BLACKBOOK

Disclaimer
This material is for educational purposes only.
It is not to be used to make medical decisions.

Medical decisions should be made only with the
guidance of a licensed medical professional.
While efforts have been made to ensure

the accuracy of the content within,
the accuracy is not guaranteed.
Blackbook
Approaches to Medical Presentations
Produced by The Cumming School of Medicine, University of Calgary

Blackbook: Approaches to Medical Presentations
Chief Editors Faculty Editor

Rebecca Phillips Dr. Sylvain Coderre
Ainna Preet Randhawa
Vaneet Randhawa Editorial Board
Dr. Henry Mandin
Consulting Editors Dr. Kevin McLaughlin
Kea Archibold Dr. Brett Poulin
Sunny Fong
Lucas Streith
Incoming Editors
Erin Kelly
Tony Gu
i
Twelfth Edition (2019). First Printing.
Copyright © 2007-2019. Faculty of Medicine, University of Calgary. All Rights Reserved.
First Edition 2007 (Reprint 2008) Eighth Edition 2015

Second Edition 2009 (Reprints 2009, 2010) Ninth Edition 2016
Third Edition 2010 Tenth Edition 2017
Fourth Edition 2011 Eleventh Edition 2018
Seventh Edition 2014 Twelfth Edition 2019
ISBN Pending Assignment
This material is covered by the following Creative Commons License:

Creative Commons Attribution-NonCommercial 4.0 International License.
This material is for educational purposes only. It is not to be used to make medical decisions.
Medical decisions should be made only with the guidance of a licensed medical professional.
While efforts have been made to ensure accuracy of the content within, the accuracy is not
guaranteed.
ii
The Black Book Project may be contacted at: Design
Undergraduate Medical Education Michael Cheshire
Faculty of Medicine
University of Calgary Illustrations
Health Sciences Centre Gray’s Anatomy (Public Domain)
3330 Hospital Drive N.W. Vecteezy.com
Calgary, Alberta, Canada T2N 4H1
blackbk@ucalgary.ca
Medical presentation schemes conceived by Henry Mandin.

The Calgary Black Book Project founded by Brett Poulin.
Printed in Calgary, Alberta, Canada.
iii
iv
A Message from the Editors
Welcome to the Twelftth Edition of Blackbook! This ongoing project is the result of the hard work
and dedication of medical students and faculty at the University of Calgary, Cumming School
of Medicine. We are proud that healthcare practitioners and trainees across North America find
Blackbook to be a useful tool.
Blackbook continues to evolve and improve during each edition. In this newest print we have
added and modified several schemes, including a new page for interpretation of pulmonary
function tests, among numerous smaller edits and spelling corrections. We’re working on an open
access, online version of Blackbook that will link to and integrate our other project, Calgary Cards
(cards.ucalgary.ca). Cards is another study aid that employs student-authored patient scenarios
in MCQ format. If students are struggling in a particular area (e.g., acid- base questions), cards is a
great way to get some extra practice. Cards is free and in constant development - check it out!
As always, we welcome feedback, suggestions, edits, or ideas for new schemes.

Please e-mail us at blackbk@ucalgary.ca.
v
Thank you and happy learning!
Rebecca Phillips, Ainna Preet Randhawa & Vaneet Randhawa
vi
Introduction to Schemes
The material presented in this book is intended to assist learners in organizing their knowledge
into information packets, which are more effective for the resolution of the patient problems they
will encounter. There are three major factors that influence learning and the retrieval of medical
knowledge from memory: meaning, encoding specificity (the context and sequence for learning),
and practice on the task of remembering. Of the three, the strongest influence is the degree of
meaning that can be imposed on information. To achieve success, experts organize and “chunk”
information into meaningful configurations, thereby reducing the memory load.
These meaningful configurations or systematically arranged networks of connected facts are

termed schemata. As new information becomes available, it is integrated into schemes already
in existence, thus permitting learning to take place. Knowledge organized into schemes (basic
science and clinical information integrated into meaningful networks of concepts and facts) is
useful for both information storage and retrieval. To become excellent in diagnosis, it is necessary
to practice retrieving from memory information necessary for problem resolution, thus facilitating
an organized approach to problem solving (scheme-driven problem solving).
vii
The domain of medicine can be broken down to 121 (+/- 5) clinical presentations, which represent
a common or important way in which a patient, group of patients, community or population
presents to a physician, and expects the physician to recommend a method for managing the
situation. For a given clinical presentation, the number of possible diagnoses may be sufficiently
large that it is not possible to consider them all at once, or even remember all the possibilities.
By classifying diagnoses into schemes, for each clinical presentation, the myriad of possible
diagnoses become more manageable ‘groups’ of diagnoses. This thus becomes a very powerful
tool for both organization of knowledge memory (its primary role at the undergraduate medical
education stage), as well as subsequent medical problem solving.
There is no single right way to approach any given clinical presentation. Each of the schemes
provided represents one approach that proved useful and meaningful to one experienced,
expert author. A modified, personalized scheme may be better than someone else’s scheme, and
certainly better than having no scheme at all. It is important to keep in mind, before creating a
scheme, the five fundamentals of scheme creation that were used to develop this book.
If a scheme is to be useful, the answers to the next five questions should be positive:
viii
1. Is it simple and easy to remember? (Does it reduce memory load by “chunking” information
into categories and subcategories?)
2. Does it provide an organizational structure that is easy to alter?
3. Does the organizing principle of the scheme enhance the meaning of the information?
4. Does the organizing principle of the scheme mirror encoding specificity (both context and
process specificity)?
5. Does the scheme aid in problem solving? (E.g. does it differentiate between large categories
initially, and subsequently progressively smaller ones until a single diagnosis is reached?)
By adhering to these principles, the schemes presented in this book, or any modifications to them
done by the reader, will enhance knowledge storage and long term retrieval from memory, while
making the medical problem-solving task a more accurate and enjoyable endeavour.
Dr. Henry Mandin

Dr. Sylvain Coderre
ix
Table of Contents
A Message from the Editors .................... v Shock .........................................................................................13

Syncope ...................................................................................14
Introduction to Schemes ........................vii Systolic Murmur Benign & Stenotic ....................15
Systolic Murmur Valvular & Other ........................16
Cardiovascular 1 Diastolic Murmur ...............................................................17
Abnormal Rhythm (1) ........................................................ 3
Abnormal Rhythm (2) ....................................................... 4 Respiratory 19
Chest Discomfort Cardiovascular ........................... 5 Pulmonary Function Tests Interpretation .......21
Chest Discomfort Pulmonary / Medistinal .....6 Acid-Base Disorder Pulmonary .............................22
Chest Discomfort Other ................................................. 7 Chest Discomfort Cardiovascular ........................ 23
Hypertension..........................................................................8 Chest Discomfort Pulmonary ................................. 24
Hypertension in Pregnancy.........................................9 Chest Discomfort Other .............................................. 25
Left-Sided Heart Failure ..............................................10 Chest Trauma Complications.................................. 26
Isolated Right-Sided Heart Failure........................11 Cough Chronic ................................................................... 27
Pulse Abnormalities ........................................................12 Cough, Dyspnea & Fever ........................................... 28
x
Dyspnea Acute................................................................... 29 Anemia with Elevated MCV...................................... 43
Dyspnea Chronic Cardiac ..........................................30 Anemia with Normal MCV ......................................... 44
Dyspnea Chronic Pulmonary / Other................31 Anemia with Low MCV................................................. 45
Excessive Daytime Sleepiness .............................. 32 Approach to Bleeding / Bruising Platelets &
Hemoptysis .......................................................................... 33 Vascular System.........................................................46
Hypoxemia ............................................................................ 34 Approach to Bleeding / Bruising Coagulation
Lung Nodule ....................................................................... 35 Proteins ............................................................................. 47
Mediastinal Mass ..............................................................36 Approach to Prolonged PT (INR), Prolonged
Pleural Effusion .................................................................. 37 PTT .......................................................................................48
Pulmonary Hypertension ...........................................38 Prolonged PT (INR), Normal PTT..........................49
Prolonged PTT, Normal PT (INR) Bleeding
Hematologic 39 Tendency .........................................................................50
Overall Approach to Anemia ....................................41 Prolonged PTT, Normal PT (INR) No Bleeding
Approach to Anemia Mean Corpuscular Tendency ..........................................................................51
Volume .............................................................................. 42 Approach to Splenomegaly..................................... 52
xi
Fever in the Immunocompromised Host....... 53 Abdominal Mass ............................................................... 72
Lymphadenopathy Diffuse........................................ 54 Abdominal Pain (Adult) Acute - Diffuse........... 73
Lymphadenopathy Localized ................................. 55 Abdominal Pain (Adult) Acute - Localized .....74
Neutrophilia..........................................................................56 Abdominal Pain (Adult) Chronic - Constant . 75
Neutropenia Decreased Neutrophils Only ... 57 Abdominal Pain (Adult) Chronic - Crampy /
Neutropenia Bicytopenia / Pancytopenia ....58 Fleeting .............................................................................76
Polycythemia ......................................................................59 Abdominal Pain (Adult) Chronic - Post-
Suspected Deep Vein Thrombosis (DVT) ......60 Prandial ............................................................................. 77
Suspected Pulmonary Embolism (PE) ..............61 Anorectal Pain ....................................................................78
Thrombocytopenia .........................................................62 Acute Diarrhea ...................................................................79
Thrombocytosis ................................................................63 Chronic Diarrhea Small Bowel ...............................80
Hemolysis ..............................................................................64 Chronic Diarrhea Steatorrhea & Large Bowel
..................................................................................................81
Gastrointestinal 65 Constipation (Adult) Altered Bowel Function
Abdominal Distention ...................................................69 & Idiopathic ....................................................................82
Abdominal Distention Ascites ................................70 Constipation (Adult) Secondary Causes .........83
Abdominal Distention Other Causes ..................71 Constipation (Pediatric) ..............................................84
xii
Dysphagia ..............................................................................85 Renal 99
Elevated Liver Enzymes .............................................86 Acute Kidney Injury....................................................... 101
Hepatomegaly ...................................................................87 Chronic Kidney Disease ............................................102
Jaundice..................................................................................88 Dysuria ...................................................................................103
Liver Mass ..............................................................................89 Generalized Edema......................................................104
Mouth Disorders (Adult & Elderly) .....................90 Hematuria ............................................................................105
Nausea & Vomiting Gastrointestinal Disease Hyperkalemia Intercellular Shift ........................ 106
..................................................................................................91
Hyperkalemia Reduced Excretion ....................107
Nausea & Vomiting Other Systemic Disease
Hypokalemia .................................................................... 108
................................................................................................. 92
Hypernatremia ................................................................ 109
Stool Incontinence ..........................................................93
Hyponatremia ................................................................... 110
Upper Gastronintestinal Bleed (Hematemesis
Hypertension...................................................................... 111
/ Melena) .........................................................................94
Increased Urinary Frequency ................................112
Lower Gastrointestinal Bleed..................................95
Nephrolithiasis ..................................................................113
Weight Gain ..........................................................................96
Polyuria ...................................................................................114
Weight Loss ......................................................................... 97
Proteinuria ............................................................................115
xiii
Renal Mass Solid ............................................................ 116 Adrenal Mass Malignant ...........................................133
Renal Mass Cystic...........................................................117 Amenorrhea .......................................................................134
Scrotal Mass....................................................................... 118 Breast Discharge ............................................................135
Suspected Acid-Base Disturbance .................. 119 Gynecomastia Increased Estrogen &
Metabolic Acidosis Elevated Anion Gap.......120 Increased HCG ..........................................................136
Metabolic Acidosis Normal Anion Gap ...........121 Gynecomastia Increased LH & Decreased
Metabolic Alkalosis ..................................................... 122 Testosterone ...............................................................137
Urinary Incontinence ...................................................123 Hirsutism...............................................................................138
Urinary Tract Obstruction .........................................124 Hirsutism & Virilization Androgen Excess ....139
Hirsutism & Virilization Hypertrichosis ...........140
Endocrinology 125 Hypercalcemia Low PTH ......................................... 141
Abnormal Lipid Profile Combined & Hypercalcemia Normal / High PTH ................142
Decreased HDL ........................................................129 Hypocalcemia High Phosphate ..........................143
Abnormal Lipid Profile Increased LDL & Hypocalcemia Low Phosphate ...........................144
Increased Triglycerides.......................................130 Hypocalcemia High / Low PTH..........................145
Abnormal Serum TSH..................................................131 Hyperglycemia ................................................................146
Adrenal Mass Benign ..................................................132 Hypoglycemia ..................................................................147
xiv
Hyperphosphatemia....................................................148 Back Pain..............................................................................167
Hypophosphatemia .....................................................149 Cognitive Impairment ................................................ 168
Hyperthyroidism .............................................................150 Dysarthria ............................................................................ 169
Hypothyroidism ................................................................151 Falls in the Elderly .........................................................170
Hyperuricemia..................................................................152 Gait Disturbance ..............................................................171
Male Sexual Dysfunction .........................................153 Headache Primary ........................................................ 172
Sellar / Pituitary Mass ................................................154 Headache Secondary, without Red Flag
Sellar / Pituitary Mass Size .....................................155 Symptoms..................................................................... 173
Short Stature......................................................................156 Hemiplegia ......................................................................... 174
Tall Stature ..........................................................................157 Mechanisms of Pain ..................................................... 175
Weight Gain / Obesity ...............................................158 Movement Disorder Hyperkinetic .....................176
Movement Disorder Tremor ................................... 177
Neurologic 159 Movement Disorder Bradykinetic ......................178
Altered Level of Consciousness Approach 163 Peripheral Weakness ..................................................179
Altered Level of Consciousness GCS ≤ 7 .....164 Peripheral Weakness Sensory Changes ..... 180
Aphasia Fluent .................................................................165 Spell / Seizure Epileptic Seizure ....................... 181
Aphasia Non-Fluent.................................................... 166 Spell / Seizure Secondary Organic .................182
xv
Spell / Seizure Other ..................................................183 Amenorrhea Secondary .......................................... 199
Stroke Intracerebral Hemorrhage .....................184 Antenatal Care.................................................................200
Stroke Ischemia ...............................................................185 Bleeding in Pregnancy < 20 Weeks .................201
Stroke Subarachnoid Hemorrhage ................. 186 Bleeding in Pregnancy 2nd & 3rd Trimester
Syncope ................................................................................187 .............................................................................................. 202
Dizziness .............................................................................. 188 Breast Disorder ............................................................... 203
Vertigo ................................................................................... 189 Growth Discrepancy Small for Gestational
Age / Intrauterine Growth Restriction ....204
Obstetrical & Gynecological 191 Growth Discrepancy Large for Gestational
Intrapartum Abnormal Fetal HR Tracing Age ....................................................................................205
Variability & Decelerations ...............................193 Infertility (Female) .........................................................206
Intrapartum Abnormal Fetal HR Tracing Infertility (Male) ............................................................... 207
Baseline ..........................................................................194 Intrapartum Factors that May Affect Fetal
Abnormal Genital Bleeding ....................................195 Oxygenation ...............................................................208
Acute Pelvic Pain........................................................... 196 Pelvic Mass ........................................................................209
Chronic Pelvic Pain .......................................................197 Ovarian Mass .....................................................................210
Amenorrhea Primary .................................................. 198 Pelvic Organ Prolapse .................................................211
xvi
Post-Partum Fever ........................................................ 212 Hair Loss (Alopecia) Localized ............................ 228
Post-Partum Hemorrhage ...................................... 213 Morphology of Skin Lesions Primary Skin
Recurrent Pregnancy Loss......................................214 Lesions ........................................................................... 229
Vaginal Discharge ..........................................................215 Morphology of Skin Lesions Secondary Skin
Lesions ........................................................................... 230
Dermatologic 217 Mucous Membrane Disorder Oral Cavity..... 231
Burns ....................................................................................... 221 Nail Disorders Primary Dermatologic Disease
Dermatoses in Pregnancy Physiologic ...............................................................................................232
Changes .........................................................................222 Nail Disorders Systemic Disease........................233
Dematoses in Pregnancy Specific Skin Nail Disorders Systemic Disease - Clubbing
Conditions .....................................................................223 .............................................................................................. 234
Disorders of Pigmentations Pruritus No Primary Skin Lesion ........................ 235
Hyperpigmentation ...............................................224 Pruritus Primary Skin Lesion ................................. 236
Disorders of Pigmentations Skin Rash Eczematous...............................................237
Hypopigmentation .................................................225 Skin Rash Papulosquamous ................................. 238
Genital Lesion .................................................................. 226 Skin Rash Pustular........................................................ 239
Hair Loss (Alopecia) Diffuse ...................................227 Skin Rash Reactive.......................................................240
xvii
Skin Rash Vesiculobullous ......................................241 Vascular Joint Pain ........................................................257
Skin Ulcer by Etiology ................................................242 Pathologic Fractures .................................................. 258
Skin Ulcer by Location Genitals ......................... 243 Soft Tissue .......................................................................... 259
Skin Ulcer by Location Head & Neck............. 244 Fracture Healing ............................................................260
Skin Ulcer by Location Lower Legs / Feet 245 Osteoporosis BMD Testing .....................................261
Skin Ulcer by Location Oral Ulcers .................. 246 Tumour .................................................................................. 262
Skin Ulcer by Location Trunk / Sacral Region Mytomes Segmental Innervation of Muscles
...............................................................................................247 .............................................................................................. 263
Vascular Lesions............................................................ 248 Guide to Spinal Cord Injury.................................... 264
Musculoskeletal 249 Psychiatric 265

Acute Joint Pain Vitamin CD ..................................251 Anxiety Disorders Associated with Panic .... 267
Chronic Joint Pain ..........................................................252 Anxiety Disorders Recurrent Anxious
Bone Lesion ...................................................................... 253 Thoughts .....................................................................268
Deformity / Limp .......................................................... 254 Trauma & Stressor Related Disorders ...........269
Infectious Joint Pain .................................................... 255 Obsessive-Compulsive & Related Disorders
Inflammatory Joint Pain............................................ 256 .............................................................................................. 270
xviii
Personality Disorder..................................................... 271 Ophthalmologic 289
Mood Disorders Depressed Mood ...................272 Cross Section of the Eye & Acronyms ............291
Mood Disorders Elevated Mood.........................273 Approach to an Eye Exam ...................................... 292
Psychotic Disorders ....................................................274 Acute Vision Loss Bilateral..................................... 293
Somatoform Disorders...............................................275 Acute Vision Loss Unilateral ................................. 294
Chronic Vision Loss Anatomic ............................. 295
Otolaryngologic 277 Amblyopia ..........................................................................296
Hearing Loss Conductive ....................................... 279 Diplopia ................................................................................ 297
Hearing Loss Sensorineural ..................................280 Pupillary Abnormalities Isocoria ........................298
Hoarseness Acute .........................................................281 Pupillary Abnormalities Anisocoria..................299
Hoarseness Non-Acute............................................ 282 Red Eye Atraumatic.....................................................300
Neck Mass.......................................................................... 283 Red Eye Traumatic ........................................................301
Otaligia .................................................................................. 284 Strabismus Ocular Misalignment...................... 302
Smell Dysfunction ........................................................ 285 Neuro-Ophthalmology Visual Field Defects
Tinnitus Objective .........................................................286 ..............................................................................................303
Tinnitus Subjective ...................................................... 287
xix
Pediatric 305 Noisy Breathing: Pediatric Stridor…….........……………............................……334
Developmental Delay ...................................................................................... 311 Pediatric Cough: Acute…………........……………..........................................……..……335
School Difficulties................................................................................................312 Pediatric Cough: Chronic……………………………......................................…….........336
Small for Gestational Age .............................................................................313 Respiratory Distress in the Newborn: Tachypnea.......................337
Large for Gestational Age .............................................................................314 Sudden Unexpected Death in Infancy……...........................................338
Congenital Anomalies .....................................................................................315 Enuresis…………………………………….................……………......................................................339
Headache.................................................................................................................316 Apparent Life Threatening Event…………….....................................…….…..340
Failure to Thrive Adequte Calorie Consumption .........................317 Pediatric Fractures………………………......……………..................................................….341
Failure to Thrive Inadequte Calorie Consumption .....................318 Salter Harris Classification………………………................................…….................342
Hypotonic Infant (Floppy Newborn) .....................................................319 Sudden Paroxysmal Event………........………...............................……................343
Acute Abdominal Pain ....................................................................................320 Non-Epileptic Paroxysmal Event………...............................…….................344
Chronic Abdominal Pain……..…………….......................……………...........................321 Pediatric Epilepsies….……..………………............................................…….................345
Pediatric Vomiting………………………….................................…………….......................,,322 Pediatric Seizures………………….................……................................……................…346
Neonatal Jaundice: Approach to Indirect Febrile Seizures………………….................……................................……................….....347
Hyperbilirubinemia…………………….…….................…………….............................323 Pediatric Mood and Anxiety Disorders…....….............................……....348
Neonatal Jaundice: Approach to Indirect Abdominal Mass…………………………………………................…................................……....349
Hyperbilirubinemia…………………………..................…………….............................324 Shock…………………………………………...…………………..........……….............................……...………….350
Pediatric Diarrhea………….……….……………..........................………...……........................325 Hypoglycemia…………………………...................…………….............................……...………….351
Constipation: Pediatric…………………………......................……………..........................326 Altered Level of Consciousness………........................................……......…..352
Mouth disorder: Pediatric…………………........................…………….........................327 Bleeding/Bruising………………………………………….....................……........................…...353
Depressed/Lethargic Newborn………............………………….......................,,.328 Thrombocytopenia……………………….............………………….............................……...….354
Cyanosis in the Newborn........................................……………..........................329 Long PT (INR), Long PTT…………………….............................……...…........…………….355
Limp.......................................................................................……………...........................330 Long PT (INR), Normal PTT………………………….....….............................……..…….356
Respiratory Distress in the Newborn..…........…………….........................…331 Normal PT (INR), Long PTT…………….............................……....……………....……….357
Pediatric Dyspnea………………………………............................…………….........................332 Dehydration……………………………………………...……………….............................……...…...………358
Noisy Breathing: Pediatric wheezing…..........…………….........................…333 Hyponatremia………………………………...……………….………………….......................................359
xx
Hypernatremia…………………………………...……………....……………......................................360 Edema ………………………………........…………………...………………….....................................….…..386
Global Developmental Delay/Intellectual Disability...............361 Dysuria ……………………………...………………….......………………................................................…387
Fever (Age <1 Month)……………………………............……….....................................……362 Increased Urinary Frequency…….....................................................….………388
Fever (Age 1-3 Months)……………………………….........……......................................…363 Scrotal Mass. ………………………………………........................................................…….……..389
Fever (Age >3 Months)…………………………..........……………......................................364 Lymphadenopathy ………………………................................................…………………….390
Failure to Thrive………………………………..................……….....................................……….365 Otalgia (Earache) …………………………...............…....................................…………….…..391
Short Stature………………………………….....................………....................................….……..366 Sore Throat/Sore Mouth……………………………....................................….....…….…392
Murmur in the Newborn (<48 Hours)…........…......................................367
Murmur in the Newborn Beyond Neonatal Period..................368
Preterm Infant Complications (<34 Weeks)....................................369 General Presentations �� 393
Preterm Infant Complications (34-36 Weeks)...............................370 Fatigue...................................................................................................395
Anemia by Mechanism……………………………..........….....................................………371 Acute Fever .......................................................................................396
Anemia by MCV……………………………………….....................................................….……..372 Fever of Unknown Origin / Chronic Fever ................. 397
Microcytic Anemia………………………….............……....................................……….………373 Hypothermia.....................................................................................398
Paediatric Infectious Skin Rash………...............….....................................…374 Sore Throat / Rhinorrhea ........................................................399
Skin Lesion (Primary Skin)………………………………....….....................................….375
Skin Lesion (Secondary Skin)…………………….……....................................………376
Rash (Eczematous)………………………………………..................................................…….377 Historical Executive Student Editors.. 401
Rash (Papulosquamous)…………………………...........................................….…………378
Rash (Vesiculobullous)……………………………............................................….…………379
Rash (Pustular)………………………………………........................................................…………380
Scheme Creators.................................. 402
Rash (Reactive)……………………………...................…....................................…….…………..381
Proteinuria……………………………......………………….…………....................................….……………382
Hematuria…………………………………...…………………...……….....................................……………..383
Acute Renal Failure……………………………….................................................…………….384
Abbreviations .................................... 403
Chronic Kidney Disease …………………………………...........................................……385
xxi
Cardiovascular
Abnormal Rhythm (1) ..........................................................3
Abnormal Rhythm (2) .........................................................4
Chest Discomfort Cardiovascular .............................5
Chest Discomfort Pulmonary / Medistinal ...... 6
Chest Discomfort Other ...................................................7
Hypertension........................................................................... 8
Hypertension in Pregnancy.......................................... 9
Left-Sided Heart Failure ...............................................10
Isolated Right-Sided Heart Failure.........................11
Pulse Abnormalities ......................................................... 12
Cardiovascular
Shock .......................................................................................... 13
Syncope .................................................................................... 14
Systolic Murmur Benign & Stenotic ..................... 15
Systolic Murmur Valvular & Other .........................16
Diastolic Murmur ................................................................ 17
1
Historical Editors Student Editors
Katie Lin Azy Golian
Payam Pournazari Harsimranjit Singh
Marc Chretien Shaye Lafferty
Tyrone Harrison
Hamza Jalal Faculty Editor
Geoff Lampard Dr. Sarah Weeks
Luke Rannelli
Connal Robertson-More
Jeff Shrum
Cardiovascular
Sarah Surette
Lian Szabo
Kathy Truong
Vishal Varshney
2
Abnormal Rhythm (1)
ABNORMAL RHYTHM 1
Types of Arrhythmia
Bradyarrhythmia Tachyarrhythmia
Abnormal Beats
(<60 bpm) (>100 bpm)
• Sinus Bradycardia • Premature atrial contraction
• Sick Sinus Syndrome • Premature ventricular contraction
• SA Block
• AV Block (1st/2nd /3rd degree)
• Junctional Escape Rhythm
• Ventricular Escape Rhythm
Narrow QRS (<120 msec) Wide QRS (>120 msec)

SVT VT or SVT with aberrancy
Cardiovascular
Regular Rhythm SVT Irregular Rhythm SVT Regular Rhythm Irregular Rhythm
(constant R-‐R Interval) (variable R-‐R interval) (constant R-‐R Interval) (variable R-‐R interval)
• Sinus Tachycardia • AFib • Monomorphic VT • Polymorphic VT (including
• Monofocal Ectopic Atrial • AFlutter with Variable AV • Regular rhythm SVT with Tosades de Pointes if in a
Tachycardia Conduction conduction aberrancy setting of long QT)
• Aflutter • Multifocal Atrial • Irregular rhythm SVT with
• AVNRT Tachycardia conduction aberrancy
3 • AVRT (ie. WPW)
Abnormal Rhythm (2)
ABNORMAL RHYTHM
auses of Arrhythmia
May present as palpitations di iness

syncope chest discomfort
ardiac Non-‐ ardiac
lectrical onduction
Structural
Abnormalities
• Valve disease • Ectopic foci
• Cardiomyopathy • Accessory pathway
• Scar tissue (previous MI)
Cardiovascular
igh utput State etabolic rugs sychiatric
• Anemia • ypoglycemia • Alcohol • Panic Attack
• Fever/infection • Thyroto icosis • Caffeine • enerali ed An iety
• Pregnancy • Pheochromocytoma • Sympathomimetics isorder
•Anticholinergics
•Cocaine 4
H Chest
T Discomfort
OM ORT
Cardiovascular
hest iscomfort Chest Discomfort
Cardiovascular Pulmonary/Mediastinal
ardiovascular ulmonary ediastinal ther
Outflow Obstruction Ischemic

Cardiovascular
utflow bstruction Ischemic Non-‐Ischemic

• Aortic Stenosis • Myocardial Infarction* • Ao
• Stable/Unstable Angina* • Di
• Aortic Stenosis • Myocardial Infarction • Aortic issection
• Pe
• Stable/ nstable Angina • ilating Aneurysm
•M
• Pericarditis
• Myocarditis
5 * Denotes acutely life-threatening causes
* Denotes acutely life-‐threatening causes

H T OM ORT M Chest Discomfort
Pulmonary / Medistinal
Chest Discomfort
hest iscomfort
scular Pulmonary/Mediastinal Other

ardiovascular ulmonary ediastinal ther
Chest Wall/Pleura Parenchymal
Cardiovascular
Vascular hest Wall leura arenchymal
• Pneumothorax* • Pneumonia with pleurisy*
• Pleural Effusion • Tuberculosis*
• Pulmonary Embolism
• Pleuritis/Serositis • Pneumothora • Pneumonia with pleurisy
• Neoplasm*
(chest pain often not • Pleural Effusion • Tuberculosis
n • Sarcoidosis
present) • Pleuritis/Serositis • Neoplasm
• Pulmonary ypertension • Sarcoidosis
* Denotes acutely life-threatening causes 6

Chest Discomfort
H T OM ORT O
Other
hest iscomfort Chest Discomfort
ardiovascular ulmonary Cardiovascular

ediastinal Pulmonary/Mediastinal
ther
Gastrointestinal Musculoskeletal
astrointestinal usculos eletal Neurologic sychiatric
Cardiovascular
• Gastro-Esophageal Reflux • Costochondritis

• astro Esophageal Reflu • Costochondritis
Disease • An• Muscular
iety/PanicInjury
isease • Muscular In ury
• Biliary Disease • erpes
• Trauma Simple Virus/Post
• Biliary isease • Trauma
• Peptic Ulcer Disease erpetic Neuralgia
• Peptic lcer isease • Pancreatitis* • Somatoform isorder
• Pancreatitis • Esophageal Spasm • Spinal Radiculopathy
• Esophageal Spasm • Esophageal Perforation*
7 • Esophageal Perforation
* Denotes acutely life-threatening causes
Hypertension
HYRTRT
HYHY RT N ON
N NON ON
ypertension
ypertension
ypertension
rimary (rimary
rimary ( ssential)
ssential) ( () ( ) )
( ssential) Secondary
Secondary ( )( () )
Secondary islabelled
islabelled
islabelled
nset
abge
etween 2age 2 and . nset nset
or a ge
2 o r
2years. or y ears.
years. Repeatedly normal blood
nset bnset
etween
between 2 a age
nd a.nd . nset age 2age Repeatedly
Repeatedly
normal normal
blood bplood
ressure wphen
ressure
pressure when
when
Positive family history. No family history. ypertensive urgency. taken aork
t home
Positive Positive
family fhamily
istory. history. No family
No fhamily
istory.
history.
ypertensive ypertensive urgency. urgency. taken taken
at homeat h w
ome w hen
woork
owr ork r w or wau
using
hen hen
n using
sing an an
No
No features of features
No features of shecondary
secondary
of secondary
ypertension. hypertension.
hypertension. Resistant hResistant
Resistant
ypertension. hypertension. hypertension. ambulatory monitor.
ambulatory
ambulatory
monitor. monitor.
• ong
• ong• standing
ong standing
standing • White • White
• White
coat coat
coat
ypertension ypertension
ypertension
• ncontrolled
• ncontrolled
• ncontrolled • Masked
• Masked
• Masked
ypertension ypertension
ypertension
• rug •
• Wrug rug
ithdrawal W ithdrawal
Withdrawal
ogenous Renal Renal

Renal echanical
echanical
echanical ndocrine
ndocrine
ndocrine
ogenous
ogenous
• Corticosteroids • Renal Renal parenchymal

p•arenchymal
• Renal parenchymal • Aortic Aortic
c•oarctation
• Aortic coarctation
coarctation • lucocorticoid eushing
cess ( ushing
• Corticosteroids
• Corticosteroids disease • bstructive Sleep • lucocorticoid
• lucocorticoid e cess e (cess ( ushing
• Cral Contraceptive
• ral • Contraceptive
ral Pills PillsPills
ontraceptive disease
disease • bstructive
• bstructive
Sleep Sleep syn ro
syn e synor ro
ro or e oisease)
e isease) r isease)
• Cocaine •C •C •C ApneaApnea Apnea •Catecholamine e cess
Cardiovascular
• Cocaine
• Cocaine •Catecholamine
•Catecholamine e cess e cess
• Black •
• Black Black
licorice l icorice
licorice •A I •A I•A I ( heochro
( heochro ( heochro
ocytoocyto a ocyto a a
• Medications • lomerulonephritis
• lomerulonephritis
• lomerulonephritis •Mineralocorticoid e cess
• Medications
• Medications • Renovascular disease •Mineralocorticoid
•Mineralocorticoid e cess e cess
• Renovascular
• Renovascular disease
disease ( ri (ary ( ri
ri alary ary
osteronis
al osteronisa l osteronis

unilateral unilateral
unilateral n a nilateral
an ailateral ilateral • yperthyroidism (mainly
renal a rtery s tenosis • yperthyroidism
• yperthyroidism (mainly (mainly
renal renal
artery
artery
stenosis stenosis systolic hsystolic
systolic
ypertension) hypertension)
hypertension)
Definition oDefinition
Definition
f hy oertensionf hyof ertensionhy ertension ypertensive
ypertensive
ypertensive
rgencyrgency BP rgency
BP u B
usually P
1 usually
sually /111 mm /11 1 g
/11
mmor mmg or g or
• ypothyroidism
• ypothyroidism
• ypothyroidism (mainly (mainly
(mainly
Systolic BP Systolic
Systolic 1BP mm B1P g mm
1or mm g or g iastolic
iastolic oBr P iastolic
BP mm BP gmm mm g g asymptomatic asymptomatic
asymptomatic
iastolic BP iastolic
iastolic 13BP mm BP g mm
13 13 mm
with g wtoarget
g target
with ith target
rgan organ organ
diastolic diastolic
diastolic
h ypertension)
h hypertension)
ypertension)
Isolated Isolated
Isolated
systolic systolic s
hypertension ystolic
hypertension h ypertension
in the ien lderly in t
the elderly he e lderly
1 mm 1 mm
1 gmm gdamage g damage
usually
damage u sually
present
usually p resent
but not
present b ut
acutely
but n ot acutely
changing
not acutely changing c hanging • yperparathyroidism
iabetes • yperparathyroidism
• yperparathyroidism
iabetes
iabetes
mellitus mellitus m
13ellitus 3 / 13gmm
/ 1mm / mm g g ypertensive
ypertensive Emergency
ypertensive Emergency Emergency BP u B
BP usually P
22usually
sually /1 22mm 22 g
/1 /1
mm mm g g •Pregnancy ( estational
Note Note Note
In children In
In children
the children the dtefinition
definition he odf efinition
hypertension of hypertension
of hypertension is is is with ewith with
volving evolving
target
evolving toarget
rgan target organ
odrgan
amage damage damage •Pregnancy
•Pregnancy ( estational
( estational
different (either systolic or diastolic BP ile) but the hy ertension hy ertension
hy ertension
different
different
approach
(either (either
iapproach
approach
systolic systolic
or diastolic
is stame.
s the iss ame.
the
or diastolic
he same.
BP BP ile) but
ile)the
but the
8
Hypertension in Pregnancy
HY RT N ON N R NAN Y
HY RT N ON N R NAN Y Clinical Pearl BP should always be
ypertension in regnancyClinical Pearl Bmeasured in a sitting position for a
HY RT N ON ypertension
N RBP mmNAN based on two Y
in g regnancy
P should aplways
pregnant atient.be
measurements measured in a sitting position for a
pregnant patient.
BP mm g based on two measurements Clinical Pearl BP should always be
ypertension in regnancy measured in a sitting position for a
pregnant patient.
BP mm g based on two measurements
re-‐e isting ypertension estational ypertension

re-‐e isting ypertension
Before Pregnancy R estational ypertension
Previously normotensive
2 weeks gestational age 2 weeks gestational age
Before Pregnancy R Previously normotensive
re-‐e aisting
2 weeks gestational ge ypertension estational
2 weeks gestational age ypertension
Before Pregnancy R Previously normotensive
2 weeks gestational age 2 weeks gestational age
No roteinuria roteinuria ( .3g/2 hr urine) No roteinuria roteinuria ( .3g/2 hr urine)

re-‐ clampsia
No roteinuria roteinuria ( R.3g/2one ohr
r umrine)
ore Adverse
No roteinuria • estational roteinuria ( R.3g/2
one ohr
r umrine)
ore Adverse
Sei ures oma
onditions • estational ypertension R one or more Adverse onditions re-‐ clampsia
R one or more Adverse
No roteinuriaonditions roteinuria ( .3g/2 whr ith urine) No roteinuria onditions roteinuria ( .3g/2Sei whr uures
rine) •oma
Eclampsia
• Pre e isting ypertension ypertension • estational ypertension ith re-‐ clampsia
hronic R one or more Adverse
Pre Eclampsia • estational R one or more A
Pre Eclampsia • dverse
Eclampsia
• Pre e isting ypertension with • estational ypertension with Sei ures oma
hronic ypertension onditions ypertension
Pre Eclampsia
onditions
Pre Eclampsia • Eclampsia
Cardiovascular
ypertension
• Primary • Pre e isting ypertension with • estational ypertension with
• Secondary hronic Pre Eclampsia aternal Pre Eclampsia etal
• Primary
• Secondary
ypertension
•Persistent aternal
or etal
•Pulmonary Edema
• Primary new/unusual headache
Adverse
•Persistent or • Visual disturbances • Suspected placental • ligohydramnios
• Secondary aternal
•Pulmonary Edema abruption etal
•Intrauterine growth restriction
new/unusual h• eadache
Persistent
Adverse onditions
• Visual disturbancesabdominal/R
• Suspected placental
• Elevated s • ligohydramnios
erum •Absent/reversed end diastolic flow in the
(S • CPersistent
2 ) •Persistent Q
r pain
oabruption creatinine/AST/A •Intrauterine
T/ growth restriction
umbilical artery
onditions • Severe n ausea
new/unusual o r
• Elevated serum
headache
•Pulmonary
• Platelet
E dema
1 1•Absent/reversed
/ end diastolic
•Intrauterine flow
fetal in the
death
(S C 2 ) abdominal/R
Adverse Q pain
vomiting • Suspected placental • ligohydramnios
creatinine/AST/A
• Visual disturbances T/ albumin umbilical
• Serum artery
• Severe nausea or pain/dyspnea
• Chest abruption 2 g/ •Intrauterine growth restriction
onditions • Persistent • Platelet 1 1 / •Intrauterine fetal death
9
vomiting • Severe hypertension • Elevated serum •Absent/reversed end diastolic flow in the
abdominal/R • Serum
Q pain albumin 2 g/
•(SChest
C p2ain/dyspnea
) creatinine/AST/A T/ umbilical artery
• Severe nausea or
• Severe hypertension • Platelet 1 1 / •Intrauterine fetal death
vomiting
• Serum albumin 2 g/
• Chest pain/dyspnea
Left-Sided Heart Failure
L T H ART A L R
L T Heft-‐Sided
ART eart
A Lailure
R SV Stroke Volume
E V End iastolic Volume
ESV End Systolic Volume
SV Stroke Volume
eft-‐Sided eart ailure E V End iastolic Volume
ESV End Systolic Volume
ection raction SV
V -‐ SV
V V
Valvular isease
ection raction SV
V -‐ SV
( reserved iastolic Systolic V V yocardial
unction) Valvular isease
• Mitral Stenosis ( reserved iastolic Systolic yocardial
• Mitral Regurgitation unction)
• Aortic Stenosis • Mitral Stenosis Systolic ysfunction iastolic ysfunction
• Aortic Regurgitation • Mitral Regurgitation (Reduced ection raction) ( reserved ection raction)
• Aortic Stenosis Systolic ysfunction iastolic ysfunction
• Aortic Regurgitation (Reduced ection raction) ( reserved ection raction)
Impaired ontractility Increased Afterload Impaired iastolic illing
• ncontrolled Severe
Impaired ontractility Increased Afterload• Transient Myocardial Ischemia
Impaired iastolic illing
ypertension • eft Ventricular ypertrophy
Cardiovascular
• Aortic Stenosis (Severe)
• ncontrolled Severe • Restrictive Cardiomyopathy
• Transient Myocardial Ischemia
ypertension • Pericardial Constriction
• eft Ventricular ypertrophy
• Aortic Stenosis (Severe) • Restrictive Cardiomyopathy
oronary Artery hronic Volume ilated • Pericardial Constriction
isease verload ardiomyopathies
oronary Artery hronic Volume ilated
• Myocardial Infarction • Mitral Regurgitation • Infiltrative
• Transient Myocardial isease
• Aortic Regurgitation verload
• Infectious ardiomyopathies
Ischemia • Myocardial Infarction •R
• Mitral Toegurgitation
ic (alcohol • Infiltrative
cocaine)
• Transient Myocardial
Ischemia
• Aortic Regurgitation
• enetic
• Infectious
• To ic (alcohol
9 10
cocaine)
• enetic 9
Isolated Right-Sided Heart Failure
OLAT R HT H ART A L R
L R Note all left sided heart failure can also lead
Isolated Right-‐Sided eart to right sided heart failure
Note all left sided heart failure can also lead ailure (the most common cause of right heart
eart to right sided heart failure failure is left heart failure)
(the most common cause of right heart
failure is left heart failure)
ardiac ulmonary
ulmonary
Rule out eft-‐Sided

eart ailure
( ost ommon)
Cardiovascular
yocardium Valves ericardium arenchyma Vasculature
• Right Ventricle • Pulmonary Stenosis • Constrictive Pericarditis • Chronic bstructive • Pulmonary Embolism
arenchyma
Infarction Vasculature
• Tricuspid Regurgitation • Pericardial Tamponade Pulmonary isease • Primary Pulmonary
• Restrictive • iffuse ung isease Arterial ypertension
Cardiomyopathy• Pulmonary Embolism
• Chronic bstructive • Acute Respiratory • Pulmonary Veno
Pulmonary isease • Primary Pulmonary istress Syndrome cclusive isease
• iffuse ung isease Arterial ypertension • Chronic ung
• Acute Respiratory • Pulmonary Veno Infection
11
istress Syndrome cclusive isease • Bronchiectasis
• Chronic ung
Pulse Abnormalities
L ABNORMAL T
ulse Abnormalities
ulsus Alternans ulsus arado us

ne ual elayed Variation in pulse amplitude E aggerated inspiratory drop in
with alternate beats arterial pressure 1 mm g
• bstructive arterial disease
(ie. Atherosclerosis) • eft heart failure • Cardiac tamponade
• Aortic dissection • AEC P / Acute E acerbation
• Aortic aneurysm of Asthma
• Aortic coarctation • ypovolemic shock
• Takayasu disease • Constrictive Pericarditis
• Normal variant • Restrictive Cardiomyopathy
Cardiovascular
Aortic Stenosis Water ammer ulse
Rapid upstroke followed by rapid
collapse
• Anacrotic
• Pulsus parvus (small amplitude) • Aortic regurgitation
• Pulsus tardus (delayed/slow • igh output states (ie.
upstroke) Anemia hypoglycemia
thyroto icosis ) 12
Shock
HO
Shoc
Warm E tremities Cold E tremities
igh JVP ow JVP
bstructive Shoc ypovolemic Shoc

istributive Shoc ardiogenic Shoc
Cardiovascular
Normal/ ecreased (Rule out ecompensated

ow JVP Bibasilar ung Crackles
Breath Sounds istributive Shock)
• Sepsis • Myocardial Ischemia or • Pulmonary Embolism • emorrhage
• Anaphyla is Infarction • Tension Pneumothora • ehydration
• Burns • eft sided Valvular isease • Cardiac Tamponade • Vomiting
• Neurogenic • Arrhythmia • iarrhea
• Cardiomyopathy (ie. CM) • Interstitial Fluid
Redistribution
13
Syncope
YN O
Rule out
Syncope Sei ure
Neurocardiogenic ardiac Respiratory ther
• Vasovagal • Pulmonary Embolism • ypoglycemia

• rthostatic ypotension • ypo ia • Anemia
• Autonomic Neuropathy • ypercapnia • Medications (CCB B
• Situational (micturition SV R Nitrates iuretics)
coughing defecation) • TIA
• Psychiatric
• Into ication
• Migraine
Stro e Volume eart Rate Rhythm
Cardiovascular
ontractility Afterload reload Tachyarrhythmia Bradyarrhythmia
• MI • Mitral/Aortic • Blood • VT/VFib • Sick Sinus Syndrome (SA

• CM Stenosis oss/ ypotension • AFib/AFlutter Node)
• CM ( V T) • Mitral Stenosis • AVNRT/AVRT • 2nd/3rd degree AV Block
• Cardiac Tamponade • Pacemaker Malfunction
• Constrictive • Tachy Brady Syndrome
Pericarditis 14
Systolic Murmur
Benign & Stenotic
Y TOL M RM R B
Systolic urmur
Benign low
Stenosis Incompetent Valve ther
yperdynamic
• Pregnancy
• Fever
• Anemia
Supravalvular Subvalvular Valvular
• Aortic Coarctation • ypertrophic bstructive

• Supravalvular Aortic Cardiomyopathy
Cardiovascular
Stenosis (rings webs) • Subvalvular Aortic Stenosis

(rings webs)
ulmonary
Aortic Stenosis
Stenosis
• ni /Bicuspid
S1 S2 • egenerative
(Tricuspid)
•Aortic Stenosis/ • Rheumatic eart
15 Pulmonary Stenosis isease
Systolic Murmur
Valvular & Other
Y TOL M RM R O
Systolic urmur
Benign low
Stenotic Incompetent Valve ther
yperdynamic
• Ventricular Septal efect
itral Regurgitation Tricuspid Regurgitation
apillary uscle ilation of Right

eaflet Annulus hordae Tendinae eaflet
ysfunction Ventricle Annulus
• Prolapse • Rupture • Ischemia • ilated • Prolapse
Cardiovascular
• ilated cardiomyopathy • Endocarditis • Infarct cardiomyopathy • Endocarditis
• Endocarditis • Rheumatic Fever • Rupture • MI • Rheumatic Fever
• ypertrophic • Trauma • Pulmonary • Ebstein s Anomaly
Cardiomyopathy ypertension • Carcinoid
• Rheumatic Fever
• Marfan s isease
S1 S2 S1 S S2
•Mitral Regurgitation/ Mitral Valve Prolapse ( S 16
Tricuspid Regurgitation opening snap) 15
Diastolic Murmur
A TOL M RM R
iastolic urmur
arly iastolic id-‐ iastolic ate iastolic
• Aortic Regurgitation • Mitral Stenosis • Mitral Stenosis

• Pulmonary Regurgitation • Tricuspid Stenosis • Tricuspid Stenosis
( raham Steell Murmur) • Severe Aortic • My oma
Regurgitation (Austin Flint
Cardiovascular
Murmur)
• Atrial My oma Prolapse
S1 S2 S1 S2 S S1
•Aortic Regurgitation/ Mitral Stenosis/Tricuspid Stenosis
Pulmonary Regurgitation
17 ( S opening snap)
Respiratory
Pulmonary Function Tests Interpretation .......21 Lung Nodule ....................................................................... 35
Acid-Base Disorder Pulmonary ............................ 22 Mediastinal Mass ..............................................................36
Chest Discomfort Cardiovascular ........................ 23 Pleural Effusion .................................................................. 37
Chest Discomfort Pulmonary ................................. 24 Pulmonary Hypertension ...........................................38
Chest Discomfort Other .............................................. 25
Chest Trauma Complications..................................26
Cough Chronic ................................................................... 27
Cough, Dyspnea & Fever ...........................................28
Dyspnea Acute................................................................... 29
Dyspnea Chronic Cardiac ..........................................30
Dyspnea Chronic Pulmonary / Other................31
Respiratory
Excessive Daytime Sleepiness .............................. 32

Hemoptysis .......................................................................... 33
Hypoxemia ............................................................................ 34
19
Calvin Loewen Amanda Comeau
Yan Yu Shaye Lafferty
Marc Chretien
Vanessa Millar Faculty Editor
Geoff Lampard Dr. Naushad Hirani
Shaina Lee Dr. Daniel Miller
Reena Pabari
Katrina Rodrigues
Eric Sy
Lian Szabo
Respiratory
Ying Wang
20
Pulmonary Function Tests
Interpretation
Respiratory
21
Acid-Base Disorder
Pulmonary
A BA OR R
Acid-‐Base isorder
p < p -‐ > p <

Acidemia Normal p Alkalemia
• Mi ed Acid Base isorder
Respiratory Acidosis etabolic Al alosis Respiratory Al alosis

etabolic Acidosis
ecrease EABV
See “Metabolic• Alkalosis”
on page 122 • ypokalemia
Elevated igh Anion Normal Anion ap hronic Acute hronic Acute

Anion Gap ap
See “Metabolic• Methanol See “Metabolic • iarrhea Hypovennlanon •C P Hypovennlanon • Asthma Hypervennlanon • Pregnancy Hypervennlanon• ypo ia
• remia Acidosis Normal
Acidosis Elevated • RTA present for • Interstitial isease
present for • Neuromuscular
present for • Psychogenic present for • Salicylates
Anion Gap” on • A Anion Gap” on • Interstitial N ephritis
hours to days minutes to hours• bstruction
hours to days • Sepsis
minutes to hours
page 120 • Paraldehyde
page 121 • Pulmonary
• Isonia id Embolism
Respiratory
• actic Acid
• Ethylene lycol * Denotes acutely life-‐threatening causes
• Salicylates Appropriate ompensation Ratio (C 2 C 3 )
Metabolic Acidosis 12 1
etabolic Acidosis i ed etabolic isorder Metabolic Alkalosis 1
Anion ap Normal Normal A Acidosis Alone Acute Respiratory Acidosis 1 1
Anion ap C 3 igh A Acidosis Alone Chronic Respiratory Acidosis 1 3
Anion ap C 3 Mi ed A Acidosis Normal A Acute Respiratory Alkalosis 1 2
Anion ap C 3 Mi ed igh A Acidosis Metabolic Alkalosis Chronic Respiratory Alkalosis 1
22
Chest Discomfort
Cardiovascular
Pulmonary
Respiratory
Aornc Dissecnon*
23 * Potentially acutely life-threatening

Chest Discomfort
Pulmonary
Pulmonary
Pleural Processes Processes that can

aﬀect the Pleura
• Pneumothorax (Tension*) • Pneumonia*
• Pleurins/Serosins • Pulmonary Embolism*
Respiratory
• Pleural E usion • Malignancy
• Malignant Mesothelioma • Sarcoidosis
• Acute Chest Syndrome
* Potentially acutely life-threatening 24

Chest Discomfort
Other
Respiratory
25
H T TRA MA
Chest Trauma Complications
hest Trauma
ardiac hest Wall ung
• Cardiac Tamponade • Rib Fractures • Pulmonary Contusion

• Pericarditis • Flail Chest • Pneumothora (Tension )
• Myocardial Contusion • iaphragm In ury • emothora
• Acute Aortic Rupture
Respiratory
Cough
Chronic
O H
ough
hronic ough ( > w s ) ough yspnea ever
Normal hest -‐Ray Abnormal hest -‐Ray
•C P
• Chronic Infection
(Eg. Fungal Tuberculosis)
bstructive isease • Neoplasm
Normal Spirometry
(FEV1/FVC ) •C F
• Interstitial isease
• Asthma • Foreign Body
•C P
Respiratory
pper Airway ower Airway ther
• Post Nasal rip / • Asthma • ACE Inhibitor

Rhinosinusitis • ER
• Neuromusclar • Post Infectious
Swallowing isorder • Smoker s Cough
• Thyroiditis • Non Asthmatic
• Mediastinal Mass Eosinophilic Bronchitis
27 • Elongated vula • Foreign Body
Cough, Dyspnea & Fever
O H * Denotes acutely life-‐threatening causes
ough
hronic ough ( > w s ) ough yspnea ever
Normal R Abnormal R
• Acute Bronchitis
• AEC P
neumonia in the neumonia in the New hanged

Non-‐Infectious Immunocompetent Immunocompromised urmur
ost ost
• Pulmonary Embolism
• Cryptogenic rgani ing • Bacterial (often non pathogenic
Pneumonia with immune competence)
Respiratory
• Wegener s ranulomatosis • Fungal (e.g. neu ocystic iro ecii)
• Viral
ommunity-‐ eripheral Stigmata

ospital-‐Ac uired Tuberculosis Intravenous rug
Ac uired of Subacute
ser
ndocarditis
• Aerobic ram
*Negative
Potentially
• neu oniae
Bacilli acutely life-threatening
• influen ae
28
• eft Sided • Right Sided
• ram Positive Cocci • Viral (Eg. Influen a) Endocarditis Endocarditis with
Dyspnea
Acute
Respiratory
29
Dyspnea Chronic
Cardiac
Respiratory
Dyspnea Chronic
Pulmonary / Other
Respiratory
31
Excessive Daytime Sleepiness
Diﬀeren ate Fa gue from Sleepiness
Respiratory
Obesity Hypovennlanon
Syndrome
32
Hemoptysis
Hematemesis
Epistaxis
Bronchins Pulmonary Vasculins
Respiratory
Pulmonary Vasculi s
Granulomatosis with polyangiins

33 /microscopic polyangiins
Hypoxemia
Normal < (Age/4) + 4
Normal < (Age/4) + 4
Pulmonary
Arterial
Hypertension
Obesity Hypovennlanon
Syndrome
Respiratory
Neuromascular Weakness
Pleural Abnormalines
Obesity Hypovennlanon Chest Wall Abnormalines
Syndrome
**
Neuromascular Weakness
Pleural Abnormalines Severe Pneumonia
Chest Wall Abnormalines Atelectasis
34
Lung Nodule
Respiratory
Metastases Granulomatosis with

polyangiins (GPA)/microscopic
polyangiins (MPA)

A T NAL MA
Mediastinal Mass
ediastinal ass
Anterior iddle osterior
• Thyroid • Aneurysm • Neurogenic Tumour

• Thymoma • ymphadenopathy • Esophageal esion
• Teratoma • Cystic (Bronchial Pericardial • iaphragmatic ernia
• Terrible ymphoma Esophageal)
Respiratory
36
Pleural Effusion
Thoracic Ultrasound should be used to

perform Diagnos c Thoracentesis
Use Light’s Criteria
Increased Hydrosta c Decreased Onco c

Pressure Pressure
Congesnve Heart Cirrhosis

Failure Nephronc Syndrome
Renal Failure with
Hypervolemia
Respiratory
(Early) Pulmonary
Embolus
SerumLDH
Serum LDHUpper
Upper Limit
Limit of
of Normal
Normal
Pulmonary Hypertension
Associated with:
- Connecnve Tissue Disease Sleep-Disordered Breathing
- Portal Hypertension
- Congenital Heart Disease
- HIV
Miscellaneous
Hematologic Disorders
Metabolic Disorders
Respiratory
38
Hematologic
Overall Approach to Anemia ....................................41 Prolonged PTT, Normal PT (INR) No Bleeding
Approach to Anemia Mean Corpuscular Tendency ..........................................................................51
Volume .............................................................................. 42 Approach to Splenomegaly..................................... 52
Anemia with Elevated MCV...................................... 43 Fever in the Immunocompromised Host....... 53
Anemia with Normal MCV ......................................... 44 Lymphadenopathy Diffuse........................................ 54
Anemia with Low MCV................................................. 45 Lymphadenopathy Localized ................................. 55
Approach to Bleeding / Bruising Platelets & Neutrophilia..........................................................................56
Vascular System.........................................................46 Neutropenia Decreased Neutrophils Only ... 57
Approach to Bleeding / Bruising Coagulation Neutropenia Bicytopenia / Pancytopenia ....58
Proteins ............................................................................. 47 Polycythemia ......................................................................59
Approach to Prolonged PT (INR), Prolonged Suspected Deep Vein Thrombosis (DVT) ......60
Hematologic
PTT .......................................................................................48 Suspected Pulmonary Embolism (PE) ..............61

Prolonged PT (INR), Normal PTT..........................49 Thrombocytopenia .........................................................62
Prolonged PTT, Normal PT (INR) Bleeding Thrombocytosis ................................................................63
Tendency .........................................................................50 Hemolysis ..............................................................................64
39
Historical Editors Lian Szabo
Soreya Dhanji Evan Woldrum
Jen Corrigan Ying Wang
Jennifer Mikhayel
Yang (Steven) Liu Student Editors
Megan Barber Andrea Letourneau
Lorie Kwong Victoria David
Khaled Ahmed
Aravind Ganesh Faculty Editor
Jesse Heyland Dr. Lynn Savoie
Tyrone Harrison
Hematologic
Nancy Nixon
Nahbeel Premji
Connal Robertson-More
40
Overall Approach to Anemia
Hematologic
41
Approach to Anemia
Mean Corpuscular Volume
Hematologic
42
Anemia with Elevated MCV
Hematologic
43
Anemia with Normal MCV
Hematologic
44
Anemia with Low MCV
Hematologic
45
Approach to Bleeding / Bruising
Platelets & Vascular System
Hematologic
46
Approach to Bleeding / Bruising
ACoagulation
R A Proteins
T B IN BR ISIN oagulation roteins
Bleeding Bruising
latelets Vascular System oagulation roteins
ongenital Ac uired
• Factor VIII eficiency • Anticoagulation (Iatrogenic)

• Factor I eficiency • iver isease
• Von Willebrand s isease • Vitamin eficiency
Hematologic
• ther deficiencies • isseminated Intravascular

Coagulation
47
Approach to Prolonged PT (INR), Prolonged PTT
Hematologic
48
Prolonged PT (INR), Normal PTT
R N T (INR) N R A TT
Normal TT ong T
Sufficient Vitamin Insufficient Vitamin

• Congenital Clotting Factor
eficiency E trinsic Factor
(Factor VII eficiency)
Vitamin eficiency Vitamin Antagonist

• Coumadin (Warfarin) use
Hematologic
hild Adult Newborn

• Antibiotics and Poor Nutrition • emorrhagic isease of the
• Fat Malabsorption Newborn
49
Prolonged PTT, Normal PT (INR)
Bleeding Tendency
Hematologic
50
Prolonged PTT, Normal PT (INR)
No Bleeding Tendency
Hematologic
51
Approach to Splenomegaly
Hematologic
52
Fever in the Immunocompromised Host
Hematologic
53
Lymphadenopathy
Diffuse
A N AT iffuse
iffuse ymphadenopathy
Reactive Neoplastic
onoclonal Reed-‐
Systemic
Infectious ther eu emia ymphocytes Sternberg ells
Inflammatory
on Biopsy on Biopsy
• Systemic upus •EBV • Acne • Non odgkin s • odgkin s

Erythematosus •CMV • Allergy ymphoma ymphoma
• Sarcoidosis • IV • Insect Bites
Hematologic
• Rheumatoid •Tuberculosis • oung age
Arthritis • epatitis
• Pseudotumor istory of
Asymptomatic
Bleeding Infection
Age > 0
atigue
• Acute ymphoblastic • Chronic ymphocytic
eukemia eukemia (CBC with
(Pancytopenia WBC ymphocytes)
differential includes
Blasts) 54
Lymphadenopathy
Localized
Hematologic
55
Neutrophilia
Hematologic
56
Neutropenia
Decreased Neutrophils Only
Hematologic
57
Neutropenia
Bicytopenia / Pancytopenia
N TR NIA Bicytopenia ancytopenia
Neutropenia
Bicytopenia ancytopenia
Isolated Neutrophil ecrease (Neutrophils and ther ell ines
ecreased)
ecreased roduction Se uestration
• Splenomegaly
Hematologic
arrow Infiltration Stem cell damage or suppression Nutritional deficiency
• ematologic and non hematologic • Chemotherapy • B12/folate/combined deficiencies

malignancies • Radiation
• Infection • rugs
• Primary Myelofibrosis • To ins
• Aplastic Anemia
• Myelodysplasia
58
Polycythemia
Hematologic
59
Suspected Deep Vein Thrombosis (DVT)
Hematologic
60
Suspected Pulmonary Embolism (PE)
S S T NAR B IS ( )
Suspected
alculate linical robability

Score
ow oints igh > oints
Negative ositive T-‐ A or

-‐ imer -‐ imer ompression S
ST
Well s riteria for Negative Non-‐ ositive

Clinical Signs and Symptoms of VT (3. )
T-‐ iagnostic T-‐ A
(leg swelling and pain with palpation of the deep veins) TR AT
Alternative diagnosis less likely than PE (3. ) ow linical igh linical
ompression S
Suspicion Suspicion
eart rate 1 bpm (1. ) ST
Immobili ation or surgery in last weeks (1. ) ositive Negative
Hematologic
Previous VT or PE (1. ) TR AT • Repeat /S in 1

Week
emoptysis (1. )
Malignancy (ongoing or previous months) (1. )
ells et al Deri ation of a si le clinical o el to categori e atients ro a ility of ul onary e olis increasing the o els utility ith the i li D D-‐ i er hro ae ost -‐
riting rou for the hristo her tu y n estigators ffecti eness of anaging sus ecte ul onary e olis using an algorith co ining clinical ro a ility D-‐Di er testing an co uter to ogra hy
61 -‐
Thrombocytopenia
Hematologic
62
Thrombocytosis
T R B T SIS
Thrombocytosis
Reactive Spurious Autonomous
• Artifact (redo CBC) • Essential thrombocytosis

• Polycythemia Vera
• Chronic Myelogenous eukemia
• Primary Myelofibrosis
Non malignant
Infectious Inflammatory Tissue amage hematologic ther
Hematologic
conditions
• Acute or Chronic • IB • Post op surgery • Rebound effect • Post splenectomy or
• Rheumatic • Trauma following hyposplenic states
disorders • Burns treatment of ITP • Non hematologic
• Celiac disease • Rebound effect malignancy
following ET • Iron deficiency
induced anemia
63 thrombocytopenia
Hemolysis
Hemolysis
Hemolysis
Extravascular Intravascular
Spleen and RES-‐ Hemolysis within
mediated hemolysis circulation
Extrinsic to Intrinsic to Complement-‐ Mechanical

Infections
RBC RBC Mediated Shearing
• Malaria • Cold AIHA • MAHA (TTP, DIC,
• Babesiosis • PCH HUS)
Immune-‐ • C. perfringens • PNH • Prosthetic heart
Mediated • Drug-‐induced valves
Hematologic
immune-‐complex • Atriovenous
• Warm AIHA hemolytic anemia malformations
• Cold AIHA • Acute HTR
• Alloimmune
delayed HTR Abnormal Hgb & Membrane RBC Enzyme
• Drug-‐induced Hgb Defects Defects Defects
AIHA • G6PD deficiency
• Thalassemia • Hereditary
• Sickle cell spherocytosis • PK deficiency
• Unstable Hgb • Hereditary
elliptocytosis 64
Gastrointestinal
Abdominal Distention ...................................................69 Chronic Diarrhea Steatorrhea & Large Bowel
Abdominal Distention Ascites ................................70 ..................................................................................................81
Abdominal Distention Other Causes ..................71 Constipation (Adult) Altered Bowel Function
Abdominal Mass ............................................................... 72 & Idiopathic ....................................................................82
Abdominal Pain (Adult) Acute - Diffuse........... 73 Constipation (Adult) Secondary Causes .........83
Abdominal Pain (Adult) Acute - Localized .....74 Constipation (Pediatric) ..............................................84
Abdominal Pain (Adult) Chronic - Constant . 75 Dysphagia ..............................................................................85
Abdominal Pain (Adult) Chronic - Crampy / Elevated Liver Enzymes .............................................86
Fleeting .............................................................................76 Hepatomegaly ...................................................................87
Abdominal Pain (Adult) Chronic - Post- Jaundice..................................................................................88
Gastrointestinal
Prandial ............................................................................. 77 Liver Mass ..............................................................................89

Anorectal Pain ....................................................................78 Mouth Disorders (Adult & Elderly) .....................90
Acute Diarrhea ...................................................................79 Nausea & Vomiting Gastrointestinal Disease
Chronic Diarrhea Small Bowel ...............................80 ..................................................................................................91
65
Nausea & Vomiting Other Systemic
Disease ...................................................................92
Stool Incontinence ...............................................93
Upper Gastronintestinal Bleed
(Hematemesis / Melena) .........................94
Lower Gastrointestinal Bleed.......................95
Weight Gain ...............................................................96
Weight Loss .............................................................. 97
Gastrointestinal
66
Historical Editors Shabaz Syed
Dr. Chris Andrews Ying Wang
Khaled Ahmed
Jennifer Amyotte Student Editors
Stacy Cormack Scott Assen
Beata Komierowski Jonathan Seto
James Lee Jacob Charette
Shaina Lee
Matt Linton Faculty Editor
Michael Prystajecky Dr. Sylvain Coderre
Gastrointestinal
Daniel Shafran Dr. Kelly Burak

Robbie Sidhu
Mia Steiner
67
68
Gastrointestinal
Abdominal Distention
Gastrointestinal
69
Ascites
AB INA IST NTI N Ascites
Abdominal istention
Ascites Bowel ilatation ther auses
igh Albumin radient (SAA ) ow Albumin radient (SAA )

11 g / serum fluid albumin 11 g / serum albumin gradient
Gastrointestinal
ortal ypertension ardiac eritoneal ther auses
• Cirrhosis • Congestive eart Failure • Carcinomatosis • Pancreatitis

• Alcoholic epatitis • Constrictive Pericarditis • Infection (Neutrophils • Serositis
• Portal vein thrombus 2 /cc) • Nephrotic Syndrome
• Budd Chiari Syndrome
Clinical pearl rule of SAA accurate. If high SAA of time it is cirrhosis/portal
hypertension. If low SAA time carcinomatosis (and cytology sensitive)
Serum Ascites Albumin radient (SAA ) Serum albumin Peritoneal fluid albumin 70
AB Causes
Other INA IST NTI N ther auses
Abdominal istention
Ascites Bowel ilatation ther auses
elvic ass eces latus rganomegaly

• Pregnancy • Constipation • epatomegaly
• Fibroids • Irritable Bowel Syndrome • Splenomegaly
• varian Mass • Carbohydrate Malabsorption • ydronephrosis
Gastrointestinal
• Bladder Mass • iet ( actose Intolerance) • Renal Cysts

• Malignancy • Chronic bstruction • Aortic Aneurysm
• besity
6 Fs of Abdominal Distention

• lui
• eces
• latus
• etus
• i roi s an enign asses
71 • atal tu our
Abdominal Mass
AB INA ASS
Abdominal ass
clude pregnancy hernia abdominal wall mass
rganomegaly Neoplastic ther auses
• iver • astrointestinal Tumours (e.g. Colonic

• Spleen astric Pancreatic)
• idneys (e.g. Cysts Cystic Renal Cell • ynecologic Tumors (e.g. varian
Carcinoma ydronephrosis) terine)
• ymphoma/Sarcoma
Gastrointestinal
eces ulsatile seudoneoplastic
• Vascular (Abdominal Aortic • Pancreatic Pseudocyst

Aneurysm)
72
Abdominal Pain (Adult)
Acute - Diffuse
AB INA AIN (A T) Acute -‐ iffuse
Acute Abdominal ain
(< 2 hours)
oo or Surgical Abdomen
pper Quadrant R/ Cardiac Pulmonary Renal Musculoskeletal Causes
ower Quadrant R/ enitourinary Causes
iffuse ocali ed
eritonitic Non-‐ eritonitic

Gastrointestinal
• Pancreatitis • astroenteritis
• Bowel bstruction • Irritable Bowel Syndrome
• Viscus Perforation • Constipation
• Intraperitoneal emorrhage • Metabolic isease (e.g. iabetic
(ruptured AAA) etoacidosis)
• Mesenteric Ischemia
• Mesenteric Thrombus
• Sickle Cell Anemia
• Musculoskeletal
73 • Trauma
• Peptic lcer isease
Acute - Localized
Gastrointestinal
74
AB INA AIN (A
Chronic - Constant
T) hronic -‐ onstant
hronic Abdominal ain
Recurrent abdominal pain Consider tumor

pper Quadrant pigastric Consider cardiac causes
ower uadrant Consider genitourinary causes
onstant ramping leeting ost-‐ randial
pper Quadrant ower Quadrant Any ocation iffuse

Gastrointestinal
• astroesophageal Reflu isease • Crohn s isease • Ascites

• Peptic lcer isease • ynecologic (e.g. Tumor Endometriosis) • Muscle Wall
•Chronic Pancreatitis • Neuropathic pain
• Pancreatic Tumor • Somati ation
• astric Cancer
• iver istention (e.g. epatomegaly
Tumor Fat)
• Splenic (e.g. Abscess Splenomegaly)
very rare
75
AB INA AIN (A T) hronic rampy leeting
Chronic - Crampy / Fleeting

Gastrointestinal
• Biliary Colic/Cholelithiasis • Bloating (e.g. Celiac isease actose • Bowel bstruction (e.g. Adhesions
• Choledocholithiasis Intolerance) Crohn s Volvulus Neoplasm ernia)
• Sphincter of ddi ysfunction • Renal colic • Irritable Bowel Syndrome
• Renal Colic • Irritable Bowel Syndrome
76
AB INA AIN (A T) hronic ost-‐ randial
Chronic - Post-Prandial


Gastrointestinal
• Biliary Colic/Cholelithiasis • bstructing Colon Cancer • Bowel bstruction (e.g. Adhesions

• astroesophageal Reflu isease Crohn s Volvulus Neoplasm ernia)
• Peptic lcer isease/ yspepsia • Mesenteric Angina
• astric Cancer
• Chronic Pancreatitis
• bstructing Colon Cancer
77
Anorectal Pain
AN R TA AIN
Anorectal ain
clude Poor ygiene ietary

Anal Trauma
Internal esion iagnosis of clusion ternal esion
• Proctalgia
Gastrointestinal
roctitis ther ermatologic Anorectal isease
• Inflammation • Malignancy • ermatitis • Fissure

• Infection (Including Se ually • Solitary Rectal lcer • Psoriasis • Fistula/Abscess (Crohn s)
Transmitted) • emorrhoid
78
Acute Diarrhea
A T IARR A
Acute iarrhea
> 2-‐ loose stools day >1 -‐2 g day >

hours <1 days
Infectious Ischemic Inflammatory ietary
Nausea Vomiting
iarrhea redominant Non-‐Bloody Bloody
redominant
• acillus cereus • Crohn s Ileitis • lcerative Colitis
• ta hylococcus aureus • Crohn s Colitis • Crohn s Colitis
Gastrointestinal
Bloody ain Small

Watery arge Volume C. difficile is under large bowel but presents
Volume rgency with non bloody diarrhea usually.
(Small Bowel)
( arge Bowel)
• Viral • Bacterial (e.g. coli Ischemic colitis is a self limiting illness in most (due
• Bacterial (e.g. erfringens ifficile al onella to vascular network from SMA IMA iliacs) whereas
cholerae coli al onella a ylo acter higella) small bowel ischemia is an abdominal catastrophe
ersinia • Parasitic (e.g. histolytica) (only one supply SMA).
• Parasitic (e.g. iar ia)
• rugs (Antibiotics a atives
Antacids)
79 • To ins
Chronic Diarrhea
Small Bowel
R NI IARR A Small Bowel
hronic iarrhea
> oose Stools ay > 1 days

clude hronic Inflammation
arge Bowel
Steatorrhea Small Bowel
Small Volume/Bloody/Painful/
ily/Foul/ ard to Flush arge Volume/Watery
Tenesmus/ rgency
Secretory isordered otility smotic

• Irritable Bowel Syndrome (diagnosis of • Magnesium Phosphate Sulfate
e clusion)
• Carbohydrate Malabsorption
• iabetic Neuropathy
• actose Intolerance
• yperthyroidism
Gastrointestinal
ucosal Tumors
• Crohn s isease (Screen with CBC

albumin ESR endoscopy)
• Celiac isease (screen with TT )
• Chronic Inflammation ucosal Neoplastic
• Whipple s isease
• astrinoma • Adenocarcinoma
• Carcinoid Syndrome • ymphoma
• Mastocystosis
80
Chronic Diarrhea
Steatorrhea & Large Bowel
R NI IARR A Steatorrhea arge Bowel
hronic iarrhea
> oose Stools ay > 1 days

clude hronic Inflammation
arge Bowel
Steatorrhea Small Bowel
Small Volume/Bloody/Painful/
ily/Foul/ ard to Flush arge Volume/Watery
Tenesmus/ rgency
aldigestive alabsorptive otility Inflammatory Secretory
• Pancreatic • Irritable Bowel Syndrome • Inflammatory Bowel • Villous Adenoma

Gastrointestinal
Insufficiency • yperthyroid isease • Colon Cancer

• Radiation Colitis • Microscopic Colitis
• Ischemic Colitis
rimary Secondary
alabsorption alabsorption
• Celiac isease • Bacterial vergrowth
• Mucosal isease • iver Cholestasis
• Ileal Crohn s isease • Mesenteric Ischemia
81 • Short Bowel/ Resection
Constipation (Adult)
Altered Bowel Function & Idiopathic
NSTI ATI N (A T) Altered Bowel unction Idiopathic
onstipation
Infre uency (< bowel movements wee )

Sensation of Bloc age or incomplete evacuation Straining
Altered Bowel unction Severe Idiopathic Secondary auses
iet ifestyle edications olonic Inertia utlet elay Irritable Bowel

• Neurally Active
Gastrointestinal
• Fibre • Pelvic Floor
• Calories Medications (e.g. yssyngergia
• Fluid piates Anti
• E ercise ypertensives)
• Psychosocial • Cation Related (e.g.
Iron Aluminum
Calcium Potassium)
• Anticholinergic (e.g.
Antispasmodics
Antidepressants
Antipsychotics)
82
Constipation (Adult)
Secondary Causes
NSTI ATI N (A T) Secondary auses
onstipation
Infre uency (< bowel movements wee )

Sensation of Bloc age or incomplete evacuation Straining
Altered Bowel unction Severe Idiopathic Secondary auses
Neurogenic Non-‐Neurogenic
Gastrointestinal
eripheral entral etabolic olorectal isease
• irschsprung s isease • Multiple Sclerosis • ypothyroidism • Colon Cancer

• Autonomic Neuropathy • Parkinson s isease • ypokalemia • Colonic Stricture
• Pseudo obstruction • Spinal Cord/Sacral/Cauda • ypercalcemia (Inflammatory Bowel isease
E uina In ury and iverticular isease)
83
Constipation (Pediatric)
NSTI ATI N ( IATRI )
onstipation
Infre uent Bowel ovements ard Small

stools ainful evacuation ncopresis
Neonate Infant lder hild
Gastrointestinal
ietary unctional Neurologic ietary unctional Anatomic Neurologic
• Insufficient Volume/ • irschsprung s isease • Insufficient Bulk/Fluid • Bowel bstruction • irschsprung s isease
Bulk • Imperforate Anus • Withholding • Pseudo obstruction • Spinal Cord esions
• Anal Atresia • Painful (e.g. Fissures) • Myotonia Congenita
• Intestinal Stenosis • uillain Barr Syndrome
• Intestinal Atresia
84
Dysphagia
S A IA
ysphagia
If heartburn present Consider ER
ropharyngeal ysphagia
sophageal ysphagia
Immediate ifficulty
elayed ifficulty
ifficulty initiating swallowing
Food sticks seconds later/ Further down
Choking Nasal Regurgitation
otor isorder echanical

Neuromuscular To i
Structural unctional Solids and/or bstruction
c etabolic
i uids Solids only
• Tumors • Myasthenia ravis
• enker s iverticulum • CNS Tumors
• Foreign Body • Cerebrovascular
Accident
Gastrointestinal
• Multiple Sclerosis
• Amyotrophic ateral
Sclerosis
• Polymyositis
Intermittent rogressive Intermittent rogressive

Symptoms Symptoms Symptoms Symptoms
• Esophageal Spasm • Scleroderma • Schat ki Ring • Reflu Stricture
• Achalasia • Esophageal Web • Esophageal Cancer
85 • iabetic Neuropathy • Eosinophilic Esophagitis
Elevated Liver Enzymes
VAT IV R N S
VAT IV R N S
VAT
VAT IV R NN SS
levated iver n ymes
VAT
VAT IVIV R
IV R
R N
N SS
levated iver n ymes
levated iver n ymes
epatocellular levated
levated iver
levated iver nnnymes
iver ymes
ymes
holestatic (does not always cause
A epatocellular
T or AST A P aundice)
holestatic (does Anot P a A T or cAause
lways ST
A epatocellular
T or AST A P aundice)
holestatic (does A P
not Aalways
T or AcST ause
Severe A T epatocellular
oepatocellular
epatocellular
r AST A P ild
holestatic
holestatic
holestatic
aundice) (does
(A (does
S does
P n not
Normal not
A aalways
ot
T oalways
lways
Br ASTccause
ile cause
ause S ilated Bile
oooderate
AAAT T T
r or Ar AST
ST A A
AST APPP aundice)
aundice)
aundice) AAAP P P A AT T T
oor or Ar AST
A T >Severe
1 N A T oderate 1 N A T <ild N S Normal ucts BAile AST
ST
S ilated ucts Bile
A T Severe
> 1 N A T 1 N A T < ild N • PBC
S ucts Bile
Normal S uctsBB
ilated ile uct
• Viral
Severe • Viral oderate • NA
ild S Normal B ile
• Common
S ilated
ile
BBile
•• A T > Severe
rugs/To 1Severe ins N T oderate
Arugs 1oderate
oderate N AAlcohol
• •NA T < N ildild • PSCS
• PBC uctsS Normal
Normal B Bile
ile S
S
Stoneucts ilated
ilated Bile
ile
Viral
AAAT T T
>> >1 1 1 NNN •• Viral
AAAT T T 111 NNN AAT
A <
T
T
<
< NN
N • • Alcoholic
PSC ucts
ucts
ucts hepatitis • Common Bile uct
ucts
ucts
ucts
Ischemia
• • rugs/To ins • AI Viral
• •Alcohol • PBC • Biliary stricture
• Viral • •Viralrugs • NA rugs hepatitis • Stone
Common Bile uct
• •• •Autoimmune emochromatosis
••Viral
NA • ••PSC••PBC
PBC
•Alcoholic
PBC • PSCstricture
Common BBile
Viral
• •Ischemia Viral
Viral ins
rugs/To • Wilson
Viral s
Viral
• •• •AI
•Viral • ••Alcohol
•NANA TPN hepatitis •• •Biliary
Stone •Common
Common ile uct
Bile uct
uct
•• •• •Wilson s ins rugs rugs
••Alcohol
emochromatosis ••PSC
•PSCrugs
• ••Alcoholic
PSC Stone • Worms/flukes
rugs/To
•Autoimmune
Ischemiarugs/To
rugs/To ins
ins • • emochromatosis
rugs
• ••AI•Wilson
rugss
rugs • ••Viral
•Alcohol
Alcohol Sepsis hhepatitis • PSC
Stone
Stone
• Biliary stricture
•• •• •Pregnancy • AI ••Alcoholic
Alcoholic
• •• •TPN Alcoholic
rugs hepatitis
epatitis • Cholangiocarcinoma
Ischemia
•Wilson
Ischemia
Ischemia
Autoimmune s •NAF
AI
emochromatosis
• ••Wilson
•AI
AI s • •• •Viral
rugs
•Viral
Viral
emochromatosis • Infiltrative • Biliary
•Worms/flukes
••PSC stricture
•Biliary
Biliary sstricture
tricture
• AF P • • A1AT
AI deficiency
emochromatosis • ••TPN• rugs
•Sepsisrugs
rugs PSC• Pancreatic cancer
•• • • Autoimmune
Pregnancy
• Wilson s Autoimmune
Autoimmune thers
Wilson
• •• •NAF
•Wilson
Wilsons ss •
• rugs•• emochromatosis
emochromatosis • ••Worms/flukes
•Cholangiocarcinoma
•PSC
PSC
emochromatosis TPN
• ••SepsisTPN • Sarcoid
•Infiltrative
•TPN
E PPs ss
••Wilson
•Wilson
• • •PregnancyAF
Wilson emochromatosis • ••AI •Wilson
•A1AT
rugs
rugs
rugs s
deficiency • thers cancer
Worms/flukes
• ••Cholangiocarcinoma
•Pancreatic
•Worms/flukes
Worms/flukes
• ••NAF
••thers
emochromatosis
emochromatosis •Sepsis
• •Infiltrative
•Sepsis • Sarcoid
Sepsis • Amyloid
• ••Pregnancy EP P
• •Pregnancy
Pregnancy •• • AI
•AI
• A1AT thers
Wilson s
AI deficiency •• Cholangiocarcinoma
thers
••Cholangiocarcinoma
Cholangiocarcinoma
• Pancreatic cancer
AF • • •NAF
•NAF
NAF
thers • •Infiltrative
• •Sarcoid
•Infiltrative
Infiltrative • Malignancy
Amyloid
• • •AF
•EAF PPP
AFP • •• thers
thers
thers •A1AT
thers
• ••Wilson dsdeficiency
•Cholestatic
A1AT
A1AT disease
deficiency
eficiency • • •Pancreatic
•Pancreatic
Pancreatic
thers cancer
ccancer
ancer
Gastrointestinal
Sarcoid
•Malignancy
• ••Amyloid Infection
••Sarcoid
Sarcoid
• •• EEE PPP Wilson
•Wilson
Wilson
thers s ss disease
• •• •Cholestatic • •• thers
thers
thers
•• Amyloid
Infection
• Cirrhosis
••Amyloid
• Malignancy Amyloid (any)
•• thers
• •Cholestatic
thers
thers disease
• •Cholestatic ddisease • Cirrhosis •Malignancy
• •Infection
•Congenital (any)
•Malignancy
Malignancy
•Cholestatic
Cholestatic disease
isease
• •Congenital • •Infection
Cirrhosis •Infection
Infection
any) Atresia
(•Biliary
• •Cirrhosis
Cirrhosis
•Congenital (any)
•Biliary
•Cirrhosis Atresia
((any)
any)
•Alagille Syndrome
•Congenital
•Congenital
•Congenital •Alagille
•Biliary Syndrome
Atresia
•Progressive Familial
•Biliary
•Progressive
•Alagille •Biliary
•Biliary A tresia
AA Familial
tresia
tresia
Syndrome
Intracholestasis
•Alagille
•Alagille
•Alagille Syndrome
Intracholestasis
Syndrome
Syndrome
A if T hepatitis NA •Progressive Familial
by biopsy R for d
A if T hepatitis NA y biopsy Familial
•Progressive
•Progressive
b•Progressive
Intracholestasis FFamilial
amilial R for d
INR and hepatic usually cholestatic 10 population RI R
Intracholestasis
Intracholestasis and therapy
INR a And h
encephalopathy
ifepatic usually
T hcepatitis
and
holestatic
u epatitis
sually 10 NA population RI
by bIntracholestasis
R
iopsy and
R t herapy
for d
A A
A i fi fif Tand
TT c holestatic
uh h hepatitis
epatitis RI
b b
y bbiopsy RRRtherapy
f or ddd
encephalopathy
INR and
INR a nd
hepatic
hhepatic
usually
A T
sually
<cholestatic
00 10 pNA NA NA
opulation by y bRiopsy
iopsy and f for
or
INR
INR a a nd
nd hepatic
epatic usually
usually c
usually <cholestatic
holestatic RIRI RI RRR and therapy
encephalopathy
encephalopathy
encephalopathy
encephalopathy
A T
and usually
and
and u
and u
A T < 00sually
u
00
sually
sually
10
10 p p
10 opulation
population
opulation and
and
ttherapy herapy
86
AAAT T T
<< < 00
00
00
Hepatomegaly
AT A
epatomegaly
Rule out concurrent splenomegaly and aundice
Infiltrative ongestive Infectious Inflammatory
• Right eart Failure • epatitis A B C • Alcoholic epatitis

• Budd Chiari Syndrome • Mononucleosis • Autoimmune epatitis
• Constrictive Pericarditis • Tuberculosis • rug Induced epatitis
• Bacterial Cholangitis • Sarcoidosis
• Abscess • istiocytosis
Gastrointestinal
• Schistosomiasis • Primary Sclerosing

Cholangitis
• Primary Biliary Cirrhosis
alignant Non-‐ alignant
• Primary Carcinoma • Fatty iver

• Metastases • Cysts
• ymphoma • emochromatosis
• eukemia • Wilson s isease
• Polycythemia • Amyloidosis
87 • Multiple Myeloma • Myelofibrosis
Jaundice
A N I
aundice
ost-‐ epatic
re-‐ epatic epatic
sually has uct ilatation on
ncon ugated yperbilirubinemia Con ugated yperbilirubinemia
ltrasound
• epatocellular
• Cholestatic
• ubin Johnson
See le ate i er n y es scheme
Gastrointestinal
Increased ecreased epatic ecreased Biliary uct Intraductal
roduction pta e on ugation ompression bstruction
• emolysis • Sepsis • ilbert s Syndrome • Malignancy • allstones
• Ineffective • rugs (e.g. Rifampin) • Crigler Na ar • Metastases • Biliary Stricture
Erythropoiesis Syndromes (I and II) • Pancreatitis • Cholangiocarcinoma
• ematoma • Primary Sclerosing
Cholangitis
88
Liver Mass
IV R ASS
iver ass
ystic Solid
Benign alignant Benign alignant
• Cystadenocarcinoma
Simple omple
•Cyst
•Polycystic iver
Gastrointestinal
isease
•Caroli s
rimary Secondary
roliferative Infectious roliferative Infectious
alignancy alignancy
•Cystadenoma • ydatid Cyst • emangioma • Abscess • epatocellular • Metastases
• Focal Nodular Carcinoma (e.g. ung Colon
yperplasia • Cholangiocarcinoma Breast)
89 • Adenoma
Mouth Disorders (Adult & Elderly)
T IS R RS Adult and lderly

outh isorders
onsider oral manifestations of systemic disease
Teeth ucous embrane

• ER ( issolves enamel)
• S gren s Syndrome ( ental Caries)
lcerating Non-‐ lcerating
astrointestinal ther ighter (White) ar er (Red) No olour hange
• Crohn s isease • Canker Sore • ingivitis
Gastrointestinal
• Chronic iver isease
• lcerative Colitis • Cold Sore • awasaki isease
• S gren s Syndrome
• NSAI s • Anemia (Strawberry Tongue)
• Acromegaly
• angerhan s Cell • ther um isease
• Amyloidosis
istiocytosis • Mucocele
• Psoriasis
• Wegener s isease • Allergic Reaction
• ingival yperplasia
• Sarcoidosis
• ry Mouth
• rug Induced
• Se ually Transmitted Non-‐Neoplastic Neoplastic
Infection
• Candidiasis • eukoplakia
• ichen Planus • S uamous Cell Carcinoma
• Anemia 90
Nausea & Vomiting
NA S A AN Disease
Gastrointestinal V ITIN astrointestinal isease
Nausea and Vomiting
astrointestinal isease ther Systemic isease
pper astrointestinal epatobiliary ower astrointestinal
• Acute epatitis
• Acute Cholecystitis
• Cholelithiasis
• Choledocholithiasis
• Acute Pancreatitis
Gastrointestinal
Acute hronic Acute hronic
• Infectious astroenteritis • astroesophageal Reflu • Infectious astroenteritis

• Inflammatory Bowel isease
• astric/ uodenal isease • Small/ arge Bowel
• Colonic Neoplasm
bstruction • Peptic lcer isease bstruction
• astric Volvulus • astroparesis • Acute Appendicitis
• Mesenteric Ischemia
91 • Acute iverticulitis
Nausea & Vomiting
NA S A AN V ITIN ther Systemic isease Other Systemic Disease
Nausea and Vomiting
astrointestinal isease ther Systemic isease
ndocrine etabolic ther rugs To ins entral Nervous System
• Pregnancy • Chemotherapy
• Sepsis (e.g. Pyelonephritis
• iabetes/ A • Antibiotics
Pneumonia)
• remia • Ethanol
• Radiation Sickness
• ypercalcemia • Carbon Mono ide
• Acute Myocardial Infarction
• Addison s isease • eavy Metal
Gastrointestinal
• Thyroid isease • Nicotine
Vestibular
igh Intracranial ressure sychiatric
(Inner Ear)
• emorrhage • Ear Infection • Self Induced (Bulimia)
• Meningitis • Motion Sickness • Cyclic Vomiting
• Infarction • Vestibular Migraine • Psychogenic
• Malignancy • M ni re s isease
• ead Trauma 92
Stool Incontinence
ST IN NTIN N
Stool Incontinence
Intact elvic loor Affected elvic loor
ongenital Anorectal
Trauma Surgery Nerve Sphincter amage
alformation
• Surgery Anorectal Prostate • Vaginal elivery
Bowel • Rectal Prolapse
• Pelvic Fracture • Severe emorrhoid
• Pelvic Inflammation
Gastrointestinal
Stress and motional

hronic onstipation Neurological onditions iarrheal onditions
roblems
• Stool Impaction with • Age Related (e.g. ementia • Inflammatory Bowel isease
overflow Strokes) • Irritable Bowel Syndrome
• Encopresis • Neuropathy (e.g. iabetes • Chronic a ative se
Congenital Megacolon
irschsprung s isease)
• Tumors/Trauma (e.g. Brain
93 Spinal Cord Cauda E uina)
Upper Gastronintestinal Bleed
R ASTR INT STINA B
(Hematemesis / Melena)
( AT SIS NA)
Acute ematemesis elena
Blood in vomitus blac tarry stools
If elena -‐10 colorectal small bowel

clude bleeding disorder
eptic lcer isease ortal ypertension

ther
( ) (1 )
• astro esophageal varices
astric Acid Non-‐Steroidal Anti-‐ Stress

elicobacter ylori
Gastrointestinal
ypersecretion Inflammatory rugs (IC Setting)
• ollinger Ellison
Syndrome
Retching
sophagitis
allory Weiss Tear Tumors
astritis
• Benign
• Malignancy 94
Lower Gastrointestinal Bleed
W R ASTR INT STINA B
ower astrointestinal Bleed
ccult (Stool ccult

vert Bleeding
blood and or iron
deficiency anemia)
In atient ut atient
• Colorectal cancer
• Angiodysplasia (colon or
Gastrointestinal
small bowel) • R E T BRIS pper I

• Perianal isease
• ccult I bleeding (ulcer bleed iverticular bleed
• Acute colitis (ischemia (most common)
esophagitis gastritis • Inflammatory Bowel
cancer) infectious inflammatory)
• Small bowel source (e.g. isease
• ther small bowel tumors • Colorectal Cancer
asymptomatic IB Meckel s tumor)
• Angiodysplasia
95
Weight Gain
W I T AIN
Weight ain
Increased Inta e ecreased penditure

• ietary • Sedentary ifestyle
• Social/Behavioural • Smoking Cessation
• Iatrogenic
Neurogenic enetic ypothalamic ituitary onadic ther auses
Gastrointestinal
• epression • Cushing s isease
• ypothalamic Syndrome • Polycystic varian Syndrome
• ementia • ypothyroidism
• rowth ormone eficiency • ypogonadism
96
Weight Loss
W I T SS
Weight oss
ecreased Inta e alabsorption Increased penditure
• I illness (upper and lower) • Small Bowel isease (e.g. Crohn s • Increased Protein/Energy Re uirements
• Psychiatric ( epression eating disorders) isease Celiac isease) (e.g. Post Surgical Infections Trauma
• Poverty • Pancreatic Insufficiency Burns)
•Abuse • Cholestatic iver isease • Cancer
• ementia • Protein losing Enteropathy (e.g. • yperthyroidism
• Anore ia as an Adverse rug Effect Inflammatory Bowel isease) • Chronic Cardiac/Respiratory distress (e.g.
C P )
Gastrointestinal
• Chronic Renal Failure

• Adrenal Insufficiency
• Poorly Controlled iabetes Mellitus
• IV
97
Renal
Acute Kidney Injury....................................................... 101 Proteinuria ............................................................................115
Chronic Kidney Disease ............................................102 Renal Mass Solid ............................................................ 116
Dysuria ...................................................................................103 Renal Mass Cystic...........................................................117
Generalized Edema......................................................104 Scrotal Mass....................................................................... 118
Hematuria ............................................................................105 Suspected Acid-Base Disturbance .................. 119
Hyperkalemia Intercellular Shift ........................ 106 Metabolic Acidosis Elevated Anion Gap.......120
Hyperkalemia Reduced Excretion ....................107 Metabolic Acidosis Normal Anion Gap ...........121
Hypokalemia .................................................................... 108 Metabolic Alkalosis ..................................................... 122
Hypernatremia ................................................................ 109 Urinary Incontinence ................................................... 123
Hyponatremia ................................................................... 110 Urinary Tract Obstruction .........................................124
Hypertension...................................................................... 111
Increased Urinary Frequency ................................112
Nephrolithiasis ..................................................................113
Renal
Polyuria ...................................................................................114
99
Dr. Andrew Wade Colin Roscher (Co-editor)
Dr. Sophia Chou Mark Elliot (Co-editor)
Dave Campbell
Derrick Chan Faculty Editor
Marc Chretien Dr. Kevin McLaughlin
Mollie Ferris
Kody Johnson
Becky Kennedy
Vera Krejcik
Keith Lawson
Vanessa Millar
Eric Sy
Renal
Maria Wu
100
Acute Kidney Injury
A T I N IN R
A T I N IN R Acute idney In ury
Acute idney In ury

Acute increase in creatinine by at least 0
Acute increase in creatinine by at least 0

re-‐Renal Renal ost-‐Renal
• Benign Prostatic yperplasia

re-‐Renal rinalysis
Renal • Constipation ost-‐Renal
Renal Systemic and CBC • Prostate Cancer
ypoperfusion ypotension • rolithiasis
• epatorenal • Shock • Benign Prostatic yperplasia

syndromes rinalysis • Constipation
Renal
• rugs Systemic Vascular
and CBC lomerular • Prostate CancerInterstitial
ypotension Tubular
• Emboli (Thrombocytopenia and (RBC casts
• rolithiasis
(Sterile pyuria
ypoperfusion schistocytosis on CBC) dysmorphic RBCs) eosinophiluria)
• epatorenal • Shock
syndromes Acute Tubular Rapidly rogressive Acute Interstitial
Tubular
• rugs Necrosis TT S
Vascular lomerular Interstitial
bstruction lomerulonephritis Nephritis
(Epithelial cell casts) Tubular (RBC casts (Sterile pyuria
• Emboli (Thrombocytopenia and
• Ischemia (severe • Cast nephropathy schistocytosis on (E.
CBC) • Antidysmorphic RBCs)
BM antibodies eosinophiluria)
• rugs (NSAI s Ab
Renal
• Shiga like to in coli)

hypotension) (multiple myeloma) • rugs • Immune comple allopurinol PPI)
• To ins (contrast • rate crystals • IV deposition (IgA post • Infections (CMV strep
Acute aminoglycosides
Tubular •Tubular
Calcium alate Rapidly
strep Acute Interstitial
lupus) rogressive legionella)
• Malignancy
Necrosis
chemotherapy) (Ethylene glycol) TT S • Pauci immune • Immune (lupus sarcoid
bstruction lomerulonephritis
(Wegener s) S gren)
Nephritis
(Epithelial cell casts)
• Pigments
101
• Ischemia (severe • Cast nephropathy • Shiga like to in (E. coli) • Anti BM antibodies • rugs (NSAI s Ab
hypotension) (multiple myeloma) • rugs • Immune comple allopurinol PPI)
Chronic Kidney Disease
R NI I N IS AS
hronic idney isease
ecreased idney function (e R < 60ml min 1 m2)

persistent over at least months
re-‐Renal Renal ost-‐Renal

(Evidence of Renovascular disease) (Abnormal urinalysis proteinuria/pyuria) ( bstruction/hydronephrosis on /S)
• Atheroemboli • Reflu nephropathy

• Renal artery stenosis • Benign prostatic hyperplasia
• rugs • Constipation
• Chronic hypoperfusion • Prostate cancer
Interstitial
Tubular Vascular lomerular
(Sterile pyuria WBC casts
(Family history ultrasound) ( ther small vessel disease) (Proteinuria)
eosinophiluria)
• Polycystic kidney disease • Atherosclerosis • iabetes • rugs (NSAI s analgesics)

• Medullary cystic disease • ypertension • Infections (chronic
• Nephronophthisis
Renal
pyelonephritis)
• Immune (sarcoid S gren)
• Multiple myeloma
• ypero aluria
• ypercalcemia
• yperphosphatemia 102
Dysuria
S RIA
ysuria
yuria No yuria
eukocytes on No eukocytes on
ipstick/Microscopy ipstick/Microscopy
Bacteriuria
No Bacteriuria No
ematuria
ematuria rethritis Vaginitis Non-‐ athogenic
ipstick positive for nitrites
ipstick negative for
(if infected with
nitrites.
enterobacteria).
• onococcal • an i a • an i a • Estrogen deficiency

• Non onococcal (e.g. • erpes Simple Virus • ar nerella • Interstitial cystitis
hla y ia richo onas • Neoplasm • Radiation cystitis
Renal
pper rinary Tract ower rinary Tract

Infection yelonephritis Infection ystitis
WBC Casts WBC Clumps
103
Generalized Edema
N RA I A
enerali ed dema
Increased blood pressure
verfill
nderfill
(Increased renal sodium
( rine Na 2 me / )
retention rine Na me / )
• NSAI s
• A I/C
• Nephrotic Syndrome
Signs of left ventricular failure
ongestive eart ailure

Altered Startling orces
forward failure
(Absolute decrease in EABV)
(Relative decrease in EABV)
ow serum albumin due to

Severely ill (e.g. in IC )
loss or impaired synthesis
Increased Interstitial Increased apillary ecreased apillary Increased apillary

ncotic ressure ydrostatic ressure ncotic ressure ermeability
Renal
• My edema ( ypothyroid) • Right heart failure • Nephrotic syndrome • Inflammation
• Constrictive pericarditis • Cirrhosis • Sepsis
• Portal hypertension • Acute Respiratory istress
• Pregnancy Syndrome
• Allergies
• Burns/Trauma 104
Hematuria
Renal
(Granulomatosis with
polyangiins/microscopic
105 polyangiins)
Hyperkalemia
Intercellular Shift
R A IA Transcellular Shift
R A IA Transcellular Shift TT ( rine smSerum)/( Serum sm rine)
yper alemia TT ( rine smSerum)/( Serum sm rine)
yper alemia
clude pseudohyper alemia
Serum otassium > mmol eukocytosis thrombocytosis
hemolysis
Serum otassium > mmol eukocytosis thrombocytosis
hemolysis
Transcellular Shift
Increased Inta e
Reduced cretion Appropriate renal e cretion
(IV potassium with reduced e cretion)
( FR TT distal flow ade uate)
Transcellular Shift
Increased Inta e
Reduced cretion Appropriate renal e cretion
( FR TT distal flow ade uate)
Increased Release ecreased ntry

Increased Serum smoles Increased ecreased Na E changer
rate Phosphate Creatinine inase ecreased Na ATPase
Renal
Increased Release
• Non Anion ap Metabolic Acidosis • Insulin eficiency/Resistance
ecreased ntry
Increased Serum smoles Increased
• yperosmolarity • 2 antagonismecreased Na E changer
• Cell rate Phosphate
ysis (e.g. Creatinine
Tumor ysis Syndrome inase
• 1 agonism ecreased Na ATPase
rhabdomyolysis) • igo in
• Non Anion ap Metabolic Acidosis • Insulin eficiency/Resistance 106
• yperosmolarity • 2 antagonism
Hyperkalemia
R A IA Reduced cretion
Reduced Excretion yper alemia
R A IA Reduced cretion
Serum
yper potassium
alemia > mmol eukocytosis thrombocytosis
hemolysis

Serum potassium > m
Increased mol e
Inta eukocytosis thrombocytosis
Reduced cretion Transcellular Shift
(IV potassium with reduced e cretion) hemolysis
Increased Inta e
Reduced cretion Transcellular Shift
rincipal ell roblem Reduced flow through ecreased lomerular

TT distal nephron iltration Rate
TT rine Na 2 me / Increased Creatinine
• ow EABV (e.g. C F cirrhosis • Chronic renal failure
hypotension)
Reduced flow through • A I
ecreased lomerular
rincipal ell roblem
TT distal nephron iltration Rate
TT rine Na 2 me / Increased Creatinine
igh Renin • ow Eigh R(enin
ABV e.g. C F cirrhosis ow Renin • Chronic renal failure
igh Aldosterone hypotension)
ow Aldosterone ow Aldosterone •A I
• ENaC blockers • ACEi/ARB • iabetic nephropathy

• AIN/CIN • Adrenal insufficiency • 2 antagonism
igh Renin • igh Renin ow Rsenin
Renal
• bstruction eparin • NSAI

igh Aldosterone ow Aldosterone ow Aldosterone
• ENaC blockers • ACEi/ARB • iabetic nephropathy TT ( rine smSerum)/( Serum sm rine)

• AIN/CIN • Adrenal insufficiency • 2 antagonism
107 • bstruction • eparin • NSAI s
TT ( rine smSerum)/( Serum sm rine)

Hypokalemia
A IA
ypo alemia
Serum otassium < mmol
ecreased inta e
Increased oss Transcellular shift
(rare cause in isolation)
• Insulin
• 2 agonists
• alkalemia
Renal oss I loss • Refeeding syndrome
rine loss 2 mmol/d rine loss 2 mmol/d • Rapid hematopoiesis
• iarrhea • ypothermia
• Vomiting • Thyroto ic periodic
igh distal igh distal flow • N suction paralysis/familial
TT TT hypokalemic periodic
• a atives
•Polyuria paralysis
Volume Status Assessment
Normal or
ABV contracted
e panded ABV
Renal
• oop diuretics/
Bartter s syndrome
• Thia ide diuretics/ igh renin ow renin ow renin
ittelman s syndrome igh aldosterone igh aldosterone ow aldosterone
• Magnesium depletion •Renal artery stenosis • yperaldosteronism • icorice intake
• iddle s syndrome 108
Hypernatremia
RNATR IA
ypernatremia
E cess free water loss
Serum Sodium >1 mmol
igh rine Volume

ow rine Volume
3 /2 hours
3 /2 hours
Renal water loss
igh rine smolality ow rine smolality ypodipsia

Non-‐renal losses
3 mmol/kg 3 mmol/kg ecreased intake of water
• ypertonic saline • iabetes Insipidus • ecreased level of
administration consciousness
• smotic diuresis • No access to water
(see olyuria scheme)
e.g. mannitol glucosuria
I loss Insensible loss

Renal
• Watery iarrhea • Burns

• IC patients
• Fever
• Inade uate intake for
e ercise related loss
109 • yperventilation
Hyponatremia
NATR IA
NATR IA yponatremia
yponatremia
Artifactual Serum Sodium <1 mmol
ypo-‐osmolar plasma
Posm 2 mypo-‐osmolar plasma
mol/kg
Artifactual Serum Sodium <1 mmol
Posm 2 mmol/kg
Normal osm igh osm Impaired 20 cretion Intact 20 cretion

2 2 mmol/kg Normal osm2 mmol/kg igh osm
• Reduced FR Impaired 20 cretion Intact 20 cretion
2 2 mmol/kg 2 mmol/kg
• ypertriglyceridemia • yperglycemia • iuretics • Reduced FR
• Paraproteinemia • Mannitol • yperglycemia
• ypertriglyceridemia • iuretics
• Paraproteinemia • Mannitol
yper-‐osmolar urine ypo-‐osmolar urine
osm 1 myper-‐
mol/kg osmolar urine ypo-‐osmolar urine
osm 1 mmol/kg
A e pression
osm 1 mmol/kg A suppression osm 1 mmol/kg
A e pression • Primary polydipsia A suppression
• Insufficient o•smole intake
Primary polydipsia
• Insufficient osmole intake
Syndrome of Inappropriate A Reduced ABV
Syndrome
Euvolemic no physiologic of Inappropriate
stimulus to A A Reduced
rine Na 2 mmol/ ABV
Euvolemic no physiologic stimulus to A rine Na 2 mmol/
• Pain/Post op
• Neurologic trauma
• Pain/Post op True hypovolemia With edema ormonal changes
• rugs • Neurologic trauma
• Pulmonary p•athology True hypovolemia With edema ormonal changes
rugs • Bleeding • Congestive heart failure • ypothyroidism
Renal
• Malignancy • Pulmonary pathology • I losses • Bleeding • Cirrhosis • Adrenal
• Congestive heart failureinsufficiency
• ypothyroidism
• Malignancy • Renal losses • I losses • Nephrotic syndrome• Cirrhosis • Pregnancy • Adrenal insufficiency
(especially • Renal losses • Reduced FR• Nephrotic syndrome • Pregnancy
thia ide diuretics)
(especially A I/CRF • Reduced FR
serum sodium correction in hyperglycemia thia ide diuretics) A I/CRF
Na corrected Na (sodium
serum .3 ( glucose in
correction )) hyperglycemia 110
Na corrected Na ( .3 ( glucose ))
Hypertension
RT NSI N ypertension onsider secondary TN

RT NSI N BP 1 / ( 13 / for M)
ypertension • nset 2 yo yo secondary TN
onsider
ypertensive urgency BP o 1r emergency
/ ( 13 (/any for
visit)M) •No F
ypertension with end-‐organ damage or (visit 2) • ypertensive
• nset urgency
2 yo yo
iagnosis based oypertensive
n repeat clinic visits o Ar mbulatory •Refractory hypertension
•No F
urgency emergency b(lood any visit)
pressure monitor Self ome pressure monitoring (visit (multi drug
• resistance)
ypertensive urgency
ypertension with end-‐organ damage or )(visit 2)
iagnosis based on repeat clinic visits Ambulatory blood •Refractory hypertension
pressure monitor Self ome pressure monitoring (visit ) (multi drug resistance)
ssential ( rimary) ypertension Secondary ypertension
ssential ( rimary) ypertension Secondary ypertension
ardiac utput Systemic Vascular Resistance

(Volume dependent) (Vasoconstrictive)
ardiac utput Systemic Vascular Resistance
(Volume dependent) (Vasoconstrictive)
Renal arenchymal ineralocorticoid

Vasoconstrictors Anatomic auses etabolic auses
iseases cess
Renal arenchymal ineralocorticoid
• lomerulonephritis • Conn s syndrome • Sympathetic nVasoconstrictors Anatomic auses
ervous system • Aortic coarctation etabolic auses
• yperthyroidism
iseases • NSAI s cess (ie. cocaine • ypercalcemia
• Nephritic syndrome • nilateral RAS
Renal
• A I/C • lomerulonephritis • icorice • Conn s syndrome pheochromocytoma) • Sympathetic nervous system • Aortic coarctation • Pheochromocytoma
• yperthyroidism
• iddle s syndrome
• Nephritic syndrome • NSAI s • Steroids ((ie.
Cushing s e ogenous
cocaine • nilateral RAS • ypercalcemia
• A I/C • Bilateral RAS
• icorice steroids) pheochromocytoma) • Pheochromocytoma
• iddle s syndrome• Renin Angiotensin
• Steroids s(timulation
Cushing s e ogenous
• Bilateral RAS ( CP) steroids)
111 • Alcohol a•buse/
ReninwAngiotensin
• nilateral (RAS
ithdrawal stimulation
CP)
• Alcohol abuse/ withdrawal
Increased Urinary Frequency
IN R AS RINAR R Q N
Increased rinary re uency
Non-‐increased urine volume (<2m min)

Rule out polyuria
Intrinsic to rinary Tract trinsic to rinary Tract
• Vulvovaginitis
• Bladder compression/Pregnancy
rinary Tract Infection rinary bstruction Small volume bladder etrusor yperactivity
Renal
(See Dysuria scheme) • Benign prostatic hyperplasia • veractive Bladder
• Prostatitis • iabetes
• Prostate cancer • MS
• Nephrolithiasis • Irritant drugs
iuretics caffeine alcohol 112
Nephrolithiasis
N R IT IASIS
Nephrolithiasis
Radio-‐opa ue Radiolucent
Calcium containing Non calcium
of stones 1 of stones
ard Stones Soft Stones ysteine Stones

alcium o alate phosphate Struvite Stones Non Calcium containing ric Acid Stones
of stones 1 of stones but opa ue
• rinary tract infection • Cystinuria • yperuricosuria
• igh protein intake
Stones with
ypercalciuria ypero aluria Anatomical problem
decreased solubility
Renal
• Increased PT • Enteric overproduction • ow urine volume • Medullary sponge kidney

• igh salt intake • ow calcium intake • ypocitraturia
• igh protein intake • ietary • RTA type I
113 • Ethylene glycol ingestion • igh protein intake
Polyuria
RIA
olyuria
rine utput > day

Increased rine Volume (>2ml min)
smotic iuresis Water iuresis

rine smolality Serum smolality rine smolality Serum smolality
• yperglycemia (uncontrolled iabetes Mellitus)

• Mannitol administration
• Increased urea concentration (e.g. Recovery
from Acute Renal Failure increased protein
feeds ypercatabolism Burns Steroids I
Bleed) ypotonic rine ollowing
• NaCl administration ypertonic rine ollowing
Water eprivation Test
Water eprivation Test
E cessive oss
• Primary polydipsia
ive AVP
Renal
osm unchanged or
osm Increased by > 0
Proper kidney response
increased by < 0
nresponsive idney
• Central iabetes Insipidus • Nephrogenic iabetes Insipidus 114
Proteinuria
Renal
Granulomatosis with
polyangiins (GPA)/microscopic
polyangiins (MPA)
115
R NA ASS Solid Renal Mass
Solid
Renal ass
Solid ystic
Benign
3 cm in si e Suspicious
Presence of fat on CT 3 cm in si e
• Angiomyolipoma (hamartoma) • Renal Cell Carcinoma

• ncocytoma • Wilm s tumor (nephroblastoma)
• Tuberous Sclerosis • Metastatic spread to kidneys
Renal
116
Renal Mass
RCystic
NA ASS ystic
Renal ass
Solid ystic
Benign Suspicious
Anechoic on ultrasound Septated/ oculated on ultrasound
Well demarcated on ultrasound/CT Irregular border on ultrasound/CT
Non enhancing with CT contrast Enhancing with CT contrast
olycystic
Simple ysts
Multiple bilateral cysts Abscess
No family history of A P
Positive family history arcinoma
Normal si ed kidneys Fever and leukocytosis
Renal
Enlarged kidneys No signs of infection

No cysts in other organs Positive allium scan
Cysts in other organs
• Polycystic idney isease • Renal Cell Carcinoma
• Tuberous Sclerosis
117 • Von ippel indau Syndrome
Scrotal Mass
S R TA ASS
Scrotal ass
ainful ainless
radual nset oes Not Trans-‐

Sudden nset If with ysuria see Dysuria Trans-‐illuminates
illuminate
scheme
• Testicular Torsion • Acute Epididymitis
• Torsion of the Testicular Appendi • Epididymo orchitis
• Trauma
• Incarcerated ernia
Tumor
Renal
Varicocele
pididymal Spermatic ord ydrocele Solid Tumor until
Soft/ Bag of Worms
proven otherwise
• Epididymal Cyst • Communicating hydrocele • Communicating/non • erm cell
• Spermatocele • Indirect hernia communicating Seminoma Teratoma Mi ed
• Traumatic/Reactive • Non germ cell 118
eydig Sertoli
Suspected Acid-Base Disturbance
A OR R
Acid-‐Base isorder
p < p -‐ p <

Acidemia Normal p Alkalemia
• Mi ed Acid Base isorder
Respiratory Acidosis etabolic Al alosis Respiratory Al alosis

Acidosis
• ecrease EABV
• ypokalemia

Normal Anion ap hronic Acute hronic Acute
• iarrhea •C P • Asthma • Pregnancy • ypo ia

• RTA • Interstitial isease • Neuromuscular • Psychogenic • Salicylates
• Interstitial Nephritis • bstruction • Sepsis
• Pulmonary
Embolism
ol * Denotes acutely life-‐threatening causes

Renal
Appropriate ompensation Ratio (C 2 C 3 )

Metabolic Acidosis 12 1
idosis i ed etabolic isorder Metabolic Alkalosis 1
ormal Normal A Acidosis Alone Acute Respiratory Acidosis 1 1
C 3 igh A Acidosis Alone Chronic Respiratory Acidosis 1 3
C 3 Mi ed A Acidosis Normal A Acute Respiratory Alkalosis 1 2
C 3 Mi ed igh A Acidosis Metabolic Alkalosis Chronic Respiratory Alkalosis 1
119
Metabolic Acidosis
Elevated Anion Gap
TAB I A I SIS levated Anion ap
etabolic Acidosis
Need to correct anion gap for albumin or every drop

of 10 for albumin (from 0) add 2 to the anion gap
levated Anion ap (>12) Normal Anion ap ( 12)

( ain of ) (loss of C 3)
Elevated serum
creatinine
ecreased N production
cess acid addition
and anion secretion
• A I/C
Positive serum Elevated Positive serum Elevated

salicylate level serum lactate ketones osmolar gap
Renal
To ic alcohol
Salicylate poisoning actic acidosis etosis ther ingestion
ingestion
• Shock • iabetic ketoacidosis • Ethylene/Propylene • Paraldehyde Iron
• rugs • Starvation/alcoholic glycol Isonia id Toluene Cyanide
• Inborn errors ketosis • Methanol 120
Metabolic Acidosis
Normal Anion Gap
TAB I A I SIS Normal Anion ap
etabolic Acidosis
TAB I A I SIS Normal Anion ap
of 10 for albumin (etabolic
from 0) add A
2cidosis
to the anion gap

levated Anion ap (>1 ) of 10 for albumin (from 0) add 2 to the anion gap Normal Anion ap ( 1 )
(Acid ain) ( oss of Bicarbonate)
istory of diarrhea

levated Anion ap (>1 ) Normal Anion ap ( 1 )
(Acid I Tain)
ract oss ( oss of Bicarbonate)
(Negative urine net charge)
Renal oss
istory of diarrhea
• iarrhea
• Fistula
I Tract oss
(Negative urine net charge) irect oss Renal oss
Indirect oss
• iarrhea Negative net charge Positive net charge
• Fistula igh FE C 3
• RTA Type II
• Carbonic airect
nhydrase
ossinhibitor Indirect oss
TT ( rine smSerum)/( Serum sm rine) Negative net charge Positive net charge
Renal
rine net charge Na Cl igh FE C 3

• RTA Type II
rincipal ell
• Carbonic anhydrase inhibitor -‐ Intercalated ell
TT ( rine smSerum)/( Serum sm
roblem roblem
rine)
ow TT igh TT
rine net charge Na Cl
121 • RTA Type IV • RTA Type I
rincipal ell -‐ Intercalated ell
roblem roblem
Metabolic Alkalosis
TAB I A A SIS
Transient
Sustained etabolic Rule • IV Bicarbonate

• Acute correction of hypercapnia
Al alosis ut
Volume Status Assessment Renal ailure with

Ingestion
• Milk Alkali syndrome
panded ffective Arterial ontracted ffective Arterial • Bicarbonate ingestion
Blood Volume Blood Volume
No signs of volume depletion Signs of volume depletion
astrointestinal oss Renal oss

ow Cl igh Cl
ower Non-‐reabsorbed Impaired tubular

astric
Bowel anions transport
• Vomiting • Villous adenoma • Penicillins • iuretics (loop/thia ide)
• N suction • a ative abuse • ypomagnesemia
• Chloridorrhea • Barrter s/ itelman s
Renal
igh Renin ow Renin ow Renin
igh Aldosterone igh Aldosterone ow Aldosterone
• Malignant ypertension • Aldosterone secreting mass • icorice
• Renovascular ypertension • Adrenal hyperplasia • iddle s Syndrome
• Renin Secreting Tumor • lucocorticoid remediable aldosteronism • En yme deficiency 122
Urinary Incontinence
RINAR IN NTIN N

rinary Incontinence
Transient stablished
Easily reversible cause Not easily reversible cause
• elirium/confusional states
• Infection ( TI)
• Atrophic urethritis/vaginitis
• harmaceuticals
• sychological/psychiatric
• cessive urine output
• Restricted mobility
• Stool impaction
Stress Incontinence rge Incontinence

verflow Incontinence
Failure of urethral sphincter to remain etrusor overactivity
istended bladder with high post void
closed Abrupt urgency
residual volume
Small Volume Moderate to large leakage of urine
Continuous small volume leakage
Precipitated by stress maneuvers Precipitated by cold temperature
/ Precipitated by stress maneuvers
More common in multiparous women running water
Renal
Impaired etrusor ontraction

Signs of autonomic neuropathy or spinal Bladder utlet bstruction
cord disease cauda e uina syndrome
123 anticholinergic medications
Urinary Tract Obstruction
RINAR TRA T BSTR TI N
rinary Tract bstruction
pper Tract ower Tract

Bladder N T distended on ultrasound istended bladder on ultrasound
ematuria flank pain / N/V rgency fre uency hesitancy nocturia
CT B
Intraluminal traluminal Intramural Bladder utflow Tract

• Retroperitoneal Fibrosis • reteropelvic unction • Carcinoma (until • BP
• Cancer obstruction proven otherwise) • Prostate cancer
• Bladder stone • rethral stricture
• Thrombus (frank • Posterior rethral
hematuria) valves
ass Stone
Renal
• rothelial cell • Calcium o alate
carcinoma • Calcium phosphate
• S uamous cell • ric acid radiolucent on ray
carcinoma • Struvite
• Cysteine 124
Endocrinology
Abnormal Lipid Profile Combined & Hirsutism & Virilization Androgen Excess ....139
Decreased HDL ........................................................129 Hirsutism & Virilization Hypertrichosis ...........140
Abnormal Lipid Profile Increased LDL & Hypercalcemia Low PTH ..........................................141
Increased Triglycerides.......................................130 Hypercalcemia Normal / High PTH ................142
Abnormal Serum TSH..................................................131 Hypocalcemia High Phosphate ..........................143
Adrenal Mass Benign .................................................. 132 Hypocalcemia Low Phosphate ...........................144
Adrenal Mass Malignant ...........................................133 Hypocalcemia High / Low PTH..........................145
Amenorrhea .......................................................................134 Hyperglycemia ................................................................146
Breast Discharge ............................................................135 Hypoglycemia ..................................................................147
Gynecomastia Increased Estrogen & Hyperphosphatemia....................................................148
Endocrinology
Increased HCG ..........................................................136 Hypophosphatemia .....................................................149

Gynecomastia Increased LH & Decreased Hyperthyroidism .............................................................150
Testosterone ............................................................... 137 Hypothyroidism ................................................................151
Hirsutism...............................................................................138 Hyperuricemia..................................................................152
125
Male Sexual Dysfunction ................................153
Sellar / Pituitary Mass .......................................154
Sellar / Pituitary Mass Size ............................155
Short Stature............................................................ 156
Tall Stature .................................................................157
Weight Gain / Obesity ..................................... 158
Endocrinology
126
Dr. Andrew Wade Parul Khanna (Co-editor)
Dr. Sophia Chou Patricia Wong (Co-editor)
Dave Campbell Soreya Dhanji
Derrick Chan
Marc Chretien Faculty Editor
Mollie Ferris Dr. Kevin McLaughlin
Kody Johnson
Becky Kennedy
Vera Krejcik
Endocrinology
Keith Lawson
Vanessa Millar
Eric Sy
Maria Wu
127
128
Endocrinology
Abnormal Lipid Profile
Combined & Decreased HDL
Endocrinology
129
Abnormal Lipid Profile
Increased LDL & Increased Triglycerides
Endocrinology
130
Abnormal Serum TSH
*
**
Endocrinology
*Refer to Hyperthyroidism (1) on page 150

131 **Refer to Hyperthyroidism (2) on page 151
Adrenal Mass
Benign
A R NAL MA B
Benign Adrenal ass
ost common neoplasm is Benign Non-‐ unctioning Adenoma
No Signs of
Signs of ormone cess
ormone cess
ositive 2 -‐ our

strogen Aldosterone
Androgen lucocorticoid etanephrines Silent Non-‐
yperplasia cess cess Nor-‐
cess Femini ation cess unctioning
ften Bilateral ypertension / etanephrines
Virili ation/ irsutism Early Puberty Cushingoid Features
ypokalemia/Alkalosis ass
eavy Menses
•Congenital •Estrogen • lucocorticoid •Aldosterone •Pheochromocytoma
Adrenal Releasing Releasing Releasing (Paro ysmal
yperplasia Adenoma ( igh Adenoma Adenoma ( igh ypertension
•ACT Plasma E2 (Positive e a Aldosterone eadache
ependent Clinical Picture) methasone Renin Ratio) iaphoresis
Endocrinology
•ACT Suppression Test) Palpitations An iety)
Independent
•Macronodular
yperplasia le of s Fo
igh AS Normal AS eo omo toma Normal AS ther
1 are Malignant
•Androgen • ther Source 1 are Bilateral
•Non functioning •Cyst
Releasing (e.g. Polycystic 1 are E tra Adrenal Adenoma •Pseudocyst
Adenoma varian 1 are Familial • ipoma • ematoma
Syndrome 1 are not Associated •Myelolipoma •Infection
Congenital • anglioneuroma (TB Fungal)
with ypertension
Adrenal
yperplasia) Amyloidosis
132
Adrenal Mass
A R
NAL MA M M
Malignant
A R NAL MA
alignant
alignant Adrenal assass
Adrenal
Suggestive of alignancy Inhomogenous ensity elay in CT Contrast Washout
( in 1 mSuggestive of alignancy
inutes) Irregular Shape iameter
Inhomogenous ensity elay
cm Calcification 2in CT Contrast W
ounsfeld ashout
nits on CT Vascularity of Mass
( in 1 minutes) Irregular Shape iameter
ypointense cmo n
to iver Calcification 2M RI ounsfeld
T1 Weighted N T nits
Biopsy on CT Vascularity of Mass
ypointense to iver on T1 Weighted MRI N T Biopsy
No Signs of
Signs of ormone cess No Signs of
Signs of ormone cess ormone cess
ormone cess
Aldosterone ositive 2 -‐ our

Androgen strogen strogen cess lucocorticoid Aldosterone ositive 2 -‐ our Silent Non-‐
Androgen cess lucocorticoid cess etanephrines
etanephrines Silent Non-‐
cess Femini ation cess cess Nor-‐ unctioning
cess Femini ation
Early Puberty cess Features ypertension / Nor-‐ unctioning
Virili ation/ irsutism Early Puberty
eavy Menses
Cushingoid ypertension / etanephrines ass
Virili ation/ irsutism
eavy Menses
Cushingoid Features ypokalemia/Alkalosis
ypokalemia/Alkalosis etanephrines ass
•Estrogen • lucocorticoid •Aldosterone •Pheo • ymphoma
•Estrogen • lucocorticoid •Aldosterone •Pheo • ymphoma
Releasing Releasing Releasing chromocytoma Metastases Metastases ( ften
Releasing Releasing Releasing chromocytoma ( ften
Carcinoma ( igh Carcinoma Carcinoma Carcinoma ( igh (Paro ysmal Bilateral) Adrenal
Bilateral) Adrenal
Endocrinology
Carcinoma ( igh (Positive Carcinoma ( igh (Paro ysmal Carcinoma

Plasma E2 (Positive Aldosterone Renin ypertension Carcinoma
Plasma E2
Clinical Picture) e amethasone Aldosterone
Ratio)
Renin ypertension
eadache
e amethasone
Clinical Picture) Suppression Test) Ratio) eadache
iaphoresis
Suppression Test) iaphoresis
Palpitations
igh Normal
AS Normal AS Palpitations le of s Fo
igh AS AS An iety) le of eo s Foomo
An iety) toma
eo omo toma
•Androgen Releasing • ther Source (e.g. 1 are Malignant
•Androgen Releasing
Carcinoma (e.g. • ther Source (e.g.
Polycystic varian 1 a1re M aalignant
re Bilateral
Carcinoma (e.g.
Adrenocortical Polycystic
Syndrome varian
1 a1re B ilateral
Adrenocortical Syndrome are E tra Adrenal
Carcinoma) Congenital Adrenal 1 a1re E atrare FAdrenal
amilial
Carcinoma) Congenital A drenal
133 yperplasia)
yperplasia)
1 a1re F amilial
are not Associated
1 are not Associated with ypertension
with ypertension
Amenorrhea
AM NORRH A
AM NORRH A Amenorrhea
Amenorrhea
Rule ut regnancy
Rule ut regnancy
ow Normal S levated S
ow Normal S levated S
•Premature
•Premature varian Failure
Bleed With rogestin ypothalamic-‐ No Bleed With varian F•Menopause
ailure
Bleed With hallenge
rogestin ypothalamic-‐
ituitary A is No Bleed With hallenge
rogestin •Menopause •Spontaneous
hallenge varian
•Polycystic ituitary A is rogestin hallenge
• ypothyroidism •Spontaneous
•Polycystic
Syndrome varian • ypothyroidism
• yperthyroidism
Syndrome • yperthyroidism
• iabetes Mellitus
• iabetes
•E M ellitus Androgen se
ogenous
•E ogenous Androgen
•Congenital se
Structural
•Congenital Structural
Abnormalities
Abnormalities
rganic ause ailed rogestin

igh rolactin ailed rogestin
Endocrinology
igh rolactin rganic ause hallenge
hallenge
• yperprolactinemia •Congenital nR eficiency •Functional
• yperprolactinemia •Congenital nR eficiency •Functional
•Infiltrative or Inflammatory • ypothalamic
•Infiltrative or Inflammatory • ypothalamic
esion esion (e.g. (e.g.
•Amenorrhea
•Amenorrhea
•Tumors •Tumors •Weight •Weight oss Eating
oss Eating
•Infarction
•Infarction isordersisorders
E ercise E ercise
•Empty
•Empty ella Syndrome Stress PStress
Sella SSyndrome Prolonged
rolonged
•Apople •Apople
y y Illness) Illness)
If bleed
If bleed with w ith progestin
progestin challenge
challenge estrogeni
estrogeni ed ed
If no If bnleed
o bleed
with w ith progestin
progestin challenge
challenge non estrogeni
non estrogeni ed ed 134
Breast Discharge
BR A T HAR
Breast ischarge
True alactorrhea ther Breast

(on microscopy) ischarge
•Neoplasm (usually blood)

• ther Internal Breast
ischarge
Abnormal TS Normal TS
rolactin rolactin
•Idiopathic
Endocrinology
igh rolactin igh rolactin Autonomous igh rolactin

Normal TS Normal ow TS roduction igh TS
•Microprolactinoma •Pituitary Macroadenoma •Renal Cancer or Failure •Primary ypothyroidism
•Steroid ormone Intake • opamine Inhibition • actotroph Adenoma
•Chronic Renal Failure •Pituitary Stalk •Bronchogenic Tumor
•Stress (e.g. Pregnancy Compression/ esion •Contraceptive
Breast Stimulation Pill/Patch/Ring
135 Trauma/Surgery)
Gynecomastia
Increased Estrogen & Increased HCG
Endocrinology
136
Gynecomastia
Increased LH & Decreased Testosterone
Endocrinology
137
Hirsutism
138
Endocrinology
Hirsutism & Virilization
Androgen Excess
Endocrinology
139
Hirsutism & Virilization
Hypertrichosis
Endocrinology
140
Hypercalcemia
Low PTH
Endocrinology
141
Hypercalcemia
Normal / High PTH
Endocrinology
142
Hypocalcemia
High Phosphate
Endocrinology
143
Hypocalcemia
Low Phosphate
Endocrinology
144
Hypocalcemia
High / Low PTH
Endocrinology
145
Hyperglycemia
Endocrinology
146
HYHY
O OLYLY M A
MA
Hypoglycemia
ypoglycemia
ypoglycemia
( m(mol/
mmol/
) )
asting ypoglycemia ost-‐ ost-‐

randialrandial
asting ypoglycemia (Reactive)
(Reactive)
ther ther
ausesauses
cess Insulin
•E Insulin
•E cess •Alimentary
•Alimentary (e.g.
(e.g. in the isn etting
the setting
of of Illness Illness
•Critical
•Critical (e.g. (epatic
e.g. epatic
FailureFailure

•Medications
•Medications (e.g. Insulin
(e.g. Insulin astric astric
Surgery) Surgery) Renal Renal
FailureFailure Cardiac
Cardiac Failure) Failure)
Secretagogues
Secretagogues Adrenergic
Adrenergic •Congenital
•Congenital En yme En yme
eficiencies eficiencies •Sepsis•Sepsis
Antagonists
Antagonists Quinine Quinine Salicylates
Salicylates •Idiopathic
•Idiopathic • ypopituitarism
• ypopituitarism
Pentamidine)
Pentamidine) •Adrenal
•Adrenal InsufficiencyInsufficiency
•Alcohol
•Alcohol • yperinsulinemic
• yperinsulinemic States S(tates
e.g. (e.g.
lucagon lucagon Catecholamine
Catecholamine eficiencyeficiency

Endocrinology
Insulinoma)
Insulinoma)
•Malnutrition/Anore
•Malnutrition/Anore ia Nervosa
ia Nervosa
Signs Symptoms
Signs Symptoms of ypoglycemia of ypoglycemia
Neurogenic
Neurogenic irritability
irritability tremor tremor
an iety an palpitations
iety palpitations tachycardia
tachycardia sweating sweating
pallor ppallor paresthesias
aresthesias
147 Neuroglycopenia
Neuroglycopenia confusion confusion
lethargy lethargy abnormal
abnormal behaviour behaviour
amnesia amnesia
weakness weakness
blurred blurred
vision vsision sei ures
ei ures
HY R HO HAT M A
Hyperphosphatemia
yperphosphatemia
( 1. mmol/ )
Increased Inta e
ecreased cretion Absorption seudo-‐
Transcellular Shift
FEP 2 Normally in Conte t of Impaired hyperphosphatemia
Renal Function
•Rhabdomyolysis •Renal isease • ypervitaminosis •Multiple Myeloma

•Tumor ysis • ypoparathyroidism •Phosphate Supplementation yperbilirubinemia
•Metabolic or Respiratory •Pseudo hypoparathyroidism •Phosphate Containing • emolysis
Acidosis •Acromegaly Enemas/ a atives • yperlipidemia
•Insulin eficiency •Bisphosphonate Therapy •Tumor ysis
Endocrinology
148
HY O HO HAT M A
Hypophosphatemia
ypophosphatemia
( . mmol/ )
Transcellular Shift Increased cretion ecreased Inta e
•Recovery From A
•Refeeding Syndrome
•Acute Respiratory Alkalosis ietary deficiency alabsorption
• ypokalemia
• ypomagnesemia I Renal •Anore ia •Aluminum/Magnesium
•Burns FeP •Chronic Alcoholism Containing Antacids
• yperparathyroidism •Inflammatory Bowel isease
•Small bowel diarrhea
Endocrinology
•Vitamin eficiency/Resistance •Steatorrhea

•Enteric Fistula
• ypophosphatemic Rickets •Chronic iarrhea
• ncogenic steomalacia
•Fanconi Syndrome
• smotic iuresis
•Acute Volume E pansion
•Aceta olamide and Thia ide
iuretics
149
Hyperthyroidism
HY RTHYRO M
yperthyroidism
igh Normal ow Radioiodine

Radioiodine pta e pta e
Autoimmune Autonomous Subacute ogenous ctopic

TS cess
Thyroid isease Thyroid Tissue Thyroiditis ormone
• rave s isease •To ic Adenoma •TS Secreting Pituitary • ranulomatous •E cessive Thyroid rug
Endocrinology
•Positive anti TS •To ic Multinodular Adenoma • ymphocytic •Struma varii
Receptor Antibody oiter • estational Trophoblastic •Postpartum
Neoplasm •Amiodarone
•Radiation
150
Hypothyroidism
HY OTHYRO M
ypothyroidism
entral rimary Thyroid ormone

Iatrogenic
ypothyroidism ypothyroidism Resistance
•Isolated TS
eficiency
•Panhypopituitarism
hronic Transient
•Subacute ymphocytic/
ranulomatous
•Thyroiditis
•Post Partum Thyroiditis
•Subtotal Thyroidectomy
Endocrinology
ongenital Thyroid entral

Infiltrative isease Agenesis egenesis
edications
ypothyroidism
•Fibrous Thyroiditis •Severe Iodine •Thionamides • ashimoto s Thyroiditis
• emosiderosis eficiency • ithium
•Amiodarone
151 •Interferon
Hyperuricemia
HYPERURICEMIA
Hyperuricemia
Hyperuricemia
Primary Secondary
Over-‐production Under-‐excretion Over-‐production Under-‐excretion

• Increased turnover • Lower uric acid
of nucleotides clearance
• Starvation
Lymphoproliferative Hemolytic
Others Endocrine Renal Drug-‐Induced
Disorders Anemia
• Acute lymphoblastic See hemolysis scheme • Psoriasis Hyperparathyroidism • Chronic renal failure • Antiuricosuric drugs
Endocrinology
• •
leukemia (ALL) • Chemotherapy • Diabetic acidosis • Sarcoidosis • ACE inhibitors
• Acute myeloid • Drug-‐induced • Hypercalcemia • Cyclosporine
leukemia (AML) • High purine diet • Diuretics
• Chronic myeloid • Organic acids
leukemia (CML) • Ethambutol
• Alcohol
152
Male Sexual Dysfunction
MAL AL Y N T ON
Se ual ysfunction
stablish ysfunction in onte t Partner Showing ess esire is not Necessarily Impaired
lobal ysfunction is likely rganic Cause
Situational Impairment Most ikely Psychological
rectile ysfunction esire

Reduced/Absent
sychological hysiological harmacological hysiological harmacological sychological

•Performance An iety •Anti hypertensives • ypo •Anti depressants •Mood isorders
• ack of Sensate •Anti depressants testosteronism •Narcotics •An iety isorders
•Focus • iuretics •Prolactinemia •Anti psychotics • uilt
•Mood isorder •Ben odia epines • yper estrogenism •Anti androgens •Stress
•An iety isorder •Alcohol • ypothyroidism •Alcohol •Interpersonal Issues (e.g.
•Stress •Sympathomimetic • yperthyroidism •Ben odia epines ack of trust in partner)
• uilt rugs (e.g. Cocaine •Chronic Pain • allucinogens •Psychosis/ elusions
•Interpersonal Issues Amphetamines) •Previous psycho social
Endocrinology
trauma
•(e.g. Abuse)
hronic isease Neurological hysiological elvis ther

• iabetes •Stroke • ypo •Trauma • ypertension
•Cardiovascular •Spinal Cord In ury testosteronism •Pelvic Surgery • yspareunia
isease •Multiple Sclerosis •Prolactinemia •Prostate Surgery • ialysis
•Peyronie s • ementia • ypothyroidism •Priapism
•Connective Tissue •Polyneuropathy • yperthyroidism •Infection
153 isease •Bicycling
Sellar / Pituitary Mass
LLAR T TARY MA
Sellar ituitary ass
Adenoma Non-‐Adenomatous Inflammatory

yperplasia
Primarily Anterior Pituitary
•Physiological (e.g. •Infectious

Pregnancy) •Autoimmune
•Compensation (e.g. • iant Cell ranuloma
ypothyroidism) • angerhan s Cell
•Stimulatory (e.g. Ectopic • istiocytosis
NR CR ) •Sarcoidosis
Endocrinology
Non-‐
Secreting Vascular amartoma Neoplasm etastatic
unctioning
•Prolactin • ncocytoma •Aneurysm •Craniopharyngioma
• •Null Cell •Infarction •Meningioma
•ACT Adenoma •Cyst
•TS • lioma
• /FS •Ependymoma
•Mi ed
154
LLAR T TARY MA
Sellar / Pituitary Mass
Size
Sellar ituitary ass
Small arge ther

( 1cm) ( 1cm)
• ypersecretion • ypersecretion
Endocrinology
• yposectretion
155
Short Stature
HORT TAT R
Short Stature
< rd ercentile
etailed istory Physical E am and Mid Parental Target eight
athological Abnormal Normal Variant
Normal uberty elayed uberty

isproportionate roportionate nset (BA CA) nset (BA CA)
•Skeletal ysplasias •Familial Short Stature •Constitutional Short
•(e.g. Achondroplasia) Stature ( ate Bloomer)
•Rickets
No ysmorphic
ysmorphic eatures
eatures
•Trisomy 21
•Noonan Syndrome
•Prader Willi Syndrome
•Russell Silver Syndrome
•Turner Syndrome
Endocrinology
eprivation ndrocrine Treatment hronic isease ther
•Primary Malnutrition •Cushing s isease • lucocorticoids • I (e.g. Celiac IB ) •Intrauterine rowth
•Psychosocial • eficiency •Radiation •Renal (e.g. CRF) Retardation
• eprivation •I F 1 eficiency (e.g. •Chemotherapy •Infection (e.g. Chronic •Bulimia Nervosa
aron warfism) •Bone Marrow TI) •Anore ia Nervosa
• ypothyroidism Transplant •Cardiopulmonary (e.g. •CNS Tumors (e.g.
•Congenital Adrenal Cystic Fibrosis C F) Craniopharyngioma)
yperplasia •Inborn Metabolism Error
•Panhypopituitarism •Immunologic
• ematologic
156
Tall Stature
TALL TAT R
Tall Stature
> th ercentile
etailed istory Physical E am and Mid Parental Target eight
No ther bvious ther bvious

Abnormalities Stigmata Abnormalities Stigmata
Normal rowth Accelerated rowth isproportionate roportionate

(BA CA) (BA CA)
•Familial Tall Stature • linefelter s Syndrome •Bechwith Weidmann

• Syndrome ( ) Syndrome (Normali ing
•Soto s Syndrome/ Cerebral growth after birth)
igantism •Weaver Syndrome
Non-‐ bese B I bese B I • Syndrome
•Marfan s Syndrome
•E ogenous besity • omocystinuria •Neurofibromatosis 1
•Se Steroid eficiency/ • yperthyroidism
Resistance ( ntreated/Severe)
Normal uberty •Acromegaly (Rare in
arly uberty nset
Endocrinology
nset Children)
• E cess
• yperthyroidism
recocious uberty onstitutional

•Adrenal Tumor •Constitutional Tall Stature
• varian Tumor (Early Bloomer)
•Testoto icosis
•Congenital Adrenal
157 yperplasia
Weight Gain / Obesity
HT A N OB TY
Weight ain besity
nergy Related Secondary

(Primary)
ecreased
Increased Inta e Neuroendocrine enetic
penditure
•Sedentary ifestyle •Polycystic varian •Autosomal ominant
•Smoking Cessation Syndrome •Autosomal Recessive
• ypothyroid • inked
•Cushing s Syndrome •Chromosomal
• ypogonadism Abnormality
• eficiency
Endocrinology
• ypothalamic besity
ietary Social Behavioural Iatrogenic
•Progressive •Socioeconomic • rugs/ ormones

•Polyphagia •Ethnicity •Tube Feeding
• igh Fat iet •Psychological ypothalamic Surgery
158
Neurologic
Altered Level of Consciousness Approach 163 Movement Disorder Hyperkinetic .....................176
Altered Level of Consciousness GCS ≤ 7 .....164 Movement Disorder Tremor ................................... 177
Aphasia Fluent .................................................................165 Movement Disorder Bradykinetic ......................178
Aphasia Non-Fluent.................................................... 166 Peripheral Weakness ..................................................179
Back Pain..............................................................................167 Peripheral Weakness Sensory Changes ..... 180
Cognitive Impairment ................................................ 168 Spell / Seizure Epileptic Seizure ....................... 181
Dysarthria ............................................................................ 169 Spell / Seizure Secondary Organic .................182
Falls in the Elderly .........................................................170 Spell / Seizure Other ..................................................183
Gait Disturbance ..............................................................171 Stroke Intracerebral Hemorrhage .....................184
Headache Primary ........................................................ 172 Stroke Ischemia ...............................................................185
Headache Secondary, without Red Flag Stroke Subarachnoid Hemorrhage ................. 186
Neurologic
Symptoms..................................................................... 173 Syncope ................................................................................187

Hemiplegia ......................................................................... 174 Dizziness .............................................................................. 188
Mechanisms of Pain ..................................................... 175 Vertigo ................................................................................... 189
159
160
Neurologic
Dr. Darren Burback Kaitlin Chivers-Wilson Jared McCormick
Dr. Brian Klassen Lindsay Connolly Dilip Koshy
Dr. Gary Klein Nichelle Desilets Aleksandra Ivanovic
Dr. Dawn Pearson Jonathan Dykeman
Dr. Oksana Suchowersky Vikram Lekhi Faculty Editor
Erin Butler Chris Ma Dr. Kevin Busche
Aaron Wong Sandeep Saran
Sophie Flor-Henry Jeff Shrum
Ted Hoyda Siddhartha Srivastava
Andrew Jun Stephanie Yang
Neurologic
Khaled Ahmed
Anastasia Aristarkhova
John Booth
161
162
Neurologic
Altered Level of Consciousness
A Approach
T R V NS I SN SS Approach
Altered evel of onsciousness
lasgow oma Scale Score

12 1 Investigate
12 rgent Investigation
Resuscitate Investigate
Rapidly eteriorating Resuscitate Investigate
linical am Blood Wor Imaging
etabolic No etabolic Structural Non-‐

ocal Non-‐ ocal
Abnormality Abnormality Abnormality Structural
• Trauma • Refer to • ypo ia • Postictal • Epidural • Post Ictal
Neurologic
• Stroke Blood Work • ypercapnea • Concussion emorrhage • Concussion

• Tumor and Imaging • yper/ ypoNa • Meningitis • Subdural • Encephalitis
• emorrhage Sections • yper/ ypoCa • Encephalitis emorrhage
• See Imaging • yper/ ypo • Intracranial
Section • Sepsis emorrhage
• Ischemia
163 • Tumor
Altered Level of Consciousness
GCS ≤ 7
AT R VA T R NS
V I SN
SS
NS I S SN
SS S
Altered S Altered
S
oma oma ther ther

• ocked in
• ocked in
Syndrome
Syndrome
Brain Involvement Brain Involvement •Stupor
•Stupor
•Persistent
•Persistent
Vegetative State
ocal esions iffuse esions Vegetative State
ocal esions iffuse esions
emispheric emispheric
Brain Stem Brain Stem
Vascular Vascular
Infection Infection
ther Systemic Systemic Involvement
therInvolvement
• emorrhage • emorrhage • ypertensive • Meningitis • Trauma/
• emorrhage • emorrhage • ypertensive • Meningitis • Trauma/
• Traumatic • Traumatic encephalopathy • Encephalitis Concussion
• Traumatic • Traumatic encephalopathy • Encephalitis Concussion
• Ischemia/ • Ischemia/ • Vasculitis • Post ictal
• Ischemia/ • Ischemia/ • Vasculitis • Post ictal
Infarction Infarction • TTP
Infarction Infarction • TTP
• Neoplastic • Neoplastic • IC
• Neoplastic • Neoplastic • IC
Abscess Abscess • ypocessesemia cesses
eficiencies eficiencies
rugs To ins rugs To ins
Abscess Abscess • ypo emia
• Skull fracture • erniation • Multiple
• Skull fracture • erniation • Multiple • iver/Renal Failure • ypo emia • Alcohols
Neurologic
• Subdural • Brain stem • iver/Renal
emboli Failure • ypo emia • Alcohols
• Subdural • Brain stem emboli • Carbon io ide • ypoglycemia • Barbituates
hematoma esion • Carbon io ide • ypoglycemia • Barbituates
hematoma esion Narcosis • B12/Thiamine • Tran uili ers
• Intracranial Narcosis • B12/Thiamine • Tran uili ers
• Intracranial • Metabolic Acidosis deficiency • ther
Bleeding • Metabolic Acidosis deficiency • ther
Bleeding • ypernatremia • yponatremia
• ypernatremia • yponatremia
• ypercalcemia • ypocalcemia
NB must be • ypercalcemia • ypocalcemia
NB must be • ypermagnesemia • ypomagnesemia
direct or indirect • ypermagnesemia • ypomagnesemia
direct or indirect • yperthermia • ypothermia
bi hemispheric • yperthermia • ypothermia
bi hemispheric
involvement
involvement • Thyroid Storm
• Thyroid Storm
• My edema Coma
• My edema Coma 164
Aphasia
A ASIA
Fluent
luent
Aphasia
luent Non-‐ luent

rammatically correct but
Agrammatic hesitant but
nonsensical tangential.
Phonemic semantic paraphasias substantive communication
Impaired Repetition Intact Repetition

Neurologic
Impaired Intact Impaired Intact

omprehension omprehension omprehension omprehension
• Wernicke s Aphasia • Conduction Aphasia • Transcortical Sensory • Anomic Aphasia
Aphasia
165
Aphasia
A ASIA Non-‐ luent Non-Fluent
Aphasia
luent Non-‐ luent

rammatically correct but
Agrammatic hesitant but
nonsensical tangential.
Phonemic semantic paraphasias substantive communication
Impaired Repetition Intact Repetition
Neurologic
Impaired Intact Impaired Intact
omprehension omprehension omprehension omprehension
• lobal Aphasia • Broca s Aphasia • Mi ed Transcortical • Transcortical Motor
Aphasia Aphasia
166
Back Pain
BA AIN Red Flags bowel or bladder
dysfunction saddle paresthesia
constitutional symptoms
parasthesis age 1 IV drug
Bac ain
BA AIN use neuromotor deficits
nocturnal
Red pain o hr igh
Flags bowel energy
bladder
trauma past
dysfunction history
saddle of neoplasm
paresthesia
constitutional symptoms
Always assess for red flags parasthesis age 1 IV drug
If no red fBac
lags a ssess
ainafter 6 wee s use neuromotor deficits
nocturnal pain high energy
trauma past history of neoplasm
Always assess for red flags

If no red flags assess after 6 wee s
Acute Subacute hronic Acute After 6
Red lags wee s No Red lags
< 6 wee s > 6 wee s
Acute Subacute hronic Acute After 6

Red lags auda uina wee s No Red lags
racture Tumor Infection
< 6 wee s Syndrome > 6 wee s
Neurologic
nresolved Radicular auda uina Spondyloarthropathies

racture Tumor Infection
Symptoms Syndrome yelopathic or steoarthritis
167
nresolved Radicular Spondyloarthropathies
yelopathic
Cognitive Impairment
NITIV I AIR NT
ognitive Impairment
Affecting ultiple ecline in Instrumental

ementia
omains Activities of aily iving
• epression • Amnestic Mild Cognitive
• elirium Impairment
• Non Amnestic Mild Cognitive
Impairment
Subcortical ementia ortical ementia
arly trapyramidal
Treatable ause Rapidly rogressive
eatures
• Normal Pressure • Parkinson s isease with • Creut feldt Jakob
ydrocephalus ementia isease
• Chronic Meningitis • untington s isease • Paraneoplastic disorder
• Chronic rug Abuse
Neurologic
• Tumor
• Subdural ematoma
• B12 deficiency
• ypothyroidism
arly anguage Abrupt nset arly
arly Impairment
• ypoglycemia and Behavioral Stepwise trapyramidal
of Recent emory
ysfunction rogression eatures
• Fronto temporal • Vascular ementia • Al heimer s • ementia with ewy
ementia ementia Bodies 168
Dysarthria
SART RIA
ysarthria
ower otor Neuron pper otor Neuron tra-‐ yramidal

Slow ow Volume Breathy Speech Slow strangulated harsh voice Ata ic ( erebellar) Rapid ow Volume Monotone
Tongue and Facial Atrophy Positive aw erk hyperactive gag Irregular Rhythm and Pitch
Speech
Fasciculations refle . Emotional lability
•Motor Neuron isease •Bilateral acunar Internal •Spinal Cerebellar Ata ia •Parkinson s isease
• esions of Cranial Nerves Capsule Strokes •Multiple Sclerosis
VII I II •Multiple Sclerosis •Alcohol
•Myasthenia ravis •Amyotrophic ateral •Tumour
•Muscular ystrophy Sclerosis •Paraneoplastic isorder
Neurologic
169
Falls in the Elderly
A S IN T R
all
Normally is a combination of multiple factors
Intrinsic actors trinsic actors
resyncope Sensory Neurological erformance usculo-‐

Syncope Impairments sychiatric easures s eletal
• Cardiac • Vision • Stroke • Weakness • Arthritis
• Non Cardiac • Vestibular • Parkinsonism • ecreased
• Neuropathy • Cognition Balance
• Proprioception • epression • ait
• ther Abnormalities
Neurologic
rugs nvironment
• Polypharmacy • Rugs
esp. • Stairs
medications • ighting
• Psychotropics
170
Gait Disturbance
AIT IST RBAN

ait isturbance
ovement isorder ereditary Sporadic

See o e ent Disor er • Vascular
schemes • Infection
• To ic
• Nutrition
• Metabolic
• Inflammation
• Neoplasm
• egenerative
Sensory Ata ia erebellar Ata ia
• Vestibular
• Visual
• Proprioceptive rogressive atalytic eficiency
egenerative (Childhood)
Neurologic
-‐ in ed
ominant Recessive Intermittent hronic rogressive
itochondrial
• Fragile • Spinocerebellar Ata ia • Friedrich s Ata ia • yperammonemia • Tay Sachs isease
• Telangiectasia • Aminoaciduria • Niemann Pick isease
• Pyruvate/ actic Acid
171
Headache
Primary
A A rimary
eadache
rimary Secondary
sually episodic sually constant
No pattern ther In lusters
• Primary Cough eadache

• Primary E ertional
eadache
• Primary Stabbing eadache
Neurologic
Autonomic ephalgias ther
ast for minutes to hours.
nilateral Bilateral Separated by hours.
ast for seconds separated
by minutes to hours
Sudden onset.
• Migraine • Tension/Stress eadache • Cluster eadache • Trigeminal Neuralgia

(Throbbing/Pulsating) (Tightening Band ike ( rbital Sharp Autonomic (Shooting stabbing)
ull) ysfunction)
• emicranial Continua 172
Headache
A A Secondary without Red lag Symptoms
Secondary, without Red Flag Symptoms
eadache
rimary Secondary
sually episodic sually constant
With Red lag

Symptoms No Red lag
Systemic symptoms focal Symptoms
neurological signs sudden
onset old age progressive
signs of increased
intracranial pressure
hronic
Neurologic
Acute
rugs
• Sinusitis • Analgesic Induced

• ental Abscess eadache
• laucoma • Substance Withdrawal
• Traumatic Brain In ury
173 • Acute Mountain Sickness
Hemiplegia
I IA
pper otor Neuron Wea ness
Tone Spastic with clasp-‐ nife resistance

Refle es yperactive -‐ lonus
athological Refle es Babins i offman
ontralateral Sub-‐
erebral emisphere
ortical nilateral Spinal ord
(Contralateral motor Brain Stem
(Corona radiata esions Above
corte )
Internal Capsule)
• Aphasia • May be without sensory • iplopia • Brown Se uard
• Apra ia loss • ysarthria Syndrome (sensory loss to
• Agnosia • May be combined with • ysphagia pain and temperature
• Agraphia contralateral sensory loss • Ptosis contralateral to weakness
• Acalculia • ecreased evel of vibration and
• Ale ia Consciousness proprioception loss
Neurologic
• Anomia • Cranial Nerve Palsies ipsilateral to weakness)
• Anosognosia • Crossed Sensory
• Asterognosia Findings ipsilateral facial
• Sei ures and contralateral
• Personality Changes e tremity findings
•Cognition/Confusion
ementia
• / Sensory oss
174
Mechanisms of Pain
ANIS S AIN
ain
Neuropathic
Nociceptive i ed
Burning shooting gnawing
Tissue amage Nociceptive/Neuropathic
aching lancinating
Visceral
(From organ/cavity lining) entral Nervous eripheral Nervous
Somatic
Poorly locali ed crampy System System
diffuse deep sensation
• Post erpetic Neuralgia
• Neuroma
• Neuropathy
Neurologic
eep Superficial
eafferentation
ess well locali ed dull Well locali ed sharp Sympathetic
oss of sensory input
longer duration short duration
• Phantom imb • Comple regional pain

• Post stroke syndrome
175 • Spinal in ury
V NT IS R R yper inetic Movement Disorder
Hyperkinetic
ovement isorder
yper inetic
E amples listed not e haustive for all Tremor Brady inetic
causes
Tics ystonia Stereotypies yoclonus horea Athetosis Ballism
• Tourette s • enerali ed • Epilepsy • untington s

Syndrome dystonia • To ic/ isease
• Attention • Writer s cramp metabolic
eficit • Blepharospasm
yperactivity • Cervical
isorder ystonia
Neurologic
• bsessive
Compulsive
isorder
176
Movement
V NT IS Disorder
R R Tremor
Tremor
ovement isorder
yper inetic Tremor Brady inetic
Action Tremor ostural Tremor

Resting Tremor
ccurs uring Voluntary ccurs While eld
ccurs at Rest
Muscle Movement Motionless Against ravity
• Cerebellar isease (e.g. • Parkinson s isease • Enhanced Physiologic
spinocerebellar ata ia • Midbrain Tremor Change
Vitamin E deficiency • Wilson s isease • Essential tremor
stroke multiple sclerosis) • Progressive supranuclear • ystonia
palsy • Metabolic Etiology
Neurologic
• Multiple System Atrophy (Thyroid iver idney)

• rug Induced • rugs ( ithium
Parkinsonism Amiodarone Valproate)
177
V NT IS R R Brady inetic Movement Disorder
Bradykinetic
ovement isorder
yper inetic Tremor Brady inetic
ar inson s isease rug-‐Induced rogressive ultiple System

(TRA ) ar insonism Supranuclear alsy Atrophy
• Resting Tremor • Neuroleptics haracteristics haracteristics
• Cogwheel Rigidity • aloperidol • Vertical a e Palsy • Bradykinesia
• Akinesia/Bradykinesia • Metoclopramide • A ial rigidity limb • / tremor
• ostural Instability • Prochlorpera ine rigidity • Cerebellar signs
• Amiodarone • / Tremor • Postural ypotension
Neurologic
• Verapamil • Bradykinesia
• Falling backwards
178
Peripheral Weakness
RI RA W A N SS
Wea ness
b ective Wea ness No b ective Wea ness

• Cardio pulmonary disease
pper otor Neuron ower otor Neuron • Anemia
pper and ower • Chronic Infection
Increased tone and refle es ecreased tone and refle es
Babinski Refle No Babinski refle
otor Neuron • Malignancy
• Amyotrophic ateral • epression
Sclerosis • econditioning
• Cervical myelo • Arthritis
• Fibromyalgia
Sensory hanges No Sensory hanges radiculopathy
• Syrin • Endocrine isease
See eri heral ea ness
ensory hanges scheme
otor Neuron and otor yopathy

Neuromuscular unction
Neurologic
Neuropathy Fatigability Variability culomotor

Pro imal muscle involvement
Atrophy Fasciculations yperrefle ia elevated C
• ead to icity • Myasthenia ravis • Polymyositis

• Progressive muscular atrophy • ambert Eaton Myasthenic • uchenne Muscular ystrophy
• odgkin s lymphoma Syndrome • Statin To icity
• Polio • Botulism • ermatomyositis
• Multifocal Motor Neuropathy • Congenital • Viral infection
179 • Spinal Muscular Atrophy
Peripheral Weakness
Sensory Changes
Neurologic
180
Spell / Seizure
Epileptic Seizure
S S I R pileptic Sei ure
S S I R pileptic
SpellSeiSeiure
ure
Spell Sei ure
nprovo ed Recurrence rovo ed Recurrence
Epileptic Sei ure Non epileptic organic sei ure/other
nprovo ed Recurrence rovo ed Recurrence
Epileptic Sei ure Non epileptic organic sei ure/other
ocal Sei ure1 nclassified enerali ed

ocal Sei ure1 nclassified enerali ed
Non-‐ yscognitive1 yscognitive2

Non-‐ yscognitive 1
yscognitive2
Features of Non-‐ onvulsive
Non-‐ onvulsive
onvulsive
onvulsive
Features of
• Aura • Aura
• Motor • Motor • Absence • Absence • Myoclonic
• Myoclonic
Neurologic
• Autonomic • Autonomic • Atonic • Atonic • Clonic • Clonic

• Tonic • Tonic
volving to Bilateral
volving to Bilateral • Tonic Clonic
• Tonic Clonic
onvulsive Sei onvulsive
ure Sei ure
1 Previously 1named
Previously named Simple Partial Sei ure
Simple Partial Sei ure
2 Previously named Comple Partial Sei ure
2 Previously 3named Comple Partial Sei ure
Previously named Secondary enerali ed Tonic Clonic Sei ure
3 Previously named Secondary
A focal sei ure may eneralievolve sed Tonic tClonic
o rapidly Sei ure
o a bilateral convulsive
181 A focal sei ure sei
may
ure etvolve
hat no sio rapidly
nitial to a bilateral
distinguishing convulsive
features are apparent.
sei ure that no initial distinguishing features are apparent.
Spell / Seizure
Secondary Organic
S S I R Secondary rganic
Spell Sei ure
nprovo ed Recurrence
rovo ed Recurrence (Secondary)
( rimary) Non epileptic organic sei ure/other
Epileptic Sei ure
ther Secondary rganic
ebrile Infection etabolic Vascular egenerative Structural regnancy
Neurologic
• Sepsis • ypoglycemia • Intracerebral • ementia • Congenital • Eclampsia
• Encephalitis • yperglycemia hemorrhage abnormality
• Meningitis • ypocalcemia • Subarachnoid • Neoplasm
• yponatremia hemorrhage • Arteriovenous
• remia • Subdural malformation
• Alcohol/drug hemorrhage
withdrawal • Epidural
• rug overdose hemorrhage 182
• iver Failure • Ischemic
stroke
Spell / Seizure
Other
S S I R ther
Spell Sei ure
nprovo ed Recurrence
rovo ed Recurrence (Secondary)
( rimary) Non epileptic organic sei ure/other
Epileptic Sei ure
ther Secondary rganic
Neurological ardiovascular sychogenic

• Migraine/Auras • Syncope • Panic isorder
Neurologic
• Movement disorders • Conversion isorder

( ystonia yskinesia • Pseudosei ures
Chorea)
183
STR Intracerebral emorrhage
Stroke
Intracerebral Hemorrhage
Stro e
Intracerebral emorrhage Ischemia Subarachnoid emorrhage
ypertension Vessel isease ther

• Essential ypertension • Amyloid Angiopathy • Trauma
(Aneurysm) • Vascular Malformation • Bleeding diathesis
• rugs (Cocaine • Aneurysm • emorrhage into tumors
Amphetamines) • Vasculitis • emorrhage into infarct
Neurologic
184
Stroke
Ischemia
STR Ischemia
Stro e
Thrombosis
Atherosclerosis Arterial
mbolus Systemic ypoperfusion
issection Fibromuscular
ysplasia
arge Small Ascending ump ardiac utput

n nown eart
Vessel Vessel Aorta ailure Reduction
• acunar • eft Ventricle •Cardiac arrest • Myocardial
Neurologic
• eft Atrium • Arrhythmias infarction

• Valvular • Pulmonary
• Atrial embolus
fibrillation • Pericardial
• Bacterial effusion
endocarditis • Shock
• Myocardial
185 infarction
STR Subarachnoid emorrhage Stroke
Subarachnoid Hemorrhage
Stro e
Vessel isease ther

• Aneurysm • Bleeding iathesis
• Vascular Malformation • Trauma
• rug se
Neurologic
186
Syncope
S N
Syncope
ardiac Non-‐ ardiac
Arrhythmia utflow bstruction Vasovagal Autonomic rthostatic
• Tachyarrhythmia • Aortic Stenosis • ehydration

• Bradyarrhythmia • ypertrophic bstructive • ypovolemia
• Supraventricular Cardiomyopathy • Medications
Tachycardia • Pulmonary Embolus
• Sick Sinus Syndrome • ther
• Second/Third egree
Atrioventricular Block entral eripheral Situational
• Emotional • Bladder Emptying
• Pain
Neurologic
• Reduced Effective Arterial

Blood Volume
• Carotid Sinus Syncope
• Tussive
• efecation
187
Dizziness
V RTI I IN SS i iness
Vertigo i iness
True Vertigo i iness

Illusion of Rotary Movement ightheaded unsteady disoriented
rganic isease sychiatric isease
• Presyncope/Vasodepressor • epression
Syncope • An iety
• Cardiac Arrhythmia • Panic isorder
Neurologic
• rthostatic ypotension • Phobic i iness
• yperventilation • Somati ation
• Anemia
• Peripheral neuropathy
• Visual Impairment
• Musculoskeletal Problem
• rugs 188
Vertigo
V RTI I IN SS Vertigo
Vertigo i iness
True Vertigo i iness

Illusion of Rotary Movement ightheaded unsteady disoriented
entral Vestibular ysfunction eripheral Vestibular ysfunction

Imbalance neurologic symptoms/signs Nausea and vomiting auditory symptoms
bidirectional nystagmus unidirectonal nystagmus
• Benign Paro ysmal Positional Vertigo

• abrynthitis/Vestibular Neuronitis
Space-‐ • Meni re s isease
Infection Trauma ccupying Vascular • Acoustic Neuroma
esion • toto icity (usually imbalance and
oscillopsia)
• Meningitis • Cerebellar • Infratentorial • Vertebrobasilar
• titis Media
• Cerebellar/ Contusion Tumors Insufficiency
• Temporal Bone Fracture
Neurologic
Brainstem • Cerebellopontine • Basilar Artery

Abscess Angle Tumors Migraine
• lomus Tumors • Transient
Ischemic Attack
Inflammatory Into ication • Cerebellar/
Brainstem
Infarction
• Multiple • Barbiturates • Cerebellar
189 sclerosis • Ethanol emorrhage
Obstetrical & Gynecological
Intrapartum Abnormal Fetal HR Tracing Growth Discrepancy Small for Gestational
Variability & Decelerations ...............................193 Age / Intrauterine Growth Restriction ....204
Intrapartum Abnormal Fetal HR Tracing Growth Discrepancy Large for Gestational
Baseline ..........................................................................194 Age ....................................................................................205
Abnormal Genital Bleeding ....................................195 Infertility (Female) .........................................................206
Acute Pelvic Pain........................................................... 196 Infertility (Male) ............................................................... 207
Chronic Pelvic Pain .......................................................197 Intrapartum Factors that May Affect Fetal
Amenorrhea Primary .................................................. 198 Oxygenation ...............................................................208
Amenorrhea Secondary .......................................... 199 Pelvic Mass ........................................................................209
Antenatal Care.................................................................200 Ovarian Mass .....................................................................210
Bleeding in Pregnancy < 20 Weeks .................201 Pelvic Organ Prolapse .................................................211
Obstetrical
Bleeding in Pregnancy 2nd & 3rd Trimester Post-Partum Fever ........................................................ 212
.............................................................................................. 202 Post-Partum Hemorrhage ...................................... 213
Breast Disorder ............................................................... 203 Recurrent Pregnancy Loss......................................214
Vaginal Discharge ......................................................... 215
191
Dr. Heather Baxter Neha Chadha (Co-editor)
Dr. Dorothy Igras Angela Deane (Co-editor)
Dr. Clinton Chow
Dr. Calvin Greene Faculty Editor
Dr. Magali Robert Dr. Ronald Cusano
Dr. Maire Duggan
Dr. Barbara Walley
Vera Krejcik
Shaina Lee
Mia Steiner
Obstetrical
Maria Wu
Danny Chao
Neha Sarna
192
Intrapartum Abnormal Fetal HR Tracing
Variability
INTRA& Decelerations
ART ABN R A TA ART RAT TRA IN Variability
ecelerations
Abnormal etal eart Rate Tracing
Abnormal Variability Baseline Abnormality ecelerations
inimal Absent Absent

ar ed Variability Sinusoidal attern
Variability 2 bpm Accelerations
bpm
• Fetal sleep • Mild hypo ia • Severe fetal anemia • ypo ic acidemia
• Prematurity ( gb ) • Fetal abnormality
• Medications • Tissue hypo ia in fetal
(analgesia sedatives) brain stem
• ypo ic acidemia
•Congenital anomalies
Obstetrical
arly decelerations Variable decelerations ate decelerations rolonged deceleration
• Fetal head compression • Cord compression • teroplacental insufficiency • ypertonic uterus

(mirror contractions) • Fetal acidemia if complicated • Maternal hypotension • nresolving umbilical cord
variable decelerations • Reduced maternal arterial compression
o ygen saturation • Maternal hypotension
• ypertonic uterus • Maternal sei ure
193 • Fetal acidemia • Rapid fetal descent
Intrapartum Abnormal Fetal HR Tracing
INTRA ART ABN R A TA ART RAT TRA IN BaselineBaseline
Abnormal etal eart Rate Tracing
Abnormal Variability Baseline Abnormality ecelerations
Bradycardia Tachycardia
11 bpm 1 bpm
aternal etal aternal etal
Obstetrical
• ypotension • mbilical cord occlusion • Fever • Infection
• rug response • Fetal hypo ia/acidosis • Infection • Prolonged fetal activity or
• Maternal position • Vagal stimulation (e.g. • ehydration stimulation
• Connective tissue disease chronic head compression) • yperthyroidism • Chronic hypo emia
with congenital heart block • Fetal cardiac conduction or • Endogenous adrenaline or • Cardiac abnormalities
(e.g. S E) structural defect an iety • Congenital anomalies
• rug response • Anemia
• Anemia 194
Abnormal Genital Bleeding
ABN R A NITA B IN
Abnormal enital Bleeding
regnant Non regnant
See lee ing in regnancy

Scheme
ynecologic Non-‐ ynecologic
• Medical (e.g. coagulopathy liver disease

renal disease)
• rugs
terus
Obstetrical
• Anovulatory
• Atrophy ervi Vagina Vulva
• Fibroid
• Polyp • Polyp • Atrophy • Vulvar dystrophy
• E ogenous estrogen • Ectropion • Vulvovaginitis • Vulvar Atrophy
• Neoplasm • ysplasia • Neoplasm • Vulvovaginitis
• Infection • Neoplasm • Infection • Neoplasm
• Endometrial yperplasia • Infection • Trauma • Infection
195 • Trauma • Trauma
Acute Pelvic Pain
A T VI AIN
A T VI AIN
Acute elvic ain
Acute elvic ain

ynecologic Non-‐ • ynecologic
enitourinary (Infection Stone)
• astrointestinal (Appendicitis astroenteritis
• enitourinary (Infection Stone) IB )
iverticulitis
• astrointestinal (Appendicitis astroenteritis
• Musculoskeletal
iverticulitis IB )
• Musculoskeletal
regnant
regnant Non-‐ regnant
Non-‐ regnant
trauterine
trauterine Intrauterine
Intrauterine terus terus vary vary
allopian Tube allopian Tube
Obstetrical
• Ectopic pregnancy
• Ectopic pregnancy • Placental
• aPlacental
bruption abruption
• Fibroid • Fibroid • Tubo ovarian abscess • Tubo ovarian abscess• Tubo ovarian abscess
• Tubo ovarian abscess
• Spontaneous abortion • Endometriosis • Torsion • Pelvic inflammatory
• abour
• Spontaneous abortion
• Adenomyosis
• Endometriosis • Torsion disease
• Pelvic inflammatory
• varian cyst
• abour
•Molar pregnancy • Pyometrium • Adenomyosis • Endometriosis • varian •Torsion
cyst disease
•Molar pregnancy• ematometra • Pyometrium• vulation pain • Endometriosis • Endometriosis •Torsion
ematometra
• Congenital A•nomaly • vulation
• pydrosalpin
ain • Endometriosis
• ysmenorrhea • Congenital Anomaly • ydrosalpin
bstetrical Emergencies • ysmenorrhea 196
bstetrical Emergencies
Chronic Pelvic Pain
R NI VI AIN
hronic elvic ain
> 6 months in duration
ynecologic Non-‐ ynecologic o-‐morbidities
• Endometriosis • Somati ation

• Chronic pelvic inflammatory disease • Se ual/physical/psychological abuse
• ysmenorrhea • epression/an iety
• Adenomyosis • Abdominal wall pain
• varian cyst
• Adhesions
Obstetrical
astrointestinal enitourinary usculos eletal
• Irritable bowel syndrome • Interstitial cystitis • Pelvic floor myalgia

• Inflammatory bowel disease • rinary retention • Myofascial pain (trigger points)
• Constipation • Neoplasm • In ury
197 • Neoplasm
Amenorrhea
Primary
A N RR A rimary
Amenorrhea
rimary Secondary
No onset of menarche by age 1 with secondary se ual characteristics
Absence of menses for 3 cycles or months
r No onset of menarche by age 1 without secondary se ual characteristics
varian tiology entral ongenital utflow

igh FS Receptor Abnormalities ow FS
ow Estrogen and n yme eficiencies ow Estrogen Tract Anomalies
• Imperforate hymen
• onadal ysgenesis • Androgen insensitivity
• Transverse vaginal septum
(e.g. Fragile Balanced • Reductase deficiency
• Vaginal agenesis (Mayer
Translocations Turner s •1 ydro ylase deficiency
Rokitansky ster auser
mosaic) • Vanishing Testes Syndrome
syndrome)
• onadal ysgenesis • Absent Testes etermining
• Cervical stenosis
(e.g. Swyer s Syndrome) Factor
• Turner syndrome
• Savage syndrome (ovarian
resistance)
Obstetrical
• Premature varian Failure
ypothalamic ituitary
(Autoimmune Iatrogenic)
• Functional (e.g. eating • Surgery
disorder weight loss stress • Irradiation
e cessive e ercise illness) • Tumor Infiltration
• Congenital nR deficiency • yperprolactinemia
( allmann syndrome) • ypothyroidism
• Constitutional delay of
puberty 198
Amenorrhea
Secondary
A N RR A Secondary
Amenorrhea
Secondary
rimary Absence of menses for more than 3 cycles or
No onset of menarche by age 1 months in women who were previously
menstruating
Rule out pregnancy ( -‐h )
ypothalamic utflow Tract

varian Negative progesterone challenge ituitary
ow FS ow estrogen bstruction
• Functional (e.g. eating disorder • Asherman s syndrome
weight loss stress e cessive • Cervical stenosis
e ercise illness)
• Infiltrative lesions (e.g. lymphoma
angerhans cell histiocytosis igh rolactin ther
sarcoidosis)
Obstetrical
• Pituitary Adenoma
• Sheehan s Syndrome
• Prolactinoma
• Radiation
Normal S igh S • Chest wall irritation
• Infection
• ypothalamic Pituitary Stalk
• Polycystic ovarian syndrome • Infiltrative esions
• Menopause amage (e.g. Tumors trauma
(positive progesterone hemochromatosis
• Premature ovarian failure compression)
challenge normal prolactin ( 3 years old e.g. • ypothyroidism
chaotic menstruation history) autoimmune chromosomal
199 iatrogenic)
Antenatal Care
ANT NATA AR
Antenatal are
At very Visit
Weight Blood pressure Psychosocial screening
Counseling re. Indications to go to hospital
irst Trimester Second Trimester Third Trimester

( 12 weeks) (12 2 weeks) (2 weeks)
• etailed history and physical e am • Fetal heart rate tones (starting at 12 • Fetal surveillance
• Estimated date of delivery weeks) • Fetal movement counts (
• ating ultrasound • Prenatal genetic screening movements in 2 hours)
• Prenatal labs (CBC AB /Rh type • First trimester screen (nuchal • Symphysis fundal height
screen Antibody screen BsAg Syphilis translucency hC PAPP A 11 1 • eopold maneuvers
serology Rubella Ig Varicella IV) weeks) • roup B Streptococcus screen (3 3
• Chlamydia/ onorrhea screen • Maternal serum screen (AFP uE3 weeks)
• rine culture sensitivity hC 1 22 weeks) • ltrasound for growth presentation
• Prenatal diagnosis biophysical profile
• Non stress test
Obstetrical
• Chorionic villus sampling (11 13
weeks)
• Amniocentesis (1 1 weeks)
• etailed 1 2 week ltrasound (dating
number of fetuses placental location
anatomic survey)
• estational diabetic screen ( g oral
glucose challenge 2 2 weeks)
• Rh antibody screen and Rh 200
immunoglobulin if indicated (2 weeks)
Bleeding in Pregnancy
< 20 Weeks
B IN IN R NAN <20 Wee s

Bleeding in regnancy
emodynamically nstable o AB s
< 20 Wee s Second Third Trimester
Bleeding from the s Not Bleeding from the s

• Cervical polyp/Ectropion
• Cervical/Vaginal neoplasm
• Vaginal laceration
• Infection
ervi pen ervi losed
assing Not assing I on No I on

Tissue and lots Tissue and lots Transvaginal S Transvaginal S
• Complete abortion • Missed abortion
• Incomplete abortion • Inevitable abortion ctopic No ctopic
Obstetrical
• Ectopic pregnancy • Cervical insufficiency

regnancy on S regnancy on S
-‐h < 1 00 -‐h > 1 00

Ectopic likely
-‐h doubled in 2h -‐h not doubled in 2h

Viable pregnancy monitor for Ectopic pregnancy or
201 ectopic or I P (implantation bleed) failed pregnancy
Bleeding in Pregnancy
2nd & 3rd Trimester
B IN IN R NAN 2nd and rd Trimesters
Bleeding in regnancy
emodynamically nstable o AB s
< 20 Wee s Second Third Trimester
o N T perform digital e amination

until the placental location is nown
Bleeding from the s Not Bleeding from the s

• Cervical polyp/Ectropion
• Cervical/Vaginal neoplasm
• Vaginal laceration
Obstetrical
• Infection
ainful ainless
• Placental abruption • Placenta previa
• terine rupture • Vasa previa
• abour (bloody show) 202
Breast Disorder
Obstetrical
203
Growth Discrepancy
R WT IS R AN SSmall mall foror estational
Gestational Age A ge
/ Intrauterine Growth Restriction
Intrauterine rowth Restriction
rowth iscrepancy
arge for estational Age Small for estational Age

( rowth th percentile for A) ( rowth 1 th percentile for A)
aternal actors etal actors lacental actors
hromosomal
T R Infections ultiple estation
Abnormalities
• Trisomy 13 1 21
• Turner syndrome
lacental Ischemia lacental onfined lacental

lacental Abruption
Infarction alformations osaicism (Rare)
• Placenta previa • Vasa previa
• Chronic insufficiency
Obstetrical
ecreased aternal
aternal ifestyle Iatrogenic
teroplacental low ypo emia
• estational hypertension/ • Malnutrition • Pulmonary diseases • Folic acid antagonists
Pre eclampsia • Smoking • Chronic anemia • Anticonvulsants
• Renal insufficiency • Alcohol • igh altitude
• iabetes mellitus • rugs
• Autoimmune disorders 204
Growth Discrepancy
Large for Gestational Age
R WT IS R AN arge for estational Age
rowth iscrepancy
arge for estational Age Small for estational Age

( rowth th percentile for A) ( rowth 1 th percentile for A)
aternal actors etal factors
• Multiparity • Male infant

• Previous history of large for gestational • Prolonged gestation ( 1 weeks)
age fetus • enetic disorder (e.g. Sotos syndrome
• Aboriginal ispanic and Caucasian races Beckwith Wiedemann syndrome
• Maternal co morbidities (e.g. diabetes Weaver s syndrome)
obesity)
• E cessive weight gain over course of
pregnancy ( lbs)
TA I ATI NS
Obstetrical
AT RNA I ATI NS • Shoulder dystocia

• Prolonged labour • Birth in ury (brachial ple us in ury
• perative vaginal delivery clavicular fracture)
• Caesarean section • Cerebral palsy secondary to hypo ia
• enital tract lacerations • ypoglycemia
• Post partum hemorrhage • Polycythemia
• terine rupture • Perinatal asphy ia
• yperbilirubinemia
205
Infertility (Female)
IN RTI IT emale
Infertility
ailure to conceive following > 1 year of

nprotected se ual intercourse
ale ( ) ne plained (1 ) emale ( 0 )
terus allopian Tube vary

vulation confirmation mid luteal serum progesterone
S or S or hysteroscopy S or S or laparoscopy
varian reserve ay 3 FS / Estradiol
• Fibroids/polyps • Pelvic inflammatory disease
• Asherman s syndrome • Endometriosis
• Congenital anomalies • Adhesions
• Adenomyosis • Previous tubal pregnancy
• nfavourable cervical mucous • Congenital Anomalies
• Cervical stenosis
ecreased S Normal S Increased S
Obstetrical
• Polycystic ovarian syndrome • Premature ovarian failure
• besity • Premenopausal changes
• Turner s syndrome
ypothalamic ypopituitarism
• Weight loss/malnutrition • ypothyroidism
• E cessive e ercise • yperprolactinemia
• Stress/psychosis • Tumors (e.g. Prolactinoma)
• Systemic disease 206
Infertility (Male)
IN RTI IT ale
Infertility
ailure to conceive following > 1 year of unprotected se ual intercourse
ale ( ) ne plained (1 ) emale ( 0 )
Sperm roduction Sperm otility

(Non obstructive a oospermia) Sperm Transport Se ual ysfunction
Abnormal semen analysis
ow testosterone
• Antibodies from infection • Vasectomy
• Cystic fibrosis gene mutation
• Post infectious obstruction See e ual Dysfunction
• E aculatory duct cysts (e.g. Scheme
prostate)
• artagener syndrome
Obstetrical
re-‐Testicular Testicular
( ypogonadotrophic hypogonadism) (Sperm production problem)
ow FS / igh FS /
• allmann syndrome • enetic abnormality (e.g. linefelter s)
• Suppression of gonadotropins (e.g. • Cryptorchidism
hyperprolactinemia hypothyroidism • Varicocele
drugs tumor infection trauma) • Mumps orchitis
207 • Anabolic steroids • Radiation Infection drugs trauma torsion
Intrapartum
Factors that May Affect Fetal Oxygenation
INTRA ART actors that may affect fetal o ygenation
actors affecting fetal

o ygenation
teroplacental
aternal actors etal actors
actors
cessive terine teroplacental ecreased etal 2

ord ompression
Activity ysfunction arrying apacity
• yperstimulation • Placental abruption • ligohydramnios • Fetal anemia
• Placental abruption • Placental infarction • Cord prolapse • Carbo yhemoglobin
• Chorioamnionitis • Cord entanglement • Intrauterine growth
• Post dates pregnancy restriction
• Prematurity
• Fetal sepsis
Obstetrical
ecreased aternal ecreased aternal 2 ecreased terine aternal edical
Arterial 2 Tension arrying apacity Blood low onditions
• Smoking • Maternal anemia • ypotension • Fever
• ypoventilation • Carbo yhemoglobin • Anesthesia • Vasculopathy (S E Type 1
• Respiratory disease • Maternal positioning diabetes mellitus TN)
• Sei ure • yperthyroidism
• Trauma • Antiphospholipid syndrome 208
Pelvic Mass
VI ASS
elvic ass
o elvic S
astrointestinal enitourinary
• Appendiceal abscess • istended bladder
• iverticular abscess • Bladder cancer
• iverticulosis • Pelvic kidney
• Rectal/Colon cancer • Peritoneal Cyst
Non-‐ regnant regnant

Obstetrical
terus allopian Tube vary terus allopian Tube vary

• Fibroid • Tubo ovarian • Intrauterine • Tubal ectopic • varian ectopic
• Adenomyosis abscess pregnancy pregnancy pregnancy
• Neoplasm • Paratubal cyst See arian
• Pyometra • Neoplasm ass scheme
• ematometra • Pyosalpin
209 • ydrosalpin
Ovarian Mass
VARIAN ASS
varian ass
Benign Neoplasms yperplastic unctional alignant Neoplasms
• Polycystic ovary • Follicular cyst

• Endometrioid cyst • Corpus lutein cyst
• Theca lutein cyst
pithelial erm ell Se ord Stromal
• Serous cystadenoma • Mature teratoma (may be • Fibroma

• Mucinous cystadenoma cystic) • Thecoma
• onadoblastoma (can • ranulosa cell tumor
become malignant)
Obstetrical
pithelial erm ell Se ord Stromal etastases
• Serous cystadenocarcinoma • ysgerminoma • ranulosa cell tumor • rukenberg tumor

• Mucinous • Immature teratoma • Sertoli Cell (gastrointestinal metastasis)
cystadenocarcinoma • olk Sac • Sertoli eydig • Breast
• Endometrioid
• Clear Cell 210
Pelvic Organ Prolapse
VI R AN R A S
elvic rgan rolapse
erniation of one or more pelvic organs

Risk factors genetics multiparity operative vaginal delivery
obesity increasing age estrogen deficiency
pelvic floor neurogenic damage (i.e. surgical)
strenuous activity (i.e. weight bearing)
terus Vaginal Ape Bladder

Slow urinary stream stress Bowel Rectum
Sensation of ob ect falling out of Pelvic pressure urinary retention
incontinence bladder neck efecatory symptoms
vagina possible lower back pain stress incontinence
hypermobility
• terine prolapse • Vaginal vault prolapse • Cystocele (anterior prolapse) • Enterocele

• Cervical prolapse • Cystourethrocele • Rectocele (posterior
prolapse)
Obstetrical
211
Post-Partum Fever
Obstetrical
212
Post-Partum Hemorrhage
ST-‐ ART RR A
ost-‐ artum emorrhage
Blood oss > 00m post vaginal delivery

R >1000m post aesarean section
terine Atony ( 0 ) Trauma (20 ) Remnant Tissue (10 ) Thrombin (1 )
• terine fatigue (e.g. • Perineal laceration (e.g. • Retained blood clots • Thrombocytopenia
prolonged/induced labor episiotomy) • Retained cotyledon or • Idiopathic thrombocytopenic
rapid labor grand multiparity) • Vaginal laceration/ succenturiate lobe purpura (ITP)
• verdistension of uterus (e.g. hematoma • Abnormal placentation • Thrombotic
multiple gestation • Cervical laceration (e.g. (placenta accreta increta or thrombocytopenic purpura
polyhydramnios fetal forceps/vacuum delivery) percreta) (TTP)
Obstetrical
macrosomia) • terine rupture • E P syndrome

• Bladder distension • terine inversion • isseminated intravascular
• terine infection (e.g. coagulation ( IC)
chorioamnionitis) • Anti coagulation agents (e.g.
• Functional/anatomic heparin)
distortion of uterus • Pre e isting coagulopathy
• rugs terine rela ants (e.g. von Willebrand s disease
(e.g. nifedipine magnesium emophilia A)
213 sulfate NSAI s)
Recurrent Pregnancy Loss
R ST-‐RR NT R
ART NAN
RR A SS
Recurrent
ost-‐ artum regnancy
emorrhage oss
consecutive spontaneous abortions

Blood oss > 00m post vaginal delivery
R >1000m post aesarean section
aternal etal
• enetic abnormalities
terine Atony ( 0 )
nvironmental Trauma (20 ) edicalRemnant Tissue (10 ) Thrombin (1 )
Anatomic
•• Toterine
in (organic
fatigue s(olvents
e.g. mercury lead)
• Perineal laceration (e.g. • Retained blood clots • Thrombocytopenia
• Smoking
prolonged/induced labor episiotomy) • Retained cotyledon or • Idiopathic thrombocytopenic
• Alcohol succenturiate lobe
rapid labor grand multiparity) • Vaginal laceration/ ervi purpura (ITP) terus
rugs
•• verdistension of uterus (e.g. hematoma • Abnormal placentation • Thrombotic
• Ioni ing
multiple radiation
gestation • Cervical laceration (e.g. (placenta accreta increta• oCervical
r thrombocytopenic • Fibroids
purpura
polyhydramnios fetal forceps/vacuum delivery) percreta) insufficiency(TTP) • Congenital
Obstetrical
macrosomia) • terine rupture • E P syndrome anomaly
• Bladder distension • terine inversion • isseminated • Polyps
intravascular
• terine infection (e.g. coagulation ( • IC)Asherman s
chorioamnionitis) ther Autoimmune ndocrine enetic syndrome
• Anti coagulation agents (e.g.
Functional/anatomic
•• Maternal infection • Antiphospholipid • iabetes mellitus • Maternal age heparin)
•distortion
Thrombophilia of uterus syndrome • ypo/hyperthyroidism • Maternal/paternal • Pre e isting coagulopathy
• rugs terine rela ants • upus anticoagulant • PC S chromosomal (e.g. von Willebrand s disease
(e.g. nifedipine magnesium emophilia A)
sulfate NSAI s)
• uteal phase deficiency abnormality
214
Vaginal Discharge
VA INA IS AR
Vaginal ischarge
Infectious Inflammatory Neoplastic
• Endometrium
• Cervi
• Vulva
Systemic ocal • Vagina
• Crohn s disease • Chemical irritant

• Collagen vascular • ouching
disease • Atrophic vaginitis
• ermatologic • Foreign body
• ichen planus
Obstetrical
Se ually
To ic Shoc
Transmitted Vulvovaginitis
Infection Syndrome
• hla y ia • Vulvovaginal
tracho atis candidiasis
• eisseria gonorrhoeae • Bacterial vaginosis
215 • Trichomonas vaginalis
Dermatologic
Burns ....................................................................................... 221 Morphology of Skin Lesions Secondary Skin
Dermatoses in Pregnancy Physiologic Lesions ........................................................................... 230
Changes .........................................................................222 Mucous Membrane Disorder Oral Cavity..... 231
Dematoses in Pregnancy Specific Skin Nail Disorders Primary Dermatologic Disease
Conditions .....................................................................223 ...............................................................................................232
Disorders of Pigmentations Nail Disorders Systemic Disease........................233
Hyperpigmentation ...............................................224 Nail Disorders Systemic Disease - Clubbing
Disorders of Pigmentations .............................................................................................. 234
Hypopigmentation .................................................225 Pruritus No Primary Skin Lesion ........................ 235
Genital Lesion .................................................................. 226 Pruritus Primary Skin Lesion ................................. 236
Dermatologic
Hair Loss (Alopecia) Diffuse ...................................227 Skin Rash Eczematous...............................................237

Hair Loss (Alopecia) Localized ............................ 228 Skin Rash Papulosquamous ................................. 238
Morphology of Skin Lesions Primary Skin Skin Rash Pustular........................................................ 239
Lesions ........................................................................... 229 Skin Rash Reactive.......................................................240
217
Skin Rash Vesiculobullous ............................ 241
Skin Ulcer by Etiology ......................................242
Skin Ulcer by Location Genitals ................243
Skin Ulcer by Location Head & Neck....244
Skin Ulcer by Location Lower Legs /
Feet ..........................................................................245
Skin Ulcer by Location Oral Ulcers ........ 246
Skin Ulcer by Location Trunk / Sacral
Region ....................................................................247
Vascular Lesions.................................................. 248
Dermatologic
218
Danny Guo Noelle Wong (Co-editor)
Rachel Lim Heena Singh (Co-editor)
Dave Campbell
Joanna Debosz Faculty Editor
Safiya Karim Dr. Laurie Parsons
Beata Komierowski
Natalia Liston
Arjun Rash
Jennifer Rodrigues
Dermatologic
Sarah Surette
Yang Zhan
219
220
Dermatologic
RNS
Burns
B RNS
Burns
Burns
hysical Agents hemical Agents

hysical Agents hemical Agen
• Thermal Burn • Acid
• Cold Burn • Alkali • Thermal Burn • Acid
• Alkali
• Electrical Burn • idants (Bleaches pBero
• Cold urn ides
• Electrical Burn • idants (Bleaches pero id
• Sun Burn chromates manganates)
• Sun Burn chromates manganates)
• Vesicants (sulfur and nitrogen mustards • Vesicants (sulfur and nitrog
Dermatologic
arsenicals phosgene o ime)

arsenicals phosgene o ime) • thers (white phosphorus
• thers (white phosphorus metals persulfates sodium a ide)
persulfates sodium a ide)
Parkland formula for fluid resuscitation

221 cc Weight (kg) TBSA burn
Dermatoses in Pregnancy
Physiologic Changes
R AT S S IN R NAN hysiologic hanges
ermatoses in regnancy
hysiologic S in hanges Specific S in onditions
igmented ther Vascular
• Striae istensae (striae gravidarum)

• istal nycholysis
• Subungual eratosis
• yperhidrosis
• Miliaria
• yshidrotic Ec ema
• irsutism (face limbs and back)
Dermatologic
ucous
ace Abdomen ormone induced S in
embranes
• Melasma • inea Nigra • yperpigmentation of • Palmar erythema • Chadwick s sign (bluish
areolae a illae • Spider Nevi discoloration of
genitalia • Cherry emangioma cervi /vagina/vulva)
• Increase in mole si e (Campbell de Morgan
number (probable) spot)
• Pyogenic granuloma
222
Dematoses in Pregnancy
Specific Skin Conditions
R AT S S IN R NAN Specific S in onditions
ermatoses in regnancy
hysiologic S in hanges Specific S in onditions
Non-‐ ruritic ruritic
• Pustular psoriasis of pregnancy

• Impetigo erpetiformis
Dermatologic
Non-‐ rimary S in esion rimary S in esion

• Intrahepatic cholestasis of pregnancy • Pemphigoid gestationis
(pruritis worse at night 3rd trimester) • Pruritic urticarial pla ues papules of
223 pregnancy (P PPP)
Disorders of Pigmentations
Hyperpigmentation
IS R RS I NTATI N yperpigmentation
isorder of igmentation
ypopigmentation yperpigmentation
ocali ed
iffuse
iscrete Areas
• Tanning
• Adverse cutaneous drug eruption
• Addison s disease
• emochromatosis
• Porphyria cutanea tarda
Dermatologic
ongenital Ac uired
• Caf au lait macules (neurofibromatosis • Freckles (ephelides)

or McCune Albright syndrome) • entigines
• Congenital melanocytic nevi • Melasma
• Tinea versicolor (more commonly
hypopigmented)
• Post Inflammatory hyperpigmentation 224
Disorders of Pigmentations
Hypopigmentation
IS R RS I NTATI N ypopigmentation
isorder of igmentation
ypopigmentation yperpigmentation
ocali ed iffuse
ongenital
ongenital Ac uired enerali ed hypopigmentation of hair Ac uired
eyes skin
• Tuberous sclerosis (white • Phenylketonuria • Vitiligo
ash leaf macules) • Albinism
Dermatologic
• Piebaldism
Scale Ac uired
• Tinea versicolor (can also be • Vitiligo
hyperpigmented) • Post Inflammatory hypopigmentation
225 • Pityriasis alba
Genital Lesion
NITA SI N
enital esion
levated epressed
Vesicles apules la ues rosions lcers coriations
• erpes simple • Scabies

• Pubic lice
Infectious Non-‐Infectious ainful ainless
• Molluscum contagiousum • erpes simple • Primary syphilis (chancre)

• uman papilloma virus warts • ae o hilus ucreyi • ranuloma Inguinale
(condyloma acuminata) (chancroid) • ymphogranuloma venereum
Dermatologic
• Secondary Syphilis • Beh et s syndrome
(condyloma lata) • Pemphigus vulgaris
• Reiter s syndrome (circinate • ichen Sclerosis
balanitis) • Erosive ichen Planus
Inflammatory Non-‐Infectious
• ichen planus • S uamous cell carcinoma (can be in situ)

• Psoriasis • Melanoma 226
Hair Loss (Alopecia)
Diffuse
AIR SS (A IA) iffuse
air oss
ocali ed (focal) iffuse
Scarring Non-‐Scarring
Irreversible biopsy re uired Reversible
• upus erythematosus
• ichen planopilaris
attern Anagen ffluvium iscrete atches Telogen ffluvium
• Androgenetic alopecia • Chemotherapy • Alopecia totalis (all scalp and

• oose anagen syndrome facial hair)
• Alopecia universalis (all body
Dermatologic
hair)
ndocrine ietary rugs Stress Related
• ypothyroidism • Iron deficiency • ral contraceptives • Post infectious

• yperthyroidism • inc deficiency • yperthyroid drugs • Post operative
• ypopituitarism • Copper deficiency • Anticoagulants • Psychological stress
• Post Partum • Vitamin A E cess • ithium
227
Hair Loss (Alopecia)
AIR SS (A IA) ocali ed Localized
air oss
ocali ed (focal) iffuse
Scarring Non-‐Scarring
Irreversible biopsy re uired Reversible
Secondary to S in air Shafts Intact or

Infectious Bro en air Shafts
isease Absent
Dermatologic
• Tinea capitis with kerion • iscoid lupus erythematosus • Tinea capitis • Alopecia areata
• Folliculitis decalvans • ichen planopilaris • Trichotillomania • Secondary syphilis
• Pseudopelade of Broc • Traction alopecia
• Alopecia Mucinosa • Congenital hair shaft
• eratosis Follicularis abnormalities
• Aplasia cutis
228
Morphology of Skin Lesions
Primary Skin Lesions
R S IN SI NS rimary S in esions
S in esion
rimary S in esion Secondary S in esion

Initial lesion not altered by trauma manipulation esion that develops from trauma manipulation
(rubbing scratching) complication (infection) or (rubbing scratching) complication (infection) of
natural regression over time. initial lesion or develops naturally over time
lat levated
• Macule ( 1 cm diameter)
• Patch ( 1 cm diameter)
Solid luid-‐ illed R Semi-‐Solid-‐ illed luid-‐ illed

• Cyst
Dermatologic
No eep omponent eep omponent urulent Non-‐ urulent luid

• Papule ( 1 cm diameter) • Nodule (1 3 cm diameter) • Pustule • Vesicle ( 1 cm diameter)
• Pla ue ( 1 cm diameter) • Tumor ( 3 cm diameter) • Bulla ( 1 cm diameter)
irm dematous Transient Itchy
229 • Wheals/ ives

Morphology of Skin Lesions
Secondary Skin Lesions
R S IN SI NS Secondary S in esions
S in esion
rimary S in esion Secondary S in esion

Initial lesion not altered by trauma manipulation esion that develops from trauma manipulation
(rubbing scratching) complication (infection) or (rubbing scratching) complication (infection) of
natural regression over time. initial lesion or develops naturally over time
levated epressed
• Crust/Scab (dried serum blood or pus • Atrophic Scar (fibrotic replacement of
overlying the lesion) tissue at site of in ury)
• Scale (dry thin or thick flakes of skin • lcer (complete loss of epidermis
Dermatologic
overlying the lesion) e tending into dermis or deeper heals
• ichenification (thickened skin with with scar)
accentuation of normal skin lines) • Erosion (partial loss of epidermis only
• ypertrophic Scar (within boundary of heals without scar)
in ury) • Fissure (linear slit like cleavage of skin)
• eloid Scar (e tend beyond boundary of • E coriation/Scratch (linear erosion
in ury) induced by scratching)
230
Mucous Membrane Disorder
Oral Cavity
S BRAN IS R R ( ral avity)
ucous embrane isorder
rosions lcers Blisters White esions
rimary ermatologic
Systemic isease Non-‐neoplastic Neoplastic
iseases
• Aphthous Stomatitis • Systemic lupus • eukoplakia
Dermatologic
(recurrent punched out erythematosus • S uamous cell carcinoma

ulcers often preceded by • Inflammatory bowel disease
trauma/emotional stress) (ulcerative colitis more than
• erpetic gingivostomatitis Crohn s disease)
• Pemphigus vulgaris • Beh et s syndrome andidiasis ichen lanus
• Bullous pemphigoid White/cottage cheese like Reticular (lace like) white lines
pla ues/scrape off easily papules
• Erythema multiforme
• Stevens Johnson Syndrome
• To ic epidermal necrolysis
231
Nail Disorders
NAI IS R RS rimary ermatologic iseasePrimary Dermatologic Disease
Nail isorder
rimary ermatologic isease Systemic isease
Nail late Abnormality Nail old Abnormality
Inflammation
iscolouration itting Thic ening nycholysis Erythema Swelling Telangiectasia
Pain
• Psoriasis • Psoriasis • Psoriasis •S E
• Alopecia Areata • nychomycosis • nychomycosis • Scleroderma
• nychogryphosis • ermatomyositis
Brown Blac ro imal
Dermatologic
il rop Sign ungal ulture ateral nly
inear Strea ateral
• Psoriasis •Junctional/ • Ingrown Nail
Melanocytic Nevus
• Malignant
White ellow-‐ Melanoma nder Acute
reen hronic
Brown Nails Trauma/Infection
• Pseudomonas • rug Induced
• nychomycosis • Acute Paronychia • Chronic Paronychia
infection
232
Nail Disorders
Systemic Disease
NAI IS R RS Systemic isease

Nail isorder
Nail late Abnormality Nail old Abnormality Nail Bed Abnormality

•S E
• Scleroderma
• ermatomyositis
oilonychia nycholysis Beau s ines lubbing

Spoon Shaped Plate Separating from Bed ori ontal rooves
• Iron deficiency anemia • yperthyroidism • Any systemic disease severe
enough to transiently halt nail
growth (e.g.. shock malnutrition)
Red iscoloration
Dermatologic
Blue iscoloration White iscoloration Splinter hemorrhages (dark red thin lines usually
painful)
• Medications • Bacterial endocarditis
• Wilson s disease • Trauma
• Silver poisoning
• Cyanosis Terry s Nails alf-‐and-‐ alf Nails uehrc e s ines
Pro imal Transverse lines
• iver cirrhosis • Chronic renal failure • Nephrotic syndrome
• Congestive heart failure • remia
233 • iabetes Mellitus
Nail Disorders
Systemic Disease - Clubbing
NAI IS R RS Systemic isease -‐ lubbing
Nail isorder
Nail late Abnormality Nail old Abnormality Nail Bed Abnormality
oilonychia nycholysis Beau s ines lubbing

Spoon Shaped Plate Separating from Bed ori ontal rooves
Dermatologic
Bronchopulmonary ardiovascular astrointestinal
ndocrine isease ther
isease isease isease
• Bronchiectasis • Cyanotic eart • Inflammatory Bowel • yperthyroidism • uman
• Chronic ung Infection isease isease (Crohn s ( rave s isease) Immunodeficiency
• ung Cancer isease lcerative Virus
• Asbestosis Colitis) • Congenital efect
• Cystic Fibrosis • astrointestinal
• Chronic ypo ia Cancer 234
Pruritus
R Primary
No RIT SSkin
No
Lesionrimary S in esion
ruritus
rimary S in esion No rimary s in esion
rimary Abnormal inding
iver unction reatinine B sychiatric

Blood lucose TS T
Tests n ymes B N ifferential isease
Dermatologic
• iabetes • Cholestatic liver • Chronic renal • ypothyroidism • ymphoma • elusions of

Mellitus disease failure/uremia • yperthyroidism • eukemia parasitosis
• Polycythemia
rubra vera
• Essential
Throbocythemia
• Myelodisplastic
syndrome
235
Pruritus
R RIT S rimary S in esion Primary Skin Lesion
ruritus
rimary S in esion No rimary s in esion
acules apules la ues Vesicles Bullae Wheals ives
• erosis (dry skin) • Varicella oster (chickenpo ) • rticaria

• Atopic dermatitis • ermatitis herpetiformis
• Nummular dermatitis • Bullous pemphigoid
• Seborrheic dermatitis
• Stasis dermatitis
Dermatologic
• Psoriasis
• ichen Planus
• Infestations (scabies lice)
• Arthropod bites
236
Skin Rash
S IN RAS
Eczematous c ematous
S in Rash
c ematous apulos uamous Vesiculobullous ustular Reactive

Pruritic/Scaly/Erythematous Erythrematous or violaceous
Blisters containing non Blisters containing purulent Reactive erythematous with
lesions. sually poorly papules pla ues with
purulent fluid fluid various morphology
demarcated overlying scale
Atopic Stasis
Nummular Seborrheic ermatitis yshidrotic ontact
ermatitis ermatits ermatitis c ema ermatitis
Erythematous
( c ema)
( iscoid c ema) ellowish red eruption on lower (pompholy ) Well demarcated
Erythematous
Coin shaped (discoid) pla ues with greasy legs. Secondary to eep Seated erythema papules
papules and vesicles
erythematous distinct margins on venous insufficiency. tapioca like vesicles vesicles erosions
(acute) or
pla ues. sually on scalp/face/central / pigmentation on hands/feet/sides scaling confined to
lichenification
lower legs chest folds edema varicose of digits. area of contact
Dermatologic
(chronic)
veins venous ulcers
Age dependent
distribution
Infants scalp face Allergic
e tensor e tremities Irritant elayed onset (12
Children fle ural areas Rapid onset re uires 2 hrs). Very low
Adults fle ural high doses of the concentrations
areas/hands/face/ agent. May occur in sufficient. ccurs
nipples anyone only in those
237 sensiti ed
Skin Rash
S IN RAS apulos uamous Papulosquamous
S in Rash

lesions sually poorly papules pla ues with
ityriasis
ichen lanus
Rosea
soriasis Purple pruritic
val tannish pink or Tinea Secondary iscoid upus
polygonal planar
Well demarcated
(flat topped) papules salmon coloured (Ring Worm)
Syphilis rythematous
pla ues thick silvery patches pla ues Annular (Ring Scarring and/or
on Red brown or copper
scale on elbows with scaling border shaped) lesion with atrophic red/purple
wrists/ankles/genital coloured scaling
knees. Auspit sign in Christmas tree elevated scaling red pla ues with white
s (especially penis) papules and pla ues
oebner s pattern on trunk border central adherent scales on
Wickham s striae
Dermatologic
phenomenon clearing on palms and soles
oebner s begins with a large sun e posed area
phenomenon lesion patch
( erald s patch)
238
Skin Rash
SPustular
IN RAS ustular
S in Rash

Acneiform Infectious
Erythematous papules and pustules on face
andidiasis
Acne Vulgaris olliculitis Impetigo Beefy red erythematous
Comedones / nodules omedones Absent Pustules centered around Pustules with overlying thick patches in body folds with
Dermatologic
cysts scars on face trunk hair follicles honey yellow crusts satellite pustules at
periphery
Acne Rosacea erioral ermatitis

Telangiectasia episodic Perioral periorbital
flushing after sunlight nasolabial distribution
alcohol hot or spicy food sparing vermillion borders of
drinks lips
239
S IN RAS Reactive Skin Rash
Reactive
S in Rash

rythema
rticaria rythema Nodosum ultiforme
Firm /edematous papules Target lesions possibly with
Tender or painful red
pla ues that are transient macules papules vesicles
nodules on shins
Dermatologic
itchy. sually lasts 2 hrs /or bullae on palms soles
and mucous membranes
240
Skin Rash
Vesiculobullous
S IN RAS Vesiculobullous
S in Rash

Vesicles N T ragile N T asily

Vesicles ragile asily Ruptured
Intraepidermal blisters possibly crusts/erosions Ruptured
Subepidermal blisters tense intact blisters
Reaction to Reaction to

Inflammatory Infectious Inflammatory etabolic
Agent Agent
Dermatologic
• Pemphigus • Varicella oster • Contact • Bullous • Porphyria • Phototo ic drug

vulgaris (chickenpo ) dermatitis pemphigoid cutanea tarda eruption
• Pemphigus • erpes oster • Mucous • iabetic bullae
foliaceus (shingles) membrane (bullous
• erpes simple pemphigoid diabeticorum)
• Bullous • ermatitis
impetigo herpetiformis
• Bullous
systemic lupus
241 erythematous
Skin Ulcer by Etiology
S IN R B TI
S in lcer
hysical Vascular ematologic Neoplastic Neurological Infectious etabolic rugs

• Trauma • Arterial • S uamous • iabetic • Pyoderma • Coumadin
• Pressure Insufficiency cell neuropathy gangrenosum • eparin
• Radiation • Venous carcinoma • Tabes • iabetic • Bleomycin
insufficiency •Basal cell dorsalis dermopathy
• Vasculitis carcinoma (syphilis) • Necrobiosis
• Melanoma • Factitious lipoidica
• Mycosis disorder
fungoides • elusions
(cutaneous t of
cell parasitosis
lymphoma)
Dermatologic
emoglobino-‐
ther roto oan Viral Bacterial ungal
pathy
• Sickle cell • Cryog • eishmaniasis • erpes simple • Tuberculosis • istoplasmosis
anemia lobulinemia •Syphilis • Coccidioido
•Thalessemia • hla y ia mycosis
tracho atis • Cryptococcosis
• le siella
granulo atis 242
SSkin
IN Ulcer
R B by Location
ATI N enitals
Genitals
S in lcer
ral ead Nec Trun Sacral Region enitals ower egs eet
ainful ainless
• erpes simple • Primary syphilis (chancre)

• ae o hilus ucreyi (chancroid) • ranuloma inguinale
• Beh et s syndrome • ymphogranuloma venereum
• Pemphigus vulgaris
Dermatologic
• ichen sclerosis
• Erosive lichen planus
243
S IN R B ATI N ead and NecSkin Ulcer by Location
Head & Neck
S in lcer
Neoplastic etabolic Vascular ther
• S uamous cell carcinoma • Pyoderma gangrenosum • Wegner s granulomatosis

• Basal cell carcinoma • Radiation
• Melanoma
Dermatologic
244
SSkin
IN Ulcer
R B by Location
ATI N ower egs eet
Lower Legs / Feet
S in lcer
hysical Vascular Neurological etabolic Neoplastic ther

• Pressure • Arterial • iabetic • Pyoderma • S uamous cell
• Trauma insufficiency neuropathy gangrenosum carcinoma
• Radiation • Vascular • Tabes dorsalis • iabetic • Basal cell
insufficiency (syphilis) dermopathy carcinoma
Dermatologic
• Vasculitis • Necrobiosis • Melanoma

lipoidica
245
S IN R B ATI N ral lcers Skin Ulcer by Location
Oral Ulcers
S in lcer
Single lcer ultiple Acute lcers ultiple Recurrent lcers ultiple hronic lcers
• Traumatic ulcer • Viral stomatitis • Aphthous stomatitis • Pemphigus vulgaris
• Angular ulcer • Erythema multiforme • erpes simple infection • ichen planus
• Aphthous ulcer • Acute necroti ing ulcerative • upus erythematosus
Dermatologic
• erpes simple gingivitis • Bullous pemphigoid
246
SSkin
IN Ulcer
R B by Location
ATI N Trun Sacral Region
Trunk / Sacral Region
S in lcer
Neoplastic hysical ther
• S uamous cell carcinoma • Physical

• Basal cell carcinoma • Trauma
• Melanoma • Radiation
Dermatologic
• Mycosis fungoides (cutaneous t cell

lymphoma)
247
VAS AR SI NS Vascular Lesions
Vascular esions
Blanches with ressure oes not blanche with pressure

Erythematous or violaceous discolorations of skin
Small dilated superficial blood vessels
due to e travasation of RBCs in dermis
• Telangiectasia
etechiae < 0 2 cm diameter

urpura 0 2 -‐ 1 0 cm diameter
cchymosis > 1 cm diameter
Dermatologic
ongenital Ac uired
• emangioma • Vasculitis
248
Musculoskeletal
Acute Joint Pain Vitamin CD ..................................251 Guide to Spinal Cord Injury.................................... 264
Chronic Joint Pain ..........................................................252
Bone Lesion ...................................................................... 253
Deformity / Limp .......................................................... 254
Infectious Joint Pain .................................................... 255
Inflammatory Joint Pain............................................ 256
Vascular Joint Pain ........................................................257
Pathologic Fractures .................................................. 258
Soft Tissue .......................................................................... 259
Fracture Healing ............................................................260
Musculoskeletal
Osteoporosis BMD Testing .....................................261

Tumour .................................................................................. 262
Mytomes Segmental Innervation of Muscles
.............................................................................................. 263
249
Dr. Marcia Clark Angie Karlos (Co-editor)
Dr. Sylvain Coderre Ryan Iverach (Co-editor)
Dr. Mort Doran
Dr. Henry Mandin Faculty Editor
Graeme Matthewson Dr. Carol Hutchison
Katy Anderson
Tara Daley
Jonathan Dykeman
Kate Elzinga
Musculoskeletal
Bikram Sidhu
250
Acute Joint Pain
Vitamin CD
A T INT AIN-‐ VITA IN
Vascular -‐ ee ascular oint ain
Infectious -‐ ee infectious oint ain
Trauma Multiple in ury sites pen Fracture Infectious oint pain
Autoimmune -‐ ee infla atory oint ain
etabolic -‐ ee athologic fractures
Iatrogenic of prior surgery

Musculoskeletal
Neoplastic -‐ ee u our
Scoliosis Talipes E uinovarus Meta tarsus adductus Bow leg nock

ongenital
nee d
egenerative egenerative isc isease steoarthritis steoporosis
251
Chronic Joint Pain
Musculoskeletal
252
Bone Lesion
B N SI N
Bone esion on -‐ray
Rule ut steomyelitis Secondary etastases
Non aggressive Aggressive
Narrow <1mm margin Broad or Indistinct argin

ostotic ultiple ytic esions
Reactive bone formation or Soft Tissue Invasion
• steochondroma • Multiple Myeloma
alignant
Bone Minerali ation
Asymptomatic or Non-‐ Symptomatic or Active Benign Constitutional Symptoms
Active Bone Scam Bone Scan No Bone Minerali ation Codman s Triangle E cessive
Scalloping estruction of
Cortical Bone
Musculoskeletal
• nicameral Bone Cysts • Enchondroma (can calcify • steosarcoma (Codman s

• Aneurysmal Bone Cysts /or turn malignant) Triangle)
•Non ossifying Fibroma • iant Cell Tumor ( Soap • Chondrosarcoma ( Popcorn
Bubble appearance) appearance)
• Ewing s Sarcoma
Not Inflammatory
Inflammatory Appearance
Appearance
• steoid steoma ( Nidus • Chondroblastoma
appearance) • Chondromy oid Fibroma
• steoblastoma (may be
malignant or sclerotic in
253 appearance)
Deformity / Limp
R IT I
eformity imp
Always chec neurological and

vascular status one oint below the
in ury
Infection Inflammation ther auses ip oint nee oint Spine Stature
• Septic Arthritis • Rheumatoid • steoarthritis • ip ysplasia • Patellofemoral • steoporosis

• Cortical Arthritis • steomalacia • Slipped Capital Syndrome • Scoliosis/Spinal
ypertrophy • To ic Synovitis • Rickets Femoral (Chondromalacia Curvature
• steomyelitis • Reactive Epiphysis Patellae) • warfism
Arthritis • egg Calve • sgood
Musculoskeletal
Perthes isease Schlatter isease
• Patella (e.g.
Tendon Rupture
islocation
Sublu ation)
254
Infectious Joint Pain
IN TI S INT AIN
Infectious oint ain
ever hills yalgia

onstant ain
Increased eat and Swelling
Signs Symptoms of Viral Infection g Rhinitis ough)
olyarticular onoarticular
• Viral Myalgia
• Viral Arthritis
• isseminated onoccocal Infection Articular eri-‐Articular
( ermatitis Migratory Arthralgia
Tenosynovitis)
• Cellulitis
• Secondary Syphilis (Red/Copper Papules • Necroti ing Fasciitis
Mucosal esions)
Musculoskeletal
• Septic Bursitis
• Fifth isease (Erythema Infectiousum • Abscess
Symmetrical Rash) • steomyelitis
• Rubella (Measles like rash)
• ymphadenitis
• Primary IV Infection • Warts
• Endocarditis
Acute nset Insidious nset
• Septic Arthritis • Fungal tuberculosis

255 • yme isease (Erythema Migrans)
Inflammatory Joint Pain
IN A AT R INT AIN
Inflammatory oint ain
onoarticular ligoarticular (1-‐ oints) olyarticular (> oints)
• out (Podagra Tophi) • out

• Pseudogout • Psoriatic (Nail Changes Pla ues)
• Early Rheumatic isease • Enteropathic (e.g. Inflammatory Bowel
• Reactive (e.g. enitourinary Infection) isease)
• Reactive
• Rheumatic Fever (recent Pharyngitis Carditis)
• yme isease (Tick bite Migratory red
Macules)
eripheral nly eripheral A ial
Musculoskeletal
Subacute Insidious
igratory Acute nset Insidious nset
Symmetrical onoarticular
• Rheumatoid Arthritis • Symmetric • Rheumatic Fever • Reactive • Ankylosing Spondylitis
• Systemic upus (Polymyositis/ ermato • Enteropathic (e.g.
Erythematosus myositis) Inflammatory Bowel
• S gren s (a.k.a. Sicca) • Asymmetric (Psoriatic isease)
Syndrome Arthritis) • Psoriatic Arthritis
• Scleroderma
• enoch Schonlein Purpura
• Polymyalgia Rheumatica
• Wegener s ranulomatosis
256
Vascular Joint Pain
VAS AR INT AIN
Vascular oint ain
onstant ain (Ischemia)

Acute nset
Increased ain with Activity ( laudication)
old tremity or yperemia
Spasm cclusion isruption ompression
• Vasculitis • Sickle Cell Anemia • Trauma to Vessel • Any structure compressing
• Peripheral Vascular isease (dislocation/fracture) the blood vessels
• Atherosclerosis • emarthrosis ( emophilia or • Abscess
Musculoskeletal
• eep Vein Thrombosis Trauma) • Cyst

• Septic Embolism (e.g. • Peripheral/Mycotic • Neoplasm
Infective Endocarditis) Aneurysm (e.g. Marfan s • islocated Bone
• Fat Embolism (e.g. fractured Syndrome Infective
long bone) Endocarditis Atherosclerosis)
• Air Embolism
• Vasculitis
257
agility ractures
Pathologic Fractures
ercise Repeated se
gical and vascular status AT I RA T R S
ow the in ury
athologic ragility ractures
ow nergy No ercise Repeated se

Always hec neurological and vascular status
etabolic Bone isease one oint below the in ury
Tumours etabolic Bone isease

See one esions Scheme
Renal steodystrophy steomalacia Ric etts

Secondary to Chronic Renal iffuse Pain/Pro imal Muscle
aget s isease Renal steodystrophy steomalacia Ric etts
steoporosis
Failure Vertebrae/ ip/ istal Radius
Weakness
Skull/Spine/Pelvis Secondary to Chronic Renal iffuse Pain/Pro imal Muscle
Positive Alkaline Phosphatase Failure Weakness
• Vitamin eficiency • Vitamin eficiency
• Minerali ation efect • Minerali ation efect
• Phosphate eficiency
• Phosphate eficiency
rimary Secondary
Musculoskeletal
• Post Menopausal • astrointestinal isease
• Elderly • Bone Marrow isorder
• Endocrinopathy
• Malignancy
• rugs (e.g. corticosteroids)
• Rheumatoid isease
Toronto Notes for Medical Students Inc. (2 ). oronto otes o rehensi e
• Renal isease e ical eference an e ie for . Mc raw ill Toronto ntario.
• Poor Nutrition
• Immobili ation
Toronto Notes for Medical Students Inc. (2 ). oronto otes o rehensi e
e ical eference an e ie for . Mc raw ill Toronto ntario. 258
Soft Tissue
259
Musculoskeletal
Fracture Healing
RA TRAR T R A INA IN
racture ealing
RA T R A IN racture ealing
RA T R A IN racture ealing
elayed nion ( 6 months) Non-‐ nion (after 6 months) alunion
elayed nion ( 6 months) racture ealing
Non-‐ nion (after 6 months) alunion
• Tobacco / nicotine
• NSAI S• Tobacco elayed / nicotine
nion ( 6 months) Non-‐ nion (after 6 months) alunion
• NSAI S deficiency
• Ca2 /Vitamin
• Ca2 /Vitamin
elayed nion ( d6
eficiency
months) Non-‐ nion ( after 6 m onths) alunion
• Tobacco / nicotine Septic
Aseptic unctional Non unctional
(R irst)Septic
• NSAI S
• Tobacco
• Ca/2 n/Vitamin
icotine deficiency Aseptic unctional Non unctional
RE
• NSAI RE F SA S ( life t hreatening) (R irst)
• • CaMulti trauma
2 /Vitamin
F A
deficiency
S (life threatening) Septic
• Small deviations • Inade uate
• Inade uate
Aseptic from normal unctional • Small
a is d eviations immobiliNon ation/
unctional
• • Fracture
Pelvic Multi trauma
• FracturePelvic Fracture
(R irst) from normal a is reduction immobili ation/
• RE• Femur
Femur F A FS (life threatening) ypertrophic Septic Atrophic reduction
racture ypertrophic
(ade uate b(R
lood irst) Aseptic
(inade uate blood Atrophic unctional
• Small deviations Non unctional
•Misalignment
• Inade uate
• igh
• Cervical
Multi trauma Spine Fracture •Misalignment
Spine Fracture flow)(ade uate blood (inade uate blood before immobili
casting
RE •F• APelvic S
igh (life
Cervical
Fracture threatening)
flow)
flow)
flow)
from normal a is before
•Premature
ation/
cast casting
• Inadereduction
uate
• Small deviations
• Multi
• trauma
Femur Fracture • Mechanical failure)
ypertrophic •Tobacco /Atrophic
nicotine removal •Premature cast
• Mechanical failure) •NSAI (inade from n ormal a is immobili ation/
•Misalignment
• Pelvic
• Fracture
igh Cervical Spine Fracture • E cessive
(ade motion
uate blood S •Tobacco uate b/lood
nicotine removal
reduction
before casting
Musculoskeletal
• Femur Fracture • Ebone
ypertrophic
•E cessive cessive
flow)gapmotion •Medications Atrophic
•NSAI flow)S
•E cessive
(ade uate blood bone gap (inade uate
•Medications blood •Misalignment
•Premature cast
• igh Cervical Spine Fracture Mechanical failure)
•flow) •Allergies•Tobacco
flow)•Allergies / nicotine before removal
casting
• E cessive motion •Biologic
•NSAIFailure S •Premature cast
• Mechanical failure) •Tobacco •Biologic
/ n icotine Failure
•E cessive bone gap •Medications removal
• E cessive motion S
•NSAI •Allergies
perative Non-‐ perative •E cessive bone gap •Medications
•Biologic Failure
ractures perative racturesNon-‐ perative Inflammation •Allergies
Soft allus ard allus Remodelling
• pen ractures • Closed ractures Inflammation •Biologic Soft Failure allus ard allus Remodelling
• pen • Stable• Closed ours ays ays Weeks Weeks Months ears
• nstable perative Non-‐ perative ours ays ays Weeks Weeks Months ears
• isplaced • nstable • ndisplaced• Stable
ractures isplaced ractures
• ndisplaced Inflammation Soft allus ard allus Remodelling
Intra• • pen
• perative •Non-‐E tra perative
articular
ractures • Intra articular
• nstableractures
• Closed
• E tra
• Stable Inflammation
ours ays ays Weeks
Soft allus
Weeks Months
ard allus Remodelling
ears 260
• pen articular • Closed articular
• isplaced • ndisplaced ours ays ays Weeks Weeks Months ears
• nstable • Intra • Stable • E tra
ST
Osteoporosis R SIS-‐ B testing
BMD Testing
ST R SIS-‐ B testing T-‐Scores
Normal 1
steoporosis 2. steopenia 1
steoporosis 2.
T-‐Scores
Normal 1
steoporosis 2. steopenia 1
steoporosis 2.
Age > 0 years Age < 0 years
• All men and women • Fragility Fracture

• Prolonged lucocorticoid use
Age >• 0 Prior
years fragility fracture Age < • 0 years
se of other high risk medication
• Prolonged glucocorticoid use
• Rheumatoid Arthritis • Aromatase Inhibitors
• All men and women • Fragility Fracture • Androgen eprivation
• Falls in past 12 months • Prolonged lucocorticoid uTherapy se
• Prior fragility fracture
• Parental ip Fracture
Prolonged glucocorticoid • se of other high risk m edications
ypogonadism/Premature
• • ther umseedications •
•
Aromatase Inhibitors
• Rheumatoid Arthritis • Vertebral fracture Menopause
• Falls in past 12 •months • Androgen
• eprivation
Malabsorption Syndrome
steopenia on ray Therapy•
• Parental ip Fracture• Smoking/ET Primary yperparathyroidism
• ther medications • ypogonadism/Premature
• ther disorders strongly associat
• ow body weight ( kg) or ma or loss ( 1 of Menopause
Musculoskeletal
• Vertebral fracture when 2 ) with rapid bone loss and/or fract

• steopenia on ray • Malabsorption Syndrome
• Smoking/ET • Primary yperparathyroidism
• ow body weight ( kg) or ma or loss ( 1 of • ther disorders strongly associated
when 2 ) with rapid bone loss and/or fracture
261 2 1 Clinical Practice uidelines for the iagnosis and Management of steoporosis in Canada
Tumour
T R
Tumour
etastatic-‐
rimary
ost common tumour in adults
• Breast
• Prostate
• Thyroid
• ung
• Renal
alignant
Benign Aggressive Non-‐ alignant
Musculoskeletal
66 of adult tumours
• steochondroma • iant Cell Tumour •Multiple Myeloma most common
• steoid osteoma •Enchondroma • steosarcoma
•Chondroblastoma •Aneurysmal Bone Cyst •Chondrosarcoma
•Fribo anthoma •Ewing s Sarcoma
•Fibrous ysplasia •Fibrosarcoma
•Non ossifying fibroma • iposarcoma
•Chondromy oid Fibroma •Rhabdomyosarcoma
•Periosteal Chondroma • eiomyosarcoma
•Malignant Fibrous istiocytoma
262
Mytomes
T S Segmental Innervation of uscles
Segmental Innervation of Muscles
T S Segmental Innervation of uscles
uscle roup Action yotome eripheral Nerve

uscle roup Action yotome eripheral Nerve
Shoulder Abduction C A illary Nerve
Shoulder Adduction AbductionC C C Thoracodorsal Nerve A illary Nerve
Elbow Fle ion AdductionC C C Musculocutaneous Nerve
Thoracodorsal Nerve
Elbow E tension Fle ion C C Radial N erve Musculocutaneous Ne
Wrist E tension E tension C C Radial Nerve Radial Nerve
Fingers Wrist Fle ion E tension C C Median Nerve Radial Nerve
Fingers Abduction Fle ion T1 C lnar Nerve Median Nerve
ip Fle ion Abduction 2 T1 Nerve to Psoas lnar Nerve
ip E tension Fle ion S1 2 Inferior luteal NNerve
erve to Psoas
Abduction E tension S1 Superior luteal N erve luteal Nerve
Inferior
nee Fle ion Abduction Tibial Nerve Superior luteal Nerv
nee E tension Fle ion 3 Femoral Nerve Tibial Nerve
Musculoskeletal
Ankle orsifle ion E tension 3 eep Peroneal Nerve Femoral Nerve

Ankle Plantarfle ion S1
orsifle ion Tibial Nerve eep Peroneal Nerve
Plantarfle ion S1 Tibial Nerve
N.B. There is considerable overlap between myotomes for some actions. The myotomes listed are the dominant segments involved.
263 N.B. There is considerable overlap between myotomes for some actions. The myotomes listed are the dominant segments involved.
Guide to Spinal Cord Injury
I T S INA R IN R
Spinal RRoot
Spinal oot Sensory
Sensory otor
otor Refle
Refle
CC Acromioclavicular JJoint
Acromioclavicular oint Respiration
Respiration None
None
CC Radial AAntecubital
Radial ntecubital FFossa ossa Elbow FFle
Elbow le ion
ion Biceps RRefle
Biceps efle
CC orsal TThumb
orsal humb Wrist EE tension
Wrist tension Brachioradialis RRefle
Brachioradialis efle
CC orsal M
orsal Middle
iddle FFinger
inger Elbow EE tension
Elbow tension Triceps RRefle
Triceps efle
CC orsal ittle
orsal ittle FFinger
inger Finger FFle
Finger le ion
ion None
None
T1
T1 lnar AAntecubital
lnar ntecubital FFossa ossa Finger AAbduction
Finger bduction None
None
TT 1212 See ermatomes
See ermatomes Abdominal M
Abdominal Muscles
uscles Abdominal RRefle
Abdominal efle
22 Anterior M
Anterior Medial
edial TThigh
high ip FFle
ip le ionion Cremasteric RRefle
Cremasteric efle
33 Medial FFemoral
Medial emoral CCondyle
ondyle nee EE tension
nee tension None
None
Medial M
Medial Malleolus
alleolus Ankle orsifle
Ankle orsifle ion
ion nee JJerk
nee erk RRefle
efle
First Web SSpace
First W eb pace ((11stst/2
/2nd Big T oe E tension amstring R efle
nd MTP)
MTP) Big Toe E tension amstring Refle
S1
S1 ateral Calcaneus
ateral Calcaneus Ankle PPlantarfle
Ankle lantarfle ion ion Ankle JJerk
Ankle erk RRefle
efle
Musculoskeletal
S2
S2 Popliteal FFossa
Popliteal ossa Anal SSphincter
Anal phincter Bulbocavernosus
Bulbocavernosus
S3/S
S3/S Perianal RRegion
Perianal egion Anal SSphincter
Anal phincter None
None
N.B. TThere
N.B. here iis s cconsiderable
onsiderable vvariability
ariability iin
n sspinal
pinal ccord
ord llevels
evels ffor
or mmotor
otor aand
nd rrefle
efle ttesting.
esting. AAlways
lways ttest
est tthe
he llevel
evel aabove
bove aand
nd bbelow
elowthe
the ssuspected
uspected iinn ury
ury 264
Psychiatric
Anxiety Disorders Associated with Panic .... 267
Anxiety Disorders Recurrent Anxious
Thoughts .....................................................................268
Trauma & Stressor Related Disorders ...........269
Obsessive-Compulsive & Related Disorders
.............................................................................................. 270
Personality Disorder..................................................... 271
Mood Disorders Depressed Mood ...................272
Mood Disorders Elevated Mood.........................273

Psychotic Disorders ....................................................274
Somatoform Disorders...............................................275
Psychiatric
265
Dr. Jason Taggart Lundy Day (Co-editor)
Dr. Lauren Zanussi Michael Martyna (Co-editor)
Dr. Lara Nixon Emily Donaldson
Haley Abrams
Daniel Bai Faculty Editor
Kaitlin Chivers-Wilson Dr. Aaron Mackie
Carmen Fong
Leanne Foust
Aravind Ganesh
Leena Desai
Psychiatric
Qasim Hirani
266
Anxiety Disorders
Associated with Panic
Psychiatric
267
Anxiety Disorders
Recurrent Anxious Thoughts
Psychiatric
268
Trauma & Stressor
Related Disorders
Psychiatric
269
Obsessive-Compulsive & Related Disorders
Psychiatric
270
Personality RS
Disorder
RSNANA
IT IT IS
ISR R R R
RS NA IT IS R R ersonality
ersonality
isorder
isorder
ersonality isorder
nduring
nduring
pattern
pattern
of e operience
f e perience
and baehaviour
nd behaviour
that d
that
eviates
deviates
from fcrom
ultural
cultural
e pectations
e pectations
manifest
manifest
in two
in otwo
r more
or mo
the following
the following
areasareas
cognition
cognition affectivity
affectivity
interpersonal
interpersonal
functioning
functioning
and iampulse
nd impulse
control control
nduring pattern of e perience and behaviour that deviates from cultural e pectations manifest in two or more of
The pThe
attern
pattern
is infle
is infle
ible aible
nd paervasive
nd pervasive
across
across
many
msany
the following areas cognition affectivity interpersonal functioning and impulse control
ocial
social
and paersonal
nd personal
situations
situations
The pattern is infle ible aThe

nd ppThe
attern
pattern
ervasive laeads
leads
tm
cross o any
distress
to distress
oar
social impairment
nd poersonal
r impairment
in important
situations in important
areas ao
reas
f functioning
of functioning
The opThe
The pattern leads to distress r attern
pattern
is stable
impairment iis
n simportant
table
and oaf nd
long
of ldong
areas ourationduration
with w
f functioning an
ith
onset
an onset
that cthat
an bce
an traced
be traced
back bto
ack
childhood
to childhood
or adolescence
or adolescence
The pattern is stable and The
of long duration
pThe
attern
pattern wis
is not ith
due an tdue
not oo
nset that
another
to can
another be m
mental traced back
ental
illness ato
illness gceneral
hildhood moedical
r am
a general dolescence
edical
condition
condition
or substance
or substance
use use
The pattern is not due to another mental illness a general medical condition or substance use
luster
luster
B B
ramatic
ramatic
motional
motional
or or
luster
luster
luster A dd or ccentric A Add
odd
r ccentric
or Bccentric
luster ramatic motional or
luster luster
luster
An ious
An iou or
Social Social An ious or earful
Social
aranoidaranoid
aranoid irrational suspicion or irrational
irrational
suspicion
suspicion
Antisocial or for social Antisocial
or disregard Antisocial
norms disregard
disregard
Avoidant for ssocial
ocial
for social
innhibition
orms norms
Avoidant
Avoidant social
social
inhibition
inhibi
mistrust mistrust
mistrust the law and rights of others the law
the alaw nd raights
nd inade
rights
of ouacy
thers
of o hthers
ypersensitivity inadeinade
uacy uacy
hypersensitivity
hypersensiti
Schi oid emotional detachment oid loid
Schi Schi ack
emotional Borderline
emotional
detachment instability
lack lack of identity
detachment Borderline
Borderline ependent
instability
instability opsychological
of identity
f identity
dependence
ependent ependent
psychological
psychologd
Psychiatric
of interest in social relationships relationships and behaviour relationships relationships on baoehaviour
and thers)
nd behaviour on others)
on others)
of interest
of interest
in social
in social
relationships
relationships
Schi otypal dd beliefs istrionic attention seeking bsessive-‐ ompulsive rigid infle ible
Schi Schi
otypal
otypal
dd beliefs
dd beliefs emotional e pressionistrionic
e aggerated istrionic
attention
attention
seeking
conformity to seeking
order
rules and codes) bsessive-‐
bsessive-‐ ompulsive
ompulsive rigi
e aggerated
e aggerated
emotional
emotional
e pression
e pression conformity
conformity
to rules
to r ules
order o rde
an
Narcissistic grandiosity need for
admiration lack of empathy Narcissistic
Narcissistic
grandiosity
grandiosity
need
nfeed
or for
admiration
admiration
lack olack
f empathy
of empathy
1. Black .W. and N.C. Andreasen (2 11). Introductory Te tbook of Psychiatry th Ed. Washington American Psychiatric Publishing Inc. pp. 2 31
271 1. 1. Black Black

.W. a nd
.W. N.C.
and
Andreasen
N.C. Andreasen
(2 11). (I2ntroductory
11). Introductory
Te tbook
Te otbook
f Psychiatry
of Psychiatry
th Ed. W
th
ashington
Ed. Washington
American
American
Psychiatric
Psychiatric
PublishingPublishing
Inc. pp.
Inc.
2 p31 p. 2 31
Mood Disorders
Depressed Mood
Psychiatric
272
Mood Disorders
Elevated Mood
Psychiatric
273
Psychotic Disorders
Medical Conditions
S TI IS R RS Para/Neoplastic
Parkinson s
Infectious
Brain tumour
AI S syphilis
Cushing s
Stroke
Epilepsy
MS S E
Medical Conditions egenerative Endocrine Vascular
Para/Neoplastic
Parkinson s
Brain tumour
AI S syphilis
Stroke
Epilepsy sychotic isorder rugs of Abuse
Infectious Cushing s MS S E Cocaine Alcohol (rare)
egenerative Endocrine Vascular Cannabis
rugs of Abuse sychosis Amphetamines

allucinogens
piates (rare) PCP
Cocaine Alcohol (rare) Rule out psychotic disorder due to substances and or
Cannabis
Medications
Amphetamines piates (rare) PCP general medical condition Amphetamines Methylphenidate Steroids
allucinogens
ces and or opamine Agonist Anticholinergic opa
Medications
Amphetamines Methylphenidate Steroids
opamine Agonist Anticholinergic opa
rominent mood syndrome (ma or ood syndromes absent (or brief
depression mania) present for relative to duration of psychotic
ood syndromes absent (or brief significant portion of illness symptoms
relative to duration of psychotic
symptoms
Psychotic symptoms Psychotic symptoms also Psychotic symptoms Psychotic symptoms
present e clusively during present outside of mood not limited to limited to non bi arre
symptoms Psychotic symptoms ma or mood syndrome episodes delusions delusions only
mited to limited to non bi arre
sions delusions only • Mood disorder with • Schi oaffective disorder
psychotic features (bipolar depressive)
Non bi arre delusions elusions developed in

conte t of close
elusions developed in uration of uration of illness uration of illness 1 month no decline
Non bi arre delusions relationship with a person
conte t of close illness 1 month 1 months months in functioning with already established
1 month no decline
in functioning
relationship with a person behaviour is not odd similar delusion
with already established
behaviour is not odd • Brief psychotic • Schi ophreniform • Schi ophrenia • elusional disorder • Shared psychotic
Psychiatric
similar delusion
disorder disorder disorder (Folie a eu )
• elusional disorder • Shared psychotic
disorder (Folie a eu ) 2 or more (1 must be 1 3) Criteria see schi ophreniform
1 or more 1) elusions disorder
1) elusions 2) allucinations Suicide 1
2) allucinations 3) isorgani ed speech Neuroleptic alignant Syndrome
3) isorgani ed speech ) rossly disorgani ed or Side effects of anti psychotics
) rossly disorgani ed or catatonic behaviour S yperpyre ia ( 3 . C) muscle
catatonic behaviour ) Negative s (affective rigidity and mental status changes
flattening alogia 2 mortality
avolition)
274
Somatoform Disorders
S AT R IS R RS
Somatoform isorder
atient presents with comple medical problem

or symptoms that cannot be e plained medically
Symptoms onsciously Symptoms Not

roduced onsciously roduced
Motivation is Focus is the sick Focus is

primary gain (to Motivation is role not Focus is a physical appearance
assume the sick secondary gain accepting symptom e hibit significant
role) reassurance distress
• Factitious isorder • Malingering • Illness An iety • Body ysmorphic
isorder isorder
Psychiatric
Pain psychological Multiple symptoms long ne or more symptoms for

Neurologic
factors important history at least si months
• Pain isorder • Somati ation isorder • Conversion isorder • ndifferentiated

Criteria Must have symptoms Somatoform isorder
pain s affecting movement
2 I s or sensation (non
1 se ual s anatomic and
275 1 pseudo neuro s une plainable)

Otolaryngologic
Hearing Loss Conductive ....................................... 279
Hearing Loss Sensorineural ..................................280
Hoarseness Acute .........................................................281
Hoarseness Non-Acute............................................ 282
Neck Mass.......................................................................... 283
Otaligia .................................................................................. 284
Smell Dysfunction ........................................................ 285
Tinnitus Objective .........................................................286
Tinnitus Subjective ...................................................... 287
Otolaryngologic
277
Justin Lui Dilip V. Koshy
Andrew Jun Wesley Chan
Dave Campbell
Joanna Debosz Faculty Editors
Sarah Hajjar Dr. Doug Bosch
Dr. James Brookes
Dr. Justin Chau
Otolaryngologic
278
Hearing Loss
Conductive
Otolaryngologic
279
Hearing Loss
Sensorineural
Otolaryngologic
280
Hoarseness
Acute
ARS N SS Acute
oarseness
If oarseness persists > months Refer to NT
Acute Non-‐Acute
< wee s > wee s
onstant Variable
Infectious Inflammatory Trauma Inflammatory yperfunction

Otolaryngologic
• Viral aryngitis • Acute • Voice veruse • Muscle Tension

• E ternal
• Fungal aryngitis Nonspecific ysphonia
aryngeal Trauma
(Monilia) aryngitis • Iatrogenic
• Bacterial ( ER Endoscopy
aryngitis Smoking Endotracheal
• Bacterial Allergies intubation
Tracheitis Vocal Abuse)
• Inhaled
281 Steroids
Hoarseness
Non-Acute
ARS N SS Non-‐Acute
oarseness
If oarseness persists > months Refer to NT
Acute Non-‐Acute
< wee s > wee s
onstant Variable
• Functional
Otolaryngologic
Benign ucosal
Infectious Inflammatory Trauma Neoplastic Neurological
hanges
• Bacterial • Chronic • E ternal • Nodules • Malignancy • Vocal Cord

Infection aryngitis • Internal (Surgery • Polyps S uamous Cell Paralysis
• Fungal • ER Intubation) • ranuloma Cysts Carcinoma • Spasmodic
Infection • Smoking • Reinke s Edema • Benign ysphonia
(Monilia) Papilloma ( PV • Tremor
11)
• ysplasia
eukoplakia 282
Neck Mass
N ASS
Nec ass
Inflammatory ongenital Neoplasms
• Thyroglossal uct Cyst

• Branchial Cleft Anomalies
• ermoid Cyst
• Teratoma
• ymphatic Malformation
• emangioma
ymphadenitis Sialadenitis rimary etastatic

Otolaryngologic
• Bacterial • Parotid Salivary land • ymphoma • S uamous Cell

• Viral • Submandibular Salivary • Thyroid Neoplasm Carcinoma
• ranulomatous isease land • Neoplasm of Salivary • Thyroid (Spread to
• Tuberculosis lands Cervical ymph Nodes)
• Atypical • Neurogenic Neoplasm • Melanoma
Mycobacterium • Schwannoma • istant site (Stomach
• Actinomycosis • Neuroblastoma etc.)
• Cat Scratch • anglioneuroma
isease • Paragangliomas
• Carotid Body
283 Tumors
Otaligia
TA IA
talgia
tologic Referred eriauricular
• Via Vagus or lossopharyngeal Nerves • TMJ Pathology

• Nasopharyngeal ropharyngeal • Parotiditis
aryngeal ypopharyngeal Pain
• Thyroiditis
• Aerodigestive Tract Malignancy
• Post tonsillectomy
Increased ain With ain nchanged With

inna anipulation inna anipulation
Otolaryngologic
Abnormal Tympanic lceration Abnormal
ternal Auditory anal astoid Auricle
embrane Tissue rowth
• titis E terna • Mastoiditis • Cellulitis/Perichondri • Acute titis Media • S uamous Cell
• steomyelitis of tis • Barotrauma Carcinoma
Temporal Bone • Trauma (Frostbite • Traumatic Perforation • Sarcoma
erpes Simple Auricular • Cholesteatoma (Typically
oster (Ramsay ung ematoma) torrhea)
Syndrome if Facial • Autoimmune
Nerve Paralysis) (Relapsing
• Furunculosis Polychondritis) 284
Smell Dysfunction
S S N TI N
Smell ysfunction
ENT istory Physical E am Anterior Rhinoscopy

Sensory Testing CT/MRI to Rule ut Neoplasms Fractures
Congenital abnormalities
Nasal bstruction ndocrine To ins and other

Trauma Neoplastic
RTI etabolic actors
• Septal eviation • Foreign Body • Alcoholism • Nasal Polyps • Smoking
• Allergic Rhinitis • Nasal Surgery • iabetes Mellitus • Juvenile • rugs
Otolaryngologic
• Bacterial/ Viral • Base of Skull Fracture • Adrenal Nasopharyngeal • Radiation

Infection (Influen a) • Nasal Fracture ypofunction Angiofibroma • To in E posure
• Adrenal
yperfunction
• Vitamin B12
eficiency
• inc eficiency
• Malnutrition
285
Tinnitus
Objective
TINNIT S b ective
Tinnitus
Sub ective b ective

( 0 ) ulsatile or Rhythmic (10 )
Vascular uscular
otentially Auscultated
• Myoclonus of
Stapedius/Tensor
Tympani/Palatal Muscles
Arterial Venous • egenerative isease of the
ead and Neck
Otolaryngologic
• Atherosclerosis • AV Shunt • Eustachian Tube
• Idiopathic Intracranial • igh Jugular Bulb ysfunction
ypertension • lomus Jugulare
• Acute E acerbation of • yperthyroidism
Systemic ypertension
• evelopmental Anomaly
• Blood flow in normal
artery near ear
• Persistent Stapedial Artery
• lomus Tympanicum
286
Tinnitus
Subjective
TINNIT S Sub ective

Tinnitus
Sub ective b ective

eard only by patient (Common) eard by others (Rare)
nilateral Bilateral
n Audiogram
n Audiogram
Perform MRI to rule out RC esion
• Acoustic Neuroma
• esion of Cochlear or
Auditory Nerve
No earing oss earing oss Somatic
• Brainstem esion
• Infarction • Metabolic Causes • TMJ
Otolaryngologic
• M ni re s isease Thyroid ysfunction • Bru ism

Vitamin A B inc • Whiplash
eficiency. onductive Sensorineural • Skull Fracture
• Psychogenic An iety earing oss earing oss • Closed ead In ury
epression
• rugs (Salicyclates • esion of E ternal • Noise Induced
Quinidine or Middle Ear • toto icity
Indomethacin) • Impacted • Presbycusis
• Idiopathic Cerumen • rugs (Propranolol
• titis Media evodopa oop
• tosclerosis iuretics)
287 • Congenital
Ophthalmologic
Cross Section of the Eye & Acronyms ............291
Approach to an Eye Exam ...................................... 292
Acute Vision Loss Bilateral..................................... 293
Acute Vision Loss Unilateral ................................. 294
Chronic Vision Loss Anatomic ............................. 295
Amblyopia ..........................................................................296
Diplopia ................................................................................ 297
Pupillary Abnormalities Isocoria ........................298
Pupillary Abnormalities Anisocoria..................299
Red Eye Atraumatic.....................................................300
Ophthalmologic
Red Eye Traumatic ........................................................301

Strabismus Ocular Misalignment...................... 302
Neuro-Ophthalmology Visual Field Defects
..............................................................................................303
289
Dr. John Huang Prima Moinul
Dr. Ying Lu Jessica Ruzicki
Anastasia Aristakhova
Jagdeep Doulla Senior Editor
Kathleen Moncrieff Dr. Monique Munro
Micah Luong
Nazia Panjwani Faculty Editor
Stephanie Yang Dr. Patrick Mitchell
Vikram Lekhi
Ophthalmologic
290
Cross Section of the Eye & Acronyms
Ophthalmology Acronyms
EOM Extra ocular movements

IOL Intraocular Lens
IOP Intraocular Pressure
OD Oculus Dexter (right eye)
OS Oculus Sinister (left eye)
OU Oculus Uterque (both eyes)
PERRLA Pupils Equal, Round, Reactive to
Light & Accommodation
RAPD Relative Afferent pupillary defect
Ophthalmologic
SLE Slit Lamp Exam

VA Visual Acuity
291
Approach to an Eye Exam
1 2 3 4 5
Obvious
Initial Slit Lamp
History Physical Fundoscopy
Assessment Exam
Trauma
A. Visual Acuity A. Lids / Lashes/ A. Retina

B. Pupils Lacrimal B. Optic Nerve/ Disc/
a. Light Reflex, B. Sclera/ Conjunctiva Cup: Disc Ratio
Accommodation, C. Cornea C. Macula
RAPD D. Anterior Chamber D. Fovea
C. Ocular Movements E. Iris E. Blood Vessels
(CN 3, 4, 6) F. Lens
Ophthalmologic
D. Visual Fields by G. Vitreous Humor
Confrontation
292
Acute Vision Loss
Bilateral
A T ON LO B •

Vision oss
A T ON LO B •

Vision oss
Acute hronic
Acute hronic
nilateral Bilateral
Ophthalmologic
nilateral Bilateral
omplete artial omonymous
ther
emianopia
• Infarct • Migraine
• Intracranial emorrhage • Systemic ypoperfusion
293 •omplete
Tumor artial omonymous
ther
emianopia
Acute Vision Loss
A T ON LO •

Unilateral
•
Acute Vision oss

•
•
nilateral Bilateral
ainful ainless
Transient
ptic Nerve ornea Retina Vitreous
Ischemic Attac
• eratopathy • Retinal etachment
• Retinal Artery cclusion
• Retinal Vein cclusion
• Ischemic ptic Neuropathy
No Abnormalities of the Abnormalities of the
ptic Nerve ptic Nerve
Ophthalmologic
• Acute Angle Closure • Temporal Arteritis Retina Visible Retina Not Visible
laucoma (fi ed dilated • emyelination
pupil) • MS
• Visual Corte Infarction • Retinal emorrhage
• • Idiopathic
• • laucoma • Vitreous emorrhage

•
294
•
Chronic Vision Loss
Anatomic
HRON ON LO A •

•
hronic Vision oss
erform slit-‐lamp e am to locali e eft Right on Scheme
Retina ptic Nerve

ens acula Cotton wool spots ptic Trac
ornea Pallor Papilledema
bscure Red Refle Micro aneurysms Visual field defects
rusen or Edema Irregular isc arge
Poor fundus Visibility emorrhage and decrease in color vision
Cup isc
Macular Edema
• eratoconus • Cataract (Nuclear • Age Related Macular • iabetic • laucoma ( pen • ptic Nerve
• Stromal Scaring Subcapsular Cortical) egeneration (Wet ry) Retinopathy Angle) Compression
• Neovasculari ation (Background Pre • Pituitary esion
• Edema Proliferative • Meningioma
Ophthalmologic
• Pterygium Proliferative) • Craniopharyngioma

• Retinitis
Pigmentosa
( ecreased night
vision loss of
HRON ON LO A • Systemic

peripheral vision)
•

inflammatory
conditions •
295 hronic Vision oss

Amblyopia
A B IA •

A B IA •

Amblyopia
Amblyopia
eprivational Strabismic
eprivational
Refractive rror Strabismic
bstruction of Visual A is Refractive rror Abnormal Binocular Interaction
bstruction of Visual A is Abnormal Binocular Interaction
• Ptosis • Severe Anisometripia ( ne ual
• Ptosis • Severe Anisometripia ( ne ual
• Congenital Cataracts
• Congenital Cataracts
Refractive Error)
Refractive Error)
Congenital
• •Congenital Corneal
Corneal pacities pacities • yperopia • yperopia
emangioma
• • emangioma • Astigmatism• Astigmatism
Retinal isease/
• •Retinal isease/ amage
amage (undiagnosed
(undiagnosed
See tra is us scheme
not responsive to treatment) See tra is us scheme
not responsive to treatment)
Ophthalmologic

•
Can cause permanent visual impairment if not treated urgently in infancy 296
Diplopia
I IA
iplopia

onocular • Binocular
•
•
• Refractive Error •
• Cataract/ ens islocation •
• Functional •
• Corneal istortion/Scarring •
• Vitreous Abnormalities
Neuronal traocular uscle

Neuromuscular unction (Non Comitant) Restriction ntrapment
• Myasthenia ravis • rbital Inflammation
• rbital Tumor
• rbital Floor Fracture
Strictly ori ontal
(Cranial Nerve VI problem) ori ontal and or Vertical
Ophthalmologic
Cannot Abduct
• Ischemia
• iabetes Mellitus
• Aneurysm ranial Nerve IV
ranial Nerve III rave s
• Tumor Eye depressed abducted ptosis Eye cannot depress when looking
• Trauma large/unreactive pupil medially phthalmopathy
• Ischemia • Ischemia • yperthyroidism
• iabetes Mellitus • iabetes Mellitus
• Aneurysm • Aneurysm
• Trauma • Trauma
297 • Subdural emorrhage
Pupillary Abnormalities
Isocoria
I AR ABN R A IT S Isocoria
upillary Abnormality
ual (Isocoria) ne ual (Anisocoria)
Relative Afferent upil efect Bilateral Impairment
• ptic Neuritis
• Ischemic ptic Neuropathies ilated upils onstricted upils
• ptic Nerve Tumor
(Mydriasis) (Miotic)
• Retinal detachment
• Traumatic/Compressive ptic • Syphilis (light near dissociation)
Neuropathy • Pharmacologic (e.g pioids Alcohol)
Ophthalmologic
orsal idbrain Neuromuscular unction
harmacologic
(Parinaud s Syndrome) ysfunction
• Tumor • Botulism • Atropine
• emorrhage • S
• ydrocephalus • Cocaine
• Amphetamines
298
Pupillary Abnormalities
Anisocoria
I AR ABN R A ITI S Anisocoria
•
upillary Abnormality
ual ne ual
(Isocoria) (Anisocoria)
hysiological
athological Anisocoria e ual in light and dark
1 cocaine pupils dilate symmetrically
• Simple Anisocoria ( . mm)
Impaired ilation
Impaired onstriction
Sympathetic dysfunction/ orner s
Parasympathetic dysfunction
i ed upil Syndrome miosis anyhydrosis ptosis
Anisocoria greater in light
Anisocoria greater in dark
arge pupil abnormal
Small pupil abnormality
• Angle Closure laucoma (mid fi ed)

• Iritis/Synechiae (not complete fi ation)
• Trauma (not complete fi ation)
Ophthalmologic
reganglionic Neuromuscular
ostganglionic reganglionic ostganglionic
Ptosis opthalmoplegia
Constriction with .1 unction No dilation with .12 ilation with .12
Constriction with .1 No constriction with .1
pilocarpine adrenaline adrenaline
pilocarpine pilocarpine
• culomotor • Tonic (Adie s) Pupil • Pharmacologic • Idiopathic • Cluster eadache
Nerve/Fascicle (Ciliary anglion • Factitious • Trauma • Carotid issection
( ther CN III Findings) esion) • Tumor ( ung Breast • Trauma
Thyroid) • Idiopathic
AR ABN R A ITI S Anisocoria

•
299 upillary Abnormality

Red Eye
Atraumatic
R Y A
•
Red ye
Traumatic Atraumatic
ids rbit acrimal System cular Surface Intermediate ayers Intraocular
• Blepharitis • Subcon unctival • Episcleritis • Acute Angle Closure

• Stye/ Chala ion emorrhage • Scleritis laucoma
• acrocystitis • Con unctivitis • veitis • Endophthalmitis
• Pre septal cellulitis • Corneal Abrasion/ • Iritis
• rbital Cellulitis Erosion
• eratitis/Corneal
lcer
• SV eratitis
Ophthalmologic

•
300
Red Eye
Traumatic
R Y T •

•
Red ye
Traumatic Atraumatic
Blunt Trauma lobe enetrating In ury

Surface In ury yphema diplopia periorbital yphema history of trauma/high Associated In ury
ecchymosis subcutaneous velocity impact reduced visual
emphysema of lid acuity
• Corneal Abrasion • rbital Rim/Mid facial • ids Swelling aceration
• ltraviolet eratitis Fracture • Con unctiva Subcon unctival
• Chemical (Acid alkali) • rbital Floor Fracture hemorrhage
• rbital Ape In ury/ • Cornea Abrasion
Ophthalmologic
Retrobulbar Fracture • Iris aceration iritis

iridodialysis
rgent lateral canthotomy • Pupil Traumatic mydriasis
• ens Cataract dislocation
• Vitreous hemorrhage
• Retina Tear hemorrhage
•

choroidal rupture
• laucoma
• ptic Neuropathy
•
Red ye
301
Strabismus
Ocular Misalignment
STRABIS S cular isalignment •

Strabismus
Rule ut Amblyopia
horia
Tropia
• atent deviation
• Manifest deviation
• Symmetrical corneal light refle
• Asymmetrical light refle
• Negative cover test positive
• Positive cover test
cover/uncover test
• Esophoria (eye moves medial à centre
when uncovered)
• E ophoria (eye moves lateral à centre aretic Non-‐ aretic
when uncovered) Non comitant Comitant
Angle of misalignment changes with direction of Angle of misalignment unchanged with direction of
Ophthalmologic
ga e ga e
• Accommodative Esotropia
(onset 2 yrs hyperopic)
ori ontal ori ontal and or vertical • Congenital Esotropia
(eso/e otropia) (Eso/e otropia hyper/hypotopia mi ed) (contralateral eye deviates
medial à straight when
• CN VI problem • CN III Problem (eye is ipsilateral covered)
(eye cannot abduct) depressed and abducted ptosis • E otropia (contralateral eye
large/unreactive pupil) deviates lateral à straight
• CN IV Problem (eye when ipsilateral covered)
cannot depress when looking
•
medially)
302
Neuro-Ophthalmology
Visual
N FieldO
Defects
ptic Nerve esion

(Monocular vision loss)
ptic hiasm esion

(bitemporal hemianopia) !
• Pituitary/metastatic
tumor
• Craniopharyngioma
• Meningioma
!
ptic Tract esion • ptic nerve glioma

(Incongruous right • Aneurysm
homonymous hemianopia) • Infection
• MS
• Sarcoidosis
Ophthalmologic
ateral eniculate Nucleus eyer s oop esion

esion (Incongruous superior
(Right homonymous homonymous uadrantanopia)
hori ontal sectroanopia)
Right arietal obe esion

(Inferior homonymous
hemianopia)
303
Pediatric
Developmental Delay ..................................................311 Neonatal Jaundice: Approach to Indirect
School Difficulties........................................................... 312 Hyperbilirubinemia…………………….…….......................323
Small for Gestational Age ........................................313 Neonatal Jaundice: Approach to Indirect
Large for Gestational Age ........................................314 Hyperbilirubinemia…………………………........................324
Congenital Anomalies ................................................315 Pediatric Diarrhea………….……….……………...........................325
Headache............................................................................316 Constipation: Pediatric………………………….......................326
Failure to Thrive Adequte Calorie Mouth disorder: Pediatric…………………........................327
Consumption .............................................................. 317 Depressed/Lethargic Newborn………............…….328
Failure to Thrive Inadequte Calorie Cyanosis in the Newborn.........................................329
Consumption ..............................................................318 Limp.........................................................................................330
Hypotonic Infant (Floppy Newborn) ................319 Respiratory Distress in the Newborn..…........…331
Acute Abdominal Pain ............................................... 320 Pediatric Dyspnea……………………………….............................332
Pediatric
Chronic Abdominal Pain……..……………........................321 Noisy Breathing: Pediatric wheezing…..........…333

Pediatric Vomiting………………………….................................322 Noisy Breathing: Pediatric Stridor…….............……334
305
Pediatric Cough: Acute…………............……..……335
Pediatric Cough: Chronic…………………….........336
Respiratory Distress in the Newborn:
Tachypnea……………………………............……............337
Sudden Unexpected Death in
Infancy................................................................338
Enuresis……………………………………..................................339
Apparent Life Threatening Event…….…..340
Pediatric Fractures………………………..................….341
Salter Harris Classification………….........……..342
Sudden Paroxysmal Event………........………..343
Non-Epileptic Paroxysmal Event………...344
Pediatric
Pediatric Epilepsies….……..………………................345
Pediatric Seizures………………….................……...…346
306
Pediatric
Febrile Seizures……………………………...…………………................347 Global Developmental Delay/Intellectual
Pediatric Mood and Anxiety Disorders…....….348 Disability…………………………………....................……………………..361
Abdominal Mass…………………………………………................…....349 Fever (Age <1 Month)……………………………............……………362
Shock…………………………………………...…………………..........………………….350 Fever (Age 1-3 Months)……………………………….........………363
Hypoglycemia…………………………...................……………………….351 Fever (Age >3 Months)…………………………..........…………….364
Altered Level of Consciousness………..............…..352 Failure to Thrive………………………………..................……………….365
Bleeding/Bruising…………………………………………............…...353 Short Stature………………………………….....................………………..366
Thrombocytopenia……………………….............…………………….354 Murmur in the Newborn (<48 Hours)…........….367
Long PT (INR), Long PTT………………………........…………….355 Murmur in the Newborn Beyond Neonatal
Long PT (INR), Normal PTT………………………….....……….356 Period….…………………………………………………...…………………....…..368
Normal PT (INR), Long PTT…………………………....……….357 Preterm Infant Complications
Dehydration……………………………………………...…………………...………358 (<34 Weks)…………………..……………...…………………...........……369
Pediatric
Hyponatremia………………………………...……………….…………………..359 Preterm Infant Complications

Hypernatremia…………………………………...……………....……………..360 (34-36 Weeks)……………………...........………………...............370
307
Anemia by Mechanism……………………………..........…………371 Chronic Kidney Disease …………………………………......……385
Anemia by MCV……………………………………….................………..372 Edema ………………………………........…………………...…………………….…..386
Microcytic Anemia………………………….............……………………373 Dysuria ……………………………...………………….......………………...........…387
Paediatric Infectious Skin Rash………...............….…374 Increased Urinary Frequency…….................…………388
Skin Lesion (Primary Skin)………………………………....…….375 Scrotal Mass. ………………………………………....................…………..389
Skin Lesion (Secondary Skin)…………………….……………376 Lymphadenopathy ………………………............…………………….390
Rash (Eczematous)……………………………………….............…….377 Otalgia (Earache) …………………………...............…………………..391
Rash (Papulosquamous)………………………….......……………378 Sore Throat/Sore Mouth……………………………….....………392
Rash (Vesiculobullous)……………………………........……………379
Rash (Pustular)………………………………………...................…………380
Rash (Reactive)……………………………...................…………………..381
Proteinuria……………………………......………………….…………………………382
Pediatric
Hematuria…………………………………...…………………...……………………..383
Acute Renal Failure………………………………............…………….384
308
Dr. Pamela Veale Debanjana Das Elbert Jeffrey Manalo
Dr. Susan Bannister Cody Flexhaug David Cook
Dr. Kelly Millar Carmen Fong
Dr. Mary Ann Thomas Carly Hagel Faculty Editor
Dr. Andrei Harabor Rebekah Jobling Dr. Marielena Dibartolo
Dr. Jean Mah Beata Komierowski
Dr. Henry Mandin Anuradha Surendra
Dr. Leanna McKenzie Shahbaz Syed
Dr. Ian Mitchell Gilbert Yuen
Dr. Katherine Smart
Dr. Sylvain Coderre
Pediatric
Jaskaran Singh
Christopher Skappak
309
310
Pediatric
Developmental Delay
Pediatric
311
School Difficulties
Pediatric
312
Small for Gestational Age
Pediatric
313
Large for Gestational Age
Pediatric
314
CongenitalNAnomalies
NITA AN A I S
ongenital Anomalies
Isolated ultiple
Association of An

alformation eformation isruption
(Syndromi
• Embryonic development • Abnormal mechanical forces • estruction/ Breakdown of • Chromosomal
failure or inade uacy (often distorting otherwise normal previously normal tissue (e.g. • Single ene
multifactorial) structures ischemia) • Teratogenic
(e.g.e oligohydramnios) • Association (e.g. V
Pediatric
Things to onsider

istory Prenatal maternal health e posures screening ultrasounds delivery neonatal
amily istory Three enerations prior malformations stillbirths recurrent miscarriages consanguinity
hysical am Variants minor anomalies ma or malformation
iagnostic rocedures Chromosomes molecular/ NA radiology photography metabolic
315 iagnostic valuations Prognosis recurrence prenatal diagnosis surveillance treatment
Headache
Pediatric
316
Failure to Thrive
Adequte Calorie Consumption
Pediatric
317
Failure to Thrive
Inadequte Calorie Consumption
Pediatric
318
Hypotonic Infant (Floppy Newborn)
Pediatric
319
Acute Abdominal Pain
Pediatric
320
Chronic Abdominal Pain
Pediatric
321
Pediatric Vomiting
Pediatric
322
Neonatal Jaundice
Approach To Indirect Hyperbilirubinemia
Pediatric
323
Neonatal Jaundice
Approach To Direct Hyperbilirubinemia
Pediatric
324
Diarrhea (Pediatric)
Pediatric
325
Constipation (Pediatric)
Pediatric
326
Mouth Disorders (Pediatric)
Pediatric
327
Depressed /Lethargic Newborn
Pediatric
328
Cyanosis in the Newborn
Pediatric
329
Limp
330
Pediatric
Respiratory Distress In The Newborn
Pediatric
331
Pediatric Dyspnea
Pediatric
332
Noisy Breathing
Pediatric Wheezing
Pediatric
333
Noisy Breathing
Pediatric Stridor
Pediatric
334
Pediatric Cough
Acute
Pediatric
335
Pediatric Cough
Chronic
Pediatric
336
Respiratory Distress In The Newborn
Tachypnea
Pediatric
337
Sudden Unexpected Death In Infancy (SUDI
Pediatric
338
Pediatric Fractures
Pediatric
339
SA T R ARRIS S A IN R ASSI I ATI N S ST
Salter Harris Physeal Injury Classification
Type opulation eatures

I ounger Children Separation through the physis S Straight through
A Above
II lder Children ( ) Fracture through a portion of the physis that e tends through the metaphyses
ower
III lder Children ( ) Fracture line goes below the physis through the epiphysis and into the oint
T Through
Pediatric
IV Fracture ine through the metaphysis physis and epiphysis
R Crush
V Compression fracture of the growth plate
htt aaos org content large g

340
Enuresis
Pediatric
341
Apparent Life Threatening Event
Pediatric
342
Sudden Paroxysmal Event
Pediatric
343
Non-Epileptic Paroxysmal Event
Pediatric
344
Pediatric Epilepsies
Pediatric
345
Pediatric Seizures
Pediatric
346
Febrile Seizures
Pediatric
347
Pediatric Mood And Anxiety Disorders
Pediatric
348
Abdominal Mass
Pediatric
349
Shock
350
Pediatric
Hypoglycemia
Pediatric
351
Altered Level Of Consciousness
Pediatric
352
Bleeding/Bruising
Pediatric
353
Thrombocytopenia
Pediatric
354
Long PT (INR), Long PTT
Pediatric
355
Long PT (INR), Normal PTT
Pediatric
356
Normal PT (INR), Long PTT
Pediatric
357
Dehydration
Pediatric
358
Hyponatremia
Pediatric
359
Hypernatremia
Pediatric
360
Global Developmental Delay/Intellectual Disability
Pediatric
361
Fever (Age <1 Month)
Pediatric
362
Fever (Age 1-3 Months)
Pediatric
363
Fever (Age >3 Months)
Pediatric
364
Failure To Thrive
Pediatric
365
Short Stature
Pediatric
366
Murmur In The Newborn (<48 Hours)
Pediatric
367
Murmur In The Newborn Beyond Neonatal
Period
Pediatric
368
Preterm Infant Complications (<34 Weeks)
Pediatric
369
Preterm Infant Complications (34-36 Weeks)
Pediatric
370
Anemia By Mechanism
Pediatric
371
Anemia By MCV
Pediatric
372
Microcytic Anemia
Pediatric
373
Paediatric Infectious Skin Rash
Pediatric
374
Skin Lesion (Primary Skin)
Pediatric
375
Skin Lesion (Secondary Skin)
Pediatric
376
Rash (Eczematous)
Pediatric
377
Rash (Papulosquamous)
Pediatric
378
Rash (Vesiculobullous)
Pediatric
379
Rash (Pustular)
Pediatric
380
Rash (Reactive)
Pediatric
381
Proteinuria
Pediatric
382
Hematuria
Pediatric
383
Acute Renal Failure
Pediatric
384
Chronic Kidney Disease
Pediatric
385
Edema
386
Pediatric
Dysuria
Pediatric
387
Increased Urinary Frequency
Pediatric
388
Scrotal Mass
Pediatric
389
Lymphadenopathy
Pediatric
390
Otalgia (Earache)
Pediatric
391
Sore Throat/Sore Mouth
Pediatric
392
General Presentations
Fatigue................................................................................... 395
Acute Fever .......................................................................396
Fever of Unknown Origin / Chronic Fever . 397
Hypothermia.....................................................................398
Sore Throat / Rhinorrhea ........................................399
393
Dr. Heather Baxter Adrianna Woolsey
Dr. Harvey Rabin Fatima Pirani
Dr. Ian Wishart
Brittany Weaver Senior Editor
Geoff Lampard Dr. Monique Munro
Harinee Surendra
Kathy Truong Faculty Editor
Dr. Sylvain Coderre
394
Fatigue
ATI
atigue
clude Sleep isturbance ifestyle Issues regnancy
rganic tiologies No rganic tiologies
ndocrine Neoplastic hronic

Infectious harmacologic sychogenic Idiopathic
etabolic ematologic isease
• Anemia • Endocarditis • ypnotics • An iety • Chronic Fatigue
• Malignancy • Tuberculosis • Anti • Somati ation Syndrome
• Epstein Barr hypertensives isorder
Virus • Anti epressants •Malnutrition/
• epatitis • rug Abuse rug Addiction

• IV (e.g. Alcohol)
• rug Withdrawal
ndocrine etabolic
• ypo/ yper • Renal Failure Autoimmune ardio-‐

thyroidism • iver Failure Inflammatory
Neurologic
pulmonary
• iabetes • ypercalcemia
• Pituitary • Rheumatoid • Congestive • epression
Insufficiency Arthritis eart Failure • Multiple Sclerosis
• Adrenal • Celiac isease • Chronic • Stroke
Insufficiency •S E bstructive • Parkinson s
• Polymyalgia Pulmonary • Myasthenia
395 Rheumatica isease ravis
Acute Fever
A T V R
ever (acute onset)
Infectious Non-‐infectious
Viral Bacterial ther Inflammatory Iatrogenic ndocrine ther
• Rhinovirus • Fungal • PE • Transfusion • Thyroid storm • eat stroke

• Influen a Virus • Proto oa (eg. • Thrombophlebitis reaction • Acute Adrenal • Sickle Cell
• Parainfluen a Virus malaria) • VT • Malignant Insufficiency disease
• Adenovirus • ther parasites • Pancreatitis yperthermia • rug fever
• Enterovirus • Neuroleptic • MI
• Coronavirus malignant
• IV syndrome
Bacteremia Septic Shoc Acute rgan

Abscess
Specific Infection
• Intermittent Bacteremia • pper Respiratory • ead and neck

• Continuous Bacteremia Tract Infection • Thoracic
• rinary Tract • Abdominal
Infection • Pelvic
• Pneumonia • E tremity
• Pyelonephritis
• Meningitis
• Skin Infection 396
Fever of Unknown Origin / Chronic Fever
V R N N WN RI IN R NI V R
ever of un nown
origin chronic fever
Infection Neoplasm Autoimmune ther
•N •S E • rug fever
• odgkin s • RA • Factitious fever
lymphoma • Polyarteritis nodosum • Trauma Non
• eukemia • iant cell arteritis infectious
• Solid tumors • Sarcoidosis hepatitis
• Recurrent PE
Bacterial Viral ther
• IV • Fungal
• EBV • Proto oa (eg.
rgan Specific
Non-‐organ specific • CMV malaria)
Infection • other parasites
• Viral hepatitis
• Infectious •Brucellosis
• Enterovirus
endocarditis • Q fever
• steomyelitis • Salmonella
• ccult abscess • ersinia
• Sinusitis • Tuleremia
• Cholangitis • Septic Phlebitis
• TI • Rheumatic fever
• Meningitis • yme disease
• TB
397 • Whipple s disease
Hypothermia
T R IA
ypothermia
nvironmental Acute Illness
• Immersion
• Non Immersion
ac of Body eat Improper
Body eat oss ther
eneration Thermoregulation
• rugs/To ins • ypothyroidism • Cerebrovascular Accident • Trauma
• Iatrogenic • Adrenal Insufficiency • Central Nervous System • Sepsis
• Burns • ypoglycemia Trauma • Vascular Insufficiency
• Malnutrition • Multiple Sclerosis • remia
• rugs/To ins
398
Sore Throat / Rhinorrhea
S R T R AT R IN RR A
Sore Throat Rhinorrhea
ommon viral pathogens

Rhinovirus oronavirus Influen a virus arainfluen a Virus Adenovirus erpes Simple Virus
nterovirus ( o sac ie cho) pstein Barr Virus ytomegalovirus IV
ost common bacterial pathogen
roup A Beta emolytic t e to o s o enes ( AB S)
redominantly Rhinorrhea redominantly Sore Throat

Acute hronic Acute hronic
• Acute Viral Sinusitis • Allergic/Vasomotor/ rug • ER

• Acute Bacterial Rhinitis • Environmental
Sinusitis • Nasal Polyposis • Trauma
• Acute ead Cold • Chronic Sinusitis • Foreign Body
Syndrome • Nasopharyngeal Cancer • Neoplasm
Viral Bacterial
• Acute viral Pharyngitis • Streptococcal

• Acute Influen a Tonsillopharyngitis
• Acute Viral aryngotracheitis • Peritonsillar Abscess
• Acute Viral Tracheobronchitis • udwig’s Angina
• Acute Infectious
Mononucleosis
399 • erpangina
Historical Executive Student Editors
2016-2017 Joshua Nicholas, Peter Rogers & Scott Belyea
2015-2016 Jared McCormick & Hai (Carlos) Yu
2014-2015 Jared McCormick & Hai (Carlos) Yu
2013-2014 Yang (Steven) Liu & Brian Glezerson
2012-2013 Neha Sarna & Sarah Sy
2011-2012 Katrina Kelly & Harinee Surendra
2010-2011 Jonathan Dykeman & Kathy Truong
2009-2010 Lucas Gursky & Ting Li
2008-2009 Linnea Duke & Mustafa Hirji
2007-2008 Brett Poulin (Founder of the Calgary Black Book Project)
401
Scheme Creators
Students Faculty
M. Abouassaly V. Lekhi K. Burak A. Peets
A. Aristarkhova S. Lipkewich D. Burback G. Pineo
M. Broniewska C. Lu K. Busche M-C. Poon
P. Chen L. Luft S. Casha H. Rabin
M. Chow A. Lys M. Clark T. Remington
R. Cormack D. McDougall S. Coderre B. Ruether
P. Davis B. McLane M. Doran A. Smithee
L. Duke J. McMann P. Federico O. Suchowersky
J. Evinu J. Nadeau K. Fraser P. Veale
A. Geist B. Poulin S. Furtado B. Walley
F. Girgis V. Prajapati N. Hagen L. Welikovitch
A. Hicks N. Ramji J. Huang R.C. Woodman
J. Hodges K. Sahi N. Jette L. Zanussi
G. Ibrahim R. Schachar A. Jones
C. Johannes P. Schneider G. Klein
D. Joo R. Simms S. Kraft Missing a credit?
S. Khan A. Skinn A. Mahalingham If you are the creator of a
L. Kimmet U. Unligil H. Mandin scheme currently used in
M. Klassen C. Verenka J. Mannerfeldt the Blackbook and believe
J. Lawrence H. Waymouth K. McLaughlin you have not been credited
J. Laxton P. Zareba D. Miller appropriately, please
K. Leifso K. Swicker L. Parsons contact us at
J. McCormick V. David D. Patry blackbk@ucalgary.ca
402
Abbreviations
AAA Abdominal Aortic Aneurysm DKA Diabetic Ketoacidosis
ACE Angiotensin-Converting Enzyme DRE Digital Rectal Exam
ACTH Adrenocorticotropic Hormone DVT Deep Vein Thrombosis
ADPKD Autosomal Dominant Polycystic Kidney Disease EABV Effective Arterial Blood Volume
ADH Antidiuretic Hormone ECF Extracellular Fluid
AIN Acute Interstitial Nephritis ENaC Epithelial Sodium Channel
ALS Amyotrophic Lateral Sclerosis FEV1 Forced Expiratory Volume in One Second
ARB Angiotensin Receptor Blocker FJN Familial Juvenile Nephronophthisis
ARF Acute Renal Faliure FSGS Focal Segmental Glomerulosclerosis
ARPKD Autosomal Recessive Polycystic Kidney Disease FSH Follicle Stimulating Hormone
BPH Benign Prostatic Hypertrophy FVC Forced Vital Capacity
CCD Cortical Collecting Duct GBM Glomerular Basement Membrane
CHF Congestive Heart Failure GERD Gastrointestinal Esophageal Reflux Disease
CIN Chronic Interstitial Nephritis GFR Glomerular Filtration Rate
CLL Chronic Lymphocytic Leukemia GHRH Growth Hormone Releasing Hormone
CNS Central Nervous System GH Growth Hormone
COPD Chronic Obstructive Pulmonary Disease GI Gastrointestinal
CRF Chronic Renal Failure GN Glomerulonephritis
CRH Corticotrophic Releasing Hormone GnRH Gonadotropin Releasing Hormone
CT Computed Tomography GPA Granulomatosis with Polyangiitis
DCIS Ductal Carcinoma In Situ GRA Glucocorticoid
DHEA Dehydroepiandrosterone GTN Gestational Trophoblastic Neoplasm
DHEA-S Dehydroepiandrosterone Sulfate H+ Hydrogen
DIC Disseminated Intravascular Coagulation HCG Human Chorionic Gonadatropin
403
HDL High Density Lipoprotein LPL Lipoprotein Lipase
HELLP Hemolysis, Elevated Liver Enzymes, Low Platelets MCD Minimal Change Disease
HIV Human Immunodeficiency Virus MCH Mean Corpuscular Hemoglobin
HPL-1a Human Peripheral Lung Epithelial Cell Line 1a MCHC Mean Corpuscular Hemoglobin Concentration
HRT Hormone Replacement Therapy MCV Mean Corpuscular Volume
HSP Henoch-Schönlein Purpura MEN Multiple Endocrine Neoplasma
HSV Herpes Simplex Virus MI Myocardian Infarction
HUS Hemolytic-Uremic Syndrome MPA Microscopic Polyangiitis
IBD Irritable Bowel Disease MPGN Membranoproliferative Glomerulonephritis
IBS Irritable Bowel Syndrome MS Multiple Sclerosis
ICP Increased Intracranial Pressure MSK Musculoskeletal
ICU Intensive Care Unit Na+ Sodium
IGF Insulin-like Growth Factor NSAIDs Non-Steroidal Anti-Inflammatories
INR International Normalized Ratio OCP Oral Contraceptive Pill
ITP Idiopathic Thrombocytopenic Purpura OSM Osmolality
IUGR Intrauterine Growth Restriction PE Pulmonary Embolism
IV Intravenous PID Pelvic Inflamatory Disease
IVP Intravenous Pyelogram PMN Polymorphic Neutrophils
JVP Jugular Venous Pyelogram POSM Plasma Osmolality
K+ Potassium PPROM Preterm Premature Rupture of Membranes
KUB Kidney, Ureter, Bladder PROM Premature Rupture of Membranes
LCIS Lobular Carcinoma In Situ PT Prothrombin Time
LDL Low Density Lipoprotein PTH Parathyroid Hormone
LGA Large for Gestational Age PTT Partial Thromboplastin Time
LH Luteinizing Hormone PUD Peptic Ulcer Disease
LLN Lower Limit of Normal PUJ Pelviureteric Junction
LOC Level of Consciousness RAPD Right Afferent Pupillary Defect
404
RAS Renal Artery Stenosis
RBC Red Blood Cell
RTA Renal Tubular Acidosis
SGA Small for Gestational Age
SLE Systemic Lupus Erythematosus
TORCH Toxoplasmosis, Other (Hepatitis B, Syphilis,
Varicella-Zoster virus, HIV, Parvovirus B19), Rubella,
Cytomegalovirus, Herpes Simplex Virus
TSH Thyroid Stimulating Hormone
TSHR Thyroid Stimulating Hormone Receptor
TTKG Transtubular Potassium Gradient
TTP Thrombotic Thrombocytopenic Purpura
UTI Urinary Tract Infection
US Ultrasound
VACTERL Vertebral Anomalies, Anal Atresia, Cardiovascular
Anomalies, Tracheoesophageal Fistula, Esphageal
Atresia, Renal Anomalies, Limb Anomalies
VSD Ventricular Septal Defect
VUJ Vesicoureteral Junction
405
Notes

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This material is for educational purposes only.

It is not to be used to make medical decisions.

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Produced by The Cumming School of Medicine, University of Calgary

Chief Editors Faculty Editor

First Edition 2007 (Reprint 2008) Eighth Edition 2015

This material is covered by the following Creative Commons License:

Medical presentation schemes conceived by Henry Mandin.

Printed in Calgary, Alberta, Canada.

As always, we welcome feedback, suggestions, edits, or ideas for new schemes.

These meaningful configurations or systematically arranged networks of connected facts are

Dr. Henry Mandin

A Message from the Editors .................... v Shock .........................................................................................13

Musculoskeletal 249 Psychiatric 265

Narrow QRS (<120 msec) Wide QRS (>120 msec)

May present as palpitations di iness

ardiac Non-­‐ ardiac

hest iscomfort Chest Discomfort

Outflow Obstruction Ischemic

utflow bstruction Ischemic Non-­‐Ischemic

5 * Denotes acutely life-threatening causes

* Denotes acutely life-­‐threatening causes

scular Pulmonary/Mediastinal Other

Chest Wall/Pleura Parenchymal

* Denotes acutely life-threatening causes 6

hest iscomfort Chest Discomfort

ardiovascular ulmonary Cardiovascular

• Gastro-Esophageal Reflux • Costochondritis

ogenous Renal Renal

• Corticosteroids • Renal Renal parenchymal

re-­‐e isting ypertension estational ypertension

No roteinuria roteinuria ( .3g/2 hr urine) No roteinuria roteinuria ( .3g/2 hr urine)

Impaired ontractility Increased Afterload Impaired iastolic illing

Rule out eft-­‐Sided

yocardium Valves ericardium arenchyma Vasculature

ulsus Alternans ulsus arado us

Warm E tremities Cold E tremities

igh JVP ow JVP

bstructive Shoc ypovolemic Shoc

Normal/ ecreased (Rule out ecompensated

Neurocardiogenic ardiac Respiratory ther

• Vasovagal • Pulmonary Embolism • ypoglycemia

Stro e Volume eart Rate Rhythm

• MI • Mitral/Aortic • Blood • VT/VFib • Sick Sinus Syndrome (SA

Supravalvular Subvalvular Valvular

• Aortic Coarctation • ypertrophic bstructive

Stenosis (rings webs) • Subvalvular Aortic Stenosis

itral Regurgitation Tricuspid Regurgitation

apillary uscle ilation of Right

arly iastolic id-­‐ iastolic ate iastolic

• Aortic Regurgitation • Mitral Stenosis • Mitral Stenosis

Excessive Daytime Sleepiness .............................. 32

p < p -­‐ > p <

Respiratory Acidosis etabolic Al alosis Respiratory Al alosis

Elevated igh Anion Normal Anion ap hronic Acute hronic Acute

23 * Potentially acutely life-threatening

Pleural Processes Processes that can

* Potentially acutely life-threatening 24

ardiac hest Wall ung

• Cardiac Tamponade • Rib Fractures • Pulmonary Contusion

hronic ough ( > w s ) ough yspnea ever

Normal hest -­‐Ray Abnormal hest -­‐Ray

pper Airway ower Airway ther

ardiac Non-‐ ardiac

utflow bstruction Ischemic Non-‐Ischemic

* Denotes acutely life-‐threatening causes

re-‐e isting ypertension estational ypertension

Rule out eft-‐Sided

arly iastolic id-‐ iastolic ate iastolic

p < p -‐ > p <

Normal hest -‐Ray Abnormal hest -‐Ray

ommunity-‐ eripheral Stigmata

Negative ositive T-‐ A or

Well s riteria for Negative Non-‐ ositive

Extrinsic to Intrinsic to Complement-‐ Mechanical

eritonitic Non-‐ eritonitic

onstant ramping leeting ost-‐ randial

onstant ramping leeting ost-‐ randial

onstant ramping leeting ost-‐ randial

> 2-‐ loose stools day >1 -‐2 g day >