oy po c|
|ovod o C`Scocseo|cocseo ocdvo~ | cg Aodo~ co po c p|eced cg|e
vo~ | cg ~oye' p' oco' zeoc c||ooodo~ co' c|' o~~o|oypocess , e g , ep
gos| cpo c v | pocceo| | s, g|cppe|qcod|oc| po cv | co' ecys| | s, g|
ove| qcodoc| po c v | oppecd c | s| 3cd ges|ed |ood c |evo~ |cs ~oy
e p ' oco' ze |e e| o ogy|o | es|o~oc, oc| cocco| d s| cgc s ~ecoc co'
oos|cc| oc ||o~ gos||opo|es s 'ecc' ec|vo~ |cs scgges|s oove' oos||cc| oc o|
| s|c' o.
3. 'c odd | oc|o pe||o|~ cgo gece|o' pys co' exo~ co| oc, ~eosceo||hos|o
|c cocges c pc' seocd o'ood pessc|e|o es|~o|e |e deg|eeo|deyd|o| oc.
|os|o|c cocges ~oyo' so oe dce|ooc|oco~ cdys|ccc| oc c d ooe| c po
| ec|s, odce |o dcg|e|opy
4. Aodo~ co' exo~ co| oc soc' d es|oo' s |e pesecce o| oosecceo|d s|ec
s oc Ac oosecce o|oove' soccdsococscc' |o| oc ~oy cdco|e oc 'ecs o oc
c|' o~~o|o|ycocd | oc v | pe| |oc | s. 'o po| oco| | eoodo~ec e' ps d s| c
gc s|e|vo, os oco zed |ecde|cess v | gco|d cg sp|esec| c c| o~~o|oy
cocd | ocs. !e oco zo| oc o| po c ocd|ecde|cess ~oy cd co|e |eo|goc
sys|e~ cvoved
OH GOD AM I SI CK
Obstet r i cal ( pregnancy, hyperemesi s gravi da)
Hyperca l cemi a
1 82 35l/O0/l0!OlOQy
Gastr oenter i ti s ( bacteri al and vi ra l )
Obstruct i on ( adhesi ons, vol vu l us, i ntussuscepti on,
pepti c str i ctur es, tumors)
Di abetes ( DKA, gastropa resi s)
Adrenal i nsuff i ci ency
Medi cati ons ( opi ates, a nt i bi oti cs, NSAI Ds,
chemotherapeut i c agents, ant i a rrhyt hmi cs)
I ntra-abdomi nal i nf l ammatory condi t i ons ( pancreati ti s,
chol ecysti ti s, appendi ci t i s, trauma)
Scl eroderma ( and other pseudo-obst ruct i ve states)
I schemi a ( mesenter i c, myoca rdi al )
eNS di sease ( mi grai nes, i ncreased i ntracrani al
pressure, meni ngi t i s, stroke)
Ki dney fa i l ure
Cl inical Conditions or Diagnoses
PA N C R E AT I T I S
VOMI T
Vascul ar
Obstruct i ve
Metabol i c/toxi c
I nfect i ous
Traumat i c
"otes
1 . !e\^'! ~~e~o~ c, see 'ocseo o~d\o~ | cg sec| o~| coc oecsed|o
c'ossj|~ecocseso|po~ceo||sVosculor cocseso|pocceo||s~c'cdeec|o|zcg
35/lO0//0lOlOQy M 1 8
-
voscc | s, o|~eoe~oo , od!l Obstructive cocseso| pocceo| |s c cde o
oy d seose/c~o e |~ os s, po~ceos d v sc ~, o~pc oy ~o g~o~ces Co~cs
d seose, sp~ c|eo|dd dys|cc| o , Asco os s' ~|es|o| o , dcodeo' d ve|c
c c~od , poooo y|cys|c| oos s Metabol ic/toxic processes cocs g po~ce
o| | s ' ~c cdeo co~o' , dcgs, e~o |o ' ce, occ|e|o||y 've, scop'o~s| ~g, <eyes
sy~do~e, ~ypeco ce~ o, o~d ~ype|g'yce de~ o I nfecti ous cocseso| po~
ceo| | s ~c cde ~c ~ps, o|~e v o ' ~|ec| o~s, <eye s sy~do~e , o' so o
|ox c/~e|ooo cpocess| , ^ycop os~oo~dAsco os s,oos|cc|s po~ceo| coc|
|ov| Traumatic cocss o| poceo||s ~c cdeex|e~o |oc~o, :<C, sc|gey,
eoso~ o|dcode~o c ce, o~do||e e~o |o~sp o~|o| o , |~e o||eo so ~oyoe
co~s deed |oxc/~e|ooo c|
2. !~e ~os|co~~ococseso|occ|e po~ceo||soe , I | bi l iary obstruction oy
go s|o~es, , z| al cohol |oxc|y,|~ese| s||ooccoc~||ooppox~o|ey-J7o|
coses| , o~d , J| drugs, v~ c~occoc~||ooooc|o7 o| coses , BAD| |~e o
|oge~ ccocses , e g , :<C', pos|opeo| ve, o~d co c c~od~ s|o| o| oe
oe ~g ~ceos g'y ecogzed.
3. A ~po|o~|d og~os| c |es| s |~eo~y ose ' eve' , o | ~ocg~ o ~o ~o' 'eve
does ~o| c' eoc|po~ceo| | s !~e' pose eve ~oy~oveso~ev~o|geo|ese
s| v|y o~d spec|c|y ~ |~ed og~osso|occ|e poceo||s.
4. |~eo~poceo|cco~d | osv~c~cocseoe evo| o~o|sec~o~y ose
c cdeeo ~sc||cecy, so voyg o~dd seose, ~ocoo~y ose~ o, A, ce
|o | c~os , cg, esop~ogcs, ovo o| , oc~s, ec|op c peg~o~cy, odo|~e
|ooodo~ o d sodes , pe|oo|ed v sccs, pe~e|o| ~gc' ce, pe|o | s|
5. Se o ~eosces o|sec~o~y oseoe ~o| ~e p|c , o~d po|e~|soe oes| |o
'oved c' ~ co y U ~eo~y osees| ~o| o~ so~' y~e' p|c |o ro ~g|~ed og~o
ss o| ~ocoo~y ose~ o. '~ |~ sco~d | o~, |~eo~y oseco~p'ex s |oo oge|o
oe| ' |eed ~|o |~e c ~e, o~d c e eve's oe ov ~co~|os||o e evo|ed sec~
eve s.
6. <o~so~s c |e o |o po~ceo| | s ~oy oe csed |o pog~os s " L||C
kAM5CM" s|s |~ese |oc|os
Co ^oo::oo \||o 48 |ou/:
ypegyce~ o ke~o |o ce , oU` ~ceose
, C ccose > zJJ ~g/d | > o ~g/ d |
L evo|ed AS! > zoJc/ A~e~ o , ~e~o|oc |dop > l J ~g/ d |
|ecocy|os s Moco c c~, o ~g/d' |
,\oC > I , JJJ/~~
,
| 5eqces|o|o~ ,> ^ '|' c' d|
|'> JoJc/' Cxyge~ dop , 'C < J ~~g|
C' depo|e~|s ,Age > ooyeos| Moo' oc~ ~, J z g/d |
'o| e~|s v|~ o~yoeo| |~ese |oc|os ~ove o~ ceosed so| co~p' co| o~s,
|~osev |~|o s|oc|os ~oy~oveo ~o|o |, o|e os ~ g os zJJJ7, o~d
|~osev |~s x|oseve s|oc|os ~oveo ~eo y l JJ7 ~o|o |yo|e ~po| e~|s
v | ~ go s|oeossoc o|ed po~ceo| | s, |~e pog~os' s s ge~eo y oe||e, o~d
~od | ed c |e o ~ove oee~ poposed |~e ~dco|oso| poo pog~os s
c cdeoc dos s , oosede| c | > ^ ~~o /'| , ~ypo|e~s o~ , o< -J~~g| , |oc~y
cod o, ~eo|o|e > I JJ| , o' gc o, oJcc/~|o~d~e~o~og cpe|o~eo'|' c d
, |oxcoo|~| . A~A'AC:' ' scoe > I z soso pedc|veo|~oeseveed'seose,
18 85l/O0/l0/OlOQy
o | ocg | so co~p ex o~dse do~ csed co cc' o| o~ !e ~po||oce o| | s\
s||o| | co|o s|o| g|s po| e|s soc d oe ~o|oed ~oec ose'yo~do|e
cod do|es|oeo e |eve~| o~o |eopy ,scg co , od oog c, e~doscop c|
7. !e|eo|~e~' |o poceo| | s s oge yscppo|ve, v | | c d es.sc |o| o

odo~o geso !~epoceos s es|ed oye ~ o| ~goo |oe ^o~ |o g|o

co~p co| o~s , |ec| o , e~ooge, e~ody~o~ cco opse, esp o|o|y|o
c|e, ypoco ce~ o, ype|g'yce~ o| s c| | co 1ee o|e ~o pove~ oe~e||s |o
oc| e ~osogos|c scc| o~, pe |oeo ' ovoge, od~ ~ s|o|o o|o| o o| cs, o
|eopyv | o|e ~ed co| o~s ' coseso|go s|o~e po~ceo| |s, ~~ed o|e e
~ovo o| s|o~es sevee y po| e~|s ~oy ~pove oc|co~e |e ~vosve
|eopes oe eseved|o|sevee'y po|e~|sv ' spec | cco~p co| os , e g ,
ooscess, psecdocys|, p eg~o| .
8. !e |o ' ov g ~e~o~ c ' s|s ~os| o|| ecocses od ossoc o| os |o
po~ceo| | s
BAD PANCREATI TI S CRAS H ES HARD
B i l i a ry di sease (chol edochol i th i asi s)
Al cohol
Drugs/toxi ns
Pancreas di vi sum
Ampul l ary mal i gna ncy ( adenoca rci noma of the
pa ncreas, pr i mary a mpul l a ry, etc. )
Necroti zi ng vascu l i t i s ( l u pus, pol ya rter i ti s nodosa)
Cyst i c f i brosi s
Reye' s syndr ome
E RCP
A t heroembol i
Tra u ma
I nfect i on ( vi ra l , par asi tes, bacteri a l )
TTP
I di opat hi c/i nheri ted
Su rgery ( postoperati ve pancreati t i s, especi a l l y
post cardi opu l monary bypass)
35//O0/l0/OlOQy M l b
--
Croh n's di sease
Renal fa i l u re
Acute fatty l i ver of pregnancy
Scor pi on st i ng
Hyperca l cemi a
E rosi on of duodenal u l cer
Sphi ncter of Oddi dysfu ncti on
H ypert r i gl ycer i demi a
Ascar i asi s
Renal t ranspl ant
Duodenal di verti cul um
186 35llO0/l0lOlOQy
1
R H EUMATOLOGY
Cl inical Symptoms and Signs
AC U T E M O N OA R T H R I T I S
HI S GOUT FI T*
Hemart hrosi s ( coagu l opathy, e. g . , hemophi l i a)
I nfect i on ( bacteri a, [ e. g . , gonococcus] , mycobacteri a l ,
f ungal , Lyme di sease, vi ra l )
Systemi c i l l ness ( Rei ter 's, SLE, r heu matoi d art hri ti s,
psori asi s, sarcoi d, Behget's)
G out/pseudogout
Osteoa rth r i ti s
U l cerati ve col i ti s/Croh n's
Trauma/forei gn body synovi ti s
F i br i n deposi t i on ( pa l i ndromi c arth r i ti s)
I schemi c necrosi s
Tumor ( metastati c, pri mary)
* Differenti al di agnosi s
`otes
1 . Acc|epo odsve g o o | eq. |es ~~ed o|e evo co| o od,
o' ~os|o coses, ~~ed o|e o|~|oce|ess|oc' eoc| ^|ec| o^
//0uO3/O/OQy M 187 .
b
2. !e oge o||e po|e^|, s|oyo'o|e|d seoseosy~p|o~s ,gos|oe^|e | s| ,
|o~ y s|o|y, o^dsexco' s|o|y ~cs|oecoe|c ' yevo' co|ed ys co' exo~ ^o
| o^ s pe|o ~ed |o oo|o s g^s o| ^|ec| o^ , s ^ co^ges| o ev de^ce o|
o|e sys|e~ c ^ess Co^s decc |ce o| |e |oo|, ce| o, o^d ec|c~ ^ ^d
v dco sscspec|ed o|go^ococco ^|ec|o^
3. .xo~ ^e o^| |'cd oygo~s|o ^o^d po ozed g| ' o y, o^d se^d |oo
cc' |ceo^dce coc^|. 'o|~o' sy^ovo'| c dco^|o ^s|eve|o^ I l Jce ' s/~~
,
,
~os| o|v . oe ~o^o^cc eo ' ' c d s cous deed o^ ^|' o~~o|oy | |
co^|o ^sess|o^ JJJJce s/~~
,
As |ece ' coc^| ^ceoses, sodoes|escs
p c o^ o| ^|ec| o^ .||cs o^sv | ~oe | o^ l JJ, JJJ \oC/~~
,
oe co^
s deedsep| c, oc||eesov deo^geo|poss o evo ces Coe|c exo~ ^o| o^
o|| c d|ocys|os ~oyes|oo so d og^os seo|' yo^doov o|e|e^eed|oos
p|o zo| o^ !e pese^ce o|cys|o s, oveve, does no| exc' cde ^|ec| o^, o^d
i f |ee s s| ' o qces|o^ o| ^|ec| o^ , |e po| e^|soc d oeod~||ed |oo^| o
o|cs c^| cc' |c|e esc |s oe ovo oo e , See|oo e ^ ^| o~~o|oy oyo| | s
sec| o^ |
4. A |eqce^|d og^os|c d e~~o ^voves d ||ee^| o| ^g ^|ec| o^s|o~ o|e
occ|e ^|'o~~o|o|yo| | des o|e^|ssoc d oeod~ ||ed |o ^|ove^ocso^| o
o| csv e ovo | ^g cc |ce esc |s `SA s soc d oev |e d ^ | o y|o cdge
|eespo^se|o o^| oo|cso o^e
I N F L A M M ATO R Y
P O LYA R T H R I T I S
AGGRAVATE D SYNOVI AL J TS*
Adu l t Sti l l s' di sease
G out/pseudogout
Gonococcemi a
R heu matoi d a rt hri t i s
Acute r heu mati c fever
Vascu l i t i s
Amyl oi dosi s
Tu bercu l osi s
E ndoca rdi t i s
Dermatomyosi t i s/pol ymyosi t i s
188 /0uO3/OlOQy
Systemi c l upus eryt hematosus
Yersi n i a, Ca mpyl obact er, Shi gel l a ( Rei t er 's)
Non-gonococca l ureth ri ti s ( Rei ter 's)
Over l ap syndromes ( e . g . , mi xed connecti ve t i ssue
di sease)
Vi ra l i nfect i ons ( reacti ve)
I nf l ammator y bowel d i sease
AI DS
Lyme di sease
J uveni l e r heu matoi d a rth r i ti s
Treponemal i nfect i on ( syphi l i s)
Sa rcoi dosi s
^|:o :c|e/ooeoo, po|yoyo|g|o /|euoo|co, p:o/|o::, |o|e:|oo| oypo:: :u/ge/y,
|eooc|/ooo|o::
* Thi s mnemoni c provides the di fferenti al di agnosi s.
`otes
1 . A qc cs o~d eosye| o og c voy|o ooo| ~|' o~~o|oy po yo| | s s os
|o ovs
o ' |ec| o~ d ec| |ec|o o| o ', ooc|e o, syp ' s, !o, e|c |
o Cys|o dcced , go.|, psecdogo.||
c ~~.~o og c, <A, S.:, vosc. | s, e|c}
d

<eoc've ~ espose |o |ec|o~ esevee ~ oody , <e |es sy~do~e,

A S, e|c |
e dopo|c , o~y os ~gspo~dy | s|
2. \ocpo| ~| o~~o|oypoyo| | s ~c' .des
o 'oooo|oys|.d es CoC, :S<, C<~oy e' p d s| gc s ~| o~~o|o|y
|o~~o ~|'o~~o|o|yco~d | os
o Sy~ov o' | c d osp o|o sovoys ~dco|edve~e |eo~ ~|ec|o.s o|
cys|o ~d.ced ~| o~~o|oy o| | s s oe ~g co~s deed `o|~o v scos j s
scc|o|ve~expessed |o~ o sy ge, eoc dop oso o~g |o o s|| ~g
o||oced <oCsoe o| ge~eo ysee syov o | . d exceo| ~o se|| ~qo|
e~o|osso |o.~o
//0uO3/OlOQy M 189
Synovi al Fl ui d Characteri sti cs
`o | uu|oy Cys|u ~occoo 'oc|ocs
A'~|s A|~|s A|~|s
Ap,ouuco C ou .o o, yo ov !co d, opuqco
\

C < 3000 co s/ 3000-50, 000 > 50, 000 co s/

co s/
||oo| u /os'y oo /os|y `/`s /os|y `/`s
cc ouco s
C .coso `ou ,v |~ ~ `ou o ov .ov
1 0- 1 5 g/o
o|socvu cos|
`o|o `ou `o~u o ~g~ g~
\scos|y Cooo, s| g g `oo os| g g `oo os| g g
of | c o
Cys|us `o Yos `o
Cu s|u / `ogu|vo `ogu|vo `os|vo
cc |co
c Spec | seo og c|es|s see<, A`A, co~p e~e~|evos, AS||es, e|c
oyv~e~u spec|cd og~os s sscgges|ed, |'ese|es|s oe ~o'cse|c usscee~
~g |oo s
d <ud ogop~ c|es's c .de
/oys oe ~dco|ed v |~ ~ s|oyo||o.~u, scspec|ed c'o~ c ~|ec| o~,
~o~oo| cc o ~vove~e~|, o pogess ved suo j o| ~| o~~u|o|y
d sodes, | ~d ~gs ~c .dep ~o yso||| sscesve ~g o~d pe o| c. o
de~ ~eo zo| o~. c~o~ cd seuse, o ~| spuceoov g, co c | co
| o~, os|eop~y|e |o~o| o~, ud s.oc~o~do cys|s ~oyoesee~
<ud o~.. descos ~oys~ov ~ceosed cp|oe syov | s, |ec| o~,
o~o g~o~cy s|eo~ecoss~oyoesee~ osdeceused .p|oe
. 1 90 //0uO3/OlOQy

Cl inical Conditions or Diagnoses

CA L C I U M PY R O P H O S P H AT E
D I H Y D R AT E D E P O S I T I O N
D I S E AS E
HOW I GOT BAD CPPD
Hyperparathyroi di sm
Osteoa rt hri t i s
Wi l son's di sease
I ron over l oad
Gout
Ochronosi s
Thyroi d di sease ( hypothyroi di sm)
Bowel di sease ( Croh n' s, ul cerati ve col i ti s)
Acromegal y
Di abetes
Congeni t al hypoca l ci ur i c hyperca l cemi a
Paget 's di sease
Post-tra u mat i c
Di sease resembl i ng r heumatoi d arth r i ti s
^|:o ooy|o|oo:|:, |ypop|o:p|o|eo|o, |e/eo||o/y co|c|uo py|op|o:p|o|e o||y
o/o|e oepo:||oo C||!j
"otes
I . !~eeoe ~c~e|ocs epo|ed d seoseossoc o| o~so|C,opsecdogoc||,
oc||e ~po|oceo|so~e sdeoo|oo e, os go|ocs, co|o'ed s|cdeso|eo|
//0uO3/OlOQy M 1 91
b
ovo oo e oveve, ^po|ec|sv | C, cocs de|o| o^ ~cs| oe g ve^ |o |e
poss o |yo|o^c^de' y ^gd seose pocess
2. ^ecooc|es|c|eo|ceo| |s d seose spo|eo|e~oo o ^|d seosev|
o ^o~o |e~oo /| o o o ^|.
3. Sc|ee^ ^gvocp csco y ^c' cdes!S, co c c~, o^d g ccose 'eve s A'so
co^s de|e|^ o^d cec op os~ ^
C R E S T SY N D R O M E
CREST*
Cal ci nosi s cuti s
Raynaud's syndr ome
Esophagea l dysmot i l i ty
Scl erodactyl y
Tel angi ectasi a
* The mnemonic presents cl i ni col characteristics.
`otes
1 . A^| cec|o~eeoc| ood eso|e seec ^ o g pe|ce^|ogeo|po| e^|sv |
C<:S!, oc||ev po|ec|sv |sc eode~o/sys|e~ csce|os s
2. Cal ci nosi s cuti s desc oes egc' o| cc|o^eocs popc ' es |o|oe | ~ o^d
v |e
3. Raynaud's phenomenon ^voves ep sod cvosococs|| c| o^o| |es~o' ' o|
|eesocdo||e o eso||e d g |s ! gges ^c cdeco d, v oo| o^, o^ds|ess A^
^ | o vosococs|| c| ve eve^| ' eods |o ||||:| po ' o ^ o||ec|ed o|eosossoc
o|ed v | |ese^so| o^ o|co dcess, | ^g' cg, o|po ^ A cyo^o| c , o|ue| pose
~oyoccc, o^d|eep sodeeve^|co yesovesv|o pe| odo| eoc|ve ype
e~ o , /eo|
4. Esophageal dysmotil ity ~oy ~o^ |es|osdyspog o, eo|oc c, |egcg|o
| o^, ocd/o o se^so| o^o|ep gos|| c|c' ' cess
5. Scl erodactyly ^voves |oc|, | cced ss ^ ove|ed g |s, v c ~oyo||ec
oveo |opeed oppeoo^ce. |eve^|co' ' yeods|od ~ c sed o ^|~ove~e^|
6. Tel angiectasi a |eo|cesscpe| c o cc|o^eocscop oy ~o'|o|~o| o^s
1 92 //0u/3lOlOQy
d
OS T E OA R T H R I T I S
I GOT MR . PAI N, DOC*
I di opat hi c pr i mary osteoa rt hr i t i s
Gout
Occupat i onal /sports
Trauma, acute/f ractu re
Met abol i c ( hemoch romatosi s, Wi l son's, Ga ucher 's,
och ronosi s)
R heumatoi d arth r i ti s
Psor i ati c art hr i t i s
Acromega l y/endocr i ne ( hyperpa rathyroi di sm, DM,
obesi ty, hypothyroi d)
I nfect i on
Neu ropat hi c
Devel opment al ( Legg-Ca l ve-Pert hes, congeni t al hi p
di sl ocati on, etc. )
Osteopetrosi s/osteochondri t i s
Ca l ci um deposi t i on di sease
* Differential di agnosi s
`otes
s|eoo|~ | s ,A| so d seoseo|po|~o ogyo| ~ovoo e, syov o o |s ' | s
syoy~ocsv|~degeeo|ve o |d seose
Heberden's nodes oe ooye oge~e|s o| |~e d s|o' |e|p~o ogeo o |s
!~eyoe |~e ~os|co~~o|o~o| d opo|~ cos|eoo|~|| s
Bouchard's nodes oe ooy e oge~e|s o| | ~e p|ox ~o' |e p~o ogeo
o |s
,
1 . CA ~oy oe c oss | ed os p ~o|y osecodo|y |/|oo

A occcs |~e
ooseceo|o de| | oo e cde y g e|oogy 'econoo

A sdce|oo c
de' y gcod | o od seose
//0uO3/O/OQy M 193
M
2. 'oco| oso|A
o ' ~|e|p~o' ogeo' o |s eoe|de~sod oocc~ods ~odes
o ' p ~os|coses o|e seco~doyod dce |o co~ge |o odeve op~e~|o
de|ec|s
c ~ee
Vo|Jsde|o ~ |y , oov egged|dce|o ~ed o co~po||~e|A
Vo' gJsde|o|~|y, ~oceed| dce|o o|e|o co~po|~e~|A
Ccond|ooo' oc| o, o sydo~eo| ee po , csco y occcs ~yoc~ge
po|e|so~d so| geeo ypogessve|o|ceA
d Sp ~e
5pondy' os| sdege~eo|ve o:| d seose
D| ||Jse | d|opo|c| csse|e|o| cype|os|os| sco c | co| o o~d oss | co|o~
o|poosp~ocs ' go~e~|s
Csleoo|lc || l| so|lce sp| nedege~eo| o o| ~ovoo' e, syov o' ~ed
sp ~o' o |s
3. C co s gso~d sy~p|o~s
o o ~~osg|odco ose|, dc oc~ g |o ||e~de~ess od po ~occc v|~
o~ge o|~o| o~ .
o ^o~ ~gs|||~ess s o|po~ e|, os ~ ~|o~~o|o|y |~ec~o| cd seose
c Cep |cs so g ~d ~gsoc~doseso|o ~eod o|e|os o | s~oved
d |o |e oge~e|~oyoe dce|oso||sscesve' g/e||Jsooos|eop~y|es
e |o | de|o~ l,, scc~oseoede~so~doocc~ods odes, vocso|vo' gcs
o~gc o| o
4. \o|cpo|A
o /|oys o|o||ec|ed o ~|s~oyoe o~o' , o| s~ov o | spoce oov g,
scoc~|o~do' sc'eoss, scoc~od|o cys|s, od ~og o os|eop~y|es
o <o

| ~e oooo|oy|es|s ~e p de| |y cocses o| seco~doyA, ~c' cd ~g

:S<, CoC, sec~ c~e~s|es, c o ys s
c Syov o | c d ~ d ecocy|os s , zJJJ \oC/~ , < zo7 '^`s| , o
c|ys|o s, good ~cc ~c o|.
5. Cco|colj o| nlssecodoyAdce|o c~de' y~g ~eco' ogc d seose
R H E U M ATO I D AR T H R I T I S
R F RI SE S
R heu matoi d factor el evated
F i nger/hand j oi nts i nvol ved
1 94 //0uO3/OlOQy
R heu matoi d nodu l es
I nvol vement of t hree or more j oi nts
Sti ff ness, mor n i ng
E rosi ons/decal ci f i cati ons on X-rays
Symmetr i c ( bi l ateral ) arth r i ti s
`otes
<~ec~o|o d o|~| | s , <A| so c~o^ c ~c |sys|e~ d so|dec~o|oc|e|zed oy
|' o~~o|oy o |d seose, csco ysy~~e|| c
1 . og^os|cc |e o
o oco||~eseve^ c|e o ooove oeeeded|od ogose <A
o. o|e|sv|~|voo ~oe o|~e|c ^ co d ogoseso|e oo| exc cded
2 . :' evo| o~ o|se|c~ rheumatoid factor co^ oe de|e~ ed oy oy~e|~od
|~o|~os< o7|o' sepos | ve |o|e
3 . Fi nger/hand j oi nt i nvolvement ^c cdeso||~| | cc~oges ^ |~e v s|od
| ~e~e|ocopop~o' ogeo ,^C|opox ~o' ~|e|p~o' ogeo' , ' | o |s
4. Rheumatoid nodul es oe | ~, |ocd, scocc|o^eocs ^odc' esove| ~e o ^|s,
ex|eso|sc|oces, o ooyp|o~ eces !~eyoe see zJzo7o|po|e^|s
5. ^c | p e o ^| ^vo've~e^| , o||~eeo ~o|e| |e|es |o so||| ssce sve ^g o|
o |e||cs os, o| cs|os|eop~y|es oc|ee poss o' eo|eosoe desc| oed g~|
o|' e|| p|ox ~o' |e|p~o o^geo' , ~e|oco|pop~o' ogeo' , v| s|, e oov, ee,
o^s' e, od~e|o|orsop~o' o^geo' o ^|s
6. Morni ng stiffness sde| ^edoso o | s|||esscpo^ovose ^g|~o|pe|ss|s
l ~oc|oe|oe~ox ~o' ~p|ove~e|
7. <od og op~ c| d ^gs ~o^d o~d v s| xoys ~cs| ~c' cdeerosi ons o
oo^ydeco c | co| o ood oce^|| oo||ec|ed o ~|s
8. Symmetry ~eoss ~c |oeocs ^vove~e^|o||~eso~e o ^| o o|e|o y.
9. S g^so^dsy~p|o~s
o |o ^| ~o|es|o| o^s
e^eo zed po , o |sve g, e||cs o~, vo~|~ , o^d ' ~|ed o^ge
o|~o| o~
Cev co' sp ^e ~os| se ocs s o| o^|oox o sco cxo| o^ ^oy cocse
eve oo| ~p ge~e|, sp o' cod sy~p|o~s, o| eve ' ove oo ^
s|e~ p|oo' e~s
C coo|y|e~o d o | ~po svoco cod ~oo |y, cocse~ooseess.
S~oc de sy^ov|sod o|o|occ|| cy
: oov ~ec~o|o d odces o ex|e~sosc|oce o| |oeo~ eod |o oe
coo oc|s| s
o^d/v s| |yp co ' yd s|o' |e p~o' o^geo' , | o |s o|e spoed.
Swan neck deformity s |'exo o| |~e ' o~d^C o |s o^d ~ype
ex|es o~o||~e o ~|s Boutonniere deformity s ~ypeex|e^s o
//0uO5/O/OQy M 195
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b
v|~ |ex o~ Carpal tunnel syndrome s ~o| .~co~~o~ Ul nar dri f
so de|o~ |yc~o|oc|ezed oy |' exo~ oddev o| o o||~e | ge|
|ps|ovod |~e c ~o
p ~oy~o 'es'v ' ~go po Sevee vo ve~e~|s oe, o7|
ee veyco~~o Boker's cyst so pos|e o ~e~o|o o|sy~ov .~
o~d| . d|o~ |~e ee ~|o |~epop |eo |osso
A~ e/|oo| Co~~o~ ~ oo|~ o~ e od |oo| Cock-up toe de|o|~ |y
occcs o||~e ~e|o|osop~oogeo

o ~|
o Sys|e~ c ~o |es|o| o~s ~c cdeve g~| oss, |o| g.e, oc~ ~ess, o~oex o,
~o o se
c |~eogo~ vo ve~e'
<~ec~o|od ~odc es see ~c~oe|^, pev ocspoge
:ye~o~ |es|o| os Si cca complex soc~ ~g, g| ||yeyeseso| o~, dy
~oc|~, odso voyg o~de oge~e~| :p sc e | so~dsc e | s ~oyo so occ.
Cod oc oe y c ~ co y s g~ |co|, o.| ~c .de pe cod | s o~d ~
|o~~o'oygo~. o~os
v

c ~o~oy p ec| | s, p ec|o e||cs os, ~|es| | o' | oos s o~d odces
Copl on's syndrome cos s|so| |es| | o | oos so~d ~c| p e~odc'es.
v. `ecoog c e~|op~e~| ~e.opo|~es , copo |c~~e | , occos o~o vos
cc | cco~p co| o~s
v e~o|o og c o~e~ o, |~o~oocy|oss , oJJJJ , ~ d ' ecocy|o
s s Fel ty's syndrome s o co~o o| o o| <A, | ~o~oocy|ope~ o, ecope~ o,
o~dsp e~o~egoy
v \osc. | s cc|oeocs, ecopo|~ c, o v sceo vo ve~e| v | ~ s
c~e~ cco~p co| o~s
1 0. ogos|cvo.p
o CoC~o~oc~o~ c, ~o~ocy|c o~e~ o Aso |~o~oocy|os s, e evo|ed
:S<, c|eosed ' g, o~deve~ eos op~ o
o <~e.~o|o d |oc|o pos | ve ~ JoJ7. `ospec | c A`A pos | ve
, zo7o|po|e~|s| o~d\<.|o sepos|ve , ol J7|
c Syov o | . d \oC oJJJzo , JJJ, ~os| y ^`s .cose ov o~d
co~p e~e|eves ov `ocys|o s
d /oysopp|ox ~o|e sy~~e|c ~vo've~e~|, os|eope~ o/deco c | co| o,
so|||ss.esve' ' g, oo~y eos o~s, o ~| spoceoov ~g
1 96 //0uO3lO/OQy
t
SYS T E M I C S C L E R O S I S
( S C L E R O D E R M A)
SCL E ROD E RMA*
S ki n changes
Ca rdi ac i nvol vement
L u ng i nvol vement
Esophageal dysfuncti on
Raynaud's phenomenon
Obstruct i on, pseudo
D ry eyes/mouth
E ndocr i ne ( hypothyroi di sm)
Renal fa i l u re
Myopathy/myosi t i s
Arth r i ti s
* Cl i nical characteristics
`otes
1 . Ski n changes c cde eo ysve ~g, po| c. o yo||e | ges od ~o~ds
.o|e, s oeco~es | ~od | ce~ed C~o~ co y, s ~ oeco~es | od o|
op c. S ~ ove |e | ges oeco~e |o.|, o~d co~|oc|ces ~ | ~ove~e|
|~ec.|oeo.s ~o~ |es|o| os c cde|e o~gec|os o, scoc.|oeocsco c |co
|o~s, so|odpeppe p g~e~|oycoges, ooo~o ~o oed cop o es, o~d
s c ces
2. Cardi ac i nvol vement c cdes pe cod | s, pe cod o e||cs o~, eo||o '
ce, odeo|o oc/ oy|~ o ^yocod o | oos sco.s ~gcodo~yopo|y
occ.s ~< I J7
3. Lung i nvolvement occ.s ~|vo| dso| po|e~|so~d so||e~ ~o~ |es|ed oy
exe| oo dysp~eo o~ddy, o~p|od.c|ve co.g Add | oo co~p co|os ~
c cde p.' ~o~oy | oos s, osp o| o pec~o o, deceosed v|o copoc |y, od
deceosed cg co~p oce . ~o~oy ype|es o |eoosece o|| oos s
coocc.| ~ < l J7
4. Gastroi ntesti nal dysmoti l ity s e o|ed | oeco~cscc o dys|c c| o~ !~ s
~oy~o~ |es|os eo|oc| , dysp~og o, |e| cx/egcg |o| o, de oyed gos|| c
//0uO3lOlOQy M 197
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b
e~p|y ^g, o' oo| cg, oodo~ ^o' po ^, o^d psecdooos|cc| o^ ooc|e| o' ove
g|ov| co^ eod|o ~o' oosop|o^ sy^do~e
5. Hypothyroi di sm ~oyoccc o^d s dce |oe |e| o^| |~yo d o^| ood es o
| o|os s
6. Renal fai l ure ~oyoccc ^s d ocs yo oso e^o c s s <e^o c s s s co
oc|e zed oy ~o g^o^| ype|e^s o^, ype|e^s ve e^cepo' opo|~y, sevee
~eodoce, e| ^opo|y, se zces o^d e||ve^| cc o |o ' c e !~ socccs dce |o
ove|oc|vo|o^ o||~ee^ ^o^g o|e^s ^sys|e~ <e^o |o ' c|e s|~e' eod ^gcocse
o|deo| ^ sys|e~ csc'eos s
7. ^cscc o e||ec|s o|sc eode~o ^c cde d s.se o|opy, ~yopo|~yv |~o.|
e^zy~eoo^o~o' | es, o^d, oey, o po'y~yos|s'\esy^d|o~e
8. o'yo|~| |s s~o^ |es|ed oypo ^, sve' ' ^g, o^d s|||^esspo| cc' o y ^|e
o^ds, | ^ges, o^d ^ees ^~oe|~o^ oJ7o| po|e^|s !e^do^seo|~|ooss
~oyoeco~eo p|oo e~, o^dco^ eod|ocopo |c^^e sy^do~eve^ | occcs
^ |~ev| s|
SYS T E M I C L u p u s
E R YT H E M AT O S U S
ORDE R H I S ANA
Oral ul cers
Rash ( mal ar)
D icoi d rash
Exaggerated photosensi ti vi ty
Renal di sease
Hematol ogi c abnormal iti es
mmunol ogi c abnor mal i ti es
Serosi ti s
A rthral gi as/a rthr i t i s ( nonerosi ve)
Neu rol ogi c di sease
Anti -n ucl ear ant i body
198 //0uO3lOlOQy
otes
1 . !~e d og^os s o| S.: depeds c po~ |~e pese~ce o| |oc o| ~oe o| |~e
ooove l I c |e o !ed seose, ~oveve, ~oy ^vo'veo~yogo~sys|e~
2. !~e| ~d ~gso| oo c' ce|s, ~o o os~, d scod os~, exoggeo|ed p~o|ose^
s | v|y, o~d o|~| | s oe oo|o ^ed oy ~ s|oyo~d p~ys co exo~ ~o| o^ . 'eco
og cc |e o ~c' cdese zces od psyc~os s , ^|~eoose~ceo| o|~edcgs o
pec p|o^|s| <e~o d seose sde| ~ed os pess|e~| p|o|e ~c o oce c o|cos|s
Seos|s ~oy oe ~o^ |es|ed os p' ec | so| pecod | s ' ~~c^o'og c c |e o |o|
d og^os s ~c cdeo pos|ve ': ce p|epoo| o^, o~| `Ao^| ood es, o^|S^
o~| ood es, oo |osepos|ve se|o ogc|es||o|syp s e~o|o' og cc| |e o ~
c cde~e~o y| co~e~ o, ' ecope~ o, y~p~ope^ o, o||~o~oocy|ope^ o
3. |e ~o^ |es|o|o^so S': ~c cde|eve, po~ceo||s, epo||s, e| ~o' dseose,
~yocod o dseose , ~yocod|s, e~docod | s|, gos|o ~|es| ^o d seose, pc' ~o~oy
d seose, d ||cse ~| ||o|es, voscc' | s| , o^d coogc opo|y, ' cpcsoc| coogc o^||
VAS C U L I T I S
WHAM! ANGI I TI S *
Wegener 's gran ul omatosi s
Hypersensi ti vi ty vascul i ti s ( Henoch-Schbnl ei n)
Associ ated wi th systemi c di sease, r heumati c di sease,
neopl asm
Mucocutaneous l ymph node syndrome ( Kawasaki 's)
Al l ergi c angi i t i s ( Churg-Strauss di sease)
Nodosa, pol ya rteri s
Gi ant cel l arter i ti s (tempora l a rter i ti s)
I atrogen i c/drug-i nduced
I nfecti on
Ta kayasu's arter i ti s
I sol ated CNS vascu l i ti s
Ser um si ckness
* Di fferential diagnosis
//0uO3/OlOQy M 1 99
`..
\oscc' | sso d sodec~ooc|ezed oy | o~~o| oo^ddo~oge| oo'oodves
se' s, o||e esc | ^g sc~e~ o |o | ssces scpp ed oyo||ec|ed vesse s '| ~oy
occcoso p ~oy ~o^|es|o| o o|d seoseo ^ co~o ^o| ov|~o|~epo|~o
' og c pocesses, od ~oy oe ~ |ed |o oe ogooo||ec| ~c| p eo|gos.
1 . Wegener's granul omatosi s voscc | s csco y o||ec|s :oo|| vesse so^d s
c' oss co 'y ossoc o|ed v | cppeo^d ove| |esp o|oy|oc| vo ve~e|o^d
g' o~ec' oep~ | s,see\ege^e|s sec| o|
2. Hypersensitivity vascul i ti s so oood gocpo|d sodes oe eved |ooedce
|o oeoc|o |o o po| cc o,edogeocs oexogeocs| o^| ge o^d vo v g
:oo|| vesse s
o e^oc~Sc~o' e ^ pc pcopo' poo e pc pco , csco' y o oc||ocs od
ove ex|e~ | es| , o| | o' g os, ' sy~p|o~s, od g o~e c' oep~| | s ^oe
co~~o ^ c~ ' de
o Associated with other primary diseaseso||e coec|ve|ssced seoses
, S. :, <A, S oges sydo~e| , ~o g^oc es , y~p~o d o e| cc oe^do|~e o ,
~o yce ece~ o| , o| o|~e ^esses,cyog'ooc' e~ o, p ~oy o oyc |~os s,
o p~o, o| |yps de| c ecy, c ceo|veco | s, o^d |es| ^o oypossscgey| .
c. l atrogenic/drug-i nduced-peni ci l l i n o^d sc' |o ~oy ^dcce o sec~ s c
ess se eoc| o
d I nfecti on scoocc|e ooc|e o' edocod | s, :ps|e ^Hov cs, ~epo| | s
e Serum si ckness |eve|, c | co| o, o||~ o g os, od y~p~odeopo|~y
I J doyso||ep| ~oyexposc|eo|z^doyso||e|secodo|yexposce|o|o
e g^ p|o|e ^
3. Mucocutaneous l ymph node syndrome , ovoso s| occ|e, |eve, cev
co' ode^ | s, co c^c|vo ede~o, oo gco o^d po ~o ey|e~ o, | ge| p
desqco~o| o, occcs c~ ' de oge s o|e| deve op~e^| o| cooo|y
o||eyo^ecys~s !eo|v | ' \ ~~cog ooc odosp | ^
4. Al l ergi c angi i ti s , CcgS|ocss| s co|oc|e|zed oy ~ype|eos ^op ' o, o' 'e
gc |s/os|~o, o^d :oo||oeo|uo vessevoscc |s ^vov ^g|voo|~oeex|o
pc' ~o^oys |es
5. Polyarteritis nodosa , /`| :oo||oeou vesse' o||e| | s ^vo v g ~c | p e
ogo^sys|e~s, ^c cd ge^o , J7| , ~csccosee|o ,^7| , pe p~e|o ^e|vocs
sys|e~ , o l7| , |oc| ,^^7| , ss , ^J7| , co|d oc, J7, ge |oc| oy , zo7| ,
odC'S, zJ7|
. 6. Gi ant cel l arteritis ,|e~poo o|e | s||o/ge vesse' o|e | s ossoco|ed v |
|eve, oe~ o, ~eodoc~e, ode evo|ed :S< 3sco 'y e de y po| e| oge
sdeve' op~e^|o|o~oc|os s|cgoxo^d e| o' sc~e~ o ogosed c ^ co y
o^dco^| |~ed oy|e~poo'o|e|y o opsy !|eo|ed v|~ ped^ soe
7. Takayasu's arteri tis oeouoIorge vesse' o||e | s, ~o|e pevo' e^| ^:os|
I
As o, o^d ~oe e y ^ |e oo|coc~o|sd ec|ooc~es ^o |es|o| o^so|e

csco' 'y sc~e~ o d s| oc| oo|o||ec|ed o|ees , ^c' cd ^gceeoo ^|o|c| o^|
i
_ Z //0uO3/O/OQy
8. I sol ated eNS voscJ| | | | scsco 'y o/|e/|o|||:, oc|o^ys ze vesse' ~oy oe o|
|ec|ed ' og^osed oy o^g og|op~y o^d o|o ^/~e^ ^geo o opsy Assoco|ed
v|~ ^\, syp~ s, ooc|e o, vo ce ozos|e v cs, odg ^s d seose, o^d o~
p~e|o~ ^eoo.se
WE G E N E R ' S
G R A N U L O M ATO S I S
L UNG H EAO*
Lu ng/pul monary vascu l i t i s
Upper respi ratory t ract di sease, si n usi t i s
Neuropathy, crani al or pr i pheral
Gl omer ul oneph r i ti s/renal di sease
Hea rt i nvol vement
Eye i nvol vement
A rth r a I g i as/a r th r i ti s
Dermatol ogi c l esi ons
Cl i n ical characteristics
`otes
1 . oss cc ^ co pese^|o| o^
o Jppeesp o|oy|oc| ^vove~e^| s ^cs | s, ^oso do ^oge
o. 'ove |esp o|oy |oc|/pc' ~o^oy ^vo ve~e^| cocg~ , e~op|ys s,
dysp^eo
c. <e^o ^vo ve~e^| g o~ec o^ep~ | s, po|e ^c o, e~o|c| o
2. `eco og cs g^s/sy~p|o~s occc ^ zz7 o| po| e^|s o^c o~o|ocs ^
vove~e^|o|co^ o' ^eveso~o^o^ec|s~c' | pexdce| ovoscc' |s~oyoccc|
.ess e' y s`Svoscc' |so ce|eoo go^c' o~o
3. od oc ~o^ |es|o| o^s , z7 o| po|e^|s| ^c' cde pe| cod | s, coo^oyvos
cc | s, o|, oey, co|d o~yopo|~y
H/0uO3/OlOQy M Zl
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b
4. p~|~o ~o og c vo ve~e|s|o |' yco~~o^,J7j co^ cc| v | s, ep sc e
| s, sc' e| | s, cve | s, voscc | s, od/oe|ooo|o ~oss|esc | ^g ^ pop|os s
5. |o ^|eo|ed sy~p|o~s c cdeo||~o g os/ o ^| po , cp|ooJ7| 1|ce sy
ov|s s oe
6. Cc|oeocs ~o |es|o| o^s o| \egees oe see ^o7o|coses od
c cdepopc es, vesc'es, pcpc|o, c ce|s, oscocc|oeocs odc' es
7. A ~po|o^|d ogos| cd s| c| o s | ~o| oe|veec \ege^e|s od y~
p~o~o|o.sgo^c o~o|os s \~ e |~e|o~e| s o ~c'|sys|e~ ^|o~~o|oyvos
cc | s, |~e o||e s o d ||cse ^| |o| o^ o|o| yp co y~p~ocy|o d ce sv~ c~ s
see^ ^ |~e cg, s , C'S, o^d dey .y~p~o~o|oss evoves ^|o ~o go|
'y~p~o~o ^oJ7o|coses, v~ e\egee|sdoeso|
202 //0uO3/OlOQy
J
E
NE UROLOGY
!~e ey |o o good d ||ee| o' d ogos s s |o s|o|v |~ o oood, o c .s ve
d ||ee| o oosed o '~e ~o opo |s o||~ecose od oov | dov og co 'y
|o o s~o e, vo gd ||ee| o oosed o |~e spec|cso| |~e cose | |~e po
| e|s s gs/sy~p|o~s oeco~e o|yp co , o ev |o~o| o oeco~es ovo
oo e, yo. co go ooc|o |~e oood d ||ee| o , |~ svoy, yo. v o| ~ ss
. .s.o pese|o| os o|d seose Cos deo oJyeood ~ov |~ ~ype|e
s o, d ooe|es, od ~ype p de~ o pese| gv |~s|oe |~eexpodedd ||e
e| o s~o. d c .deo ' co.ses o|s||ose, o.||~e vo g d ||ee| o' 'eo|.es
u|~eo|~ o~oo| c d seose, ~e~o~oge, od e~oo s~ os e y e| o og es |
| ~eC!sco s~ovs o ~oss es o^, | ~eyo. d oe||e e|. | o| ~eoood d ||e
e| o' |o c .de|.~oodoo ooscess | |~e po| e|deve opso |eveod s
|o.d |o ~ove o sed ~e|o| o o|e o| l JJ, |~e~ yoc s~o. d e|. |o |~e ex
,oded d ||ee| o od e|evevosc. | sod |ec|o |oodd |oyo. vos g
d ||ee|o'
\ |~o.|o co~pe|e | o d ||ee| o d ogos s, o o e|. |o |~e | o d |
|ee| o v~e o |ypco' cose oeco~eso|ypco , yo.v ~ ssd ogoses
General Considerati ons
H ow to Make a Broad Di ferenti al Di agnosi s
esp|e| ~es|eeo|ypeo| e.o ogyos o ~ys|e o.s od ocoe o oc oox,
|~ee oe seveo e||ec|ve ~e|~ods |o ~e poy p~ys c o ~oe o co~pe|ed |
|ee| o d ogos s|o e.o og co d seose
Diferential by Etiology
!~e ^: C' `: C ~e~o c s o .se|. s|o | g p' oce |o deve op o
co~p' e|e e.oog cd ||e|e| o d ogos s !oevev
N0u/OlOQy 203
b
Me|ooo' c d seose , e g , ~e|ooo c e~ceo oo|~y, ecodys|o~y,
\ so~sd seose|
c~doc| ~e d seose , e g , d ooe| c ~ecoo|~y, ~yxede~o co~o, yo
g yce~ cse zces|
D.gs/~ed c ~es, e g , o|oge~ c, occde~|o , se'|od~ ~s|eed|
' ~|ec|o~s , e g , ~e~ ~g | s, eese~ceo | s, \de~e~| o, ~e.|osy s|
Co~ge~ |o oo~o~o |es , e g , s ~o o | do, C~ o ~o |o~o| o~s, ~.sc.
'o|dys|o~y|
| ~~.~o' og cd seose , e g. , vosc. | s, ~yos|e~ ogov s|
Meo os~s, e g , ~oy|.~os, ~e|os|o|cd seose|
cxo| c , s|o~ge d seoses o|c ~ce|o ~e| o' ogy, e. g , ~c | esc' eos s,
Cc ' ' o ~oo|
Dege~eo|veocesses , e g , A' z~e ~e|s, o ~so~s|
Ccc.o|o~o exos.es , e g , e~v o~~e~|o oocc.o| o~o |ox ~s, |o.~o|
Cod ovosc. o, e g , ~|o|c| o~, e~ooge, e~oo s~, o~e.ys~, o|eo
ve~ocs ~o' |o~o| o~|
Di ferenti al by Anatomy
A de|o ' ed .~des|o~d ~g o| ~e.oo~o|o~y, o |~o.g .se|.' ec se y o
co z ~g es o~s, ~o ~| ~gd og~oses, o~d ~ess ~g/oo ~gco eogces
d.| ~g |oc~ds, s~o|eq. ed|o~oe ooscd ||ee~| o s !~es ~es|~e|~ods
|o s|o| o| |~e ~.sc e o~d vo ooc o~o|o~ co y |o |e ceeoo co|ex
:xo~'eso|o~o~o|o~ cd ||ee~| o |o| veo~ess oe o|e~|~eses
l ^.sc e, o'y~yos|s|
z `e.o~.sc. o| .~c| o~ , ~yos|~e~ o govs|
J e eo' ~e|ve, Cc ' 'o ~oo|
^ `eve ex.s, ooc o o~yo|oy|
o `e|ve oo|,d sce|~ o| o~|
^e~ ~ges/s.oo|oc~~o dsoce, ooc~o d | s|
S ~o' cod , s ~o cod|.~o||
o oo|~s|e~ , o~| ~e ~|o|c| o~|
- S.oco| co' s||.c|.es ooso' go~g o, |o o~.s , ' oc.~o ~|oc| o~ ~
|e|~o cos. e|
l J Co| co' s| cc|. es ceeo c ~, ceeoe' .~ , ~ dd ece|eoo' o|ey
~|oc| o~|
H ow to Make a "Worki ng" Di ferenti al Di agnosi s
Lsse~| o ~|~edeve' o~e~|o| o .se|c vo ~g d||e|e~| o' d og~os s s|o ~g
c| | cco' c~o|oc|e|s|cs|o~|ecose ~o~|o~d cs~g |e~|o o|ovdov~|~e
oroodd ||ee~| o ee ~ es|eo| o|d og~os s ov do yo. \~ov ve~ o
c| s|o
/
o|oco~o oo.se se' |c ~ ~o\ ~g|ed og~os so|o' co~o' v |dovo
20 . N0u/OlOQy
sezc|e, os ~p' yo ed ~e| g d s|oc| gyoc |o~ |~e coec|d ogos so|
~e g | s- ||~ gsdo|| |, go ooc| |o ||e o/ooo o||e/eo|o| ^oesce o|~
g ~os oee oveooed
Di fferential by Time Course
~oyd seoses, od po| c. oy e.o og cd seoses, |~e|~eco.seo|
sy~p|o~o|oogy sc||co |o |e ge|y oovg dov|~ed ||e|e| o ||e|e|
e| o og es oe scgges|ed oyd ||e|e|| ~ecoc|ses |e ~ ||e|sy~p|o~sv |~
co~p e|e |eso' c| o oe|vee ep sodes voe o d ||ee|se|o|d ogoses |~o
c~o c, godco y pogessvesy~p|o~s A ~ s|o|y o| ~eodoc~ev |~ o.seo
odvo~ | g~ g~| oedce|o ~ go e o po| e|v|~|~e|s|| ~ecocse, oc|
|~esecodcocse s ~o|ecos s|e|v|~ o oo |.~o |o so s poss o e|oo
~ s|oyo|ep sod c sy~p|o~s |o oe god.o y pogessve , s.c~ os cescedo
|os e| sc~e~ co||ocs| !oe o coe|c ~ s|oyo||~e| ~ g o||~esy~p|o~s
A good ~ s|oyo||~e| ~ecocse c cdes o|oy v~e|~e|~esy~p|o~s
o|e |e ~ ||e|o co| .ocs, oc| o so |~e |o ov g |o~o| o v~e|~e |~e
sy~p|o~sveemox ~o o| ose|, op d y p|ogessve, opogess g o s|ep
v se|os~ o, v~o||oc|o|s exoce|oo|e/pec p |o|e sy~p|o~s odv~o||oc|o|s
o~e oo|e sy~p|o~s, | epsod c, |~e d.o| o od |eq.ecy o| |~ecp sodes,
od |od v~o|odeossoco|ed sy~p|o~soccc
ee s o gee|o ovevevo||~e |e o|os~ poe|vee | ~eco.se od|~e
ose|o| | o sy~p|o~sod e| o ogy
HYPERACUTE
(seconds-mi nutes)
ACUTE SUBACUTE
( mi nutes-hours) ( days-weeks)
Hemorrhage
f----------------------------------------------------------
I schemia *
f-------------------------------------------------------------
Seizure*
f-------------- --------- - - - - - - - - - - - - - -)
Trauma
f- ---- ---------------- - - - - - - - - - - , - - - - - - - - - - - - - - . - - - ,)
I nfarction
f-------------------------------------------------------- - - - - - - - - - - - - - - -)
Mi grai nous*
_- - - - - - - - - - - - - - - - - f----------------------- - - - - . - - . - - - - - - -)
CHRONI C
(weeks-months)
Toxi n
(- - - - - - - - - - - - - - - - - f------------------------------------------------------- - - - - - - - . - - - - .)
Metabol i c
(- - - - - - - - - - - - - - - - - f----------------------------------------------- - - - - - - - - - - - - .
)
I nfection
f------------------------------------------------------------------------------
I nfl ammatory
(- - - - - - - - - - - - - - -f---------------------------------------------------
Neoplastic
1- - - - - - - - - - - - - - f--------------------
Compression Inontraumatic) (
- - - - - - - - - - - - - - f- ------------------
Degenerative
f-------------------
* Denotes etiol ogies that are parti cul arl y l i kely to cause i ntermi ttent symptoms with complete
resolution of symptoms between episodes
Di fferential by Age of Patient
| s ~e p|c od ~po|o||o oov |~e d ||ee| o d ogoss oosed o |~e
ogeo||~epo| e|. A occ|e eco og cde| c | ~os o e| e yd ||e|e| ' s| o|
e' ye| o og es o -Jyeoo d| ~o | does o zJyeoo d geeo , co
ge |o' , |oc~o| c, ~ go ocs, od |ec| ocs e| o og es oe ~oe ||eqce|
N0ulO/OQy 205
yocge|po|e|s de| po|e|s o|e ~o|e ' se y|o ~ove sy~p|o~s eo|ed |o s
c~e~ c, eop os| c, c~o cco~pess o, o|degeeo| ved seoses
Di fferenti al by Neuroanatomi c Local i zati on
!~e~os| oos cd s| c| o e.|ooo|o~y sv~e|~eo es o soco|ed
|~ece|o' evo.ssys|e~ ,|~e oo odsp o' codjo |~e pe p~eo evocs
sys|e~ , pe p~eo' eves, e|ve oo|s, e. o~.sc. o .oc| o od ~.sc e|
So~e c co exo~ o| o | d gsoe .se|. ~o g | sd s| c| o |~e
exo~p'e oeovd ogoses s.gges|ed oyo g ve co~o o| oo|exo~| d gs
ode.|o og c oco zo| ooe poe|~eses
Factors Di sti ngui shi ng Location of I nj ury
C`S ``S
.xo ' d g , oo /sp o codj , eves/oo|s/`/|/.sc e|
Cranial Nere Exam
\sco' 'oss e'd cc| ,occp|o' |o|c|j /ooc. ooss ,e|oo|ey
occ' .s oj
p|cdsc `oo o o o|eo /oyoeooooo oesde
oooo |y, ceosed oy,op|c e.'sj
|ocoo' pess.ej
ocoveoess oe~eodspoed ,|o|o' 'oe~eodveo,

e sposyj
|o|c|j
Motor Exam
/.sc'e|oe Ac.|ey deceosed, 'o|e eceosed
ceosed
A|op~y Aose| Ac.|eyoose|, 'o|e pese|
'osccc'o|os Aose| Ac.|e'yoose|. 'o|e|pese|
eep|edo e|'exes Acc|ey~ypooc|ve
.
o|e ypooc|ve
~ypeoc|ve

oo s /oyoepese| Aose|
C o.s /oyoepese| Aose|
,~c | p esce|oss, cee ,|odc. opo|~y, ecopo|~y,
oo |oc|, |oco o ~yopo|~y, yos|~e oj
oeed, o|o |.o,
sp o' cod c|yj

o|~ cppeod ove ,oy||op~co|eo'sceoss

~o|oe.o s gs A.S|,cevco's|eossj
Di ferenti al by Ri sk Factors and Coexi sti ng
Medi cal Condi ti ons
^o gO d ||e|ec| o' d ogos sso e' yoc |~e oos so|| s|oc|o|s s|oo
~o|dy, |o soy|~e ' eos|. oveve|, | ss|oc|o|s scc~ osecv |o~e|o' exposces,
~ed co| os, dcgs/o co~o' , od coexs| cg ~ed co' cocd | ocs o|e ~e p|c'
206 N0u/OlOQy
o||ov g dov |o o good vo|^g d ||e|e^| o' . oexo~p' e, d ooe|es, ~ype
|es o, o| o | o o| o, od s~o ^g o|e o s\|oc|os ossoc o|ed v |~cee
oo |oc| o^. '|eex s| ^gco^ce ~ g~| scgges|seveo s |oc|o|s, c' cd g
~e|os|o| c d seose, ~~c^oscpp|ess o , o^d exposc e | oc~e~o|~e|opec| c
dcgso^d/ood o| o, eoc~o|v~ c~v ~o d|~ed ||ee^| o' o s' g~|'yd |
|e|e^|voy ' ~~c^oscpp|essed s|o|cs oy |se|scgges|sov~o' e ~os|o| |ec|os
v~ c~ voc' d ^o| o ~o y oe co^s deed ^ o ~~c^oco~pe|e^| po| e^| .
^|ove^ocsd| cgoocse ^ceoses |~e poss o |yo| ooc|e o edocod | s, sp o
ep dco ooscess, o^d o|o ooscess, os ve' os \ Je~ o co ' eod |o
e^cep~o opo|~y, se zces, ~yoc o^cs, o^d ^ecopo|~y |go|o^sp o^|o| o^
~os o v~o e ~os|o|d sodes ossoc o|ed v |~ dys|c^c| o^ o||~e|osp o|ed
ogo^, ~~c^oscppess o^, ods dee||ec|s o|~c | p e ~ed co| o^s
Jse|~ese|oc|osos~ |so^d scgges| o^s, oc| do^o| e'yo^|~e~| o~oe
|~e d og^os s o| exo~p' e, |~e o'co~o' cv~o cs|sezed od ^ov ~os o ~e~
poes s ~oy~ove ~od o o co~o v | ~d|ovo' se zc|ev |~ o pos|c|o' !odds
poo ys s, oc| do| ~ ss |~escoduo ~e~o|o~o ~e go| |o ' ^g dov^ |~e s|o |s,
v~ c~ s| ~eeo' |eoso^ ~esezed o^d s~e~ poe| c. ' |yoc c~p| o| ~eco^c' c
so^ |~o| ~e ~os ~od cs| o^o' co~o' v | ~dovo se zce, |~e yoc ~oy| d
yocse|c^~opp yovoe^ed|osee~ ~ ~e^ o| ^g ^|~e~ dd eo|| ~e g~|
H ow to Do a Good Neurol ogi c Exami nati on
!~ee oe seveo' ospec|s o|| ~eec|o' og co' vocp |~o|o ec qceod ~cs|
oeco^s de|edv~e^evo co| go po| e|v|~ eco og co d seose The hi story
is cri ti cal . !~e ~ s|oy s v~ee yoc v ge| |o|~o| o ego d g| ~eexoc|
sy~p|o~s|~e po| e|expee^cesoexpee^ced o^d |~e |~e coc|seo||~ese
sy~p|o~s. ' ~o^ycoses, |~e~ s|oy ~oes|~ed og^os s, od |~eexo~ ^o| o
se|ves ~e|e yoso co| ~o| o olyoc~ s|o co' d ogos s
<eo' ze, ~oveve|, | ~o| |~e sy~p|o~s | ~e po| e^| |epo|s co^ so~e| ~es
,o||e-j oevogceo^dd || cc' ||o ^|epe|. | s ^ |~ese coses |~o||~eexo~ o
|o^ poyso eyo'e A po|e| ~oyco~p'o ^o|v sco oss ^ |~eeleye, oc|o
exo~ o| o , | oeco~es c eo| |~o| |~e po| e^|oc|co' y~os o e|| ~o~o^y~ocs
~e~ o^op o !~ sds| ^c| o^ so|geo|vo' ce, |o~o^occ o|v sco' oss ^dco|es
d seose ^ |~e eye o| |~e oood scpp y|o |~e e| ^o , |o~ | ~ecoo|d o||e|yl ,
v~ eo e||v sco | e dcc| scgges|s po|~o' ogy | ~e| g~| occ p |o ooeo |s
oood scppy ,|o~|~eve|eoo'oos o o|ees| !~evocp od |eo|~e||~cs
oe s g | co^|' yo' |eed oy |~e exo~ | d ^gs, v~ c~ ~e' p|oc o|y|~e po| e^|s
^|epe|o|o^ o| ~ s/~eeco og cde| c |
|so~e| ~ ^g s|oc^d o^ exo~ |~o| s ^co^s s|e^|v |~ |~e po| e|s ~ s|oy,
|~ sdoes ^o| ^ecesso ' y ~p y ~o ge ^g, oc| o|~eo d || cc|y occco|e'y
desc o ^g sy~p|o~s Avoys oe sce yoc cdes|o^d v~o||~e po|e^| s ||y ^g
|odesc| oe So~epo| e^|sco~p o o|veoess,v~e^|~eyeo' y~eo^ c~o
^ess, odv ceve|so. A po| e^|~oyco~p'o ^o| o occ|e o scoocc|e ose|o|
N0ulOlOQy Z
veoess, o.|exo~ o|o s~ovs sevee o|op~y A|op~y s o s g o| ove
~o|o|e.o d seose, o.| | s o|pese|oc.|ey ' |~ scose, |.|~eq.es|o
g vo. d oe ecessoy|o |y |o e c |o ~oe c~o c, od pe~opss.o|' e| ~ s
|oyo|veoess , oo|~e poss o |y s o peexs| g c~|o cveoess v |~ o
s.pe ~posed ev, oc.|e s. ||
o~ |~ese exo~pesyo. co see |~o| |~e e.o og c ~ s|oy odexo~ o
|o oe |eeo|ed od |~o|, v~ e|~e~ s|o|yo|e s.gges|s'ed ogos s, |s ~
po|o||osy|~esze|~e |o~o|o|o~ oo|~|oco~e.pv||~ecoec|osve
odd | o, eo ze |~o| |o oosc e.o ogc|.c|o s ~po ed, |s o|eosy|o
e' oo y |es| ~ g~e e.o og c|.c| os, e , | o po|e|s o| ~ s poo yzed o
poe|c,|~e|e~o|ocood o|o sd ||c. ||oossess, evse, |vo.'doe.|o
|o ooe o po| e|os ~ov gseveey ~po ed ~e~oy ||~epo| e| sop~os c.
The Mental Status Exami nati on
Agood ~e|o s|o|.s exo~ o| o eoves odo.o|ooo.|| ~epo|e|s level
of arousal |o|~e ex| exo~ e !e~s e s eepy, e|~og c, s|.po|o.s
~oy ~eo s g~|y d ||ee||~ gs|od ||ee| exo~ es. !~eoes|~e|o s|o|.s
exo~ s ~py s|o'es v~o| |~e po| e|co ocoo| do o exo~p e, !~e po
| e|vos ovoe, vo|c~ g |eev s o , od speo g o~o y, o !~e po| e|
vos os ee, oo.soo e|o|oc| es| ~. o| o, o.|vo. d |o ooc|os eep |.
s| ~.o|ed
<e~e~oe|o c~ec oosco dooec|ve |o~o| o s l~e po|e|ori ented
to person, pl ace, and time? Assess |e po| e|s attenti on . !~ s s ~os|eos y
doe oy ~ov g ' ~e po| e| epeo|o se es o| odo~ .~oes, s|o| g v |~
|~ee .~oes J secodsodvo g.p.| |~epo| e| so ogeoo e|o
coec|yepeo||~e~ , o~o s |ve |o seve .~oes os ~oysecods| !~ s
s ov os|~e og! :poo |o po|e|s o||e|o s ~po ed, os de~os|o|ed
oy o d g | spo o| ess |~o o, |~e ~oe co~p' co|ed ~e|o s|o|.s|es| g ~oy
oed || c. '|o |epe|. 'o s|oce, o po| e|v |~o d g |so o| J s o| e y
|ooeoo e|oe~e~oe||~eeoo ec|s o ~ .|es, o.||~ sdoeso| ecesso y
~pyo p ~oy ~e~oy poo e~ od ~oy .s| |epese| pooo||e|o |o |~e
exo~ e ~po edo||e| o ~oy~eo s ~py|~o||~epo| e| speocc.pedo
ox o.so~oys g ooc.|eco|.s oo s|o|eo ecep~o'opo|~y
Speech s ~po|o||o ossess |o oo|~ | .ecy, ' og.ogeo.|p.|| od co~
p|e~es o , og.oge p.|| A ~po ~e| o|s~oo|~ od| .e|o.|p.|s.g
ges|sdys|.c|o o||~e do~ o| , .s.o y e||||o|o' ooe , oocos oeo| , v~ e
| .e| o.|p.|v | ~o oo ly|o .des|od spoe ' og.oge d co|esdo~oge
|o|~edo~ o| po e|o|e~poo oeo ,\e ces oeo| || c.' lyv |~oo|~| .
ecyodco~pe~es o s.s.o y|~ees. |o|o ~oeex|esvedo~ o|~e~
sp~ee eso ,s.c~ oso ~ dd eceeoo o|e|y |o|c||
Crani al Nerve Exami nati on
o ec|veossess~e|o| ~oyo||~eco o e|ves ,C`s| sposs o e,od|~.s
oo s|e~ |.c|o ~oyoeossessedeve co~o|oseo|o|~e|vse.coope|o|ve
208 N0ulO/OQy
po| e|s Aoo|~o | es |~ec| o o' e|ve exo~ .s.o ' ys.gges| .de|' y. cg
oo s|e~ po|~o ogy
eN I : Sese o|s~e .s.o y s o||es|ed, o.| ~oy oe oyos g |~e po|e|
|o de||yo c~ooc|es|coo~o v|~ eyesc osed , e g , co||ee, |ovesj
eN I I : C~ecv:uo| |e|o: | oco|o|o|o, Copo| e|see ~ove~e| o' '
| e' ds-Co po| e|co.|| ges o | e ds-jod oo|ocoses.o pup||o/y
/eoc|v||y
eN I I I , IV, VI : ove |~e po| e||o'ov |~e ~ove~e|o| g~| o' d ec|os
!o||: eye oooeuve/ ,oc. ocep~o c| !~ s s ~os| .se|.' po|e|s v~ose
cosco.sess s ~po ed Ao~o opos|ve esposeocc.sv~evgoo.s y
o|o| g|~e po| e|s ~eod |o oe s de, od |~eeyes devo|e |o|~e oppos |e
s de Aooo~o' o| ego| ve espose sv~e|~eeyes do o|~ove |~e
oo |s ego|d'ess o| ~eod pos| o |~edo seyes oe oose| A|. ycosc o.s
po|e|~oyoeoo' e|ovo .|o yove||de|~ se|ex, es. | g o |o se ego
| vees. |
Co|o co|o/c: ,oc.oves| o.' o| eo coo soe spec|ed |oo c' eovev
o||~eeo|d|.~s, |~e po| e|s ~eod s~ype|ex|ededooo.| JJ, od ceco'd
vo|e s go|ed |ooeeocoo .Ao|~o o pos|veespose o ovoe
po|e| s dev o|o o||~eeyes|ovod |~e || go|ed eo od ys|og~.s oeo| g
ovoy|o~ | ~e | go|ed eo , S ce ovose po| e|sco vo' .|o y ~ove|~e
eyes, ods ce cod co o cs co oeq.|e o.seo| g, co o csoese do~ d
co|ed ovoe po|e|s. | Ao~o o pos|veespose c o co~o|ose po|e| s
devo|oo||~eeyes|ovod |~e || go|ed eo, v |~ oys|og~.s Aooo~o'
o ego| veesposes~ovs oeyedev o| o A||e| o ~ .|es, epeo| |~e|es|
v|~ |~eoppos|eeo
eN V: As|~e po|e||oc ose~ s/~eeyes, |o.c~ , o.seo p |o p|cj|~e
po| e|:|oceo|~e|oe~eod, c~ee, odc~ oe |~e|sde, od ~ove|~epo
| e| de| |yspec | co' ' yo po | |o|~ep'oce|o.c~ed
eN VI I : As |~e po| e||o c ose ~ s/~eeyes | g~| yod 'oo |o|~eoo |y
|o o.y|~eeye' os~essy~~e|co y .oos|oo sy~~e|cs~ ' e As|~epo|e|
|o p.||o.| ~ s/~ec~ees od |y|o ge| yp.s~ |~e oo.|o||~ec~eesv|~
yo.|| ges As|~e po|e| |o c ec~ ~ s/~e|ee|~ |oge|~eod oo|osy~
~e|c co||oc| o o||~ep o|ys~o ~.sc e ,s|e|c~es|o~ |~e c~ / ov|o | ~e
c ovc es|
eN V /VI I : Co/oeo| |e:|/ g~| v spo|co||o o|| ss.e s o.s~ed ge| y
ogo s||~ecoeo, oppooc~ g|o~|~es de, o||o~|~e|o| | A pos|ve e
spose s eyec os.|e/o' s g !~ ss~o. d oe doe o oe eye, |~e|~eo|~e|.
Coeo s~oy oeoose| po| e|sv |~o ~ s|oyo|co|oc| 'es .se !~ s|es| s
o|o.| e' ype|o~ed ovoe po|e|s
eN VI I I : \~ spe .~oe|s , o e||es| |o |~e po| e|s eo|o~ o d s|oce
o|ooo.| I |oo|od o|e ||~epo| e|co epeo||~e.~oe|s
eN I X/X: Cog |e:|Js ~g o | po||og.edepesso|, |o.c~|~e ooco|
|~eoop~oyxo oes de, |~e |~eo|~e, od oo|oo gog v|~ sy~~e| c
po' o|ee evo| o ' ||~epo| e| s | .oo|ed, o | pcos| ' ' oe.sed '.' ' go
|~eedo||oc~eo | .oe s o| eco~~eded os o ~e|~od |o|es| g | ~egog
e| ex A deceosed o oose| gog so~e| ~es co oe |o.d o|~ev se
N0u/O/OQy Z
M
o~o' po| e|s , oc| o osy~~e| c gog csco ' y s d co| ve o| oo s|e~
po|~oogy

CN XI : Ago s| es s| oce, ~ove | ~e po| e| s~|cg ~ s/~e s~oc' des cp

,|opez .s|od|c ~ s/~e| ~eod |o oes de ,s|eoc e do~os|o dj <e~e~oe,
d || cc' |y|c g|~e ~eod |o |~e g~| dco|eso veo e||s|e|oc' e do~os|o d,
odv ceveso
CN XI I : As |~e po| e||o s| coc| ~ s/~e||og.e !~e |ogcev dev o|e
|ovod |~e veo s de
Motor Exami nati on
A |~ocg~| ~e~o|o|exo~ o| o os |yp co yd sccssed |e| ess g | co|yo
po| e|coopeo| o, |~ee so o|o|oo ec|ve |o~o| o |o|co oee' c|ed
oy o s ' 'ed exo~ e.

Muscl e bul k s ve|yooec|ve, od|oco o|/op|y o||o:c|cu|o|on: oeos g

o|c~|o cove ~o|o ec|o d seose, A.S, ecopo|~y, od c. opo|~y, so~e
| ~es ~yopo|~yj
Muscl e tone co oeossessed oy poss ve y ~ov go o | | ~o.g~ |s | c
|ogeo| ~o| o ||occo |one o||e|s || eo| o |ess|oce, od| ~e~ove~e|
v see~ ~p !~ sde~os||o|ese |~eoocc|ecppe~o|oe.|o es oo o
' ove ~o|o eco ' es o 'po:|c |one o||es ~oe es s|oce|~e|os|e|~e
~ove~e| Spos| c |y sseev |~scooc.|eo c~o c.ppe|~o|oeco cy
, sp o cod cy, ceeoo' |oc|, oo |c~o, ~c'| p esc e|os s, A'Sj ||g|o|y
s~ovs eqco' ess|oce|~ocg~oc||~e e| e oge, |ego|d'esso||~e veoc|yo|
|~e ~ove~e| ccos oo' 'y | g d|y ~os o |o|c~e|yqco |y, v~ c~ s|e|e|ed |o
os cog|ee|ng , o so s~, o|~e| ooso' gog' od seosej :xpe| eceo ds
geo|y | ~eoccco|e evo co| oo| ~csc e|oe
Pronator dri ft s o exce e| ~e|~od o| |es| g |osc o| e co|| cosp o'
veosess !~e po| e| sosed | o~o' d oo|~ o ~s|c' yex|eded ||o|o|
~ ~/~ese' |v |~ |~e po ~s cp !~e po ~ss~oc' d oe eve' od o| |occ~ g
eoc~ o|~e| !~epo| e|~cs||~e ~o |o |~ spos | ov |~ ~eeyes cosed A
pos|ve d||| , od ~ece, ev deceo|co| cosp o veosess| s c~ooc|e|zed
oy o|o'y o dovvo|d ~ove~e| o| |~eo||ec|ed s de, oc| o so poo| o o|
|~o|ex||e~ |y
Sco|'e ove| ex||e~ |yveosess sscgges|ed oyexternal rotation of the
hi p o||es|
ec|strength testi ng o| d v dco' ~csc' es s goded o |~e |o' ' ov g
sco' e
o 'o~ove~e|
I !v|c~ o|o | ~ove~e|
z ^ove~e|o.| o| ogo s|gov|y
J '.' ' ~ove~e|ogo s|gov|y o.| o| ogo s||ess|oce
^ ^ove~e|ogo s|po|| o ess|oce
5 ^ove~e|ogo s||c |ess|oce
A + o s g o||e s .sed |o deo|e s~o' e vo o| oso|s|eg|~ , e g ,
s' g~| veoess ogo s| |c' ' ess|ocevoc d oe o |o/o|y:|: o|p|eg|o ~eos
210 N0ulOlOQy
|~o||~ee s o oosevoo e ~ove~e| |o/e:: ~eos|~ee s veoess oc| s| '
oosevoo e~ove~e|
Ao|~e po|o||~e ~o|oexo~ |~o|ossesses s|eg|~ v |~o.|d ec|oe
ooe~.sc e|es| g sfuncti onal testi ng. Co |~e po| e|eos y se|o~ o
s || g pos | o |o o s|od gpos | ov |~oc|p.s~ g .p v |~|eo~s-A
oo |y|odo|~ ss.gges|s pox ~o' oveex|e~|y veoess Co |~e po| e|
vo .ps|eps- S|od o oe eg- opo oe eg- oe g oo e |o s|od o
oes | p|oes ~p' eso| eos|^ |o^+ pove |~egos|oce~ .s oe g oo e
|o s|od ooes ~ee ss.gges|s o| eos||~e so~e degee o|pove |~eo
|e o| o o s
oes| ~epo| e| ~oveo resti ng tremor , o so s~| - oes| ~epo| e|
~oveo |e~o v~e|oced | o~o |o pos|.e, s.c~ osv~e| ~e~odsoe
o.|s|e|c~ed- !~ s s co ed o postural tremor od s o|e p~ys o og c, o.| ~oy
oe|o~ o ,esse| o |e~o|
Cerebel l ar Exami nati on
Co | ~epo| e|op d' yodo |eo|e ypo| | ~epo ~o|| ~e~od od |~e
dosc~ o||~e ~od o o s.|oce- !~ s s|~e rapid al ternating movement test,
v~ c~ ossesses |~e ceeoe .~s oo |y|o cood o|eogos|s odo|ogo s|s
~po ~e|o||~ s s|e~ed dysd odoc~o es s
A i ntention tremor so|e~o|~o|vosesv|~ ~o|o|ovod o po| cc' o
po | . | sc~eced |o oy ~ov g |~e po| e| op d yo' |eo|e po | g , od
|occ~ g| |~e exo~ es oc|s|e|c~ed | geod |~e po|e|s ose (finger-nose
fi nger test) .
!~e heel-knee-shi n test vo ves|occ~ g oe ~ee' |o |~e oppos|e ee od
s~oo|~ y ~ov g |~e~ee dov |~eoppos|e s~ |o |~eo' eod ooc.p|o
|~e ee. `o~o' 'y |~ s s o s|eody ~ove~e|, o.|po|e|s v|~ o|oxo vooo e
|~e~ov g eg|o~ sde|os de.
A oo |y|o pe|o~ oyo||~ese|es|s , |~eooseceo|s g | co|~o|o
veoess| s.gges|s ps o|eo ceeoe odys|cc| o
Gai t and Stance Exami nati on
Co | od s|oce~oyoeooseved cos.o 'yv~e|~e po| e| svo g |o
|~e exo~ goeo `o~o go | ~oso oov s|oce, | c d ~ove~e| , od
sy~~e|co ~sv g g `o~o s|oce ss|eodyv|~|ee|s deoys deod o
svoy g Spec|c~oecves cooe|es|ed o|e | ~eexo~.
Tandem gai t s|es|ed oy ~ov g |~e po| e|vo ~ee |o |oe o s|o g~|
e, odo d || c. |yv |~ |~ s , o|ox cgo |j s.gges|s ~ d e ceeoe ' o dys|cc
| o oeseode' de ypo| e|s ~oy ~ove so~e d ||c. |yv|~|ode~go |v|~
o.|spec|cceeoe od seose
Ataxic gait s c~ooc|ezed oy .s|eod ess, svoy g, vo g v|~ |~e
|ee|v de yopo|, odo oo ' |y|ope|o~|ode~go |
Hemi paretic gai t de~os|o|esdeceosed ~ove~e|o||~eveos de, v|~
~e po| e| ~ovg |o 'eo ovoy|o~ |~e poe|c eg odsv g | ooc|o |o|
N0u/OlOQy M 21 1
, c c.~d.c|o^| . !e o ~ sv ^g .s.o y s dec|eosed o^ |e o||ec|ed s de, o^d
| eo ~~oyoee' d ^o |exed os|.e
Parki nsoni an gai t c oss co' y oso s|ooed |o|vod os|.ev | s~o'
s.||' ^g s|es o^d o |e^de^cy| o|o ' ove oocvod , e|o. s o^| !. ^s oe
^o| ~odev | o s~oo| o|o| o^ , o.| .s.o yco^s s|o| o se es o|s~o ' s|es
,e^o'oc |.^ ^g| 'o ^so^ o^ o|e^|s ~oy oved || c.|yge|| ^gs|o|ed vo s
^g, o.| o^ces|o|ed ~oy oc|.o' 'yvo' |os|e| o^d|os|eo^doe .^oo e|os|o
,|es| ^o| o^|
Steppage gai t sossoco|edv | o |oo|do, o^d | s ^vovess ~'ys|e
^g gev| |e o||ec|ed eg so |o| |e |oo|, v c s o^g ^gdov^, co^
c'eo |ego.^d !eseo|e^|so||e^ gve o s|oyo|s|.~o' ^g/| ^gove|
|e |oes o^ |e veos de
Scissor gai t ssee^ ^ o|e^|sv |o sos|c oooes s, s ^o cod ^ .y,
ceeoo osy| o^dsovs ^ceosed |o^e ^ |e| godd.c|os, s.c|o|v~e^
eveos|e|o|vod so||e~|ed, |e'egsoc|.o ' ycoss, e^ce|e ^o~escsso|
Sensory Exami nati on
' | s ^o| ^ecessoy| o~e~o zeevey oss o eco~o oo| o^o|e e|o
^eve ode~o|o~o se^soy oss, oveve|, so~ege^eo' g. de ^es oe e
|.' A ^ , oo|oo| c| s ~oeocc.o|e|o^o |^geo|~o ^go.|oeoso|
se^so|y oss.
<oo|
C
C
Co
!^
!l 0
.o
S l
`eve
<odo'
J ^o
/ed o^
Dermatomes to Remember
Se^soy s|c.|o
!.o
/dde|^ge
' ^y
` e
Jo c.s
og|oe
Soeo||oo|
Peri pheral Nerves to Remember
Se^soy s||ca|o^
os.o|o^d
' ^ysdeo|o^d
'o|o|o^d
'o|eo|eo|oca|o^eoas
`eo^eo
'o|e|oosec|o|| g
.o|eo osec|o|eg o^ddo|s.o||oo|
| s ^o cod co~|ess o^ s s.sec|ed, oe ce|o ^|o cec|oo sensory
level o^|e||.^s Peri anal sensation s ~o|o^||ocec ^ o|e^|s v| s.s
ec|ed co.do eq. ^o es o^s
212 N0ulO/OQy
ssoco|ed sesoy oss, e
.
'oss o| po od |e~peo|.e o

es deo|
|e oody od 'osso|v o|o| o ood popocep|o o |eo|e
.
scooc|e|s|c
o| o e~sp o ' es o ps ' o|eo |o |ev oo|oy/popocep| ve 'oss , oov
Seq.od syd|o~e|
Deep Tendon Refl exes
Aeosyvoy|oe~e~oeo.gyv ceve |oo|ssevev c|edo e
| exes s |o s|o|o||e oesod ~ove .p
Co.|
l z
J^
5-6
7-8
Gradi ng of reflexes i s as follows:
Absent
<e|ex
Ae
ee

ceps
!ceps
trace Fl icker of muscl e contraction
<oo|
S l Sz
.J'^
C5-C6
C7-C8
1 + Hypoactive (moy be normal , especi ol l y in muscul ar or obese patients)
z+ Normal
o+ Hyperactive, usually shows spread of reflex (may be normol , especi al l y
i n thi n or anxi ous potients)
4+ Hyperactive, cl onus (always abnormal )
Spread o| o e| exe|es |o ve oe e|'ex s oe g ceced od ~.sc' e
co|oc|oocc.s oo|ee|ex Clonus |e|es|oepe||ve e|exco|oc|os
o||eo s g es| ~. .s, .s.o 'ye c|ed oyoo.p| dos| exo o||e o eoy|'e
exo~ e|
Pl antar response se c|ed oy o q. c, ox o.ss| ~. .s ,sco|c gv | o
ey o o|e ~p e~e| | |o |e o|eo p o|o ospec| o||e|oo| A | exo e
spose sve |e g|eo||oe |exes od s |e o ~o espose o|od.|s od
o dec de A ex|esoespose,pos|veooo s | sve |e geo||oeex
|eds, dos |exes|od|e o|e|oesspeodopo| ! ss .s.o yos go|.ppe
~o|o e.o d seose ,ceeoo |oc|, sp o cod co~pess o, |.~o| , o.|co
oe o~o |o|s
`eurol Ogi C Exami nati on Summary
Mental Status
.eveo|oo.so desc p| o
e|o| o |o se |
.
p oce, | ~e, s |.o| o
r A||e| o d g | spo , o~o o|
Speec | .e|-co~pees o-
N6u/O/OQy M 21 3
Crani al Nerves
' -v sco | e ds, cosesco pcp ' oy |espose
' ' , '\, \ pcp oy eoc|v|y/o soco|o, ex|oocc o ~ove~e|s
do' ' s eyespos |ve=eyesdev o|e oppos|ed |ec|o o|eod |c|
co'd co o cs-pos |ve=eyes dev o|e |o co' y |ovod go|ed eo ,
v |o v |oc|ys|og~csovoy|o~ || go|ed eo|
\|oc o' seso| o , coeo e|'ex , sesoy| eyeo ve coeo
|occedv |co||o v sp
\' |oco' expesso -||oeeod ~ove~e|sspoed, 'eso sooove |e
|oco cc ecs,ce||o | , ||o|eeod sveo, eso spe|pe|o ,oe' sposy|
\ ' ' -eo g
' /, /-poo|esy~~e|y, gog
/' eod |c| ,s|eoc' e do~os|o d| , soc de|s|cg ,|opez cs|
/ ' |ogcepo|cs o devo|es|ovodveos de
Motor Exam
oc cec|osy~~e|y, o|opy, |osc cc o| os
!oe cecs|o|sy~~e||y, s|oe|' occ d, spos| c, g d,cogvee g| -
S||eg|/pove J `o~ove~e|
I !oce/|' ceo|~ove~e|
z ^ove~e| oc| o|ogo s|gov |y
J ^ove~e| ogo s| gov |y oc| o| ogo s|
ess|oce
^ ^ove~e|ogo s|po| o' ess|oce
o ^ove~e|ogo s||c ess|oce
cc| oo' |es|s '|oo|od| || o| ~soc|s|e|cedv | po' ~s cp A' so,
co po| e| | se||o~co v | oc| pcs g cpv | o|~s- s|odo | p
|oe:- s|od o ee s- op- op o oe|oo|-
!|e~o |es|g |e~o, pos|co oesse| o |e~o
Cerebel l ar Exami nation
<op do' |eo| o ~ove~e|s ,dysd odoco es s|
ge|ose| ge|, |e| o|e~o||
ee'ees
Gai t and Stance Exami nation
Cosco go | oose|veos po|e|vo s |o|oo~od dc g|o~o ec|o
exo~
!ode~ go | vo s|o g| ' e ee |o|oe
Spec |c Co |s o|ox c c|c g, cs|eody, svoy g, v des|oce, e~
po|e| cdeceosed ~ove~e|o veoss de, c cc~dcc| o o| eg, de
c|eosed o|~ sv g, po so o s|ooped, s c|| g, e||opc' s o ,
eo oc| cs, |es| o| o , s|eppoge|oo|dop, vo' ss v | g s|ep o
veos|oo|, sc sso| egsc|ossves|epp g|ovo|d.
Sensory Exami nation
^odo |es|o|es| g| |occ, p p| c, |e~peo|ce, v oo| o , pop o
cep| o
Sesoy eve' cecsv | p cp od dov | csve scsp c ocs o|
sp o cod ' es o
214 N0u/lOQy
e oo seso| o c~ecsv| scsp c o o| 'ove cod o cocdo eqc co
' es o
Deep Tendon Reflexes
<oo| <e|ex
S Sz Ae
.J'^ ee
CoC o ceps
CCo !ceps
Cod go| <e|'exes
o Aose|
|oce ' cseo| ~csce co|oc|o
l+ ypooc|ve
z+ 'o~o
J+ ype|oc|ve, ~oys~ovsp|eod
^+ ypeoc|ve, po|~o og c, c ocs
Cl i nical Symptoms and Signs
ALT E R E D M E TA L STAT U S
I WATCH D EATH
I nfecti on
Wi t hdrawal
Acute metabol i c derangement
Trauma
eNS pathol ogy
Hypoxi a
Def i ci ency
E ndocr i ne
Acute vascul ar
Toxi ns/dr ugs
Heavy metal s
N0ulO/OQy M 21 5
CT, LP, AND E E G H I M
Cerebrovascul ar acci dent ( brai nstem i schemi a/i nfa rct)
Trauma
Low bl ood pressu re/hypotensi on
Psychi atr i c
Anoxi a/hypoxi a
Neopl asm
D rugs/toxi ns/wi t hdrawal
E pi l epsy ( nonconvu l si ve stat us, post-i ct al )
E l evated bl ood pressu re ( hypertensi ve encepha l opathy)
Gl ucose l ack/hypogl ycemi a
Hemorrhage/bl eed ( i ntracrani al , especi al l y posteri or fossa)
I nfect i on ( meni ngi ti s/encephal i ti s/sepsi s)
Metabol i c/endocr i ne
!~e| |s| ~e~o c s s~o||e o.|essco~pe~es ve !esecod ~e~o c
s~oeco~pe|e, od |poes|. o|o ospec | coppooc|o|~ese po|e|s.
!~eC!, '', od ::Coe oo| |eq. ed |oo' po|e|s !~e|o' ' ov gdesc oeso
ogozed oppooc~|o| sco~~o p|oo e~
`otes
A|eed ~e|o s|o|.s e|es|ooyoc.|e os.oocc|ec~oge |~e eve o|co
sc o.sess, |og g ||o~ ~ d co|.s o |odecp co~o C~o c poo e~sscc~
osde~e| o o|~e|o e|odo| ooe o|cos deed |~ sd sccss o .
1 . ' | o |eo|~e|o| cooo o uocoo:c|ou:oe:: s o ~ed o| |op dy de||y g
od|eo| goy |eve|s o ep|ocess Protocol :
o AoCs , A voy, oeo| g, C c.' o| o| , v |o' s gs, s.pp e~e|o' |
ecessoy, p. seox ~e|yod AoC, :CC
o \ ' e v | o~o so e Sed o' ood |o CoC v | ~ d ||e|e| o' od
p o|e e|s, eec|oy|es, oJ`, ceo| e, g .cose, Co, ^g, !, '1 |~e|es|s |o
oecos deed c .de |oxcoogy scee, ' veezy~es, o~~o o, o ood c.
|.|es, . o ys s
' ge|s| cg' ccose, | ~e I JJ ~g |~ o~ e, |~e oJ~' oJ7dex||ose
so .| o '\

<op d ossess~e|o|c co s |.o| o , exo~ o| o Cos deeod C!

sco :~ege|||eo|~e|s c cde|~e|o ov g
21 6 N0ulO/OQy
|op o|e ovedose scspec|ed, `o'oxoeJ Jl ~g/g '\
' |sezce oc|v|y o|ed, .oozepo~ z ~g \
' | |ec| os.spec|ed, oeg '\o| o o| cs, |~e poceedqc c' yv |
C!od .
'| ~e| o| o d|ec|ed, | coo|e, ypeve| o|e, ~o |o l g/g '\,
C!, co ecoscge|y
e| |ve|eo|~e|v deped o |~eco.se o||~eco~o
2. !~eexo~ o| oo| | ~eco~o|ose po| e| cooeoo|~ q. cod ~e p|.
de|e| ~ g| ~ee| o ogyo| |eco~o, see ov !o oo Cood 'eco' og c
:xo~ o| o, poge zJ|
o Mental stat us: Jse spec | c desc| p|ve | e~s, ovo d vogce |e~s e
s eepy o| ' e| ~og c !o v~o| eve o| s| ~c csdoes | ~e po| e| espod-
ve|oo , |occ, po -
o Crani al nerves: C~ecs pcp ' s, eye ~ove~e|s , do s eyesj , co|eo s,
|oc o' sy~~e|y, odgog ,seepogezJ-| o spec | cso ~ov| ope|o|~ |~ese
|es|s| C|o o e|veooo~o' |es scgges| o|o s|e~ dys|cc| o
c Motor/sensory: ose|ve | ~e po| e|s ~ove~e|s |o|e oyoov ocs
osy~~e| es oss ve y ~ove |~e po| e|s ~os |o ossess |oosy~~e|y o|
~.sc e|oe oes |~epo| e|~ovespo|oeocs y- s|~e ~ove~e| pc|pose
| c - oes | ~e po| e| ~ove |o co~~od- oes |e po| e| ~ove |o ox o.s
s| ~c -\~e ossess g|~epo| e|s eoc|o|oox o.ss| ~c' , o|evuo|so||
o| ~o|o| espose soo|o ed |u/po:e|u| |||o/oo| ~eos ~ov g |~e ~o
ovoy||o~| es| ~c csod ~p es |eg |yo| | ~ece|eoo co|ex !eco/||co|e
po:|u/|og s desc oed os o | ex o |espose |e cppeex|e~|yodex|e
so |e ove|, od scgges|s co| co' dys|cc| o !ece/eo/o|e po:|u/|og
vo'ves ex|es o o| oo|~ cppe| ood ove ex|e~ | es espose |o o ox ocs
s| ~c' cs, od |~ s ~p es oo s|e~ dys|cc| o . |o oo|o/ /e:poo:e s.gges|s

seve|e o|o s|e~ dys|cc| o o pe p~e|o po|o ys s , C. ' o oo| sydo~e,

o|oge cpoo' ys s|
d Reflexes: .oos|o| osy~~e|yo| deep|edo e|exes C~ec|oc' o.s
od ooo s\ esposes
3. !eeoe||ee ~ec~o s~so|co~o/depessed ~e|o s|o|.s
o o 'o|e|o ceeo|o ~e~ speedys|cc| o , e g , o o|eo |oc|s, o o|eo
scodco s, ~yd|ocep~o cs, ~e g | s, scoo|oc~o d ~e~o|~oge, gee|o' zed
sezce oc| v ly|
o oo s|e~ dys|cc| oo y
ec|oo s|e~ c|y, oo s|e~ |oc| o, |c~oso|o'eedsj
oo s|e~ co~p|ess o/d sp oce~e|oyscpo|e|o| o' ' es o , e| o
| osecodoy|oscpo|e|o| o' |c~o, ede~ooo eed|
c ||csece|eoo od oo s|e~ dys|cc| o , e g , ~ypox o, ~ypogyce~ o,
d cg |ox co| os, c|e~ o, ~epo| cecep~o opo|y, ~e g | s, s.oooc~o d
~e~o~oge|
Jo||o|e/o| ce/eo|o| oy:|uoc||oo o oedoeso|cocseco~o , e , o c o|eo'
|oc| o | c~o does o|exp o co~o, c ess ~e o| o odco~pess oc o|
oo s|e~ s||cc|ces osoccc|ed
N0ulOlOQy Z
4. Appooc~ |o |~e d ||e|e~| o' d ogcos so|co~o
oeovo|e|~o|oo cs|e~ es ocsdoco|ovoyss~ovcpc' eoyo~C!scocs, so
| oo ~s|e~ po|~o'ogy s s|ocg ys.spec|ed ocd |~e C!sco~ s co~o' , coc
sde| ~e.o og cco~sc |o| o~ o~d ^< scoc~ ~g
COMATOSE PATI ENT
t
ABCs, Como PROTOCOL
t
r
Broi nstem exomi nation/reflexes
Intact Abnormal
I I
r- CT r- CT --
Abnormal
t
Bilateral subdurals
Hydrocephalus
Bilateral i nfarcts
Multiple contusions
Subarachnoid bleed
Meningitis/ encepha-
litis
Cerebral edema/Reye's
Epidural bleed
Neoplasm(s)
Abscess(es)
Vasculitis (i nfarcts)
Sinus thrombasis
Metabolic insult
suprimposed
on old foal lesion
Normal
t
Meningitis/encephalitis
Toxic encephalopothy
Metabalic encepha
Iopathy
Drug-induced
Hypoxic/anoxic
Acute bilateral infarct
Seizure
Hypotension/shock
Hypertensive encepha-
lopothy
Sinus thrombosis
Abnormal
t
Brainstem hemorrhage
Brai nstem neoplasm
Brainstem infarction
Subarachnoid bleed
Supratentorial mass
with herniation
Brai nstem/ cerebel lar
abscess
ATAX I A
Ca n ' t St a n d Very Wel l
Cerebel l ar ataxi a
Sensory ataxi a
Vesti bul ar ataxi a
Weakness
218 N0u/OlOQy
Normal
t
Acute brainstem imarct
Toxic encephalopothy
MetaboliC encepha-
lopathy
Meningitis/encephalitis
Drug-induced
Hypoxic/anoxic
Basilar migraine
AC U T E ATAX I A
U NABL E TO STAND
U nderl yi ng weakness ( may mi mi c ataxi a)
Nutr i ti onal neuropathy ( vi tami n B1 2 defi ci ency)
A rteri ti s/vascu l i t i s
Basi l ar mi grai ne
Labyr i nt hi t i s/vesti bul ar neuroni t i s
E ncephal i t i s/i nfect i on
Tra u ma ( postconcussi ve)
Other ( rare metabol i c or geneti c di seases)
Stroke ( i schemi a or hemor r hage)
Toxi ns ( dr ugs, tol uene, mercu ry)
A I cohol i ntoxi cati on
N eopl asm/paraneopl asti c synqromes
Demyel i nat i on ( Mi l l er Fi sher, Gu i l l a i n Barre, MS)
C H R O N I C ATAX I A
CAN' T STAND
Congeni t al mal format i on/Chi ari
Autosomal recessi ve ataxi as
N utr i t i onal ( vi tami n B1 2 defi ci ency)
Tra u ma ( postconcussi ve)
St roke sequel ae
Toxi ns ( dr ugs, tol uene, al cohol )
Autosomal domi nant ataxi as
Neopl asm/paraneopl asti c syndromes
Demyel i nat i on ( MS)
N0u!OlOQy I ZI
-

..
A|oxo s|esco ec|veco~p' o c| o oo ec|ve | cd cg o| ~po ed cood co| oc,
csco y ~oc |es|ed osoc ~po ~ec|o|go | o dex|e|y c|eoosecceo|s gc|
coc|~cscc' oveocess
Dysdi adochoki nesi s s oc ~po ~ec| o||eoo |y |o pe||o~ op d o' |e
co| cg ~ove~ec|s
Dysmetria s ~po ~ec| c |e co|~o' occe eo|oc ocd dece eo| oc o|d
|ec|ed ~ove~ec|s Usco' 'y evo' co|ed oy | cgecose| cge ocd ee' cees c
|es|s
I ntenti on tremor s oc exoggeo|ed osc o| oc o|o ~o, ~os|p|ococcced
os | sopp|ooc cg o |oge|, ocd essec| o yoosec|o||es| o o||e oeg cc cg
o|o ~ove~ec|. ' c|ec|oc |e~o so ~oc|es|o| oco|dys~e|| o
Titubation so ~odeo|e|eqceccy eod ||e~o|, csco yoc|eopos|e o.
1 . !e ti me course o|o|ox o e ps co ov |ed ||eec| o' d ogcos s. Acc|e
o|ox os csco' y o|e dce |o occ|e o|o c c c|y, |oc~o, c|oc|, o' eed| , c|oxco
|oc, c|ec| oc, c| o~~o| oc/oc|o ~~cce|eoc|ocs ,voscc | s, po|oceop os| c|,
o ~ g|o ce C|oc co|ox os csco 'y o|ecocsed oy cocgec|o ~o' |o|~o| ocs,
seqce' oeo|oo c c c|y , pos|s|oe, ce|eoo' po' sy, ||oc~ol , ~c'| p' esc' eos s,
o|o c|c~os, o|gece| cd seoses , ed|e cs, o|oxo|e' ocg ec|os o| .
2. Eval uation o| o|oxo cc cdescood co| oc|es| cgocdsecsoy|es| cg.
o. ' cgecose| cge !epo| ec| sos\ed | ocse|e cdex| cge | oo |e|
co|e'y|occ s/e|cose ocd |eexo~ cesoc|s|e|ced | cge
o 'ee'\cees c !e po| ec| s osed |o |occ oce ee |o |e oppos |e
\cee ocd|ec ~ove |e ee' dovc |e s c|o |e |oo|.
c. op d o' |eco| cg ~ove~ec|s !e po| ec| s |o o |e|co|e' y p|oco|eocd
scp co|e e|e|ocd, csco' ' ypo|| cgoc| e| go oco|e ozoc|o' sc|oce.
c |e' ove|ex||e~|es, | s ~oy oe|es|ed oy ov cg |e po| ec||op e |e|oo|
oc |e |'oo.
d. op ocep| oc os | oc secse s |es|ed oy ov cg | e po| ec| dec||y
ve|e|o d g | s oe cg~oved cpo|dovc o| o o c| , csJo y c|epo' ocgeo'
| cgeo |oejv ||eeyes cosed A| eos|oce o c| oceoc ' ~o s|es|ed sev
e|o' | ~es. | o de| c |s de|ec|ed d s|o' 'y, coc| cce |es| cgp|ox ~o' 'y cc| ' |e po
| ec| s oo e|o dec||y ~ove~ec|s coec|'y, . e , | pos|oc secse s ~po ed c
| e| cge|s, |o ovv| |es| cgo||evrs|, e oovoevec soc de|o de|e~ ce
|e ex|ec| o||e de| c |j
e. o~oe|g s gc . ! s s|es|ed oy ov cg |e po| ec|ossc~eo co~|o|oo' e
s|occev ||eeyesopecocd |e|ee|osc'oseosposs o e, |ecc os cg s/e|
eyes Coc| cced s|oo ' |y so cego|ve o~oe|g, ocd cs |oo |y/|o' cg v |
eyesc'osed so pos|ve o~oeg. A pos|ve o~oe|g s cdco| veo| ~po ed
pop ocep|ve cpc| . |oooe|g |es||ng |s no| use|u| |n po||en|s unoo|e |o s|ono
s|eoo||y ||| ||e|| eyes open
ZZ N0u/OlOQy
"
3. A|oxo ~oy oe d v ded ^|o |occo|egoes |~o|o||e^ co^ oe d s| ^gc s~ed
oycoe|c' s|oy o^d exo~ ^o| o^ So~e d so|des ~oyoeossoc o|ed v |~
~oe |~o^ o^e|ypeoo|ox o , ^ po|| cc o, ceeoe' ' o o^dves| oc o o|ox o
o||e^occc||oge|~e|
o Cerebel l ar ataxi a s c~ooc|e zed oy dys~e| o, dysd odoc~o ^e
s s, ~ypo|o^ o, o^d c^s|eodygo | ^ |~e oose^ce o|s g^ | coc| ~o|o|veos
^ess, ^ocseo, o vo~ | ^ g 'ys|og~cs ~oy oe pese^| Ce|eoe' o o|ox o
~oyoe c ^ o|eo o o o|eo' 3^ o|eo ceeoe' ' o o|ox o scgges|s o |oco
es o^ , |uoo/, | n|o/c|, o|eeo, ou|||p|e :c|e/o:|:| , v e o o|eo' ceeoe ' o
o| ox o s ~oe e y dc e| o d || cse cocses , o|co|o|, o/ug | n|ox|co||on,
po/oneop|o:||c
o Sensory ataxia scocsed oy ~po |ed pos|o^ se^seo^d ^o|oyceeoe'
o po|~o ogy ^d ^gs co^s s|e^| v|~ se^soy o|oxo ^c cde ~po ed se^so
| o^, po|| cc' o y pop ocep| o^ o^d v oo| o^ 'ocseo, vo~ | ^g, o^d
^ys|og~cs oe ^o|see^ v |~ se^soyo|ox o :| o' og es ^c cde ^ec opo| es
o^dsp ^o cod doso co' c~^ po|~o ogy, e g , v||oo|n 5 oe||c|ency, neu
/o:yp||||:/|ooe: oo/:o||:
.
c Vesti bul ar ataxia |yp co' ' y sossoco|ed v | ve|| go, ^ocseo o^dvo~ |
^g ~po ed cood ^o| o^, d ~ ^ sed ~eo ^g, ^ys|og~cs, o^d go | ^s|oo ' |y
o' so ~oy occc. \es| oc o| cocseso o|ox o ^c' cde |ooy/|n|||||:/ve:||ou|o/ neu
/on|||:, o/o|n:|eo |:c|eo|o, o^d ou|||p|e :c|e/o:|:, o~o^go|~es
d Weakness dce|o ~e~ po|ess ~oy~o^|es|oy|o' ' ^go|go|d s|coo^ce
o^d s^o||ceo|ox o ' ^|ese|| ^go|s g^ | co^|~o|oveo^ess, | sd || cc' ||o
ossess cood ^o| o^ sepoo|ey S g^ | co^||oco' veo^esss~oc'd |ose |e pos
s o |yo|o |oco ce|eoo' es o , |uoo/, |n|o/c|, o|eeo, oo:ce::|
4. I ntoxication so co~~o^ cocseo|occ|e o|ox o ||e^d ^g oge^|s ^c' cde
~o^yo^|co^vc so^|s ,e g , p~e^y|o ^, co|oo~ozep ^ejo^do coo'
5. A good fami ly hi story s esse^| o' ^ |~e evo' co| o^ o|c~o^ c o| |ecc|e^|
o|ox o ^ go ^eso||e^ occc ^ pe|so^sv | o pos | ve|o~ y ~ s|o|y o| ~
go ^e~eodoces , oco, p~o|opoo o, ^ocseo, vo~ | ^gj ^e|ooo' cd seoses
pese^| ^g v|~ ecc|e^|o pogessve o|oxo o||e^ ~ove oc|oso~o' ecessve
^e |o^ce, ~opesycpc| ^ed seose, o|oxo|e o^gec|os o, '| ede co|ox oj
Ac|oso~o' do~ ^o^| |o|~so| o|ox o ^c cdevo^ ppe ' ^docd seose , cee
oe o|~e~o^g oo os|o~o| , o vopo^|oce|eoe' ' oo|opy, o^d^oc~odo]osep
d seose
6. Work-up |oo|ox o depe^ds o^|~e d ||ee^| o d og^os s 'eco ~og ^g
,C! occ|e y, oc|^<' s oe||e| |oc~|o^ csy~p|o~s| s^ecessoy |o|oco eso^
sscspec|ed Acc|e, ^o^|oco o|oxovo|o^|s|es| ^g|oo' coo' o^d dcg ^|ox
-o| o^ ' ^ po| e^|sv |~ s^ov^ ~o' g^o^cy, voscp |o ~e|os|oses ,C!/^<' j
o^d poo^eop os| csy^do~es , oc|oo^| oodesj s~oc' d oeco^s de|ed 'c~oo|
pc^c| c|e s~oc d oe pe||o|~ed ^cosesv~e|e C`S ^|ec| o^ s' se' y, |eve|,
~e^ ^g s~cs| 'o| e^|s v| p| ~o| 'y se^so|yo|ox o s~oc' d oeevo co|ed |o
cocses o| se^soy ^ec opo|y o^d do|so' co' c~^ po|o' ogy oy cec ^g
\'<'/<'<, g ccose, o^dv |o~ ^
81 2
.
'
Neurology . 221
M
AU TO N O M I C D I S O R D E R S
A BP DROP, I G U ESS
Amyl oi dosi s
Botu l i sm
Pa rki nson's di sease
D i abetes
Ri l ey-Day syndrome/fa mi l i al dysa utonomi a
Uncol ogi c/paraneopl ast i c
Porphyri a
I di opath i c/I atrogeni c
G ui l l a i n- Barre syndrome
U remi a
Et hanol /a l cohol i sm
Shy-Drager syndrome
S pi nal cor d di sorders
`otes
Ac|o~o~ c d sodes co~s| |c|e o v de |o~ge o| ~ec o' og c de o~ge~e~|s,
v c ~o~|es| p ~o ' y|ocg sy~p|o~s o|oc|o~o~ cdys|c~c| o~, ~c cd ~g
oc|~o| ~|ed | oo|os|o|c ypo|e~s o~/sy~cope, cod oco||y|~ os, o |e|ed
oc ~o| o~, ~po ed |e~peo|c|e egc o| o~, d opoes s/o~ d|os s, sexco'
dys|c~c| o~, o~d oove /o' odde|poo e~s
1 . Ac|o~o~ cdys|c~c|o~co~occc|dce|o ~po |~e~|o||eoc|o~o~c~evocs
sys|e~ ~ |e oo ~, '|y!/oge/ :yno/ooe, |ypo||o|oo|c |uoo/, |o/||n:on: o|:
eo:e| , sp ~o co|d , |uoo/, oye||||:, ou|||p|e :c|e/o:|:| , oc|o~o~ c ~eves , o|o
oele:, CuI||o|n5o//e :yno/ooe, ooy|o|oo:|:| o|~ec|o~cscc' o c~c|o~, oo|u||:o
Sys|e~ cd seoses ,pe/|p|e/o| vo:cu|o/ o|:eo:e, connec||ve ||::0e o|:eo:e, p/os|o
: ||:o ~oy ~o~|es|v|oc|o~o~
_
sy~p|o~s Ac|o~o~c ~po ~e~|oeco~es~o|e
p|o~oc~ced v| odvo~c ~goge, p|oo~ged oedes|, o~d vo ocs~ed co| o~s.
2. Ac|o~o~ csy~p|o~s o|e |o|e y|eso' e ~o~ |es|o| o~ o| oc ~de'y ~g
i ~ess,o~d|ed og~osso||e~ s~odeoosedo~|ecombi natio of autonomic
I
1 222 Neurology
i mpai rment and other cardi nal si gns/symptoms. oexo~p e, |e |o ov cg
d ogcoses|eo|ceoc|oco~ csy~p|o~s cco~o co| ocv | o|~e|s
o |o/|o:oo:, '|,|ogeoodys ces o, g d|y, pos|co cs|oo |y , es|cg
|e~o c 'os csocs|
o Cu||oo 5o//scoocc|e ocse|, oscecd cg poo' ys s, o|e| ex o, oc|o
co~ c cs|oo |y
c |e/p|e/o| vo:cu|o o:eo:e, oooe|e:o|os|o|c ypo|ecs oc, ~po ed
d s|o c cc o| oc, poo voccd ~eo cg c ex|e~ | es , ~ypegyce~ o c oo
oe|e:|
3 . ^ocoge~ec|o|oc|oco~ cd sodeso|ec ssy~p|o~o| c, ooce ||e uooe/|y
og cooo|oo |o: oeeo oogoo:eo ooo : oeog |/eo|eo
o |os|o|c ypo|ecs oc ~o c|o cgood ydo|oc ocd sod c~, godco
pos|co c~ocges, d scoc| cceypo|ecs oc ~ed co| ocs, ovod po'ocged coc
' v 'y coo~ydoco|soce ~oy oe e p|c c po|ec|s v|~ d || cc ||o coc|o o
|~os|os s
o o' odde dys|c cc| oc| occ d o oddes ~oy espocd |o oe|ocec~o
Spos| c o odde|s ~oy oe |e oxed cs cg popocl e ce ocd/o| oxyoclyc c
' c|e~ ||ec|se|co|e|ezo| oc o||ec s e p|c c pevec| cg c coy ccoc| cecce
cce|o cpo|ec|s , u||p|e :c|e/o::, :poo| co/o o:eo:e|
c Sexco dys|c cc| oc pec e ~p oc|, ~ed co| oc , ecdoc ce ocd co
og c/gyceco ogcevo co|oc
D I P L O P I A
H I NT: I S CT DON E?
Central
Hemor r hage, cerebel l ar
I nfa rct/TI A
Neopl asm ( brai nstem tu mor)
Toxi c/metabol i c
Peripheral
I nfect i ous/men i ngi t i s
Subarach noi d hemorr hage/aneurysm
Cancer ( carci nomatous meni ngi t i s, caver nous tumor)
Thyr oi d opht hal mopathy
N0u/OlOQy 223
D i abetes
Orbi tal process ( orbi ta l fracture/mass)
Neu romuscul ar j uncti on di sease ( myasthen i a)
Eye probl em ( l ens subl uxat i on)
CT WH OM? MOST CT I MAGE D
Central
CVA/i schemi a, brai nstem
Toxi ns/dr ugs
Wer ni cke's
Hemorrhage, cerebel l ar
Oncol ogi c ( brai nstem tumor)
Mu l t i pl e scl erosi s
Peripheral
Myast heni a g ravi s
Orbi tal process ( or bi tal f racture/mass)
bubarachnoi d hemorr hage
Trauma ( shear i ng I nj u ry to crani al nerve)
Caver nous si nus process
Thyr oi d opht hal mopathy
I nfect i ons ( herpes zoster ophthal mi cus)
Ma l i gnancy ( carci nomatous meni ngi ti s)
Aneul ysmal compressi on
Gra nul omatous ( sarcoi d, Tol osa- Hunt)
Eye probl em ( l ens subl uxati on)
Di abetes
^|so unoe| |e||p|e|o|. |nc|eoseo |n||oc|on|o| p|essu|e os | n pseuoo|uoo| cere

o||j con couse c|on|o| ne/ve |C|;\| po|sy ||| |esu||on| o|p|op|o
Notes
p' op o s|esco ec|vesy~p|o~ o|doco' ev s oc .
Dysconj ugate gaze s |e oo, ec| ve exo~ co| oc| cd cg o|eye a. so| gc
~ec|, v c~oy o|~oy^o| oeossoco|edv | sy~p|o~so|d| p' op o.
224 Neurology
1 . :xo~ ^o| o^ ^c' cdes d ec|oose|vo| o^ o|eye ~ove~e^|s ^o oxes o|
~ove~e^|. 'oes |e po|e^| |epo| eso c| o^ o|d p' op o |o^eeye s coveed-
's |e v sco' occ|y ^ oo|~ eyes eqco -
2. '|cgso^d|ox ^soe o co~~o^ cocseo|d p op o ||e^d ^goge^|s ^
c cdecooo~ozep ^e, p~e^y|o ^, o^do' co~o
3 . Co^ge^ |o s|oo s~cs, | ^o| co|ec|ed, eods|o scppess o^ o| |e v sco
~oge||o~o^eeye !cs, | s poss o e|oo po| e^|v | ~oov ocs ydysco^ c
go|e goze no| |oco~p o ^o|d p op o
4. ^o^occ o d p op o , d p op o v |~ o^e eye coveed| o' ~os|o voys s sec
o^doy|o ^|oocc od seose.
5 . A CN ' | ' palsy ~oyoeo cocseo|d p' op o A co~p e|eC'' ' po sycocses
p|os s, ^oo |y|o ~ove |e eye cp, dov^ , o ^vo|d, o^do d o|ed, c^eoc|ve
pcp ^o^y oe ^co~p e|e Co~p|essve es o^so|C' ' , o^ec|ys~s, |c~os|
o|e ~os| e' y|ococse pcp oy ^vove~e^|o^d s~oc d oe ~oged A po|e^|
v | oppop| o|e ~po ~e^| o|eye ~ove~e^| o^d ^o pcp ' o|y ^vo ve~e^|
~os| se yoso medi cal CN ' | ' palsy , pesc~ed |o oeo ~ co ^|oc|o^o||~e
^eve | oes| , espec o y | |~e po| e^|~osd ooe|es Ce^eo' ' y|~esepo|e^|s do
^o|^eedo oo ^C!, o^d po' syesoves oveo |ev veess !eys~oc d oe|o'
'oved c'ose'y, ~oveve, |oe^sce |~o| |~epcp does ^o| oeco~e ^voved
6. ' p op oco^ oeo ~o^|es|o| o^o|cavernous si nus di sease. !~ecove^ocs
s ^cs so^ ^|oc|o^ o co~po||~e^|oco|ed oe~ ^d |e oo |o^d o|e|o |o |e
p |c|oy !e coo|d o||e|y, C's ' ' ' , \, o^d \ , o^d|~e\I o|o^c~ o|\ poss
|ocg~ |~s o|eo !~e\z oo^c~o|C' \ occcpes|~e ~os| ^|eo| po|o^ o|
|e cove^ocs s ^cs \~e^eveo co~o ^o| o^ o| C' de| c |s ^vo v ^g ' ' , '\,
\ I , \z, o^d/o\ sde|ec|ed, o s||cc|co' es o^ ^ |~e cove|^ocs s ^css~oc d
oe |c ed oc|v |~o^ ~og ^gs|udy, pe|e|e^| o' 'y o godo ^ c~e^~o^ced^<'
7. Herni ati on so co^d | o^ v~ee o scpo|e^|o| o ~osscocses o|e|o d s
p' oce~e^|o| |~e oo ^s|e~ od co^ cocse o^ ps ' o|eo' po' sy ^vo v ^g |~e
pcp o| e^|s vooe ~e|^ o| ^g ~ove o' |eed ~e^|o s|o|cs, o^d|cso|e ^o|
'sey|o oe co~p o ^ ^go|o^y|~ ^g, e|o o^ed p' op o !~e|ypco c ^co p c
| ce ^ v~ c ~e ^ o| o^ s o co^ce^ s |eco~o|ose po| e^|v | o o ov^
, e , |xedo^dd o|edj pcp ' e^ o| o^ |eqc es ~~ed o|e||eo|~e^||o|edcce
^|oco^o p|essc|e , ~ype|ve^| o|o^ , ~o^^ |o | o^d po~p|C!sco^^ ^g|o de
|e| ~ ^e |~e cocse o| |~e p|oo e~. |o||en|s ||| o o||o|eo pup|| ono o no|oo|
oen|o| s|o|us o|e no| |em|o||ng
, 8, Ce^||o' cocses o|d p' op o s|ed ooove ^vove p| ~o y |~e oo ^s|e~ o^d
ceeoe' c~ !ee~oyoeo|e|evde^ceo|oo ^s|e~ o ceeoe' ' o|dys|c^c|o^
,o|e C' po' s es, o|ox o, ype|e| ex o, cpgo ^g|oes, e~ poes sj |oog|ng
s|uo|es o|e |no|co|eo |n po||en|s ||| o||e| |oco| neu|o|og|c ||no|ngs.
9, e| pe|o' cocses o|d p op o ' s|ed ooove ^vo've |~eeye |se| o^dco^ o'
^e|ves , ' ' , '\, \' j A coe|c op|o ~o' og cexo~ ^o| o^ svo|o^|ed, po|cc
o' y ^ coseso|~o^occ' o|d p' op o |oog|ng s|uo|es o| ||e o|o|n gene|o||y o|e
no| neeoeo |o| |n||oocu|o| couses o| o|p|op|o, oeo|co| C|||| po|sy, o| oyos
||en|o g|ov|s oveve|, ve^ cce|o ^oooc| exo~ | ^d ^gs, ~og ^g ~oy
~e p|oe' ~ ^o|e|e~o|e o~ ^ocsposs o ' | es.
N0u/lOQy ZZO
D I Z Z I N E S S
So Ver y Di zz y Now
S yncope/presyncope
Verti go
D i sequ i l i bri u m
Nonspeci fi c
OL D SPI N NI NG MAMA
Otol i th ( beni gn posi t i onal verti go)
Low bl ood sugar
Demyel i nat i on ( mul t i pl e scl erosi s)
S troke/TI A/bl eed
Post-trau mati c
I ntravascul ar vol ume depl et i on/hypot ensi on
N eu roma/neopl asm
Neu roni t i s/l abyri nt hi t i s
I ntoxi cati on ( EtOH, drugs, medi cati ons)
N eu ropathy/myel opathy
G I bl eed/anemi a
Mu l ti factor i al /mi grai ne
A mi nogl ycosi des/ototoxi c medi cat i ons
Men i ere's di sease
Anxi ety/hypervent i l at i on
ZZO Neurology
A H OBBL E D MAN SP I NS
Anemi a
Hyperventi l ati on/psychi atr i c
Other ( mul ti factor i a l , mi grai ne)
B eni gn posi ti ona l vert i go
B l eed/hemor r hage
Labyri nthi ti s/vesti bul ar neuron i ti s
E ndocri ne/metabol i c ( hypogl ycemi a)
Demyel i nati on ( mul t i pl e scl erosi s)
Meni ere's di sease
Ami nogl ycosi de toxi ci ty
Ne u ropathy/myel opathy
Syncope/hypotensi on
Post-tra u mati c
I ntoxi cati on ( Et OH, drugs, medi cati on)
N eu romalneopl asm
St roke/TI A
Notes
1 . A co~p o ^| o|d z ^ess ~oy~eo^d||e|e^| |~ ^gs|od ||e|e^|peopl e !|y
|o ~ s|o co' ' yde|e~ ^ev~ c~co|egoyo|sy~p|o~s|~e po| e^|~os ,|~eseco|e
go|esco^oe |e~e~oe|ed oy|e~^e~o^ c 5oVe|yDzyMov
o Syncope/presyncope: ' g~|~eoded^ess, |o ^|^ess, pos|c|o x ~oe
e y|o ^c' cde o~y|~~ o, deceosed co|d ococ|pc|, o|~os|os s, oc|o^o~ c
^ec|opo|~y, vosovogo' e|ex.
o Verti go: ' ' ' cs o^ o| ~ove~e^| o| po| e^| o sc oc ^d ^gs, o||e^ v |~
^ocseo, vo~ | ^g x ~o|e ' e y |o ^c' cde oe^ g^ pos | o^o ve|| go,
ooy ^|~|s, ^e^ ees, ^S, pos|||oc~o| c, ves| oc o^eve ^eco~o
c Di sequi l i bi rum: c^s|eod ess, |ee ^g d c^, c c~s ^ess, vooo y 'x
~oe e y |o ^c cde dcg ^|ox co| o^ , :|, o~ ^ogycos de o|o|ox c |y,
sevee pe p~eo ^ecopo|~y, ~J | |oc|o o .
d Nonspeci fi c: A^x e|y, veo^ess, vogce, d || cc | o desc oe x~oe
e' y|o ^c cde~ype|ve^| o| o, sys|e~ cd seose , o^e~ o, ~e|ooo' cl , ~c |
|oc|o o' .
N0u//OQy ZZ/
2 . \e~ exo~ ~ ~g o po| e~|v | ~ d zz ess, | y|o epodcce |~e po| e|s
sy~p|o~sv| ovo|e|yo| ~oe.ves
o C~ec|oo|os|oss oy o ood pess.e od pc se ,s.p e od s|o~d gj
od ~o|eoys.o ec|veco~p' o ~|s| epo|e~|os
o e|o~ | ~eo' e , oooy| ~o~e.ve ,see o | |od ogose oe g
pos |oo ve|go.
c ypeve| o| o ~oyepodcce sy~p|o~s o|d zz ~ess ossoco|ed v |
o~x e|yopo co||ocs
d \o so vo ~o~e.ve ~oy epodcce sy~p|o~s eo|ed |o deceosed co
d ococ|p.|
A po| e|~oyco~p o o| so~e |o~ o|d zzessv|~ ~o|e|o~ oeo| |~ese
~oecves | s ~os| ~e p|c ||~e po| e|co~ de|e|~ ~ev c~ ~o~ecve oc|.
o y|epodcces|esy~p|o~sco~p s ~g |~ec~e|co~p o |
3. \e|eoooos o sce~ o oe|y co.:e: :o|o|eo ve|go ves| go|e |o|
o.g~ y |o o|~eev dece o| oo s|e~/ ceeoe o dys|.~c| o~ , o|eco o'
~eve po s es, o|ox o, ypee|ex o, .pgo ~g|oes, e~ poes s| .
4. ^eoee: o:eo:e s ossoco|ed v |~ ~eo g oss 5eogo po:|ooo| ve/|go
od |ooyo|||:/ve:|o.|o oe.oo|: o|e~o|
5. ~ ~oycoseso|d zzess, ~os ~g e|oc|os|o~dso.|os|eco.so|veo~e
A co~o ~o| o o| |oc|os ~oycosp e |o ~oe |~e po| e~| ~oe sy~p|o~o| c
|o~ o~y oe|oc|ovoc d o oe oexo~p e, o po| e~|~oy~ove ~ d oo
oe|c oe./opo||y, co|ooc|:, o~do s|oyo| o|co|o| oo.:e !e co~o o| oo|
pe|peo e.opo|~y, deceosed v s.o occ |y, od d ~ ~ s~ed ceeoe o|.c
| o~, p cs |e poss o |y o| o d ooe|c oc|oo~ c ecopo|y, pc| | s po| e| ~
|e ~c ||oc|o o .o|egoyo| | sd ||e|e| o d og~os s
6. 5eogo po:|ooo| ve|go 5|\j scooc|ezed oyo||ocso|ve||go|o ov
go coge ~ eod pos | o~ , ~os|co~~oy o gove oed o| ' oo g
.p ' | s~os|co~~o~ |ee de yod s|ocg~||ooeco.sed oy|ee| oo| g
co c | co| o~s,o|o |~s| ~|~epos|e ose~ c c.' ocoo
o !e Hal l pi ke maneuver s .sed |o d ogose | scod | o !e s|o| g
pos|o~ sv|| epo|e~|s|| g, |eexo~ es|o~d ~g| o| es de, o~d|oc ~g
| epo|e|,v | ~| eexo~ ~eso~dss.ppo| ~g| epo|e|s ~eod !~epo|e|
~oyo' do~|o|eexo~ ~es e' oov !e| ~o' pos|o sv|~|~epo| e|scp ~e,
eyes ope~, |~eec ex|eded JJ oeov|~ep oeo||~e oed, od|eeod
o|o|ed JJ o|eo y|ovod |~es de oe g|es|ed ,|e s de |eexo~ e so|
!e~oe.ve voves op dy ~ov g| ~epo| e||o~ |~e | |s| pos | o~| o|e
seco~d !e|es| scos deed pos|ve , d ogos|c|ooe gpos | o~o ve|go|
|, o||e o o e| o|ecyo| JJJ seco~ds, |e po|e| deve ops o |os oo ~ys
|og~cs |ed ec|o o||es de oe ~g|es|ed. 3po~ s |g .p, |ee o||e so
|o|s oo ~ys|og~cs |e oppos|ed ec| o :oc s de s |es|ed |o de|e ~ ~e
v c~s de s voved ccos oo y, oo| s desoe o||ec|ed
o .Torsi onal nystagmus s |~e ~o ~oo| o\ !~e eye on |e s deo||~e o|
|ec|ed ooy ~| de~os|o|es o ~os| y o|eo ~ys|og~.s |ovod |e o||ec|ed
s de, v~ ' e|~eoppos|eeyesovs o ~oeo|o|oyco~poe|, v|~ |e|op o|
|eg ooe o|o| ~g|ovod |~eo||ec|ed s de.
ZZ N0ulOlOQy
c Avo o| o o| |e o ' p e ov os Epl ey's maneuver ~oy oe csed |o
d s odge |e o||e~d ~gco c | co| o~ !e o' p e s pe|o~ed |o |e sy~p|o
~o| cs de, |e , v|~oc|o ov~g |~e po|e||o s| cp, |~e po|e| s oed |o|~e
osy~p|o~o|cs de ^|oo ' o|eo decco |cspos | o~ ~o 'y, |o~|~ s' o|eo decc
o|cs pos| o~, |~epo| e^|s o oved |o s| cp !~e po|e~|soc d|ee' ve|| g ^ocs
|~|ocg~oc||~e~o^ecve, oc||o|e | sco~pe|ed, |eve|gos~oc d eso've
d ' |:peys ~o~ecve| s c~scccess|c' , |~e po|e^|co~ oe ~s||cc|ed ~ ves| oc
o exe|cses|o deses| ze |~eves| oc o|oppo|o|cs !~ese co~ss| o|se |od~ ~
s|eed o p e ~o~ecves do^e |vo |o |~ee | ~es o doy, v |~ |ve epe| | o^s
eoc~ | ~e
e \es| oc o|scppesso~|ssccos ~ec' z ~e p|oo^g| ~epeod o|ves| oc o|
deses|zo|o~ o^d oe ge~e|o y ess ~e p|c , excep| ~sevee coses ^vo v ~g
de~ydo| o^ s|o~ ocseo o^d vo~ | g
H E A DAC H E
CT SCAN ME?
Cl uster
Tensi on
Si nusi ti s/oti ti s/mastoi di t i s
Cravi ng ( drug-seeki ng vs. rebound)
Aneu rysm/a rter i ti s
Neu ral gi a, tr i gemi nal
Mi grai ne
E l evated i ntr acrani al pressu re ( subdu ra l hematoma,
hemorr hage, AVM, t umor, pseudotu mor,
hypertensi on, hydrocephal us)
/|:o |n|ec||on |oen|ng|||:/oen|ngoencep|o||||:j, oe|ooo||c, p:yc||o|/|c, po:|||,
o:|eoo/||/|||:, po:|concu::|ve, :|nu: ||/oooo:|:
N0ulO/OQy ZZ
l
CAN' T STOP H EAD PAI NS
Cl uster/mi grai ne
Arteri ti s ( temporal , l u pus)
Neu ral gi a ( tri gemi nal )
Tensi on headache
Si nus t hrombosi s (venous)
Trauma ( post-concussi ve)
Usteoarth ri ti s/muscu l oskel eta I
I
Post- LP

. Hydrocephal us
E l evated bl ood pressu re
I A neu rysm/subarachnai d hemorr hage
o rugs ( opi ate rebound headache, steroi d wi t hdrawal ,
oral convacepti ves)
P seudot umor cer ebri
Arteri ovenous ma l formati on
nfect i ons ( meni ngi t i s/meni ngoencephal i ti s)
Neopl asm
S i n usi t i s/oti ti s/mastoi di t i s
Also: psychiatric, metabolic (hyperthyroid, Cushing's, chronic lung disease with
hypercapnia)
Notes
eodoc~e so geceo |e~csed|odesc| oeocypo ^|c' se^so| o^ ^vo' v ^g|e
s||cc|ceso||ec|o^ c~, |oce, ocd/o|cecs
1 . s|oy so' ~po|o^| ^ |~e d og^os so| eodoce. ces| ocs|oos\ c
c cde|e |o''ov ^g
o |ec p |o| ^g|oc|o|s s||ess, |oc~o, ce||o ^|oods, co||e ^e, o co~o , | ~e
o|doy, dcgcse
o odo~osy~p|o~sv sco sco|o~o, |ocoveos^ess/cc~o^ess, opos o
c <op d|yo|ocse|seco^ds, ~ ^c|es, oc|s
d 'eco|o^ , cc oo o|e|o , |e~poo , occ p |o' , ce|v co j o^d ^o|ce ,loo
o |ig, s|ooo ^g, p|essce e, o^c co| ^g| o| po c
e Assoco|ed sy~p|o~s cocseo, d p op o, ve|go, vo~ | ^g, oc ~o| oc,
230 N0u/OlOQy
|eve, go | d s|coo^ce, o' |eed ~e^|o s|o|cs, se zces, p~o|op~oo o, exoce|
o|ed oys|od g
| 'co| o^ seco^ds, ~ c|es, ~ocs, doys, do y/c~o^ c
g A ev o| g |oc|osqc e|, s' eep, oo ges cs, doess, p.esc|p|o^ ~ed
co| o^s
~ |~e pe| ^e^|~edco ~ s|oyco^ce, ~ype|es o^, pego^cy, ~ s|oy
o|s ~ o ~eodoc~es, |o~ 'y ~ s|o|yo|~ go ^e, ~ed co| os, ||oa~o
2. !o scoo ^o| | osco^\o| so~eco~p o ^|s scc~osnew-onset severe
headache, sei zures, recent change in pattern of a chroni c headache,
and/or focal neurol ogic deficits ~oy ^dco|e| ~e^eed |oo ~og ^g s|cdy
oveve, oc| ^esco^ g o|po| e^|s v|~ sy~p|o~s o|c' oss c ~ go ^eo^do
^o|oco ^eco og cexo~ ~oso vey ovy e do|eveo ^go |eo|oo e ^|oco
^ o' oo^o~o |y <oc| ^esco^ ^g o|po|e|sv|~c~o c~eodoc~eco~p' o |s
, ~ g|o ^eo^o^~ g|o ^e| od o o^|oco ^ec|o og cexo~ o so|e^ds |o ~ove o
ovy e do|de~o^s|o| g||eo|oo' e ^|oco^ o d seose
3. Appooc~ |od og^osso|c~|o^ c ~eodoc~e see|oo' e. oe ovoe o||ypes
o|c~|o^ c~eodoc~es |~o|do^ ||| ve' ^|o|~eseco|ego|es, ^c cd g|e~poo'
o| e | s, ' cpcs, so~e p | c |o y|c ~os, c cs|e ~eodoc~es, ~ype|cop^eo sec
o^doy|o pc ~o^oyd seose, odso~ee^doc^opo|~ es
Approach to Di agnosi s of Chroni c Headache
C~ooc|es'cs
Cse|
!~ecocseo|
po
.a|o|o
ocs,doys|
'oco|o
ao |,o| po
'ocseo,
vo~ |g
'g~|od ^ose
ses|v|y
Migraine
^c|es
^ox ~o 1 5-60
~ c|es,
normal between
headaches
oasvees
J 'o|eo' , oc| co
oeoe|~esde
!~|ooo ^g, pcso|e
Common with
headache
Co~~o
eodoc~e!ype
Tension
oasdoys
^odeo|e, waxing
and wani ng,
may be
persistent
, .oys|vees
,~o|~s|

'o|eo , esp
|o|o' , occp|o
Ac~ey, pessa|e' e,
~csce|eso
'o
'o
Elevated fep
.oys-vees
Gradually worsen
i ng ove|~e
~o^|~s
d o|eo ||oco
eso, o|~e
vse oo|eo
`|essae' e, da'
'oc|co' , early
morning
'o
(Table continued on next
p
age. )
N0ulOlOQy 231
Approach to Di agnosi s of Chroni c Headache (Continued)
Characteristics
Headache Type
Migraine Tension Elevated fep
Focal neurol ogi c
si gns
Stereotyped and No
transient, often
Gradual onset and
progressive,
sometimes
di pl opi a
Seizures
Papi l ledema
vi sual (scotoma)
Very rare No
No No
Occasi onal
Yes
4. Summory o| spec|ceodocejpes
. Type Symptoms
Cl uster
Mi grai ne,
common
Mi grai ne,
cl assi c
Temporal
arteritis
I ncreased
i ntracrani al
pressure
With
focal
lesion
Without
focal
l esion
Post-LP
Uni lateral stabbi ng peri /retro-orbi tal pai n; i psi lateral l acri mati on,
rhi norrhea
Occurs i n "cl usters" of dai ly attacks over a period of weeks,
between cl usters may be asymptomatic for weeks/months/years
Duration usual ly 1 5-30 mi nutes, may l ast 2-3 hours
Unl ike mi grai ne patients, may be agi tated, general l y do not si t sti l l
Episodi c, recurrent, throbbi ng, uni- or bi l ateral pai n
Associ ated with l i ght and noise sensi tivity, nausea and vomi ti ng
Duration usual ly 2-4 hours, may l ast up to 2-4 days
Patients seek quiet, dark areas and try to sleep and be sti l l
Si mi l ar to common mi grai ne but preceded by focal neurol ogi c
di sturbance (vi sual scotoma, numbness, aphasi a, vertigo) and
l asti ng a few mi nutes to an hour
Throbbi ng temporal or bitemporal pai n i n el derl y patient
Associ ated with monocul ar visual l oss, j aw cl audi cati on, tender
temporal artery( ies) to pal pation
Wakens from sl eep
Associated with earl y morni ng vomi ti ng
May have papi l l edema on funduscopic exami nation
Tumor -focal neurol ogi c deficit, seizures, h/o systemi c cancer
Abscess-focal neurol ogi c defi ci t, sei zures, may have fever,
evidence of systemi c embol i (check fundi , nai l beds, cardiac
mur mur)
AVM-focal neurol ogic deficit, seizures, head brui t
Pseudotumor cerebri -.may have visual l oss (decreased vi sual
fields and/or decreased vi sual acuity), sixth nerve palsy/di pl opia
Hydrocephal us-may have gait disturbance, decreased upgaze,
i ncontinence
Often positional , better when l ying down
Duration may last up to a week
(Table continued on next page. )
ZJZ N0u/lOQy
Symptoms Type
Subarachnoi d
hemorrhage
Abrupt onset, may have i ni ti al l oss of consciousness
"Worst headache of my l ife"
May have fever, stiff neck, al tered mental status
Meni ngi ti s/
encephal i ti s
Tension
Associated with fever, stiff neck, al tered mental status
May have seizures (especi al ly herpes encephal i ti s)
"Pressure-like" or " hat-band" bifrontal or bi occi pi tal pai n
May be associated with neck/shoul der/back pai n
Often chroni c
Rebound Associated with worseni ng of headache as anal gesics/narcotics
wear off
Di agnosi s of excl usion
5. !eopy|o ~eodoc~e s depecde^| oc |~ed ogcos s !eo|~ec|v |~ oco
ges cs/^oco|cs ~oy|e~poo y o ' ev o|e d sco~|o|, oc| does co||eo||~e
co.seo||e~eodoc~e I n general
, beware of treati ng pai n whi l e leavi ng the
underl ying etiol ogy untreated , e g , ~e^ ^g | s, ~e~o~oge|
L o s s O F C O N S C I O U S N E S S
VAGAL SYNCOP E
Vol ume l oss/bl eedi ng
Aort i c di ssect i on
Gl ucose drop
A utonomi c dysf unct i on
Low ca rdi ac output
Sei zure
Your mama's vi si t i ng/a nxi ety/psychogeni c
N euroca rdi ogen i c/ref l ex
eVA/subarachnoi d hemor r hage
Orthostati c hypotensi on
P u l monary embol i sm/per i pheral vascul ar di sease
E l evated bl ood pressu re
/|:o oo:||o/ |g/o|oe
N0ulOlOQy Zdd
ACLS ! I HAVE TO PASS OUT
Aorti c aneu rysm/di ssecti on
Cough/mi ctu r i ti on/refl ex syncope
Low gl ucose
Si nus hypersensi ti vi ty, ca roti d
I at rogen i c/drug/medi cati on
Hemorr hage, suba rach noi d
A utonomi c neuropathy
Vasovagal syncope
Et hanol i ntoxi cati on
Transi ent i schemi c attack
Ort hostati c hypotensi on ( hypovol emi a, poor vascu l ar
tone)
Psychogeni c
Asystol e/heart bl ock
Sei zure
Subcl avi an stea l
Outfl ow obstructi on
U nderpowered hea rt/car di omyopathy
Tachyar rhyt hmi a
/':o oo:|'o ogo|oe
THI S MADE ME VAGAL
T l A/cer ebra l i schemi a
Hypertensi on
I ntracra n i a l hemor r hage ( suba rach noi d)
Sei zure
Myocar di al i nfarct i on
Aort i c di ssecti on
D rugs/al cohol
E moti ons/psych i atr i c
Zd4 N0u/lOQy
Mi grai ne
E mbol i sm, pul monary
Vol ume l oss
Arrhyt hmi a
Gl ucose drop
Autonomi c
Low ca rdi ac output ( congest i ve heart fa i l u re, aort i c
stenosi s, pul monary hypert ensi on
/|:o neu/oco/o|ogen|c//e|ex :yncope
otes
Sy~cope , e , |o ~| ~g| sde| ~eooso |o~s e~|oss o|co~sc ocs~ess o~d pos
'.o |o~e dce |o ~po ed ceeoo oood |ov
I . A desc p| o~ o| |'e spe s ccc o |o oppopo|evocp o~dd og~os s
!'epo|e~|osve oso~yeyev|~essess'oc d oeqces|o~ed ~po||o~| ' s|o
co' ~|o~o| o~co~ oed vded ~|o|'ee| ~epeods
o Prior to |eevenlpos|.o c'o~ges ,e g , po|e~|s|o~ds cp| , p|ecp|o|
~g |oc|os , s pped ~eo s, p'ysco exe| o~, sevee s|ess, cocg', ~ c|c | o~| ,
sy~p|o~s , 'eodoc'e, d zz~ess, c'es| po ~, s'o'~esso| oeo|', 'eo| po p|o
| o~, |o ~|~ess, |oco ~e.o og csy~p|o~s, ~o.seo| , o~d eyev|~essdesc|p|o~s
, o' |eed oe'ovo/~e~|o|o~, po o, excessvesveo| ~g|
o DJ|| cg|eevenl, .sco y|o~|'eeyev |~ess| op d|yo|o~se|, d.|o| o~
o|ep sode/.~espo~s ve~ess, ovo c~|oy~o|ooc|v|y, op~eo, ove| sez.e
oc|v'y, ~ .y|o |'e po|e~|, oss o|co~| ~e~ce
c Alle||e eveclo e~|o| o~/espo~sve~ess, o~~es o, op d |y o| ecov
ey |o oose' ~e~e~|o s|o|e, ecc|e~|epsodes
' ~ odd | o~, pe|~e~| ~|o~o|o~ ooo.|p|eex s| ~g ~ed co' co~d | o~s, cce~|
~ed co| o~s, ece~|o co'o / d.g ~ges| o~, o~d |o~ 'y ' s|oyo||o ~| ~g o|
sez.es soc d oesocg'|
2. Co~d | o~s|'o|~oy ~ ~ c sy~cope ~c cde :e|zu/e, o/ug/o|co|o| |n|ox|co
||on, :uoo/oc|no|o |eoo//|oge o~d oo:||o/ o|g/o|ne Co~d | o~s ossoc o|ed
v|' |o~|~ess oc| ~v'c' co~pe|e osso|co~sco.s~ess s oe ~c .de |ypo
g'yceo|o, oneo|o, |ype/ven||'o||on, pon|c o|:o/oe/, o~d |y:|e/|o
3 . !'ed ||ee~| o |o sy~cope co~ oe|'o.g'|o| ~ |o. ~o o co|egoes
o Neurocardiogeni c-reflex ~' o|o~o|'eo|vo o.|o~o~c~evocssys|e~
' ~c cdesvosovogo o||oc, coo|d s ~cs sy~do~e, ~ c|c | o~, co.g',
vo so vo, e~o| o~o s|ess
s| ~g. s'ed oy |'e pese~ceo| pec p |o| ~g eve~| o~doose~ce o|
cod oco~d pe p'eo voscc opo|'oogy Js.o 'y ~yoc~ge| peso~s
N0u/O/OQy 235
o Orthosta|| c -dop oood pess.|e d.e|o ~oo |y |o ~o |o ~voscc o
|o~e
^ed co| os, pos|.o co~ge, e.opo| es , espec o y oc|oo~ c| ,
ecodegeeo|ved seose, pe peo vosc.' od seose, ypovo e~ o
s| gc sed oy o|os|o| c |ocycod o/ypo|e~s o~ o. exo~, o~d
s|oyo| spe scoe o| ~gv| pos|co co~ge.
c Card ogen c-d ec|cod ocpo|oogy
Cod o~yopo|y, oo|c vove d seose, |ocyoy|~ o, oodyo|y|
~ o/osys|o e
s| ~gc sed oy cod ocsy~p|o~o|o' ogy , e g , ces| po ~, po p |o
| os| , sov cod ocd seose, od :CC ooo~o |esdc ~gspe' '
d Other-~ sce oeocs
ypogyce~ o, ceeoo sce~ o/ ~|oc|, ~|oc|o~ o e~o oge,
oos o ~ go ~e, dcg/o coo ~|oxco| o , pc ~ooye~oo s~ , ':| ,

oo| cd ssec| o~
Sys|e~ c~e|ooo ccocses, ypogyce~ o, |oxco| o| ossoco|edv |
vooz ~ess , ~oe god.o' o~se| \osc.' o cocses .s.o' y d.e |o o
scdde~ ~eco~ co oos|cc|o~ o|ceeoo vosc. o|.e , |oc|, d ssec
| o~| . Co|os|op cco.ses ~c cde ': o~d ~||oco~ o' oeed
4. <e|ex sy~cope s d.e|oexcessvevogo s| ~.' o| o , v c sovs |e eo|
|o|eod deceosesce|eoo' o' ood |' ov, co.s ~g .~co~sc ocs~ess Caroti d
si nus syndrome sd.e|o excessvepess.ese~s | v|yo||ecoo|d s ~.s ! g|
co os o o|e ex|e .o' pess.|e o~ |e ~ecs co~ povose sy~cope |e|
s~ov~ p|ovoco|e.s o| e|'ex sy~cope ~c .de ~ c|. | o~ , vo sovo ~oe.ve,
o~dcocg g Vasovagal syncope so |ype o| e|ex syocope | gge|ed oy
po ~, |eo, o o|e s.dde~ e~o| oo s|ess | |yp co y occ.s odo' esce~|s
o~d yo.~g odc|s o~d ~oyoe ~o|e ' se y ~|e se|| ~go| po oged s|o~d ~g,
|o| gce, o~d/o|os| g
5. ^ed co|o~sco~~oy ~p co|ed o|os|o|c ypo|es o ~c cdeo~| y
pe|es ve d.gs, d ce|cs, |og'yce| ~ odo|eo|e o vosod o|os, || cyc c
o~| depesso|s, peo| oz ~es, | .~, co' c .~ co~~e' o ocses, o~d oe|o
o'ocses
6. Codoc co.seso|sy~copeco~ oe eveo ed oy pysco' exo~ o~d :CC |
~oyoe~ecessoy|o ~o~ |o po|e~|sv| cod oc|e'e~e|yo o o|e~o~ |o
|ode|ec|o |o~s e~| oy|~ o :cocod ogopy ~oyde~o~s|o|e aorti c
valve di sease ocardi omyopathy.
7. ' | o vos.p|oo |o~s e~|osso|cosc ocs~ess s|o ys||o g||ovod
o AoCs, | epsodeove|, |e~ poceed v | |.||e|evo Jo| o~ ~c .d ~g s
|oy o~dexo~
o :CCo~doood p|essce ~o~ |os
c. Acc.cecs, p.' seox ~e|y
d .oooo|o|y s|cd es |o oe co~s deed e' ec||o' y|es, g' ccose, oU'/C,
CoC, e|oo , |oxscee~
8. c |e voscp , o~d |eo|~e~|| depe~ds o~ | e scspec|ed co.se o| |e
ep sode
o Sezce C!/^<' , ::C
Zd N0u/lOQy
o Cod oc co d oc |e e~e|y/o |e ~oc |o|, ec~ocod ogo~, co d oc
e^,~es
'c ~ocoye~oo s~\C sco^, p. ~o^oyocgogo~
c |~os|o|c so~e coses ~oyceed povoco|ve|es| cgscc~ os | ||oo e
d 'ecocod oge^ c | ^ | o vo.p ^ego|ve o^d ~ s|oyscgges|ve o|
e|ex sy^cope, geceo y co |c|~evocp seqc ed
e Ceeoovoscc o
Ao||cd ssec| oc/o^e.ys~c~es|xoy /C!, ocgogo~
Scoooc~co d ~e~o ~oge/ce|eoo o^e. ys~~eod C! ^<' ,
A^g ogo~, .~oo p.^c|.e
!ocs ec| sc~e~ c o||oc~eod C! /^<' , coo|c/ve|eoo dopp e|,
ocg og|o~, coogc o| o^ oos|cdes
| ^e|ooo c
'ypogyce~ oc~ecse|.~g ccose, od~ cs|e \g .cose
c|oxco| o oood e|~oco , sec~ o. ce'oxsceec
M O N O C U L A R V I S U A L L o s s
BLI N D
B l ood vessel s ( arteri ti s, hemor r hage, embol i sm)
Lens ( cataract)
I nfect i on
Nerve (tu mor, opt i c neuri t i s, g l a ucoma-vi a pr essu re
on nerve)
Detached reti na/ot her reti nal di sease
GRAVE VI SI ON E D
Gl a ucoma
Ret i nal /ocul ar mi grai ne
A rter i ti s, tempora l
Venous t hrombosi s ( centra l reti nal vei n occl usi on)
Embol i sm ( centra l reti nal a rtery occl usi on)
N0u/OlOQy 237
p
Vascul ar occl usi on ( ca roti d)
I nfect i ons ( CMV ret i ni ti s)
Seni l e cataract
I ntraocul ar bl eed
Opt i c neuri ti s
Neopl asm ( opti c nerve g l i oma)
E l evated ser um vi cosi ty ( si ckl e cel l , pol ycyt hemi a)
Detached ret i na
MONO- VI S I ONE D
Mi grai ne, ocu l ar/reti nal
Occl usi on, centr al ret i nal artery
Neopl asm
Occl usi on, centra l ret i nal vei n
Vascul i t i s, tempora l ( gi ant cel l )
I nfect i on
Seni l e cata racts
I ntraocul ar bl eed
Opt i c neuri ti s
Not monocul ar vi sual l oss
E l evated ser um vi scosi ty
Detached reti na
^|so. g|oucoo
Notes
^ococc' o v sco 'oss se |e|o sco ec|ve epo|o|||ocs ec|v sco' ' oss coce
eye ,osopposed |ooev sco' | e dlo|ocoo ec|ve | cd cgo|dec|eosed v sco'
occ|y c oceeye. secdo|c~o|ce|eo| ocdo|ecocses o| cceosed c|oco
c o' pessce gece|o' ' y p|odcce o o|eo s gcs/sy~p|o~s
1 . It is cri ti cal to di sti ngui sh between monocul ar vi sual loss and a vi sual
field cut. \ | ~oocc' o|v| sco oss, sco occ |y sd ~ c sed cone eye, ocd
|e |es|oc s c |eeyeoop||c ce|ve. \ |ov sco' | e dcc|, v s oc s ~po' |ed c
o pr| cc' oro|eoo| |ev sco'| e' d coo|n eyes, ocd| e' es oc s c| eop|c||oc|
Zdb Neurlogy
o| |~e o|o c Thi s di stinction can be made cl ear by testi ng vi sual acuity and
vi sual fields one eye at a ti me. So~e|~es, po| ec|s ~ s|oeo v sco' |e dcc| |o|
~ococc o v sco oss o^ |~e so~es de , oc, co^ | see oc| o| ~y e||eye | .
cexo~, ~oveve|, |~epo|ec|de~o^s|o|eso e||v sco' | e dcc| c oo|~ eyes
2 . !|ce ~o^occ o|v sco' oss s cocsed oy o ' es oc c |~e eye oop| c ^eve
, o^|e o|o |~e op|c c~ os~j , ocd| ~cs ~oy oe dce |o poo' e~s c |~e ecs,
e| ^o, o'oodvesse s, o| ~eop| c^e|ve |se'|.
3 . Amaurosi s fugax s|~escoec|ve co~p o ^| o|||o^s ec| v sco oss c o^e
eye, o||ec desc|oed oso ve o|s~odeco~ ^gove||~eeye !~ s sessec| o' y
o |ocs e| sc~e~ co||oco| |~e e| co, ocd ~oy oecocsed oye~oo |o~ |~e
~eo|||o|~ece^||o e| ^o' o|e|y, o^ c' ce|o|ed co|o|d p oqcecocs cge~oo o
occ cs o^, o||e~po|o o|e||s ^vov ^g|~eco|o|d o|ey
4. | sc| | co' co||o ~ ss |~ed ogcoss o| temporal arteri tis oecocse po~p|
||eo|~e^|coc d p|evec| co~pe|e ^|oc|oc o| |~e e| ^o !~e c osscc c co p c
|ce so pe|soc > oge o, v|~ c^ 'o|e|o o o o|e|o sevee ~eodoc~e, |ecde|
|e~po|o o|e|es, ovgode|eve, o^e~o, ocd e evo|ed :S< A~ocos s|cgox,
po' y~yo' g o |~ec~o| co, ocd ovc' ocd co| oc ~oy occc| !eo|~ec| sv |~
p|ed^ soce J l JJ ~g/d ocd soc' d co| oe de' oyed |o oo|o c |e~poo'
o||ey o opsy, oc|o opsy s~oc' d oe pe||o~ed o o|eo yv |~ ^ J doys o| ^ |
o|^g s|e|o ds. :S< s~ocd oe ~o^ |o|ed ocd csed |ogc de|~eopy ' ccoses o|
occ|e |e| co' sc~e~ o, ' \~e|~y' pedcso' oce ~os oeec csed
5. p~| ~o' ~oscop cexo~ ^o| o^ s o soo| g|eo| ~po|occe ^ evo' co| cg
~o^occ o|v sco oss, s ^ce ce^|o' |e| ^o' o|eyocc' cs oc , cec||o' e| co' ve ^
occ cs oc , |e| co de|oc~~ec|, co|ooc|s, c|ec| o^s/e| ^ | s, ~e~o~oge, o^d
op|cd scede~oco^oede|ec|ed
PTO S I S
L I D DROP
Li d i nfi l trat i on ( by tumor or i nf l ammatory t i ssue)
I nfecti on ( zoster, botu l i sm)
D i abetes/thyroi d
Drugs
.
Receptor qnti bodi es ( myast heni a)
Ocu l osympatneti c pal sy/ocul omotor pal sy
P roptosi s
Neurologv 239
TE NSI LON ME, DOC
Thi rd nerve pal sy
Eyedrops ( steroi d)
Neuromuscul ar j u ncti on di sease ( myastheni a)
Su rgery
I nfect i on ( herpes zoster ophthal mi cus)
L i d i nf i l trat i on ( by t umor or i nf l ammatory t i ssue)
Ocul osympatheti c pa l sy ( Hor ner 's syndrome)
Neu rotoxi ns ( botu l i sm)
Myopathy ( muscul ar dystrophy, myotoni c dystrophy)
E nophthal mos ( eyeba l l retract i on i nto or bi t)
D i abetes/thyroi d di sease
Opposi te l i d retracti on
Cl uster headache
^|:o congen|o| p|o:|:
!
i
I Notes
|
|os s so p~ysco | cd cgo|ocepo peoo' |ssce oe cgs~o e|~oc |~e o|~e,
e , o doop cgeye d
1 . |oss ~oy oe |~e esc |o|o po|| o oco~p'e|e|~ d ceve posy ,v|~ osso
c o|ed op~|~o' ~op' eg o ocd pcp ' o|y d o| oc/cceoc|v|y| . o| o |c' ' desc p
| oco|| |d ceve po' sy, see co|es5-9 ccde|~e eod cg' p op o, poge225.
2. '|oss spo|o||~eocc'osy~po|~e|cpo syo ocessyod|o~e,v ccoc
s s|s o| uni lateral ptosis, mi osi s ( smal l pupi l ) , ocd anhi drosi s of the face (de
creased sweati ng) .
!e sy~po|e| c po|voys go dovc |e sp co' co|d |o |e|o|oc c eve' ,
v~ee|eyex ||~ecodocdoscecd|e cecos|esy~po|e|c|ccs|o |~esc
peo|cev co' gocg oc, |ec |o ov |e c|eco coo|d o|eyocd, c' | ~o|e'y,
|~eVl d v s oco|coc o ceveV |o |~eeye.
Acy es oc | ~o| c|e||cp|s | e occ' osy~po|e| c po|voys coc esc' | c
oce|ssycd|o~e, cc' cd cg|c~o, ' ccg, ~ed os| co' , |~y|o d, poycgeo , y~
po~o, sp co' codj , |oc~o, ocd cocgec |o cocses, osve' ' os , ess ' se yj
coo| d d ssec|oc/occ cs oc, cev co' d sco|| o, ~ec cg | s, oo cs|e~ c|oc|,
sy cx, po o, pcec~o|oox, ocdA.5 As gc | coc| popo|| oco|o|ce|'scoses
oe dopo| c, v|~ o ~ g||eqcec| yo|d ooe|es ocd ype||ecs oc c | s . d o
po| cgocp
Z4 N0u/lOQy
3 . 'ec o~cscc o d seose, spec | co' 'y ~yos|ec o gov s, ~oy p|esec| os
p|oss ,o||ec o o|eo oc|osy~~e| c| ! so||ec sossoco|edv | | cc|co| cg
occ o po s es , d p op g |oc o veocess, veocesso| speec ocdsvo ov
cg, ocdcecocdsoc deg d' eveocess 'o| c|eqcec|'y, |e veocesso|
|ec|s |e ~csc es o| |esp o| oc . Cooc|e| s| co y, ~csc es oe |o| gcoo e |
sc. ec|ed | oscs|o ced coc|oc| oc . c, oy~csc es, s~oo| ~csc e, cod oc
~csc e, ocdsecso| ocoe cco||ec|ed
!e Tensi l on (edrophoni um) test s e p|c c |e d ogcos so| ~yos|ec o
^yos|ec o scocsed oy oc|oo| ood es |o |eoce|y co' ce, AC| ecep|o
'o~o y, ACcosses|esycopse, ocds |o |e ecep|o, ocd evec|co' 'y s~e
|ooo' zed oy oce|y co cees|e|ose,AC:| c ~yos|ec o, |eACecep|os
po|o ' y ooced, ocd AC s ~e|ooo zed oy AC:oe|oe |coc o cd |e |e
cep|o :dopoc c~ s oc AC: c o|o, de oy cg |e ~e|ooo' s~ o|AC ocd
cceos cg|e e' ood o|AC o cd cg|o|epo| o yo oced ecep|o !cs,
od~ c s|o| oc o| ed|opoc c ~ |o o ~yos|ec c po| ec| soc d cceose |e
s|ecg|o| cvoved ~csc' es
4. Ac eye d ~oyoppeop|o|cevec vec | s co~o , |co~pod |oo |e
||oc|ed eye d , e g , pop|os s| oc |e oppos|es de ' ev se, o co~o ' d ~oy
oop|o|c ||eeyeoo |se' |s|e|oc|ed c|o|eoo |dce|o osso|oo|o| ssce.
R I G I D I TY
DOPAMI NE
Dystoni a
Ul i vopontocer ebel l ar atrophy ( OPCA)
Pa rki nson's
A n kyl osi ng spondyl i ti s
Men i ngi smus ( meni ngi t i s, suba rachnoi d hemor r hage)
I ncreased tone/spasti ci ty
Neurol epti c mal i gnant syndrome
E l evated i ntracra n i a l pr essu re
`otes
< g d|y so coc| ccocso c|e|~ ||ec| cc|eose c ~csc' e|oce|ocgoc||e|c' '
|ocgeo|possve ~ove~ec|.

N0u!OlOQy Z4l
p
Cogvee' ^g so |o|~ o| | g d|yco|o.|e| zed oy y|~ c, oce| se
ess|o^ce|ocgoc||e o^geo|~o| o^
.eodp pe s o |o ~ o| | g d|y co|oc|e zed oy u^ |o|~ |es s|o^ce
|ocgoc|| e

^geo|~o| o^
Spos| c |y s o^ ^c|eose ^~csc e|o^e|o| s ~ 'd v |s' ov ~ove~e^|o^d
~o|epo^oc^ced v | |op d ~ove~e^| C oss co y, op d possve ~ove~e^| s
~e|v | ^ceos ^gess|o^cec^| ' o po ^|o|v c|eess|o^ceoeoss, c osp
s^ |e pe^o~e^o^ | .
1 . < g d|y~oyoe cocsed oy.
o 'ec|o og cpo|oogy
:x|opyo~ do /ooso go^g od sodes ,dys|o^ o, o vopo^|oceeoe
oo|opy, 'o|s ^so^s, d|cg e||ec|s|
Co|cosp ^o' ^vo've~e^|,spos| c |y, e'evo|ed ^||oco^ o pessce/e

^ o| o^|

o ^e^ ^geo | |o| o^ , ~e^ ^g | s, scoooc^o d e~ooge|

c Sse' e|o ~~oo |y, o^sy os ^gspo^dy' | s, seveesp ^o os|eoo| | s|
2 . ^ ge^eo , ^c|eoses ^ ~csc e |o^e ~oy oe dce |ocorti cospi nal o ex
trapyramidal po|oogy !e|e|~ | g d|y ~oy oe csed |o e|e||o ype|o^cso|
ex|opyo~ do o g ^ , o^d spos| c |y e|es |o ^ceosed |o^eo|co| cosp ^o'
o g ^ s| ^gc s ^gcooc|e|s|cso|`eoc oe sc~~ozed ^| e|oo' e :x||o
pyo~ do sy^do~eso| g d|yoe ^o| csco y ossoco|ed v | ype|e|'ex o,
ooo ^ss s g^s, o poo ys s, o^do|e ~oeo||e^ ossoc o|edv | o|e ~ove
~e^| d so|des scc os||e~o|, co|eoo|e|os s, o|ox o, o^d/o|dys|o^ o
s g d|y
I
Cogvee o|'eodppe
i Assoco|ed oo^o|o ovee^|s Yes
Assoco|ed veos^ess/po|oyss `o
eep|e^do^ e|ex/po^|o `oo'
espo^se
Spos|c|y
C osps^|e
'o
Yes
|^ceosed/cpgo^g
3. Acc|ege^e|o' zed g d |y so||e^o^ e~ege^|s g^ ^ | o' ||eo|~e^|o ~s o|
~o ^|o ^ ^gv|o' |c^c|o^s v e|op d' yde|e|~ ^ ^g |ee|o'ogy
o. AoCs, v|o' s g^s, ~o^|o|s, O
2
o. \oscpoyscspec|ed d og^os s
I ncreased I CP /herni ati on: :^:<C:'C ^oy|eqc e ^|coo| o^, y
peve^| o| o^, o^d/o|~o^^ |o . og^os|c|es|s ^c' cdeeodC!/^< .
' og^os|cco^s de|o| o^s ^c' cde ~oss' es o^, ^||oc|o^ o' o' eed, C'S
^|ec|o^, eod ||oc~o
Meni ngiti s: :^:<C:'CY CecsCoC o^d d ||ee^| o , e ec|o' yles,
oJ'/C|, g' ccose, ccces, c ~oo pc^c|ce , | o ev de^ce o| ^
c|eosed ^||oco^ o' p|essc|e| .

' . Subarachnoi d hemorrhage: :N:<C:'CY CecsCoC, p| o|e| e|s,

'!/'!l, '< , e'ec|o'y|es, oU'/C|, g' ccose, head CT
242 Neurlogy
Neuroleptic mal ignant syndrome: '^.<Cc'C <. eoc|o|~ecocses
o|occ|e g d |y, oo|o ~ed co| o ~ s|oy, c~ec|ox scee, CoC,
e ec|oy|es, g ccose, oJ'/C
Dystoni a: J<C.'! <c eo.|o|~ecocseso|occ|e g d|y, oo|o ~ed
co|o ~ s|oy
c !eo|~e| s d ec|ed |ovod |~e cde y g pocess
4. C~o c g d |y s ~oe se yo pe~oe|seq.e oe o| e.o og c .y
, spos| c |y| o o e.odegeeo| ve cod | o , o so s , CA| , o d.e|o
see|o ~|o|os , oy os gspody | s, seveesp o os|eoo|~ | s|
5. Acc|e o|oge cdys|o ceoc| os ~oyocc. espose|o |~eopyv |~
p~eo|~ oz es, ~o ope do , o| e~e| cs, od o|~e e o|ed d cgs !eo|~e|
v |~d p~e~ydo~ e e eves |~edys|o o ~os|coses
T R E M O R
S HAKE I T U P
Stage f r i ght/emoti onal
Hyperthyroi d/hypogl ycemi a
Al cohol wi thdrawa l
Ki nesogeni c
E ssenti a l/fa mi l i a l
I ntenti on
Toxi ns/dr ugs/medi cat i ons
U nderl yi ng metabol i c condi t i ons ( uremi a, hepati c
encephal opat hy, Wi l son' s)
Pa rki nson's
H E LP, I ' M SHAKI NG
Hypogl ycemi a
Essenti a l
Li t hi um/val proate/other medi cati ons
Par ki nson's
N0u/OlOQy Z4d
I ntoxi cati on ( e. g. , sti mu l a nts)
M etabol i c/aster i xi s
Stage fr i ght/emoti onal
Hyperthyroi d
Al cohol wi t hdrawa l
Ki nesogeni c
I ntenti on
Nor mal /physi ol ogi c
Genet i c ( e. g. , Wi l son's, Hu nt i ngton's di sease)
"otes
!e~o sde| ~edoso~ vo c|oy ~y|~~ c osc o|oy ~ove~e~|
Asteri xi s s o cod | o~ c~ooc|e zed oy o ~y|~~ c, ep sod c oss o|
~.sc e|oe ^oyoeco~|csedv|~|e~o
1 . !e~o|co~ oed s| ~gc s~ed ~|o|~ee ~o |ypesoosedo c' co|eo|ces
o Resti ng tremor s|ypco yo coose, e'o|veysov, Jo ~e||z||e~o|~o|
s ~ox ~o v~e |~eo||ec|ed o|eo s o| es| Us.o y ossoco|ed w |~ |o~so|
po| so s~
o. I ntention tremor s o |~y|~~ cosc ' ' o| o~ |~o| oeco~es ~oe poocced
os|~e o||ec|ed oeo opp|ooc~eso |oge|, o~d soose~|o ~ ~o o| es|od
o|| ~eoeg ~ ~go|~o| o :|o oges ~c .deo |o~so|ceeoe od seose
c Postural /acti on tremor s o ~y|~~ c |e~o pese~| v~e~ |~e o||ec|ed
oeo s oc|ve'y ~o |o ~ed ~ o po| cc o pos|c|e od. g oc|ve ~ove~e~|,
o.|oose|o|es| ~ys o og c||e~o|, o' co~o v|~dovo' , ~ype|~yo d s~, o~d
|o~ o esse~| o' ||e~ooe o good exo~p' es
2. Si x cardi nal si gns of parki nsoni sm: |es| g|e~o, g d|y, oody ~es o,
|exed pos|ce, oss o| pos|.|o |e|exes, o~d |eez ~g o| o de||ed ogoss
o| po| ~so~ s~, o|eos| z o||~e|eo|.|es~cs|oe p|ese|, o~d o| eos| 1 o|
|~ez ~.s|oee |~ees| g|e~o|oo|ody ~es o.
3. o ~so~ s~~oyoedvded |o|oc~o osyd|o~es.
o. dopo|~ c. `o~ove|o ogyo sosd seose.
o Sy~p|o~o| c. .e|o o~ de~| | oo e sc | d|.g d.ced , p~eo|~ oz e,
~o' ope| do' | , ~ydocep~o' cs, ~ypox c, pos|e~cep~o | c, poo|~yo d dys|.~c
|o, |oxc, ~ogoese, cooo ~o~oxde, des ge d.gs /!, cyo de| ,
pos||o.~o| c, |.~o|, ~|oc|o~ .
c o|\ sop .s. o so o v |~ odd | oo' s g | co~| sy~p|o~s
A'zne ~esd|seose, ~.'| p' esys|e~ o|op~y, pogessvescpocc eo|po sy.
d Cee| c. he||ed |o~so| po| so~ s~o ' e|vodeSpo|z, .| g
|ocs d seose, \ sosd seose
Z44 N0u/lOQy
4. ' c|ec| oc |e~o s c~ooc|e zed oy ~po ed | cge| cose| cgeocd ~ee
cees~ c~ocecves !~esepo| ec|so||ec ~oveo|~eev decceo|ceeoe odys
|ccc| oc , scc~ os cys|og~csocd go | cs|oo |y Uc o|eo c|ec| oc |e~o| s
scgges| ve o||oco' ceeoe' ' o d seose scc~ os c|o|c|, o eed, o | c~o, ocd
s~oc doeevo' co|edv|~^<' , C! |occ|e|
.
5. 'os|co ooc| oc|e~o sco|pesec|o| es|, ocd, o |~ocg~ | s .ocg~|oc|
oy ~o|ooc|v|y, s co|g|eo|yo~p |ed cpoc oppooc~ |o o |oge|' e c|ec
| oc |e~o os| c o ||e~o ~oyoe oov ocs s ~p' yoy ~o' d cg |~e o| ~s oc|
s|e|c~ed
6. Two maj or tpes of action tremor cc' cde|~e |oov cg
o ~yso'og c !~ s|e~o s s ~p y oc exogge|o|oc o|o co~o p~eco~e
coc , csco y o l ^ ~e|z| | s p|ec p |o|ed oy ~ocy s| ~c , cc cd cg
ocx e|y/|eo, ~ype|~yo d s~, co||e ce, |~ c ~, vo p|o coc d, o' co~o /dcg
v |~dovo' , exe|c se, ocd ec~occed od|eceg c s| ~c' o| oc , cc cd cg
p~eoc~|o~ocy|o~o|
o o~ o o essec| o |e~o Usco y ^o ~e|z s~o cg o| |~e ~ocdso
~eod, o||ec oo e|ooescppessed oyoco~o , vo oo' e c c|ecs|y ||~ee so
|o~ 'y ~ s|o|y , csco yoc|oso~o' do~ coc| | , | s cocs de|ed |oo|||o| |/eoo/, |
|o~ ' y~ s|oy sco| evdec|, | s|e~ed e::eo||o| |/eoo/, ocd | |~oc|es|s oc' y
o|e c |e, | sco ' ed :eo|'e |/eoo/
7. cgsossoco|ed v|~ ||e~o| cc cdeodeceg cdcgs, o' oc|eo , ~e|opo
|eeco | , s| ~c oc|s , ~e|~y p~e do|e, coco ce, co||e ce, o~p~e|o~ ce| , |~eo
p~y ce, pedc soce, vo p|ococ, ocd |~ c~
8. Management of tremor depecds cpoc|~e|ypeo||e~o
o ' d opo|~ c po| csoc oc ||e~o ~oy |espocd |o co|o dopo/' evodopo,
dopo~ ce ogoc s|s , oo~oc| p| ce, pego de| , o| oc| c~o ceg cs , ||
~exyp~ec dy , oecz|op ce|
o Sy~p|o~o|c po csoc s~o sos~oc d oe ~ocoged oy |eo| cg |~e cocse
, e , d scoc| cc cg o||ecd cgdcg, dec| |y cg ocd e ~ co| cg |ox cexposc|e,
e e|o|~yd|ocep~o cs, e|c |
c. Seveeyd soo cgdcgess|oc| po csoc oc ocdessec| o ||e~os ~ove
oeec scccess|c y|eo|edv|~s|e|eo|oc|c|~o' o~o|o~y
d Ceeoe o|e~oo so ~oyoe |eo|ed depecd cg oc |~e cocse , . e , |e
~ovo o| ~e~o~oge, exc s oc o||c~o, e|c |
e :ssec| o |e~o s e||ec|vey||eo|ed v |~e |~ep|op|ocooo| p ~ doce
N0ulO/OQy 245
WE A K N E S S *
MI SS GI MP
Myel opathy ( acute)/myopathy
I nfect i on
Str oke
Systemi c i l l ness
G ui l l ai n- Ba rre syndr ome
I atrogeni c/dr ugs
Myast heni a
Para l yt i c toxi ns/per i odi c par al ysi s
|o|e. ^|:: C|^| eop|o:|ze: ||e ocu|e cou:e: o| oo|o/ weo|ne::.
G, I ' M L I MP, CAN' T STAND
G ui l l ai n- Barre syndrome
I atrogeni c ( paral yti c agent s, ami nogl ycosi des, steroi ds)
Myopathy/myosi t i s
Lou Gehri g's di sease ( ALS, motor neuron di sease-
usual l y gradual )
I nfect i on ( pol i o, botu l i sm)
Myel opathy ( acute)
.
Peri odi c pa ra l ysi s, porphyri a, pa raprotei nemi a
Cus h i ng 's
Arter i ti s/vascu l i t i s/st roke
Neopl ast i c ( meni ngi t i s, paraneopl ast i c)
Toxi ns ( l ead, arseni c, pufferf i sh, t i ck para l ysi s)
Acute/subcute, bi lateral wi th mi ni mal sensor
y
i nvolvement
Z4O Neurology
Systemi c i l l ness ( anemi a)
Thyroi d
Addi son's
Neu romuscul ar j uncti on di sease ( myast heni a,
Lambert-Eaton syndrome)
.
D i abeti c amyotrophy
`otes
\eocess s|~e epo||ed sy~p|o~ o|de~ocs|oo' es gc o|dec|eosed s||ecg|
o|~cscc o coc|oc| o^ !~e cocseo|veo\cess ~oy oe o| o^y 'eve' o|| ~e
~o|o c^ | , oo c, sp ^o co|d, eve |oo|, pe|pe|o' ^e|ve, ^ec|o~cscc o| ccc
| oc, o|~csc e| ' |o so ~oyoccc secocdoy|osys|e~c o|psyc~ o|| c ' cess.
1 . Local i zati on of weakness co^ oede|e ~ ^ed ||o~ oc' yo |evqco' | eso|
|e po| ec|s co~p' o c|s/pys co s g^s sy~~e||y, secso|y cvo' ve~e^|, o^d
deep|ecdoc |e|'exes/p' o^|o |espo^ses
.eso^ Osco y o~ ^e^|
.oco|oc Sy~~e||c Se^so|y .oss !<s 1ces Up?
Central
oo ^ 'o C||e^ ps 'o|eo' ' ^ceosed Yes
|oveo\^ess ,dec|eosed
occ|e'yj
Sp ^o Cod /oyoe es, csco y~ove ' ^c|eosed Yes
seso|y'eve ,deceosed
occ|ey|
Peri
p
heral
e|,~eo' eve /oyoe es eceosed 'o
'eco~cscc o es `o eceosed 'o
cc|o
/csce es `o eceosed `o
Both
/o|o ec|o /oyoe `o ' ^ceosed es
d seose
DTRs deep tendon reflexes
Muscle weakness due to brai n l esions is di scussed under "Stroke. " Muscle weakness due to
spinal cord lesions is di scussed under "Myelopathy. " Muscle weakness due to peripheral nerve
lesions is discussed under "Neuropathy. "
2 . Amyotrophi c lateral scl erosis ,A.S, o soco' ' ed .oc Ce| gsd seose, ~o|o|
^eco^d seose| s cc qce c |~o| |p|ese~|sv|~ c~o^ c, p|ogessveveoscess,
N0u/OlOQy Z4
odo exo~ o|o ~os ~ xed cppe, ceosed |oe, ceosed '<s, cpgo g
|oes| od ove,o|op~y, |osc cc o| os| ~o|oeco s gs
J. Acc|e/scoocc|eveoess co oeoe~egecy, espec o y ||~e |eg|y
o| |~e o voy od esp o|oy ~csc es s co~po~sed. ogoses |~o|~e |
coe|c ~o |o go|esp o|oy|cc| o c cde Cc ' ' o oo, peodc po|o
ys s, occ|e ~yeopo|~y , ~ g~ cev co | , od ~yos|~e o Se o v|o copoc |es
oe c | co '~e ~ooge~e|o||~esepo|e|s
4. geeo , neu|opo||c cou:e: o| eo|ne:: v oeveoed s|o y od v ' '
~ove so~e sesoy vo ve~e| , od eco~cscc o cc| o od ~cscc o
cocses o| veoessv oeveoe| pox ~o y od ~ove o sesoy vove
~e| odd | o, ou:cu|o/ cou:e: o| eo|ne:: ~oys~ov e evo|ed ~csce e
zy~es ,C, o do ose|
5. Gui l l ai n-Borre syndrome so s gc o|ecopo|~ ccocseo| occ|e/scoocc|e
veoess v~ c~ sesoyco~p o |s oe o| o||e po~ e| | s c~ooc|e
zed oysy~~e| c, d s'o'opox ~o , pogessve ~o|o poo yssv|~o|e|ex o
!ogno:: so||e ~odec' co' 'y, oc| co oescppo||ed oy de'oyed eveco
dcc| o s|cd es .c~oo pcc|c|e ~oy|eveo e evo|ed CS po|e v |~oc|peo
cy|os s
|eo|oen| se |~e p' os~op~e|es s o| |oveocs ~~cog' ooc' Coe|c'
~o |o go|esp|o|oy|cc|o ,oyvital capacity) odoc|oo~ c|cc|o , oy
v |o s gs| s ecessoy|o de|e ~ ev~e |eve| osscc os |coo| o ~oy
oe eqc ed |~e|scppo||ve coe c cdes osp o| o pecoc| os , | o| |c
oo|ed| , pop~yoxs |o| deepveocs|~o~oos s, decco |cs pop~y ox s, oove
od o oddecoe, c|| | oo' scpp' e~e|o| o, od ogeo| ~o|o execses |o
peve|co|oc|ces
6. Myastheni a gravis co p|ese|v|~ occ|e/scoocc|eveoess od esp o
|o|y sc|| c ecy !yp co c co c~ooc|e| s| cs c' cdevox g od vo g
sy~~e| c pox ~o ex|e~|yodoc oo , co o eve| veoessv |~ ose
soy 'oss !ogno:: sscgges|ed oy |~e c co' pc|c|e, od co oe scppo|ed
oy o pos|veTensi l on test , see |~e '|osssec|o| .^Co so s~ovs o c~ooc|e
s|c dece~e|o espose |o epe||ve s| ~c o| o C~es| ~og g ~oy de~o
s|o|e o ossoc o|ed |~y~o~o Ace|y c~o e ecep|o o| ood es ~oy oe
de|ec|ed '~esec~
|eo|oen| occ|e y vo ves scppo| ve coe ~cc~ os oc| ed ooove ,|o|
C. o ooe|v|~coe|c ~o |o go|v |o copoc |yod |coo| ov~e ec
essoy. os~op~ees s od o| c~o es|eosedcgs , py| dos| g~ e, eos| g
~ e| oe cse|c occ|e y !~y~ec|o~y s d co|ed o coseso| |~y~c | c~o|,
od ~oy ~e p ~oy o|~ecoses oecocse o| oeop os| c|~y~ c~ypep o
s o Co| cos|eods od o|~e| ~~coscppesso|s ,ozo|~ op| e, cyc op~os
p~o~ de| oe csed |o og|e~ |~e|opy
7. o|e's v~o cdego iatrogeni c paral ysis |o ~ooge~e|o|o ve| 'o|o
~ove oee epo|ed|oe~o po|oyzed |oo po oged peod o| | ~e,doys
|ovees| o||e d sco| co| o o| |~e poo y|c oge|, sp |e o||~e , o~o' y|
s~o|~o|veso||~eseoge|s !~e e ~ood o|pooged pos||eo|~e| po|o
ys soppeos |o c|eosev|~ ogedc|o| o o||~eopec| c po|o ys sodv |~
|~eseve |yo|o|~esys'e~ c esses ,espec o 'y eo |o ce|
248 N0u/OlOQy
8. Endocri nologi c causes of weakness ~c' cde|e |o ov ~g
!yo d !yo|ox c-godco y pogessve, espec o' y ~| gs/pe v c
~csc' es, ~o~o C
!yo|ox c pe od c poo' ys s o||ocs o|sy~~e| cveo~ess,
csco yv| ov
!yo d op|o ~opo|yexop|o ~os o~d veo~ess o|
ex|oocc o~usc es
^yos|e~ ogov sossoco|ed v| dys|yo d s~ ,e|eype
oypo|
ypo|yo d s~d||cse ~yo g os, s|||~ess, s oved co~|oc|o~,
o~d eoxo|o~ o| ~csc'es
Ade~o Add so~sge~eo zedveo~ess,|o| goo ' |y, ossoco|edv |
e ec|oy|e ~oo' o~ce
Ccs ~gspox ~o veo~ess,o' so~oyoesee~ o|eco|co
s|eod |eo|~e~|
9. Sys|e~ ccocseso| ~o~spec | cveo~ess ~oyoe seco~do y|o o~e~ o,
co~ges|ve eo||o ce, ~o ~c| | o~, deco~d | o~ ~g, co~ce, e|c
1 0. Seveo' poo'y|c ~|oxco| os ~oy eod |o occ|e veo~ess o~d eve~ es
p o|oyco' ' opse !ese ~c cdeoo|c s~, | cpoo' yss, pc||e|s ~ges| o~, o~d
poo'y|cse' ' | s poso~ ~g.
Cl inical Conditions or Diagnoses
D E M E N T I A
DE ME NTI A
Degenerat i ve
Et hanol /toxi ns/dr ugs ( ch ron i c)
M u I t i -i nfa rct
E ndocri ne/met abol i c
Norma l pressu re hydrocephal us
Tu mor/t ra uma
I nfect i on
Al zhei mer 's
N0ulOlOQy 249
W
DE ME NTI A MI ND
Degenerati ve ( Par ki nson's, Pi ck' s)
Ethanol
Mul ti -i nfarct
Endocri ne (thyroi d di sease, Cushi ng's, Addi son' s)
Nor mal pressure hydrocephal us
Tumor
I nfecti on ( H I V, neurosyphi l i s)
Al zhei mer 's
Meta l s and other ch roni c i ntoxi cati ons
I nj ury ( contusi ons, chroni c subdural s)
Nutri ti ona l /metabol i c ( 8 1 2 defi ci ency, Korsakoff's)
Depressi on/psychi atri c ( pseudodementi a)
Notes
'e~e~|o so~ ocqc |ed co~d | o~ co|oc|e|zed oyc|o cde|e|oo|o~ o| ~
|e''ec|co |c~c| o~o~dossoc o|ed v | ~po ~e~| ~ o| 'eos||eeo| |e |o' ' ov
~go|eos. ' o~gcoge, ~e~o|y, v scospo| o' s ' ' s, pe|so~o' |y, o~dcog~ | o~ . '| s
not ossoco|edv |o~occ|eco~|cs o~o' s|o|e.
1 . oy de| ~ | o~, it is not possible to make a clear diagnosis of dementia in a
patient with an acute encephalopathy. ~y o||e| |ee~cepo' opo|yc eo|s
co~ |e d og~os so|de~e~|o oee~|e||o ~ed
2. Standard work- up |o| |eve|s o e cocses o|de~e~| o ~c' cdes C!/^<
( normal pressure hydrocephalus, neoplasm, multi-infarct), !S ( dysthy
roidism) , \<./<'< ( neurosyphilis) , ol z, o~d |o o|e. | |e o~se| s scoocc|e
o op d ypogess ve, o~ .' ( subacute o~d chronic infections) soc d oe
s||o~g yco~s deed.
3. 'e~e~|o ~cs|oed s| ~gcsed||o~ o ~c~oeo|o|eco~d | o~s.
o Aphasi a: ! s s pce yo~oo~o~o lyo| o~gcoge expess o~/ co~pe
e~s o~ . \ |opos o, | ~oyoe d ||cc' ||ode|e|~ ~e|o||epo|e~|os ~|oc|
~e~oy o~d ~|e' ec|co' |c~c| o~. Apos o ~oy oe o po| o|de~e~| o, oc| oy
|se| sscgges|veo||oco ceeoo po|oogy.
o. Depressi on/pseudodementi a: Seve|e depess o~ ~oy ~o~|es|osex
|e~gpsyco~o|oe|o|do| o~ 'o| e~|sv | psecdode~e~| o ove o p ~o|y
psyc o| cd so|de, o~d |e sy~p|o~s esove cpo~ scccess|c' ||eo|~e~|o|| s
d sode !ey|e~d|oo~sve| do~ | ~ov |od ec| qces| o~s, o~dsov~o
ev de~ce o|co|| co' dys| c~c| o~ \e opos o ! s scsco y o d og~os so|
250 N0u/OlOQy

exclusion. I t i s i mportant to realize that depression can accompany many de

menting i l l nesses without being the cause of the dementia.
. c. Acute confusional state/deliri um: This is the most important disorder to
disti nguish from a dementia, because del i ri um requires urgent di agnosis and
teatment of its underlying cause. Cl i nical features associated with del i ri um i n-;;
Jude a waxing and waning course, abrupt onset, underlying medical disease,
and hal l uci nati ons. I t is possi bl e for a demented patient to become del iri ous
( i . e. , a patient with Alzheimer's disease develops a cystitis or pneumonia and
becomes more confused) , but the di agnosis of dementia cannot be made for the
first time in a del irious patient.
MY E L O PAT H Y
BAD STRAI N
Bl eed/hemorrhage/arteri ovenous mal formati on
Abscess, epi dural
Demyl i nati ng di sease ( mul ti pl e scl erosi s)
S
pondyl osi s/stenosi s
1ruma
Radi ati on
Arteri at occl usi on/vascu l i t i s/i nfarcti on
I nfecti on
Neopl asm
IT'S SAVI NG THE CORD
diopathi c '
roxie/iatrogeni c ( i nt
r
athecal chemotherapy)
'Systemi c l upus eryt
h
ematosus
Neurlogy ZO
b
Spondyl osi s/stenosi s ( degenerati ve spi ne di sease)
Arachnoi di t i s
Vascul ar/i schemi a
I nfecti on ( tra nsverse myel i ti s, syphi l i s, Pott's
di sease/tubercul osi s)
Nutri ti onal ( B 1 2 def i ci ency)
Geneti c ( Fr i edr ei ch' s ataxi a)
Tra u ma
H emor r hage/arteri ovenous mal formati on
E pi dura l abscess
Congeni t al (tet hered cor d, Chi a ri mal for mati on, syr i nx)
Oncol ogi c ( pri mary spi nal t umors, epi du ra l and bony
metastases, carci nomatous meni ngi ti s)
Radi ati on
Demyel i nati on ( mul t i pl e scl erosi s)
Notes
^yeopo|y so^ypo|o' og cp|ocess eod ^g|osp co co|d dys|c^c| o^ .
1 . C' ^ co s gcso|o ~ye'opo|y ^c cdeveo\cesso^d secsoy'oss oeov|e
eve'o|sp co cod c c|y
2. A |ocg|ec' oss c~o|o| ^d cgso|o ~ye'opo|yo|e cppe ~o|o| ^ecoc
s g^s ,spos| c|y, ypee|ex o, cpgo ^g |oes| , upper motor neuron si gns may
be absent acutel y; |o| s, occ|e ~o|o| ^d ^gso| o ~ye opo|yoeo||eco
| occ d po|oys s
3. A c oss csecso|y| cd cgo|sp ^o' cod dys|ccc| oc so sensory level, e ,
cc~ocess o secsoy ' ossoc|e|c^oe' ov o ce||o c de|~o|o~e. !h s s ^
vo' coo' e c 'oco z ^g|e seg~e^|o|co|d cvoved
4. <e~e~oe |o| |e sp ^o' cod e^ds o| L H2. | |e 'ove ex||e~ | essov
cppe|~o|o cec|oc s g^s, ocd |e cppeex|e~|esoe ^o|~o , ~oge|e |o
occocd cppe' c~oo|sp ce. ' |o ' |oc|ex|e~ |esoe cvoved, ~oge|e ce
v co' sp ce
5 . Acute myel opathy i s a neurol ogi c emergency. ~og cg sc ge^| ^ o' '
coses, o^d' \~e|y ped^ so'oce soc d oeod~ ^ s|e|ed ccoseso| ~ye'opo
|y |esc' | ^g |o~ |oc~oo ^eop os~ 'e| ^ |veocc|e|e|opy ~oy cc' cdesc|
g co deco~pess oc/sp ce s|oo zo|o^ocd, |oceop os| cd seose, |od o| oc
6. ' | s ~po||o^|| ooo|o ^ocy s|o|y o||oc~o, ooc\/^ecpo c, peex s| cg
cocce|, ~c | p esc'e|os s, oove /o' odde|dys|ccc| o^, ocd p|evocs od o| oc|o
|esp ce.
ZOZ N0ulO/OQy

N E U R O PAT H Y
P R I M A R I LY MOTO R
A TAD L I MP
A myot rophi c l ateral scl erosi s
Toxi n ( hexane, dapsone)
Anti -GM 1 ant i bodi es
Demyel i nat i on ( Gu i l l a i n- Ba rre, ch roni c i nf l ammatory
demyel i nat i on pol yneu ropathy [ eI DP] )
Lymphoma
I nfect i on ( pol i o, di pht her i a, hepat i t i s, H I V)
Meta l , heavy ( l ead)
Por phyr i a
P R I MA R I LY S E N S O R Y
GET PAI N OR N U MB
Geneti c
E ndocr i ne
Toxi c
Pol ycl onal /monocl onal ant i bodi es
Amyl oi d
I nfect i on
Nutr i ti onal
Occupati onal ( ca r pal t unnel )
Radi at i on
N0u/lOQy 253
b
N eopl asm/paraneopl asti c
Uremi a
Medi cati on
B rachi al neuri ti s
M I X E D S E N S O R I M OT O R
WEAK AN D TI NGLE
Wor k-rel ated/t rauma
El evated I gG ( par aprotei nemi a)
Autoi mmu ne vascu l i t i s ( pol yarter i ti s, l upus)
Ki dney fai l u re/ur emi a
Al cohol
Nutri ti onal
Demyel i nati on ( CI DP)
Toxi n ( mercu ry)
I nfect i on ( H I V, Lyme di sease)
N eopl asm/paraneopl asti c
Geneti c
L i ver di sease
E ndocri ne ( di abetes, thyroi d)
`otes
'ec|opo|~y socyd sode||~o|o||ec|s p ~o 'y pe p~eo ceves ocd s~oc
|es|ed oy sy~p|o~s o|veocess o secsoyd s|coocce o| oo|~ So~ed so
de|s coc ~ ~ ccecopo|~ es oy cocs cgs ~ 'o| sy~pIos, odoe cc cded c
|~ed ||eec| o d ogcosesooove, evec|~ocg~ |~ey cvove ~oe|~oc cs||~epe
| p~eo' ce|ves ,A'S, ooc~ o cec | sj
Paresthesia so secso| oco|cc~ocesso|| cg cg.
Dysesthesia s oc ccco~|o|oo esecso| oco| | cg cg, p c' cg o| oc|c cg,
o||ec e c |ed oy' g~| , co~o y cocpo c|c' j |occ~ .
Hypesthesia/hypoesthesia sosecso|oco|cc~ocess, d ~ c s~edseso| oc
ZO4 Neurology
""

1 . C' c co' 'y, |o d ogcos so|cou|o,o|ycocooo dodg|oo|'yoyco|ogo| z cg

| osy~,|o~s c|vo voys ' s|, oy|y,oo|coc|o,o| cd s|cooco,| o| s, ,|
~o| 'y socso|y, ~xod socso| ~o|o|, o , ~o| 'y ~o|o Sococd, co|ogo|zo|o
coc|o,o|yoy |socso|/dc|o| oc occ|o, ocs/doysj, scoocc|o,voos/~oc|sj,
ococ c, ~oc|~s/yoo|sj
Categori zi ng Neuropathy Symptoms
Cso|/
y,oo| s|coocco
co|o Primarily Motor Mixed Sensorimotor Primarily Sensory
Acc|o Cc ' o c

o sycdoo Aso c o,oszos|o|

`ooyo |s
A S,Ca o

o'o|
`ococscaoo'ocodo
, ~yos|~oco,dcgdacod|
^yo,o|~y,,oodc
,ooyss|
Scoocc|o C~oc c| o~o|oy ooo|os A~yod
doyo o| cg A' S o,oszos|o
oco,o|y 3o o .yod sooso
!oxs, ~oxoos. ood| Aco~oo'o|od ^odco|o
`oo,o|o o o `a||oo'do|cocy `c||oodo|
`ococscc od sooso ,o g ,

i
.
i .
.

| cocy ,o g ,
, yos|~o o| !oxs, ~oxoos
.
oso+cj
,
.
.

. :|
^yo,o|~y,,oyyos |s| ^odco|os `oooo,os|c
^o|o ocod sooso <~oc~o|o'ogc `os|odo|oc
,A.S| Socod |~oo,y
\osca o \|o

:
`oocoo,os|c |oxc|y
`oo,o|oo~o
y,o|~yods
.o,osy
C|co' ' oss
,oyo.o,o|~y
Coc `oo,o|o o o ooo|os A~y'od
ood|oyo|ososoy A S ood|oy
oco,o|y Ooo sosoy
`o.o~.sc. od sooso Aco~oo o|od oco,o|~y
, yos|oc oj `c| | oo do|coccy o,oszos|o
^yo,o|~y, cscco ,o g
.
i
.
i .
.
:
j 'y~od sooso
dys|o,~y| !ox s, ~oxocos, oso c| ^odco|os
^o|o o+o d sooso ^odco|os 'c||oo do|
,A.S
.
,os|,o o <oao|oogc c ocy, o g
.
sydoo| Socod

i .
.
:
. :|
\oscc o `os|odo|o
`oocoo,os|c |~oo,y
(Table continued on next page.1
N0u/lOQy W ZOO
Categori zi ng Neuropathy Symptoms (Continued)
Cse|/
co|o
Ccoc
(cont )
Primarily Motor
!ye o| s|c|ooce
Mixed Sensorimotor
`ooo|e e o
yo|~yod s
.e|osy
eed|oyo|o sesoy
ecoo|~y
C|co ess
oyecoo|~y
Primarily Sensory
2 . !~e d ||ee| o d ogos s |o o ~o 'y ~o|o ecopo|~y c cdes o|~e|
cod | osscc~os~o|oecod seose, ec|o~cscc o| cc| o , '^| | dys|cc
| o, od ~yopo|~ es 'ecooo|o~ c oco zo| o co oed ||c | Ceeo y,
|~e ~o|o ecoo|~ es cocse deceosed e|exes, v~ e ~o|o| ec|od seose
,A.S| ~os ceosed e|exes od cpgo g |oes. 'ecopo| es od A'S |ed |o
cocsed s|oveoess, v~ e '^| d seoses od ~yopo| es, |~eveoess s
~oe pox ~o
Sgs
A|o~y
<e|'exes
`'o|oesose
s||oc|oo|
veoess
osccco|os
Sesoyoss
Cl ues for the Di fferenti al Di agnosi s
Neuropathy
es, |c~|oc
yooc|ve
ov
s|o
es, |c~|oc
es, soe|es
s+o
sode
Myopathy/NMJ
Disease
es, |c~o c
\ooo e
ov
'ox o , ocoo|
'o
`o
Motor Neuron
Disease/ ALS
Yes, ovoys c~|oc
ye|oc|ve
O
s|o , oc oo
es, ovoysc~oc
`o
3. Acute weakness ~oy oe dce |o ceeoo , ec|opo|~ c, eco~cscc o|, od
~cscc o d so|des. 'od ||ee| o d ogos so|gee|o zed occ|e/scoocc|e
veo\ess see \eo\ess, poge z^. o|occ|e |oco veoess see S||o\e,
pogezz
4. Chroni c weakness |~e ooseceo|seso|yco~p o |s ~e |svo|\cp|o
'^| d seose, A'S, od ~yopo|~y, odd | o |o |~e |ev p ~o| y~o|o| ec
opo|~ es. Js g |~e ooove c~o|, |y |o d s| gc s~ c co y v~ee|~e po|~o'
ogy s \o|cp depeds o |~e ecooo|o~ c oco zo| o od ~oy c cde
:^C/`C\, cev co' ^<' , |es o |es|, C, o do ose, :S<, v|o~ o
,
, od
c e/sec~ |o|e eec|op~oes s

5 . ^os| nonacute neuropathi es |o |o |~e co|egoyo| seso ~o|o| o| |

~o| ysesoy !~e|e so ~oss ved ||ee| o d ogos s |o |~ s, od voc
ZOO N0u/lOQy
s~oc d oe o ~ed o| |~e ~os| co~~o^ o~d |~e ~os| |eo|oo' e ~ecopo|~es ,co|
~ecesso ' y|~eso~e|
Di agnostic Tests Di agnosi s
Se|c~g ccose, g ccose|oeoce|es| ooe|c ~ecopo|~y
oJ`, C
Je~ c ~ecopo|~y
!S ypo|~yo d s~, ~ype|~yo d s~
.vee~zy~es
epo|c d seose
\ |o~ ~o
.

o , , de|c e^cy
\
A S
.S<, A`A, < oyo|e|s ~odoso, cpcs,
3| ^e/se|c~ po|e ~e'ec|op~oess <A, e|c
A|c , < , o, gc oc, C/<, oopo|e e~ o
~o~~ogo~ ooeop' os| c ~ecopo|~y
<'<, \<. Syp~ s
.y~e| |es .y~ed seose
\ |o~ ~: 'eve \ |o~ ~: de|ce~cy
Cov|~ ~o~o^e, p |c |oyC!/^<' Ac|o~ego c~ecopo|~y
oecoe|c'v|~|~es~o|gc~oppooc~ ' o^|ode|evey|es|o|o^ce' ecde
c ~ co 'yv~c~ d og~osesoe e'yo~d|es||o|~ose|s|. ' |od og~osss~ode
od sy~p|o~s pess|ovose, co~| ce |~evocp ~e|~odco' y A so, ooo|
|o/ge| |o |oo| |o/ /|:| |oc|o/: |o ~ecopo|~es,e g , o co~o , |ox exposce, |o~ y
~ s|oy, ~ov~ ~o g~o~cy, ~edco|o^s, ~ov^ ~ed co co~d | o~, \d|cgcse|
6. 'pec|||c ||eo|~e^|o| ~ec|opo|~ es so ~ed o| |~e c~de|'y ~gcocse ' odd
|o~ , :yop|ooo||c e'e| ~oy oe ~e p|c' ^ coses o| po ~|c ~ec|opo|~y ee oe
so~e scgges|ed ~edco|o~so~d|~e cses
A~ | p|y ~e, o|~e!CAs C~o~ cpo ~|c ~ecopo|~es
, ov~ed c~dose|
Cooope~| ^ o ~|c ~ecopo|~ es, d ooe|c, pos|zos|e|
Copso c ~ ,|op co | ooe|c, pos|zos|e
'~e^y|o ~, co|oo~ozep ~e ! ge~ ^o ^eco g o
Asp | ^, ocpo|e~, ~op|oxe~ Ce^e|o ~o~^oco|co^| ~| o~~o|oes
Code ~e, oxycodo~e Ce^e|o ^oco|co^o' gescs
7. ~ odd | o~ |o p~o|~oco og c ~|eve~| o~, ge~eo' scppo|vecoe ~oy oe
oe~e| c o , ~c' cd ^g p~ys co |~e|opy, ogeo| ~o|o~ exec ses, podd ^g,
s ~co|e, o|~o|cs, so|e|yovoe~ess.
8. ^edco|os~ov~|ococse^ecopo|~y ~c cde
Drug Type of Neuropathy Comments
so^ oz d ' ^ | o' 'yse^soy, |~e~ ~ xed !|eo|co~co~|o~| yv |~o
:|~ o^o~de S ~ ' o |o so oz d
ydo oz ^e S ~ 'o |o so oz d
` |o|co~|o~ ' | o ysesoy, |~e~ ~ xed
sc' | o~ ~ | o yse~soy, |~e~ ~ xed
\ ^c| s| ~e ~ | o yse~soyo| ~ xed
C q' o| ~ ~o ' yse~so|y
:spec o y ce~cs
ose |e o|ed
.spec o' 'y p|opo
cep| o/v oo| o^
(Table continued an next page)
N0ulO/OQy 257
Drug
Chlorampheni col
Phenytoi n
Metron idazole
Ami tri ptyl i ne
Dapsone
Ami odarone
Neuromuscul ar
bl ockers
L-tryptophan
Type of Neuropathy
Mild sensory
Mi ld mi xed sensori motor
Si mi lar to phenytoin
Si mi l ar to phenytoin
Pri mari ly motor
Mi xed sensori motor
Pri mari ly motor
Mixed sensori motor
Comments
Associated with optic
neuropathy
Associ ated with chroni c
(years) use
Associ ated with chroni c
(years) use
Associ ated with chroni c
(years) use
o7of patients aher months
Prolonged venti l ati on/I CU
Associ ated with i mpuri ti es,
results i n eosi nophi l ia-
myal gi a syndrome
9. Focal neuropathi es, rather than a general probl em wi th al l peri pheral
nerves, i nvolve i ndi vi dual peripheral nerves and ohen are caused by local com
pression . Common syndromes i ncl ude:
a. Carpal tunnel syndrome Cl i ni cal : pai n/numbness i n di gi ts I ^, worse
at ni ght, rare weakness, positive Ti nel 's and/or Phal en's si gn. Locati on: wrist.
Di agnosi s: NCY slow through carpal tunnel ; ri sk factors are repetitive moti on,
rheumatoi d arthri ti s, acromegaly, hypothyroi di sm, amyloi d. Treat: anti -i nfl amma
tory drugs, wri st spl i nts, proper adi ustment of workstati on/posture. Surgery i s
someti mes necessary.
b. Ul nar neuropathy Cl i ni cal : pai n/numbness in di gits 4o, hand weak
ness, cl aw-hand defor mi ty. Di agnosi s: NCY sl Ow al ong course of ul nar.
Locati ons: several , especi al ly el bow. Treat: symptomati c, surgery to rel i eve
compressi on.
c. Radi al neuropathy Cl i ni cal : wrist drop, i mpai red sensation on back of
hand. Location: axi l l a or upper arm. Di agnosi s: NCY; causes i ncl ude crutch i n
axi l l a, arm over back of chai r or edge of bed ( "Saturday Night Pals/I , humeral
fracture, lead toxi ci ty. Treat: underl yi ng cause.
d. Meral gi a paresthetica Cl i ni cal l ateral t hi gh pai n/numbness, purel y
sensory. Location: i ngui nal l i gament. Di agnosi s: cl i ni cal ; ri sk factors are obe
si ty, pregnancy, di abetes, ti ght/heavy workbelt/harness, backpacki ng. Treat:
rel i eve compressi on . Beni gn.
e. Peroneal pal sy Cl i n i cal : weak dorsi fl exi on of foot, top of foot numb
ness, often weak fool-eversi on . Locati on: head of fi bul a. Di agnosi s : cl i ni cal ,
NCY; ri sk factors are plaster cast, prol onged leg crossi ng whi le seated, ti ght
knee boots, emaci ati on, fi bul a fracture, di abetes. Treat: underl yi ng cause.
ZOb Neurology
.
1
BI TE TON GU E
B l eed/hemorr hage
I nfect i on
Trauma
S E I Z U R E
E tha nol/d rugs/toxi ns
Tu mor
Oxygen l ack/i schemi a/hypoxi a
Noncompl i a nce ( subt herapeut i c meds)
Gl ucose l ack/hypogl ycemi a
U remi a/metabol i c
E cl ampsi a
I CONVU LS E BI G TI ME
I nfecti on
Coca i ne/drugs
Oxygen l ack/i schemi a/hypoxi a
Neopl asm
Vascul ar ma l for mati on
U remi a
Lytes ( hypoNa, hypoMg, hypoCa)
Si nus t hrombosi s
Ethanol wi t hdrawal
B l eed/hemor r hage
I di opath i c
Gl ucose l ack/hypogl ycemi a
Trauma
I nbor n error of metabol i sm
Medi cat i ons ( too much, too l i tt l e)
E cl ampsi a
/0u/OlOQy 259
".
Asezce so c co ~o|es|o| oo|excessve, ooo~o syc~oocsoc|v|y
o| ecos |~e ceeo|o co|ex | s csco y |os e|, od ~o |es|o| os
c cdeo |e|o|oso|coscocsess, vo' c|oy~ove~e|s, scdde osso|~o|o
|oe, od seso|y d s|c|ooces ,espec o yo |oc|o|yo|gcs|o|oyl
Epi l epsy s o |e~ eseved |oc~o c, ecc|e|sezces A :ng|e :ezu/e
ooe: no| oo|e o oogno:: o| ep|ep:y
1 . !~e desc|p|o o| |~e sezce s ~e' p|c d ogos:od||eo|~e| A good
descp|o o|o sezce c cdesoy p|e~o |oysy~p|o~s epo|ed oy |~e po
| e|, oy|oco ~o|ooc| v|yo|eddc g|~e sezce,v~e|~e|~e ~o|o oc|v|y
vos ~y|~~ cod syc~oocs, |~e peseceod d ec|o o|eyedev o| o, es
p |o|oy po||e , v~e|~e |~e po| e|vosoo e|o |espod |oveoo s| ~c' cs,
v~e|~e||~e po| e|o | ~ s/~e||ogceo expe eced co| ece, od| ~e
p|eseceoddco|oo| pos|c|o co|cs o
2 . Major types of seizures:
o. Aoseces|o g, o s g, vey o e|, pec p|o|ed oy ~ypeve| o| o ,
ose| c~ d~ood, o pos|c|o co|cs o
o Ceeo zed |o cc o co ' |oc ex|e~ | ess|||e | o y,|o cl , |~e
cdego ~y|~ ~ c co||oc| o od e' oxo| o , c o c| , pos| c|o' co|cs o s
o' voys pese| ,|o so~edegeel , ~oyoe ossoc o|ed v | ~ cyoos s, |ogce
o| g, od co| ece ^oy o||en :|o/| o: o |oco|/po/|o| :ezu/e ono oe :ec
onoo/|y gene/o|zeo, po/|cu|o/|y n oou||:
c S ~p epo| o' ~oyoe ~o|o| ,|oco ~o|o||v|c~ g| osesoy,|oco se
soy d s|c|oocel , v |~ oo |e|o| o eve' o| cosc ocsessdc| gep sode,
o pos|c|o co|cs o ^oy :econoo/|y oecooe gene|o|zeo |oncc|onc.
d. Co~p ex po| o o|eo|o coscocsess, oc|o~o| s~s , ' ps~oc g,
eye o s g, svo ov g, p c go| c o|~es|, peceded oy oco , ccsco s~e ,
|os|e| ^oy :econoo/|y oecooe gene/o|zeo |oncc|onc
3. Treatment by seizure type
o. !eo|~e|o|oosecesezc|esp ~o| yv|~ e|~oscx ~ deo|vo'pococ d
o. !|eo|~e|o| p ~o ' ygeeo zed sezces s csco yv |~vo' p|o coc d
c !eo| ~e| o| secodo 'y geeo zed se zces s p ~o y v |~ cooo
~ozep e, p~ey|o , ovo po coc d
d !eo|~e|o| po|| o' se zc|es , s ~p e o co~p' ex| s p ~o| 'y v |~ cooo
~ozep e, p~ey|o , o|vo' pococ d

|~e ~ed co| os csed |o |eo| ep epsy c cde c~ o|ozepo|e, c' o

ozepo~, |e' oo~o|e, gooope| , p~eooo|o |o , p ~ doe, | ogoo e, |opo
~o|e, od o~o| g e
4. | s ~po||o| | od s| gc s~ oe|vee se zc|e, sycope, od psyc~oge c
sezc|e/psecdose zces
I o Syncope s|yp co ypeceded oyo g~|~eodedess, pec p |o|ed oypos
I |co c~oge, esc |s o |o' /co ' opsev |~ oss o| cosc oJsess ' os| go'y
1 260 N0u/OlOQy
seco~ds, o~d~os ~opos|c|o'co|cso~ ccos.o~o' 'y, olev~yo o~ ctil
~oy occo~po~ysy~cope Sy~cope s csco' y p|ec p |o|ed oyo vosovogo' |e
oc| o~, oc| s o soossoco|ed v |~ o||~y|~~ o, o|~os|o|c ypo|e~s o~, ov co|
d oc oc|pc|, o~doo||cvove d seose. See |~e 'osso|Co~sc|ous~esssec| o~
o Ageneral ized tonic-cl oni c seizure ~oyo sopese~|v|~o|o /co opse,
oc| sossoco|edv|~g|c~| ~g o|op~eo, occos o~o' cyo~os s, |o~ c|e~ c' o~ c
~o|o|oc|v|y, so~e|~es|o~gceo | ~g o~d ~co~| ~e~ce, o~dovoys pos| c|o
co~|cs o~ , csco y os| ~g o ~ ~c|es o| o~ge| . !e dc|o|o~o|o ge~e|o zed
sezc|e s csco y 'o~ge| |~o~ o sy~copo eve~|, ' os| ~gseco~ds|o ~ ~c|es.
c Pseudosei zures ~oy oe d || cc | |o d s| ~gc s~ ||o~ ep ep| cse zc|es,
~deed, |e|vo d so|de|s |eqce~| yove|' op ' ~ge~e|o , psecdosezc|esoccc|
~ |e p|ese~ce o|ooseve|s, o|e no|s|e|eo|yp c, ~ove ~o pos| c|o co~|cs o~,
o~do|e ~o|ossoc o|ed v | se | ~ c| ocsoc| v |y ' e |o' ~g o| |o~gceo | ~g.
^o|o| oc| v |y ~c cdes co~p' e|e yosy~c~|o~ocs ~o ~ove~e~|s, s||cgg ~g
ogo ~s||es||o ~|s o||es s|~geyeope~ ~g, o~d|epeo|eds de|os de~eod~ove
~e~|s 'o~eo| |ese s d og~os| c, oc|co|e|c oose|vo|o ~e ps ovod p' oc ~g
|ese po| e~|so~o~| co~vc' so~|s o| ~c|eos ~gdosoges c~~ecesso| y
5. ||e oo:| coooon cou:e o| o :e|zu|e n o po||en| || o |non :ezu|e o|:
o|oe| : :uo||e|opeu|c oeoco||on !~ s~oyoe dce |o ~o~co~p' |o~ce , dueto
s dee||ec|s o| ' oco|c~de|s|o~d ~g| o| ~c|eoseddos ~g |eqc |e~e~|s.
6, ~d co| o~s|o|~ec|o ~og ~gs|cdes
o. 'ev|oco'o~se|se zc|e o|sezc|ev|~ |es dco' |oco ~ec|o og cde| c |
o. S|o|csep ' ep| ccso|c~~ov~e|o ogy
c 'evo~se|sezc|e, c~ce||o ~|ocoly} v|~oc|~ov~ p|ec p |o~|
d. A~yseco~dse zc|e,excep|lyp co oose~ce ~o|p|ev ocs' y ~oged.
| s ~o| ~ecesso|y|o |e ~ogeo po| e~|v ~ o ~ov~ se zc|e d so|de| o||e| o
|ypco sezce ,see ~c~oe|o ooove. '| s ~o| ~ecesso|y|o ~ogeo c~ d v |~
|yp co oose~cese zc|es.
7. ~d co| o~s|o|' c~oo| pc~c|c|e.
o S|o|csep ' ep| ccso|c~~ov~ e|o ogy
o. o|e~|s c~de scspco~ |o|scoo|oc~~o d e~o||~oge
c. o|e~|s c~de|scsp c o~|o|C`S ~|ec|o~ , ~e~ ~g | s, e~cep~o' | s
8. 'o|sezc|es seco~do|y|oo' co~o' v |~d|ovo' o~d~e|ooo' coo~o|~o' || es,
o~| co~vc' so~|so|eo'voys seco~d ~e ||eo|~e~|, ||s|' ~e ||eo|~e~| sd ec|ed
o||~e c~de|' y g p|ocess , e. , ||eo| v |d|ovo , co||ec| e'ec||oy|eoo~o~o'
| es, co||ec| ~ypogyce~ o, e|c.
9. General ized convul sive status epi lepticus ~eo~sco~| ~cocs ge~eo' zed
co~vc s o~so|epeo|ed ge~e|o' zed co~vc' s o~s v|oc| |u|| |ecoveyo| ~e~|o'
s|o|cs oelvee~ se zc|es|o|o pe| od os| ~ggeo|e||o~ JJ~ ~c|es
Protocol for treatment ,'o|e '|e~s 1 -4 o|ege~eo''ydo~e~eo|'ys ~c|o~eocsy
I . Co|e|c yoose|vesezceoc|vly AoCs Scpp'e~e~|o' |~ecesso|y
2. \ ' ~ev |~ ~o~o so ~e. Se~d L'ood |o| CoC, e ec||o'y|es, oU',
Co, ^g, g' ccose, o~| co~vc' so~|'eve s. Se~dAoC Se~d J/A, co~
s de||oxsc|ee~ :CC~o~ |o| ~g.

J Acccc~ec, |e~ I JJ mg |~ o~ ~e, Ie~:0~ o|oJ7 dex||ose soc

| o~ | ~dco|ed.
NOulOlOQy M Z
b
4. Lorazepam 2 mg '\. Do not exceed 2 mg/mi n . May repeat up to
0. 1 mg/kg. Cal l neurologist.
5. Phenytoi n ( Fosphenytoi n) 20 mg( pEl /kg '\. When usi ng phenytoi n,
do not exceed 50 mg/mi n . When usi ng Fosphenytoi n, do not
exceed 1 50 PE ( phenytoi n-equivalents) /mi n. Moni tor ECG, respi ra
tion and blood pressure.
Phenytoi n ( Fosphenytoi n) 5- 1 0 mg( PE) /kg ' \. Maxi mum rates per
mi nute as descri bed above. Maxi mum dose 30 mg( PE)/kg.
. Consi der i ntubation if not al ready i ntubated.
o Phenobarbi tal 20 mg/kg 'V. Do not exceed 1 00 mg/mi n.
9. Consider barbi turate coma ( i n consultation with neurologist) .
1 0. Common drugs having i nteractions with anticonvulsants i ncl ude erythromyci n,
H2 blockers, i soni azi d, methyl pheni date, phenothi azines, warfar i n, oral contra
ceptives, and other anticonvulsants. Drug i nteractions may resul t in i ncreased or
decr.eased anticonvulsant levels or al tered efficacy of the concomitantly admi nis
tered drug. In general , newer anticonvul sants have fewer drug-drug i nteractions.
1 1 . A rough cl i nical gUide to phenytoin level s:
01 0 No nystagmus
Above 1 0: Gaze-evoked nystagmus
. Above 20: Gai t ataxia
Above 30: li mb ataxia
Above 40: Stupor/confusi on
ST R O K E
SAVE D BRAI N
bubstance a buse/dr ugs/medi cati ons
Al tered coagul ati on/hypercoagul abi l i ty
Vascu l i t i s
E mbol i
'Di ssecti on
: B l eed/hemorr hage/AVM
Ra re causes ( e. g . , mi grai ne, i atrogeni c)
A therothrombosi s
I nfect i ons
Neopl asm
ZOZ Neurology

D EAD H EADS
Drugs/medi cati ons
E l evated bl ood pressure
Arteri ti s/vascu l i t i s
Decreased perf usi on ( cardi ac arrest, hypotensi on)
Hemorrhage or Hypercoagul abi l i ty
E mbol i sm
At heroscl erosi s
Di ssect i on
Spasm ( mi gra i ne)
Note: !|^! |L^!' emphasizes the vascular causes of stroke.
CVAS, DO I CT T H E M?
Cocai ne/drugs
Vascul i t i s/col l agen vascul ar di sease
A t heroth rombosi s
Syphi l i s, terti ary/meni ngovascul ar
Di ssecti on/dyspl asi a ( fi bromuscul ar)
Ora l contracepti ves
I ntracrani al bl eed ( aneu rysm, AVM)
Ca ncer
Thrombosi s, si nus
Trauma/her ni at i on
H ematol ogi c* /hypercoagul abl e* *
E mbol i c ( i ncl udi ng para doxi cal )
Mi grai ne
Neurology Zb
L SAVE THE M B RAI NS
D i ssect i on/dyspl asi a ( fi bromuscul ar)
Oral contracept i ves
Si nus t hrombosi s, venous
A t herothr ombosi s
Vascul i ti s/col l agen vascul ar di sease
E mbol i sm ( i ncl udi ng pa radoxi cal )
Trauma/her ni at i on
H ematol ogi c* /hypercoagul abl e* *
Exogenous toxi ns/dr ugs ( e. g . , cocai ne)
Mi gr ai ne
B l eed/AVM/aneurysm
Radi at i on
Angi ography
lnfect i ons ( neurosyphi l i s, meni ngi t i s)
Neopl asti c ( bl eed, meni ngi t i s)
Syst emi c hypotensi on/shock
*Thrombocytosis, polycythemi o, sickle cell anemi a
* * Protei n C deficiency or resistance, protei n S defici ency, ontithrombin I I I deficiency, mal ig
nancy, onticordol i pi n anti body syndrome, factor Y defici ency, homocysti nuri a
Notes
5||o\e e|es|o|e scddecocse|o|o |oco cec|o og cde| c | |o|doesco|e
so|ve !ee| o ogyo| o s||o\e s gece|o ' yvoscc o, e |e e~oog co| s
che~ c. !evoscc o|evec|~oyoepec p |o|ed oyo d||e|e|ccde| y cgcocse
| c|ec| oc, |c~o, e|ed |oycocd!ocl
Transi ent i schemi c attack (TIA) e|e|s |o |e scddecocse|o| o |oco' ceu|o
og cde| c ||o||esoves c 24 ocso ess
Reversi bl e i schemi c neurologi c defi ci t ( RI ND) so cec|oog c de| c | |o|
os|s ocge|oc l doyocd ess|oc J vees, essec| o' 'y, o ~ ds|oe
Hemi paresi s |e|e|s |o o veo\cess oc oce s deo| |e oody. Hemi pl egi a
|e|es|o po|oys|so| oces deo| | eoody
Astereognosi s s|e coo ' |y|o dec| |yoo ec|s oy |occ oc'y.
Agraphesthesio s|e coo |y|o dec| |y e||e|s/cc~oe|s|ocedoc|es c
v |oc|v sco' cces.
ZO4 Neurology

1 . !ypeso|s|ose
o Hemorrhagi c-e|es |o |oco o eed ^g, csco y ^|o o|o ^ poe^c~y~o
Assoco|ed v |~ occ|e ~ype|e^s o^ , coogc opo|~y, o~y' o d o^g opo|~y, occo
s o^o y|oc~o
o !c|oobol| ce|es | ogodco occ cs o^ o'ceeoo o|e es oy oco
p oqces/|~o~o Assoco|ed v |~ o^gs|o^d ^g ~ype|e^s o^, d ooe|es, o|~eo
sc'eos s
Smal l vessel /' acunar -occ cs o^ o' ~ covesse s, |yp co' 'y ^ deep
g|oy~o||eo^d/ooo ^s|e~
Large vessel thrombosi s ~ay ^o| ~eocoo|d oc |v|~ o ovgode
oo vey~ g~godes|eos s
c Embol i c-e|es| oo scdde^ occ cs o^ o|ceeoo o|e es oyoood c'o|s
|~o| o g ^o|e esev~ee ^ |~evoscc osys|e~ ^oy oe o|ey|oo|ey , coo|d
|o ~ dd eceeoo , oo|c |o coo| d ove|eoooos o | , cod oge^ c , ~eo||o
oo ^| , o poodox co , ve^ocs sys|e~ | ~ocg~ o| o sep|o de|ec| |o o|e| o
sys|e~ | ooo ^| Assoco|ed v | ~cod oco~y|~ os ,espec o y o| o | o o
| o^| , | g~||o e||s~c^|s, vo vc o| eo|d seose
2. Hemorrhagi c strokes co^ e||ec|vey oe d og^osed oy o ^o^co^|os| ~eod
C! |/e:en|o|on scsco y|~o|o|o veyoocp|o^se|o| ^eco og cde|c'v~ c~
~oy^o|| |ve |o |~evoscc o| po||e^s desc oed oeov \ey oge e~o
~og cs|oses ^|~eceeoc~coc d es. ' ^ deceosed ~e|o s|o|csseco^doy
|o~e^ o| o^, po:|e/o/ |o::o |eoo//|oge: ooy 'eoo |o o ve/y /opo oec/eo:e n
|eve| o| con:c|ou:ne::.
:||o|ogy s ~os| o||e^ ~ype||e^s o^ |/eo|oen| co^s s|s o|ge^| eco|o o|
ex|e~e ~ype|e^s o^, scppo|ve coe, o^d occos o^o y ,espec o y ^ pos|e o
|osso/ceeoe o o eeds| sc g co evocco| o A^| coogc o| o s co^|o ^d
co|ed |/ogno:|: |o |c^c| o^o ecovey o||e ~e~o ~og c s|oses s csco y
oe||e|o^o||e| sc~e~ c, e , |~ o~oo|coe~oo c| ^|o|c|s
3 . Seveo s||ose sy^do~es ove oee^ desc oed os l acunar/smal l vessel
thrombosis; |~o| s, ^vov ^g s~o ^|oc|s os o esc |o|occ cs o^ o| | ^y pe^e
|o| ^gvesses !~esep/e:en|o|on: ^c cde|~e|o ov ^g c co sy^do~es
o Pure hemi sensory deficit ,co^|o o|eo |oo |~o o~ c ^|oc||
o. Pure hemi paresis ,co^|o o|eo |o o^ ^|e^o copsc e ^|oc||
c. Cl umsy hand-dysarthria , ~c | p e oco zo| o^s|
d Ataxia/hemiparesis oo|~co^|o o|eo |oo po^| ^e ^|oc||
^se| o| sy~p|o~s ~oy oe s|c||e ^g, s|epvse de|e oo| o^ o ~oy oe o^eo|
g|odco 'y vose^ ^g!'As !~e |yp co d s|| o.| o^ o|o ~e~ se^soyde| c | ^
vo'ves |e |oce, o~ , o^d 'eg eqco 'y, oecocse |~e se^soy| oes oe c ose' y
co~poc| |^ |~e|o o~cs, so eve^ o s~o' sc~e~ c es o^ v ' se yo||ec|o' .
. sevse |o pure hemi paresi s, v~ c~ s~oc d oe e o| ve' yequal i n t he face,
arm, and leg, os|~eco|| cosp ^o | oes oe covded c ose y ^ |~e ^|e|co
copsc e
|||o|ogy s~os|' \e'yco^ cype|e^svedo~oge|os~o' ' pe^e||o| ^gves
se' s. '|eo|oen| occ|e' y co^s s|s o| ovo d ^g ~ypo|e^s o^, cs ^g oc|' p o|e' e|
oge^|s, o^dscppo|veco|e .o^g|e~ ||eo|~e^| ^voves d ~ ^ s~ ^g| ss|oc|o|s
scc os s~os ^g, ~ype|e^s o^ , ype p de~ o, o^dd ooe|es A^| coogc' o| oc
N0ulOlOgy ZOO
s c^p|ove^ !sscep os~ cogecoc|vo|o,!'A| ~oy oe oece| c o' v | c|e | |s|
J ocs
4. Large vessel thrombosis ~oypresent v | g|odco yvose^ cg ,cesce^doj
T'Aso|o^ oocp|o^se|o|sy~p|o~s 3sco' ysy~p|o~soccc c ovoscc od s|
oc| o^ os desc| oed oe'ov Co|o| d occ cs o^ ~oy p|ese^| v | o^y ~ dd e
ceeoo o|ey ^|o|c| oc , dce|o co' o|eo |ov |o |e ps ' o|eo oc|e o cee
oo' |o~ |e oc|e oco~~ccco| cg o|ey| Etiology s csJo yoc o|eosce
|o|c p' oqcev | ' oco | o~ocs |o~o| oc. Treatment occ|e' y cc cdes!'A,
ovo d cg ypo|ecs oc , o^dscppo| ve co|e Co|o|d ecdo|eec|o~y s cd
co|ed |o symptomatic s|e^os s o| `J7 og|eo|e|, o||ec ^ |e se|| ^g o|!'As
: ~ege^| co|o| d ecdo|eec|o~y s cc povec Ac| coogc o| oc s ccpovec
Coo|d ecdo||e|ec|o~y ^ |e se|| cg o|co~pe|ecoo|d occ cs oc s geceo y
^o| cdco|ed
5. Embol i sm c oss co' ' ypresents v | o^ oo|cp|ceco'og co' de| c ||o|s ~ox
~o o|o^se| Sy~p|o~s occc| c o voscc o d s| oc| oc osdesc oed oe' ov.
!e e~ poes s o| ~ dd' ece|eoo o||e|y ,^CA| occ cs oc d ||es |o~ |o|o|
' occco d seose ^ |o| ^CA c|oc|oc cocses hemi paresi s that is greater i n
the face and arm than the leg ocd s csco' ' yossoc o|ed v | e~ se^soy oss
c o s ~ o| d s|| oc| oc Etiology s oyocc cs oc o| oc o|ey oyo o'ood c o|
|o~e |eoco|eo||ey , e g , coo| d|o ~ dd' e ceeoo j , |eeo| ,cod o
ge^ cj , o |e vecocs sys|e~ v o o | g| |o e||scc| , poodox co | . Treatment
occ|e y ~oy cvo' ve!'A, |o oved oyo^| coogc o| oc , espec o ' y c coses o|
o|o | o| o| oc o^d s~o' ' ceeoo c|oc|s Acc|eo^|coogc'o| o^ c|ese|| ^g
o|o ve|y' o|gece|eo|o' c|oc|oc oso^ cceosed s\o| p|ec p |o| ^g e~o|
og c||o^s|o~o| o^ .
6. .oco' zo| o^o|' ogevesse' d seose (thrombotic oembol i c)
o Spec |cs gcs/sy~p|o~s
Anterior , e. , co|o|d
o||e|y|
Posteri or , e. , ve|eoo'
oos 'o| o||e esj
: |e|
o. \oscc' o|sy^d|o~es
^o^occ ovsco 'oss
Ag|opes|eso
\ scospo| o' de| c |s
' p op o
A|oxo
\e| go
'oces gcs/sy~p|o~s
oppos|e o|~/ eg
s g^s/sy~p|o~s
e~ po|es s
'yso| o
\ sco' | e dcc|,csco' ' y
'CA, oc|~oyoe
p|esec|v | o|ge
^CA ^|o|c| o^sj
Anterior cerebral artery Coc||o'o|e|o'
ZOO Neurology
e~ ceg' ec|
Apos o
As|e|eog^os s
|ys|og~cs
o 'o|e|o' s gcs/
sy~p|o~s
\o~ | cg
e~ se^so|yoss
'eg weo\cess >
|oce/o|
' ^coc| cecce

Mi ddl e cerebral artery

Posterior cerebral artery
Vertebral basi l ar arteries
Coc||o'o|eo'
Coc|o'o|eo
Coc||o'o|eo'
' ps o|e|o
^oy oe o o|e|o
'oce/o|~ veocess
> ' eg
e~secsoyde| c |
e~ocops o
e~ocops o
^ 'd e~ po|es s
e~ secsoyde| c |
e~ poess
e~ secso|yde| c|
Coc o cevepo sy
'osso ye~o|ox o
7. Standard workup for stroke cc' cdeso eodC!, e~ooge| , CHC,||o~
oocy|os s, po'ycy|e~ o| , g' ccose , d ooe|esl , ocd ' p ds ,ype' pde~ o| |e|
o' ood|es|s v c ~oy oe cse|c cc cde! /!f ,coogc' opo|y, codeqco|eoc
| coogc o| oc| , :S< ,voscc | s| , ocd \<'/<< , cecosyp ' s| Coo| d dcp' ex
soc d oe doce ccoseso|oc|e oc |cc o| oc s||oes ocd !'As !ocsc|oc o'
opp e s e' p|c' cevo co| oo| pos|e o|c |cc' o| oc ,ve|eoooos ' o csc||
c eccy| . :cocod ogopy spe|o|~ed|o c'eoc|vo'vc o| esocsocd o| o' o
vec| cc o||o~o cpo| ec|ssuspec|ed o|ov cgoce~oo c c|oc|. ^ogce| c
esococceocg ogopy so coc cvosve~e|odo|v sco z cg o' o||e coc o
voscc o|ce , oc|e| oocd pos|e oc cc o| ocl , ocd |e eso c| oco|^<Aos
g|eo|y ~poved ove|| eos||evyeos.
8. `c young pati ents , ^oyeos o d| o po|ec|s v| coc' eoe| o' ogy, |e
vo|cp|os|oe/ceeo|o' c|oc|oc coc oe~cc ~oe ex|ecsve ocd ~oy c
c' cde po|e c C, p|o|e c S, oc| co|d o p c oc| oody, oc| | o~o c ' ' , |oc|o\,
ocd o~ocys|e ce, ype|coogJ'oo' es|o|es| , ocg ogopy, o|e o' d ssec| oc, |
oo~cscc o|dysp oso, ocec|ys~|, ^< ,|c~o, A\^| , c ced|cgsceec ,coco ce,
o~pe|o~ ces| , .', c|ec| oc, c| o~~o| oc/voscc | s|,ocd|ocsesopogeo eco
v | ocoo' es|cdy, o|| o sep|o' de|ec|v|poodox co' e~oo' s~| .
9. <ecec|'y, |ecseo|!A osoeec eco~~ecded cocc|es|oe. Cocs de| |
c po| ec|svopesec|| o~ed co' coev | c J ocso| ocse|o| ceco' og co
sy~p|o~s, ove s gc | coc|ceco' og cde| c |s, ocd ove co ev decce o| c
|ococ o' e~o||oge.
Neurol ogy Gl ossary
Agraphesthesia s|e coo ' |y |o dec| |ye||e|s/cc~oes||ocedoc |e sc v|
oc|v sco' cces
Akathi si a desc oes oc cvo cc|o|yes|esscessocd coo |y|o s|s| ' ' .
Altered mental status |e|e|s| oocyocc|eo|scoocc|ecocge c|e'eveo| coc
sc ocscess, ocg cg ||o~ ~ ' d coc|cs oc |o deep co~o. Sycocy~ocsv |
N0u/OlOQy ZO
..
de c~ Coc c p|oo' e~sscc osde~ec| o o ~ec|o e|odo|oc oe co|
cocs de|ed c | sco|egoy
Amaurosi s fugax s|e sco ec|ve co~p' o c| o| |ocs ec|vsco oss c oce eye,
o|ec desc| oed osove o| sode co~ cgove||eeye
Astereognosi s s |e coo |y|o dec| |yoo ec|s oy|occ oc y.
Asteri xi s so cocd | occooc|ezed oy coc|y|~ c, epsodc ' osso| ~csc e
|oce ^oyoecoc|csedv| |e~o
Ataxia s|escoec|veco~p o c|o|oo ec|ve|rd cgo| ~po ed coo|d co| oc,
csco y~oc |es|ed osoc ~po ~ec|o|go |odex|e |y c|eoosecceo|s g
c | coc|~cscc' o|veocess.
Autonomi c di sorgers cocs||c|eov deocgeo|ceco ogcdeocge~ec|sv c
~oy~oc|es|p| ~o ' y|ocgsy~p|o~so|oc|oco~ cdys|ccc| oc, cc' cd cg
oc|co|' ~|ed |o o||os|o|c ypo|ecs oc/syccope, cod ocoy|~ os, o
|eed oc| ~o| oc, ~po ed |e~pe|o|ce egc' o| oc, d opoess/oc dos s,
sexco' dys|ccc| oc, ocd oove' /o oddepoo' e~s
AVM s |e ococy~ |o o|e ovecocs ~o' |o|~o| oc , oc ooco ~o |ocg eo|
o'oodvesses|o|cocdeve'op c |ecec||o cevocssys|e~.
Choreoathetosi s soc cvo cc|oy ~ove~ec|d sode|cooc|ezed oy |op d,
e|\y, docc cg' e ~ove~ec|s , coeo| ossoc o|ed v | o scpe ~posed
cpocv|| cg, |ov cg, coc| ccocs ~ove~ec|s, o|e|os s| .
Cl onus socoocp|, cc d |ec|oco se|eso|~cscc' ococ||oc|ocs cespocse| o
o scddecs||e|c A socsed |odesc oe epe||ve, y|~ c~csc' ecoc|oc

| ocsseec cso~e |ypes o|sezc|es.

Cogwheel i ng so |o|~ o| | g d |y cooc|ezed oy y|~ c, oce| e ess
|occe||ocgoc||e |ocgeo| ~o| oc
CT s| eococy~|o|co~pc|ed |o~og|opy, o d ogcos|c ceuo ~og cg|es|
CVA s |e oc|ocy~ |o ce|eoovoscc o occ dec| , |e|e|s |o ocyocc|e cee
oovoscc' opo|oogy, geceo ' y sce~ ooe~ooge
Dementia s oc ocqc |ed cocd | oc cooc|ezed oycoc cde|e oo|oco| c
|e'ec|co' |ccc|oc ocd ossoco|ed v| ~po ~ec| c o|'eos| ||ee o| |e |o
' ov cg oeos ocgcoge, ~e~oy, v scospo| o s s, pesoco' |y, ocd
cogc | oc | snot ossoco|ed v| ococc|ecoc|cs oco' s|o|e.
Di pl opia s|escoec|vesy~p|o~ o| doco'e vs oc
Dizziness so sy~p|o~ v| ~ocy ~eoc cgs, oc| po| cc' o y csed oy po|ec|s
|o e|e| |o |ee' cgso||o c|cess/ g|eodedcess, ve| go, ocd/o.cs|eod
cess/d seqc o| c~
Dysconj ugate gaze s|e oo ec|ve exo~ co| oc | cd cg o| eye ~ so gc~ec|,
v c ~oy o|~oyco|oeossoc o|edv |sy~p|o~so|d p' op o
Dysdiadochoki nesis s oc ~po ~ec|o||eoo |y|o pe|o~ op do' |eco| cg
~ove~ec|s
Dysesthesi a s oc ccco~|o|oo e secso| oc o| | cg cg, p cs' cg, o oc c cg,
o||ec e' c |ed oy ' g|, co~o' 'y cocpo c|c' | |occ
Dyski nesi a soc ooco ~o |y o| ~ove~ec| ! s csco y |e|e|s| oexcess ve
~o|o| oc| v |y , .dopo cdcced dys ces os, |o|d ve dys\ ces o| , oc| o' so
~oy |e| ec| o sevee gece o zed s ov cg o| ~ove~eo| , po csoc oc
o|ody ces o| .
ZOo N0u/lOQy
1

I
Dysmetria s ~po ~e~| |~e~o~o occe eo|o~oddece'eo|o~ o|d ec|ed
~ove~e|s 3s.o yevo .o|ed cy| ~ge~ose| ~geo~d ~ee'sees~ ~|es|s
Dystoni a s o cod | o~ o' ~po ed ~csc e |o~e, v~ c~ .s.o y s ceosed,
pess|e|, o~do' o~ ex|e~e o'|~e ogeo| ~o| o~|o |~e o||ec|ed oeo
EMG s |~e ocoy~ |o e ec|o~yogo~, o d ogos| c |es| |~o|exo~ es |~e
e ec' co pope|es o| ~.sc e|ss.e , o~oogo.s|o|~ee ec|oco|d ogo~ |o
|~e~eo||
Epi lepsy so |e~ eseved |oco~ c ecce~|se z.es A :|og|e :ezu|e ooe:
oo| oo|e o oogoo:: o' ep'ep:y
Gegenhal ten desc ces o~ ~oc |y|o e ox~.sc es sccec|ed |o possve ~ove
~e| exo~ ~o| o~, ||ee sos | po| e~| sess| ~g |~eexo~ ~es ~o| o~s
Headache so geeo |e~.sed|odesc ce o~y po |. se~so| o~ ~vov ~g
'es|cc|.eso||~eco .~

, |oce, od/oec
Hemi paresi s e|es|oveoess/po| o poo ys so~o~es deo||~ecody
Hemi pl egi a e|es |o co~pe|e poo ys so|oe s deo||~e cody
Hypesthesi a s o seso| o o' ~.~cess, d ~ s~ed se~so| o~ Syoy~ocs
v ' ~ypoes|~es o
I n}ention tremor s o exoggeo|ed osc o| o~ o|o ~c~os| po~occed os |
soppooc~ go |oge|, od esse~| o yocse~|o|es|oo||e ceg ~ go|
o ~ove~e~| 'e~| o|e~o so ~o~|es|o| o~o|dys~e| o
Lead-pipe s o 'o~ o| g d |y c~ooc|ezed cy c~ |o|~ es s|oce| ~o.g~oc|
' ~eo~geo|~o| o
LP e|es |o c~co pcc'.e, o so ~ov oso s ~o |op
Monocul ar vi suai loss se |~eo s.c ec|ve epo|o| |os e|v s.o 'oss oe
eye , osopposed |o oe v s.o | e d| o o oc ec| ve| d ~go|deceosed
vs.o oc. oeeye
MRI s |eocoy~ |o ~og~e| c eso~o~ce ~og g, Q d ogos|c ~eco ~og
g |es|v | ~ geeso .' o~ |~o~ C!, c.|v~ c |oes o~geo~d sge~e
o y ~oe expe~sve
Myelopathy so~y po|~o og cp|ocesseod ~g|o sp o' co|d dys|cc| o
Myocl onus e|es |o o scdde, o~y|~~ cco|oc|o ospos~o| o ~csc'eo|
go.po| ~csc es Co~|oc| o~s geeo y oe c~ d ec| oo' , osy~c~|oo.s,
od osy~~e' c
Nerve conduction study so d og~os|c |es| |~o| oos o| |~ee ec| co |c~c| o~
o|pe p~eo eveso~d oo|s
Neuropathy s o~yd sodev~ c o||ec|s p ~o y pe p~eo ~e|ves od s
~o~ |es|ed cysy~p'o~so|veo~ess o sesoyd s|cco~ceo co|~
Paresthesia so se~so| o~o| ~.~c~ess o| ~g ~g
Ptosi s so p~ysco | ~d ~go| o~epo peco |sscece ~gs~o' e|~o~| eo|~e,
e , o doop ~g eye d
Reversi bl e i schemi c neurol ogi c deficit ( RI ND) s o ~eco og cde| c ||~o| os|s
oge'~o~ 1 doyod ess |~o~ J vees, esse| o y, o ~ d s|oe
Ri gi di ty so co~| ~co.so ~|e~||e~| ceose ~.sc'e |o~e|~ocg~o.||e|c
o~geo|possve ~ove~e~|
Sei zure s o c ~ co ~o~ |es|o| o~ o|excess ve, oc~o~o , sy~c~o~o.s oc|v|y
o| e.os ~ |e ceec|o co|ex | csco y s| os e| , o~d ~o~ |es|o| o~s
N0u/OlOQy Z
..
^c' cdeo' |e.o| o^so|cocsc ocs^ess, cvo c^|oy ~ove~e^|s, scdde^ oss o|
~o|o|oce, o^dsecso|yd s|c|oo^ces ,espec o yo|oc|oyogcs|o|o|yj
Spasti ci ty s o^ ^ceose ^ ~csc e|oce |~o| s ~ ' d v |~ s ov ~ove~ec|o^d
~o.ep|ococccedv |l op d ~ove~ec| C' oss co' y, op dpossve~ove~e^|
s~e|v |~ ^c|eos ^g .ess|occec^| ' o po ^| o|v~c~ |~e |es s|occeoeos
, c osp\c |e p~eco~eco^j .
Stroke e|es| o|~escddec o^se|o|o |oco cec|o og cde| c || ~o| does ^o||e
so've !~ee|oogyo|o s|o\egece|o' ' y s voscc o, e |~e~e~o.~og co| s
c~e~ c !~e voscc' o evec| ~oy oe p|ec p |o|ed oy o o ||eec| c^de| y cg
cocse, e g , c|ec| o^, |c~o, ~e|ed |oycocd | o^j
Syncope sde| ^edoso ||o^s e^|'osso| co^scocscesso^dpos|co'|ocedce|o
~po ed ce|eoo' o'ood |ov Sy^ocy~ocsv |~|o ^| ^g.
Ti cs oe s|eeo|yp c, cvo' cc|oy, epe| | ve spos~od c~cscc o| coc|oc| ocs
!yp co' ' yoo' e| ooescpp.essed o e|y, o^y | ooeo oc| v | ~ ^ceosed
seve |y ||e^ oppeopc.pose|co|se~ pc|pose|c'
Titubation s o ~ode|o|e|eqce^cy~eod ||e~o|, csco yo^|e|opos|eo|
Torticol l i s so |o~ o||oco dys|o^ o ^vo v cg pess|e^| coc|oc|oc o|cev co
~csc' es, ' eod ^g|o o ~eod

| ' |.
Transient i schemi c attack (TIA) e|es|o|~escdde^ocse|o|o |oco' ^eco og c
de| c ||~o||esoves c z^ ~ocso' ess
Tremor sde| ^edosoc ^vo c^|oy, |~y| ~~ c, osc ' ' o|o|y~ove~ec|
Weakness s|~e|epo|edsy~p|o~o de~o^s||ooes gco|deceosed s|ecg|~
o|~cscc oco^|oc| o^

Z M0ulDQy
ABG
ALS
ANA
ARDS
ATN
AVM
AVP
BOOP
BUN
Cl DP
COPD
CPK
CVA
CXR
DDX
DKA
DVT
ECG
EEG
ESR
GERD
GVHD
I TP
I VF
L
LP
MCA
MCV
E
Ap PENDIX
Acronym Dicti onary
Arteri al bl ood gas
Amyotrophi c l ateral scl erosi s
Anti nucl ear anti body
Adul t respi ratory di stress syndrome
Acute tubul ar necrosi s
Arteriovenous mal formati on
Argi ni ne vasopressi n
Bronchi ol i ti s obl iterans-organi zi ng pneumoni a
Bl ood urea ni trogen
Chroni c i di opathi c polyradi cul opathy
Chroni c obstructi ve pul monary di sease
Creati ne phosphoki nase
Cerebrovascul ar acci dent
Chest x-ray
Di fferenti al di agnosi s
Di abeti c ketoaci dosi s
Deep vei n t hrombosi s
El ectrocardi ogram
El ectroencepha l og ra m
Erythrocyte sedi mentati on rate
Gastroesophageal refl ux di sease
Graft versus host di sease
I di opathi c thrombocytopeni c pur pura
I ntervertebral foramen
Left at r i al myxoma
Lumbar puncture
Mi ddl e cerebral artery
Mean cell vol ume
-jj0/O/X M Z
MI
MS
NCV
PCA
PI E
PT
PTI
RDW
RPR
SI ADH
SLE
TI A
TPN
TSH
VDRL
VOD
Myocardi al i nfarction
Mul ti pl e scl erosis
Nerve conducti on velocity
Posteri or cerebral artery
Posti nfecti ous encephal omyel i ti s
Prothrombi n t i me
Parti al thrombopl ast i n t i me
Red blood cel l di stri buti on wi dth i ndex
Rapi d pl asma reagi n
Syndrome of i nappropri ate secreti on of anti di ureti c hormone
Systemic l upus erythematosus
Transi ent i schemi c attack
Total parenteral nutri ti on
Thyroid-sti mul ati ng hormone
Veneral di sease research l aboratory
Veno-occl usive di sease
ZZ -jj0/O/X
DI FFERENTIAL DIAGNOSI S MNEMONI CS is a memory ai d
to hel p you form comprehensive diferenti al diagnoses for
common i nternal medi ci ne and neurology problems. Clever,
often witty mnemonics al l ow you to organize di agnostic
possibilities quickly and efectively for a wide variety of cl i nical
scenarios. The method succeeds because each mnemoni c
provides you with a framework on which to construct the
diferential .
This book assures that your eval uations wi l l be thorough, and
di agnoses will not be missed!
For More Memory Aids . . .
The SECRETS SERI ES

has been extraordi nari ly popul ar,
and the di sti nctive approach has given bi rth to a wide range
of books i n the major medical specialties and subspecialties.
Questions and short answers as wel l as an i nformal tone are
employed to make the text enjoyabl e as well as useful . The
l ist i s constantly changi ng and expandi ng. Her are a few of
the more than btitles:
| c!5LhL15, Z/0
| |PhL5LhL15, Z/0
LNh| NL5cLhL15, Z/8
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|LMP1N LhL Z/0
| N|L1| U5| 6L5L 5LhL15
NL||hL!5LhL1o
NLUhL!5LhL15
NLUh5| LNL5LhL15
h!/hL5|| hP1h! PhL 5L
h|LUMcoLhL1b
5UhL 5LL15, 4/0
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