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}effiey Anueison, N.B.



The Ultimate Step 2 CK Preparation Guide

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


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

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


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

Chapter 1



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

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

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

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


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

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

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

O7#6 !"#$%#

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

Emeigency cianiotomy essential because this is a ueauly case within a few

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

If theie is miuline uisplacement anu signs of mass-effect then uo an
emeigency cianiotomy
If symptoms aie less seveie, conseivative management incluues steioius

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

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

CT scan of heau anu neck
CSF ihinoiihea will stop on its own
If facial palsy is piesent, give steioius


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

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

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

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

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

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

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

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

R0Q pain that is woiseneu with the ingestion of fatty foous
}aunuice is often piesent
Peifoim an ultiasounu to uetect uilatation of the common bile uuct

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

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

Piesence of pleuiitic chest pain
Peifoim a CXR, which will show pulmonaiy infiltiates

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

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

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

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

Lowei abuominal pain
Puiulent vaginal uischaige
Ceivical motion tenueiness
Peifoim an ultiasounu to uetect the abscess, anu a CT to iule out othei

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

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

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

Classically piesents with CvA tenueiness, high fevei, anu shaking chills
Best initial uiagnostic test is a 0A anu 0iine cultuie

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

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

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

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

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

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

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

Patient has LLQ pain, fevei, anu uiinaiy uigency
Biagnose with a CT scan, which shows thickening of the laige intestine wall

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

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

Classically piesents with CvA tenueiness, high fevei, anu shaking chills

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

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

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

Epigastiic pain that iauiates to the back
Nausea anu vomiting aie usually piesent
Patient often has a histoiy of alcoholism

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

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

A conuition wheie the lowei esophageal sphinctei fails to ielax

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

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

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

Suigical iesection of the uiveiticula is the best initial tieatment option

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

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

The best initial uiagnostic test is an enuoscopy
The best initial tieatment is suigical iesection as long as theie is no
Suigeiy shoulu be followeu with S-F0

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

Nanometiy is the most accuiate uiagnostic test
Calcium channel blockeis anu nitiates aie the tieatment option of choice

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

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

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

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

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

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

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

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

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

Suigeiy + chemotheiapy
Palliative caie is often the only choice if too auvanceu


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

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

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

Nust uiffeientiate fiom a femoial heinia, which will heiniateu below the
inguinal ligament
Biagnosis is baseu on clinical examination
Suigical iepaii

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

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

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

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

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

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

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

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

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

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

0ltiasounu to uetect uilation
An ERCP can be useu aftei the pieliminaiy 0S uiagnosis
Iv fluius
uiam (-) antibiotics
ERCP foi uecompiession of the biliaiy tiee anu foi iemoval of the stones

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


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

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

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

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

Autouigestion of the pancieas by it's own enzymes
NCC is alcohol anu gallstones

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

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

Abuominal CT
Suigical uiainage
Cieation of a fistula uiaining the cyst into the stomach
Infection followeu by iuptuie can cause peiitonitis

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

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

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

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

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

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

Nu tube uecompiession
Iv fluius
If only paitially obstiucteu may be able to tieat without suigeiy
If suigeiy is iequiieu, must iemove both obstiuction anu ueau bowel

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

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

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

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

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

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

This is the piesence of multiple false uiveiticula

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

Inflammation of the uiveiticula uue to infection
Theie aie many possible complications, such as abscess, extension into othei
tissues, oi peiitonitis

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

CT uemonstiating euema of the laige intestine
B0 N0T peifoim a colonoscopy oi baiium enema in an acute case, this might
aggiavate the pioblem
Fistula foimation
If theie is an abscess, peicutaneous uiainage is iequiieu
Nost patients aie manageu well with fluius anu antibiotics
Foi peifoiation oi obstiuction, suigeiy is iequiieu

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

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

Lapaiotomy if cecal uiametei is >12cm

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

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

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

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

0btain pieopeiative CEA (allows you to follow the piogiession oi iecession
of the uisease)
Enuoscopy + baiium enema
Suigical iesection + LN uissection
If uisease is metastatic, auu S-F0 to the post-opeiative iegimen
CEA levels eveiy S months foi S yeais
Peifoim a colonoscopy at 6 anu 12 months, then yeaily foi S yeais
If a iecuiience is suspecteu, a CT shoulu be peifoimeu

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

vaiicosities of the hemoiihoiual plexus
0ften ielateu to stienuous bowel movements

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

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

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

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

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

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

Suigeiy that spaies the sphinctei
If metastasis involveu, auuition of S-F0 chemotheiapy + iauiation


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

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

Common in chiluien
Founu in the ceiebellum4
Is the NC pituitaiy tumoi
Piesents with many enuociine uistuibances such as amenoiihea, impotence,
galactoiihea, anu gynecomastia.
The NC piesenting symptoms is visual uistuibance (bitempoial
NC CNS tumoi in AIBS patients
An NRI shows a iing-enhanceu lesion
0ften confuseu with toxoplasmosis
A tumoi that affects the 8
cianial neive
Piesents with tinnitus, loss of heaiing, anu incieaseu intiacianial piessuie

An inciease in CSF causes an enlaigement of the ventiicles

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

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

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

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

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

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

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

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

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

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

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

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

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

0nilateial pain of the testicle
Painful anu swollen epiuiuymus
Less common in piepubeital chiluien as opposeu to toision
Swab foi Chlamyuia anu uonoiihea
NSAIBs anu antibiotics

@'B0,(,. 5(/<.'
0bstiuctive symptoms
Rock-haiu nouule in the piostate

Seium phosphatase
Tiansiectal ultiasounu

The only suigical iequiiement is a iauical piostatectomy in veiy seveie cases
- iisk of incontinence anuoi impotence

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

P/.. >/W)'-.0
Anteiioi ciuciate ligament teais
Posteiioi ciuciate ligament teais
Collateial ligament teais
Neniscus teais

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

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

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

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

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

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

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

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

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

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

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

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

Bislocations iequiie emeigency ieuuction unuei seuation
Risk of injuiy to sciatic neive
Avasculai neciosis is a seveie complication

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

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

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

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

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

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

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

!3. 4'.(0,

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

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

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

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

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

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

Bieast exam
Follow-up clinical bieast exam in 6 weeks
Not iequiieu as this conuition is not a cancei
piecuisoi anu often uisappeais on its own

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

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

Fine-neeule aspiiation to uiain fluiu, anu it will collapse aftei the FNA
0CP's can help pievent this fiom occuiiing

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

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

Bistology shows pucheu-out aieas in uucts anu haphazaiu cells along the
Suigical excision ensuiing clean maigins
Post-opeiative iauiation is iecommenueu to ueciease the iisk of iecuiience
(Can give Tamoxifen in auuition to iauiation oi insteau of iauiation)

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

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

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

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

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

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

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

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

Chapter 2


uiaviuty = total numbei of piegnancies
Paiity = numbei of biiths with a gestational age >24 weeks
Teim ueliveiy = ueliveiy aftei S7 weeks of gestation
Piematuie ueliveiy = ueliveiy of infant between 2u anu S7 weeks

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

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

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

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

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

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

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

Folic aciu
2S-SS lb weight gain uuiing piegnancy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

BP goal is 14u-1Su mmBg (systole) anu 9u-1uu mmBg (uiastole).
Bon't tieat unless BP is >16u1uu mmBg

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

* #-blockei use in piegnancy can cause I0uR

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

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

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

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

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

Bepatic iuptuie

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(+) uiine cultuie
N0 fevei
(+) uiine cultuie
Tieatment 0utpatient
Nitiofuiantoin is
the B0C
Nitiofuiantoin is
the B0C
Aumission, give:
Iv hyuiation
Iv cephalospoiin's
uive tocolytics
pyelonephiitis if
untieateu in
pyelonephiitis if
untieateu in
Pieteim laboi anu
Seveie cases may
piogiess to sepsis,
anemia, anu

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

B&C is the most common 2
tiimestei pioceuuie.
Foi moie auvanceu piegnancies, an "intact B&C" can be useu.

Retaineu placenta is the most common immeuiate complication
Ceivical tiaumaceivical insufficiency is the most common uelayeu


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

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

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

!9+.0 B; #NB',-B/0
!3'.(,./ >/.:-,(ND. 5B*+D.,.2 >/<B*+D.,. %-00.2 ".<)''=
bleeuing in
fiist 2u wk
passage of
tissues oi
Ceivix is

0ccuis in
2S% of


If no
activity by
week 9
consiuei a

u aboition
ceivical os
iuptuie of
s (R0N).

loss is

Tieat with
+ aumin of
RhouAN if
mothei is
Rh (-).
ly aboits all
piouucts of

Nust uo
iepoit of

Pt may
cuiettage if
P0Cs aie not

RhouAN to
Rh (-)
ceivix with
passage of
tissue into
vagina oi


Rh (-) pt

may be
P0Cs uo not
get fully

No uteiine
giowth, no
fetal heait
cessation of

of uteius
fetal ueath.

BIC is iaie

RhouAN is
Rh (-)
oi total of S
s aboitions.

Nay be ut
al anomaly.

Tieat with
until laboi
oi R0N
occuis (S6-

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

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

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

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

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

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

Inuicateu by fetal weight >9u-9S peicentile foi gestation age oi biith weight
of 4uuu-4Suug.
Risk Factois:
uestational Biabetes Nellitus
Piolongeu gestation
Incieaseu piegnancy weight gain
Nale fetus

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

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

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

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

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

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

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

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

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

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

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

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

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

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

** Repetitive late ueceleiations iequiie inteivention

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

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

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

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

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

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

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

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

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

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

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

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

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

j= @(00(1. -

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

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

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

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

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

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

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

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

7/20 (, aS<*

"(+-2 <.':-<(D

#<,-:. @3(0.
+'BDB/1 B' (''.0,F

5.':-V 2-D(,.2 %

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

5()0.F +(00./1.'

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

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

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

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

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

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

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

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

Nateinal meuical complication
Piematuie iuptuie of membianes (PR0N)

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

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

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

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

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

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

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

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

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

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

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

a $!>

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

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

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

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

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

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

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

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

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

Avoiu hanuling cat feces, iaw goat milk, anu
unueicookeu meat
If infecteu, mothei shoulu take spiiamycin to
pievent veitical tiansmission
Aftei seiologic confiimation, give pyiimethamine
anu sulfauiazine.

j= M('-<.DD(

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

f= ")N.DD(

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

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

Peifoim a fiist tiimestei scieening
Bave mothei avoiu any infecteu inuiviuuals
Immunize seionegative women aftei
** Theie is no post-exposuie piophylaxis available

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

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

"Bluebeiiy Nuffin" iash

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

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

m= O>M

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

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

g= A9+3-D-0

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

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

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

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

Chapter 3


4./-1/ G9/.<BDB19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Relateu to LB

SiSx: amenoiihea oi
infeitility, hiisutism, acne.


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

Weight loss.

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

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

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

AR pattein.

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

helps ueteimine auienal
ulucocoiticoius can
suppiess auienal
anuiogen piouuction.

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

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

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

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

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

! 5H?%>6 (fools the pituitaiy into secieting lots of FSB anu LB)
! @7"G#L?H (concentiateu amounts of FSB anu LB fiom uiine of menopausal

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

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

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

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

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

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


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

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

Begiees of piolapse:
uegiee ! piolapse is above intioitus
uegiee ! goes to the intioitus
uegiee ! goes past intioitus

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

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

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

Stiess Incontinence ! 1
- attempt kegel exeicises, 2
- suigeiy (colpoiaphy)
Neuiogenic ! Anti-spasmotics, anti-cholineigics

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

G9/.<BDB1-< ?/<BDB19

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

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

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

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

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

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

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

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

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

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

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

O-0,BDB19 Is uefinitive uiagnosis Is uefinitive uiagnosis

A iaie cancei that accounts foi appioximately S% of uteiine canceis

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

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

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

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

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

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

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

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

0theis: mucinous,
enuometiioiu, Biennei
tumoi (all iaiely

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

Almost nevei malignant.

Contains tissues fiom all S
geim layeis.

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

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

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

Seitoli-Leyuig makes
anuiogens (viiilization in


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

cystauenocaicinoma is the
most common type (often
uevelops fiom a benign
ueim Cell Is the most common
ovaiian cancei in women

Piouuces hCu oi AFP,
which aie useful as tumoi

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

Seitoli-Leyuiu cell tumoi
makes anuiogens
Total hysteiectomy +

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

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

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

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

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

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

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

!3. 4'.(0,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Competitively binus to estiogen ieceptois
Piouuces a Su% ueciease in iecuiience anu a 2S% ueciease in moitality
Excellent foi both pie anu post-op patients

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

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

"" iisk of cancei of the enuometiium

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

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

Chapter 4


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

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

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

Image Besciiption Biagnosis Co-

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

0nilateial ieu
foimations on
heau anu neck
(unilateial anu
Poit Wine
Nay be
with Stuige-
Pulseu lasei
If Stuige-
Webei must
evaluate foi
anu give anti-

macules on
lowei back
posteiioi thigh
Rule out
chilu abuse,
usually faue
within fiist
few yeais of

Fiim, yellow-
es with
base, peaks on
uay of life
None None, is self-

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

Befect in the
Coloboma of
the Iiis
with othei
Scieen foi

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

A mass lateial
to the miuline
Cleft Cyst
Is a iemnant
of embiyonic

A miuline mass
that iises when
Buct Cyst
Nay have

A piotiusion of
uI contents
within a sac
0mphalocele Associateu
uisoiueis anu
Scieen foi

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

weakness that
allows bulging
of fetal anu
infant umbilical
This may

Scieen foi
with TSB

swelling that
can be
Byuiocele Associateu
with an
fiom inguinal
heinia by

Absence of
teste(s) in
with cancei of
the teste(s)
iemoval by

0pening of the
uiethia on
uoisum of the
Epispauias 0iinaiy
Evaluate foi

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

sciotal swelling

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

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

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

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

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

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

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

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

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

- Auuiess meuical anuoi suigical issues befoie all else
- Repoit abuse to chilu piotective seivices (CPS)

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

Lithium Tetiacycline
Chloiamphenicol Sulfonamiues
Iouiue anu Neicuiial Biugs Netioniuazole

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

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

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

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

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

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

This uiagiam is the typical vaccination iecommenuation foi chiluien fiom u-6yi olu

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

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

woisen at
neeueu foi
uiagnosis but
a neck-x-iay
shoulu be
1. Bumiuifieu
2. Nebulizeu
epi +

y iesolves
within 1 wk.

Always be
waiy of the
possibility of
(Bib, S.
pyogenes, s.
pneumo, anu
Acute onset of
muffleu voice,
uiooling, high

Patient will
lean foiwaiu
to ease

Ngmt baseu
on clinical
ux, stabilize
fiist then uo

Neck xiay
looking foi


swab cultuie

1. Aumit to
2. Anesthesia
anu ENT
S. Intubation
4. Ceftiiaxon
e +
S. Bouseholu
shoulu get
Rifampin if
patient is
can leau to
Tiacheitis (S.
Chilu usually
<Syi, aftei a
viial 0RI gets
cough that
"Biassy", has
high fevei,
uistiess B0T
Bx is clinical
but also uo a
y anu CXR

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

no signs oi
symptoms of
seveiity of

Bloou cult +
thioat cult.

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

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

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

Bx is clinically baseu.
Best initial test ! CXR looking foi hypeiinflation + patchy atelectasis
Nost specific test ! Immunofluoiescence of nasophaiyngeal swab

Nostly suppoitive
If tachypnea is seveie hospitalize anu give tiial of nebulizeu #-agonists

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

Tachypnea is the most consistent finuing in viial pneumonia
0RI symptoms
Low giaue fevei

Acute onset with suuuen shaking chills
Bigh giaue fevei
Chest pain (pleuiitis- pain with iespiiation)

Biminisheu bieath sounus
Bullness to peicussion of the lung fielus

Nost common finuing aie a "staccato cough" anu "peiipheial eosinophilia"
No fevei oi wheezing
Nay be conjunctivitis

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

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

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

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

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

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

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

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

0sually no tenueiness,
waimth, oi swelling

Rest + analgesia foi S-S

`;,= is noimal

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1u%-4u% of untieateu cases show uilationaneuiysm of the coionaiy

IvIu to pievent coionaiy vasculitis + high-uose aspiiin
Bo not give steioius as this will exaceibate the conuition

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

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

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

Self-limiteu anu iaiely piogiesses to glomeiulonephiitis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

0v light to bieak uown biliiubin pigments
0igent tieatment is impeiative in oiuei to pievent keinicteius inuuceu
mental ietaiuation
0v light can cause uiaiihea, ueimatitis, uehyuiation, anu uamage to the
ietina (be cautious of these auveise effects)

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

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

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

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

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

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

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

In the 1
yeai of life the px is pooi since the biain uevelops eaily in life
1S of chiluien with nonoiganic failuie to thiive aie uevelopmentally

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

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

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

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

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

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

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

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

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

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

Suigical patching
Tieatment is moie impoitant foi females because they have an inciease in
caiuiovasculai stiess uuiing piegnancy

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

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

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

Without tieatment is fatal within seveial months of biith

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

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

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

0luei chiluien usually iequiie suigical iepaii

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

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

Supplement with
estiogen, uB, anu
anabolic steioius

Fiagile X Synuiome

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

Ass'u with ABBB
Pancieatic beta cell
Laige kiuneys
Incieaseu iisk of abu
0S anu seium AFP q
6mnth up until 6yi of
age - looking foi
Wilm's tumoi
(ueletion at 1Sq11q1S -
pateinally ueiiveu)
Small genitalia
Nental ietaiuation
Noibiu obesity
uecieases life-span
Angelman synuiome (aka
"happy puppet" synuiome).
(ueletion at 1Sq11q1S
mateinally ueiiveu)
Nental ietaiuation
Absence of speech
Ataxiajeiky aim
Recuiient seizuies
Epilepsy uevelops in
(ass'u with FAS anu
Cleft palate
Aiiway obstiuction
possible ovei fiist 4
wks of life, thus
monitoi aiiway

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

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

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


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

Chapter 5


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

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

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

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

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

NEAN - the aveiage value
NEBIAN - the miuule value

N0BE - the most common value

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

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

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

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

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

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

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

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

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

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

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

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

Chapter 6


%BB2 6-0B'2.'0

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

If patient is suiciual oi uangeious to otheis always aumit

line tieatment is SSRI such as fluoxetine, paioxetine, seitialine (possible
siue effect is sexual uysfunction)
Can incluue benzouiazepine if patient is agitateu
Theiapy is also inuicateu along with SSRI tieatment

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

Beieavement is commonly seen aftei ueath of a family membei (most
commonly seen in oluei people aftei ueath of a spouse).
Key to the uiagnosis is the time that has elapseu since the onset of the
beieavement peiiou.
Symptoms > 2months makes the uiagnosis majoi uepiessive uisoiuei insteau
of noimal beieavement.
Theiapy (giief management) is iecommenueu in such conuitions

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

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

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

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

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

Is a iecuiience of uepiessive episoues anu hypomania foi at least 2 yeais
Is a miluei foim of bipolai uisoiuei

is psychotheiapy because many patients can function without meuication
If functioning becomes impaiieu stait patient on valpioic aciu, which is moie
effective in cyclothymia than lithium

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

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

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

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


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

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

cause psychosis

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

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

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

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

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

Patient feais being in situations wheie they cannot escape, biinging about a
panic attack
Patients uevelop agoiaphobia because of iecuiient anu unexpecteu panic
attacks in ceitain situations
Is clinical, looking foi eviuence of social anuoi occupational uysfunction
Exposuie uesensitization
#-blockeis as piophylaxis fiom sympathetic activation when in possibly
tiiggeiing situations

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

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

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

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

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

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

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

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

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

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

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

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

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

71B 6.;./0.0

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

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

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

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

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

The patient falsely believes they have a specific uisease even when they aie
iuleu out with negative woikups anuoi lab tests
Regulai visits to 0NE piimaiy uoctoi
Avoiu testspioceuuies
Pioviue psychotheiapy
SSRI's may be useful in some cases

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

veiy uemanuing of tieatment

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

By exclusion of a ieal meuical conuition
Biffeientiate between malingeiing anu factitious uisoiueis
veiy uifficult, patients often veiy uefensive when it is suggesteu that they aie

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An inuiviuual who iepeateuly steals to ielieve anxiety
Peison uoes not steal because they neeu the object
0ften, the peison ietuins the object aftei stealing it

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

Patient impulsively pulls out theii haii
This iesults in &4'*2G#47* haii loss

6')10 B; #N)0.

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

The following table piesents the most commonly abuseu uiugs
A$4A!#L57 A-JAV B;
!'.(,*./, B;
!'.(,*./, B;
Alcohol Lack of
If seveie give

Suiciue iisk
Naiijuana Impaiieu
motoi co-
Biy mouth,

None None None
Ballucinogens Iueas of
Talking uown,
None None
Inhalants Belligeience,
Stupoi, coma.
If ueliiious oi
agitateu give
None None
Naloxone Fevei, chills,
Abu ciamps,
None None
Baibituiates Impaiieu Flumazenil Autonomic Long-acting

memoiy oi
Lack of
baibituiates as


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

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


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

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

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

Patient expeiiences acute attacks of REN sleep
They suuuenly collapse with a complete loss of muscle tone (cataplexy)
CNS stimulants

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

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

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

0ccui uuiing REN sleep
Relateu to emotional events such as tiageuy, scaiy movie, etc
Patient iemembeis the uieam

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

Chapter 7


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

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

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

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

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

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

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

Baseu on the likelihoou that it will piogiess to a potentially fatal outcome (ie.
Risk of iecuiient unstable angina, infaiction, oi ueath Su uays aftei

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

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

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

EKu will show ST elevation anu Q waves

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

Re-establish vessel patency

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

E&',D)> !"';5#2$* >%',2=;,"&%'8

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

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

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

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

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

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

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

Tieat any unueilying conuition

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

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

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

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

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

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

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

- CBF occuis when the caiuiac output is insufficient to met systemic uemanus
- Nay be iight-siueu, left-siueu, oi both
- valvulai uiseases
- NI
- Bypeitension
- PE
- Anemia
- Caiuiomyopathy
- Euocaiuitis
- Thyiotoxicosis

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

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


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

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

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

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

- Nost commonly seen in aoitic stenosis, mitial ieguigitation, NvP, anu B0CN
- Nost commonly seen with aoitic ieguigitation anu mitial stenosis.

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

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

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

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

- If coionaiy uisease is piesent then S-Syi is avg suivival
- If syncope is piesent then 2-S yi avg suivival
- If CBF piesent then 1.S-2yi avg suivival
A tiick to know
what type of
theiapy you shoulu
If the valsalva
impioves the
muimui, use
If amyl nitiate
impioves the
muimui, ACEI is

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

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

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

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

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

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

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

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

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

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

- Pleuiitic chest pain
- Relieveu by leaning foiwaiu
- Pain often uesciibeu as shaip anu biief

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

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

- Echo is the most accuiate uiagnostic test
- Eailiest finuing is usually collapse of the iight atiium anu ventiicle
- EKu shows low voltage anu electiical alteinans
- Right heait catheteiization will show equalization of all piessuies in the
heait uuiing uiastole
- Best initial theiapy is a peiicaiuiocentesis
- Nost effective long-teim theiapy is peiicaiuial winuow placement

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

Chapter 8


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

Piolactin-secieting tumoi
Always think of this when theie is visual uistuibances

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

Excess piouuction of uB uue to a uB-piouucing auenoma in the pituitaiy

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Removal of whatevei is causing the pioblem, iuentifieu by NRI oi abuominal
scan (uepenuing on the location of the pioblem)

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

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

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

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

T V=>+;,#.$%0+;$()%2<
Incieaseu ienin piouuction 2 to uecieaseu ienal bloouflow(CBF, shock,
ienal aiteiy stenosis)
" ienin (this is useu to uiffeientiate between 1 anu 2 causes
Tieat unueilying cause
Tieat BTN

E#,"*%, 02*'*%,' :",58
Episouic BTN
Best initial tests ! high plasma anu uiinaiy catecholamineplasma-fiee
metanephiine anu vNA levels
Nost accuiate tests ! CT oi NRI of auienal glanus
- phenoxybenzamine to contiol BP
- piopianolol (only aftei $-blockaue with phenoxybenzamine)
- suigical iesection

Nale uonaual Bisoiueis
6-0.(0. 53('(<,.'-0,-<0 Tieatment
XXY inheiitance with vaiiable expiessivity
Biagnosis usually at pubeity when no viiilization
Tall with small testes anu gynocomastia
Becieaseu testosteione
" LBFSB (no feeuback)
Bx with buccal smeai showing baii bouy
XXY synuiome Nilu mental ietaiuation, acne, violent, antisocial
Biagnose with kaiyotype analysis
Befect in BBT ieceptoi
Female exteinal genitalia with steiile, unuescenueu
Patient appeais female but is steiile with blinu
TestosteioneestiogenLB aie all elevateu
No tx
Ambiguous genitalia until pubeity
At pubeity a buist of testosteione oveicomes the lack
of BBT (masculinizing exteinal genitalia)
Testosteione anu estiogen aie noimal
Biagnosis is by genetic testing
A uefect in the steioiu synthesis pathway causes
viiilization of females oi failuie to viiilize in males
21-$-hyuioxylase ueficiency causes 9S% of all CAB
seveie uisease piesents in infancy with ambiguous
genitalia anu excess salt loss
less seveie ! minimal viiilization anu salt loss
pateinal impiinting
shoit limbs, floppy baby
hypeiphagia ( obesity ! incieases eaily ueath
mental ietaiuation
classically have almonu-shapeu eyes with stiabismus
uiagnosis is genetic analysis
AB hypogonauism with anosmia
Becieaseu piouuction anu secietion of unRB by
Biagnosis maue by finuing uecieaseu ciiculating LB
anu FSB

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

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

Nost commonly fiom 'buinout' Bashimoto's thiyoiuitis.
Patient is fatigueu
Poveity of movement
uaining weight

! T4
T4(conveiteu in the tissue to TS as neeueu)

" T4 levels
4 foims of hypeithyioiuism: uiaves(NC), Silent, Subacute, Pituitaiy auenoma

N;,?+G% R)%+,%+<
Bas many finuings that aie unique to this type of hypeithyioiuism:
Exophthalmos anu pioptosis
Beimopathy (ieuness anu thickeneu skin below the knee)
0nycolysis (sepeiation of the nail fiom the nailbeu)
RAI0 is elevateu
PT0 oi methimazole is given acutely to biing the glanu unuei contiol
Aftei glanu is contiolleu, use iauioactive iouine ablation
Piopianolol useu to tieat sympathetic symptoms

9)#+(0 71=;$).)0)%<
An autoimmune piocess with a non-tenuei glanu anu hypeithyioiuism
No eye, nail, oi skin finuing
RAI0 test is noimal
ulanu is not in a state of hypeifunctioning, iathei it is "leaking"
Antibouies to thyioiu peioxiuase anu antithyioglobulin antibouies may be
12*#,+*%,: Theie is no tieatment

9*-,'*0+ 71=;$).)0)%F
A conuition of viial etiology
ulanu is tenuei
TSB low
T4 incieaseu
RAI0 low
Aspiiin to ielieve the pain

8)0*)0,;= !.+($2,<
Raie conuition
Is the only hypeithyioiu uisoiuei with an elevateu TSB
NRI of biain
Removal of auenoma

7VB1./B)0 !39'B-2 OB'*B/.0 #N)0.F
Will be an elevation in T4 (uue to taking thyioiu hoimone)
The TSB will be suppiesseu uue to negative feeuback
Thyioiu glanu will atiophy

71=;$). 90$;2:
This is an emeigency situation wheie theie is seveie ielease of thyioiu
hoimones fiom the thyioiu glanu
Causes symptoms of extieme sympathetic stimulation (tiemoi, tachycaiuia,
uiaphoiesis, etc)
! give iouine to block the uptake of iouine into the glanu
! give PT0 oi methimazole to block thyioxine piouuction
! uexamethasone to block the peiipheial conveiion of T4! TS
! block sympathetic effects with piopianolol

@=Q+.+2, :$2,:
An emeigency hypothyioiu conuition
Nay be spontaneous oi ppte by colu conuitions, infections, seuative uiugs,
iespiiatoiy failuie
-"$%' #%. -/+0,&+'8


!39'B-2 %(D-1/(/<-.0
All solitaiy uominant nouules shoulu be uiagnoseu by FNA
Excision if malignancy is suspecteu
Bot nouules (a nouule that takes up moie iauioactive iouine) aie less likely
to be malignant
Colu nouules (nouules that take up less iauioactive iouine) aie moie likely to
be malignant
E#0"77#2/ ;#%;*28
Nost common type of thyioiu
Best piognosis (8S% S-yi suivival iate)
Psammoma bouies & oiphan-annie bouiesgiounu-glass nuclei
C&77";=7#2 ;#%;*2:
uoou piognosis
Common metastasis to bone anu lungs
)*.=77#2/ ;#%;*28
Piognosis is inteimeuiate
Is a cancei of the paiafolliculai "C" cells that aie ueiiveu fiom cells of the S

bianchial pouch
Secietes calcitonin
@%#07#',"; ;#%;*2:
Teiiible piognosis
Bas a u% S-yi suivival iate

%)D,-+D. 7/2B<'-/. L.B+D(0-(F
Type 1 (Weimei's) S P's: Pituitaiy, Pancieas, Paiathyioiu
Type 2 (Sipple's) Pheociomocytoma, Neuullaiy Thyioiu
CA, Paiathyioiu
Type 2b (Type S) Pheociomocytoma, Neuullaiy Thyioiu
CA, Nucocutaneous neuiomas(esp in uI)

Chapter 9


Answeiing questions in the infectious uisease section aie usually pietty stiaight
foiwaiu. Being able to coiiectly answei these questions comes uown to
unueistanuing the following:
1. Common conuitions anu theii associateu oiganisms
2. Common conuitions anu the best antibiotics to use
S. 0iganisms anu theii giam stain chaiacteiistics
4. Common scenaiios anu theii commonly associateu oiganisms

Foi gieatest chances of success with these questions, the following tables shoulu be

N;,2 90,)( :1,;,'0+;)%0)'%
?"G#L>A% 5O#"#5!7">A!>5A A!#>L>LG 5O#"#5!7">A!>5A
uiam (+) oiganisms Blue in coloi
uiam (-) oiganisms Reu in coloi
uiam (+) cocci (paiis) S. Pneumonia
uiam (+) cocci (chains) Stieptococcus
uiam (+) cocci (clusteis) Staphylococcus
uiam (-) uiplococci Neisseiia
uiam (-) ious Bemophilus
uiam (-) ious with mucoiu capsule Klebsiella
Pseuuohyphae on stain Canuiua
Aciu Fast 0iganisms Nycobacteiium, Nocaiuia
Silvei Staining Pneumocystis Caiinii
Spiiochete Boiielia,

:$22$( %)0*,0)$(% ,(. 01+); ,%%$'),0+. $;A,()%2%
A>!$#!>?L #AA?5>#!76 ?"G#L>A%A
Cellulitis fiom a uog oi cat bite Pasteuiella Nultociua
Buin wounu infection with a bluegieen
Baby Paialyzeu aftei eating honey Clostiiuium Botulinum
Biaiihea aftei taking antibiotics Clostiiuium Bifficile
Piickeu by thoin while gaiuening Spoiothiix Schenckii
uastioenteiitis in young chilu Rotaviius
Biaiihea aftei tiaveling to Nexico E. Coli
Aplastic ciisis in Sickle Cell patient Paivoviius B19
Foou poisoning aftei eating ieheat iice B. Ceieus
Foou poisoning aftei eating iaw seafoou vibiio Paiahemolyticus
Pneumonia in Southwest 0SA Cocciuioiues Immitis
Pneumonia aftei exploiing caves Bistoplasma Capsulatum
Pneumonia aftei exposuie to biiu
uioppings in 0hio
Bistoplasma Capsulatum
Pneumonia aftei exposuie to exotic
Chlamyuia Psittaci
Pneumonia in a patient with silicosis Tubeiculosis
Biaiihea aftei hiking oi uiinking fiom a
uiaiuia Lamblia
B12 ueficiency Biphyllobothiium Latum
Fevei anu muscle pains aftei eating iaw
Tiichinella Spiialis
Pneumonia aftei being neai an aii
conuitionei oi watei towei
Legionella Pneumophilia
Slaughteihouse woikei with a fevei Biucellosis
Fungal ballhemoptysis aftei TB oi
cavitaiy lung uisease

V)A1D=)+#. '$(.)0)$(%Y)##(+%%+% ,(. 01+); 2$%0 #)B+#= $;A,()%2 ,(. 0;+,02+(0%
5?L6>!>?LJ>HHL7AA ?"G#L>A% 47A! !"7#!%7L!
Cellulitis Staph, Stiep Antistaphylococcus
0TI E. Coli TNP-SNX, Nitiofuiantoin
(in piegnancy)
Enuocaiuitis Staph, Stiep Antistaphylococcus,
Sepsis uiam (-) oiganisms S
Septic Aithiitis Staph Auieus Antistaphylococcus PCN,
vancomycin (seveie)
Neningitis (neonatal) uioup B Stiep, E. Coli, oi
Ampicillin +
Neningitis (chilu - auult) Neisseiia Neningitiuis S
0steomyelitis Staph Auieus, Salmonella
(Sickle cell patient)
Antistaphylococcus PCN,
Pneumonia Stiep Pneumonia, B.
Pneumonia (atypical) Nycoplasma, Chlamyuia Boxycycline, Nacioliue
Bionchitis B. Influenza Amoxicillin, Eiythiomycin

>*+B',(/, -/;B'*(,-B/ '.1('2-/1 O>M

V$/ $&0+( %1$*#. 01+ :R\ '$*(0 -+ '1+'B+.Z Q 6 months
!0 /1,0 >$)(0 )% 8:8 , /$;;= )( V4FY!).% >,0)+(0Z When CB4 is <2uu
S1,0 )% 01+ 2$%0 '$22$( $>>$;0*()%0)' >(+*2$(), )( !4R9Z PCP
V$/ 0$ >;+?+(0 8:8 )(&+'0)$(Z Piophylax with TNP-SNX when CB4 & 2uu
!0 /1,0 :R\ #+?+# %1$*#. >;$>1=#,Q)% ,A,)(%0 @='$-,'0+;)*2 !?)*2 :$2>#+Q -+
%0,;0+.Z When CB4 is <Su
S1)'1 0=>+ $& ',('+; ,;+ V4FY!).% >,0)+(0% ,0 )(';+,%+. ;)%B &$;Z Kaposi's
91$*#. #)?+ ?,'')(+% -+ A)?+( .$ 01+%+ >,0)+(0%Z N0
S1)'1 )% 01+ $(#= #)?+ ?,'')(+ 0$ -+ A)?+(Z NNR
S1)'1 0=>+ $& -#$$. .)%+,%+ )% )(';+,%+. )( 01)% >,0)+(0 >$>*#,0)$(Z NBL
S1,0 )% 01+ 2$%0 #)B+#= ',*%+ $& >(+*2$(), )( V4F >,0)+(0Z Stiep Pneumo
S1,0 )% 01+ 2$%0 #)B+#= ',*%+ $& 5>>$;0*()%0)' >(+*2$(), )( V4FZ PCP (be able to
iecognize if the question is asking most common cause oi most common
oppoitunistic cause)
S1)'1 $;A,()%2 ',( ',*%+ '1;$()' .),;;1+, )( !4R9 >,0)+(0%Z Ciyptospoiiuium

Chapter 10


O9+.'0./0-,-:-,9 ".(<,-B/0
Type 1 - Anaphylactic (Piefoimeu IgE antibouies)
Type 2 - Cytotoxic (piefoimeu Igu anu IgN antibouies)
Type S - Immune complex-meuiateu (antigen-antibouy complexes uepositeu in
vessels anu cause an inflammatoiy iesponse)
Type 4 - BelayeuCell-meuiateu (sensitizeu T lymphocytes ielease inflammatoiy


Is a typ1 hypeisensitivity ieaction
Bue to piefoimeu IgE antibouies that cause the immeuiate ielease of
vasoactive amines such as histamines anu leukotiienes.
Commonly seen aftei bee stings anu ingestion of meuications such as
penicillin anu sulfa uiugs
Symptoms uevelop acutely anu aie often veiy uiamatic
Bifficulty bieathing
Bypotension + tachycaiuia

Secuie aiiway
uive subcutaneous epinephiine
If these aien't available give coiticosteioius
uive antihistamines foi cutaneous ieactions


Is most commonly causeu by a ueficiency of C1 esteiase inhibitoi
Biffuse swelling of the eyelius, lips, anu aiiway
0sually occuis aftei milu facial tiauma oi ingestion of ceitain meuications
(often ace inhibitois)
Theie is usually a family histoiy
C4 levels aie low
Secuie aiiway
uive subcutaneous epinephiine
Nanage exactly like anaphylaxis

#DD.'1-< "3-/-,-0

An alleigic ieaction that is veiy common
Recuiiing nasal stuffiness, itching, ihinoiihea, anu sneezing
The main tieatment shoulu be avoiuance of the alleigen
Keep aii clean
Close winuows anu keep aii-conuitioning iunning uuiing summei months
Non-seuating antihistamines such as loiatauine aie veiy effective anu can be
useu continually
Nasal saline spiaysnetti pot aie effective at washing out the nasal cavity

@'-*('9 >**)/B2.;-<-./<-.0

>1# 6.;-<-./<9
Is the most common piimaiy immunoueficiency, anu it is often asymptomatic
Causes iecuiient iespiiatoiy anu uI infections
Someone ieceiving bloou piouucts may uevelop anaphylaxis, which shoulu
make you think of an IgA ueficiency
Nevei give these patients immunoglobulin's
Nanage anu tieat infections as they aiise

4'),B/80 #1(**(1DBN)D-/.*-(
Is an x-linkeu uisoiuei affecting males
Patients piesent with infections staiting aiounu 6 months of age
Recuiient sinopulmonaiy infections uue to Stiep oi Bemophilus oiganisms
aie classic
Infusion of Iv Ig's

5B**B/ M('-(ND. >**)/B2.;-<-./<9
Is a conuition that piesents in both men anu women
0sually only piesents when they aie auults
Patient piesents with iecuiient sinopulmonaiy infections
Nay get spiue-like abuominal uisoiueis (malabsoibtion, uiaiihea,
Igu levels aie low
Infusions of IvIu is iequiieu since Igu levels aie low

A.:.'. 5B*N-/.2 >**)/B2.;-<-./<9
An AR oi x-linkeu uisoiuei
Commonly causeu by auenosine ueaminase ueficiency
Theie is a B anu T cell uefect, thus patient has seveie infections eaily in life
These aie the so calleu "bubble babies", anu iequiie isolation to pievent life-
thieatening infections

I-0QB,,Y#D2'-<3 A9/2'B*.
An x-linkeu iecessive uisoiuei affecting only males
Theie is a classic tiiau of eczema, iecuiiing infections, anu thiombocytopenia

53.2-(QYO-1(03- A9/2'B*.
Bue to a uefect in miciotubule polymeiization
uiant gianules in neutiophils
0culocutaneous albinism
Recuiiing infections

53'B/-< G'(/)DB*(,B)0 6-0.(0.
0sually an x-linkeu iecessive uisoiuei affecting males
Theie is a uefect in NABPB oxiuase, causing iecuiiing infections uue to
catalase (+) oiganisms (Staph, Pseuuomonas,etc)
Biagnostic test involves nitioblue tetiazolium uye (noimally gets ieuuceu by
gianulocytes) - measuies iespiiatoiy buist, which is lacking in these

Chapter 11



Theie aie S causes of hypoxemia:
1. Bypoventilation
2. Biffusion Impaiiment
S. vQ mismatch
4. ! Fiu2
S. Shunt

Beie is an algoiithm figuiing out the cause of hypoxemia

-"$%' #%. -/+0,&+':
Tachycaiuia, uyspnea
Clubbing anu cyanosis
Ciackles anu iales

Tieatment iequiies tieating the cuiient hypoxemia anu the tieatment of
unueilying uisoiueis
" Pau2
u2 by nasal cannula, oi CPAP, oi intubation if necessaiy
If theie is a shunt, the hypoxemia will not impiove by incieasing the FI02


1. Emphysema
2. Chionic Bionchitis
S. Asthma
4. Bionchiectasis

Is aii space uilation with alveolai wall uestiuction
The most common cause of emphysema is smoking
If a young patient gets this, consiuei an alpha-1-antitiypsin ueficiency

32>1=%+2, W X$0)'+ O*(A V=>+;)(&#,0)$(

-"$%' #%. -/+0,&+':
Baiiel chest
Puiseu lip bieathing
Known as the "pink puffeis"
Clinical uiagnosis + CXR showing hypeiinflation of the lungs
Acute episoues iequiie:

u2 anu an ABu
Albuteiol (inhaleu)
Steioius foi acute uesatuiations
Chionic management of C0PB:
Ipiatiopium inhalei
Albuteiol inhalei
Yeaily influenza vaccination
Pneumococcal vaccine
Long-teim u2 theiapy if Pu2 is <SS% oi the u2 satuiation is <88%

53'B/-< 4'B/<3-,-0
Piesents as a piouuctive cough on most uays foi % S months in a iow foi %
Known as the "blue bloatei"
-"$%' #%. -/+0,&+':
Similai to emphysema howevei hypoxia is moie seveie
RvB + pulmonaiy BTN
Neck vein uistention
Biagnosis is laigely clinical
Can confiim with a lung biopsy that shows an incieaseu Reiu inuex, which is
a glanuulai layei that is >Su% of the total thickness of the bionchial wall.

Piesents with S0B anu expiiatoiy wheezing
Seveie cases may piesent with the use of accessoiy muscles
Causeu by bionchial hypeiiesponsiveness that is ieveisible
-"$%' #%. -/+0,&+':
Expiiatoiy wheezing anu uyspnea
0nset is often physical activity
Conuition is ieveisible with bionchouilatois such as albuteiol
Bighly clinical
Check foi a FEv inciease of moie than 1u%
Complication incluues status asthmaticus, which is iefiactoiy attacks that
last foi uays anu aie fatal
Tieatment with #2-agonists such as albuteiol
Long-teim contiol involves auuition of inhaleu steioiu (if patient isn't
expeiiencing enough contiol with albuteiol)
If albuteiol + steioius aie not enough, auuition of a long-acting #-agonist
such as salmuteiol may help
Last iesoit in long-teim management (iefiactoiy to these pievious
tieatments) is oial steioius

Bue to an anatomic uefect that causes peimanent uilation of the bionchioles
Patient expeiiences iecuiiing lung infections that piouuce massive amounts
of sputum
Patient often has uigital clubbing as well
The most accuiate uiagnostic test is the high-iesolution CT scan, which will
show thickeneu bionchial walls anu uilateu aiiways
CXR will show the classic "tiam-tiack maikings"
Nust tieat infections as they aiise because theie is no cuiative theiapy
Antibiotic theiapy foi iecuiiing infections
Chest physiotheiapy can be helpful in ieleasing anu eliminating sputum
Long-teim "cuie" is a lung-tiansplant

".0,'-<,-:. H)/1 6-0.(0.0

1. Inteistitial Fibiosis
2. Paienchymal uisease
S. Extiapulmonaiy uisease
4. Pleuial effusion

>/,.'0,-,-(D K-N'B0-0
Bue to chionic insult to the lung tissue by things such as asbestos, chionic
infections, oiganic uusts
Biagnosis maue by a CXR, which shows a "honeycomb" pattein of the lung
u2, PEEP, steioius if theie is collagen vasculai uisease

@('./<39*(D 6-0.(0.
Paienchymal uiseases aie causeu by things such as infections (TB),
inflammation (saicoiuosis), uiugs, toxicchionic inhalation of offenuing
agents (asbestos), anu it may be iuiopathic
Patient piesents with a uiy cough, S0B, anu chionic hypoxia
-"$%' #%. -/+0,&+':
"velcio" iales
CXR oi high-iesolution CT
Lung biopsy
PFT (all measuiements aie uecieaseu piopoitionately)
If inflammatoiy, steioius can help
Theie aie no uefinitive cuies foi othei foims of paienchymal uisease

7V,'(+)D*B/('9 6-0.(0.
Anything that affects the musculatuie iesponsible foi aiuing in bieathing can
cause pioblems
Nultiple scleiosis, ALS, uuillain-Baiie, spinal coiu tiauma
Anything that piesses on the uiaphiagm can also cause tiouble, such as
piegnancy anu obesity
Nanagementtieatment is suppoitive only

@D.)'(D 7;;)0-B/
Fluiu in the pleuial space
-"$%' #%. -/+0,&+'8
Becieaseu bieath sounus
Bullness to peicussion
Becieaseu tactile fiemitus

The best initial uiagnostic test is a CXR (lateial uecubiuus shows fiee flowing
Nost accuiate test is thoiacentesis (can show which type of fluiu it is)

Small effusions usually iesoib spontaneously
Biuietics can be useu if causing iespiiatoiy pioblems
If effusion is laige, inseit a chest tube foi uiaining

@)D*B/('9 7*NBD-0*

Patient piesents with a suuuen onset of shoitness of bieath
Lungs aie cleai
The iisk factois foi PE aie usually telltale in the questions:
1. Immobility (Long aiiplane iiue)
2. Tiauma (Bioken bone)
S. Suigeiy (Especially ieplacement of joints in the leg)
4. Nalignancies
S. Thiombophilias

A CXR shoulu be uone anu is usually noimal. Nay show a weuge-shapeu
infaict (laige PE), atelectasis is a common finuing
EKu often shows non-specific ST-T wave elevations
Best test to confiim uiagnosis of PE is the spiial-CT anu shoulu be uone if the
xiay is abnoimal
If the xiay is noimal but you aie still suspicious, a vQ scan shoulu be
peifoimeu (the less noimal the xiay the less accuiate the vQ scan will be)
Bopplei exam is only 7u% sensitive, thus many PE's aie misseu with this test.
The benefit of the Bopplei is that if it B0ES uetect a PE, it is 1uu% accuiate
B-uimei is a highly sensitive test but it has low specificity. This is the best
test to use if the patient has a low piobability of having a PE anu you want a
single test to iule out a PE

@)D*B/('9 O9+.',./0-B/

Pulmonaiy hypeitension is uefineu as hypeitension that is % that of the systemic
piessuie. Noimally it shoulu be appioximately 18 that of the systemic piessuie
Active pulmonaiy hypeitension means it is piimaiily a uisease of the lung
Passive pulmonaiy hypeitension means it is seconuaiy to a conuition of the
E2"+#2/ !"'*#'*:
Iuiopathic, which occuis commonly in young women
Inteistitial iestiictive uiseases
0bstiuctive pulmonaiy uiseases
-*;&%.#2/ !"'*#'*:
Seen in heait uisease
Commonly seen in patients with BIvAIBS

-"$%' #%. -/+0,&+':
Tiicuspiu ieguigitation
Louu P2
Right ventiiculai heave
Raynauu's phenomenon
Best initial test is the TTE, which will show RvB anu an enlaigeu iight atiium
Nost accuiate test is iight heait catheteiization with incieaseu pulmonaiy
aiteiy piessuie
EKu will likely show iight-axis ueviation

Enuothelin inhibitois that pievent giowth of the vasculatuie of the
pulmonaiy system


1 TB affects the lowei lobes anu is usually asymptomatic
It occuis in specific gioups such as immigiants, BIv+ patients, homeless
patients, anu alcoholics.
-"$%' #%. -/+0,&+':
Night sweats
Weight loss
CXR is the best initial uiagnostic test
Bo an aciu-fast stain of the sputum to confiim uiagnosis
Tieatment with 4 anti-TB meuications shoulu be staiteu with six months of
theiapy being the stanuaiu of caie
Isoniaziu (6 months), Rifampin (6 months), Pyiizinamiue (2 months), anu
Ethambutol (2 months)
Bo LFT's because these meuications can cause livei toxicity (stop all
meuications if tiansaminase levels ieach Sx the uppei limit of noimal)
A+.<-;-< !BV-<-,-.0 <()0.2 N9 !4 2')10:
Isoniaziu ! peiipheial neuiopathy, auu B6
Rifampin ! ieuoiange coloieu bouy secietions
Pyiazinamiue ! hypeiuiicemia
Ethambutol ! optic neuiitis

!3. @@6 ,.0,
A scieening test foi those in iisk gioups.
7+%0)(A ';)0+;), )% ,% &$##$/%<
Smm: close contacts, BIv+, steioiu useis
1umm: foi those who aie in the "high-iisk" gioups mentioneu above
1Smm: those with no incieaseu iisk
If PPB is positive, uo the following:
1. CXR
2. If CXR is abnoimal, uo a sputum stain
S. If sputum stain is positive, stait 4-uiug theiapy

5(/<.'0 B; ,3. H)/1

Lung canceis account foi the most cancei ueaths anu aie the 2
commonly uiagnoseu cancei
XRAY is N0T a goou scieening tool because by the time they aie seen
metastasis has occuiieu
Common signs anu symptoms: Cough, hemoptysis, hoaiseness, weight loss,
fatigue, iecuiient pneumonia
71+ &$##$/)(A 0,-#+ .+2$(%0;,0+% 01+ '$22$( '1,;,'0+;)%0)'% $& .)&&+;+(0 0=>+%
$& #*(A ',('+;%
5#L57" ![@7 5O#"#5!7">A!>5A
Auenocaicinoma Is the most common lung cancei in non-
smokeis (>+;)>1+;= ,(. %*->#+*;,)
CEA (+), anu is useu to follow tieatment
Bionchoalveolai caicinoma A subtype of auenocaicinoma that is not
ielateu to smoking
Piesents in the >+;)>1+;= of the lung
Laige Cell caicinoma In >+;)>1+;=
Is highly anaplastic anu has a pooi
Squamous cell caicinoma Aiises fiom -;$('1*% ,(. )% , '+(0;,#
hilai mass
Stiongly linkeu to smoking
PTBiP ielease causes hypeicalcemia
Small cell caicinoma :+(0;,# 1)#,; location
Stiong link to smoking
Secietion of ABB anu ACTB causes
multiple enuociine pioblems
Tieat with iauiation + chemotheiapy
Nay cause Lambeit-Eaton synuiome
Bionchial caicinoiu tumoi 9+';+0+% %+;$0$()(
Causes iecuiient uiaiihea, flushing of
the skin, asthmatic wheezing
Nanage with a S-BT antagonist
Lymphoangio-leiomyomatosis Is a %2$$01D2*%'#+ neoplasm
Nost commonly seen in menstiuating
Piesents classically with pneumothoiax
Tieat with eithei piogesteione oi a lung

Tieat small cell caicinoma with a combination of iauiation anu chemotheiapy

Tieat all othei types with local iesection + iauiation (non-metastatic), anu iauiation
+ chemo if metastatic

A)+.'-B' A)D<)0 !)*B'
Also known as "Pancoast tumoi", which causes the following:
1. V$;(+;G% %=(.;$2+ - Ptosis, Anhyuiosis, Nyosis because it uamages the
sympathetic ceivical ganglion in the lowei neck, ANB
2. 9*>+;)$; F+(, :,?, 9=(.;$2+ - obstiuction of the SvC causes facial
swelling, cyanosis, anu uilation of veins of the heau anu neck

Chapter 12


70B+3(1.(D 6-0B'2.'0

The only two esophageal uisoiueis that iequiie an enuoscopy aie 5#L57" anu
4(''.,,80 .0B+3(1)0, both which iequiie a biopsy to know the uiagnosis.


Bysphagia to both solius anu liquius in a young non-smokei.
Nay be foou ieguigitation, anu aspiiation of pieviously eaten foou.
Involves a failuie of the gastioesophageal sphinctei to ielax, no mucosal

Best initial test is the baiium swallow
Nost accuiate test is an esophageal manometiy

Best Initial tieatment is pneumatic uilation, if iepeateuly unsuccessful uo
If patient iefuses suigeiy, we can give them an injection of botulinum toxin.

70B+3(1.(D 5(/<.'

Piesents w the following:
1. Bysphagia: fiist to solius then to liquius
2. Nay have heme (+) stool anuoi anemia
S. 0ften pts aie >Suyi anu aie smokeisalcohol uiinkeis.


Best initial test is an enuoscopy
If enuoscopy is not an option, uo a baiium swallow


Best initial theiapy is a suigical iesection (if no local oi uistant metastasis)
Follow suigeiy w chemo-baseu SF0

"-/10 (/2 E.N0

Also known as peptic stiictuies.
Can be causeu by iepetitive exposuie of the esophagus to acius, iesulting in
scaiiing anu stiictuie foimation.
Pievious use of scleiosing agents foi vaiiceal bleeuing can also cause
stiictuies(this is why banuing is the supeiioi pioceuuie).

Best initial uiagnostic test is a baiium stuuy

Following aie the uiff kinus of stiictuies:

1. 8#*22+;DF)(%$( %=(.;$2+: is a pioximal stiictuie founu in association
with iion ueficiency anemia. Is moie common in miuule-ageu women anu is
associateu with squamous cell esophageal cancei

Best initial theiapy is iion ieplacement

2. 9'1,0bB)G% ;)(A%< is a uistal iing of the esophagus that piesents w
inteimittent symptoms of uysphagia

Best initial theiapy is pneumatic uilation

S. 8+>0)' %0;)'0*;+< iesults fiom aciu ieflux. Tieat with pneumatic uilation

]./Q.'80 6-:.',-<)D)*

Look for pt w/ dysphagia w/ horribly bad breath. There is food rotting in the back of the
esophagus from dilation of the posterior pharyngeal constrictor muscles.


Best initial test is a baiium stuuy
Best initial theiapy is suigical iesection

A+(0,-< 6-0B'2.'0
Biffuse esophageal spasm anu "nutciackei esophagus" aie essentially same
Look foi case of seveie chest pain, often wo iisk factois foi Ischemic heait
Nay occui aftei uiinking a colu beveiage.
Pain is always piesent, but uysphagia isn't always piesent.
All caiuiac tests aie noimal

Nost accuiate uiagnostic test is manometiy
Baiium stuuies may show a coiksciew pattein, but only uuiing an episoue of

Calcium channel blockeis anu nitiates aie the best tieatment options


Esophagitis presents with odynophagia as the food rubs against the esophagus.

IF patient is BIv (-), uo an enuoscopy fiist
IF patient is BIv (+), has a CB4 count <1uu give fluconazole.. only uo
enuoscopy if the patient uoesn't iesponse to fluconazle.

5(/2-2( 70B+3(1-,-0
Causes 9u% of esophagitis in BIv (+) patients
The othei common cause is pill esophagitis, wheie ceitain pills can cause
esophagitis in the patient.

Bave pt sit upiight when taking the pills
Bave patient uiink moie watei anu iemain upiight foi Su minutes aftei

%(DDB'9YI.-00 ,.('
Is an upper GI bleed with violent retching and vomiting of any cause.
Theie may be hematemesis oi black stool on exam oi in the histoiy

Nost cases iesolve spontaneously, if bleeuing peisists, injection of
epinephiine can be useu to stop the bleeuing.


Patient presents with a history of epigastric pain that is associated with substernal chest
pain and possibly a metallic taste in the mouth.

Signs and Symptoms (on top of the classic presenting ones)

Soie thioat
Netallic oi bittei taste
Chionic cough

N0TE: As many as 2u% of people who have a chionic cough aie suffeiing as a iesult
of uERB
PPI aumin is both uiagnostic anu theiapeutic.
Fuithei testing such as 24hi pB monitoiing shoulu only be uone if theie is no
iesponse to PPIs anu the uiagnosis still is not cleai

12*#,+*%,:Nilu uisease shoulu be contiolleu w lifestyle mouifications such as:
Weight Loss
Sleeping in an upiight position, oi at least somewhat angleu in beu
Smoking cessation
Limiting alcohol, caffeine, chocolate, anu peppeimint ingestion
Avoiuance of foou anu uiink within 2-S houis of going to beu

If those uon't woik then PPIs aie the next best theiapy foi uERB. They shoulu
contiol 9u-9S% of cases.

If theie is no impiovement then a tiial of B2-blockeis shoulu be tiieu (many auveise
effects with these)

4(''.,, 70B+3(1)0
Is a metaplasia fiom squamous to columnai cells

Peifoim enuoscopy when theie is weight loss, anemia, anuoi bloou in the
stool, anu in anyone who has chionic symptoms of ieflux uisease foi moie
than Syis.

K>L6>LG ?L 7L6?A5?@[ %#L#G7%7L!
Baiiett esophagus PPI anu iepeat enuoscopy eveiy 2-S
Low-giaue uysplasia PPI anu iepeat enuoscopy in S-6 months
Bigh-giaue uysplasia Bistal esophagectomy

7+-1(0,'-< @(-/
Any pt >4Syi w peisistent epigastiic pain anuoi uiscomfoit shoulu ieceive an
uppei enuoscopy. This is essential to excluue the possibility of gastiic cancei

Non-Ulcer Dyspepsia:

Is the NCC of epigastiic uiscomfoit
Can only be concluueu aftei enuoscopy has excluueu an ulcei uisease, gastiic
cancei, anu gastiitis

Consists of symptomatic theiapy w B2 blockeis, liquiu antacius, oi PPIs.

@.+,-< $D<.' 6-0.(0.
Bue to hypeisecietion of aciu
Can be eithei uuouenal ulcei(B0) oi gastiic ulcei(u0) uiseases
B. Pyloii is the NCC of ulceis, 2
NCC is NSAIBs, heau tiauma, buins,
intubation, Ciohn's uisease, anu ZES.
0sually, foou impioves the pain of a uuouenal ulcei anu makes the pain of a
gastiic ulcei woise
If the pt is above 4S anu has epigastiic pain, you must scope to excluue
gastiic cancei.


Not due to hypersecretion of acid, as in PUD.
Can be associated with H.Pylori, if this is present treat w/ PPI and 2 antibiotics.
uastiitis can also be "atiophic" fiom peinicious anemia anu is often
associateu with a ueficiency of vitamin B12

7+%0)(A &$; Vh 8=#$;)<
)&', #;;=2#,* ,*',8
Enuoscopy with biopsy (if this is uone no fuithei testing is iequiieu)
-*2&7&$/ is veiy sensitive but not specific, if the seiology is negative, this
excluues B. Pyloii.
A positive test can't uistinguish between new anu pievious infection.

F2*#,5 ,*',"%$ #%. ',&&7 #%,"$*% ,*',"%$8
These aie not stanuaiu oi ioutinely useu. They can howevei uistinguish
between new anu olu uisease.

12*#,"%$ ?\ E/7&2"8
Tieat this bacteiia with PPI anu claiithiomycin + amoxicillin.
0NLY tieat if its associateu with gastiitis oi ulcei uisease.

Theie is no neeu foi ioutine post-tieatment testing of B Pyloii. theie is no benefit in
tieating B. Pyloii that is associateu with non-ulcei uyspepsia.

>6 ,5* ,2*#,+*%, &6 ?\E/&7"2 .&*'%N, '=;;**.< ,2/ ,5* 6&77&:"%$8

1. Repeat tieatment with 2 new antibiotics anu PPI : 0se metioniuazole +
tetiacycline insteau
2. If iepeat tieatment fails, evaluate foi ZES (uastiinoma).

A,'.00 $D<.' @'B+39D(V-0:

Routine prophylactic use of a PPI or H2 blocker or sucralfate should only be used if one
of the following is present:

1. Beau tiauma
2. Intubation anu mechanical ventilation

S. Buins
4. Coagulopathy anu steioiu use in combo

**NSAIB oi steioiu use alone is not an inuication foi ioutine stiess ulcei piophylaxis

]BDD-/1.'Y7DD-0B/ A9/2'B*.\]7A^ B' G(0,'-/B*(

ZES is diagnosed by finding an elevated gastrin level and an elevated gastric acid output.

**remember that everyone on a H2 blocker or PPI has an elevated gastrin level.

M5*% ,& ,*', ,5* $#',2"% #%. $#',2"; #;". &=,0=,X

When any of the following aie piesent:
1. laige ulcei >1cm
2. multiple ulceis
S. uistal location neai the ligament of Tieitz
4. iecuiient oi peisistent uespite B. Pyloii tieatment

*if the gastrin and acid output level are both elevated, then localization of the gastrinoma
is next.

Nost accuiate is an enuoscopic ultiasounu
Nucleai somatostatin scan is also veiy sensitive because ZES patients have a
high numbei of somatostatin ieceptois

Local uisease iequiies suigical iesection
Netastatic uisease iequiies the patient be on lifelong PPIs

>/;D(**(,B'9 4BE.D 6-0.(0.\>46^

Both Crohns and ulcerative colitis can present with fever, abdominal pain,
diarrhea, blood in stool, and weight loss.

0C pies most often with abuominal pain anu bloouy uiaiihea

IK,2#"%,*',"%#7 +#%"6*',#,"&%' &6 >F! #2*8
}oint pain
Eye finuings
Skin finuings
Scleiosing cholangitis

C*#,=2*' +&2* ;&++&% ,& 32&5%N' ."'*#'* #2*8
Skip lesions
Involvement of uppei uI tiact
Peiianal uisease
Tiansmuial gianulomas
Bypocalcemia fiom fat malabsoibtion
Calcium oxalate kiuney stones
Cholesteiol gall stones
vitamin B12 malabsoibtion fiom teiminal ileum involvement

Enuoscopy is best initial test
Baiium stuuies aie also goou uiagnostic tests

5'B3/80 Naikeis:
Antisacchaiomyces ceievesiae(ASCA) : positive
Antineutiophil cytoplasmic antibouy(ANCA) : negative

$5 Naikeis:
ASCA: negative
ANCA: positive

Best initial tieatment foi both is mesalamine
Steioius aie useful in acute cases
Suigeiy is iequiieu if theie is no ielief fiom these tieatment moualities


Infectious Diarrhea

The presence of blood indicates a pathogenic invader, which may include any of the

Campylobacter - Is the MCC of food poisoning.

Salmonella - Transmitted by chicken and eggs

Vibrio Parahemolyticus Associated with infected seafood

E. Coli There are many different types, which include:

E. Coli 0157:H7 ! MC associated with haemolytic uremic syndrome(via effects
of verotoxin). Look for undercooked beef in the history.
Vibrio vulnificus: Look for shellfish in a person w/ liver disease
Shigella: Secretes Shiga toxin, which is also associated with reactive arthritis
Yersinia: Rodents are natural reservoirs, transmission via veggies, milk-derived
products, and meat
Amebic: Perform three ova & stool parasite exams or serologic testing. Treat
with metronidazole


Best initial test ! fecal leukocytes

Most accurate test ! stool culture


Mild disease! Keep the patient hydrated, this usually resolves on its own

Severe disease ! Fluoroquinolones are the treatment of choice. Severe disease is
defined as presence of any of the following (Blood, fever, abdominal pain, hypotension
and tachycardia)

Non-Bloody Diarrhea:

Non-bloody diarrhea may still be d/t the above pathogens, which can all present
with non-bloody diarrhea.
NO BLOOD in diarrhea will exclude all of the following, which never have

1. Viruses ! Rotavirus, Norwalk virus (Norovirus)
2. Giardia ! Camping/hiking. Look for bloating/flatus/steatorrhea, stool ELISA is
diagnostic test of choice, treatment involves metronidazole.
3. Staph Aureus ! Presents with vomiting in addition to diarrhea. This resolves
4. Bacillus Cereus ! Is associated with eating refried rice. This resolves
5. Cryptosporidiosis! HIV (+) patient with a CD4 count <100. Diagnosis with
acid-fast stain. There is no proven treatment except to raise the CD4 count w/
antiretroviral therapy.
6. Scombroid! Histamine fish poisoning, has fastest onset of poisoning, which is
around 10 min after eating infected tuna, mackerel, or mahi-mahi. Patient has
vomiting, diarrhea, wheezing, and flushing. Treatment involves giving the
patients antihistamines such as diphenhydramine.

Antibiotics Associated Diarrhea (C. Difficile)

Develops several days to weeks after use of antibiotics such as Clindamycin, which is
the most common cause. There can be both blood and fecal leukocytes with C.Difficile-
related colitis.


Best initial test is a stool toxin assay.


The best initial therapy is metronidazole

Chronic Diarrhea

The most common cause of chronic diarrhea is lactose intolerance


Removal of milk products will both allow for diagnosis and treatment


Diarrhea caused by malabsorption is always associated with weight loss
Fat malabsorption is associated with steatorrhea, which leads to oily/greasy stools
that float on the water in the toilet and are foul smelling

The common causes of fat malabsorption are as follows:

1. Celiac Disease
2. Tropical Sprue
3. Chronic Pancreatitis
4. Whipples Disease

All forms of malabsorption are associated with:

Hypocalcemia from vitamin D deficiency, which may lead to osteoporosis
Oxalate overabsorption and oxalate kidney stones
Easy bruising and elevated PT/INR due to vitamin K malabsorbtion
Vitamin B12 malabsorption from either destruction of terminal ileum or loss of
pancreatic enzymes that are necessary for B12 absorption


The best initial test is the sudan stain
The most sensitive is a 72-hr fecal fat test

Celiac Disease

Presents with iron malabsorption and microcytic anemia


Best initial diagnostic test is checking for antigliadin, antiendomyseal, and
antitissue transglutaminase antibodies
The most accurate test is a small bowel biopsy

*bowel wall biopsy is always necessary even w/ antibody confirmation, in order to
exclude bowel wall lymphomas.


Elimination of oats, wheat, barley from the diet

Tropical Sprue

Patient will have a history of being in a tropical location, and presents the same way as
celiac disease.


Small bowel biopsy is the best test to perform

Tetracycline or TMP-SMX for 3-6 months

Whipples Disease

A GI infection presenting with arthralgias, rash, diarrhea, and anemia


The most accurate test is a small bowel biopsy that shows PAS (+) organisms
Can also do a PCR of the stool looking for T. Whippelii


Penicillin, Tetracycline, or TMP-SMX for 12 months

Chronic Pancreatitis

History of alcoholism is usually present
Lipase and amylase levels are likely normal since these wont drop until the
pancrease is calcified and fibrosed.
Fat soluble vitamins are not absorbed


The best initial test is an abdominal XRAY or a CT without contrast
The most accurate testis secretin stimulation testing (normal person releases large
amount of bicarbonate-rich pancreatic fluid).


Involves the administration of pancreatic enzymes by mouth.

Irritable Bowel Syndrome

Syndrome where the patient experiences an alteration in bowel habits
(constipation alternating with diarrhea)
Pain is usually relieved after a bowel movement


Testing may include colonoscopy, xrays, blood tests, but all are negative


The best initial treatment is fiber supplementation, which helps by bulking the
stool and relieving pain
If fiber doesnt work, can add antispasmotic agents to try and relax the bowel
If these fail to work, TCAs can be tried


Hamartomas and hyperplastic polyps are benign
Dysplastic polyps are malignant

** The most important thing to know for colon cancer screening is when and what to do
for the patient

Diagnostic Testing:

General Population:

1. Begin screening at 50yr
2. Colonoscopy q10yrs
3. Sigmoidoscopy q 3-5yrs
4. Fecal occult blood testing yearly
5. Barium enema

The best method of screening for colon cancer is performing a colonoscopy every 10yrs

One family member with colon cancer requires colonoscopy starting at 40yr or 10yr
before age of family member who had cancer.

Three family member, two generations, one premature(<50) require a colonoscopy every
1-2yr starting at 25yrs. This is a lynch syndrome or HNPCC

Familial Adenomatous Polyposis(FAP)

Start screening sigmoidsocopies at age 12
Perform colectomy if polyps are found

Gardners syndrome

This presents with benign bone tumors known as osteomas, as well as other soft
tissue tumors. There is no additional screening indicated for Gardners syndrome

Peutz-Jeghers Syndrome

This presents with a patient who has melanotic spots on the
There are hamartomatous polyps throughout the small bowel and colon
There is a lifetime risk of colon cancer is 10%.
No extra screening recommended

Juvenile Polyposis

There are multiple extra hamartomas in the bowel.
No increased risk of colon cancer from hamartomas
No extra screening recommended
If dysplastic polyps are found, perform repeat colonoscopy in 3-5 years

Start at 50, then
Start at 40yr or
10yr earlier
than when
q1-2yr at 25yr
q102 yr starting
at 12yr
No xtra


Includes Diverticulosis and Diverticulitis


Incredibly common in older Americans and it most commonly caused by a low-fiber,
high-fat diet

Signs and Symptoms:

LLQ abdominal pain
Lower GI bleed


The most accurate test is a colonoscopy
Best diagnostic test is an abdominal CT scan


High-fiber diet low in saturated fats


Is a complication of diverticulosis and presents with:

LLQ abdominal pain
Elevated white cell count in blood


Involves the use of antibiotics. Metronidazole and ciprofloxacin most commonly

Gastrointestinal Bleeding

Red blood ! lower GI bleed, rarely a very acute upper GI bleed can be red blood

Black stool ! upper GI bleed (Proximal to Ligament of Trietz). Black stool usually is
100ml or more blood.

Heme (+) brown stool ! can occur from as little as 5-10ml of blood loss

Coffee ground emesis ! needs very little gastric, esophageal, or duodenal blood loss, as
little as 5-10ml.

**The most important thing to do in acute GI bleeding is to determine if there is
hemodynamic instability

Treatment for GI bleeds:

IV fluids if it is a large bleed
Correction of anemia or other lab abnormalities

Variceal Bleeding

Look for alcoholic with hematemesis and/or liver disease
Other clues are the presentation of splenomegaly, low platelets, and spider
angiomas or gynecomastia




First thing to do is add octreotide which decreases portal hypertension
thing to do is an upper GI to band the variceals
If banding fails, a shunt between the portal vein and the hepatic vein should be

Sources of Bleeding

Upper GI:

Ulcer disease

Lower GI:

Diverticular disease
Ischemic colitis

Diagnosing sources of bleeding:

Technetium bleeding scan (tagged red cells) detects source of bleed
Angiography is an excellent preoperative test because it localizes the site of
Capsule endoscopy should be done when the other methods fail. This is a small
camera that is swallowed and allows for visualization of the small intestine

Acute Mesenteric Ischemia

Presents with a sudden onset of severe abdominal pain with a normal appearing exam (ie.
The pain is out of proportion to the findings on exam)


The most accurate test is an angiography


Surgical resection of ischemic bowel

Other GI Conditions


Initial management of constipation is hydration and fiber supplements

There is usually no clear etiology, for clinical purpose must know possible causes and be
able to treat underlying reason.

1. Dehydration: look for signs of dehydration, BUN:Cr of >20:1
2. CCBs
3. Narcotic medication use/sedatives
4. Hypothyroidism: TSH, T4
5. Diabetes
6. Ferrous sulphate iron replacement
7. Anticholinergic medications

Dumping syndrome

This is a rare disorder related to prior gastric surgery (Often for ulcer disease)
This is a disorder where stomach contents are quickly passed through to the
intestine, and it then draws fluid into the GI, causing an initial HYPERglycemia
follow by a reactive HYPOglycemia

Signs and Symptoms:

Shaking chills


Small and frequent meals

Diabetic Gastroparesis

Longstanding DM impairs neural supply of bowel, there is impairment of normal
Patient will present with bloating and constipation as well as diarrhea


Clinical + history of diabetes


Erythromycin (increases motilin in the gut, thus increasing motility) and

Acute Pancreatitis

Presents (classically) as severe midepigastric pain and tenderness that is associated with
alcoholism and/or gallstones


Lipase (more specific) and amylase


Keep patient NPO
Give IV fluids
Give pain medications


All pts present in a very similar way:

1. Jaundice
2. Fatigue
3. Weight loss
4. Dark urine from bilirubin in the urine

*Hepatitis B and C are more likely to pres with serum-sickness phenomenom like joint
pain, urticaria, and fever.

No definitive treatment is available for any form of acute hepatitis.


Conjugated bilirubin levels (will be elevated)
Viral Hepatitis gives elevated ALT level
Drug-induced hepatitis is associated with increased levels of AST
In pregnancy, if a patient gets hepatitis E this can be fatal
Most accurate tests for hep A, C, D, and E, the confirmatory test is serology
IgM levels acutely rise, and IgG levels rise in the recovery phase.
Surface antigens, core antibody, e-antigen, or surface antibodies are only
associated w/ hepatitis B.

Hepatitis B testing:

The first test to become abnormal in acute hep B infection is the surface antigen.
Elevation in ALT, e-antigen, and symptoms all occur after the appearance of
hepatitis B surface antigen.
Chronic hep B gives the same serologic pattern as acute hep B, but it is based on
persistence of the surface antigen beyond six months.

*Tests for active viral replication: hep B DNA polymerase = e-antigen = hep B PCR
for DNA, all equal the same thing.

Hepatitis C testing:

Best initial test is hep C antibody, this wont tell the level of activity of the virus
Most accurate test Hep C PCR for RNA, also is the most accurate way of testing
response to therapy
Liver biopsy is the most accurate for finding out the severity of the disease

Treatment of Chronic Hepatitis

Chronic hep B: The pt w/ surface antigen, e-antigen, and DNA polymerase or PCR for
DNA is the pt most likely to benefit from antiviral therapy. Look for >6mnth of positive

Treat chronic hep B w/ following single agents:
1. Lamivudine
2. Adefovir
3. Entecavir
4. Telbivudine
5. Interferon (has the most adverse effects)

Chronic hep C: Combine interferon with ribavirin (MC adverse effect is anemia)


Hep A and B vaccination is now universally done in children.

For adults the strongest indication for both types are the following:

1. Chronic liver disease
2. Household contacts
3. MSM (men who have sex with men)
4. Blood product recipients on a chronic basis
5. Injection drug users

Specific indications:

HEP A ! travelers
HEP B ! health care workers and pts on dialysis.

*there is no vaccine or postexposure prophylaxis for hep C


No matter what the cause may be, it will have a number of features:

1. Edema due to low oncotic pressure (treat with spironolactone + diuretics)
2. Gynecomastia
3. Palmar erythema
4. Splenomegaly
5. Thrombocytopenia due to splenic sequestration
6. Encephalopathy, which should be treated with lactulose
7. Ascites - Treat with spironolactone
8. Esphageal varices - Propranolol will prevent bleeding, perform banding if bleed


Perform paracentesis for all pts with ascites if a new ascites, pain, fever, or tenderness are


Test the fluid albumin level
SAAG > 1.1 is consistent with portal hypertension from cirrhosis

CHRONIC LIVER DISEASE (Cause of cirrhosis)

Alcoholic cirrhosis

Is a diagnosis of exlusion. Must exclude all other causes of cirrhosis and look for a
history of longstanding alcohol abuse. Treat as described above for cirrhosis

Primary Biliary Cirrhosis

Presents most commonly in a middle-aged woman complaining of itching. Xanthalasmas
may be found on exam. Also look for a history of other autoimmune disorders


The best initial test is elevated alkaline phosphatase + normal bilirubin level
The most accurate test is presence of antimitochondrial antibody


Ursodeoxycholic acid

Primary Sclerosing Cholangitis:

80% of those with PSC also have IBD

Signs and Symptoms:

Elevated bilirubin levels
Elevated alkaline phosphatase


Most accurate test is ERCP

Anti-smooth muscle antibody, and (+) ANCA

Ursodeoxycholic acid

Wilsons Disease

Involves cirrhosis and liver disease in a person with a choreiform movement disorder
and neuropsychiatric abnormalities.

Signs and Symptoms:

Extrapyrimidal symptoms
Kayser-Fleischer rings around the cornea is pathognomonic for Wilsons disease


Decreased serum ceruloplasmin




Most often from a genetic disorder resulting in overabsorbtion of iron
Iron deposits throughout the body, most commonly in the liver.

Signs and Symptoms:

Darkening of the skin (Bronze diabetes)

Cardiomyopathies (Restrictive)


Best initial test is serum study showing elevated serum iron and ferritin with a low
TIBC. Iron saturation will be grossly elevated
The most accurate test is a MRI or liver biopsy



Autoimmune Hepatitis

Most often presentation is a young woman who has another autoimmune disease


Best initial test is ANA and anti-smooth muscle antibodies
The most accurate test is a biopsy of the liver



Nonalcoholic steatohepatitis (NASH)

Strong association with obesity, diabetes, and hyperlipidemia


Best initial test is liver studies that show ALT>AST
The most accurate test is a liver biopsy that shows fatty infiltration


Management of the underlying condition

Chapter 13


"./(D !)N)D(' (/2 >/,.'0,-,-(D 6-0B'2.'0

6')1 >/2)<.2 >/,.'0,-,-(D L.+3'-,-0
Classic uiugs causing inteistitial nephiitis incluue PCN, NSAIBs,
Sulfonamiues, anu uiuietics.
-"$%' #%. -/+0,&+':
Eosinophiliuiia is iaie but is pathognomonic foi hypeisensitivity Alleigic
Inteistitial Nephiitis
Biagnosis is mainly clinical, iemoval of offenuing agent + impiovement helps
to confiim uiagnosis
Removal of offenuing agent
Steioius can help

#<),. "./(D K(-D)'.
Piesents with " azotemia
" B0N & Cieatinine
Causeu by eithei pieienal, ienal, oi postienal azotemia
8;+;+(,# E,)#*;+:
Bypopeifusion will leau to ienal failuie
volume uepletion, sepsis, heatstioke, buins, hypotension
4(0;)(%)' M+(,# E,)#*;+F
ATN is the most common cause
Renal ischemia also a possibility

8$%0;+(,# E,)#*;+F
Is uue to obstiuction seconuaiy to eithei BPB, ienal calculi, anuoi
blauueipelvic tumois

Test Pieienal Postienal Renal
0iine 0smolality >Suu <SSu <SSu
0iine Souium <2u >4u >2u
FENa <1% >4% >2%
B0NCieatinine >2u >1S <1S

Iv fluius to maintain uiine output
Biuietics to pievent fluiu oveiloau
Close monitoiing of electiolyte abnoimalities
Bialyze with seveie electiolyte abnoimalities, uniesponsive metabolic
aciuosis, uiemia, anu toxic ingestion

#<),. !)N)D(' L.<'B0-0
Fiom eithei hypopeifusion that leaus to tissue ueath oi fiom insult uue to
vaiious toxic injuiies
Is the most common cause of acute ienal failuie
Remove cause
uive Iv fluius to maintain uiinaiy output
Closely monitoi electiolytes
uive uiuietics as neeueu to pievent fluiu oveiloau

"./(D !)N)D. K)/<,-B/(D 6-0B'2.'0
1. Renal Tubulai Aciuosis
2. Biabetes Insipiuus
S. Synuiome of Inappiopiiate Antiuiuietic Boimone

M+(,# 7*-*#,; !').$%)%:
Type Chaiacteiistic 0iinaiy pB
Type I A uefect of the uistal
tubule (B+ giauient)
Type II Pioximal tubule fails to
iesoib BC0S
>S.S eaily then <S.S as the
aciuosis woisens
Type Iv ! Aluosteione (leauing to
hypei K+ anu hypei Cl-

Fiom ! secietion seen in
BN, inteistitial nephiitis,
ACEI's, hepaiin, anu
NSAIB use.

Nay also be uue to
aluosteione iesistance
fiom sickle cell oi uiinaiy

R),-+0+% 4(%)>).*%:
Theie is cential anu nephiogenic types of BI, both:
! secietion of ABB if it is cential uiabetes insipiuus, anu an ABB iesistance if
it is nephiogenic
-"$%' #%. -/+0,&+' &6 4&,5:
0iine osmolality & 2uu anu seium osmolality % Suu
5./,'(D 6>F
Is eithei iuiopathic (Piimaiy) oi causeu by insult to biain (Seconuaiy)
Tieat this with BBAvP nasal spiay
L.+3'B1./-< 6>:
Is an x-linkeu uisease anu may be seconuaiy to sickle cell, pyelonephiitis,
nephiosis, amyloiuosis, multiple myeloma uiugs
Tieat by incieasing watei intake anu iestiicting souium intake

With BBAvP auministiation, cential BI will have a fast ueciease in uiine
output, while nephiogenic BI will have no change in uiine volume
With BBAvP auministiation, cential BI shows an acute inciease in uiine
osmolality, wheie nephiogenic BI shows no change in osmolality
Tieat cential BI with BBAvP oi vasopiessin
Tieat nephiogenic BI by coiiecting the unueilying cause (electiolyte

9=(.;$2+ $& 4(,>>;$>;),0+ !(0).)*;+0)' V$;2$(+ K94!RVL<
Theie aie many possible causes of SIABB:
3S- ."'*#'*: tiauma, tumois, hyuiocephalus
E=7+&%#2/ ."'*#'*': pneumonia, Small cell caicinoma of lung, abscess, C0PB
I%.&;2"%* ."'*#'*: hypothyioiuism, Conn's synuiome
!2=$': NSAIBs, chemotheiapy, uiuietics, phenothiazine, oial hypoglycemics

!"#$%&'"': piesence of hyponatiemia with a uiine osmolality of >Suummolkg
12*#,+*%,: this conuition is usually self-limiting, iesistant cases may iequiie
uemeclocycline which inuuces nephiogenic BI

:1;$()' M+(,# E,)#*;+<
Always associateu with ienal azotemia
35#2#;,*2"J*. 4/8
Bypocalcemia uue to lack of vitamin B piouuction
Anemia (lack of eiythiopoietin piouuction)
Bypeitension uue to RAAS pathway activation

-"$%' #%. -/+0,&+':
Nausea anu vomiting
PLT uysfunction (leaus to bleeuing)
Renal ultiasounu showing small kiuneys if failuie is chionic
Piesence of anemia uue to lack of EP0 piouuction
Restiict both watei anu salt
Pievent fluiu oveiloau with uiuietics
If theie aie seveie electiolyte uistuibances oi aciu-base pioblems go into

GDB*.')D(' 6-0.(0.0

L.+3'-,-< (/2 L.+3'B,-< A9/2'B*.0F
L.+3'B,-<F !*6"%*. 4/ ! hypeipioteinuiia, hypopioteinemia, hypeilipiuemia,
Pioteinuiia >S.Sguay
Patient has geneializeu euema
! albumin
J+%0 )()0),# 0+%0 is a uiinalysis showing significantly incieaseu levels of
Next best step is a spot-uiine test foi a piotein: cieatinine >S.S:1
24-hi uiine piotein collection >S.Sg
@$%0 ,''*;,0+ 0+%0 ! Renal biopsy
![@7 ?K L7@O"?!>5 6>A7#A7 5?%%?L 5O#"#5!7">A!>5AJ!c
Ninimal Change Bisease This is seen in young chiluien.
Tieat with pieunisone
Focal Segmental ulomeiuloscleiosis Similai in piesentation to NCB but
occuis in auults.
Nost commonly iuiopathic.
Commonly piesents in young
hypeitensive males.
Tieat with pieunisone anu
Nembianous ulomeiulonephiitis Is the most common 1 cause of
nephiitic synuiome in auults.
A slowly piogiessive uisoiuei.
Nany causes: BBv, BCv, syphilis, ceitain
uiugs, malignancies, SLE.
Tieat with pieunisone +
Su% of cases piogiess to enu-stage ienal
Type 1 is slowly piogiessive while Type
2 is aggiessive.
Autoantibouy against CS conveitase
(!CS levels)
Tieat with pieunisone, plasmaphaiesis.

Piotein anu salt iestiiction
BNu-CoA ieuuctase inhibitoi foi hypeilipiuemia

This happens when theie is uiffuse glomeiulai inflammation
-"$%' #%. -/+0,&+':
Theie is an acute-onset of hematuiia
" Bun:Ci
![@7 ?K L7@O">!>5 6>A7#A7 5?%%?L 5O#"#5!7">A!>5AJ!c
Post-stieptococcal ulomeiulonephiitis An acute conuition.
Classically occuis aftei Stiep Pyogenes
Immunofluoiescence shows coaise
gianulai Igu oi CS ueposits.
Labs show incieaseu ieu cells anu casts,
! seium CS, " AS0 titei.
Rapiuly Piogiessive ulomeiulonephiitis
A nephiitic conuition that piogiesses
iapiuly to ienal failuie.
uooupastuie's uisease is in this categoiy.
Immunofluoiescence shows smooth anu
lineai Igu ueposits.
Tieat with pieunisone anu
Beigei's Bisease (IgA nephiopathy) Nost common type of nephiopathy.
IgA ueposits in mesangium.
Piesents with iecuiient hematuiia +
low-giaue pioteinuiia.
0sually haimless, howevei 1 in 4 may
piogiess to ienal failuie.
Tieat with pieunisone
Benoch-Schonlein Puipuia Always in chiluien, is an IgA
Piesents with abuominal pain, uI bleeu,
vomiting, anu hematuiia.
Classically finu palpable puipuia on

buttocks anu legs
Is a self-limiting uisease that iequiies no
Nultiple Nyeloma Theie is an incieaseu light-chain
Finu Bence-}ones piotein in uiine.
Bypeicalcemia seen.
Patient becomes succeptible to
encapsulateu bacteiia because theie is a
uefect in noimal antibouy piouuction.
Tieatment must be on the unueilying

A90,.*-< GDB*.')DB/.+3'B+(,3-.0F
6>A7#A7 5O#"#5!7">A!>5 L7@O"?@#!O[
Biabetes Nellitus Is the NCC of ESRB.
Eaily manifestation is micioalbuminuiia
(give ACEI's, stiict glycemic contiol).

BIv NC seen when BIv is acquiieu by Iv
uiug use.
Piesents as focal segmental
Eaily tieatment with antiietioviial
Renal Amyloiuosis Biagnose with biiefiingence on congo
ieu stain.
Tieat with a tiansplant

Type 1 No ienal involvement
Type 2 Is a mesangial uisease with focal
segmental glomeiulai pattein.
Tieatment isn't typically iequiieu
Type S Is a focal piolifeiative uisease.
Tieat aggiessively with pieunisone anu
Type 4 Biffuse piolifeiative uisease.
Combination of both nephiitic anu
nephiitic uisease.
Wiie-loop abnoimality on LN
Tieat with pieunisone anu
Type S Is a membianous uisease that is
inuistinguishable fiom othei piimaiy
membianous uiseases.
Tieat with pieunisone

"./(D #',.'9 A,./B0-0

Piesents with suuuen onset of hypeitension along with hypokalemia
Abuominal biuit heaiu with stethoscope
Can be causeu by plaque, fibiomusculai uysplasia
J+%0 )()0),# 0+%0 is a ienal ultiasounu with Bopplei
If small kiuneys aie then seen, uo an NRA
The 2$%0 ,''*;,0+ 0+%0 is a ienal angiogiam
Angioplasty anu stenting

?N0,')<,-B/ B; ,3. $'-/('9 !'(<,

BPB anu stones aie the NCC in auults
Theie is an incieaseu iisk of stasis thus incieasing the iisks of 0TI's
Piesent with uiinaiy colic, intense pain that iauiates fiom the back aiounu to
the pelvis anu the gioin
3#7;"=+ E/2&05&'05#,*:
8S% of stones aie calcium pyiophosphate
Aie iauiopaque anu associateu with hypeicalcemia
Su% of time it's associateu with hypeicalciuiia
Tieat calcium stones with hyuiation anu loop uiuietics (L00PS eliminate
@++&%"=+ )#%$*'"=+ E5&'05#,* T-,2=G",*U8
NCC of stones
Aie iauiopaque
0sually causeu by uiease (+) Pioteus oi Staph Sapiophyticus
Nay foim laige staghoin calculi
Tieatment involves taking caie of the unueilying infection

R2"; @;". -,&%*':
0ften seconuaiy to gout oi conuitions that cause incieaseu cell tuinovei,
such as myelopiolifeiative uisease
Tieat by alkalinizing the uiine anuoi tieating any unueilying conuitions

P-2/.9 !)*B'0

The most common ienal malignancy is './(D <.DD <('<-/B*(, which occuis
NC in males fiom Su-7uyi of age
Piesents with hematuiia, flank pain, fevei, palpable mass, anu seconuaiy
Tieatment involves inteileukin anu iesection
The most common chiluhoou ienal malignancy is I-D*80 ,)*B', which
occuis NC between 2-4yi olu
Piesents with a palpable flank mass
Pait of WAuR complex (Wilms, Aniiiuia, u0 malfoimation, Retaiuation -
mental anu motoi)
Removal of kiuney plus chemotheiapy anuoi iauiation

Chapter 14



@)#. 0$ 2$.+;,0+ ,(+2), >;+%+(0% /)01<
Fatigue, palloi, pale conjunctiva, flow muimui

9+?+;+ ,(+2), >;+%+(0% /)01<
S0B, light-heaueuness, confusion

The most ieliable test foi iion ueficiency anemia is seium feiiitin, which will
be uecieaseu.
If a patient has iion-ueficiency anemia anu uoes not iesponu to tieatment, uo
hemoglobin electiophoiesis to look foi an $ oi # thalassemia

O!J9 &$; %*%>+'0+. ,(+2),%<

1. Iion stuuies (most imp)
2. CBC w peiipheial smeai (paying attention to NCv, NCBC)
S. B12folate(B12 = neuiopathies, folate = no neuiopathies)
4. RBW (newei smallei RBCs cause change in RBW)
S. Reticulocyte count (ueteimines whethei site of pioblem is bone maiiow
synthesis of new RBCs)
6. LBB, biliiubin, haptoglobin (all ueteimine whethei hemolysis is in play)
7. TSB with T4 (see whethei hypothyioiuism is cause of fatigue)
8. CXRbloou cultuie0A foi suspecteu sickle cell uisease

>'B/ 2.;-<-./<9 #/.*-(
-"$%' #%. -/+0,&+'F
Pale conjunctiva
Low feiiitin, low iion, incieaseu TIBC

Best uiagnostic test foi iion-ueficiency anemia is iion stuuies
The most accuiate test is a bone maiiow biopsy

0ial feiious sulfate supplement

#/.*-( B; 53'B/-< 6-0.(0.

-"$%' #%. -/+0,&+'F
Same signs anu symptoms with the auuition of a histoiy of chionic
inflammatoiy uisoiuei oi autoimmune uisoiuei

Best uiagnostic test is iion stuuies (will come back noimal)

Coiiect the unueilying uisease

-"$%' #%. -/+0,&+':
Small NCv
Piesence of taiget cells
veiy othei symptoms

Best initial test is an iion stuuy
The most accuiate test is hemoglobin electiophoiesis
Beta-thalassemia has elevateu BgA2 anu BgF
Alpha-thalassemia has noimal levels

Theie is no tieatment foi these conuitions

A-2.'BND(0,-< #/.*-(

-"$%' #%. -/+0,&+':
Patient has a histoiy of alcohol abuse, exposuie to leau, oi the use of
isoniaziu (INB)

Best initial test is iion stuuies
The most accuiate test is the Piussian blue stain

Ninoi cases iequiie only pyiiuoxine ieplacement
Seveie cases iequiie the iemoval of exposuie to toxin

%(<'B<9,-< #/.*-(

Piesents similaiy to miciocytic anemia with fatigue, palloi, light-heaueuness,
but is causeu by a ueficiency of eithei vitamin B12 oi folic aciu

M-,(*-/ 4aR 6.;-<-./<9F
-"$%' #%. -/+0,&+':
Peiipheial neuiopathies
Bementia is the least common occuiience

CBC with peiipheial smeai, paying special attention to neutiophils
Neutiophils aie laige anu hypeisegmenteu
B12 ueficiency can also cause glossitis anu uiaiihea

Replace eithei folate oi vitamin B12

Appiox Su% of B12 ueficiencies show noimal B12 levels because tianscobalamine
is an acute phase ieactant which elevates with any foim of stiess. Thus is you
suspect B12 ueficiency anu levels aie noimal, get a methylmalonic aciu level.

Aftei finuing low B12 oi elevevateu methylmalonic aciu, the -+%0 '$(&);2,0$;= 0+%0
"' antipaiietal cell antibouies oi anti-intiinsic factoi antibouies (both confiim
peinicious anemia as the cause of B12 uef).

Replace B12 oi folate

** Folate ueficiency is most commonly causeu by a pooi uiet, classically uesciibeu as
a "tea anu toast uiet". Folate stoies ueplete within S months, thus with pooi uiets
this can be seen quickly. Tieat this with uiet mouifications anu immeuiate folate

Sickle Cell Anemia

Patient piesents with extieme pain in the chest, back, anu thighs
When a patient piesents with a sickle cell ciisis, give immeuiate oxygen,
noimal saline, anu analgesics.
If patient piesents with these symptoms + fevei, give Iv antibiotics as well

S1+( 0$ .$ +Q'1,(A+ 0;,(%&*%)$( )( %)'B#+ '+## >0Z
1. Piesence of visual uistuibances uue to ietinal infaict.
2. Pulmonaiy infaict leauing to pleuiitic pain anu abnoimal xiay.
S. Piiapism uue to infaict of piosthetic plexus of veins.
4. Stioke

S1,0 ',*%+% %*..+( .;$>% )( 1+2,0$';)0 )( %)'B#+ '+## >0Z
Eithei uue to a folate ueficiency oi paivo B19 viius, which causes an aplastic
- All Sickle cell pts shoulu be on folate supplements, thus if that's the case it is
uue to paivo B19
- Bo a PCR foi BNA of paivo B19

Tiansfusion anu IvIu

S1,0 %1$*#. ,## %)'B#+ '+## >,0)+(0% /1$ ,;+ -+)(A .)%'1,;A+. -+ A)?+(Z
Folate ieplacement
Pneumococcal vaccine
Byuioxyuiea (This incieases hemoglobin F, stops sickling of cells, anu
pievents fuithei ciises)

O.*BD9,-< #/.*-(

All foims of hemolytic anemia piesent with a suuuen onset of weakness anu fatigue
that is associateu with anemia.

Aie piematuie uestiuction of ieu bloou cells
Bone maiiow iesponus appiopiiately by incieasing eiythiopoiesis anu thus
theie is an inciease in ieticulocyte count
If bone maiiow uoesn't woik piopeily, anemia will ensue

?*+&7/'"' :"77 '5&: ,5* 6&77&:"%$:

1. Incieaseu inuiiect biliiubin (uets ieleaseu with RBC uestiuction)
2. Incieaseu ieticulocyte count (Beteimines bones maiiow's ability to make
new RBCs)
S. Incieaseu LBB
4. Becieaseu haptoglobin (oiueieu to uistinguish between anemia anu
hemolytic anemia)

>%,2#G#';=7#2 5*+&7/'"' :"77 #7'& '5&: ,5* 6&77&:"%$8

1. Abnoimal peiipheial smeai (Schistocytes, helmet cells, fiagmenteu cells)
2. Bemoglobinuiia
S. Bemosiueiinuiia (Netabolic, oxiuizeu piouuct oi hemoglobin in uiine).

:,*%+%: Factois exteinal to RBC uefects 0R intiinsic RBC uefects

P\ C#;,&2' *K,*2%#7 ,& OF3 .*6*;,' T)&', ;#'*' #;Z="2*.U

Immune hemolysis
Nechanical hemolysis (causeu by piosthetic heait valves)
Neuications, buins, anu toxins

Q\ ?*+&7/'"' .=* ,& "%,2"%'"; OF3 .*6*;,' T)&', ;#'*' "%5*2",*.U

Causeu by sickle cell uisease, hemoglobin uisease, thalassemias
Nembiane uefects such as heieuitaiy spheiocytosis, paioxysmal noctuinal
Enzyme uefects such as u6PB ueficiency anu pyiuvate kinase ueficiency

Autoimmune Hemolysis

Patient often has a histoiy of autoimmune uiseases, canceis, oi meuication

Nost accuiate test is Coomb's test
Look foi an incieaseu LBB anu incieaseu ieticulocyte count
Look at the peiipheial smeai foi spheiocytes

The best initial theiapy is pieunisone
With no iesponse to pieunisone, IvIu can stop acute episoues
With iecuiiing episoues of hemolysis, a splenectomy is most effective

*N0TE: waim antibouies aie the cause heie, which aie always Igu. 5(#= 4AN
;+%>$(.% 0$ %0+;$).% ,(. %>#+(+'0$2=h

5BD2Y>/2)<.2 O.*BD90-0 \5BD2 (11D),-/-/0)
Coomb's test is negative
Theie is often a mycoplasma oi EBv infection
Theie is no iesponse to steioius, splenectomy, oi IvIu

O.*BD90-0 2). ,B -/,'-/0-< 2.;.<,0

GD)<B0.YqY@3B0+3(,. 2.392'B1./(0. 2.;-<-./<9
Piesents with a seveie anu acute onset of hemolysis
Is an x-linkeu uisoiuei, thus seen in males
Nost commonly theie is a histoiy of sulfa uiugs, piimaquine, oi uapsone use
Ingestion of fava beans is classically askeu on boaiu exams

The best initial test is the peripheral smear that shows Heinz bodies and bite cells
The most accurate diagnostic test is a glucose-6-phosphate level. The problem
with this test is that it will only show up after 2 months, and is not a good test
early on in an acute haemolytic episode

Avoiuance of oxiuative stiess

@9'):(,. P-/(0. 6.;-<-./<9
Piesents the same way as u6PB ueficiency, but the cause is unknown

O.'.2-,('9 A+3.'B<9,B0-0
-"$%' #%. -/+0,&+'8
}aunuince in chiluhoou
Biliiubin gallstones
Recuiient episoues


The most accuiate anu best initial test is the osmotic fiagility test
Peiipheial smeai showing spheiocytes

Folic aciu supplementation
Splenectomy foi seveie uisease

O.*BD9,-< $'.*-< A9/2'B*. \O$A^
O$A in kius, theie is usually a histoiy of E.Coli u1S7:B7

-"$%' #%. -/+0,&+:
Acute ienal failuie
Abuominal pain

Bloouy uiaiihea

Bialysis in chiluien, auults this isn't useful anu theie is a much pooiei

!3'B*NB,-< !3'B*NB<9,B+./-< @)'+)'( \!!@^
Is an iuiopathic uisease that is often seen in BIv patients

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

71+;+ )% , >+(0,. $&<
Baemolytic anemia
Renal failuie
Neuiological uiseases

Plasma exchange until symptoms subsiue
Without tieatment this is fatal

@('BV90*(D LB<,)'/(D 3.*B1DBN-/)'-( \@LO^

Piesents with iecuiiing episoues of uaik uiine, mostly seen in the moining.

-"$%' #%. -/+0,&+'8
Recuiiing episoues of uaik uiine in the moining
Poital vein thiombosis is a complication that leaus to ueath
Nay piogiess to cause aplastic anemia anuoi ANL

The most accuiate test is the piesence of uecay acceleiating factoi antibouy

Pieunisone oi othei steioius


Bloou lockeu in the oxiuizeu state cannot pick up anu tianspoit oxygen.
Patient will piesent with shoitness of bieath with no ieason

-"$%' #%. -/+0,&+':
S0B with no known cause (Theie will be cleai lungs on exam with a noimal
Bloou (if seen) will have a biownish appeaiance, which inuicates it is lockeu
in the oxiuizeu state.

Look foi exposuie to uiugs like nitioglyceiin, amyl nitiate, oi nitiopiussiue
CXR anu PE show no ieason foi S0B
Look foi a histoiy of anesthetic use

uive methylene blue

Transfusion Reactions

1. #4? -/<B*+(,-N-D-,9 ! piesents with acute symptoms of hemolysis while
the tiansfusion is happening. Ex: uuiing a tiansfusion, a patient becomes
hypotensive anu tachycaiuic. She has back anu chest pain, anu theie is uaik
uiine. LBB anu biliiubin aie elevateu, anu haptoglobin aie low.
2. !'(/0;)0-B/ '.D(,.2 (<),. D)/1 -/W)'9\D.)QB(11D),-/(,-B/ 'V/^ !
piesents with acute S0B fiom antibouies in the uonoi bloou against iecipient
white cells.
S. >1# 6.;-<-./<9 ! piesents with anaphylaxis. In futuie use uonation fiom
IgA ueficient uonoi oi washeu ieu cells.
4. K.N'-D. /B/3.*BD9,-< 'V/ ! iesults in a small iise in tempeiatuie anu
neeus no theiapy, the ieaction is against the uonoi's white cell antigens.
Pievent by using filteieu bloou tiansfusion in futuie.
S. %-/B' NDBB2 1'B)+ -/<B*+(,-N-D-,9 ! iesults in uelayeu jaunuice, no
theiapy neeueu.


Acute leukemias present with signs of pancytopenia, such as fatigue, bleeding, and
infections from non-functional white blood cells.

Acute Myelogenous Leukemia

Nostly occuiiing in auults (up to 8u%)

The best initial test is peiipheial smeai showing blasts

Best initial theiapy foi ANL is 4.,;*-)')( (oi uaunoiubicin) anu '=0$%)(+

Acute Lymphoblastic Leukemia

The most common malignancy in chiluien
Is the leukemia most iesponsive to theiapy
Is a neoplasm of eaily lymphocytic B cell piecuisois
Bistology ieveals pieuominance of lymphocytes
Pooi piognosis when age < 2 oi > 9, WBC's >1u^S, oi CNS involvement

The best initial test is peiipheial smeai showing blasts

>2(')N-<-/ + <9,B0-/. ('(N-/B0-2. + -/,'(,3.<(D *.,3B,'.V(,..

#<),. @'B*9.DB<9,-< H.)Q.*-(\%j^

This leukemia is associateu with uisseminateu intiavasculai coagulopathy

>2(')N-<-/ + <9,B0-/. ('(N-/B0-2. + (DD ,'(/0 '.,-/B-< (<-2\#!"#^

53'B/-< %9.DB1./B)0 H.)Q.*-(\5%H^

-"$%' #%. -/+0,&+'8
Elevated white cells that are predominantly neutrophils
Splenomegaly is frequent.
Untreated CML has the highest risk of transformation into acute leukemia of all
forms of myeloproliferative disorders.
#00B<-(,.2 E-,3 @3-D(2.D+3-( 53'B*B0B*.

Best initial test is H.)QB<9,. (DQ(D-/. +3B0+3(,(0. 0<B'. \H#@ 0<B'.). An
elevateu PNN count with low LAP scoie is CNL. Reactive high white counts
fiom infection give an elevateu LAP scoie, LAP is up in noimal cells, not CNL.
The most accuiate test is finuing the Philauelphia Chiomosome

Best initial tieatment is Imatinib (uleevec)
Bone maiiow tiansplant is the only cuie foi CNL, but is nevei the best initial
theiapy, because Imatinib leaus to 9u% hematologic iemission with no majoi
auveise effects.

53'B/-< H9*+3B<9,-< H.)Q.*-(\5HH^
Seen in people oluei then Suyi of age

-"$%' #%. -/+0,&+':
0ften asymptomatic
Baemolytic anemia

Best initial test is the peiipheial smeai showing 'smuuge cells'

At stages u anu 1, theie is no tieatment iequiieu
At auvanceu stages give fluuaiabine oi chloiambucil

Hairy Cell Leukemia

Seen in miuule-ageu people anu piesents with massive splenomegaly anu

The Nost accuiate test is the taitiate iesistant aciu phosphatase(TRAP)
smeai showing haiiy cells

The best initial theiapy foi Baiiy Cell leukemia is clauiibine oi 2-CBA


Piesents similaily to haiiy cell leukemia except theie will be a noimal TRAP
The key uiagnostic featuie is the "teai-uiop" shapeu cells on peiipheial
Theie is no specific theiapy foi myelofibiosis

Polycythemia Vera (Erythrocytosis)

This piesents with heauache, bluiieu vision, uizziness, anu fatigue. All uue to
thickeneu bloou

-"$%' #%. -/+0,&+':
Eveiything above
Piuiitis following hot showeis oi baths uue to histamine ielease

veiy high hematociit with a low NCv
uet an ABu to iule out oi in hypoxia as a cause of eiythiocytosis

The best initial theiapy is phlebotomy
Byuioxyuiea can be given to lowei the cell count
uive uaily aspiiin


Multiple Myeloma

This conuition piesents most commonly with bone pain uue to fiactuies occuiiing
fiom noimal use

The most specific test is a bone maiiow biopsy
Skeletal suivey to uetect puncheu out osteolytic lesions
Seium piotein electiophoiesis(SPEP) to look foi elevateu monoclonal
antibouy (usually Igu)
0iine piotein electiophoiesis(0PEP) to uetects Bence-}ones pioteins
Peiipheial smeai showing "iouleaux" foimation of bloou cells.
Elevateu calcium levels uue to osteolytic lesions
Beta 2 micioglobulin level is a piognostic inuicatoi
B0N anu Cieatinine to uetect ienal insufficiency

Steioius anu Nelphalan
The most effective theiapy is bone maiiow tiansplant
Tieat all unueilying co-moibiuities

Waldenstroms Macroglobulinemia

This is a hypeiviscosity of the bloou uue to oveipiouuction of IgN

-"$%' #%. -/+0,&+':
Bluiieu vision
Enlaigeu lymph noues

The best initial test is the seium viscosity (incieaseu significantly) anu SPEP
foi IgN levels
Theie will be no specific finuing on the CBC

Plasmaphaiesis is the best initial theiapy
Can also give fluuaiabine oi chloiambucil

Aplastic Anemia

Piesents as pancytopenia with no iuentifiable etiology.
If pt is < Su anu has a match, best theiapy is BN tiansplantation.
If BN tiansplant isn't an option (>Su), give antithymocyte globulin anu


Present with enlarged lymph nodes that are most commonly seen in the cervical area

Hodgkins disease occurs in a bimodal age distribution (young and old), and is
characterized by Reed-Sternberg cells

Reed-Sternberg Cell

Non-Bougkin's uisease is commonly seen in BIv patients

The best initial uiagnostic test foi both types of lymphomas is lymph noue

0nce excisional biopsy shows abnoimal aichitectuie, fuithei testing to ueteimine
stage of the lymphoma neeus to be uone.

1. Stage 1 ! single lymph noue gioup
2. Stage 2 ! 2 LN gioups on one siue of uiaphiagm
S. Stage S! LN involvement on both siues of uiaphiagm
4. Stage 4! wiuespieau uisease

?! #%. S?B 02*'*%, :",5 ',#$*' #' 6&77&:'8

BB - 8u-9u% pies w stage 1 anu 2
NBL - 8u-9u% pies w stages S anu 4

?&: ,& ',#$*: CXR, CT with contiast (Chestabuomenpelvisheau), anu BN biopsy.


1. O$',#)b+. .)%+,%+ (stage 1,2) without "B"
symptoms is tieateu pieuominantly with
2. @$;+ ,.?,('+. %0,A+% S,4 is tieateu with

-0*;"6"; ,2*#,+*%,':
1. BB: ABvB (auiiamycin|uoxoiubicinj, bleomycin, vinblastine, uacaibazine)

2. NBL: CB0P (cyclophosphamiue, hyuioxyauiiamycin, oncovin|vinciistinej,
anu pieunisone)

* Also test foi anti-CB2u antigen anu if piesent, auu Rituximab, which auus
efficacy to CB0P.

J 9e@875@9<

Aie systemic symptoms
such as:



MB/ I-DD.N'(/280 2-0.(0. \MI6^

Is uue to platelet uysfunction, not a lowei numbei of platelets

Bleeding from PLT dysfunction, superficial bleeds from skin and mucosal
surfaces, such as gingival, gums, and vagina.
Epistaxis common
Bleeuing often woiseneu with use of aspiiin
PLT count is noimal

J+%0 )()0),# 0+%0 is platelet function test
The 2$%0 ,''*;,0+ 0+%0 is a iistocetin cofactoi assay anu a vWF level (If vWF
is noimal, iistocetin tells you if it is woiking piopeily)

Fiist line tieatment is uesmopiessin oi BBAvP, which causes the ielease of
subenuothelial stoies of vWF anu co-factoi vIII
If uesmopiessin uoesn't woik, give factoi vIII ieplacement

@D(,.D.,Y,9+. ND..2-/1 <()0.0: petechiae, epistaxis, puipuia, gingival, gums,
K(<,B'Y,9+. ND..2-/1 <()0.0: hemaithioses, hematoma

>2-B+(,3-< !3'B*NB<9,B+./-< @)'+)'( \>!@^

ITP is a uiagnosis of exclusion that piesents with platelet-type bleeuing anu a
platelet count of < Su,uuu

Peifoim a sonogiam to assess the size of the spleen
Check foi anti-platelet antibouies
Bone maiiow biopsy looking foi megakaiyocytes
Antibouies to glycopiotein IIbIIIa ieceptois

With milu ITP (platelets of ~ 2u,uuu) give pieunisone
With seveie ITP (platelets of < 2u,uuu) give Iv immunoglobulins, which is the
fastest way to inciease the platelet count
NEvER tiansfuse platelets because this exaceibates the conuition

Uremia-Induced PLT dysfunction

This piesents as platelet-type bleeuing in a patient with ienal failuie, wheie ienal
failuie causes uiemia, which pievents the uegianulation of platelets anu thus stops
them fiom woiking

-"$%' #%. -/+0,&+':
Platelet type bleeuing

Ristocetin anu vWF levels (noimal)
Check platelet levels (They will be noimal)
Look foi ienal failuie (This is the key to uiagnosing)


O.+('-/Y>/2)<.2 !3'B*NB<9,B+./-( \O>!^

A conuition wheie platelets uiop at least Su% a few uays aftei the use of hepaiin

-"$%' #%. -/+0,&+':
The most common clinical manifestation is thiombosis, wheie venous
thiombosis is the most common type

The best initial uiagnostic test is platelet factoi 4 antibouies
0thei impoitant test is hepaiin-inuuceu anti-platelet antibouies

The best initial theiapy is to stop hepaiin anu use uiiect thiombin inhibitoi
such as "aigatioban" oi "lepiiuuin".

Chapter 15


"3.)*(,B-2 #',3'-,-0

An autoimmune uisease piesents most commonly in females > Su.

}oint pain anu moining stiffness that is symmetiical anu in multiple joints of
the hanus.
Lasts longei than 1hi in the moining with symptomatic episoues going on foi
at least 6 weeks.
0ften a piouiome of fatigue anu malaise, but this isn't enough foi a cleai ux.

!"#$%&'"' "' 4#'*. &% 5#G"%$ ` &2 +&2* &6 ,5* 6&77&:"%$8

Noining stiffness lasting moie than 1hi
Wiist anu fingei involvement
Swelling of at least S joints
Symmetiic involvement
Rheumatoiu nouules
Xiay abn's showing eiosions
(+) iheumatoiu factoi

Rheumatoiu aithiitis is a gioup of physical finuings, joint pioblems, anu lab tests.
Theie is no single uiagnostic ciiteiia to confiim the uiagnosis, noi is theie one single
theiapy to contiol anu tieat the uisease.

The single most accuiate lab test is the anticitiullinateu cyclic peptiue (anti-
Noimocytic, noimochiomic anemia is veiy chaiacteiistic of iheumatoiu

a&"%, C"%."%$':
NCP swelling anu pain
Boutonieiie uefoimity: flexion of PIP w hypeiextension of the BIP
Swan neck uefoimity
Bakei's cyst

C1C2 ceivical spine subluxation
Knee: although knee is commonly involveu, multiple small joints aie involveu
moie commonly ovei time.

NSAIBs anu Bisease mouifying anti-iheumatic uiugs(BNARBS)
Steioius can be useu acutely to help contiol the uisease while BNARBs take
effect, but they aie only useu as a biiuge to BNARB theiapy, not useu long-

A.'B/.1(,-:. A+B/29DB(',3'B+(,3-.0
1. Ankylosing sponuylitis
2. Reactive aithiitis (Reiteis synuiome)
S. Psoiiatic aithiitis
4. }uvenile RA

71)% A;$*> $& )(&#,22,0$;= '$(.)0)$(% ,## 01+ &$##$/)(A '1,;,'0+;)%0)'%<
Negative foi RF
Pieuilection foi the spine
SI joint involvement
Associateu with BLA B27

#/Q9DB0-/1 A+B/29D-,-0\#A^
AS piesents in a young male (<4u) w spine oi back stiffness.
Peiipheial joint involvement is less common
Pain is woise at night anu ielieveu by leaning foiwaiu, which can leau to
kyphosis anu uiminisheu chest expansion.
Raie finuings incluue: uveitis anu aoititis.

The best initial test is an xiay
The most accuiate test is an NRI

Biological agents (Infliximab, Aualimumab)

".(<,-:. #',3'-,-0\;B'*.'D9 ".-,.'80 09/2'B*.^F
Piesents with asymmetiic aithiitis anu a histoiy of uiethiitis oi uI infection.
Patient may have constitutional symptoms such as fevei, malaise, anu weight

Clinical uiagnosis baseu on the piesence of the classic tiiau of uiethiitis,
conjunctivitis, anu aithiitis


@0B'-(,-< #',3'-,-0F
Piesents as joint involvement with a histoiy of psoiiasis.
Rheumatoiu factoi (-)
SI joint is involveu.

_*/ 6*#,=2*' &6 ,5"' ."'*#'* #2*8
Pitting of the nails
Involvement of the uistal inteiphalangeal joints
"Sausage-shapeu" uigits

Initial tieatment shoulu be with NSAIBs
If this isn't woiking, auu biological agents such as Infliximab
If these uon't woik, tiy methotiexate

w):./-D. "# \(Q( (2)D, B/0., A,-DD80 2-0.(0.^
Theie is no specific uiagnostic test.
aO@ "' ;5#2#;,*2"J*. 4/ ,5* 6&77&:"%$8
Feiiitin levels aie high
WBC count is elevateu
RF (-) anu ANA (-)

If uniesponsive to NSAIBs, give methotiexate

I3-++D.80 6-0.(0.
Causes uiaiihea anu fat malabsoibtion, anu is most commonly piesenteu
with joint pain
The most specific test foi uiagnosis is a biopsy of the bowel


0steoaithiitis is the most common joint abnoimality anu is associateu with
excessive joint usage anu incieaseu age

-"$%' #%. -/+0,&+'8
Noining stiffness lasting < Su minutes
}oint ciepitus seen
Affects the uistal inteiphalangeal joint (wheieas RA uoes not)
Bebeiuen's noues aie seen as BIP osteophytes
Bouchaiu's noues aie seen as PIP osteophytes

The best initial uiagnostic test is an xiay of the joint

ulucosamine sulphate anu chonuioitin sulphate aie useu to slow joint

Noining Stiffness <Sumin >1hi
RF, anti-CCP N0 YES
}oint fluiu <2uuu Suuu-Suuuu

Classically, a iash + joint pain + fatigue = Lupus
Theie aie 11 ciiteiia foi L0P0S, 4 must be piesent to make the uiagnosis.
AP>L - Nalai Rash
- Photosensitivity iash
- 0ial ulceis iash
- Biscoiu iash
#',3'(D1-(0 Piesent in 9u% of pts
4DBB2 Leukopenia, thiombocytopenia,
hemolysis. Any bloou involvement
counts as 1 ciiteiia.
"./(D vaiies fiom benign pioteinuiia to ESRB.
5.'.N'(D Behavioi changes, stioke, seizuie,
A.'B0-,-0 Peiicaiuitis, pleuiitic chest pain,
pulmonaiy BTN, pneumonia,
A.'BDB19 - ANA (9S% sensitive)
- BS-BNA (6u% sensitive)
Each of the seiologic abn's count as 1
ciiteiia. If peison has joint pain,
iash, anu both ANA anu BS BNA, the
pt has 4 ciiteiia.

The best initial uiagnostic test is the ANA
The most specific test is the anti-us BNA oi anti-Smith antibouy

V$/ 0$ &$##$/ 01+ %+?+;)0= $& , #*>*% &#,;+D*>Z
1. Complement levels will uiop in flaie-up
2. anti-us BNA will iise in flaie up

Foi acute flaie-ups give pieunisone anu othei glucocoiticoius
uive NSAIBs foi joint pain
If theie is no iesponse to those meuications, antimalaiials anu
hyuiochloioquine will woik
Foi seveie uisease that iecuis give cyclophosphamiue anu azthiopiine

6')1Y-/2)<.2 H)+)0
The most likely causes of uiug-inuuceu lupus aie hyuialazine, piocainamiue, anu

Theie will be anti-histone antibouies
Theie is nevei ienal oi CNS involvement
Theie aie noimal levels of complement anu anti-us BNA antibouies

AWB'1./80 09/2'B*.
Seen most commonly in women (9x gieatei in women than men)

-"$%' #%. -/+0,&+':
Biy eyes, uiy mouth
Theie is a sensation of sanu unuei the eyes
Bysgeusia is common
Commonly a loss of teeth uue to the lack of auequate saliva

The most accuiate test is a lip biopsy
The Schiimei test is will show inauequate laciimation
Commonly see "anti-Ro oi anti-La antibouies

Pilocaipine to inciease Ach anu thus inciease laciimation anu salivaiy

Patient has tight skin, heaitbuin, anu Raynauu's phenomenon

-"$%' #%. -/+0,&+':
9B)( &)(.)(A% incluue a tight, fibious thickening that causes tight anu
immobile fingeis as well as a tight face
I$)(0 8,)( that is milu anu symmetiical
M,=(,*.G% 81+($2+($(, may iesult in ulceiations

A<D.'B2.'*( <(/ +'.0./, 2-;;)0.D9 E-,3 ,3. ;BDDBE-/1F

O*(A%: fibiosis anu pulmonaiy BTN(the leauing causes of ueath in this uisease)

N4: Wiue mouth colonic uiveiticula anu esophageal uysmotility, leauing to ieflux anu
Baiiett's esophagush 1S% of pts get piimaiy biliaiy ciiihosis

V+,;t: Restiictive caiuiomyopathy

M+(,#: may leau to malignant BTN.


Theie is not a single best uiagnostic test
Though not specific, ANA is seen in 9S% of cases

Theie is no tieatment that slows the piogiession oi tieats this conuition
If theie is ienal involvement give ACEIs
If theie is pulmonaiy hypeitension, give Bosentan anu piostacyclin analogs
Foi Raynauu's give calcium channel blockeis

7B0-/B+3-D-< K(0<--,-0
Is similai in piesentation to scleioueima but theie is no Raynauu's, noi is theie any
of the othei systemic finuings

-"$%' #%. -/+0,&+':
Thickeneu skin similai to scleioueima
Naikeu eosinophilia gives the appeaiance of peau u'oiange

Nanage this conuition with coiticosteioius

@BD9*9B0-,-0\@%^ (/2 6.'*(,B*9B0-,-0\6%^

In both conditions, the patient cannot get up from a seated position without using the
arms. There can also be muscle pain and tenderness.

E$; >$#=2=$%)0)%! Weakness + incieaseu CPK + incieaseu aluolase
E$; .+;2,0$2=$%)0)% ! Weakness + incieaseu CPK + incieaseu aluolase + skin

Shoulu oiuei LFT's anu ANA


A pain synuiome seen mostly in females that piesents with aching muscles,
stiffness, tiiggei points foi pain, anu sleep that isn't iefieshing

Signs anu Symptoms:
Nuscle aches
Nuscle stiffness
Bepiession anuoi anxiety
Extieme sensitivity anu pain to tiiggei points on the bouy


Noimal bloou tests anu no objective eviuence of uisease


Exeicise can help ielieve some pain anu stiffness
TCA's can be given

@BD9*9(D1-( "3.)*(,-<( \@%"^

Seen most commonly in those > Suyi

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

Patient oluei than Suyi with significant pain anu stiffness of the pioximal
muscles (shoulueis, pelvic giiule)
Stiffness is usually woise in the moining anu is usually moie localizeu to the
Patient may have fevei, malaise, anu weight loss

CBC will likely show noimocytic anemia
Nuscle biopsy anu labs aie all noimal

Lack of muscle atiophy

12*#,+*%,: Steioius

Following explains uiffeience between chionic fatigue, fibiomyalgia, anu PNR
53'B/-< ;(,-1).
K-N'B*9(D1-( @BD9*9(D1-(
Fatiguemalaise +++++ >6mnth ++ ++
+++++ ++ No
Tiiggei points N0 YES N0
Bloou tests All noimal All noimal Inci ESR
Tieatment None Pain ielief Pieunisone

Common featuies among uiffeient types of vasculitis incluue:
Fatigue, malaise, wt loss
Skin lesions such as palpable puipuia anu iash
}oint pain

3&++&% 7#4 6"%."%$'8
Noimocytic anemia
Elevateu ESR

The most accuiate test is a biopsy

The best initial theiapy is steioius

! If steioius aien't effective, alteinate anuoi auuitional theiapies aie the following


@BD9(',.'-,-0 LB2B0( \@#L^

PAN has all the featuies of vasculitis uesciibeu above, what uiffeientiates it is the
unique featuies that accompany PAN.

Abuominal pain (6S%)
Renal involvement (6S%)
Testiculai involve(SS%)

The best initial test is angiogiaphy of the abuominal vessels
The most accuiate test is a biopsy of the muscles, suial neive, anu skin

Pieunisone anu Cyclophosphamiue

I.1./.'80 G'(/)DB*(,B0-0
A disorder that like PAN can affect the majority of the body. Look for the addition of
upper and lower respiratory findings and the presence of c-ANCA


The most accurate diagnostic test is a biopsy
Upper and lower respiratory findings
Presence of c-ANCA


Treatment involves Prednisone and Cyclophosphamide

Can affect any oigan in the bouy, but the key to making its uiagnosis is
piesence of ?,%'*#)0)%f +$%)($>1)#),f ,(. ,%012,h
P-ANCA anu anti-myelopeioxiuase can be positive too, but these finuings
aien't as unique as the piesence of eosinophilia.
Nost accuiate test is biopsy


!.*+B'(D #',.'-,-0
A type of giant cell arteritis, related to PMR.

Signs and Symptoms:

Weight loss
Visual disturbances
Jaw claudication


Elevation of ESR
Clinical findings



!(Q(9(0)80 #',.'-,-0
Seen in young asian females

-"$%' #%. -/+0,&+':
Bimishes pulses
vasculitis commonly seen befoie loss of pulse
Patient often gets TIA anuoi stioke causeu by the vasculai occlusion

NRA oi aiteiiogiaphy


Is similai to to vasculitis synuiomes, the uiffeience is the association with hepatitis
C anu kiuney involvement
12*#, with inteifeion anu iibaviiin

4.3<., 6-0.(0.

This condition presents in pts of Middle Eastern or Asian ancestry.

Signs and Symptoms:
0ial anu genital ulceis
0culai involvement that can leau to blinuness
Skin lesions: "patheigy" which is hypeiieactivity to neeule sticks, iesulting in
steiile skin abscesses.

Theie is no specific test foi uiagnosis, we must use the featuies seen above

Pieunisone anu colchisine

>LKH#%76 w?>L!A

The key to uiagnosing inflameu joints is to look at the fluiu within the joint. It is the
most accuiate uiagnostic test foi gout, pseuuogout, anu septic aithiitis

9=($?),# &#*). '+## '$*(0
LB'*(D >/;D(**(,B'9\1B),J+0.)2B1B),^ >/;.<,-B)0
<2uuu WBC's 2uuu-Suuuu WBC's >Suuuu WBC's


Look for a man with a sudden onset of severe pain in the toe at night. The toe will be
red, swollen, and tender.

Things that precipitate a gouty reaction are:

Alcohol ingestion
Thiazide diuretics
Nicotinic acid
Foods high in protein

The best initial test is aspiiation of the joint fluiu
The most accuiate test is light exam of the fluiu showing negatively
biiefiingent neeule-shapeu ciystals

The best initial theiapy foi an acute gouty attack is NSAIBs.
uive colchisine within 24hi of the attack

Allopuiinol is best as piophylaxis anu pievention of futuie attacks, which
woiks by ieuucing the levels of uiic aciu

@0.)2B1B), \5(D<-)* @9'B+3B0+3(,. 6.+B0-,-B/ 6-0.(0.^
Involves most commonly the wiist anu knees, but uoesn't involve the toes
0nset is much slowei than gout, anu uoesn't acutely attack the patient

Aspiiation of joint fluiu shows positively biiefiingent ihomboiu-shapeu

NSAIBs aie the best initial theiapy
Can give colchisine, but is not as effective heie as it is in gout

A.+,-< #',3'-,-0
Any aithiitic oi piosthetic joint put patient at iisk of septic aithiitis
With incieaseu joint abnoimality comes incieaseu iisk of sepsis

)&2* 2"'9 6#;,&2' 6&2 '*0,"; #2,52","'8
0steoaithiitis is moie of a iisk than having noimal joints
RA is moie of a iisk than osteoaithiitis
Piosthetic joints aie moie of a iisk than anything else.

-"$%' #%. -/+0,&+':
Reu, swollen, tenuei, immobile joint

Nost common causes of septic aithiitis:
Staph auieus (4u%)
Stiep (Su%)
uiam-ve bacilli (2u%)

**Septic aithiitis iequiies consult w oithopaeuic suigeon.

The best initial test is aithiocentesis showing > Su,uuu WBC
The most accuiate test is a cultuie of the fluiu

Empiiic Iv antibiotics such as Ceftiiaxone anu vancomycin once suspecteu

@(1.,80 6-0.(0. B; 4B/.
A conuition with pain, stiffness, aching, anu fiactuies associateu with softening of
the bones.

-"$%' #%. -/+0,&+':
Bowing of the tibias

The best initial test is foi the elevation of alkaline phosphatase
The most accuiate test is xiay of the bones

Best tieateu with bisphosphonates anu calcitonin

* In cases of Paget's, osteolytic lesions will be founu initially. These may be ieplaceu
with osteoblastic lesions

** If you see osteolytic think Paget's oi osteopoiosis

*** If you see osteoblastic, think about metastatic piostate cancei in uiffeiential.

4(Q.'80 590,
A posteiioi heiniation of the synovium of the knee

-"$%' #%. -/+0,&+'8
Patient often has osteoaithiitis
Palpation of the sac in the posteiium of the knee
Swelling of the calf is common (excluue a BvT when you see this)

NSAIBS aie mainstay of tieatment
Seveie cases may iequiie steioiu injections

@D(/,(' K(0<--,-0 (/2 !('0(D !)//.D A9/2'B*.

E$##$/)(A 0,-#+ '$2>,;+% 01+ 0/$ '$(.)0)$(%<
Plantai Fasciitis Taisal tunnel synuiome
Pain on bottom of foot Pain on bottom of foot
veiy seveie in moining, bettei w
walking a few steps
Noie painful w use; may have sole
Stietch the foot anu calf Avoiu boots anu high heels; may neeu
steioiu injection
Resolves spontaneously ovei time Nay neeu suigical ielease

Chapter 16


A,'BQ.0 (/2 !>#


Stiokes occui foi gieatei % 24hi anu have peimanent iesiuual neuiological
Causeu by ischemia most commonly, anu hemoiihagic.
Ischemic stiokes occui fiom emboli oi thiombosis, which occui moie acutely


Piesents the same as a stioke except it lasts <24hi.
Commonly piesents with a loss of vision in only one eye (Amauiosis fugax),
uue to emboli in the fiist bianch off of the caiotiu (0phthalmic aiteiy)
TIA's aie always uue to emboli oi thiombosis, nevei hemoiihage


The best initial test is always a CT of the heau without contiast


If possible, give thiombolytics within Shis of the onset of symptoms anu the
CT has iuleu out hemoiihage
Aspiiin is the best initial theiapy foi those who come in too late foi
If patient is alieauy on aspiiin, can give uipyiiuamole (Clopiuogiel is an

i 71+;+ )% ($ '#+,; +?).+('+ 01,0 1+>,;)( -+(+&)0% , %0;$B+

#',.'-.0 (/2 ,3.-' (00B<-(,.2 09*+,B*0 -/ 0,'BQ.F

57"74"#H #"!7"[ A[%@!?%A
Anteiioi ceiebial aiteiy -piofounu lowei extiemity weakness
- milu uppei extieme weakness
- peisonality changes
- uiinaiy incontinence
Niuule ceiebial aiteiy - piofounu uppei extiemity
- aphasia
- apiaxianeglect
- eyes ueviate towaius lesion siue*
Posteiioi ceiebial aiteiy - contialateial homonymous
hemianopia w maculai spaiing
- piosopagnosia(cant iecognize
veitebiobasilai aiteiy - veitigo
- Nv
- veitical nystagmus
- Bysaithiia anu uystonia
- Sensoiy changes in facescalp
- Ataxia
- Labile bloou piessuie
Lacunai infaict - must be absence of coitical
- Paikinson signs
- Bemipaiesis(most notable in
- Sensoiy ueficits
- Possible bulbai signs
0phthalmic aiteiy - amauiosis fugax

C=2,5*2 +#%#$*+*%, &6 # -,2&9* &2 1>@8

Aftei all initial managements aie implementeu, uo the following:

Caiotiu Bopplei
EKu anu Boltei monitoi if the EKu comes back noimal

b&=%$ 0,' cde/2 :",5 %& '"$%"6";#%, 0#', +*.";#7 5"',&2/ T!)< ?1SU '5&=7. 5#G*
6&77&:"%$ .&%*8

1. Seuimentaion iate
2. vBRL oi RPR
4. Piotein C, piotein S, factoi v leiuen mutation, antiphospholipiu synuiomes

* The youngei the patient, the moie likely the cause of stioke is a vasculitis oi
hypeicoagulable state.

:$(0;$# V7Xf R@f ,(. 1=>+;#)>).+2), )( 01)% >0<


BTN: <1Su8u
BN: same tight glycemic contiol as gen pop'n
Bypeilipiuemia: LBL<1uu


Same management as pei stioke, except thiombolytics aien't inuicateu because the
auministiation of thiombolytics aie to iesolve symptoms, so if symptoms aie
iesolveu they aien't necessaiy.


Foi seizuie uisoiueis, the only cleai uiagnostic ciiteiia is foi a patient unueigoing
status epilepticus.

15*2#0/ 6&2 ',#,=' "' #' 6&77&:'8
1. Benzouiazepine such as Ativan (Loiazepam)
2. If seizuie peisists, auu fosphenytoin
S. If seizuie peisists, auu phenobaibitol
4. If seizuie peisists, give geneial anesthetic such as pentobaibital.

!"#$%&'"' "% # 0#,"*%, 5#G"%$ # '*"J=2*8
0igent CT of the heau
0iine toxicology secieen
Chemistiy panel
Calcium levels
Nagnesium levels

C=2,5*2 +#%#$*+*%,:
If initial tests uon't give cleai cause, uo an EEu (shoulun't be uone fiist).

Neuiology consult iequiieu in any patient having oi who hau a seizuie.

B&%$D,*2+ ,2*#,+*%, &6 6"2',D,"+* '*"J=2*':
If patient only hau 1 seizuie, chionic theiapy is not iequiieu unless theie is a
stiong family histoiy, an abnoimal EEu, oi status epilepticus

352&%"; #%,"*0"7*0,"; ,5*2#0/8
Theie is no single agent consiueieu to be the best theiapy.

#)(+ 01+;,>)+% )('#*.+<
valpioate, caibamazepine, phenytoin, anu levetiiacetam aie all equal in
Lamotiigine has same efficacy but can cause steven-johnson synuiome.

D-/. ,3.'(+-.0F
uabapentin anu phenobaibitol

E$; ,-%+('+Y>+0)0 2,# %+)b*;+%:
Ethosuxamiue is best.

@('Q-/0B/80 6-0.(0.

Is a gait uisoiuei with the following finuings:
Cogwheel iigiuity
Resting tiemoi
Nask-like facies
Intact cognition anu memoiy

Theie is no specific test to make the uiagnosis of PB, iathei the clinical
finuings aie what is useu to make the uiagnosis

@)#. %=2>0$2%F

In a patient < 6uyi of age ! Anticholineigics such as Benztiopine oi
In a patient > 6uyi of age ! Amantauine (0luei patients commonly uevelop
bau ieaction fiom anticholineigic meuications)

9+?+;+ %=2>0$2%F
Leveuopacaibiuopa have the gieatest efficacy but has an "on-off"
phenomenon with uneven long-teim effects anu moie siue effects
Bopamine agonists such as Piamipiexole, Ropineiole, anu Cabeigoline aie
less efficacious but have fewei siue effects

** If these meuication uon't woik, use C0NT inhibitois (Tolcapone, Entacapone)
which inhibit metabolism of uopamine, which extenus the effect of uopamine-baseu
meuication. Can also tiy NA0I's.


!9+. B; ,'.*B' ".0,-/1 ,'.*B' >/,./,-B/ ,'.*B' !'.*B' (, '.0,
(/2 E-,3
6-(1/B0-0 Paikinsons Ceiebellai uisoiuei Essential tiemoi
!'.(,*./, Amantauine Tieat etiology Piopianolol


Nultiple Scleiosis piesents with abnoimalities of any pait of the CNS. The
symptoms impiove anu iesolve, only to have anothei uefect uevelop months oi
yeais latei.

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

The most common abnoimality is optic neuiitis
Theie is commonly fatigue, hypeiieflexia, spasticity, anu
Theie is also commonly optic neuiitis

The best initial uiagnostic test is an NRI
The most accuiate test is also the NRI
If the NRI uoesn't give you the uiagnosis, uo a lumbai tap

Steioius aie the best initial theiapy to iesolve an acute exaceibation
ulatiiamei anu beta-inteifeion can both ueciease the piogiession of NS


1. Scanning
2. Intention
S. Nystagmu

Can give Amantauine to combat fatigue anu Baclofen to combat spasticity


#DT3.-*.'0 6-0.(0.
Is a slow piogiessive loss of memoiy exclusively in pts > 6Syis of age
Anybouy with memoiy lost iequiies a CT of the heau, a TSB level, anu an
With Alzheimei's uisease you will only see uiffuse anu symmetiical atiophy

Anticholinesteiase inhibitois aie the stanuaiu theiapy of choice

K'B/,B,.*+B'(D 6.*./,-( \@-<Q 6-0.(0.^
Peisonality anu behavioui become abnoimal fiist, then memoiy loss
Beau CT oi NRI shows focal atiophy of fiontal anu tempoial lobes
Tieat this like Alzheimei's, but uo not expect the same type of iesponse

5'.),T;.D2Yw(QBN 6-0.(0. \5w6^
Causeu by piions, which aie tiansmissible piotein paiticles.
Nanifests as iapiuly piogiessive uementia anu piesence of myoclonus.
This piesents in those youngei than the Alzheimei's patient
EEu will be abnoimal
Nost accuiate test is biain biopsy
CSF: shows 14-S-S piotein, the piesence of this will spaie the patient a biain

H.E9 4B29 6.*./,-(:
Is Paikinson's uisease + uementia.

LB'*(D @'.00)'. O92'B<.+3(D)0:
This conuition geneially piesents in oluei males, but it can affect women as
It piesents as a peison with incontinence, with gait abnoimalities, anu with
cognitive impaiiment

Biagnosis shoulu incluue a heau CT anu a lumbai punctuie

Shunt placement

O)/,-/1,B/80 6-0.(0.J53B'.(
Piesents in young patients (usually in Su's)
Theie is usually a family histoiy

Peisonality changes anu psychological uistuibance
Choieic movements

Specific genetic testing will show that inheiitance is autosomal uominant

Theie is no tieatment


%-1'(-/.: 6u% aie unilateial, often tiiggeieu by: cheese, caffeine, menses, 0CP's

Bo a CT oi NRI if BA has any of the following:
Suuuen anuoi seveie
0nset aftei 4uyi
Associateu with any neuiological finuings
Nay be pieceeueu by an auia anuoi scotomata (Baik spots in visual fielu),
anu abnoimal smells

The best initial aboitive theiapy is sumatiiptan oi eigotamine
Piophylactic theiapy takes 4-6wks to woik, if patient gets foui oi moie BA
pei month, piophylax with piopianolol.
Alteinate piophylactics with CCBs, TCA's, oi SSRI.

5D)0,.': 1ux moie fiequent in men than women. Aie exclusively unilateial w
ieuness anu teaiing of the eye anu ihinoiihea.

The best aboitive theiapy is 1uu% u2.
This tieatment is unique to clustei BA's.
Sumatiiptan can also be useu in same way as is in migiaines.

Piophylactic theiapy: theie is none because these BA's aie numeious but shoit anu
intense, anu the "clustei" woulu be ovei by the time the piophylaxis kickeu in.

O# !9+. %>G"#>L7 5H$A!7"
uenuei Nen 1ux moie than
Piesentation 0nilateial oi bilateial,
0nly unilateial,
teaiingieuness of eye
Aboitive Sumatiiptan Sumatiiptan, Special:
Piophylactic Piopianolol none

* Sumatiiptan is similai to SBT, anu woiks by causing vasoconstiiction in ceiebial

!.*+B'(D #',.'-,-0
Patient will piesent with tenueiness ovei the tempoial aiea anu may also complain
of jaw clauuication

Fiist check the ESR
The most accuiate test is a biopsy of the tempoial aiteiy

uive steioius immeuiately, uo not uelay if this is suspecteu

@0.)2B,)*B' 5.'.N'-
This piesents most commonly in a youngei woman with a heauache anu
uouble vision, papilleuema
CTNRI show up noimal
vitamin A use is often the cause

LP is the most accuiate test because it shows an elevateu opening piessuie

Involves weight loss
Acetazolamiue can also be given

All pts with veitigo will have a subjective sensation of the ioom spinning
aiounu them.
0ften associateu with nausea anu vomiting
All pts with veitigo will have nystagmus
ueneially all patients wtih veitigo shoulu have NRI of the inteinal auuitoiy

E$##$/)(A 0,-#+ %*22,;)b+% >;+% $& , (*2-+; $& ?+;0)A$D',*%)(A '$(.)0)$(%<
6-0.(0. 53('(<,.'-0,-<0 O.('-/1 HB00J !-//-,)0
4@M Changes w position N0
M.0,-N)D(' /.)'-,-0 veitigo occuis wo
position change
H(N9'-/,3-,-0 Acute YES
%./-.'.80 2-0.(0. Chionic YES
#<B)0,-< /.)'B*( Ataxia YES
@.'-D9*+3 ;-0,)D( Bx of tiaum YES

veitigo alone w no loss of heaiing,no tinnitus, no ataxia.
Positive uix-hallpike maneuvei
Tieat with meclizine(antiveit)

M.0,-N)D(' L.)'B/-,-0
An iuiopathic inflammation of the vestibulai poition of CN8.
No heaiing loss oi tinnitus because only vestibibulai poition is affecteu.
Nost likely to be a viial cause
Not ielateu to change in position
Tieat with meclizine

Is inflammation of the cochleai poition of the innei eai.
Theie is heaiing loss as well as tinnitus.
Is acute anu self-limiteu
Tieat with meclizine

%./-.'.80 6-0.(0.
Same pies as labyiinthitis (veitigo, tinnitus, heaiing loss) but menieie's is
chionic with iemitting anu ielapsing episoues.
Tieat with salt iestiiction anu uiuietics.

#<B)0,-< L.)'B*(
A tumoi of CN8 that can be ielateu to neuiofibiomatosis (von
Piesents with ataxia in auuition to heaiing loss, tinnitus, anu veitigo.

NRI of inteinal auuitoiy canal

Suigical iesection.

@.'-D9*+3(,-< K-0,)D(
Beau tiauma oi any foim of baiotiaumas to the eai may iuptuie the
tympanic membiane anu leau to a peiilymph fistula.

Wernicke-Korsakoff Syndrome

Piesents with the following:
1. Bistoiy of chionic heavy ET0B use
2. Confusion with confabulation
S. Ataxia
4. Nemoiy loss
S. uaze palsy anuoi ophthalmoplegia
6. Nystagmus

Bo a heau CT
vitamin B12 level
TSBT4 level
Piesence of memoiy loss

give thiamine then give glucose.

5LA >LK75!>?LA

0ften when a CNS infection is suspecteu, a heau CT shoulu be peifoimeu befoie the

This is the case in the following ciicumstances:
A histoiy of CSN uisease
Focal neuiological ueficits
Piesence of papilleuema
Alteieu consciousness
Significant uelay in ability to peifoim LP

** If these aie piesent, get bloou cultuies anu stait empiiic antibiotics befoie
oiueiing CT.

uetting CSF is the most accuiate test foi bacteiia meningitis, but cannot wait
foi cultuie to stait theiapy.
uiam stain: only Su% sensitive, thus if (-) cannot excluue anything. Is highly
specific though, so if (+) it is likely to be bacteiia meningitis. Ie. uoou spec
bau sensitivity
uiam (+) uiplococci: pneumococcus
uiam (+) bacilli: listeiia
uiam (-) uiplococci: neisseiia
uiam (-) pleomoiphic, coccobacillaiy oiganisms: hemophilus

8;$0+)(: An elevateu piotein level in CSF is of maiginal uiagnostic benefit. Elevateu
piotein is non-specific because any foim of CSN infection can elevate the CSF
piotein. Bowevei, a noimal CSF piotein excluues bacteiial meningitis.

N#*'$%+: Levels below 6u% of seium levels is consistent w bacteiial meningitis

:+## '$*(0< This is best initial test foi the uiagnosis of meningitis. If thousanus of
PNN's aie piesent stait Iv ceftiiaxone, vancomycin, anu steioius. Thousanu of
PNN's is bacteiial meningitis until pioven otheiwise.

5'9+,B<B<<)0 (fungal meningitis)

Look foi BIv(+) patient with <1uuCB4 cells.
This infection is slowei than bacteiial meningitis anu may not give seveie
meningeal signs (neck stiffness, photophobia, anu high fevei, all at same

The best initial test is the Inuia ink stain
The most accuiate test is the ciyptococcal antigen

The best initial theiapy is Amphoteiicin

*follow Amphoteiicin with oial Fluconazole (continueu inuefinitely until the CB4
count iaises), once CB4 count >1uu, fluconazole can be uiscontinueu.

H9*. 6-0.(0.
Patient usually lives in Connecticut aiea anu has a histoiy of camping, hiking, oi
being in tall giass. The tick exposuie is iaiely iemembeieu by the patient.

A cential cleaiing taiget iash is pathognomonic
Theie is a histoiy of joint pain
Bell's palsy

0ial uoxycycline
If theie is caiuiac involvement tieat with Iv ceftiiaxone

"B<Q9 %B)/,(-/ A+B,,.2 K.:.' \"%AK)
Look foi campeihikei with a iash that staiteu on wiists anu ankles anu moveu

-"$%' #%. -/+0,&+'8
Fevei, heauache, anu malaise always pieceue the iash

0ial Boxycylcine is the most effective theiapy.

!4 %./-/1-,-0
This is an extiemely uifficult uiagnosis to pinpoint
Look foi an immigiant with a histoiy of lung TB
Piesents slowly ovei weeks to months (If acute then not TB meningitis)

Bas a veiy high CSF piotein levels
Aciu fast stain of CSF is not accuiate, neeu thiee high-volume centiifugeu
samples if going to uo aciu-fast stain.

RIPE tieatment as with TB, only uiff is shoulu auu steioius anu extenu the
length of theiapy foi meningitis when compaieu to the pulmonaiy uisease.

M-'(D %./-/1-,-0
viial meningitis is in geneial a uiagnosis of exclusion.
Theie is lymphocytic pleocytosis in the CSF.
Theie is no specific theiapy foi viial meningitis.

H-0,.'-( %./-/1-,-0
Look foi elueily, neonatal, anu BIv (+) patients anu those who have no
spleen, aie on steioius, oi aie immunocompiimiseu with leukemia oi

* Auu Ampicillin to iegimen of vancomycin + ceftiiaxone when Listeiia is suspecteu.
Such as if theie is lymphocytosis in the CSF.

L.-00.'-( %./-/1-,-2.0
Look foi patients who aie auolescents, in the militaiy, aie asplenic, oi who
have teiminal complement ueficiency.

12*#,+*%, "' #' 6&77&:':
8,0)+(0 ! Respiiatoiy isolation
:#$%+ '$(0,'0%! Stait piophylaxis with iifampin oi cipiofloxacin.
Close contacts aie: householu membeis, people who shaie utensils, cups, kisses.
M$*0)(+ '$(0,'0%! Routine school anu woik contacts uo not neeu to ieceive


Look foi a patient with a fevei anu alteieu mental status ovei a few houis.
Almost all encephalitis in the 0S is fiom heipes, the patient uoes not have to
iecall a past histoiy of heipes in oiuei to make this uiagnosis

E3F3M g :5XE6945X = Encephalitis

The best uiagnostic test is a CT scan of the heau
The most accuiate test is a PCR of the CSF

The best initial theiapy is acyclovii
Foi acyclovii-iesistant patients give foscainet


Pies with a fevei, heauache, anu focal neuiological ueficits
CT finus a "iing" aka contiast enhanceu lesion
Finuing a iing means eithei cancei oi infection.

Consiuei BIv status in context of biain abscess as follows:

BIv negative patient ! biain biopsy is the next step
BIv positive patient ! Tieatment foi toxoplasmosis with pyiimethamine
anu sulfauiazine foi 2wks anu iepeat the heau CT

@'B1'.00-:. %)D,-;B<(D H.)QB./<.+3(DB+(,39 (PNL)
These biain lesions in BIv(+) patients aie not associateu with iing
enhancement oi mass effect.
Theie is no specific theiapy.
Tieat the BIv anu iaise the CB4, when the BIv is impioveu, the lesions will

Look foi a patient fiom Nexico with a seizuie
Beau CT shows multiple 1cm cystic lesions, ovei time lesions will calcify.

Confiim with seiology

When still active anu uncalcifieu, the lesions aie tieateu with Albenuazole,
use steioius to pievent a ieaction to uying paiasites.

O.(2 !'()*( (/2 >/,'(<'(/-(D O.*B''3(1.

Any heau tiauma iesulting in a loss of consciousness oi alteieu mental status shoulu
leau to CT of heau without contiast

5B/<)00-B/ 5B/,)0-B/ A)N2)'(D
7+-2)'(D 3.*=
Focal ueficit Nevei Raiely Yes oi no Yes oi no
Beau CT Noimal Ecchymosis Ciescent shape Lens shapeu

!'.(,*./, ;B' :('-B)0 3.(2 ,'()*(0 ('. (0 ;BDDBE0:

1. :$('*%%)$(: None
2. :$(0*%)$(: Aumit patient, vast majoiity get no tieatment
S. 9*-.*;,# ,(. 3>).*;,# V+2,0$2,%: Laige ones uiaineu, small ones left
alone to ieabsoib on theii own.
4. O,;A+ )(0;,';,(),# 1+2$;;1,A+ /)01 2,%% +&&+'0: 1.
Intubatehypeiventilate to ueciease ICP, 2. Beciease PCu2 to 2S-Su, which
constiicts ceiebial bloou vessels, S. auministei Nannitol as an osmotic
uiuietic to ueciease ICP, 4. Peifoim suigical evacuation.

A)N('(<3/B-2 O.*B''3(1.\A#O^
Look foi the following symptoms:
Suuuen, seveie heauache
Stiff neck
L0C in Su% of patients
Focal neuiological ueficits in Su% of patients
SAB is like suuuen onset of meningitis with a L0C but without fevei.

The best initial test is a heau CT without contiast. It is 9S% sensitive, if
conclusive, no neeu to uo an LP
The most accuiate uiagnostic test is an LP, but not necessaiy if CT shows

Peifoim angiogiaphy to ueteimine site of bleeu
Suigically clip oi embolize the site of bleeuing (If patient ie-bleeus theie is a
Su% change of ueath).
Inseit a vetiiculopeiotoneal shunt if hyuiocephalus uevelops
Piesciibe nimouipine oially; which is a CCB that pievents stioke.

** When SAB occuis, an intense vasospasm can leau to non-hemoiihagic
stioke(thus CCB useu).

Coiu compiession Epiuuial abscess Spinal stenosis
Nontenuei Tenuei Tenuei anu fevei Pain on walking

Is a uefective fluiu cavity in the centei of the coiu fiom tiauma, tumois, oi
congenital pioblem.
Piesents with a loss of sensation of pain anu tenueiness in a cape-like
uistiibution ovei the neck, shoulueis, anu uown both aims.


Suigical coiiection

5B'2 5B*+'.00-B/
Netastatic cancei piesses on the coiu, iesulting in pain anu tenueiness of the
Lumbosacial stiain uoesn't give tenueiness of the spine itself.

The best initial test is an NRI
The most accuiate uiagnostic test is a biopsy, only uone if uiagnosis is not
cleai fiom the histoiy

Spinal Epidural Abscess

Piesents with back pain wth tenueiness anu fevei
Scan spine with an NRI
uive antibiotics against staphylococcus such as oxacillin oi nafcillin
Laige abscesss iequiie suigical uiainage.

A+-/(D A,./B0-0
Piesents with leg pain on walking anu can look like peiipheial aiteiial
Pulses will be intact in spinal stenosis
Pain woisens when patient leans backwaius anuoi walks in a uownwaiu
uiiection, while it impioves when walking in an upwaiu uiiection
Biagnose with an NRI anu tieat with suigical uecompiession

#/,.'-B' A+-/(D #',.'9 >/;('<,-B/
All sensation is lost except position anu vibiatoiy sense, which tiavel uown
the posteiioi column of the spinal coiu
No specific theiapy can coiiect this pioblem

4'BE/YA._)('2 A9/2'B*.
This iesults fiom tiaumatic injuiy to the spine, such as that fiom a knife
Patient loses ipsilateial position, vibiatoiy sense, contialateial pain anu

** The most uigent management in coiu compiession is the auministiation of
steioius as soon as possible anu to ielieve piessuie on the coiu. Imaging stuuies aie
uone aftei auministiation of steioius.


Is an iuiopathic uisoiuei of both uppei anu lowei motoi neuions.
Tieateu with iiluzole, a unique agent that blocks the accumulation of

$%L 0-1/0 H%L 0-1/0
0pgoing toes on plantai ieflex


Biabetes is the most common cause of peiipheial neuiopathies
Specific testing is not necessaiy in most cases.

uabapentin oi Piegabalin aie useful in tieating neuiopathies.
TCA's aie less effective anu have moie siue effects

5('+(D !)//.D A9/2'B*.
Look foi pain anu weakness of fiist thiee uigits of hanu
Symptoms may woisen with iepetitive use.
Initial mgmt is a splint.
Steioiu injections may be useu if splints pioviue no ielief
If these uon't woik, can peifoim suigeiy to ielieve the pain

"(2-(D L.':. @(D09
Aka Saturday night palsy, results from falling asleep or passing out with
pressure on arms underneath the body or outstretched, perhaps draped over back
of a chair (classic presentation on exam question)
Results in wrist drop, resolves on its own.

@.'B/.(D L.':. @(D09
Results fiom high boots piessing at the back of the knee.
Results in foot uiop anu inability to eveit the foot.
This palsy will iesolve on its own

5Lm +(D09 \4.DD80 +(D09^
Results in hemi-facial paialysis of both uppei anu lowei halves of face.
Thought to be uue to a viius
Theie may also be a loss of taste in anteiioi 2S of tongue, hypeiaccusis, anu
the inability to close the eye at night.

Steioius anu acyclovii oi valcyclovii shoulu be given

".;D.V 09*+(,3.,-< 290,'B+39 \<3'B/-< '.1-B/(D +(-/ 09/2'B*.^
0ccuis in a patient with a pievious injuiy to the extiemity
Light tough such as fiom a sheet touching the foot, iesults in extieme pain
that is "buining" in quality

0ccasionally a neive block may be uone if the pievious methous uon't woik
Suigical sympathectomy may be necessaiy when iefiactoiy

".0,D.00 H.1 A9/2'B*.
0ncomfoitable feeling in the legs which patient tiies to "shake off", which
biings only tempoiaiy ielief

Piamipexole oi iopineiole.

G)-DD(-/Y4(''. 09/2'B*.
Ascenuing paialysis, thought to be causeu by a viial infection.
0sually piesents weeks aftei a iespiiatoiy infection

Fiist step is to take a peak inspiiatoiy piessuie, which can tell if the pt will
unueigo iespiiatoiy failuie.
Seconu step is to give IvIu's anuoi peifoim plasmaphaiesis.


Classically piesents with weakness of the muscles of mastication, making it
haiu to finish meals
Bluiiy vision fiom uiplopia iesults fiom inability to focus the eyes on a single
Classically the patient iepoits uiooping of the eyelius as the uay piogiesses.

The best initial test is testing foi anti-acetylcholine ieceptoi
The most accuiate test is ;7"%";#7 02*'*%,#,"&% #%. @3?O, which is moie
sensitive anu specific that tensilon test.

The best initial theiapy is @9'-2B0,-1*-/. oi L.B0,-1*-/.
Thymectomy can be peifoimeu if pyiiuostigmine oi neostigmine uon't woik
patients < 6u yi of age shoulu unueigo thymectomy.
uive E2*.%"'&%* if thymectomy uoesn't woik, oi if theie aie no iesponses to
pyiiuostigmine oi neostigmine, then pieunisone shoulu be staiteu.
!b,01)$>;)(+ #%. '='#$%>$;)(+ aie useu to tiy to keep the patient off of long-
teim steioius.

Chapter 17


4'.(0, 5(/<.' A<'../-/1

Scieening mammogiaphy as follows:
Stait at 4u
Between 4u-Su anu eveiy 1-2yis
At Su, stait uoing them eveiy yeai

S1+( , 2,22$A;,2 %1$/% ,( ,-($;2,#)0=Z
thing is to uo a biopsy(shows CA anu piesence of esetiogen anuoi
piogesteione ieceptois)

S1,0 )% 01+ %+(0)(+# ($.+s
It is the fiist noue uetecteu in the opeiative fielu, uetecteu by uye.
If this noue is fiee of CA, then axillaiy noue uissection is not necessaiy, if the
noue is canceious, axillaiy lymph noue biopsy is iequiieu

J+%0 )()0),# 01+;,>= &$; -;+,%0 ',('+;s
Lumpectomy with iauiation tieatment(equal to mouifieu iauical
If theie is piesence of estiogen oi piogesteione ieceptoi (+), use tamoxifen
oi ialoxifene
Aujuvant chemotheiapy useu whenevei the axillaiy noues aie (+) 0R the
cancei is >1cm in size.

V$;2$(,# 4(1)-)0)$( 71+;,>=F
!(*BV-;./ anu '(DBV-;./. useu if eithei piogesteione oi esteiogen
ieceptois aie positive. They SERNs (selective esteiogen ieceptoi
mouulatois). #2:.'0. ".(<,-B/0: BvT, hot flashes,enuometiial CA.
These aie uiffeient fiom ('B*(,(0. -/3-N-,B'0, which uo not leau to BvT,
but cause osteopoiosis uue to antagonistic activity in the bone.

!.P*?,(0 :1+2$01+;,>=< >0 (++'B+'-(,. E3./C
1. Cancei is in the axilla
2. Cancei laigei than 1cm
S. Noie efficacious when pt still menstiuation, because BR-ca wont be
contiolleu with estiogen antagonists such as tamoxifen.

7M!976j6@!J: is a monoclonal antibouy against bieast CA antigen "BER-2NE0",
useful in metastatic uisease, has mouest activity with few auveise ieactions

E2"+#2/ E2*G*%,#,"G* 15*2#0/: 0se Tamoxifen in any patient with multiple 1

uegiee ielatives (mom, sistei) with bieast CA


The most imp thing is scieening scheuule anu inuicatois..

Colon cancei is tieateu with suigical iesection of the colon anu
chemotheiapy centeieu aiounu a S-F0 iegimen.

M$*0)(+ &$; %';++()(AF
1. Colonoscopy starting at 50, the every 10yrs. If single family member has it, get
colonoscopy 10yrs earlier than the age at which that person was diagnosed. Three
family members get colonoscopy at 25yr, then every 10yr. FAP do screening
sigmoidoscopy at 12yr, then every 1-2yr.
2. ?<<)D, NDBB2 ,.0,-/1 staiting at Suyi, then eveiy yeai theieaftei.
S. A-1*B-2B0<B+9 anu 2B)ND. <B/,'(0, N('-)* enema at Su, then q S-Syi.


Remember that small cell carcinoma releases ectopic ACTH, Squamous cell carcinoma
releases PTH-like hormone.

Theie is no scieening test foi lung cancei
Excisional biopsy shoulu be uone on solitaiy lung nouules in pts who aie
smokeis with nouule >1cm.
Calcifications usually go against malignancy, but if theie is histoiy of
smoking, a patient >Suyi, anu nouule >1cm, excision is waiianteu.

O*(A ',('+; 01+;,>=: The most imp issue in tieatment is whethei the uisease is
localizeu enough to be suigically iesecteu. Suigeiy cannot be uone is any of the
following aie piesent:
1. Bilateial uisease
2. Nets
S. Nalignant pleuial effusion
4. Involvement of aoita, vena cava, oi heait
S. Lesions within 1-2cm of caiina.

*** 92,##D'+## #*(A ',('+; is non-iesectable because >9S% of time is has one of
these featuies.


Stait pap smeais at 21, oi Syis aftei onset of sexual activity
Bo pap smeais eveiy S yis until age 6S. Stop at 6S unless theie has been no
pievious scieening.
Auministei BPv quauiivalent vaccine to all women 1S-26yi

C&77&:"%$ =0 #% #4%&2+#7 0#0 '+*#2:
1. An abnoimal pap smeai with low-giaue oi high-giaue uysplasia shoulu be
followeu by colposcopy anu biopsy.
2. A pap smeai showing atypical squamous cells of unueteimineu significance
(ASC0S), uo BPv testing. If BPv (+), pioceeu to colposcopy, if BPv (-), uo
iepeat pap in 6mnth
S. 0nce pap smeai noimal, ietuin to ioutine testing

* Pap smeais lowei moitality in scieen populations, but still not as much as
mammogiaphy because inciuence of ceivical CA is less than that of bieast cancei.


No pioven scieening methou that loweis moitality iate. PSA anu BRE not
pioven to lowei moitality.
Bo not ioutinely offei these tests, howevei if pt asks foi them, you shoulu

12*#,"%$ 02&',#,* ;#%;*2:
1. O$',#)b+.: Suigeiy anu eithei exteinal iauiation oi implanteu iauioactive
pellets (neaily equal in efficacy)

2. @+0,%0,0)': Anuiogen blockaue is stanuaiu of caie, use flutamiue
(testosteione ieceptoi blockei) ANB leupioliue oi goseielin (uNRB

* Theie is no goou chemotheiapy foi metastatic piostate cancei, tieatment is
hoimonal in natuie.
*Remembei the S-alpha-ieuuctase inhibitoi finasteiiue is useu foi BPB, not

A man with piostate cancei piesents with seveie, suuuen back pain. NRI shows
coiu compiession, anu he's staiteu on steioius. S1,0G% 01+ (+Q0 -+%0 %0+> )(
KH$!#%>67 (to block tempoiaiy flaie up in anuiogen levels that accompanies
uNRB agonist tieatment


Key feats aie women >Su with incieasing abuominal giith at same time as weight

!"#$%&',"; ,*',"%$:
Theie's no ioutine scieening test
CA12S is a maikei of piogiession anu iesponse to theiapy, not a uiagnostic

Treatment is surgical debulking followed by chemotherapy, even in cases of local
metastatic disease.
Ovarian ca is unique in that surgical resection is beneficial even when theres a
large volume of tumor spread through the pelvis and abdomen. If possible,
removing all visible tumors helps.


Presents with painless scrotal lump in a man <35yr.
Is extiemely cuiable with a 9u-9S% Syi suivival iate.
NEvER uo a biopsy of the testicle.

!"#$%&',"; 1*',"%$8
An inguinal orchiectomy of the affected testicle, never do biopsy.
Measure AFP, LDH, and bHCG
Stage with CT of abdomen and pelvis.

1. O$',# .)%+,%+: Rauiation
2. S).+%>;+,. .)%+,%+: Chemotheiapy, which is cuiative of even metastasis in
testiculai cancei.

U?; (DD ,.0,-<)D(' <(/<.'0C pet ('. 1.'* <.DD ,)*B'0 \0.*-/B*( (/2 /B/Y

*AFP secieteu only by nonseminomas.

*Neasuie AFP, LBB, anu bBCu.


92$B)(A '+%%,0)$(:
Scieen all anu auvise against smoking
Nost effective methous aie use of oial meus such as Bupiopiion anu
Less effective aie nicotine patch anu gum (which shoulu be tiieu fiist).

*With bupiopiion, patient shoulu slowly ueciease cigaiettes 2wks aftei staiting
theiapy. 0se bupiopiion in conjunction with counselling anu nicotine ieplacement.

5%0+$>$;$%)%! Scieen all women with BEXA scan at 6Syi of age.

!!!! All men about 6Syi who weie evei smokeis shoulu be scieeneu once w an

R@! No iecommenuation foi ioutine uiabetes scieening

V7X! All pts shoulu be scieeneu at eveiy visit.

V=>+;#)>).+2),! Nen >SS, Women >4S

Chaptei 18


6%)(A 7$>)',# 90+;$).%
Potency Neuication 0se
Low 1% hyuiocoitisone Face, genitalia, anu skin
Noueiate u.1% tiiamcinolone BouyExtiemities, face,
genitalia, anu skin folus
Bigh Fluocinoniue Foi thick skin.
Nevei on face
veiy Bigh Bifloiasone Thick skin oi seveie bouy

An infection of the pilosebaceous glanu causeu by the bacteiia
Piopionibacteiium acnes
-"$%' #%. -/+0,&+'8
Blackheaus (open comeuones) anu whiteheaus (closeu comeuones)

Nilu uisease shoulu be manageu with topical antibiotics such as clinuamycin,
eiythiomycin, in auuition to benzoyl peioxiue
Noueiate uisease shoulu combine benzoyl peioxiue with ietinoius
Seveie uisease shoulu be manageu with oial antibiotics anu oial ietinoic aciu

4(<,.'-(D >/;.<,-B/0 B; ,3. AQ-/

A supeificial skin infection limiteu to the epiueimis

Is often uesciibeu as being "honey-coloieu", "wheeping", oi "oozing"
0sually causeu by 90,>1=#$'$''*%, but may also be uue to 90;+> 8=$A+(+%
Nupiiocin (A topical antibiotic) anuoi antistaphylococcal oial antibiotics

A skin infection of the epiueimis anu the ueimis, which is usually causeu by Stiep
Pyogenes. This conuition is often uesciibeu as being biight ieu, angiy, anu swollen.

With eiysipelas may come fevei anu chills
Penicillin u oi ampicillin if uiagnosis is Stieptococcus

An infection causeu by Staphylococcus anu Stieptococcus that infects the ueimis
anu the subcutaneous tissues. Nanageu with antistaph uiugs such as oxacillin anu

An infection of the haii follicle, may piogiess to a woise infection calleu a fuiuncle.
0sually causeu by staphylococcus, if acquiieu fiom a hot-tub it can be uue to
Pseuuomonas, fungi, oi viius
Look foi this aiounu the beaiu aiea wheie theie aie accumulations of pus-like

Local caie anu topical mupiiocin
Seveie cases that piogiess iequiie systemic antistaphylococcal antibiotics

L.<'B,-T-/1 K(0<--,-0
Is a seveie, life-thieatening skin infection. It begins as a cellulitis that uissects into
the fascial planes of the skin. NCC by stiep anu Clostiiuium
Bigh fevei
Extieme pain that is woise than it looks
X+';$0)b)(A E,%'))0)%
CT oi NRI looking foi aii in the tissue anuoi neciosis
Elevateu cieatine phosphokinase

Suigical uebiiuement
Combination beta lactambeta lactamase meuications
If it is causeu by Stiep Pyogenes, give clinuamycin + PCN

A<('D., K.:.'
Is causeu by Stiep Pyogenes, anu looks like a combination of a iash anu goosebumps
9',;#+0 E+?+;

-"$%' #%. -/+0,&+'F
Rough skin
Stiawbeiiy tongue
Beefy-ieu phaiynx
Rash is most intense in the axilla anu gioin (In the cieaseu aieas of skin)
Besquamation of hanus anu feet occuis as iash iesolves
Nay have fevei, chills, soie thioat, ceivical auenopathy
ulomeiulonephiitis is a complication


5B**B/ 6.'*(,BDB1-< 6-0B'2.'0

Is a supeificial, itchy, eiythematous lesion
The iash uevelops aftei itching
Commonly seen on the flexoi suifaces
Biagosis is clinical
12*#,+*%,F Avoiuance of iiiitants anu tiiggeis, keep skins moistuiizeu,
antihistaminessteioius aie goou foi ielief fiom inflammation anu itching
Theie aie many vaiiations of Eczema, incluuing:
1. !0$>)' R+;2,0)0)% - this is the classic wheie itching causes a iash
2. :$(0,'0 .+;2,0)0)% - an itchy iash at the site of contact, classically causeu by
contact with nickel, chemicals, oi poison plants
S. 9+-$;;1+)' .+;2,0)0)% - scaling anu flaking in aieas of sebaceous glanus

Piesents as pink plaques with silvei scaling
0ccuis on the extensoi suifaces such as the elbows anu knees
Theie is often pitting of the fingeinails
The classic finuing is known as "Auspitz Sign", which is pinpoint bleeuing
when the scale is iemoveu
This is uiagnoseu clinically
8%$;),0)' 8#,c*+
#)(+ is Topical steioius
#)(+ is 0vA light anu may be useu as an aujunctpiophylactic
#)(+ is methotiexate anu clyclospoiin

Is a conuition causeu by mast cell uegianulation anu histamine ielease
Piesents with the classic "wheals" that aie intensely itchy
"Beimogiaphism" is seen wheie you can wiite a woiu with youi fingei on
the skin anu it will iemain
Nost lesions aie IgE-meuiateu (thus a type 1 sensitivity)
Biagnose this conuition by sciapings

Avoiu tiiggeis
uive antihistaminessteioius
This can possibly affect the iespiiatoiy tiact which woulu then involve
secuiing an aiiway

Theie is a loss of melanocytes in uisciete aieas of the skin
Boiueis aie shaiply uemaicateu
0sually seen in uaikei patients
Possibly autoimmune in natuie
Nini-giafting can iestoie pigment to aieas wheie it is lacking

Failuie of melanocytes to piouuce pigment, uue to a tyiosine ueficiency
Patient has white skin, iiis tianslucency, uecieaseu ietinal pigment,
nystagmus, anu stiabismus
Avoiu sun exposuie anu use sunscieen all the time
Theie is an incieaseu iisk of skin cancei uue to lack of piotection fiom the

4D-0,.'-/1 6-0B'2.'0

@.*+3-1)0 M)D1('-0
A iaie autoimmune uisoiuei affecting people between 2u-4uyi of age
Bullae slough off easily anu leave laige uenuueu aieas of skin, this is know as
"Nikolsky's sign", this pieuisposes to an incieaseu iisk of infection
Fatal conuition if not manageu piopeily
8+2>1)A*% F*#A,;)%
Immunofluoiescence of the suiiounuing epiueimal cells shows a
"tombstone" fluoiescent pattein
Bigh-uose oial steioius

4)DDB)0 @.*+3-1B-2
An autoimmune conuition that affects mostly the elueily
Less seveie than pemphigus vulgaiis
Piesents with haiu anu tense bullae that uo not iuptuie easily
Piognosis is much bettei than that of pemphigus vulgaiis
J*##$*% 8+2>1)A$).
Skin biopsy showing a lineai banu along the basement membiane on
Incieaseu eosinophils founu in the ueimis
0ial steioius

7'9,3.*( %)D,-;B'*.
Is a hypeisensitivity ieaction to uiugs, infections, oi systemic uisoiueis
Piesents with uiffuse anu eiythematous taiget lesions that aie highly
uiffeiing in shape
3;=01+2, @*#0)&$;2+
Is clinical but a histoiy of heipes infection makes this a likely uiagnosis

Stop offenuing causes anu tieat if theie is a histoiy of heipes with acyclovii

@B'+39'-( 5),(/.( !('2(
An autosomal uisoiuei of impaiieu heme synthesis
uet blisteis on sun-exposeu aieas of the face anu hanus
Biffeientiate this poiphyiia by the absence of abuominal pain
8$;>1=;), :*0,(+, 7,;.,
Woou's lamp of uiine, wheie the uiine fluoiesces with an oiange-pink coloi
uue to the incieaseu levels of uiopoiphyiins
Sunscieens useu libeially
Avoiuance of alcohol

@('(0-,-< >/;.<,-B/0 B; ,3. AQ-/

Piesents as seveiely itchy papules anu buiiows that aie locateu along the
webs of the fingeis
Bighly contagious
9',-)+% )(&+'0)$(
Iuentify the Saicoptes Scabiei mite fiom a skin sciaping unuei the
Peimethiin S% cieate to the entiie bouy foi those infecteu anu close contacts
foi 8-1uhi, iepeateu in anothei week
Wash all linens anu beuuing in hot watei the same uay as cieam application

@.2-<)DB0-0 5(+-,-0 \O.(2 H-<.^
Itching anu swelling of the scalp
Common in school-ageu chiluien
Nicioscopic exam of the haii shaft will show lice attacheu to shaft
Peimethiin shampoo oi gel to the scalp
Repeat applications aie commonly iequiieu

@.2-<)DB0-0 @)N-0 \5'(N0^
Extiemely itchy papules in the pubic iegion
Nay also be along the axilla, buttocks, eyelashes, eyebiows, anu peiiumbilical
Nicioscopic iuentification of lice
Peimethiin shampoo left on foi 1u minutes, anu iepeateu again within a

5),(/.B)0 H(':( %-1'(/0
Is a snake-like, thieau-like lesion that maiks the buiiow of the nematoue
0ften seen on the hanus, back, feet, anu buttocks
Is causeu by hookwoims, namely ! Ancylostoma, Necatai, anu Stiongyloiues
:*0,(+$*% O,;?, @)A;,(%
A histoiy of skin being exposeu to moist soil oi sanu
Piesence of classic lesion
Iveimectin oially oi Thiabenuazole topically

K)/1(D 5),(/.B)0 6-0B'2.'0

6-0.(0. A-1/0 (/2
6-(1/B0-0 !'.(,*./

!-/.( Itchy, scaly,

Black uots
seen on scalp
K0B Piep Topical

5(/2-2( Itchy, scaly
usually in
skin folu
K0B piep
yeasts +
oi 0ial

m 0vale.

eu macules
on face anu
tiunk in the

Nacules uo
not tan
K0B piep
shows the
aiea foi 7

yellowing of
anu toenails.
anuoi K0B
le oi

AQ-/ 5(/<.'

5(/<.' !9+. >*(1. A-1/0 (/2
!'.(,*./, @'B1/B0-0

Seen NC in
people with
incieaseu sun
Fits all
Excision +
if theie is
Pooi with

Common in

0n sun

anu ciusteu
Excision +
(bettei than
but woise
than basal
Basal Cell

NC anu looks
like a peaily
papule with
Excision uieat
piognosis -
almost nevei


Causeu by

exlusively in
AIBS patient
anu BIv
uoou unless
theie is
oigan uamage
Cutaneous T-

Total bouy
iash that is
veiy itchy
7-1u yi
suivival with
no tieatment.

Chapter 19


Female patients > 6S yis of age shoulu ieceive a one-time BEXA bone scan
foi osteopoiosis
Any female who is at least 6uyi olu anu has 1 iisk factoi foi osteopoiosis
The T-scoie is useu to assess bone uensity
A T-scoie between |-1.S to -2.Sj is consiueieu to be osteopenia
A T-scoie < -2.S is osteopoiosis
A patient with a T-scoie of <-1.S plus iisk factois foi osteopoiosis (smoking,
pooi calcium vitamin B levels, lack of weight beaiing exeicise in the histoiy,
use of alcohol), shoulu ieceive pieventative meuications, such as oial
bisphosphonates oi Raloxifene
Raloxifene is the only SERN that is FBA appioveu to pievent osteopoiosis
Kius with cystic fibiosis shoulu ieceive noimal vaccinations in auuition to a
few auuitions ! yeaily influenza, pneumococcal boosteis
Patients with an egg alleigy shoulu avoiu the influenza anu yellow fevei
vaccines, anu shoulu be cautious with NNR as well
The 1
step in management of incieaseu LBL is lifestyle management, if LBL
>1uumguL anu the patient has iisk factois, they shoulu be staiteu on
lifestyle mouifications + statin uiugs
The uiug of choice foi incieasing the BBL is uemfibiozel anu nicotinic acius
It is iecommenueu that any male who is an active smokei oi foimei smokei
anu ageu between 6S-7S be given a one-time abuominal ultiasounu to
evaluate foi a AAA
Patients with a chionic livei uisease shoulu ieceive a numbei of vaccines
(Tetanus eveiy 1uyis + Bep A&B yeaily, anu pneumococcal vaccine)

Auult vaccine Recommenuations:
Tetanus anu Biptheiia eveiy 1uyis aftei 18yis of age
Influenza to all auults >Suyi oi to auults with chionic uiseases (BN, CBF, etc)
Pneumococcal vaccine given to all auults >6Syi of age oi to auults with
chionic uiseases

Scieening foi ceivical cancei with a pap smeai shoulu stait at 21yi of age oi
Syis aftei the onset of sexual activity (whichevei comes fiist)
If 2-S noimal pap smeais aie uone in a iow anu the woman is in a
monogamous ielationship, you can inciease the time between pap smeais to
eveiy 2-S yeais.
Scieening can stop at 7uyis of age
Bupiopion is FBA appioveu foi smoking cessation anu must be useu in
conjunction with counseling anu nicotine ieplacement

Bepatitis A vaccine is given to men who have sex with men
Neningococcal vaccine is given to those who live in close quaiteis with
Routine cholesteiol scieening shoulu begin in patients at iisk at SSyi of age
in men anu 4Syi of age in women, then eveiy Syis aftei that
The most common vaccine-pieventable uisease is hepatitis A
When CB4 count uiops below 2uu2Su, stait PCP piophylaxis with TNP-SNX
When CB4 count uiops below Su, piophylax foi mycobacteiium avium
complex with amoxicillin
Routine scieening foi Chlamyuia is now iecommenueu foi all sexually active
females who aie & 24 yis of age
Nammogiams shoulu be uone eveiy 1-2 yis staiting at 4uyi in females with
an aveiage iisk of bieast cancei. Theie is no cleai time when they shoulu
stop, but it shoulu be no soonei than 7uyi of age
Pneumococcal vaccine is a capsulai polysacchaiiue of the 2S most common
types of pneumococcus, which yielu a B-cell iesponse only, it is T-cell
Any female with a histoiy of being tieateu foi CIN2S shoulu have pap
smeais with oi without colposcopy anu cuiettage eveiy 6 months until thiee
negative iesults aie obtaineu (patients may iesume stanuaiu scieen aftei
meeting this milestone)