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Crush the Boards

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The Ultimate USMLE Step 2 Review

FIRST INDIAN EDITION 2001
0 2000 by Hanley & Beifus, Inc.

This edition has been published in India by arrangement with Hanley & Belfus, Inc.. Medical Publishers, 210 South 13th Street, Philadelphia, PA 19107. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission from the publisher. For sale in India, Bangladesh and Sri Lanka only. Publishedby Jitendar P Vij Jaypee Brothers Medical Publishers (P)Ltd EMCA House, 23/23B Ansari Road, Uaryaganj New Delhi 110 002, India Phones: 3272143, 3272703. 3282021 Fax: 011-3276490 e-mail: jpmedpub@del2.vsnl.net.in Visit our web site: http://www.jpbros.20m.com

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. . . . . . . . . . . . . . . . .9 39 43 4 Gastrocnteroki yy . . . . . . . . . Neiirology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 131 147 155 Genenal Siirgwy Ophthalmology v . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 1 1 Internal Medicine . . . . . . . . . . Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Iiitrodiictiori . . . . . . . . . . . . . . . . . . . . . Cardiovascular Medicine . . . . . . . . . . . . . . . Endocrinology Nephrology . . . . . . . . . 7 Rhcumatolog y Hematology Oncology 47 51 59 69 79 87 I 14 Infectious Disease Dcrmatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ilpiderniology ami Biostatistics . . . 17 l’ulmonology . . . . . . . . . . . . . Psychiatry Gynecology Ohstetrics . . . . . . . . . . . . . . . . . . . . . . . . I’rwcntive Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 I?. . . . . . . . . . . . . . . . . . . . . . . .5 . . . . . 25 2. . . . . . . . . . . . . . . . . . . . . . . . Genctics 95 99 103 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . Symptoms. . . . . . . . . . . . . .. . . . . . . . . . . Signs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 173 175 179 181 .. . . . . . . 193 195 197 . . . . . . and Syndrornes Abbreviations . . . . . . . . . . . . 161 165 . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . Vascular Surgery Ilroloyy . . . . . . . . . . . . . Nose. . 27 Emergency Medicine . . . Pharriiacology . . . . . . . . . . . . . 207 219 Index . . . 203 . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . Neurosurgery . . . .. Pediatrics . . . . . . . . . . . . .. . . . . . . . . . . . 185 191 30 31 Radiology . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .vi Contents 22 23 Orthopedic Surgery . . . . . andThroat Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Photos . . . . . . . . . . . . . . . . . . . .. Laboralory Medicine Ethics . . . . 24 25 Ear. . . . . . . . . . . . . . . . . .. . . . . . .. .. . . . . . . . . . . . . . .

Step 2 stresses tlie things that are necessary to he a good first~.Yoii don'^ have vii . Don’t forget to st. linless tlie patient is rrnstable and immetii-. Cardiac pathophysiology is high-yield. It is much more high-yield to know rare complications and presentations of common diseases.year resident in the emergency room or a general clinic. Yon must know cut-off values for the treatment of common conditions (at what iitrrnhers d o you treat hypertension arid byperi:liolesterolernia. as well as pharmacology and microbiology (which hugs cause which conditions in specific patient populations). The other topics that frequeiitly appear on Step 2 are treatable emergency conditions. knowing the next step. Usually. as a fiiture house officer. may have to diagnose and treat at three o’clock in the morning while on call.This hook was written because I felt tlicre was not a good. high-. manage. A presentation may he normal (especially i n pediatrics arid psychiatry) and necd n o trcatment! 4. these are the situations that you.ted. when you are asked about a rare disease. and treat coinrnon conditions is stressed. what would yon do? What kinds of questions would you ask the patient? What tests would you order? What medications might you give? Tliere are also five geiieral tips I would like to pass on to those preparing for Step 2: 1. tliough. as is common EKG pathology The behavioral science/psychiatry questions are also siniilar to those in Step 1 Overall. Knowing how to diagnose. Always get more history when it is an optiori. I f a patient presents with chest pain. and a t what C114 counts d o you need clrernoprophylaxis in HIV?) 3. and that focus is clinical. Knowing how to niaiiage exotic or rare conditions is low-yield. Not just theory. comprehensive. . Step 2 has a different fbcus. Sonre inforination from Step 1 is high-yield for Step 2. ate action is needed. but if you know all the concepts in this book. Remember. Epidemiology and biostatistics are . Just 1)ecause you never took air ophthalinology r o t a h n doesn’t mean tlicrc won’t be any questions ahout it on the exam. you should do inrich hetter than just pa yon should CRUSH THE BOARDS! Step 2 is the same level of difficulty as Step I .TIie exam covers a Lot of information. you simply need to recognize i i from a classic presentation. hut practice--in other words.udy your subspccialties.yield review hook for the USMLE Step 2. but the questions are more relevant to the practice of medicine. The goal of tlie book is to provide information that has appeared on recent administrations of Step 2.

hut knowing coininon and life-threatening diseases in the stibspccialtics can increase yon score substantially 5.. Studying for Step 2 can seen1 like an overwhclming task. M. Adam Brochert.. Introduction to be an expert.viii . most need a concise review or the tested topics. Given the rime constraints of medical students in iheir clinical years. . Kernember that residency programs don’t usually see the breakdown of your score. only those magic 2. It is my hope that CIWSHTI4E BOARDS will meet your needs in this regard. don’t skip stitdying a subject because you hate i t and aren’t going into it).and 3-digit overall scores (in other words.D..

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Internal Medicine

Hypert.ensive emergencies: usually occur wlren hlood pressure is > 200/ 1 00 mmHg. lkfined as l i y ~ x r ~ e n s i o n acute md-organ damagc (i.c., severe liypertension plus one of thc folwith lowing: acute left ventricular failure, unstahle angina, myocardial infarction, or encephakqm thy; symptoms include one or more of the following: headachcs, mental status changes, vomiting, blurry vision, dizziness, papilledema). Hypertensive emcrgencies are a n exception to the rule of ineasuring blood pressure 3 timcs befbre treating! Use nitroprusside, nitroglycerin, diazoxide, or lahetalol emergently. Secondary hypertension: clues incliide onset heforc 30 o r after 55 years of age and other suggestive history o r lab values. In a young woman, the m i s t crxnmon cause is hirtli control pills due to fibrous dysplasia (renal oiitiiiue them), followed hy renovascular hypertensi bruit: use intravenous pyclogram or arteriogram fbr diagn treat with balloon dilatation or aiigioplasty). In a young man, think of excessive alcohol intake or exotic conditions (pheochromocymna. Cushing's syndronie, Conn's syndrome, polycystic kidney disease). In elderly patients with new-onset hypertension, think renovasciilar Iiyxrtension due to atherosclerosis (renal bruit: ACE inhibitor prccipitates renal failure). If you suspect secondary hypertension (95% of cases of hypertension are essential, primary, or idiopathic), remember the following hints arid tests to order:

1. Plieoclirornocytoma: urinary catectrolamines (vanillylrnandelic acid, metanephrine) plus intermittent severe hypertension, dizziness, and diaphorcsis 2. Polycystic kidney disease: flank mass, family history, elevated blood urea nitrogen, creatinine
3. Cushing's syndrome: dexamethasone suppression test or 24-hr urine cortisol level 4. Kenovascniar hypertension: intravenous pyeiogram o r angiogram; loiik for bruit

5. Conn's syndrome: high aldosterone, low renin

. Coarctation of ttic aorta: upper cxtrernity hypertension only, uneqrial pulses, rad iofeinoral
dclay, associated with Turner's syndrome, rib notchirig on x-ray

Note: loweriiig hlood pressure lowers risk for stroke (hypertension is the m o s t irnportant risk factor), heart disease, myocarclial infarction, rcnal fiiilure, alherosclerosis. aird dissccting aortic aucurysni. Coronary disease is the mast common cause of drat11 arnmg untreated lrypertcnsivc patients. 1)oii't forget to trcat isolawd systolic or diastolic liylyl'ertcnsion if it persists. Note: Nitroprusside dilates arteries arid veins. wlrereas nitroglycerin is a verrodilator only and othtxr medications arc arterial dilators only (hydralazine, alpha I antagonists, calciiini clianuel

Internal Medicine

blockers). Vt.nodilators reduce preload, whereas arterial dilators reduce afterload (nitroprusside does hoth).

Universal screening is geiicrally not recommended. Screening in patients who arc obese, > 45 years old, have a positive family history, or are mcmhers of certaiii ethnic groups (black, Arnericaii Indian, Ijispanic) is niore accrpted hut not iinifixmly
Classic symptoms of diabetes are polydipsia, polyuria, polyphagia and weight loss. Diagnosis

is made by a fasting plasma glucose 2 126 iiig/dl (after a n overnight fast) or a random glucosc (no fasting) 2 200 mg/dl. If the patient lras classic symptoms. one ineas~irciiieirti s enough t o (:onfirina diagnosis, hut in ail asymptomatic paticot, the test sbould tic repeated. Rarely, an oral glucose tolcrancc test (OGT’J’) is done arid DM is diagnosed W ~ C I Ilcvrls 2 200nig/dl are rcached withill or at 2 hours after a 75-gm glucose load is administered orally.

The goal of treatment is to keep postprandial glucose < 200 mg/dl and fasting g l ~ ~ c o <e 130 s mg/dl. Stricter control results in too many episodes of hypoglycemia (look for symptoms of syrnpatlietic discharge and mental status changes)

Important points:

I. Rcmeinbcr tlic iniportaiice (6Gpepiide in distir~guisliing hctwccrr too mricli cxogcnous
inulin (low C.-peptide w i t h accidental overdme in a diaIx3tic o r factitious disorder) and an iiisuliiioma (high C-peptide).
2. Bccaosc IV contrast agents can precipitatc acute renal failure i n diabetics and other rcnd patients, yori should u s e contrast only if ahsolutcly iicccssary Makc surc that the patient is well-hydrated befbre using contrast agcllts in diahelics aiid Telial patients t o prrvent
rt.iinl darnage.
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3. I>iagrrosis of diabetic ketoacidosis (type I cliahctes mellitus) req iiircs liypvrglyccrnia. hyperke.tonemia. and ineraholic acidosis. Treatment involvcs fluids, 1V regrilar in sulirr , and potassirrm aiid phospliorus rcplact~incnt. not IISC hicarbonate i.iiiJcss the pI 1 i s < 7.0. 110 Scarch f i r tlie causc, which oftcn is irifectiori.Tlw inornlity rate is a h i t 10%.

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Internal Medicine

4. Diagnosis of nonketotic liyperglyceinic liypcrosm(11arstate (type 11 diahetes mellitus)

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quires hypcTglyceniia and hyperosmolarit.y without kctoneinia. Treatment involves fluids, lluids, flnids. IV insnlin, and electrolyte replacernent.The iiiortality rate is abont 50%.

Long-term complications of diabetes siiclli tiis include atlicrosclcrosis. coronary artery disease, myocardial infarction, retinopathy, a i d rreplir(ipatliy. Use of ACE inhibitors helps t o prevent ncphropathy; 30% of cnd-stage renal disease is causcd by diabetes mcllitns. Diabetes is associated with a n incrcased risk of infectioiis, peripheral vascular disease (claudication. atrophy), gangrene (the niost common cause for nontraumic amputatiim is diabetcs), and neuropathy. Peripheral neuropathy (autonomic and sensory) causes many problems in diabeti5:s:
m

Castroparcsis (early satiety, nausea; treat with metocloproniide and cisapride)
Cliarcot's joints (detbnned joints dut: to lack of sensalion; patient piits too m u c h stress 011 joints)
Irnpotcnce (from arrtononiic neuropathy as well as peripheral vascular disease)

Cranial nerve palsies (especially 3,4,6-ocular palsies; usually resolve sponraneously witliisi a few niontlis)
Orthostatic hypotension (due to lack of effective sympathetic innervation; when patient stands up, heart rate and vascitlar tone d o not increase appropriately to maintain blood

pressure) Note: Diabetics commonly have n o chest pain with a myocardial infarction because of sien.. ropatliy ("silent" MI). Diabetics are also prone to foot infections, ulcers and gangrene because they cannot feel their feet and blood flow is poor so that infection does not heal well. Patients shoold wear comfortable, properly fitting shoes and regularly inspect their own feet. When retinopathy becomes proliferative, the treatment is panretinal laser photocoagulation to prevent progression and blindness. A l l diahetics sllould be followed once a year by an ophthalmologist t o monitor retinal changes.
Know how to u s e regular and neutral protamine Hagedorn (NPH) insuliii. Regular insulin = : 45 iniiiutcs until onset, peak action at 3--4 hr, and dnration d a c t i o n for 6-8 hr. NPH insnliil = 1 - 1 3 hr until onset, peak action at 6 - 4 lrr, and dnration of ahont 1%-20 lir.
a If patient has liigh (low) 7 night before.
m

AM

glucose, increase (decrease) NPIl insulin at dinner the
AM

If patient has high (low) noon glucose, increase (decrease)
If patient has high (low) 9
PM

rcgrilar insulin.

If patient h a s high (low) 5 I'M glucose. increase (decrease) rnorning NPH.
I

glucose, increase (decreasc) dinner time regular insulin.

Soinogyi effect vs. dawn phenomenon. The Soinoyyi clfect i s the body's reaction to hypoglycemia. If too rniicli NPI-T insulin is given at dirincr time the night hi4bre, the 3 AM glucose will be low (hypoglycemia) .The body reacts by releasing stress hormoncs, which caiise the 7 AM glucose to he high. Treatnicnt is t o decretisc insnlin. The dawn pbeiiorneuori is hyperglyi'cmia cnnsed b y normal ciarly AM grow111 liorsnorx sccretion. 7 AM glnu~sc high. without 4~AM hyis piiglycernia (glucose nornral or high at 4 ~ ~ ) . ' l r ~ a t n i e i r(1 itrcrcase insulirr. is i t

Follow cornpliance with hcrniiglohin Alc level, which i s a n accurate ineasiire of overall ~ 0 1 1 trol fin the p r w i o i i s 3 rrionths. Patients arc not afraid t o fudge thcir Iioine test nurnhcr t o pleas(!
their doctors, and this is rhe way t o catch them

Internal Medicine

5

For surgery, patients with diabetes are allowed nothing by mouth (NPO). Give one-third t o one-half of normal insulin dose, then monitor glucose closely through case and postoperatively, using 5% dextrose in water (DSW) and IV regular insulin to maintain glucose control.

Medications in diabetics: Chlorpropamide may cause syndrome of inappropriate secretious of antidiuretic hormone (SIADH), Patients with type I DM are not helped by sulfonylurea medications. Avoid beta blockers, which prevent many of the physical manifestations of bypoglyce~nia (tachycardia, diaplioresis); therefore, neither you iior the patient will know if the patient is be-. coming hypoglycemic.

Measure total cholesterol and high-density lipoprotein (tlU1.) every 5 years (uiiless abnormal), starting at age 20 (although t h i s recommcndation i s 1101 universally accepted). Start ear-~ lier if tlie patient is obese o r has a strong farnily Iiistory. Look for xanthelasma (know what it looks like), corneal arcus (in younger patient.s), lipemic-looking srrnrn, arid obesity as markers of possible familial hypercholesterolemia. Family members should be tested. Also, look for pancreatitis with n o risk factors (e.g., n o alcohol, gallstones) as a marker for familial liypertri glyceridemia.

permission.)

Risk factors for coronary lieart disease (I.,lX. and ror.al cbolrsterol are risk factors for CHI>, hut do not count t l v m in deciding to treat or not to treat high cholesterol): Age (men 2 4.5, women 2 5s or with Iirematnrc merinpanse and therapy)
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estrogen replacement

exercise and estrogens. uremia. decreasc alcohol arid smoking. Siiioking is tlic single most significant source o f prcvrntahlc morbidity a n d prelnatnre dcath in tlie United States. exercise) befire initiating drng therapy. Be aware of secondary causes of byperlipide~~a: uncontrolled diabetes mcllitns.g. If you give a patient one risk hXor fbr being iualc. glucocorticoids. 1. they arc used first orrly if the other two choices are iiot appropriate or if patient has extrcrriely high cholesterol (> 300 mg/dl.111. androgens.IIUL -. Atherosclerosis is the innst important cause of perinan(!nt disability and accounts for more hospital days than any othcr illness (traiislatiom: understand ntherosclerosis for the Dottrds) . cliolesterol. Note: l-ligli N D L is protective against atlierosclcrosis and is illcreased by moderate alcohol ~011somption ( I --2 drinks/day) hut not high alcohol iutakr. obstructive liver disease. First-line agents are niacin (poorly tolerated but effective) and bile acid-hindiug resins (t:. and saturated fat in diet. Wlieri(:ver yon . .) ~d Male sex is also considered a risk factor because inen develop coronary heart disease earlier than women (hut postmclropansal wornen quickly catch up with age-matched I T I ~ I I ) . can t l i e i i be calculated from tlic formula I. excessive alcohol intake (increases triglycerides).. wlriclr is a marker for familial hyper~:liolcsterolemia). Note: Iipoprotein analysis involves incaniring total cholesterol. hypothyroidism.ire riot siire which risk factor to rlirninate. IIDL is decreased by smoking. hot when associated with high cholesterol caiises more coronary hc.(triglycerides/S) Note: Always give new patients at least 3 monrtis to try lifestyle modilications (dccrcase c a l o ~ ~ ries. and liyr’ertriglyceridel~lia. Atcherosc. . 2 60 nig/dl is considered t o be protective and negates one risk lactor. smokii~g a safk is guess. Obesity is not a i l independcnt risk factor for boards piirposcs. cholcstyraniine). llDL and triglyccrides.Internal Medicine Family history of premature ( X I 1 (defincd as definite myocardial infarctio~~ sudden or death in fatlier/first-degree male relative < 5 5 years old or mother/lirst-degree female relative < 6 5 years old) Cigarette smoking (> 1 0 cigarettdday) B Hypertension (2 I40/90 rninHg or on aiitiliypcrtcnsive rnedications) Diabetes mellitus I Low 111X (< 35 mg/tll) (Note: 11111. Str and type A personality ( h J k fbr a liard-driving attoriiey) are cont hc risk factors by somr cliniciaus). HMG CoA-reductase inhibitors arc the most effective drugs and are cons id^^ ered f i r s t h e agents by some.= total clrolestcrol . progcs~erone. and medications (oral contraceptives. pliysical j oactivity crsial (prcsnrned t o ~4 81 Hypertriglycerideriiia alone is not considered a risk factor.lerosis is iiivolved in al)ont one-half of all deaths in the IJnitcd States and oil(?-lhird O f deaths hetween ages 3 5 and 6 s .art disease tliaii high cliolesterol alouc. thiazides.111. do not give liiiri a second risk factor fbr age (use one o r tlie other in men). nepliroric syndrome. and hcta blockers). but fix board pnrposcs.

antitrypsin deficiency). may he fatal. livrr. Alcdlol is the most mnnriori cause ol cirrhosis a i d esophageal varices. days after thc last . Smoking by pregnant woman increases the risk of low birth weight. Wlieri parents smokc. and breast cancer.acnte arid often reversible. esc)phagus. esophagus. Smoking cessation preoperatively is the hest way to decrease risk of postoperative polnionary cornplications. and seizrtrcs (rum fits). and cessation stops Buerger's disease (Rayuaud's symptoms in a yourig rrialc smoker).i e s can a ~ e~iii diazepoxide and &t:r Iong~-actirig bcnzod iazcpines) or. preniaturity. if yon give tlrern in t l i ~ rev< yori may precipitate Wernicke's encephalopathy Wernicke'~ K ~ r ~ ~syndromes. barhit iiratcs. liyperrcflexia. Always give thiamioe hefore glucose iii an alcoholic. Smoking also increases risk fix thc following caiicers: lung (90% of cases). o f ~ s ataxia. Korsakoff's syndrome = anterograde amnesia a i d confahulation. Both are diie t o tlriarnine deficiency. rarely. W ~ ~ ~ ~ a d~ ~ ~ ~ l'irst conics a~ i ~Qc ~ ~ ~ . The nrost likely calm is dainagc.internal Medicine 7 Important points: 1. 1?. spontaneous abortion. 4. 8. in which case you shonld consider alpha.c ulcrr disease. Altlrongli the clianges of cinphysema are irrcversihle. sweating. pancreatic. 7. do give women smokers postnienopausal estrogen thcrapy Important points: 1. 70-80% of deaths in fires. Syrnptoms inclnde tremors. I~ninpliysen~~i almost always i s due to smoking (unless the patient i s vcry young or has no srnoking history. 2. 11may increase the risk fix gastric. Smoking is the hest risk factor t o eliminate t o prevent heart disease-related deaths (responsible for 30--45% of deaths due to coronary heart disease deaths). stillbirth. Do not give hirtli coiitrol pills t o WOIII~IIovcr 3 5 who smokc. Wernicke's syndrome = ophthalmoplegia. including otitis media. Chronic ohstructivc pulmonary disease is oftcm due t o smoking. nystagmus. Treat 011 an illpatient hasis. A l c o h o l i s iiivdved in roughly 50%)of fatal car accidents. Smoking possibly incrcases sto~rrach cancer also. hladder (50% of cases). Smoking rctards healing ofpept. Alcohol increases the risk for thc following cancers: oral. and 3 5 % oCsuicides. 6. Nexi is al(:o. larynx. kidiiey. 67% of drownings and Iionii-. Alcohol w i ~ h ~ ~ a w be.~--4. colon. Usc l ~ ~ r i ~ o ( ~ i ~ ~(chlor~. Risk decreases by 50% withiii 1 year comparcd with continuing smokers and decreases to tlie level of p. risk of death still decreases after snioking cessation. 4. vs.-IC8 liours after last ~ ~ / s w m~ ~ c t witlrdrawal y ~ drink.larynx. which usually oc:curs 2. oral cavity. 3. clrildrerl at increased risk fix astlinra and npper respiratory inf+ctions. and lung. wliicli consists of Iialhrcinations (amlitory/vicual) and illnsions without auto~iomic sysnptonis. pharynx.Iiolic halhicim~sis. and cervical cancers. syndrome. atid infant mortality. tierits who never smoked in 15 years. chronic and irrrvcrsible. Finally comes ilclirinm treniens. 5. pancreatic. pharynx. 3. cidcs. fatal. 2. and confusioI1. t o the rnarnillary bodies arid thalamic iiirclpi. Gradually taper the dose ovcr days.

The i~iortality i s high. pancreatitis (acute and chronic)..) or is cornpensating fbr respiratory alkalo . or vasopressin. ascites. Alcoholics tlevelop j u s t about every type of'vitarnin and mineral deficiency. which i s the most coninion caiise of prevcntable riiental retardatim Incidence. a i d autonomic lability (sweating.. the paticnl has either rnetaholic alkalosis (pfl > 7. 1. j a i n dice.1 S % of people ahuse alcohol. especially coninion are deficiericies of folate. Here are good hasic h i n t s : '1.1~) is or ~xjrrrpeiisatingh r respiratory acidcisis (pH < 7. 2. staphylococci) 2. ccrehellar degciicration.). magnesium. If hicarbonatc is low. asterixis. poor sleep. niicrophtliah~~ia. Eschericliia coli. Mallory-W tears. Alcohol abuse is inorc conn11011 in ineu. hepatitis. Bleeding varices are treated with stahili~ation(lluids. Alcohol may precipitate Iiypoglyceinia (but give tliiarnine first) 3. Skid-row alcoholics corninonly develop aspiration prieiinionia with weird hugs such . proloiigcd prothrombin time. fetal alcohol syndrome: nicntal retardation. hlood). 4 ~ ) r i s coinpcirsating fbr metaholic acidosis (pH < 7. when given pf-I. Stigmata of chronic liver disease in alcoholics: varices. Iiypoalbuininemia. It also causes testicular atrophy. N o alcohol i s good alcoliol during pregnancy.4.rsakoff syndrome (via thiamine deficiency). liyperhiliruhineiuia. and rhahdornyolysis (awtc and chronic) The best treatment fbr alcoliolisrn i s Alcoholics Anonymous o r other support group. spontanwus bacterial peritonitis. If CO. $lit: patiall eillrer has mctabolic acidosis (pll < 7. plH tcills you whether you are dealing with acidosis or alkalosis. tory alkalosis (pll > 7 . testicular acrophy. cirrhosis. and thiarniiic.urn) arid eiiteric organisms (e. and cardiomyopa~liy(dilatcd). Ifit is high. hepatocellular livcr cancer.4. and anemia. fatty change in the liver. I. the patient h a s cither respiralory acidosis (pH < 7. caput medusae. Rongl Alcoholism has a heritable component and is cspecially p Important points: 10. streptococci.g. and cardiac dcfects. and rerate Irletdiiig i s coninion. d from fathers to sons. which occasionally is fatal. encephalopathy. Disulfiram also may he tried (patients get sick whcii they drink hccausc o f akohol dchydroge- nasc enzyme inhihition) Alcohol is a definite teratogen. then iippvr endoscopy and sclerothcrapy with cauterization. I. brain darnage. increased pulse and temperature). banding. especially early Try transjugular intrahcpatic portosystemi~ shunt (TIPS) before portacaval shunting Iirmx!dures (splenorcnal i s the i ~ i ~ iphysiologic sllunl Iypc) st You innst know liow to interpret simple blood gases. O L . Weriiicke/K[.. CO. palp&ral fissures. hrinorrhoids. peripheral neuropathy (via thiainine deficiency). o 3.4) or is (:om: pcrisatirrg fbr rrictabolic alkalosis (pH i 7.Internal Medicine drink aiid involves hallucinations a n d illusions plus confiision. An estimated 1 in 3000 births is affected by fetal alcohol syndrorne. gynecomastia. is low.as KltlisielI(i species(currant-jelly sput.mk at bicarhoiiate. It' i t i s high. spidr:r angiomas.Treat on an inpatient hasis. Conditions commonly cansed by alcohol include gastritis. and hicarhonate. palmar crythema. microccpbaly. rnidfacial hypopla~ short sia. the patient has eithcr rcspira.4). 4.uok at CO. anaerobes. You sliould I x able t o r )gnixt.4).

aspirin/salicylate ovcrdose 3. volrime contraction. drugs (opioids. if severe. anorexia. 3." Alkaliirization oftlie iirinc (with h i c a r h ~ i i d t ~ ) spcrds excretioii. lethargy. vomiting. Ilypovihuic hypoiiatrcmia sliorild he trmted with salinc. and Iiistory of "swallowing swcral pills. and coina.'I'lic paticlit is prob ably ahout to (:rash and needs intubation. carhonic anliydrasc inlribitors 4. . meriingitis. mcntal status changes. 0 and other riieasLires Note: Beware the asthmatic wliosc. sleep a p c a 2. ' l i e first step in detcmiiiiing the GUISC or true Iiyponatrcmia i s to look at the viiliiinc statiis: 1. asthma. Orcasioiially. heu7.Internal Medicine 9 Clinical correlation: common causes of different primary distiirbances 1. aspiriii/salicylate overdose. The rnetaholic alkalosis that risiially compensates for respiratory acidosis is 110 longer cornpensatory and hecomes the primary disturbance (elevated pH and hicarhonate) 7.reated with rleri~eclocycliiic(a tetracycliiie that caiiscs renal d i a ~ ~ hctes iiisipidus). is < 7 . cliest wall proiierris (paralysis. metlia~~oi/c~Irylerre glycol. alcohol. cramps. disorientation. hyperaldosteronism irin overdose caii twi) primary disturbances (respiratory alkalosis and mcta~ g tirniitris and/or Iiypoglycciiiia. w h m refr'ictivr: t o conscrvativc managemcrit. pll may h e alkalinc during tlic day (csyecially in patiencs with sleep apnea) hecaosc tliey hreattic l x i t r r wlrr:n they arc awake or have just recovered from a n episode of broncbitis. lactic acidosis (sepsis/sliock). antacid ahuse/niilk~~alkali syndrome. blood gas goes from alkalotic to noririal. seizures. diarrhea. Do not iise bicarhoiiate t o treat low pH unless the pH have failed (always try saline first). Respiratory acidosis: chronic ohstructive pulmonary disease. opioids. Sleep apnea. Metabolic acidosis: ethanol. Signs and symptoms of hyponatrcinia are conliision. 1:rrvolemic and Iiyp~~rvolrIriic Iryponatreniia slroiild hc treated with Srce writcr rcstviction aird p s s i N y diurcti(:s f o r hypervolernia. 2. anxicty/Irypcrveritilatio~~. Treatment i s water restriction. Syridrorne oi'inappropriate . I n ccrtaiii ptticnts with chronic lung disease. diahctic ketoacidosis. potassi~iirris elevatctl. arid other respiratory rleprmsanis). m a y canse right-sided hcart failurc (cor pulmonale) Treatment. SIADI-I i s i. voiiiiti~ig. small cell canccr of lung. or c l r l o r ~ ~ propainide. retion of antidiuretic I~ormone(SIADH) coinnioirly results from liead traima or siiqyry. 6. pain). Respiratory alkalo. p r i l n ~ o i i a r y ii~teciioirs(p~ieriimiiiiao r tubcrcrilosis).odiazepiiies. harbitwates. nrcmia. With Addison's discasc and hypoal~losteri)nisrr~. postoperative or otIx!r painfiil states. Metabolic alkalosis: diuretics (cxccpt carhonic aiiliydrase inliihitors).

diarrhea. prcrnatirre veiilriciilar a n d atrial contractiotis aird vcutricular arid atrial tdcliyarrliytliinias. I lypokaleinia and hypcrcalwmia also miisc a s i m i l a r irnpaiirmeiit in renal con( t h a t may niiinic diabetcs i n s i p i d u s (1)I). m u s e cliaiiges in iiin ~ ~ ~. Treatment inv(ilves water rel>lacement. illability to drink (paralysis. nephroi ~ insipidus. liypcrreflexia. I J wavcs. arid arrqiliorcriciir 13) a m i is trc:atcd with a tlriaxirfe dinwtic (paradoxical effect). becausc y o n may caiisr braiiist?ni damago (ccillra~ pontine inyelinolysis). 1 mctlioxyfluraiic.Thc inost famous (and most trsted) elS(!ct d'liypokalcrnia. diabctcs i i i s i p i d i r s (pituitary or ncphrogenic). sodiirm decreases by 1 . t'otassiirru shoiild hc walclicd careftilly i l l d l Iialieirls takiiig (ligilalis. is OII the lieart. Never correct hyponatremia rapidly. . Common causes iuclnde dcliydratioir . <:orrect t h e sodiurn wlicn the paticnt l i a s lryperglyccrriia (once glircosc exceeds 2 0 0 m g / d l . deineclocyckine.Oficlr the pa^ tieirt i s s o dcliydrated that tiornral salinr may he i i s c d at first iuitil tlie patielit i s Ircmodynaniically stahle. Hypcrtonic salirie is used only v h e n the patient bas seizures due to Iiypoiiatreuria and. Nephrogmic 131 may he caused by rnedications (litliium.4.Si% NaCI). ~ e ~ ~ ldiahetes~ ~ e n Pituitary I N resporids to vasopressin.t o 1iy~x)kalcriiin wlrcir IIic p<iticnl is taking digitalis. For t h i s rcasoii. 7. Tlir Iicari is ~iarticularly serrsitiv<. Hypokalemia causes muscular weakness.Internal Medicine 4. Changes in pIJ inay ptassiiorii (alkalosis cuiscs hyp& lernid. bicarboiiatc is givw I O scvercly Iiypcrkalcinic patiwts. 1:ivc~~pt:rccnt ir~i~irial d(>xtrosein water should not hc uscd Pituitary vs. incliiding weakncss of siirooth nirrscles. The patient may have an ileus and/or Irypotensiio~i. (:specially if' thcy SI) fakir diiirclics (. C a i t r a l 111 rnay he causcd hy Slicelran's syndronic (postpartum Iiemorrhage c:aiises sliock arid pituitary iiifbrction I apoplcxy ]).6 rsiEq/l~.only briefly and caiitioirsly Norind sdiiic is (I betler choice 99 t times out of IO0 for IJo(ir(1 Iiuqioses. x i c l o s i s nlcinia). ~ ~ genic 1 1 does not. 1~yperlipidcinia and scvcrc Iiyperprotciireiiria may caiise a false (spriorrs) hyporiatremia hy tlicir osrriotic e f K u . look fbr inability to breast f c d and utber cndocrinc deficieiicics. status chariges. dernentia). Bmportatrc p""i1ts: 1. tlic inost c o i i i i ~ ~ cause ( ~ Iiypoiiatreinia is iirappropria~:or rxc on f fluid administration. ami iatrogerric adiriiriistratiori of excessive salt. Sickle cell disease also may cause Iiyperuatrmiia due 10 kidiwy darriagc t h a t impairs r e n a l concentrating ability..for each iiicrcase of LOO ing/dl in glucose). Mtiscrrlar weakness may lead to paralysis arid veotilatory failure. rcnal disease. W:VCII 11. tlicn switcli t o ~ ~ i i ~ ~ ~ l i a l ~ ' salirrc (0.I very cnmmoii owiirrcncc) . seimrcs. and c o i i i a . 1IKG firidiiigs irrcludc IOSS o f 7 ' wave. however. of derariyed pll most likcly will correct tlrc potassiinri dcrarigciiicrrt antorriati to give or rcsvict potassiiuri). diuretics. Oxycociri adrninistratiou inay caiisc 1iyp11rratrt:niia in pregnant v\mririi (oxytocin lias an Thc signs and ~ y ~ ~ ~f ~ ~ o i n ~ Iiypoiiatreiriia are siiriilar: c o ~ ~ S u s iiricntal Iiyperiiatrciriia and ~~n. h i a surgical patient.

eiiceplialopath~ dr:~~ merrtia. i n f l i t a l retardatiorr. Arrliytliniias include asystole and veiitriciilar librillation. absent thymic shadow) failurc (bccause of the kidney’s role in vitainiir D niiciabolisrn) m I . 110 not replace potassium too quickly! The best method oTrcplaccment i s oral. the most tested of which i s tctairy. Repeat thc test.Try stopping all implicated ine<ications.5) and/or cardiac toxicity is apparcnt (more than peakedT-waves). Tlie best method oftherapy is oral (decreased intake. beta blockers. all four parathyroids rnay i~lisi toiriy havc heerr acdeiitally reinoved) J’set~dol~y~ioparatlryroidisri~ fingers. and adrenal insufficiency (associated with low sodium and low hlood pressure) . Signs and s y m p ~ o may include weakness or paralysis. i t i s difficult to corrcct the hypokalernia unless you also correct tlie hyp~~magnrseiiria. laryngospasm. or ACE inhibitors). whicli i s cardioprotective. which also fbrces potassiiiin inside cells. If. do iiot exceed 20 unEq/hr. EKC shows T interval p ~ o ~ o n ~ a t i ~ n . bypoaldosteronism (watch fbr hyporeninemic hypoaldosterouism in diabetes). a n d a siric wave pattcrri. but if potassium n i i i s t he given IV. EMG changes (in order of inueasitig potassium value) include tall. slrort stature. First give calcium gluconate. Tetany is evi-. With lryperkalcrnia. and cor”ions. prepare to institute dialysis erncrgeritly og~c Hypocalcemia produces ~ ~ e l i ~ o l findings.l y ~ i ~ ~ p a r a t l i y r ~ ~(watclii ifbr ~ ~ ~ ~ s ~ t h y r o i d c cpaticnts. PR interval prdoiigation. especially if‘ h e patient i s asyiriptolnatic arid the EKG i s normal. widening of QRS. inrrnediatc 1V therapy is needed. sodium polystyrene resin). severe tissue destruction. potassium is very high (> 6.inflammatory drugs. If Iiyponiagoeseniia is present. Con~n~on causes of hyperkaleiiiia iiiclude renal hiltire (acute or chronic).Tlien give sodium bicarbonate (alkalosis causes potassiuin to shifl imide cells) and glucose with insulin. loss o f 1’ waves. ~~~~~~0~ causes: m I)i(korge’s a Renal syndroiirc (tctany shortly after birth. fieniolysis causes a false hyperkalemia. even tliougli i t does not clrarige potassiiirn 1evels. dcnced by tapping 0 1 1 tlie facial nerve to elicit contractiori of the facial iiiusclcs (Clivostek’s sign) or applying a touriiiquet or blood pressure cuff and inllatiirg it to elicit band muscle (carpopedal) spasms (Trousseau’s sign). peakkcd T waves. Monitor the 1:KG if potassiunr must I x given quickly 3. rrredications (potassium-spariiig diuretics. If the patient has renal failure or initial treatment is ineffective. arid rrorriral (slrort lcvels of’paratliyroid tioriiioii(: 1 I’TF% I with cnd ~orgari uiircsp(. however.risivericss to PTII) Acutc paiicr@atitis m Vivainin I) deficierrcy s i m pi Reiial tubular acidosis . nonsteroidal ail ti~.Internal Medicine f 2. but the most itnporrant (arid most ~s tcstcd) effects are cardiac. Other syrnptonis are depression. you sliould wonder whether tlrc lab specimen is hernolyzcd.

.

.~ I I _ ~ Internal Medicine ~~~ I3 ..

associated findings inclrrdr hypotension and oliguria/ariuria. 8. Definition ofshock: a state in which blood flow to and perfusion o f peripheral tissmrs is inad equate to sustain life... tliiarniiie. cystic fibrosis. frozen plasnia. (pyridoxiilc) deficicncy. even in the preserrce of adequate vitainiri K. Boiic changes first appear at the lower ends of the radius and ulna. Scptic 4. Removal of the ileum and tlrc tapeworm lliyhyllohothriu~n lutum also cause R. use iiivasivt: licrm. Isoniazid cauws B. bossing of the skull. deficiency 4.g. parenteral supplerrients arc re<] idrcd if higlr-dose oral suppleruents fail. V11. Anticonvulsants (especially pberiytoin) niay causc folate deficirncy 6. but clicck rblate. celiac discdsc. duodenal bypass. isotrrtinoin) musl have a ncgative pregnancy lest heftire iiiedication is started and must he put on s o m e form of hirth control as well as counseled about the risks of teratogenicity if they become pregnant. chronic giardiasis). sprue. 2. Alcoholics can have j tist about aiiy deficiency. deficieucy most corninonly is due to peruiciirus aneirria. Chronic liver disease (cirrhosis) may cause prolongation of the prothroinhin time (PT) hecause of inability to syrrtliesize clotting factors. supplerrreirts. bowlegs. deficieircy.herapeutic d . Vitumin K is given to all newborns as prophylaxis against bemcrrrhagic disease of tlie newborn. delayed fontanelle closure. and knock-knees. vitarnir~K is ineffective. I f the paticnt doesri't respond t o a fluid holus a t i d you arc givw the clioicc. 7. in which antiparieta1 cell antibodies destroy the ability t o secrete intrir~sic factor. 5. IX. Periodic pregnancy tests also should he offered. Hypovolemic 2. cirrhosis. pailcrcas iiisufficiency. Vitamin h i . Conditiorrs associated with pernicious auerriia iiiclude liy~~otliymidisrii vitiligo. and X as well as proteins C and S. D. E. Altbougtr not included in a rigid definition of shock for hoard purposes. bilc duct obstruction.. 3. Vitamin K is needed for the synthesis of factors 11. Cardiogenic 3. ( h e flirids while you're ttiiiikiiig. I'ragmatically speaking. arid magnesium. there are four clinical types of shock 9.'14 Internal Medicine Is l Important points 1. . Rickets causes intcresting physical findings: craniotabes (poorly niineralized skull and bones that feel like a ping-pong ball).'licat with fresh. Schillirig's test is rrsad to diand agnose the cause of B . round masses on anterior rib cage).. Tachycardia is also usually present. J n such patients. 1'atit:nts taking isoniazid (cspccially youiig patients) arc oftcn given prophylactic 13. rachitic rosary (costoclrondral beadiug with small. Ncurogenic Your job is to figure ou( why tlie paticnt is iii sliock while kcclpirig him or her alive. Ikficieiicy of fat~~solublt: vitanrius (A.dynanric moiritoring (Swam Cam catheter) t o lrelp make diagnostic and t. kyphoscoliosis. K) often is due ti) rnalal~sorption(e. Vitamin A is teratogenic and aiiy female patient given oiic of the vitamin A m a l o g s as treatment lbr acuc (q.

s l r o of brcath. Antihistainincs help (inly w l ~ e i tiL1r reaction i s mild. Cardiogeriic shock: liistory of myocardial infarction. a n d kccp NIX). Patients liave chcst pain. administer O. Piilriioiiary ernbolus: look for risk factors l'or dcep vciii t l r r o n ~ h ~ ~ s i s (Virclrow's triad: endotlrelial dainage. Nola: I\A(:s (airway. The patient h a s cold.Internal Medicine '15 Associated findings help to diffkreirtiate tlrc e t i d q y of shock: 1. arid positivc V / Q s c a n Hcpari prevent fiirthcr clotting and emhdi. Swan . Use hroad-. tenting of skin. iaclryprrea. clicst pairr. (:ircn~ation)C O B l f first. voinitiiig. pulmonary congestion (on exam arid x-ray). spntam and urine criltirrcs plus others i f hisrory dictates) 3. or after surgery Other signs include orthostatic liy~y~"t~:risii~ri. (:aiisc:d I)y St(iyhylococcus (tureus toxiri. 6.. right--axisshift oii EKG. tachycardia. 1. fluslJed skin. surikeii eyes. irrtul)ate i f necessary (do a Ira. I'alicrrts in s l i w k oftcrr lrccd heroic ~ ~ ~ c a s loi survive. Wypwolciiiic: liisrovy of fluid loss (blood. Septic shock: ftwr. clairiiriy skirr aiid looks palc. . pancreatitis. a n d siinken foutaiiellc (in cliildren) 5. vital signs. slrellfisli. diuretics. swrating. Patients usually need diuretics-~-fluid may irrakc thcrn worse! 4. or several risk factors fix coronary artery disease. iiri i i f o i r t p u t . skin f l u s l i r d aild warm to ilw tiiiicli.spectrirrn aiitihiotics aftcr paii-t:ult urilig tlir paticrit (get hlood. diarrhea. 2. penicillins. avoid rrarcorics if possihlc ~ rcs rigcs arc oficrl rill iinportanl c h r ti) i n i p c i i d i r ~ g dooin). stasis. breathing. Iirtiibatc at t l r c drop of a hat. Nniirogcrric shock: history of s c v t w ceiitral iicrvoiis systcni trauma or hlccd. Pericardial tani~~oiiadc: Iristory of stab woirnd in left (:liest.~ i t y to driiik watFr). l a o k for skirr dcsqiiarnatiwi. ixjngestive heart failure. a n d recent surgery (espxially i)rtliopcdic or pelvic surgcry) . Toxic slrock syndmnrc: classic patient is W C I I I I ~ of reproduct ivc age who leaves tarnpoiis I~ in placc too lorrg. clieostomy or cricot1iyroidoti)iny if laryrigeal edema prevents intubation). Iiy~)~:r~~jagnlal)le history ol' receiit delivery (amniotic fluid statc:). pcanuts. swollen leg). J'liiid l o s s may be internal. Distended iieck veins. Usr corticosleroids when the reaction i s prolonged or severe (not first. dec:p vciii thrornhosis (psitivc Ilornan's sign with p i n f i l l . Anaphylaxis: look for hcc stings. wliitc blood cell c0111it clrarigcs. clarnrny skirr and looks pale. Monitor a l l patirnts for at leasi 6 lioiirs after initial reaction. 130 peri cardioccntesis emcrgeiitly . inahil. Moriitor EKG. parasterrial beam. cxtrenres of aye. einholus). as in a ruptiired abdoininal aortic aiieurysm o r spleen. disteiidcd ricck veins. sulfas. Ii(mog1ohin. The patient has cold. and hcniatocrit. and oilier iiiedica~~ tions.line driigs f i r treatrncrit i)fanaplryldxis). Treat with cpiiic!phrine a n d fluids.G a i n pararncttm. arlerial Iilood gases (AllGs). Ilcart raw may he normal. fractures (fat ernboli).

Dobrrtamine: beta. agonist used to increase cardiac output hy increasing contractility (ICU equivalent of digoxin) 2. reassess the patient to determine whether the bolus helped. Epiueplirine: used Cor cardiac arrest and anaphylaxis. see trauma section (Surgery) .. you ~ m s watch for fliiid overload. agonist effects to increase contractility Highest doses have alpha. agonist elf' . Give patielit steroids! For shock iii the setting of trauma. After the holus. especially in a postoperative patient who has taker1 steroids i n the past year and received 110 extra steroids perioperatively. Pliaiylephrine: used for its alpha.16 Internal Medicine Note: Most patimts in shock need fluid. agoiiist effects and cause vasoconstriction. l>opamine: low doses bit dopaminc receptors in reiial vasculature arid kcep kidney per-~ fiised. agonist cffc:cts. 3. Of course. 5. Norepinephrine: used for its alpha. Also has hcta a g w riist cffkcts. Note: Reniernber Addison's disease as a cause of shock. 4. which may cause congestive lirart failure (cspct cially in cardiogenic shock wlicn the patient is already in failure) IV medications and their use to support Mood pressirre should he understood: 1. Higher doses have beta. D o not be afraid to b o l u s twice if the first holus has no effect. 6. giveir in hypotension to increase periplieral resistance so that perfhion 10 vital organs can hc rnaiutained. The standard bolos is 10--20 nrl/kg of nornial saline (roughly 1-2 L infused as fast as it will go). Milrinone/amrinone: phosphodiesterase inhibitors u s e d in refractory heart failure (not first-line agents) because they have a positive inotropic effect.

strong family history. wliirh usually nieaiis t h a t you try to riiakc sure that the paticiit has iiot had a i n y ~ ~ ocardial infarction (MI). iiausra and voiniting may Be prcscnt. 111. Pain sliould not he sharp axid wc!ll-localizcd or r r l a t e d to ccrtaiii (bods. Pain characteristics: usually dcscrihcd as crushing. 17 . I’ain usually does iiot resolve with nitroglycerin (as it often does in angina).DI1. (lis l I~ia. EKG: after an MI. X-ray may show cardioincgdy and/or pulnionary for congestion. Palimits are ofterr diaphoretic.ahoratory values: a paricnr with a p~issil~lc sliould liavc serial (icterminations of crcatirie MI kinase (the MI< isoenzymc) or troponin I/]’ (usually drawn cvwy 8 Iiours times 3 hcfi~re MI is ruled ou~). niay . a patient under the age (iC. > LIxI. new I I ~ I I ~ I I I I I C liypotcrisiorl. ~~~ i. ST segrnent clevation.10 is cxtrei~ielynnlikely to liavc liad an MI. Findings tliat make MI unlikely: 1. not reproducihlc on palpation.actatc dcliydrogcnase (LDII) clcvatim a i d (lip (I. poorly localizcd suhsternal pain that may radiate to the slioulder. Wrong age: in h e abseucc (if known heart diseasr. 3. arm.) also may be riseti. think along the linev d a n MI. 2. 3.g lasts ar least a lralf-liour. Aspartate a~i~inotransli~rasc is also ckvared but IIO( wed cli~iically MI. 2. or risk h c t o v s fix coronary artcry disease (CAD). leads IT. its sot~rcc t h e is cliest wall. and aVP for an inferior infarct). and/or Q wavcs in a segrnental distrihution (cg. or jaw. 1. especially i f the patient prcsmts aiicr 24 Iionrs.~likr tended neck veins. SS or S4. ecbocardiogra~~lry show vcritriculnr wall rriotion almorrnaliries. tarliycardic. iiot a11 MI.When a paticnt preseiits w i t h chest pain. and/or shock shoidd itlakc yo11 S. your job is t o makc s m ! tlrat l l i c a n s e is iiot lifiitlireatening. Paill nsua1l. Physical characteristics of pain: if the pain is reproducible by palpation. a u d pallc. yon shonld see flippcd or flattened?' waves. Findings tliat elevate suspicion of MI: 1. Risk factors: a 50Lycar-old inarathoii riiiiner who eats well and has a high H D . Physical exam: pirlrnoriary r a t a in ttrr ahscnce of otlier j ~ i l c ~ ~ r ~ ~ ~ i syinplonis. witliout otlier risk factors for coronary heart disease is unlikely to liavc had aii MI.. Z.

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Perry JF Principles of 8askc Surgical Piactice Phila 3. d y t p i i m .) and generally r t coiisrdercd a hctugn corrrlitron Treat with NSAIDAo r a c p t i o 6. and CXI rrity irilar<tt). \ c v r i ( IIW cringc3 lieart failure. Piilnioiiary vniholus follows UvT. Siiperiicial throrriboplilrhrtit ( cytliciiia. ddrvery ( a i ~ i ~ r i o t ifcl i i i d tmbi)lti\j. In paticrits with DVr. tcndcrnr.\s. or f r a ~ t i i i e s(fat ciriholr) S y i n l i t o i t i t iiiiludc tacliypu?a. 7. arid pal~ialile ~ clrit 111 a supw fictal vciir) it iiot a risk factor foi piilmoiidry e r n b o l i m i (1’1. V = V wave. wcdgc-sliaped d c f a t dnc t o a p ~ ~ l i i i o nyaiin f a r i t . etpc cially tor mtliopedic lup or kiice mrgery . Iiciiioptysis (if l u r ~ g infarct). The hest DV’T propliylaxir for s111 gery i t pncitriiatrc coinpr 1011 IIOOI~ and carly ‘iiiibula t m i .rr wall ancurystri.A wavp. p i r r or teirdtmcss. IlVTs coinmonly present wit11 i t n i l a t r i a l leg rwcllrng. cdcina. systeiiiic a n l r ~ o a g u ~ a ~ ii r mi c c r s a y t r ( J s r IV I i c p ” i . and/or liomari’~ sign (present in 30%) 4.no( aitcrral cmbolr 7ire (’xiepitroii r i a pat<n t { r x a m c n o v d l e . on a (liest Y ray you i r u y wc a i ~ . which are transminod to the lrft atiiiim and ulti mately resulting in pulmonary hypeitension l h e left ventricle IS liv pertraphied duo to tlic chronic preawro overload (Fruin James FC. 1c f t ridcd lieart i l o t t ( I 1 0 1 1 1 atrial l’ilmllati~iri. Corry RJ.nor PI*s Rtglit srdrd clot\ that vrrrliidi/e (IWTs) (diitc p1-5. and l i y p ~ ~ ~ m wt i y ii. M = mean pressure IFrom m tlie leftventrirlt-. followed h y gradual cro\wvcr to oral w a i f a r m Patients arc rriarntarncd on warfarin for at I c a t t 3 i i i o n t h ~postrbly pcrinancntly if they exprrtcme irioic tliari oiic cpitodc .Cardiovascular Medicine - struction to flow atrt of tho atrium and an increase in pressiirr in the left atrium and iiulmonary veins Pulmonary lhypertension d e v ~ l o p s secondarily A . The hest way to diagrrotr IlVT I\ dopplcr ultratowid or iiiiprdantc plctl gold standard 15 vciiograpliy.i c ~ jarid cicatli i f wvcre Rarcly. clwtt p a i n . use low dmr Iicparrri i f anibtrlatioii i s not powlile W a r h i o is an alternative. or cil(lm arditi\) that ciillioli/c (aiisc aiterial s i d c i l r i i f m t + (ccri)kc and rcnal. 111 wlrrcir the c l o ~ niay ( r o t \ o v c r to tlic left trdc of tlic (rririlatroii aiid t a ~ s c a11 <ii ’ . bat i t 15 riivarivc arid u w a l l y r rtcrved for the dtagiiosit i s i i o t clear 5. vcrruiiul. GI.

.~ - Cardiovascular Medicine 21 Note: 17rcniia causes a qualitative plarclct dekct. Vitarnio C dcficicncy and cliroiiic cortico stcroid tlirrapy may caiiss a bleediug ieiidcirry witli nwwial coagulation tests.

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~ a s ~ r o e ~ o ~ h reflux disease (GERD) i s d o c t o inappropiidtc, i i i i ~ i ~ i i i t t lower a~eal ~i~t rrophagcal \pliiiictcr (].I$) r c l a x a r i o ~‘The iiicirlciicc ir greatly tiic \cd iu paiicntr with a ~ liiatal i i c r i i i a GlW3 picsciits as “hcarttiurii,” oltcn iclated t o cating and lyiirg snpini liiltial treamrnt 1s t o Plevatc thc licad of die bed a i i d to avoid ~ o l l c ca, l ~ o l i o ltohau o, rpiLy a n d fatty , food\, c hocolate, arid medication\ with a i i r i ~ t i o h n c ~ rpropertics If t h i ~ gi~ approach fails, dntacick, f 12 hhckcr\, a i i d proton purnp inhihitorc may hr tried Surgery i s rcwrved fiir severe aril caw’s (Niiscrr fundoplrcation) Scq iiclac of C1:RD iiicludc w q i i i a g m \ , ewphdgcal ipli~geal canccr), cropliageal olctr, liciiioirliage. a i d krrett’r irirta w i w i r e (may iniiiiic ~~laria/cr~ipliageal e n i ~ ~ a r c i i i o i i i a ~d

Hiatal hernia, as the term i s commonly u\ed, iniplies a rliding hiatal hcrnia, that

i\, tlic

elitire

gastroeropliageal j i i n ~ t i o niiiovc\ ahovc the diaphragm, piilliiig the r t o ~ n a c hwith it--a coiiiiiio~~ b c r i i p firidmg A prac\opIiageal hiatal bcriiia ineanr that tiic gawoecopiiag:cd and jtin~tion stays hekiw ilic diaphragm, titit tlie rtmiacli Iierniatcr through ~ l i c diaphragm into tlie tliordx lliis is a i l micoimnoii, srriuur ‘ypc of herilia that may hcc ixnr strangiilated aiid rliould bc repaired wgrcally

apllraqmdtrr hidtiia In d paiaoaophdgrdl h r m d , thc gasi,otwphageal jimclioii is fixed below I h r did piiragm, allowing p i t of the m i n a c l i tn h e n w t c mto thr rhe?t (from Cidpo JU, Hamiltnn MA, Ldgman S Mediciiw & Prdiuirics Pliilddelphd. IlanlPy ( Nelfus, 198R, with j ) i m i w o i i I I

riiesophoyeal hernia

30

Gastroenterology

I

Peptic ulcer disease presents with clirorric, intermittent, epigastric pain--hnming. gnawing, or aching---that i s localized a n d often relievcd by antacids or milk. Look for epigastric tenderIJCSS. Patients may h a w occult blood in stool a n d nausea or vomiting. Peptic ulcer disease is more comiiiori in males. The two typcs are gastric and duodeJla1.

Important points:

1. Ihdoscopy i\I ~ e c o n i i n g first-lint- diagnoslic stiidy (upper GI harinm study i s classitlie cally dorie first) and is moue seiisitive (hilt inore expeiisive) tliari x-ray.
2. Always biopsy any gastric ulcer biopsied initially)
IO

exclude malignancy (duodenal ulcers do not have to he

3. The major complication is perfbratiorr. t n o k for peritoneal signs, history of peptic ulcer disease, or free-air oil a h d o i n i n a ~ x-ray. Treat w-it11 airtibiotics and iaparotorny will1 repair of perfbration: I(' ulcers are severe, atypical, or uonhealirrg. think about Zollingcr-Ellison syirdroinc (get gastrin level) or stomach ('aiicer.
Diet clrangcs (Ire not tbought to help heal ulcers (hut reduced alcohol or tohacco use may help).

Start treatirient with antacids, IH2 ldockers or proton-pump inhibitors, as well as antihiotics to eliminate H. pylori. Triple thcrapy (arnpicillin or amoxicillin. metronidazole, and I>ismuthj is t l i e gold standard, but many rcgiiriens are in u s c .

4. Surgical options slioukl be considered a h hilure of"edica1 treatment or in patients with cornplications (pcrfbration , hleeding) . Comin(in procedures includr antrectorny, v a g o ~ ~ torrry, and I$illrotli 1 and 11.After surgery (espwially Mlroth procedures) watch for dur~iping syiiclroiiie (weakness, diuinrss, sweating, nausea or vomitilly after eating). Patients also may develop hypoglycemia 2--3 hr after the meal, which causes the same syinptonis to recur; af).rtW loop syndrume (hilious vomiting a h a meal relicvcs abdominal pain), bacterial overgrowth, arid vitamiri deficiencies (Bli arrd/or iron, causing anemia)

5. Aclilorliyrlria, (lie ahseiice o t hydrogen chloridc, is associated with pernicious anemia (antiparietal cell antilmlirs rlcstroy parietal cclls a n d thus cause achlorhydria and BI, rleficiency) .

7Jpper versus lower ~ a ~ ~ r o i n ~ ~ ~ t(,i ~ tablc, top o f next p"gC) hlecding a ~

an^ points:
I. Thc first step is t o iniilcf sure tliat the paticnt is slahle (AiICs, IV fluids a n d Mood i f d d ) ; thrrr gct a diayriosis.

. hiloscopy is tisualiy

ihc First I

(.,. ,: ,,I 1: I M V ~ I I I J I x-ray sttidie 'is\i(ri

rbrincd (irpl)i:r or lowcr, depmding on syirrptorrrsj i i i d first, hi11 rrrtk~scopy morc sensitive. is

Gastroenterology .

Irrilahle bowel syiidromc (11%) i s a c o m m o n C ~ S of GI complaints. treat wit11 ~netronidarole(if i t fails or i s not a clmice.32 Gastroenterology ~~ ~~ I ~~ ~Iicrpetiibrn~is. and gastroenteritis. hut hecausc i t is very common. I~icrriiilytic aucrriia rneutcd r c d l i l o d ctrlls). 4.coininon arid prcwiitahlt: c a i w C J ~ ti1 in iioderilcvveli~pc(l a 2. [rag: a n d a c i w rciial f a i l u r c ’ l i e a t supportivrly I’atierits m a y need d i a l . greasy. l’aticiits arc anxiotis C or ~iciisotic i d Iiavc a Iiistory of d i a r r l i r a aggravated hy str(:ss. i i i i l y with iirvasivc hactcria such as Sliip!lln.atus. Iiyliertl~yniidisrn. Malabsorption: caiiscs i i i c l u d e gluterr in tlie diet). aiicl/or iiiiicris i n the stool. and cokirectal caiicer as causa of diarrlwa. . ally I!. IBS is ttrrce times m o r e C O I ~ I I O I Iiii Serrralcs tlrar indles.lood cclls. hyp~ikaici~ria). Altcrctl intestinal transit: afier howcl re.’ltcat with nietronidaz(ile. nialodoroirs s t o o l s that float) due to srriall howel iiivolverricnt aiil uniqw pr(itozoa1 cysts i n the st(iol. l f t l i c patient has a history of‘autihiotic use. If the test i s positive. I~l(iating. Yersinio. ysis a n d / o r t r a n s l i r s i m l s .. 1 1 1 to in~ 3. (at c~nteiit (sreatorrhca). factitious diasrhca ( s ~ r r r t ~ p t i t i ~ ~ u s Iaxativi: ahuse. w h i t e tjlood cells in stool (noi with toxigenic liacteria. Iiclinet cells. 5. dilficile toxin. ~cytes. Iiifcctious causes: look fin fcyer. stop and ac sprue (look fix ~ l c r m a t i t i s 4. r I a n d stciol exa~nination. Crohn’s disease. 5. t i m i s or medicatioiis h a t interfere with howel Important points: 1. a n d wlritc 1. i t is the iiiost likely diagnr i n tht: alxeiice o f positive furdings. and Cnmpylohocter spp. 3. kiok Ibr cicciilt bkmd in stold. \yatcIr (br cieliydratioii a i i d c l ( ~ t n i l y t c di irhanvcs (c. dosis.and sigmoidoscopy. coli).) in c l t i k l n m . ‘This diagnosis of exclosion rcquires hasic l a b trsts.) and inaS rrveiige caused hy I!. 6. lh a rrctal cxaiii. fimctiori. SulmonelL. tliiuk ofC111striiIi111n difficile arid test tllc stool for (1.~ Inflammatory bowel disease . especially in ~oiiiig adiilts. I!xiidatiw diarrhea: i n f l a n ~ r ~ r a t in~h lw ~iiiiicosa carr ir ~ I ilarrirnatory howel discasc (Crohn’s discase or 1111 swpagt: of h i d . Flikers and stream driirkers m a y get Ciiirdio cirts with stea~orrliea(farty. Diarrllea stops with NPC) st. k i o k for psychosocial strcssors in the history a i d rrorrnal pliysical filldings arid diagnostic tests. n i c t a h d i c a c i ~ areas. coli or Shigella SI). l h not fiirgvt a l x w t iliabctic diarrhca. 11SV V ~ l l C t J l l l ~ C ~ ~ l l ) . (. m I r - ally hy iiicdical pcrsoiirwl).g. Witlr all diarrlira. watch l b r l r c ~ r ~ o l y t i c urcnric syndrtirnc: thr~rinh~icyt~~pciiia.urd exaiiriric s t o o l fiir ova o r parasites. a atidonrinal p a i n rclicved by ddecatioii.

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.

and jauiidicr. Patients may present with atypical chest pain. (. 4. h 1. fat). forceful. Look fix ~iositivc and r . Cliolcstyrainine lirlps with syi~ipt~iiris. Hepatormal syudrmic: liver failure causes kidney failure (idiopathic) 9. surgery (myotomy) (See figure. Esophageal disorders: dysphagia is usually an esophageal complaint. ant1 loss o r derangenient or peristalsis. phcnothiaziiies. Coii~niouhilc duct ohsiruction Jiom canccr: risrially pancreatic canccr. Hypoglycciriia: liver siores glycogcu. 1. and. Scleroticriiia: may cause aperistalsis dnc to fihrosis aiid atrophy of s i i i ~ i ~ iit ~ i ~ i s d c . and dark uriiic that is strongly bilirubin~-posi tive. antiiniclear antibody arid mask-~likc Ijcies. 4.. surgery (myotoiny). Diffuse esophageal spasrdnotcracker esophagus: hoth have irregular. o r infection. ofte GI hleed. Hepatic cnceplialopathy : mostly due to hypera~ii~nonen~ia. Corruiion bile duct ~ibstruction with gallstonr: look fbr Iristory of gallstones or tlit. Primary biliary cirrhosis: middle-aged woman with 110 risk factors foi. Otlicr call.y 2. esopliagcal dysmotility. top of iiext page. 2.r I. Disseniiriatcd intravascular coagnlation: activated clotting fictors iisnally cleared by liver. clay^ colored s t o o l s . Cholangitis: Charcot's triad = fevcr. as a last resort. Parrereatiris: mort: than 80% of cases arc duc to alcohol a i d gallstmc~. liyl~e'triglyci:rideinia. l'atients have iiiterinitteut dysphagia for solids arid liquids with 110 heurthurn. i t not. pruritus. Kayiiaud's plicnmienou. 1. conjngalcd hilirnbiii Ilia1 is more elevated than unconjugaled hilirutiin. Aarrett's csopliagiis: colurnnar nictqdasia duc t o acid reflux. inarked pruritus. must IK fbllowcd wiili prriodic endoscopy and biopsies to rule out prc)grcssion to adeii~~cari:iii~iiti~.ES hcconies i n c i ~ n ~ p ~ ~ c npatients may devekip GERD. Biliary tract disease: jaundice inay he caused hy hilc dnct ohstrnction. pneumatic hallooii diiatatioii. tclaiig ieclasias) . I I S ~ : endo-. 5. four 1s (fi.owc.liver or hiliary disease. Aclialasia is risiially idiopatliic but may b e secoiidary to Cliagas' disease (Soiitli America). presents like cholangitis. Diagnosis can bc made with esopliagcal manometry. forty. Achalasia: hypertensive lower rsophageal sphincter ( U S ) . audrogrns) or pregnancy. 10. n precipitated by protciii. Clrolcstasis: often from iiiedicatious (oral coiltracaptivcs. sclcmdactyly.gnose with c:sojdiageal inanonietry Treat with calcinin ~:hannel blockers arid. l 3. viral iri1t~:timis(ininrips.) 3. Primary sclerosing cholangitis: young adults with iriflainniatory howcl disvase (usually ulcerative colitis). fertilc. if' needcd. 8. J ~ m k markcdly elefor vated alkaline pliospliatase. jaundice. Treat with antibiotics. scopic retrograde clrola~igiopa~icr~~aiograpl. iric nplcte relaxation of LIS. 6. and remove stones surgically or endoscopically. other a i i t o i ~ n r n i i u c syrnptoms (CREST LT calcinosis. Illtrasouud cdii oftmi iinagc the stoiic. and p s i tivc antiinitocliondrial antibodies. iio treatmerit (other hut i h a u liver transplantation) i s available.male.oxsacki~ virus). sonietiiiies cholangiocarciiioiria or t i o w ~cancers. aiid nicdications . . IJuconjugared hiliruhiir is not excreted in the uriiie because i t is ciglitly hound to alhniniii. paiiifirl esophageal coiitractioiis that cause intermittent chest pain Ijia. rest of work-up is negative.Gastroenterology ~ 7. Barium swallow reveals dilated esophagos with distal "birdbeak" narrowing. trauina. Treat with calcium channel blockers. right upper quadraiii pairi.

. Patictits liavc abdoniiiial pain radiatii~g tlic back. chronic palicnratitis wilh alcdiol abstinence. Gaslwgrafrii). ‘They IISLI ~ W i ~ ~ § ally are seeii with voiriitiiiy and retcliiiig (alcoholics and hulimics).. and Tat-sol tible vitamin snpplcrr~ents.Treat each or the fhllowing corirlitioiis will1 siirgical repair. I’crforatcd peptic disease also niay have elrvatcd ainylasc ail6 prcsmts siinilarly. IV fluids. and rlcvatcd amylase/lipase. narcotics (inerperklinc.I pc:rhration. gastric distvticioii.k flanks. if riot iatrr.Gastroenterology (steniids. ‘Thc cxcc. tlicy are risually due to vomiting or retching (alcoholics a n d hulimics). x. 1101 niorphir~e) Grcy~-Turncr’s sign = tiliic/hlac.ptioii is iwpliagcal 1~~%(ira1io11 hecnirsc the Iiirigs roleratc barinin wcll Iiot devckip cliernical p ~ i ~ : i i ~ ~ i ~from s m i r I water.ach iirixdl transmits air t o tlrc GI tract). r. and trcat with iiiimcdiate siirgical repair and drainage. and diaktcs (with chronic pancrvatitis). Iloerhavc’s tears are fiill-tliickiless esophageal raptures. leukocytosis.ray Treatiiiciit: NPO. brit patients liaw free air 011 ahd~~iriiual and history of peptic iilccr disease. hoth iridicatc: severe pancreatitis). iiasogastric tubc. Diagllosis and trcatimrnt are don(: endoscopically (sclerosc any hlt Is). ~ ~ l l o ~ y tears arc~superficial esoplrageal crosiiiiis that m a y C~IISC:a GI Idced.tx. Diagnose with endoscopy o r bariiim eueina. Complications iriclride psc (antibiotics aiid surgical ab. coll~l‘ast . Note: ~ i t suspected (. k ahlc t o rccogoim a sketelr o f t h i s inost COIIIIIIOII variant. Ciillen’s sign = hlur/hlack umbilicus (hotlr arc d u e to herrrorrlragic exirdat. broiiclius to dic distal cwipliagiis (Ircrlw. iicvcr use hariurn (wliiclr may catis(: c l i a i i i c d peritonitis) h Usc water-soluble coiI1rasI irrs~cad(e. . ~ ~or 11 ~ ~ ~ i ~ n ~top ~ 9 ~ i ~ T~ach@oesoplra~cal fistula: tlic m o s t C O ~ I I I ~ Ovariaiil ( 8 5 % cir cases) has esoplrageal atresia II with rl fistula h r n tlv. m Treat >cyst (drain surgically if syiiiptoinatic).&.genic (frorn endoscopy).. soluhle . ~ ~ ~ ~ r~ ~ ~ n i ~seen in~ n ~ ~ i:hiklren: (see tahle. oral pancreatic crrzylrlr replaceinort. azathioprinc). a h ( s rlrainage). nausca a r i d vomitto ing tliat docs not relieve rlic p a i n .

f l ~ " Gastroenterology ~ ~ 33 ~ .

f i x 11 yperbilirul~inerrlia d kernictt. [lac.Trrat with surgery 6.on syndronies cause conjugated Iiy~~erbiliruhiuci~iia. I. Ilreast milk jaundice: breast&&di n f a n t s with peak bilirubin of 10-2. opistliotonos.rus.0 ing/dl occrrrring 21 2-3 weeks o f agr. Metabolic: Crigler-Najjar syndroinc causes hy perbiliruhincmia.s mg/dl. Physiologic jaundice: in 50%)of norinal infants. pwks at 2-61. Look for anemia.ook for poor feeding. Mliruhiii is < 12 mg/dl. 5. Treatment fix unconjugated liyl)(. rises higher than 1. The last resort i s exchange trailsfusion (do not wen think about it unless the lcvel of unamjugated bilirnhin i s > 2. Pathologic jaundice: lcvcls risc h i g h t h a n norrnal and coiitiiiw to rise or fail appropriately. Note: Any i n h t born to a mother with active hepatitis 13 sliould get the first irnrnuilizatioll slint aiid hepatitis 13 i i i i r r i i i n ~ ~ g l o b ~ hirtli. 4. periplieral smear ahnormalities.0 mg/dl).’t)ilirubineinia that persists. Tlic yinnrgest. i v c r iirsuh. seizures. to dccrcase 1. o r rises rapidly i s ptl<ltOthfX4pyto COIivert the nnconjrrgatcd hiliruhin to a water-sduhie forill that can hc cxcrctcd. and higher level of unconjugated bilirubin. iiifi. Biliriihin j s niosrly ~rnconjogatcd. and ot1it.r i l l ~ ~ c s s e s l iiiay prolong iiconalal jaondicc arid lowcr the threshold Sor kcrnicterns. and returns to nornial 1)y 2 weeks. Medications: avoid snlfa drugs in rwonates (displaces bilirnhin from a l b a r n i n and may precipitate kernicterus). peaks at 3 . family Iiistory. cven more coirniion i n preniatnre infants.In preterin infants. Biliary atresia: f‘ill-term i n f a n t s with d a y . and/or apnea t o accompany severe jartndice. biliriihin i s < 15 mg/dl. days. GiIhert’s disease cairses mild unconjrigatr:d liy~ierbilirtibinernia.Trcat with temporary cessation o f breast fixding (switch to hottle) until janmlicr resolves.Gastroenterology ~ I _ hilinihin and suhseqiient deposit i n t o h e hasal ganglia. ~ 4 days a n d may he clevated for np to 3 wecks.or gray-colored stools and high levels of conjugated bilirnhin. Any jaundice present at birth is pathologic.ction/sepsis. and Rotor and Dubin- severe unconjugated Jo1iol. m sickest infhiits arc at greatest from Rlr i i i ~ : ~ ~ i ~ i l ~ a t i o i lcongcnital rcd cell diseases that cause beniolysis br ity in the neonatal period. Iiyi~ottiyroidisiii. ciidity. In fiill-term infants. cystic fibrosis.~ at ~ l i ~ .

l and/or t r i i o 'I'SII i s nosinul. tliyroid~stiiii~llatirig li~irmonc (TSII) is low in Graves' disease. oi~ 4. ~ y p ~ ~ ~ hLook ~ oclassic symptoms o Fatigue. and no treatiiieiit i s 11 is ulwlcrlyirig disorder.himoto's tliyroiditis: inmt c01111~11o11caris('. iiillamnratio~r. ariciiiia ofclir(inic disease. t l i y r o x i i i e ['T. Ixit the pituitary arid 11ypothala1nr1s 1g rionnally and cxliihit the appropriaie r q i o ~ ~ toethc glalid's action. il' hut rm:s low level.).~ y p o t l i y ~ ~ ~ iin y s ~ ~ i i d i he ass<iciatcd lrypercliolester~ilroiia.r~rcrs. May caiisc r r c t i i i i s i r i iii cliilrlreri (strinted growth aird 9 . he c o ~ i i ~ t icailsc in 11. Causes o f hypothyroidism: 1. . Sick-euthyroid syirdninic: ally illii( inay decrease 'I. the 1ierfi:clly 11or11ia1. Check thyroid liiriction I ('l'SI3. tlrc p i t u i t a r y or lry~~otlialai~rus is iiialfiiiictioniirg. IJislory cif'iippc'r respiratory infection or n ~ ~ i i n psscoiiirnoii. slow speccli. associatcd w i t h other autoiilirnniie d i s ~ cascs (cy. from tuiiior. (primary) is low. ~~eriiicioiis aiicniia. is for the pituitary tc I t x s TSN because ( i f feedback inliibitioii. Srihac. Cive NSAllIs fbr i s y ~ i i p t o n r e l i e f l'atients (ificii rrcovcr without trcatrrrcnt. awarc' that i t frequently o r w r s (. I-lar. l+ir exainple. gland itsell' i s mall'~uicti~)ntlic ing (v. dccrcascd reflexes. hi priluary cudocrine disn~rb. enzymr deiicimicyj. tender tliyroid i~ glaiid. vitiligo.Y o o m i l s t irriderstaiid tlw lrypothalamic-pituitary axis s o t h a t yori c a n distingirisli priiriary Srom sccondary disorders. 'Tile (:oiiditioi~ scli' liiiiitiiig. tlic pituitary or trypotlialamiis is irralfriiictioniny. l. constipation. lupiis). because it s l i ~ ~ u l d s be ng higli levels ofTS14 drim w h c ~ tllc Icvel of t l l y ~ ~ i roid IiorriioIic is inadequate...ute thyroiditis: a(:iitc viral i n f l a i ~ i m a t i owith kver arid crrlarged. For exams ple. Histology sliows lyrrrphocyte infiltration o f the gland. free thyroxine iiidex [ I W ] ) . which resolves with treatment. I . r 3. clsuallyTSr1 is Iiigli.s.$/.: iifTSII o r tlic hy~~otlialainus stwctcs kiw Icvels of'tl~yr~itropin. AIicr trt:atiiieiit fiir l~yypcrthyroidisrri. a n d / o r coarse hair.ook for positive aiitirnicr~isonial antihod-~ ics. hecause the thyroid i s ~ n a l liinclioiiing and overpr~idiiccsthyroid hormone.. rnenstrual disturbances y for i ~ i ~ ~ ~ r (usually menorrhagia). Treat with thyroid Iior~~~ioiic (synthetic T4). 'rile appropriate respmse. cold intolcrarice. carpal turln(:l syndrorrre. )II? (TRH) in paticnts liyfi("hyroidisrir..g. ymnine ( T 3 j . alidT. 111a secolidary e~idocrine distrlrbance. but 'ary excq11 fix the ncy: r a r c iii TIS. bradycardia.

aird hyperkalciuia.. dizzin a n d syncopc." Clieck tlryroid functioir t(:sts. wiiic:li activate the ontcndcr. thyroid--hiiidiny glol~tiliri(TI'&) may be elevatcd. arid either approach is a( tahir. I'aticrrts tiavc positivi: i l i y r o i d ~ s t i i i r r r l a i i r i g ir~riiiiiiii~glol)ii lins/tlryroid~stirnirlatiiigairtibodics. physically and nmitaliy. arrxiety. aiiorexia. wcighr Ios!. Toxic adenoma: < r i i e nodule is pallpahlc and tias liigti radioactive iodine uptake. free tlryroirl horrrron~~ irot clcvatcd. a i i d death.ii of oral ci~iitraccptiv(. ficat intolerance. I'or patients 24-4. Proprarrolol is iisi:d for thyroid s t o r m (thc patient decoinpcnsates. aiidT. lixoplitlialinos arid pretihial myxrdeina are specilk h r Graves' disrasc. 110 riot treat. roidisiri due IO inllariimation belore coiivcrting t o 1iypo~Iiyr~)idisiii. from very Iiigli thyroid Iioriixiiic. versial. and "thyroid stare. is Nephrotic syndrome or large protein Ir~sscs aiiy kiird and aiiaholic stcroids can decrcase'Il3G of (agaiii. when not obvious. 7Jsc surgery fix patients iiiider 2. t h e rest o f t h e gland shows decreased uprake (thymid cancer i s rarely hyprrfiiiictional) 4.5 or prcgriaiit woint'ii a i d radioactive iodinc fix patients over 40. rciial sliutdown. llsrially TSII i s IOW. rneristrtrai irrcgularities (~iylyl~i)ii~eii~irrliea). treatment is cwitrii-. nanscia and voniitiiig.tioris).asrd skin pigmentatiori. patierit m a y die while you wait Sor the ilrc . 7Jnrirr rrictabolic s( ion. i s done by adiriiirisrerisig adreiiocorticolropic h o r m o n e (ACTH) a n d seeing wbetiier levels of'plasma cortisol irrcrriase over hasclirrc.0.raves' discasc: hy far. Trcat with hydrocortisoiie arid IV fluids to avoid adrenal cri . (. Treatlllcill begins with antithyroid drrigs (pri)pyltliioriracil or rriethimalolc). i t t o s t c o i n I i i o i i cause. palpitations.Endocrinology Hyperthyroidism: syinptorns include iicryousiiess. primary adrerial insufficiericy) : tlic i n o s i lism is idiopathic (probably aritoirriiniiirc).TS€Iis normal and yoii should not treat) ~ ~ y p o a d ~ e ~ a (Addison's disease..s/t:strog~~rs. h o k for im:rc. Altlioiigh this causcs elevation or total thyroid horrnoue levels. liyptciisior ular colla )sc. c l i R i i s e goiter also is pr(wiit. palpi tations. Wliole glaiid takes iip cxc 2.l (primary) i s Iiigli. 110 not delay givirrg steroids to d o t h i s test if tlic patierii is doing pcx~dy. arid TSH is normal. The diagnosis of'liypoadi-cnalisiir. sprxifc fbr (.raves' disease. levels) and syi~rpto. rnatic tachycardia. iiicrt:ased appetite. Thyroiditis: IIashinioto's or siihaci~t(: thyroiditis may prodrrcc a traiisient Iiyl>erthy~. d+ hydration. Radioactive iodine iiptakc i s high i n riodiilcs. diarrhea. l i x o p h h a l r i i o s arid pretihial myaedciira art. hypoiratr~:rnia. irisonrnia. Causes of hyperthyroidism: 1. Note: In pregnancy and ot her slates (adinirristratii. aud arrliytlrrnias. hut decreastd in tlic rest ofthe gland. taclrycardia. weight IOSS. Most patielits evciitually rcqirirr fiirthcr therapy. I'lumrner's discase/toxic iniiltinodiilar goitcr: I i y j ~ ~ r t ~ r n c t i ~ inodirlcs muse a Iiiinpy ~iiiig goitcr without positivc a n t i hodies or cxoplrtlialmos/pretihial iiiyxcdcriia. surgery) patierits m a y liavc: a n adrerial crisis--~~~ abdoiriinal pain. 3. atrial fibrillation. irifec.

postural liypotensioir. swl'atin ing. and cnt o n t the tumor after stabilizing the patient with alpha aiid Diabetes insipidus (DI): Syniptoins iriclude severe polydipsia and polyuria (paticnts may nriirate 25 Wday). ".est. Ccnlral disease responds to ADH. If tlic screen is p s i nrandeliv acid LVMA] and/or horriovanillic acid [EIVA~J. Cnsliing's disease is Cusliing's syndrome caused by pituitary ~.ADH docs not help). lung infections. imna. Ft'or board piirp~~scs. "buffalo t i u ~ ~ i pstriae.etos mcllitris .Treat with tlriazidc diuretics (paradoxical c f k t . Iieadachcs. if possible. secondary diahetes or glucose intiileraiice. Look fbr moon facies. Look for Iiypcrtension. hypertension.and intrapatient fluctnation. and psychatric disturbances (depression. Syndrome o f i i ~ ~ ~ ~ ~ l secretion of antidiuretic hormone (SIADN): syinptoins iiiclnde . renal bruit. Get a n MI11 of of the brain if levels olACTII and cortisol are h i g h . osteoporusis. do an abdornioal CT. poor wound Ilealing. oxytocin---^ he carefill in p r q " t pativiits). which is tlionght to cause the skin Iiyperpigmenlation in primary adrenal insufficiency. small ccll lung cmccr. mental status c h a n p . plasma cortisol is not a gorni test because of wide inter. first screen with a 7. cirrhosis. I. I Central DI: look for trainiia. edema.verprr)ductioii ACTH. variahlc sodinin aiid poi. or sarcoidosis. Other causes are adrenal neoplasms that produce steroids aiid sinall cell cancer' of the lung. nephrotic syndrome).assiuni. Pheochrounocytoina: popular on the boauds.Endocrinology 41 decreased. Iliagnosis is made by first doing a screening t. menstrual ahnormalities. Serondary Iiyperaklosteronisrii is ninch rimre coinrnon. When access to watcr i s restricted. which rnay prodnce ACTH. clrl~~rpropairiidc. wliicli may cause death. Instilin rcsisiaucc/dial. Get a CT scan of the ahdomen. and treat unclerlyi~ig cause. hypokalcinia arid low renin. although central Dl is often idio-~ pathic. and pain. and/or feeling of impending dor>in. If y o u are suspicions. Giving aritiditirctic I ~ o r n i ~ n (ADH) detcrini a c s ie wlietlier tlic came i s central o r neplrrogenic. Trcat by curing the neoplasm.not give I i y ~ i c r t ~ ~ n i c a r i d do noi try t o corrcct byporiatrcnria a g ~ do salinc. a Nephrogenic U1: look for nicdicatioiis as cause (lirhinni. as i s melanocyte-stimulating lioriiione (MSH). Iiypernatreinia.ook for hypertension. Nypsraldos~c11. ~ ~ 1 9 e C~ U S ~ Sy n: i1v:rcascd risk of the fb1Iowiiig prd)lerns: ~ ~ C a '1. and i s related io hypcrtcns i o u (especially with renal artery stenosis) arid cdeinatous disorders (congestive Ireart failure. wild sw~ings blood pr ure. denieclocyclinc). patients rapidly devclop dehydration and hyperuatremia. psychosis). Then do a dexanietliasonc snpprt~ssi~iii tcst. Hyperadrenalism (Cushing's syndrome): usually due t o prescribed steroids in the U. Live. whcrcas nepllrogcrric disease does i i o ~ . tachycardia. I.Patients also may have glrrcose intolerance &e to high catectiolarnines.oiiism: primary discase is known as Conn's syndronre and is c l u c to an ade~. and high renin.mk Ibr ni~dicatims (~norpliinc. tranriia. Overall mortality (at any age) 2.Tlir best choice is nsually a 2 .S.s to fall after srrrgary). 1 ~ ~ Iionr urine test lor frce cortisol. Trcat with water restriction. dizziness.4-lmur wine t LO look for catecliolarnines and tlicir break-down p r o d n m (vanillylrnetanephrines). mctlioxyflurai~r. neoplasm. postopmtive status (watch for all elcctro1ytc. Trcat with AlXI/vasopressiri.o~ria~c 1 i y p m ~ " ~as a i well as low levels ol'cvery other clectrdyte (urd lab valuc) hecarisr ofrlilntio~i from exccssive watrr reteiitioir. truncal obesity. Look fbr interinitteiit hyp~rtension h a t is very t high. gressivcly or qnickly Rapid correction rnay caiise hrainstc~n dmrage. Treat tlic underlying causc. which usually is duc lo a pituitary adeuorna.

42 Endocrinology .

.

rniiiiary rrlcrtia congestive hcart tailiire. voiiiiting---fii~rri liiiild~.1iattit. Causcs i n adults iricliiilc d i a l x t c s i n e l l i t u s . Aiiotlier coininon carisr is polycystic. h y p e r t i ~ n s i i i nhematuria. and 1~11- 5. Iiipu. and oliguria. dialysis m a y I)? required lndicatiorrs for dialysis irrclnrlc urciiric enceplialopathy.~ ~ c i iraAytriction rob li i a . Skirr pigmentation holic byprndticts uid pmrit .frnui lack ot erytliropoietiii (syiitlictic <:rytIirqx)ictiiiinay correct) 7. p c n i c i l l a ~ n i r ~ captopril) e. c&wia. . Ccrrtral nervous systein disturbances-~ ~~lllelltal Status changes and eve11 clinvulsiolls o r coma from toxi ii hiildbiili 9.r~ . Iiypertcmsion. ht!iriia--. berry aneurysiiis . hypertension. Paticnts rimy liavc some proteinitria. The majority or cascs o f CKF are d u r t o diaheles nicllitiis (iriimlxr o n e cause of CRI:) a n d hypertension. i nl . to Nephritic syndrome: oligtiria. hyp~. Note: I n all cascs ARF. and lryperlipiderriia/lipiduria. hepatitis €3. lieart failure. Lrxik for p o s i t i v e fairlily Iristory (risidly aritos~~mal doimiiiant.Trcat siipportivcly. it i s usually due iiiininral change dist:ase. and / 1iypt.ljrowti and j t c l x s due t o i i i c t a ~ ~ i o i i ~ -diw to dccreascd ccllular irnitiurrity Treatment of CRr: rcgular dialysis. 111children. pH i. Azotcrnia--liiglr BUN/crt~alininc 2. Auorexia. a ~ r ~ t c n i (rihing RlJN/crcaLinine).arise CRF i f the insult is sevrrc! or prolonged. The i i s u a l C J I I S C is ~~~ist-sirepto~~icc~l gl~iii~ier uloiiephr Chronic renal failure (CRF): any of the causes o f A R F inay (.and d r i i g s (gold. 1 Iylierkalrinia-~~kiiow changes EKG 4. 1:Iuid rctrrition--~~rnay caiise 1iypc. a n d treat witli steroids. hypervoleniia. (if Nephrotic syndrome: proteinuria (> 3 . and Irypertcnsion c ~ i i r t r o I .np toxins of .lorneruloiitrpiiritis: l ~ r o ~ ~i s post-strept[icoccal syiidroine. aiiiykridosis.nts m a y havv priiloirgcd hleediiig to tinic tcst 10. L S ) . I~Iy~i~icalcciiria/Iiypcrpli~ispliatcniia~-vita~nin 11 prodnction iiqraircd. Metabolic acidosis 3. Metabolic derangeinents due to C R F 1.s. in. ~~ 11. ' I lo ~ ~y ciirc is rural trarrsplant. palpable renal ma.rkalemia scverc enoirgh to cause arrliythnria. Red hlood cell casts 011 urinalysis cliiicli the diagnosis. naiisca. they prescnt with edcma. 5 grri/day). but not i n r l r nephrotic rmgr. Urcuiic ~ i ~ r i ~ a r d i t i s . airtosoma1 re fbrni prcscrits in children). kidney disease (mnlliplc cysts in kidney).ion. and 1reinaia twia.44 Nephrology (. r:dcina (classic exitin ple is rnorning periorbital edema). in the circle d'Willis. pericarditis. p t i ~ s ~ pliate rcstrir:tiiiri/IJiiid~rs (sliiiiririiiiii or &:iitiii c ~ r l ~ o ~ ~t~rytliropi~ic~ atcj. Iir:rnaturia. w w r -soIiiIiIc vitaniirrs (rerrrovcd dnriirg dialysis). iisiially SC'CII in clrilype drrn with history of upper rcspiratory infection or strep throat 1-3 weeks earlier. hcjne'loss leads to r e n a l osteodystr~qiliy 6. Measure 14&Iioiirurine prolcin t o c1inr:h the diagnosis. 13lceding~~-~-duedisortlcrcd platclct fiincti<nr.~albunrinernia. and cysts in livcr. (iftcn after an infecti(~n. sever? metabolic acidosis (mtighly.

.

Sfnphylococcos s p p ) .Iyperrrricemia: froin gout or from Icukcinia treatment (allopurinol and 1V fluids arc given before chci~~otlrerapy prevcn(ivr incasiires) as 4. t o liypcrparat hyroidism or maliginlicy (m(atastas<*sor s o wmious ccll lung caiicer--secrctirrg parat hyroid hornione) 2. Underlying causes of stones: 1. Infectirin: from a n i ~ n o n i a ~ p r ~ ~ bigsi (Proteus.Nephrology and should be treated with lots of hydratiolr and pain control ( t o i f stone will pass). If stoiie docs 1 w t pass. €iyl":r(:aI(:i~uli~i:dat. . i s i i i a d r o f c y s t i i i c a i i d iii repetitive stone ii)rining patients. I. ~ystiiirirIa/amini)acidriria: suspwt if tlw stoil<. i t needs t o be rcmovcd surgically (preferably cndoscopically) o r by litlmtripsy. i. 3.ook fix Staghorn ~l~ cin~ calculi.

Patients should avoid alcohol (may Iirwipitakc ari attack). gold. G o u t is iriorc c o ~ i i i i i oiii m c i i t l i m i~ wonicii. Look fiir systeniic: symptoms (fever. Gout: classically t s witlr podagra (yorit iii tlic big tor). aspiratc fluid f r o m tlic aflbcted joiiit for exaniiiiatiorr. aiid/or jir[iAciiicid/allopnrin(il ( t i c 4 Iicr liir acute altacks) . Maiiitenanw thcrapy iiiditdes high fluid iirtakr. hut cliildren are ofieii negative. liveitis). red.pwt stirnrthiiig otlrer tlran CIA. Iiydroxy~. hactcria (Cram s t a i n and culture). worsciiiiig 0 1 s y r i i l w m i s iii evciiiirg and afier iisc. arid crys~als: Other key differencedpoints: 1. OA: few signs ofiiillaiiriiratioii on e x a i i i (lacks Iirit. Rlicuniatoid arthritis (KA): positive rheuinaloid factor cliiiclics Ilir diagnosis in most pa. p u i i c l i c c l . hcideircc increases with age..iion o f uric acid b y \lie kidney) arr u s c d for' aciitc attack. aiid stcroids (for had Ilarc~~ulis). malaise.ciitaiicoiis nodules. glircose.. : 43 . chloroquine. tciidcr joints s w i i i n all tht! o t l i r r s of this group). Pscridr~goiitrlioiiilwid sliqwd crystals with weakly positive hircfririgeircc. ' h a t with wcight rcductioii aird NSAlIIs as ncrdcd.irid I3oiiclrard's (I'll') iiodcs. Whim in dooht o r if y o i i Arthritis: ttie largc niajority of c a ~ are diic to astemrtliri~is . I m i k Iiapwl crystals ( d i c r r uric acid &posits. Syiiiptoiiis iirclndc Hcherdeii's (1311') . tophi (suhciitaiicoiis 3. Colclii(:iire or N6AJl)s (not Jspiriii. proloiiged iiir)riiiiig st and swan neck and houtonniPre deforrnitifs. 2.~ 4. r"ricarditis/plcural effusion.TreaI with NSAIlk. tielits.(On). Exaiiiinc tlie lliiid fix (:ell coiiiit a i d diffbreiitial. The hiizz WOK! i s pannus (art iciilar c looks likc gramilatioii I iie duc L o clirciiiic iiiflaiiiiriation).~ i i iIcsioiis in hone x ~ ~ r a y ) necd t and i n s i d c Iciikocytvs) with negative hircfriiigtncc. which causcs decreased excrt. pcii larniuc. s u l i .. and h w i y spurs. alkalinization (if thc rrriiic.

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Screening test i s ANA. tlme is a positive ANCA titer.xychloroquine. Ikrmatoniyositis: polyniyositis (see below) plus skin involvemerit (heliotrope rash aroriiid the eyes with associated pcriorbital edema i s classic). Steroids may help. 4. arthritis. hut iiistcad of a r u i ~ glomerular antibody. Raynaud's phenomenon.S m i t h antibody i o confirm. Muscle cnryrrrrs are elevated. . pliotoseiisitivity. Patients develop coronary vessel vasculitis and sul-lseq uent aneurysms..Treat with cyclopliosl7hamidc. esophageal dysmolility. heartburn aiid mask-like. Muscle biopsy estahlislirs t h e diagnosis. aiid ciil1gr. which may throm hose and came a myocardial infarction (suspect Kawasaki's disease in any child who has a myocardial infarctiori). Vasculitis involves riiediom-sized vrssels. often associated with other autoiinmune discase. 3. Trcat with eyedrops and good oral I iy gicne.hnlineruia. and/or arthritis. a n d kidi1e. Treat with NSAIDs. arieinia or pancytopenia). positive aritiiiuclcar antibody (ANA). Patients classically have trow ble rising out of a chair or climbing steps (proximal lnuscles afkcted). discoid rash. kidiiey darnage. Systemic lupus erythematosus: malar rash. conjunctival injcctioii.- Rheumatology 49 1. leukocytosis.~ tiiria/proleiiiiiria. It is callcd "pulsclcss discasc" hccause you m y iiot hc able t u ii:el the patient's piilsc or measurc blood pressure mi oii( tlie aortic arc11 and [lie hrariclrcs that arisc f r m i it. and/or periplieral ncuropathies. Takayasii's artcri tends to a f f k t Oriental wonicn betwt:en 15 and 30 years old. 4. Polyarteritis nodosa: associated with hepatitis B infection and cryogl(. Sjiigreu's syndronic: dry eyes (keratoco~ijuriclivitis sicca) and dry roooth (xerostomia). abdominal pain. 8. Wegencr's granulomatosis: resembles Goodpasture's syndrome. leathery facies. cervical lyniphadenoparliy. 'lieat with steroids and/or ~:yclopliospl~arnide. Angiogram shows thr cliaracteristic: lesiorrs. Bclicet's syndrume: the classic patient i s a %O~soine~Iiiiig with paiiifiil orsl a d g r i i i ~ ~ inan tal dccrs. telangiectasia) .~ . pericarditis/pleuritis. acntc renal failure) iiivolvcmciit. blood-penias (thrombocytopcnia. arthritis. liydr(. Patients have increased incidence of' iiialignaiicy. . Kawasaki's syndrome: affc s chilrlren less tlian 5 years old (morc common in Japancsc a n d lemales). seizures) ahid oral ul may all be presenting synlptolns. nasal perforation).y (hematuria. an? hcrna. Lab ahnormalilies includc high ESR. high fiver (lasts > 5 days). dyspnea). confirmatory tests are anticcntromerc antibody (for CREST) aiid antitojioisornerase (sclerodcrma). neurologic disturbances (depressiou. 5. positive anti-Smith antibody. Patients present with fever. sclerodactyly. Look fbr nasal (nose bleeds. renal disturbances. 2. and steroids. positive Veiiercal Disease Research Laboratory o r rapid plasma reagin test f o r syphilis. psychosis. strawberry tongue. electromyography is irregular. Biopsy is the gold standard iiir diagnosis 6. Carotid involv )logic sigirs or stroke. Treat during acute stage with aspirin arid inlravcrioris i ~ i ~ n r u r i o g l o b uto ireduce tlie risk of coronary ~ ~i aiieiirysin development. anemia. leukopenia. Patients may also liavc iivciris. Sclcroderma/progressive systemic sclerosis: look for CREST symptoms (calcinosis. Use ANA liter as a screening test. Paticots present with tr~incalrash. late skin dcsquamatiori of palms and soli:s. Steroids may Irclp. lung (beinoptysis. positive lupiis anticoagulant. weight loss. a n d otlicr skin lesions (especially c r y tlrcnia nodosum).stive heart failirrc i s not l ~ ~ i c o ~ n i n o ~ i . a n t i .

Wawh for uveitis (especially i n pauciarticulav fbriii) . Classic sitcs ofinvolvemmt arc in t h e pelvis an d skull. Treat with NSAIDs. Oftcm d iii asymploniatic patient througli an x-ray.Rhoumatbloav Fibromyalgia vs. polymyositis vs. or paraplegia. iiiorc c0rr1~1io11 111e11. Watch for a persm who has lidd 10 buy larger-size hats. Patients may complain of hone pain. osteoarthritis. Alkaline phosphatase is markedly elevated in the p s w t c e of normal calcium arid plwsplioriis. possibly eiidlrniate or calcitoiiin for sewre discasr. SCCII iii patients > 40 years old. h r able to retn~gnirea Pagetoid skull (frontal Bossing). polymyalgia rheumatica Paget’s disease: a disease ofhoric i n wliicli hone is hmkcii dowri aiid regcnrrated. rlreiirriatoid factor is oftcn negative. o l t c i i siiiiiiltancously.Tlie risk r 1 1 osteosarconia is increased in affected hones. Note: With jiivenile RA. nerve dcafncss.

Steps to diagnosing the cause of anemia: 1.ook for classic findings t o give y o u a n easy cliagnosis. tlralassemia. a i i d fragiiie~itcd K s (iritvavascitlar Ircrriolysis) R wi Sphcuocytcs arid rlliptocytes (linrrdirary splrrr~~cytosls/clliptocyrosis) Acaiitliocytcs/spur cells ( a l ~ e t ~ l i l .P U dcficiency. hcmopliilia. deficieucics as well as (.1'11 defcieiwy) "Rite cells" (Ircrriolytic a~icriiias) IJowellLJolly hodics (asplrwic pat icnrs) I roil iiicliisioirs ill RIICs i)Y bone marrow (sideri)lkistic aricrriia) 'li~artlro~~-stia~ieil (myeIo<ibrosis) RBCs Scliistocytes. Periplicral srri(. and clik~rainphenicol. Medication history is important. many inedicatioiis can cairsc anciiiia tlirorigli various mechanisrns. liglit-beadedncss. Other iinportant points of tlie history include blood loss (trauma or surgery. r ~ ~ ~ r o t e i i ~ c i i ~ i a ) . which cause hc~iiolysis G X .ar: I. which c a u s w red blood cell antibodies arid hemolysis. hrlnict cells. sysmlic ejection murmurs (from liigli flow). dizziness. angina. chloroquine and sulfa drugs. fillatc.Anemia is defined as heiiioglohio < 12 nig/dl in woIiicIi or i mg/dl ill ~ncri. positive srool guaiac in GI bleed). iiirst and foremost. Tlic mean corpuscrrlar v d u m e (MCV) tells yoii wl~ctliertlic arrciiria is microcyric (MCV < S O ) . Iiematemesis). Co~nplete hlood COLIIIL (CRC) with diffkrcntial aiid red^ hlood cell (NK) indices.o r macrocyric (MCV > 100) : 2... arid signs of the uiiderlyiny cause (c. dyspnca mi pxwtion.Ytni must know what the fdlowiiig look like: Sickled cells (sickle cell disease) I lyperseginciitrd neutrophils (1Llate/n. pallor (especially o f the sclera aiid i~iucous iiic. jamidice in liciiiolytic anemia. Classic examples incliide methyldopa. mcleiia. syncope.I 0 0 ) .I Ideeds). w h i c h causes megain loblastic anemia. ooririocytic (MCV : 80. and a l c i h l i s m (wliicli teiids to cause inm. which c a w s aplastic aririnia. deficimcy) Hypochrtmric and microcytic IlBCs (iroii cleficimcy) Basophilic stippling (kad poisoniiig) ~1 H e i n z bodies (G-6. family history (e. and B. G-6-PD deficierrcy). palpitations. phenytoin. arid claudicatim Signs inclwle tachycardia.mhranes).g. cbroiiic diseases ( a m m i a of cliroiiic disease).g.. y ~ n p t i ~ r i i s 14 S include fatigttc. liemoglohin aiid Iiematocrit inust be below norrrial.

In a paticiit over 40. Reticulocyte index (RI) should he > 2% with anemia. microcytic): the most c o m m ~ n cause of anemia in the U S .~Vinsou syndrome (esophageal wel) prodncing dysphagia. also known as trarisfkrrii~). Give iron suppierrrents to all iiifants except hrllLtcrm infants who arc cxclnsivc!ly breas1~fe. tliri iinderlying catisc if possible and (rear with oral iron snpplcinerrta~ior~ for rouglily 6 months. liver disease) n Echinocytes and burr cells (uremia) I Pdychromasia (from reticulocyto should alert yon to possibility rfherrrr)lysis) Ronleaux fixination (multiple myeloma) n Parasites inside RBCs (malaria. Jron supplcmen~s alsu arc counrnonly given &iring prcgnancy and lactation hecause OS incrcascd de~narid. giving cow's milk bdi)re I year of age may caose anemia tlrrough GI hleciding.d. and low TIBC saturation. Other clues to the presence of hemolytic anemia: Elevated lactate dehydrogenase Elevated hiliruhin (unconjugated as well as conjugated if the liver is working) Jaimdice I. ~. so is not the prohlem). Rarely paticmrs have a craving for ice or dirt (pica) or Plucnrner.ow or absent haptoglobin (intravascular 1i~:molysis) Positive urohilinogen. lron deficiency (hypochromic. rirle out coI0n canccr as a caiise of clwouic blood loss. treat iron clefkicncy To anemia. and glossitis). you can make a reasonable differential diagnosis if the came is not obvious.~ fants and at 2 niontlis I b v preterm infaiits. Start iron siipple~rlc~rtatio~i -6 rni)ritlis fbr full w x r in-at 4.Witl~ lhese three parameters. . hiliruhin. iron deficiency anemia.Target cells (thalassemia. bernoglohin in urine (only conjugated Iiiliruhin appears in the urine. hahesiosis) 3. the n i a r r ~ w not reis sponding properly A reliciilocyte index > 3% should make you think of hemolysis as the cause (the marrow is responding properly. Iron deficirncy anerrria is c o m m o n in W O I I I ~ I I~)fvei~ro[!luctive I>$>age causc of riieristrnal irr(p1arities. otherwise. clcvatcd total iron-hiuding capacity (TIBC.ook for low iron/ferritin level. I. and hemoglobin appears only when haptoglobin has heen saturated. correct. as in hrisk intravascular hemolysis) Causes of anemia: 1.

A Schilling test risiially deteririi~ics etiology. Look for elevated hemoglobin A. 4. looks Like) Hcnal papillary iiccrosis Aiitosplfricct~jiiiy (in1 ioiis w i t h cucapsiilatcd hugs) a Splenic sequcstratioii crisis A m t r clrrst syndrome (mimics [iiiciiiiioiiia) I'igrncirf cliolelilliiasis m I'riapisrir B Strokc Iliagiicisis i s made h y hciiioglobiii elcctroplroresis. Watc ations of' sickle cell &vase: Aplastic crises (due to jiarvovirns B 19 infcctioii) I3one p a i n (due to microinfar femoral liead) m the classic example i s ava. iron i s contraindicated because i t may cause riverload. Lrxik fix ruacrocytrs arid hyperseynientcd neutrophils (even one s l i o u Id make y m i think of the diagnosis) arid low fbiate levels (scri~irior ~ 1 3 C .S. the llsiral rcplacenient route i s iiitraniusciilar. hut Ily do i i o t appear until arouiiil 6 iiio1111isof age lier:a~isco l l a c k of a d u l t . spasticity. tea and toast). achlorhydria (no stornach acid sccretioii. x.There are fbur gcne loci for alpha-chain and only two fLr lieta. I w a u s t i iiiost patients caiiiiot absorb W.y (macrocytic): conimonly seen in alciholics and pregnant woii~cli.). nncleatcd RISCs. and Uiphyllobothtium loium (fish tapeworm) infection. and antihidies to parietal cells.. deficiency (macrocytic): most commonly dire to pernicious aneriiia (antiparietal cell antibiidics). hyperscgrrieiitcd ~reutnqihils). spleno~negaiy. Screciiing is (loire at birth.-ray of tire skull showing a "crew-ciit" appearance.. Thalassemia major is more dramatic a n d severe. ahsorption and the association with vitiligo and lrypotiryroidisin. diet (strict vcgaii). Sickle cell anemia: siiiear givcs it away. Asians). Peripheral snirar liioks thc same as in fiilaie deficiency (oiacrocytes. of Rare causes iricl iide poor diet (eg. chronic pancreatitis. L. ) 3. diffuse hasophilia 011 peripheral smears. hyper lcxia. A1 tlialassemia is syinptorriatic at birth. Folate deficie1ic. riic~lioirexate. and positive biiiily coiiiino1i i n blacks. terrniiial ileum resection. Thalassemia (microcytic. No trcatrrieiit is reqirircd for w i a . iiiciiiia). tlie patient has iieurvlogic ikficiclicics (ICISSof s~iisatio~i Iirit or pcisitiun senst:. All w~iiieii reproductive age should take folatc supplements to prevtm iiivral tube dcfi:cts. target cells. l m a tlialassernia i s not symptomatic until 6 rnonths of age.Treat with iml folate. ataxia.. Treat with as-needed traiisfiisions and irou chelation therapy t o prevent heinocliromitosis. Rcmemher the pliysi&gy oFB. am1 malalisorptiori.oiik f i r low SCTUITI R. dar necrosis o f tlir Dactylitis (hand-fbot syiidroine. Look h r very high percentage of' reticnlooyt Sickle cell aiiciiiia ahnost always is seen in blacks (8%) are hetivozygoics i n [J. clevatcd s t ~ i i i acli $1). or tlic fetus dies in utero (hydrops). p<jsitivcBatiiriski sign. Meditcrraneans. kriow w h a t if. (p-thalasscmia only) or Iiemi~globin (p~F thalassemia only). prolonged coiirsc of trir~irthoprirn/su Ifa~netlioxazole.-ch~iin thalassemia. Otlier causes inchide gastrectomy. Diagnosis is made liy heinoglobin electrophorr .. parrsc'hesias. l ..Hematology 53 2. hypochromic) : I ~ I I I S h e dii'fereniiated froirl iron deficiency L Iron levels arc normal in thalassemia. de-. patients often are asymptomatic as they are uscd to living at a 1owc:r level o f heini~glohin and lierna~ocrit. 5.anticoiivuisaiit tlrcrapy (espcciaily pheiiytoin). Vitamin B.

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I l a trans(iisi(in reaction occurs. r~iazej>i~re. oilier hein~~glohiiiopattries (lieiiiogld>ins C a i d 1: fairly c o n ~ i i i o n. arid disseiiiirratrd iiitravasciilar coagulatioii 'I'lir most coniiiioii cause of t i ~ i i i c ~ p l i i l i voii Willebraiid a.salicylatrs. ) malaria. litw~oiyti(~ n:nctim .iirgativc rtsuh hrcause all . ~necliaoical valves (wliicli lirinolyzc RRCs). di nriiiate(l iiitmvascrilar criagnlation. giant a n d / o r is I)izarre-lookiiig $"lets. Clor~riitiurnperfringens. radiation.he ie.yLosis (diKwcnt size). tlironi hotic thr~i~nliocytojieiiic j i ~ ~ r ] > i i aai. I>iscontinne the triggering iiicdication first! 16. Iiave diflirrciit iiidii~ati~iiis: 1. Other causes: cndocriue fail tire (csprcially pituitary and thyroid). D o not prrform the assay inimediately direr h c i i i d false.d llcinolytic iireiiiic syndrmnc (look tiir scliiscocytes/KHC Crag ri riieiits and appropriate otlier fiiidiiigs).ry(iprecipitat~~: coiitains f i l ~ r i ~ ~ o g d factor 8. Aplastic anemia: iisually idiqiatliic. h o k Ibr drcrmsed whitc sulfii and Id<iod cells arid platelets t i i acciirii~ialiyaneiiiia. tliroiiibotic r l ~ r ~ ~ m l ~ ~ i c y t o p e i i i c purpiira) 2.yiiic assay. gold). C-6-PD deficiency: X~linked reccssivc (inales affrcted).ir marked a1isoc. nialig iiancy (especially It~ukernias). Wholr t)lood: used only fix rapid. Washed RRCs: frcc (if traces ot plasma. o r a f c r in t i o n o r diahetic kctriacid( h d i c s and h i t c crlls are sven om pcripliera nvar. tlic f i step is L o stop the tmnsiusiii~~! fin klirilv reacti(in 1. aiid Irypcrsplenism (always accoriipaiiied by splc~iomegaly arid &en by low platelcts aiid white blood cells) Transfusions: always bascd on cliriical groiiiids. iii 7. and platelets. not the lah v a l o r . Iiradachr. Myelopbtldsic anemia: usually c h i c tu i ~ ~ i y c l ~ i d y s p l a s i a / ~ ~ i y c l ~ i ~maligriant i r i n or l i r ~ i s i s sion and dcs~riictioo horie m u r o w (iiiost c o i ~ i ~ i i o i i of cause). aiid tcardrop--slialied RHCs on the pcripticral sincar. blood trausfiision reaction is lab crror. theii try aiititliyiiiocyte glohiilin o r boiie i i i a r r o w traiisplarit. 'Treat by avoiding preci~iitatingh o d s and iiiedicatii)iis. Ikesli frozen plasina: coittains all clotting factors. 15. I. 14. habesiosis. and medications ( c l i l r i r a i i i ~ ~ l i e i i i c o carha l. may be caused b y cherr~otliorapy. pheiiylhiilazo~~e. iiiassive hlo~id loss o r excliaiigc transiiisiorrs (poison iiig. l i i o k fiir sudden h r i i i o l y s i s o r aiiernia after fava ljeari OL'drrig rxposiirc ( ~ i i t i i i i a i a r i a l s . C. thcrc i s no sncti thing as a "trigger valuc" fix t r a n s f ~ i s i o n 1)iffirrcnt Mood c o r n p ~ i i i c r i t s .if the drlcr RBCs already have l i t : yoiiiiger RHCs arc n o t af tcd.glohiiiiiria.. Typr 0 ncgativc c a i he I w l ~ r iyrili caniioi wait Tor I h o d typiiig or tlic lilood harik ckics 11ot liavc tlic patirnt's i t y p t . Packed RRCs: used instead of wlivlc td(iod when the patient rieeds a transhsiori 3. good for IgA de.cxik I. A hoiir inarrow hiopsy is usually done and i n a y reveal no cells ("dry tap" hecause marrow is lihrotic) or ~iialigriaiit~~kioking cells. swere warfarin [joisoniiig) or vitaiiiiri K will 11ot work (liver failurc). iiscd an ~ i i discasc. Granul(icytcs: rarely used fbr nentro~r~iiia sepsis carised hy chcinorlierapy with . paroxysirial iioctrirnal o r wld licnii. lliagiiosis i s i i i a d e enz. suHi drugs).OOO/pl) 5.Hematology 55 '13. ficieiicy arid allergic o previously seiisitized patients r giveii for syiriptomatic tlimrnhocytcipeiiia (usually < I O. iriost common iri Iilacks a r i d Mtditrrrauraus. Treat tlie patient. ~ i ~ i i k i l i i c y t o s (diSfkrcnt sliape). drugs. used fbr Illeeriing diatlicsis wlicri one c a i i i i ~ wait t fix vitaiiiiii K to takc effect (dissciniiiated iniravascuhr coagulaticm.ii~ik (chills. iit~clcatedKRCs. wlitic blood cells. S t o p any possil)ic caiisativv niedication. hack pain) Sroiii aiiti1)iidics to white Ijlood d s . fi-ver. zid~ivirdine.

cliest pain. or. a h g y . jaundice) from antibodies to KBCs. thrrjrnbricytop[:nia. drug ria. discomfort. and snake bites). eczema. rhcutiiatoid arthritis. wh ing. 1'TT for intrinsic system (pro Iongcd hy heparin).ook the clas-fbr sic oozing/ blceding from punctare or 1V sites. rarely.Treat tlie underlying caiise (evacuarc uterus.ook for associated Inpus. DIC usnally inail ts as bleeding ctiatli l~. arid decreases in fibrill and clottiiig factors (inclutliug facmr 8. Paticnts iriay need trans usions. aropy. or antithrombin 1 1 also may cam? increased teridency toward throm1 bosis. and other cosriplications. hut patients may h a w thrombotic tendencies. Disseminated intravascular coagulation (DIC): i u o s t comiiionly due to pregnancy and obstetric complications ( S O % ) . shock. lupiis erythematosus. wliicli is nomial i n hepatic ). nialigriarrcy ( 3 1 % ) . pi& rnonary c:mholisiu. JgA dcliciency. dyspnea. I'atients with asswiated oliguria shciuld tic treated with IV fluids and diuresis (mannitol or furosernidr). PaLients arc treated with anticoagulant tlierapy to prexnt deep venous tlironthosis. posirivv 1)-dimer and incrcascd fibrill degradaiion prottncrs.g. frcsli frozen plasma. a prolonged P T brit the patient I n s a telld e w y toward tbrotiibosis. disseminakd intravascular coagulation. and adrenal insufficiency l Basophilia: think of allergies.. iiiflarrntiatory bowel disease). Massive transfusicms m a y k a d IO blediog diathesis from rlrr~imbocyt~~peuia for oozing froin puiicture/IV sites) and citratc (calciunt chelator). Clotting tests: PT for extrinsic system (prolonged hy warfarin). prostatc surgery. blood dyscrasias (cspa:ially lyniplioina). and hleedlng time (H). dyspnea. and tranina (es idly hrad tranma. I. Ixiffler's syiaironie ( 1 ~ ~ 1 nronary cosiiiophilia) . parasitic inkxions. neoplasm. antoirnniune diseases (e. or b l o ~dyscrasia. and/or history of miscarriages. thro~rrbotic nrernic syndrome. attgiocdema. edema. h e p r i n ( d y iu tfir 11 ttce l i f t hrombosis) Eosinophilia: causes irrcliide idiopathic etiology. protcin S.56 Hematology (anxiety. dizziness. tliroin hocytopcnic purpura. parital thromboplastiii time (I'TT). 1)eficieircies 1 in protein C. Look for prolonged prothroinhin time (PT). positivc Venereal Diseasc R Laboratory ( ' rapid plasma rcagin tesl for syphilis. lii~ni~ilytic . (look Patients also may develop liyperkalernia. sis. give antibiocics). or allergic reaction (urticaria. and BT for platrlet lirnctiori: ' ~ l i r o n i h o c y t o ~ ~ rmaya he caused hy idiopatliic tl~ror~tl~ocyt~ipcniic ~ii piirpriia. T Bleeding problems: hipiis anticoagulanl may carrsc. actions. anaphylaxis) to an unknown component in the donor serum.

petechiae). prif. Note: Do 1101 give platelets ti? a patient with thrombotic thrornhocytopcnic pirrpiira or hepariiiassociated tliroinb~~cytopenia. autoimmune disease.llicular and snhperiostcal Ireuiorrliages are uiiiqur t o scurvy Patieiits have a poor dietary hismry (thr. and capillary fragility I3leeding is due t o collagen problems in vessels. splenic sequestration. Bleeding from thromhocytopenia i s in the form of petechiae. 13ler:ding tendei1r:y also may be due to inlieritt:d connective tissue disorder (F. and alcohol. Treat with oral vitamin C. They Vitamin C deficiency (scurvy) may cause bleeding similar to that seen with low platelets (splinter arid gum hemorrllages. but it is rarely a clinical prol~lern. . pscudoxantlioina elasticiirn. osteogcn i i n p c r l ~ ~ x or chronic a) steroid use.Hematology 57 HIV. niyalgias and arthralgias.hIers--Danloss y i l ~ ~ drome. 11eparii1 (treat b y f i r s t stopping licpariii). nose bleeds. and easy bruising. other medications (especially quinidine and snlla drugs). classic cxarnple is I i o t dogs aiid soda). Marfari syiidrorne. may cause tlrr~i~~ihosis..

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Rlood Dyscrasias .

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Occidt hlmd in the stool (if a patient > 4 0 years old sliould be corisidered colon cancer uiitil proved otherwise. Patients with metastases have sev- eral options for hormonal therapy: orchiectomy. I. androgen-receptor antagonist (flutainide). and radiation therapy is usrd rbr local disease or pain from bony metastases. peak incidence between 60--75 years) 2. look for weight loss. 6. eithcr do flexible sigmoidoscopy and a . Patients may present with asymptoniatic blood in stool (visible streaks oc Mood on stool or guaiac-positive). estrogen (dietliylstilhestrol). Iiiflamrnatory howel disease (ulcerative colitis > Crolin's disease.Oncology 53 3. As with any cancer. Race: black > wliitc >Asian s~~gges-. cyproterone) Cliernotberapy does not work. In patients with a palpable breast mass. 60% o f i n e n > 80 2. 5. hiit hotli increase risk) 4. 'Ihrcnt. Family history (especially with familial polyposis or Gardner. even if not palpable (ncedle localization biopsy). Patients also corninonly present with hack pain fromwrtebral metastases (osteoblastic) Local prostate cancer is treated with surgery (prostatectomy). and others (e. Age (not seen in men < 40 years old: incidence iiicrea. Acid pliosphatase is elevated only when tlre cancer lias hroken through the capsule. Tainoxifi:n (or othe. bc. dysuria. high-fat diet (weak evidence) Important points: I. Patients present late.r endocrine therapy) generally improves survival if the ti~riior cstrois gen receptor-positive (EK+) and even more so if the tuinor is also progesterone receptorpositive (PK+). gonadotropin-releasiiig hormone agonist (leuprolide). lfnodcs are positive. give chcinotherapy.ow-fiher. To rule out colon cancer. . Age (incidence begins to increase after age 40.g. a lesion that is detected on mammography and looks s q k i o u s sliould he hiopsied. it was replaced with the inore sensitive PSA as a screening tool.ook for prostate irregularities (nodule) on rectal exam. Look lbr s y i i ~ p t ~ ~ m s tive of benign pi-matic liypertroplry (hesitancy.cause early prostate cancer is asymptomatic. Risk factors: 1. frequency) witli Ircmaturia and/or clcvated prostate-specific antigen (PSA) or acid pliosphatase. change in stool caliber ("pencil stool") or frcqucncy (alrernating constipation and f~equtiicy) with left-sided colon canccr. a n m i i a with right-sided colon cancer. have prostate cance:^) with age. m a n A rnogram that looks benign should riot deter you from doing a biopsy On the other hand. Do iiot do mammograms in wollieii under 3 5 (breast tissue ~ O O dt:risc lo see cancer). 4. for t h i s reason. the decision to d o a biopsy is a clinical 011~. L. or I.ynch syndronre) 3.. I Ob Kisk factors: 1. Mastectomy and breast-conserving surgery plus radiation arc considercd equal in dficacy In either case. do an axillary node dissection to determine spread to the nodes.

most people now start with colonoscopy 3. 5. More than one-half are malignant. For t h i s reason. migratory throinhophlebitis (Trousseau syndrome. Glucagonoma (alpha cell tumor): hyperglycemia with high glocagoii levcl and migratory necrotizing skin crythema. Any ovariau cnlargrmerrt iii a postmeiiopausal woniari is caiicw until pnivcd otherwise. loss of consciousness). Adjuvant clicmothcrapy is sometimes done with 5-fluorouracil (5-FU) and levamisole or leucovorin. you will provide the third part of Whipple's triad: give glucose to relieve symptoins.64 Oncology harium enema or d o a total crkmoscopy If you see any lesions with a flexible sigrnoidoscope or barium enema. PANC REAT1C CANCER m Classic presentation: a smoker iii the 40-80-year-old range who h a s lost weight and is jaundiced. As thc good doctor. Symptoms may include epigastric pain. Gastrinoma: Zollinger--Ellison syndrome is gastrinoma plus acid hypersecretion and peptic ulcer disease (gastrin causes acid secretion). blacks > whites Surgery (Whipple procedure): rarely curative. Carcinoernljryoiiic antigwi (CEA) is o f t m elevated with colon cancer. C o l w cancer frequently metastasizes to the liver. ascites. diabetics > nondiabetics. with resection of involved bowel. it is used only to f d o w known cancer. and a preoperative level i s usually measnred. 2. most ovarian e~~largerniwts are .p e p tide is high with insnlinoma. CEA should return ti) normal levels. and/or bowel oh^^ structiou in a pmtrrienopausal woman. Colon cancer i s a coiniiion cause oi'a large bowcl oljstrirction in an adult. are Ninety percent of irisulin~imas benign and cured with resection. stupor. 1 LIwomen of' rrproductiv? age. they may he in an unusual location (distal duodenum or jejunum). cliernotherapy is the only option. Treatment is primarily surgical. 3. Prognosis is poor. Peptic ulcers are often multiple and resistant to therapy. if possible. takc history and check C-peptide first to make sure that the patient is not a dia-~ betic who accidentally took too nmch insulin or a patient with factitious disorder. snrgical resection is often attempted. 4. the prognosis is dismal Cell oforigin: ductal epithelium Islet cell tumors: 1. CEA is not used as a screening tool for colon canwr. Insulinoma (beta cell tumor): most common islet cell tumor. pelvic: mass. C . Ovarian caucer usually presents late with weiglit loss. After surgery to remove the tumor. low with other conditions. I n your \vrirk-up. Periodic monitoring of CEA postoperatively helps to detect recurrence hefore i t is clinically apparent. With iii~tastases elsewhere. 6. nontender gallbladder (Courvoisier's sign) Epidemiology: males > females. if the metastasis is solitary. Look for two-thirds of Whipple's triad: hypoglycemia (glucose < S O mg/dl) and central nervous system syinptoms due to hypoglycemia (confusion. or a palpable. you l i e d to do a total colonoscopy with rcrnoval and histologic exarninatioii of all polyps/lesions. which also may he seen with other visceral cancer).

< 20 years old at first coitus. Treat with surgery and/or radiation. Most ovarian cancer arises ~ I J ovarian epithelium. ! Krukenbcrg's tumor: stomach caiicer with metastases to both ovaries. Ultrasound i s a good first test to evaluate ail civasian lesion. hair. proceed to conization. 1. Teratoiina/dcrmr>id cyst: look for a description of thc tumor tecth/hone. ascites. and/or 2. Give fecmale pa-. Iiivasive cervical cancer begins in the transformation zone and usually presents with vaginal hlcediiig or discharge (may he postcoital. even if they present with a n unrelated complaint. or abnormal I T I ~ Y strual bleeding). Follow up a n y dysplastic Pap smear with colposcopy-dirccted hiopsies and endocervical curettage. receding h a i r l i ~ ~deepening c. the most corninon ovarian canccr. Granulosa/tlieca-cell tuniiir: causes f(miniration and precocious puberty Terms worth knowing: a Meig's s y n c h n e : ovarian fibroma. may show iip 011 x-ray. voicc. Papanicolaou smears decrease thc incidence and nnortality of wxvical cancer. to dicthylstilhcstrol causes clauy'riters t o gel clear cell cancer of the P o ~ t ~ ~ n bleedingu s ~ ~ until proved otherwise: end~iinetrial ~ ~ a is canccr caiiccr is r h c no st coviinion canccr to present in t h i s fashion (fburtlr most c01r11non cancer i n WOIIICII) . If rhc Pap smear shows rnicroinvasivc cancer. and right hydrothorax. tierits a Pap snicar if they are due. 2. Maternal expwxire cervix or vagina. prognosis is usually poor. or marriage 2. Note: Oral contraceptives have heen shown they also reduce endrimetrial calices. pregnancy. clitoromegaly) 3.I Oncology 65 benign. Seroiis cystadeoocarcinoina. intermenstrual spotting. ~ c an t eudomctrial biopsy fix any pa~ient with ~ i o s t ~ n ~ ~ ~ i ~ tiiredingl (as well as a ~ a spi i c a r and )pausa i . High parity (which protects against ciidomctrial cancer) Important points: 1. IO scchice the incidcnce of ovarian cancer hy 50%. Smoking 4. I'rankly invasive cancer necds surgery and/or radiation.eydig cell tunlor: causes virilization (I~irsntism. 3.Trcatment inclitdes drht1lliing surgery and chemotherapy. often h a s psammoma bodies or1 lristopatliology I Germ cell tumors make good cluescious: 1. Sertoli-I. Risk factors for cervical cancer: 1. IO includr skin. Multiple sexoal partners (role of human papillornavirus and possihly herpes) o r coittls with a promisamus person 3.owsodoeconmnic status 5.

Any woman with uncxplained gynecologic bleeding that persists needs a Pap smear.ate incnopai~se 4. papilledema. in adults. Test. papilledema. 111 cittrer group.The most coinnion type is prolactinoma (liigli pvolacrin levels with galactorrhea and menstrual/sex~ral dyshoctioii). and vomiting with a negative C?'/MKI has pseudotumor cerebri. neurologic deficits. projectile nausea and vomit-ing). rans sill ti in in at ion and ultrasound help to distiiiguish hydrocele fluid^^ filled.'T'he main risk c factor is cryptorchidism. 2.oiiset seimres. it is acoustic neuruma (watch for neurofibromatosis).icular cancer: the I I I O S ~ o n " n i solid malignancy in men < 30 years old. look fbr new. Pituitary tumors: look fbr hiternpoval hnrniano1)sia (order a n MRI if the patient has it). 3. endocervical curettage.6 Oncology ~ endocervical curettage).raceptives have hcen shown to reduce the incidence of uterine as well as ovarian can 2. 3. blurred vision. The most common type is scminonra (radinsimsitiv?). ohcse woman who has headaches. whereas in cbildren twc)-thirds are infratentorial (posterior fossa/cerebellar). Other types niay causc Cushi rig's discasc or Iiy~~~!rtliyroidism. estroyen-sccreti~lgiieoplasrn (gramilosa~-!hcca tumor). Dial)ctes niellitirs 5. not a malignancy. Treat with surgery and radiation MIS Brain tumors: in adnlts two-thirds of primary tinniors (metastases arc inore coininon than primary tuniors) arc supratentorial.. Sarcoma botsyoides: feniale c'nild with a "bnnclr of gralxs" coming 0111 of her vagina. fbllowed hy ependymoma. Chronic. and endometrial biopsy Risk factors for endometrial cancer: 1. Obesity 2. which may be followed b y radiation and chemotherapy. depending on tlre tinnor. I. Most uterine cancer is adenocarcinoma and spreads by direct extension.The most common type in adults i s glioma (most are intraparenchyrnal astvocytornas with little or n o calcification). Treatment is surgical removal. and estrogen replacecell ment (increases risk of cancer only if taken w i t h u t progesterone) Important points: 1. as in polycystic i~vary/Stein-l. watch fix craniopharyngion~a(a remnant ofl<atlike:\ pouch). The most common posterior fossa tnmors in children are astrocytoma and medullohlastoma. external to tlic brain substance). In children. also look for hydrocephalus and ataxia. Oral conc. the m o s t conlinon types are crvchellar astrocytoma and medrrll~~blastoma. Ntilliparity 3. Gallbladder disease 7. Itnportant poi nt s to rcmember: 1. . In children. It is heavily calcified and shows up on skull x-ray (most likely tiiinor in children if it shows up on s k u l l x-ray).eventl~al syndrome. In children. A young. Hypertension 6. followed hy meningioma (usually calcified. or signs of intracranial hypertension (headache. unopposed estrogen stimulation. traiisilliiiiiitrates) from canccr (solid).

i~ld"nixiulc or arca o f d e c r c a s e d uptake is 11iorc S I L S pici~:ius than iiorn~al/increasettIiptakkt. Paiiciits also m a y Iiave a ~ i l ~ c o c h r o n r o c y t ~ i ~ r ~ a (intcrmitteiit. and increased calcitonin level (medullary tliyroid caiicer~-~~rtsuallypatients with iiiiiltiple e m in d~icrine neoplasia type 11). smoking. Liver tumors: hepatocellular cancer i s caused by alcoliol. and the iiicideiice is incrc-asing. Other t i i i r i ~ r s tht.) 4.ieiit prescnts w i t h a nodolc i n the tliyroid gland. 4. and an errlarycd liver.iiecdlc aspiratim or opeii biopsy. aud diaphriresis). gerlerally left alone. rccrig~~ize ~ r a y ~ o ~ ~ ~ c x ~ ~ firldiirgs ~ ("srrliburst" appearance : femiir or proxinral tihia) ~ iri distal . I'dticnis o r i c ~arc sini)kers or work iir i tlit. the Adrenal tumors: may be functioiial and cause p r i m a r y hyperaldostcronisrri (Con~i'ssyiidroint. pet thyroid liinction tests. liver: of 1. Bc suspicious (if canccr in any of the fbllowirig sceiiarios: "cold n ~ i d i r l e "mi iinclcar scan. history of childlro~idirradiation. ruhbcr/dyr i r i d i i s t r y (aniline dye exposure).Nasopliaryngeal cancer: 1 in 1 Asians. prognosis is p w r . riglit r i p p quadrant pain. 011a niiclc'ar scan. Hepatic adenoma: worncxr of repr~idiictive taking oral coritraceptiv agr ( n r cancer rriay rcgrcss. Pahicnts presmit late. livcr flukes (Clonnschis) may hc foiiiid in iiirmigraiits. Helicubocter pylori also is implicated. Thyroid cancer: t l i e pai. and ariytliiirg else iliat cirrhosis (lieiiiocliroinatosis i s especially kn<iwn io ca11:1sc livcr cancer). Ilrpaiitis C i s more Likely to caiisc canccs in the c h r m i c scttirig than l i e p a t i t i s 8. ~ t ~ 10-30 year-olds. hradachcs. liepatitis. I'atients have a liistory of'alc~i~iolis~ii.stimularing I r m n ~ ) u is~thc h r s t scrct:rring test. The riiost c o i ~ i i i i i i itype is s q i i a ~ i i i i o u s cell. He~iiangioiria: i n o s t co~iiniorr thc priiiiary is done if thr patient i s symptomatic. To evalnatc a rrodule in the rliyroid. Consider finc. Krukcnbcrg's tumor is sto~nach cancer with bilatcral ovarial1 rnctastases. Cystoscopy is iisiially dmie first t o eva1rrat." wliich p r q r c s s 10 dysphagia fbr liquids in a cliniiiic srniikcr and drinker (hlacks > whites). Surgery is the only hope Ibr cure.-~c~opr[)tciiioft eii elcvated and can he oicasurcd post(ip~rativelyto detect is . rrialc patient. Check ?4-Iioiir urine ratecholarnirres (vanillyltr~a~~dclic homovai~illic acid. acid). Stomach cancer: risk factors are Japanese raw.. Ixvarise early cariccr i s asymptolnatic. i t miist be biopsied to exclude nialignancy. and/or liernoclirornatosis o r (ither muses of cirrhosis and presmi with weight loss. Thyroid. J "c. iiodulc described as "stony hard. severe hypertension w i t h mental status cbaiiges. LUIIIO~ or the liver.50% of paticmis 1iave a history o f ulccrativr colitis.) or liyperadrcnalisin (C~~:ishiiig's discasc). "toxic" or fiincti~inal r nodules arc ti+ likely to be cancer. possitk anemia. rhc Iwst pre ventiwi is proper vacciiiaUoii. h i r bepatitis 13. 5. and (:sniplaints that " m y fbod is sticking. Vir(:lrow's r i d e i s left sripraclavicitlar node cnlargerrieiit due t o visccral cariccr sprmd (classically stornacll canccr). fix ticpatitis C. Surgery 2. and c o ~ i s u i i i p t iori ~ ~ ~ smoked ineat.r a potential bladder cancer. If a gastric iilcer i s seeu oii upper GI harirrm opy. rcirieinlicr asswiation with Epstein-Barr virus Esophageal cancer: weight loss. Cliolangiosarco~na: ."recent or rapid i:iilargeriicnt. Barrctt's esopliag~is(colrmnar inctaplasia of esopliageal sq ~~airioils cpitheliiim d u e t o acid refhix) m a y give rise t o adcriocarciiioina o C the csophagns. Bladder cancer: h i k fbr persiistciit. painless hcinatnria. t h e Rest prevention is avoidance of hlood transfirsions. Aiigiosart:oina: locik for industrial exposure t o vinyl cliloridc. hiptitis. iiicrcasiiig age. Wepat~hlastoma: inairr primary liver timior in children. Alplra.

like all otliers.~ acid i ~ HIAA) i s iiicrca. Note: I'atieiits with canccr. sqriariiriiis. Histiocytosis: CD I positive. wlicrcas Wilrns' t i i i i i o i arises in I IIC kidney aiirl tlriis d i s t r r t s the calyceal archittxtun:. diarrhea. or the liiiiireriis i n diildrrn a n d adolrsccnts. i i i c o l o r o r inuhiple (the Iiiggcr lhc ksiori. Tumor markers I 0 1 . color (cliarrgr. It is Imiigii IIUI may w r a k e n h o i i c cnouglr to cause a Retinoblastoma: ieukocoria ill a y(n111g child (red reflcx is wliitc willi .I pcnliglit) or iiirilalcra~ exciphtlialmos. ciiiiimouly 011 the tipper body or i i i the o r a l cavic). lytic. also I i x k lor pour ~ a Iiygiene. hiit carcinoid i s the iiiost comnoii appendiceal Iumor. neuroblastoma: lxitli prescric as flank masses in childreri at a peak age [if around 2 years old. eveii in terininal patients.aiiws 10 m a k e thc tunior asymptonratic. s y i n p t ~ ~ i i hegin (carcinoid syndrimc): is episodic ciitancoiis Ilusliiiig.s taneorisly (for unknown reasom) Oral cancer: due to smoking tir chcwing tobacco aiid drinking. bordrrs (irrcgiihr). wlricli mist be difrercritiated fiorri oral hairy leiikc)plakia. The classic way t i i diflcrriitiaic tlic two (altliongli y o u slmiild always get a iie diagnosis to inakc sure) is intravenoiis pyelography: neurohlastomas teiid not t o distort the calyces of the kidney (iricist come from the adrvnal gland).Tlic dassic d p r i o r i i s a rash tliat does iiot riispi~nd multiple t r ~ d t n i c i i t s . alxloiiiiiial craiiips. l Oral caiiccr often starts as leukoplakia (know tlic appcaraiiw). a vascular skin Iiiiiior that slarls as a papiile (ir plaque. watch Lbr ion. Hasal cdl w i r c i ! ~ s ex i t r m i r l y coii~r~ioii d aliiiost ucvcr ~iit:ras~asi~c an '(jiiamoiis cancer rarely i i i m s t a . Biopsy airy suspicious Icsion (cxcisiiinal hiops y) W i l d tumor vs. ~ .I<rloru 1lJcr l h sic a p p e x a i i c e of h s a l ocII cmcrr (pearly. (a prcrdrict of scrotoiiiii Brcakdowii) Eaposi's sarcoma: i n I~IIV-positivv paticrits. Flowcvcr.s. and riglit-sidcd Iicart valve darriagr. wdl-dmiarcatcrl Icsion i n rlic proxiinal prticm pal Iioliigic fractorc. iiiiihilicatrd. l'he liver breaks down sel:ot(iiiiii aiid other vasoactivc secrctcd sirhsc. look l i k e timiis rackcts). tiic i i i m ? likcly Ilia1 il is iira~igiraiil).whicli i s associatcd with Epstein-Barr virus and affects HlV-posi~ive patiairs. hiit whim carcinoid rnvlastasims 10 tlre livcr and vasoactivc prodiicts rcach the systcriiic circiilarion. Rarcly. Unicarricral bone cyst: expaiisiile. Uriiiary .'& ABCDs o f melanorria slrould make yon suspicious diiialigiiaiicy 13iopsy any l a s i o i i with ally OF s: asyniinetry.Carcinoid tumors: tlic iiiosl co1iiiiiiiii localiou is the sinall l)uwel. tclaiigicc(asias). riie1ani)iria ci~mrnonly iiietastasi/t. to Skin cancer: ultraviolet light iricrrascs risk or basal. iiiheritcd fbrin may he Iiilateral. r i c ~ i i r o h l a s t ~ ~ i nmay rrgrcss s p m a.l ~ y d r o x y i i r d i ~ l r a c ~ t(5. Birbcck graiiulcs (cytoplasinic inclusion Bodies that. have the rigIiI lo refiise trcatiiiciit. and tilelanoma skin canccr.

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is classic c m s e in skidkow alcoholics and horricless people. High mortality rate because of patients affected and severity (if pneuiiwnia (abscesses ciniinioii) . (. inflncna. Viral pneumonia: viruses ~:ommonly cattsc respiratory infections (respiratory syncytial virus. f k carnet is ai1 alternaiive. 5. CMV has iiitracelhlar inclusion hodics.irrlira dftcr biking o r drinking FviJrn a siremi: Giordia lornblia. Chhitnydio pneumonine: second only to Mycopiasmrl sp. I’CP shows up with silver stains---know what it looks like. Called “atypical” pet~u~noiiiaw I cause it is differciit from S. the alternative is pentamidine. cephalosporin.Treai with aiiiplioterichi R. ‘Treat with trinietlioprim/sulfarnetlioxazole. Treat empirically wi tli tliird-generation peiiicillin/ ceplial(isporin plus aniinoglycosidc. N.Treat with oral pot as^^ sium iodide or ketoconazole. iieutrq~e1iiaa d li[)spital~acquired piieuinonia. Cliest x-ray shows a patchy. enteric grain-lie@ timr organisms (e..ram-tiegative organisms: Pseudomonas sp. presents similarly hut has negative cold-agglutinin antihody titers. Look for positivc cold-. Iilnpycyna aiicl Itmg alwmscs are relativcly criiiiinon. Staphylococcus uureus: cdu liospital-acquiretl p n e ~ ~ ~ n c iand p i i ~ r ~ i i i o ri l~ nia r i pauicnts with l cystic fibrosis (second t o Preudomonus sp. Et. Treat witli ganciclovir.Infectious Disease 71 ainpicillin/am~ixicillin. classic. Pneumocystis curinii pneninonia (PCI’) atid cyloiiiegaloviros (CMV). DCP is more coninion.g. with long p r d m n i c a n d gradual worsening of malaisc. cysts i r i stool. iiitravenous drug aliiiscrs. at which point you slionld institute PCY prophylaxis iii a n HIV-positive patient. diffiise hr~inchopneumnnia(the x-ray classically looks tcrrihle. and sore throat. Cnltures usually are positivc. nicnin~itidis (encapsulated hugs) f’iiciinioiiiain lie Sontliwest (Califbrnia. Klehsirlln si).negal tive coccobacilli are see11 on spi~tom Grain stain. dry n o ~ ~ p r o d u c t i v e coiigli. always suspect in HIVposiiive patjents. coli) arc: com~rro~i wiib aspiration. 4. Empiric treatnie~ii “atypical” pneuirronia is crythroniycin.~~le i‘grain-. Prreumonia afler cave exploring o r exposnrc io hird droppings in Ohio and Mi River valleys: Iiistopliisinu capsulritum 1’11~i1monia after expsiire t o a p or cxotic hird: Cliloinydia psiltuci ” wa Fiiiigiis ball/licrnoptysis after tuhcrcr~lar cavitary disease: Asptr’gillus s p . influenmc. headaclies. 3. adenovirus) 8. Pnerniioiiia in a patient with silicosis: tubercnlosis ia 1)i. Aplastic crisis in sickle cell disease o r other Iirinoglobinopatliy : plrvovirus 819 Sepsis afier splenectmny ( o r autosplencctorny in sickle cell disease): S. 7. although the patient does not fed that bad). jineumoniue. as cause [if pneuiiic~nia adolesccnls in and young adults. bronc~ioa~vc(i~ar often is req tiired to obtain lavage the diagnosis. Mycoplusina sp: most c o ~ n i i ~ o n adolcsceuts and young adnlts (the classic case is a cr)llrgc ill student wlio lives in tile dorm and has sick contacts). of 6.agglntinin antihody titers (may cause heiuolysis/arieinia). or tri~~it~thopriiii/sulfai~~etli~~xa~. Classic infectious diseasc questions: Patient stuck with tllorii or gardener: Sporuthrix schenckii (a fiingus). trcat witli rnetroriid~volc . and p a t i c n t s with clironic granok~matous disease (look fbr recurrent Iiing abscesses). parainfluenza.Ariniiia) : Coccirlioidcs iinmitis. PCP is acquired wlren the CD4 cixnit is brlow 200. I!.ally is associated with cystic fibrosis. pneumonise.).

between sccondary and tertiary stagcs is the latent phase. (positive tape test. whcn the diseasc is quiet and asymptornatic.se~reado~noaos (S. I’licunionia after being in a hotel. Note: Watch fbr false. Look fix gurnnias (graiiulonias in many different organs). scc gynecology . and periorbital edema afier eating raw meat: Trichinella rpriilis (trichinosis) Castroentcritis in young children: rotavirus Food poisoning after eating reheated rice: Bucillus cereus I s I?iod poisoning after eating raw seafood: Vibrio purahncmolyticus Diarrhea aAer travdiirg to Mcxico: khcrichin coli (Monlezuma’s revenge) B Diarrhca alier antibiotics: Clostriilium difficile. Charcot joints).72 Infectious Uisease a Pregnant P women with cats: Toxoylosmu gondii U . the rash On (rnacnlopa~~r~lar) hcgiris oii thc head and neck aod spreads ilownward t o cover t1~1e trirnk (c~~phalocauclal progr ion). Screen all pregnant women with VDRL/RPK. l’rcponmiu yallidum also can be seen with darkfield microscopy bur not with a Gram stain. Sccondary: roughly 6 weeks to I8 inonths after infection. Treatment is penicillin. if positive. treponenial antibody. 2.) or rapid plasma reagin (RPR) test. 11 ologic symptoms and signs (neurosyphilis. witlioirt blue. Koplik‘s spots look (tiny white spots on buccal mucosa) are seen 3 days aiier high fever. ArgyllRohcrtsiin pupil. absorhed (FTA-ABS) or inicrohemagglutiiiation Treyonmu pallidurn (MHA-TP) test. deticicrrcy and ahdoininal symptoms: Diphyllobothrium latum Seizures with ring-enhancing brain lesion on C T Toeniu sulirim (cysticercosis) Bladder caircer (squarnous cell) in Middle East and Africa: Scl~istoro~nr~ huemutobium B Worm inkctioir in children: Eiiterobius sp. near air conditioner or water tower: Legionello pneumophila.. treat will] metronidazde or vaiit:orriyciir Infant paralyzed after eating honey: Clostridium botulinum (toxin blocks acetylclloline release) Genital lesions in children in the ahseiice of sexual ahiise/activil y: ~nolluscum contagiosurn m Cellillitis after cat or dog bitcs: Portcurella multocida (trcat cat and dog bites with prophylactic ampicillin) with fever: Bruccllu sp. n u s d e pain. . Other syinptorns iricludc cough. treat with erytlrromycili) Rurii wound infection with blue/grcen color: P. . and lyinphadrnopathyi~ 3. use crytliromycin for penicillin allergy. dernentia. and/or thoracic aortic ane orysms. supportive trcaui~eiitonly urrless ottierwisc spedlicd): 1. aureus also sp. perianal itching) Fever.Threc stages: 1. the next day. eosinophilia. runny nose. iiiacw lopapular rash (especially involving palnis and soles of feet). . Coniplications inclodc pm:uirionia (giant-r:ell pneinnonia. confirm with fluorescent. look fix condyloma lata. I’or (ither scxit~ ally transmitted disea. Primary: look for painlcss cha~icre that resolves on its own witlliii 8 weeks. . Tertiary: occurs years after iiiitial infeection.~pr)sitive VDRI./IWR in patients with lupus erythematosus. Measles ( r ~ ~ e o ~ a ) :fbr a reason for paticnt not to he irnmnrrized.green cobr) C O T I I ~ ~ Ohut JL s Slaughterlionsr worker 6 Syphilis: screen with Venereal Disease Research Laboratory (VDKI. and coi~jrrirctivitis/photopt~obia. par tabes dorsalis. ~ ~ f e ~ t i o ~ ~ rashes (most often in chilclrerr .

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poor time. to N eriu givc all contacts rifatupiii as propliylaxis. A l l patients o~i s need f o r m a l hcariiig evaluatioii after a bout ofrneniiigitis. jaundice. epilepsy. IV fluids). R S V / b r o n c h i o l i t look for R m o n t h s old patient. J k not examine the I ilirmt or irritate the p a t i m t in airy way----yoii may prccipilate airway olistriiction. intercostal rctractimis. influelime i f y o u have t o (:boose. Note: I l i p l r t h c r i a (CoIynebacteriom diphtherioc) a n d pcrt ussis (Wortletello penussir) slroiild hc corisid if the paticiit i s n o t i r n i n r i n i x d .T l l r m i s t c o ~ r i ~ i i i~eur(ilogic e q i i d a of111 iiigitis is l i c a r i i i g l o s s . About 50-~7.~ i hate. d r o o l i n g .. the otlrcr causative agcirt is influrirza. other causes are parairiflueriza a n d i n l l u c n z a . 102O F in tlie absrnce of oilirr sigiis o f ri's(:i~. I > i l f i r s t i hyperiiiflat of tlic liiiigs i s d a s sic o n chest x-ray. i i ~ l l ~ ~ w c d days lacer ns I--~7. and f k r ) a i d roughly 1-~2days later dcvelop a "harking" c(iirg11. aiid rcspiratory distress t with no cougliiiig. k i o k for flattent:d diaplrragnis. cough. altered consciousness. iiiflua~nica i i t l S. Patients start with symptoiiix < i f viral ripper respiratory i r r i k t i o n (rliinorrhea. otlisr licalrlr ~ ~ n ~ l i l c w ~ s ) . Usc rihavariii ill jiaticiits with rc s y i r i p t o i i i s o r in( risk (cymosis. m o t o r deficits/paresis. Look for lethargy. liavioral disorders. 2. u s i i a l l y occurs in fall or winter-. but sirriple f r h r i l e seimres also are p o s s i h l e if tlie paticiit i s h e t w w i i 5 iiioriths and 6 ycars old a i d has A f k r 3. Iirtiricliodilators. with r a p i d progressio~i o Iiigli fever. pliu topliobia. Seizures may lx seen.. The m a i i i cause by far iised to be Iluemophilus influet. chaptw Pediatric respiratory infections: the hig t h e e are croup. 1. h r ccrehrospirral h i d findi iigs in Ineiiingitis. cpigl(ittitis.~~res in the presence o f c i t l i e r sigiis OS ~ n e r i i i i g i t i s sepsis. Look for l i l t l e or iio prodniine.g. hirt with w i d c s p r r a d vaccinati(in. r l r i r d ~ ~ ~ ~ e n e r a iqi io in l o s p ( i r i 11). or hypotlierinia. H. and c x p i r a t o r y wh ing. W l i ~ ia i case o f c p i g l o ~ t i t i ss preseiitcd. hulging fonlanellc. the first step i s to he prepared to cstablisli ail airway (iirtii. m i s t tciit. .~~~- - Infectious Disease 75 signs). O v e r 7 5 % of cases are caused by KSV. Pick H. tiy r a p i d rcspirations. tonsils. Croup/acrrte laryiigolraclieitis: look for paiicnt to h e 1--2 ycars old. a n d / o r IIVUI~ myocarditis. 1)iphtlirria i s associated with grayis11 ps~iliiorrlcrrrhrarics arid (necrotic cpittitrliuiii arid inllairiinatory cxudare) on tlic pharynx. . and rcspiratory syncytial viriis (RSV)~--Iiigh yield! 1. Trcat hotti w i t l i anti hiotics. c I a 3. hyper-.s p c c t r i uantihiot ics i n i m e d i a t c l y a t t e r t l i c ii p r ~ i c e t l u r c'. Tlie "steeplc sigii" is classic 011 latcral x-ray of I neck.n c g a ~ i v r ) rneniirgitis. vision testing also i O t h e r scqnelai. usually occurs ill fall or wiiitcr.. Treat with aritihi(itics (e. Tlic "tlrunrh sign" is classic O lateral neck x ray. vomiting. t o r i c appearaiice. proceed to occiir or l u m b x p i i i i c t i i r e iiiirnediatcly a n d begin I ~ r o a d . Tlx ~)attirwt also rriay liavc crackles on ausciiltation t l i c clicsc. l'ertiissis i s associatcd with scvcre ~iar~ixys111a1 o i i g I i i i i gaiid a lrigli -pitched ~: whooping iiispiratury iioisi: (classically called " w l i o o p i o g coriglr"). m Watch Ibr liprpcs c~iici!plralitisi f thc i n o t h e r lins Iicrpcs siinplcx lesi<iiis at rhc t i i i i c OS tlic i n f a n t ' s birth. a n d Icariiiiig/hr.ivc If rnciiingitis is doc. E p i g l o t t i t i s : t h e patient usually is 2-5 years old. C. and signs of generalized sepsis (hypoteiision. Treat supportively w i t h a m i s t tcnt am1 racemic epitieplrrine. traclieustomy ifriecded) . Trcat s r i p p ~ i r t i v c l y (oxygen. T l i ~ hrst p r e v r n t i o i i i s irnriiuiiizarion.rcie type b. t 11c neurology SIP.5'% cases arc duc to p a r a i n f l u c n ~ a of virus.include i r i r i i t a l retar&atioii. rcspi- ratciry distress). Muinps aiid measles are p' i hlc causes of aseptic (nonhactcrial or c u l t i i r e . I'aticiits start with s y ~ ~ i p t o r of v i r a l iipper respiratory id ion.ook fix t c i i i p o r i Iolw ahiiorriialities 011 a CT or MRI scan o l ' t h c Itcad. inspiratory stridor. U ~ I ~ E Uarc S cqiially freqiicnt. l i o a r s ~ ~ ~ i cand ss.

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Treat cmpirically with standard nrinary tract infection antibiotics.c(:al perii cilliii (cg. i~i&i:ti(ins prostlietic inrplauts (Iivart if valves. Treat cinpirically with antistaplrylococcal penicillin o r . . 'Treat carrier with antihiotics. wlro ~:>rten start with inipetigi). and a rash that desquamates) sScalded skin syndrome (preformed toxin that affects younger clrildrut..fever. niet11 ci II i n . o t h c r infixtiinis i w itli an tistal~liyb. Staphylococcus saprophyticus: c ~ i t i i i i ~ n caiise 111 irrirrary tract iltfectiou. vascnlar g r a f ~ s )and scpsis. Stqihylococcos epidermidis: causes 1V cathetcr inkctioils. tlicn dcsqiiaiiiatc) I Impetigo n Celliditis Won ud inficti<nis ml'iieiiriionia (often fbrms lung abscess or cnrpyetila) 81 Fnrunclc or carbuncle Note: 1-Icalth care workers wlm arc clininic: nasal carriers may causc nosoc(imia1 infectims.ci. d icloxaeihi)or van ciiinyci11. classically in a woman w h o Icaves tampon i n place too long and develops hypote~ision. vancimiyci 11. ?kcat ah. with incisio~iand drainage.Infectious Disease __ mToxic shock syndromc (prd'ornmcd toxin.

Common terms t o describe skin finding .

arc 1. ti) .r area. a n d ' .l~itIla(:. also may hc rluc to irritating o r I m i c sitlistancc. uremia. t~ and ~ r i i d clrar w i i t r d l y wliilr tlicy cxpaiid p ~ ~ i p l i ~ ~ r a l l y . itchy. scahies. dc(id(irant).Av(iirlairce oi'the i i i i i i c tlic arrtigcii a g ~ i i it s required. trcat with ilaiilruff s h a r l i p i x i . irray h a w autoiiiiitiiiiic In have a n t i h i d i e s t o iiielatiiii. Iiypothy~~ r r~s m i d i s i n . and liclieii plairus. i t n c c d r d . s k i u is r e d aiid itshy a r i d ufteii has vesiclrs o t .. SCCII in o b i l i a r y disease.$. coiiditioiis kiiiiwit as cradlc ~ d arid rlandrutt as p fiir scaling skin on tlic scalp a n d cyclids. wcepiug skin on tl~e Itcad. coiii111oii t i i i t i a ~ i o t ~ Limk ). well as l)Iq)liaritis (cyclid i i tiic. 'Titicx c o r p o r i s (hiidy/trunk): l o o k fix rcd rirrg~~sltal~e(l lcsiotts that l ~ a v rai. Treatriiixic i1lvolvt:s . Thr higgcst ~irt:hlrm is scratching. i i i t known as: ions. 1. iiii'kcl earrilrgs.0 Dermatology _ l _ Vitiligo: ilrpigirtcirta~ioit i f iuikiiown c t i h g y . antiliisrarriincs. This s l i r i m i c wttditioii begins in tlw first yrar d'lifc with rcd. or tltyriiid Pruritus: niay b e a clue to diagiii (IS serious a n d c o i i i r i i o t i conditioiis. assiiciarcd w i t h i ~ c r r t i c i i ~aiiernia. w h i c h leads 1 0skitr hrcahs a n d possililc h a c t c r i a l i i i k c r i o t i . 10 d Atopic dermarit.l'Iic rash i s wrll i : i ~ i : t t n i s ~ r i t i ead d fiiun~! i~ n ciitly iii tlic area ot'cxposiirc.is: look fbr f a m i l y a i d personal history of allcrgivs (e. i\ddisoii's iliwase. parietal cclls. itpi)cr cxtrctnitics.ook fix question t h a t tiicittioiis n e w cxposiirc to a classic o l h d i r l g agent ( ~ i o i s o ivy.. top or I l C X l 1"Igc) Sehorrlieic dermatitis: c'iii. hay fever) axid asthioa.rvi)idarice iif dryiitg soaps. arid topical stcriiids (. dcpciiiliiig on location. aud diabctic mellitus. a n d sounctiiitcs arounr! t h e dia1ii. ligilrc. ritrgworiti). p d y c y t h r r n i a rubra vera (classically aitcr a warin shower or h tact OII: atopic dcrmatitis. patch tvstirig can l x daw. I'rurgal skin infectiorrs (dcrniatiipliytr. Contact dermatitis: o f i w diic: LO a typv IV liypcrsciisitivity rractiiiir.

Tinea cruris (jock itch): rrrore coiiimoi~ ohesc malcs. kctocoi~azolc) or griscofiilvin. . 5. micorrazolr. o o h o t hygiene is part ~ d oi'treatmcnt.. 3.g. distorccd tocoails (otiyclii~~riycosis).2. tire otlrers can he treated with topical anti(itirga!s (c. i f tlrc hair h ~ ) r e s c r under Womi's lamp. if i r d o e s I ~ I tile p r o b d ~ l e s . which usidly rcsolvcs on i t s own. Micmsporuni sp. who lravc scaly patches of hair loss a i d iriay liavc a n irillanled. Tinea capitis (scalp): mainly aftccts children (higlrly contagious). scaling web spaccs bctwcen thc toes that o l i e i i itch arid thickened. ~rsrrally rlie crural ii~lds thc in ill of i ~ p p c inner thighs. boggy grmnlolna ~f t l ~ c scalp (krlowrl as kerion). <iiagrl<)scd scrap t. which i s hcwr iix sc'vcrc o r persistent inkctiijtrs. rrl tinea capitis. 'Tinea urigiiiurri (oriyclroniycosis): tlrickencd. i s the causc. d i s t o r t e d trails witil debris nri&r the rrail edges. cat Trichophyton sp. r Most fiiiigal skirr i n k t i o n s arc d u e t o Triclrnphyton spccks. 4.y iiig tlic lesioii and doiiig a ptassiium hydroxide (KOH) prqnratiori to visiraiizc the limgus or a ciiltnre. Irlfc i o l l s arc. Tinea pedis (athlete's foot): look for Inaccratcd. Griscoiulvin (oral) mwt he iiscd to treat tinea capiris aiid orrycliornycosis. (:lotririiazolc.

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lclronle (polycy\tic ovary).tiL h i m \ look like aiid liow they arc ( k s ( c i hcd (dry. or scx/tiiastiirhatio~~. and drugs (minoxidil and phniytorii) Baldness: watch out for trichotillomanra (ptychlatiic patientt puillng out tlicrr hair) and alopecia areata (idiOpathic and ascocia1i. well circumscribed.lla\ hkickagr ot pi locelixcom glaiidc Rcric hat not Ijrcii proved to he rdaml to hod (hut i f tlic patwrit relacct i t t o a food.. lilackhca(ls).~-~ Dermatology ~ Acne: know tlic description of acnc comedones (wliitclit~ads. or cbcinothcrapy) as exotic ( a i w s of irregular. U t s h i i i g ’ ~ syndn . m a l erythromycin ( f o r P o m \ ciadi<ation). hut it IF n o t rclatcd to drct Hirsutism: iriost cominonly idiopathic. salicylic acid.ntllal \y. VOK clitoromegaly. suprrlicial pus fillcd cy\?\ with pwtihlr inflarninatory skm chaiiges Proptnnilmtcnum acne7 15 thought t o he partially involvrd i n pathogriiesis as w<. . topical ort tit tolytic< (coal tal. you can try dircontiiiumg it).dt with topical mctronlrla/olc or oral tetracyc Liiw I lie patliogcrrcsis 1s unknown.d with arrliiiiic~usoriia~i d other a o l o a i t t i h o t t r r s . (osinetics may ag Im gravate it Trratnietit optioiir arc multiple Stai t with topical hciiroyl peroxide. Stein I cvr. papulct. top of iicxt page) (3. \ d i n g p a p n l c ~ n d p l q n < ~ s 1wnrly I ~ l s t o r y d t m positlvc a ) 1s Ptorratis occurs mostly i i whitcs with o i i s c t i n early sdriltliood C l ~ i s w i Icrro~ts drc fouritl oii thc scalp and rxterisor wrfnrrt o f tltc elbows a n d kiie-es I’aticnts iimy lr~vc pitlirrg o f thc nnrls and arthritis that i twrriblrs rhernnatord arthritis h i i t is r l i r i t r n a t o ~ d tor iwgauvc ~>iagnosict ta( i inadr hy ap11c~aiar~hiit hopty can lw uscd (01 douhtful c r~tcs ‘lrmnicni i t coiripicx h u t 111volvct cxpowrc t o rilri. syphilir. ~ r m i haldmg) irididlca~ea n mdrogen a1 reting i>vanaii tniijol Oilier cantcs 111 dude corticoswroid administration. inflamed nodule?. aiitlualin) (See iigrirr. cxrrcisc. o r a l tetra<yelint. pirstulrs. lolnicant\..iviolrt Irglx (e g siinhglit). and topltal tretinoin Tlic Ins1 resoil i s oral isotretniwi Iwtrcunoln i s highly elfcuivc hnc teracogcni( (pregnancy retting heforc arid during tlirrapy 15 ~nanddlory)and nidy canse dry \kin atid rnn( mat-. not pi uritlc. t h i try topical elindamyein. silvery. muscle and joint pain. a Iiipw. but olhcr signs of vrrili/atmn (rlwp~ming e . and livei fniictiorr abnoriditiet Rosacea: looks likc acnr hut starts in rnrddle agr I o o k for rhuiopliyiiia (hlilhoirr rrd I I O I ~ )and coexisting blepharuir Tr(. pat<liy ljakiirctr Male pattrrn haldnes\ IS considerid a genetlc ditordcr that reqiiirrs andlogent to hc cxpr(2ssrd Psoriasis: know what cla.

4 ~~ Dermatology .

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color chaogc. niacin. if surgery fails. Prognosis is directly related 10 tlie depth of vertical invasion._ _ I Dorniatology - Malignant melanoma: usually arises from pretxistiug moles.cimiplex vilarnins (rihoflavin. h o k h r hlack (k)&OLI tlic palrns arid soles o r under t h e fingcriiail. arid criistirrg nipple in an adul~. Srqxrficial spreading inelanonla tends to stay supcrficial and has tlie hest prognosis.) Paget's diseasc ofthe ni ple: uatcli Ibr a cini1att:ral red. Nodular inclanoma is the worst because it tends to grow downward first. Remember your ABCDs: asyrrrrnctry. and increasing diameter). irregular borders. wosrra~i. Look fbr classic mucosal lesions o r an expanding. ~ ~ v i t a m i n (1. (See figure below. strange rash or skin lesion that docs r i o t respond to multiple treatments. uiidcrlyirig hrcast cancer with c x t a ~ s i o n tlic skin must hc rnled out. . melanoma teiids to be of thc acroleritiginoiis type. Althonglr tincoitirnoii in hlacks. An to ~ ~ ~ watdi h~ ~ i r deficicrrcics o S 13. Kaposi's sarcoma: seen in AIDS pat'icnrs. o w i n g .'rwat with surgery. tlrc prognosis i s poor. pyridoxine) o r ~ ~ i : i ~ ~ .

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tlriiik of mcniiigitis as a cause.trt.csioris cause dcafiiess. Facial (CN 7 ) : iurrervates mnsclcs of facial cxpr ion. skin o t external car. . loop diuretics. aniinoglycosidcs. siicllr as tiiinor or stroke. Trigcrninal (CN 5): iniicrvales muscles of mastication and racial sensation (iucluding the afferent limb of the corneal reflex). . 5.90 ~ Neurology eye p a i n (optic neuritis. Troclilrar (CN 4) and ahdrrcens (CN 6): see ophtlialmology chalitcr.g. give artificial tears IO prcvciit corneal iilccratiou... glaui 8. Extracranial cau coma). a i i d loss (11' gag or cough rcllex.thirds ( i f torigue. ~ ory (CN I I):i1iirt:rvares slerriocl~~irloi~iastoid traperius nrrrsclcs. If tlic patient i s young aiid/or femalt. which is characterizcd hy iiiiilateral shooting pains in the fact: in older adults and often triggered hy activity (e. 9. think of acoustic neuroma). uncal berniation). Oculoiiiotor (CN 3): the c a l i x may 1~ benign (hyperlension. arid n o t r r a t i i i c i i t is needed. mastoiditis). Patients may ht: nnahle to dost: the eye. Cranial nerve (CN) lesions: 1. I)iff?rentialc hclweerr ripper inotor i i e i m i n lesions (the h e l l c a d is spared o n the affected sidc.'Tllink of aortic ancurysirrs 01' tuiiior's. 1. tlliiik of toxins and incdica~ t i o i i s (aspirin. oral cavity pain (tootllache). and stapedius muscle. a n d / o r t l i c diseasc i s bilateral. 8. Patients may have trigeminal iienralgia (iic douloureux). If CNs 7 arid 8 are affktcd. Kall~~rann's syndrome i s anosmia plus horiisonc. nal car. lacrirnal and salivary glands (except parotid gland). Patielits with Bell's palsy may g(. rrijddlc ear pain (otitis media. Vagus (CN I O ) : iuiicrvatcs ~ n i i s c l i ~ s palare. Vesribrilococlilear (CN 8): fbr hcariirg and balance. think oCpossible ccrehello-pontiiie arigle tiinior (e.t lryperacrlsis due to stapedial iriusclc paraly. bitemporal hemianopia due t o a lesion at tlie optic d~iasiri). and nonspecific (malaise from m y illness). hrusliing teeth). cisplatin). With scrious caiiscs tlie p p i l is dilated a i i d nonreactive ("hlowri"). laryiix (illcront lirrrb of gag of rellcx). dyspliagia.g. especially in neiiro(ibroiriatosis). Olfactory (CN I ) : rarely important clinically.g. and the cause is Ltsually I3pll's palsy or tuiiior) ofthe facial nerve. arid carotid hody and siiitrs. I a o k liir Iioarstxiess. IJrgciir diagiicisis aiid trcatnicnl arc reqttircd. 6. (. on Step I boards. With a aud (~"NI 1 Icsiwr. consiclcr niiiltiple sclerosis. plrarynx. cspecially l'anc~iast hnig I U I I O ~ S . acoustic rieirrorna.. as Most comnionly tested are hiteinporal herniauopia and monocular loss of vision (see oplrtlialmology clraliter) 3. Treat with carbama~. sinus pain (sinusitis).pin-~n~leasir2g 2. vyiistvdiii hirefractive errors. iritis. hi cliilclren. a n d skin of cxtrriial tsar. tinnitus. herpes zoster with cranial ilervc involverneot. dhdoririiial viscera. arid vertigo. With henign causes tlic pupil is spared (~ioriml). taste buds in base of toiigric. 4. L o o k fcir l i i s s o r gag reflex and lo Ixiswri(ir tlrii-d o S tmig~re. taste in anterior two-. Iiarotid gland. or stroke. diahetrs mellilas) or serioas (a~iciirysrii.lossopliaryngeaI (CN 9) : innervates pharyngeal inuscles arid i i i i i c o ~ ~ s irremhrancs (aFfercnt liiirb of gag rdlcx). Iiypogonadisin diie to deliciericy ( i f gonad~. taste in pmteririr tlrird o f tongue.titinor. triiiic~rs (with C N 7 coinvolve-ineiit. Optic (CN 2): you iiiiist he alilr t o localize tlie lrsim throngh tlic resultant visnal deficit (e. In adults. and the cause is usually stroke or tiiinor) and lower inolor i i c r m r i 1t:sjons (the fbrclwad i s involved on the aSrected side. Make sure t o ri11e out other causes. .epioc anti-epilepsy arid medications. tlw patiwt lias trothli: riiriiiiig thc head t o tlrr o p p o s i t r s i d r ollcsioii dnd slrciulder droop.

focal) scinires: may he motor (e. Fecbrile scizitres: hetwecn clrc ages of 6 months atid 5 years old. or psychic (cognitivc or affective syinp~orns). with phenytoin. Vitamin B. 4. Simple partial (local.tion i s followed by clonic contractions. cncaine.. if possible. plienytoin and valproate also are c-f 3.: peripheral sensory neuropathy (watch for isoniazid as J. Iiaiiorrliage) Metabolic disordcr (hypoglycemia. a pro truded tongue deviates to the side of the lesicin. also watch (i)r pIic~iclrrotr~or. valproatc also is effective. and positive Bahinski's sign 2. r~eriptieral neuropathy. or valproatc. Coarplex partial (psychomotor) seimrcs: any simple partial seirurc fbllowcd by iinpairment of consciousness. I~allucii~atio~~s). L : dmiciitia. ~isuallylasting 2--5 irrinutcs. carbin niorroxidc) too-rapid aniici)nvrilsant I h u g withdrawal (alcohol. contiision. a m i n o spccitic sc:inve treatmciit is required. lreat will1 plienytoin. Vitamin deficiencies may preserr~with ncurol~igic sigix a i d symptoms: 1. nystagmus.g. tumor. Vitamin B. Iieadaclic-. ataxia. ataxia.Thcre i s no postictal state (an important differential point). l o s s of'vibration sense in lowcr rxtreinitics. Wit11 a CN I 2 lesion. to fix Secondary seizure disorder rriay he caused by: %1 Mass (tniiior. cause arid givc prw pliylactic 13. or other serions cause of seizure.ylorlla) a liclainpsia .'rrcat the urtderlying cause ofthe k w r . The first-line agent is carbarnarepine. Treat 5. and give accraminoplie~r.treniia) Toxiris (lead. tonic muscle contrac. oficn with cye or inuscle flutterings. or valproatc'. Make sure that affected cltildren do not have ~neningitis. 1)arbitiiratcs. confiision. Thiamine: prripheral nenropalhy. miiscle sore~~css). hyperactive reflexes. Thc seizure i s usually of the tonic-clonic. spasticity.~areflexia. hypoxia.. ge~ieralizcd typc. car1)amazepinc. carbarnazepiiie. Jacksonian ~ n a r c h ) sensory . con f i r s i o n .They arc brief ( I 0---30-second duration).g.Tlie first-line agent i s ethosuximide.TIickey point is that is IIOL iinpaired.~np a serious condition. clrildren may llave a seimrc due to fever. (e. Vitamin A: vision loss 5. o~~l~rlialrno~ilegia. The hoard question will givc cloes in the case drxription if you are ~ X J X T I C ~ piirsiic work. ataxia. then 20 seconds later resmncs the sentence. 2. bcrtzodiazepi~ies.Neurology 91 11. and gam palsy ~/vibr t~iry ~ 4.1iypoiia. Abseirce (petit mal) seiznres: never hegin after Ilie agc of 20.The classic description is a child irr a classroom who stares off into space in the middle of'& sentence (the child is 1101 daydreaming But having a seizure). to patients faking isoniazid i f give11 thc choice) Five main types of seizures are ttrsicd on hoards (althorrgh tliere arc othcrs): 1. Patients oficn have iiicontinencc and a postict.al staw (drowsiness. l o s s of' position sense. 1-Iypoglossal (CN 12): innervates rriuscles o f tlre toiiguc. delirium. Such cbildrcii do not have cpilcpsy. rlcmctntia 3. T h i c clonic (grand mal) seizures: the classic seizures t h a t may bave an aura. and the cliances or their geiting it. arc just barely higher than in tlic general population. generalized seimrcs in which the main rnanifestation is l o s s of consciousness. plienylk~!toriiiria. Vitaiiiiii E: l o s s [ i f ~ ~ r o ~ ~ r i ~ i c ~ ~ i t i o rsensation. witlidrawal) Ccrehral edema (sevtw or inaligiranf 1iypi:rtensiori. Patients perform purposeless movements and rnay become aggressive if restraint is attenilited (people wlio ger in fights o r kill pcople are not 1 1 seizure!).

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IQ often is less than normal.ients with MG improve after removal of the thymus. improves muscle weakness. Diagnosis is made with the Tensilon test. Diagnosis is clinical Note: Do r i o t h g e t the rarc glycogen strwagc dism 'vc) as a cairse (hr imiscular weakiiess (especially McArcllc's disease.ook f& riiuscle weak. 3. urinary urgency. and general muscle fatigability. 'rrcatnrerrt is supportivc a n d includes genetic counscling. 2. The key phrase i s "ragged red fibers" on hiopsy speciincn. excessive bronchial secretions. Symptoms of parasympathetic excess also arc present (e. Myotonic dystrophy: antosomal doininant disorder that presents hcrwcen 2. Watch fbr associated thymomas. Other muscular dystrophies: 1. ~ t m s t patients die hy age 20. he "walks" the hands and feet toward each other). Important points: 1. Life expectancy i s normal. 5. Look fix coexisting mental rctardation. Do IIOI fbyyet ~~rganopliosplrate poisoning as a cause fbr rrryasthmic-likr inrrscle wcakrms. a r i d pseudohypertr[)pliy of the calves (due to fatty and fihrous infiltration of the dcgeireratiiig nruscle). especially toward the ciid of the day. L o o k for ptosis. Mitochondrial myopathics: iriteresriiig because they are inherited mitochondrial defects (passed only koiir iiiotlier 1 0 offspring. bcgiiis in adulthood. arid tcsticolar/ovariari atrophy. ness. Injection of edroplroniur~i(trade nunc: Tensilon) .g. which is considrred p a r t of standard treatiiient. Treatment is sirpportive. Myotonia (inability t u relax I ~ I I I S C I ~ S ) classically presents as inability to relax the grip (inahility t o release a handshake). Ami noglycosides in high doses may cause myasthenic-like muscular weakness and prolong the effects of muscular blockade in anesthesia. Limb-girdlc dystrophy: affects pelvic and sliouldcr muscles. Usually it occiirs with agricultriral expostire. l3ecker musc:nlar dystrophy: also ail X-linked recessive dystrophin disorder. inalcs cannot transinit). hut milder 2. Oplitlralinoplegi~ usually is prescnt. baldness. Treatment is atropine and pralidoxiine.. with sparing ofthe extraocular muscles (MG almost always has proiirineiir involvement of extraocular rntiscles). Eaton-I. neostigmine). a defkicncy in glycogcir pliospliorylase that is relatively mild and prcwirts with weakiicss ami rrainpirlg after exercisc) . 1:aton~~Lanlbcrt syndrome has a dill fereut iiiectiariisrn o f rliseasc (impaired relrase o f acctylcholine froin nerves) and a differential r c s p i s e to rrpetitivc nerve stiiiinlalion (MC worsens. markedly elevated creatine kinase. a short-actiiig aiiticholinesterase. slroulder girdle) and begins between ages 7 and 20. Eaton-lambert syndrome: a paraneoplastic syndrome (classically seen with s m a l l cell lung cancer) characterized by muscle weakness.arnhcrt irnproves). diarrbca). Most patients have aiitihodies to acetylcholine receptors in their sc:rum. most pat. diplopia. miosis. MG usually presents in women aged 20-40. 4.94 Neurology Note: Nerve conduction velocity is slowed with a periplicral iieuropattry Myasthenia gravis (MG): autoimmune disease that destroys acetylcholine receptors. Gowers' sign is classic (when the patient tries to rise from a prone position. Edrophonium causes worsening of the rriuscular weakness. Muscle biopsy establishes the tliagiiosis. Treat with long -acting anticholinesterase (pyridostigmine. Muscular dystrophy: most commonly due to Dricbeiinc irirrsciilar dystrophy. a n X-linked reivc disorder of dystropliin that iisiially presents in hoys aged 3 . ~ 7I.0 and 30 years o f age. ~aci~~scapiiloliiimeral dystrophy: autosonial d o m i n a n t disease tliat affects the areas in tlre name (face.

look h r a positive family liistory. s w h as idiiyat’hic tliri... watch Six a positive Cixjrrilis’ I w t . do not give aspirin. severe rracl ioiis. Steroids are soiiietir~ics given fill. eyelids. cdt:matoiis iiasal tnrhiiiates with many cosinophils in clrar.icolliyri. and seasonal exacc:rbatioos. allergic rhinitis. m With chronic type I hypersensitivity (atopy. c. Patients 11ave diffirse swelliiig of lips. Treat anaphylaxis immediately by securing the airwa]r. 5 . atopy.Thc deficiency is autosoinal domiiiant. you may precipitate a sevcrc asthmatic attack. 111-~icaria. C4 complement i s low. iriyastlieriia gravis. . elevated IgE levds. pernicions arieinia. tlieii an antihistarninc. (. wliich cause rc:lcase o f vasoactive amines Iiistamine. ruhher glove allergy). bul only itothcr optioiis arc iiol preseiit. in which case do a cl. androgens are iised for long-tcnii treatment to increase liver production of C 1 esterase iiilii bicor. Graws’ disease. family liistory. if needed. Pale. whidl redcl with antigen a i i d caiisc secoiiclary inflarnniatioii.Types of hypersensitivity reactions: 1. Treat acutely as anaphylaxis. hluish. Type I (anaphylactic): duc to prefi)rined 1gE aritibodics. Type 11 (cytotoxic): dile t o prrfimned IgG a n d lgM. Exainples are anaphylaxis (bee stings. 2. transfiision reactions. and some fiirnis of asthma..mhocytoppiiic piirpiira. i l l pr~g~iaiicy. thc traiisplantcd organ deteriorates in frmt of your eycs) Note: Wirli aiicriiia.tomy. food allergy [rspecially peaiiuts and sliellfish I. K + If patients have nasal polyps. allergic rliiiiitis). Goodpastnrc’s syndromc (watch f i x linear irriiriiiiiofluoresrerice on kidney hiops)y). nic:dicatiorrs [ e s ~ pccially penicillin and sulfa drugsl. ~1 Watch fix C 1 esterase inhibitor (complenient) deiiciency as a cause o f liereditary ailgioederna. watcli iijr a positive in& rect Cooin tis’ L ~ I S I . and pmsihly tlir: airway. look fbr eosiiiophilia. UIII‘Clated to any allcrgr!~~ cxposiire. leiikotrirnes) iroln i i i a s t cells and basophils. bay fever.hlastosis f h l i s (RIi incoinpatihilily). Examples are autoimmuiie liemolytic i n i a (classic canses are methyldopa or penicilliir/suHa drugs) and d i c r cytopcmias car1 by aiitibodics. watery iiasal secretions also are classic. arid hyperacute transplant rejection (as s o o n as tlie anastoinosis is iriadc at traiisplaiir snrgcry. peiiiphigus. Skin testing may idrntify an allergen i f i t i s not ohvioris. Laryngeal cdeiiia may prevent iii- B tubation. Patiruts also iiiay Iiave allergic “shiners” (bilateral infraorhital edema) and a traiisvers(: nasal crease (from frequent nose rnhhing).rytIir(.e. some astliiiia. Give subciitaneous cpincplirim.

cr)iitact dermatitis (especially poison ivy. i f a patient comes to yon fbr testing hcp: iit risk-taking behavior. inactivatrd polio vaccirre. and annual influenza vaccines to all WV-positive patients. 9. the pacicnt autorrratically is considered to have AIDS (even without opportunistic idections) . nickel earrings. start prophylaxis for Mycolmterium avium intnlcellulare with rifahitine.g.. ~ rocorrversion in the hack of your mind as a dirferential diagnosis for any sore throat or Epsteinllarr virus-type prescntatioii. Keep s e . pharyngitis. Do annual piirificd protein derivative tist for tnbercnlosis iiiWWpatients.ray if the patient is anergic. rvmiirin with a Western blot test. and ylorneriiloncpliritis (. srart prophylaxis fix Yaeuinocystis ccirinii pneumonia (PCl'). a n d loss of dclayctl liyper~~ scnsirivity ( t y p e IV) o i i s k i i i testiiig (aiiergy) ~ ~ . get an annual chest x. Use triiiretlioprim~siilfariietl~oxazolc ('TMP-SMX) or pentamidine (if thr patient is allergic to or i i d e r a r i t ofTMP-SMX) 4" Orice the CIM count i s less t h a n 100.ole. iicriientia. licpatitis 13. grannlornas. 12.. Type 1x1 (immune complex-mediated): diie t o deposits of anrigen. Once crj4 < 200. you shorrld retest the patienl in 6 inont'rrs if the initial test i s negalivc. chrimic bepa~itis). I h all tests brforc you tell tlic p t i e n t ariything! It takes at least I m o n t h lor aritihodies t o d ~ c l ~thercforc. Otlicr ~:oiiinionlysccii J~IJVseqirelac includr wasting syndrome (progrcssive weight loss). Civc ineaslcs. . malaise. rash. periplicral rierrropatlries. Do not give oral polio vaccine LO HIV-~positivc patients or their contac 10. lymphadenopathy). $3. Ring ciiliaricing Icsiorls iir h e lxairr usrially incan toxoplasniosis or cysticercosis (Toaio solium) .-antibodycomplexes (usually in vessels) that cause an inflarnnlatory response. medications) . Examples are serum sickness. cosmetics. Diagnosis is madc with tlic enzymc~.6 lmmtrnology 3. if positivr. throinbocytopenia. Exaniplcs inchi& tuberculosis skin test. A positive India ink prqnratiou o f the cerelmxpirlal Hoid means Cryptococcus neoformons rncninyitis. Watch for Kaposi's sarcoina or noli-H(lodgkin's lyniplionia (cspecially primary B-cell lyiriplioriias ol the ccntral trwvoiis systcin) 11. Once the C1M coiint is less than 200. chronic transplant rejection. Once the diagnosis of HIV infection is made. 2. consider cryptococcal and candida1 prophylaxis with flucona7. Human immunodeficiency virus (HIV) /AIDS: initial seroconversion may present as a mononucleosis-type syndroinc (fever. lupus. Important points: 1. 6. which release inflammatory mediators. Anriretroviral therapy shoiild be started when the C I H coiiiit falls below 500 (or soon tx) 3. the patient should grt a CIM count every 6 l-nonths. Give pncuinococcal. cryoglobulinemia. niiiinps. should he coufirmcd with a second assay If die second assay i s p o s itive. polyarteritis nodosa.linked immunosorhent assay A). rlieumatoid arthritis. 5. 4. Type IV (cell-mediated [delayed]): due to sensitizcdT lyrnphocytes. and rubella (MMR) vaccine to I-IlV-positivepatirnts (the only live vaccine given I O NIV patients!) 7. which.

Immunology 99 14. Also look for abscnt or hypoplastic thyinus and coiigeiiital heart defects. 3. hilateral intrrstitial infiltrates. A-cells are low or absent. 20. Retest d e r 6--12 m o n t h s . think ofPCP first. and brush biopsy t o make the diagnosis. 5. Alternatively.ook for hypocalcemia and tetany (frorn ahsent parathyroids) in the first 24-48 hours of life.'rile diagrrosis i s clirrched if the question melitions deficient nitrol-. methenamine silver) of iiidimd sputum. IgA deficiency: most common primary imtnunodeficieney. and give the infant AZT for 6 weeks after birth.g. i f not. Many cases arc duc to adenosine deaminase deficiency (autosomal recessive). IgA is low. and IgG subclass 2 may he low. Cryptosporidium and Isospora sp]?. Recent studies indicate that cesari-an section also may rednce transmission.ook for recurrent lung arid sinus infections with Streptococcus and Haemopliilus q)p. 5. Look for severe hypoxia with normal x-ray or diffuse. L. you may cause anaphylaxis due to dzvelopment of anti-IgA antibodies.d immui~odcficiency(SCID): may he autosomal recessive or X-linked. Give pregnant HIV~. 17. Any young adult who presenis wiih herpes zoster should make you think ofH1V. Severe conibine. Look for classic triad: eczema.asc t o their infants through breast milk. Chronic granuloriiatoirs disease: usiially X-linked rc . because they can traiisrnit the dise. 16. IJse gancidovir for cytomcgalovirus retinitis. 18. Do not give im-murioglohuliiis. IIiCeorgc syndrome: caused by liypoplasia o f the third and fourth pharyngeal pouchcs.. Wiskott-Aldrich syndmnie: X-linked recessive disorder that affects males. Other signs inclwle an absent or dysplastic thynius and lymph nodes. infections begin after 6 montlis when maternal antibodies disappear.) . Look fbr recurrent respiratory and GI infections. 4.lne tetrazoli~mi clyc rcdiicriori by gralnilocytes. I. Usually the patient has a dry. nonproductive cough.aiidT~cclldefects aiid severe infections in the first few months o f life.ive disorder that ~ftects males. your job is simply to recognize the classic case presentation: 1.idovudine (AZT). I’seudo~nonnossp. which patients lack. Giemsa. 15. l’alicnts have a defect in reduced nicotinamide adenine dinncleotide phosphate (NADPH) oxidase activity and t h i s get r e c ~ ~ r r e infeci. Any adult patient with ihrnsli should make you think of €IIV or leukemia. PCP nlay he detectahle with silver stains (Wright-Giemsa. use bronchoscopy with bronclioalveolar lavage.ions with catalase-positive organisms (e. Patients hm! B. HIV-positive mothers sliould not breast-feed. and cutaneous anergy iisirally is present. This test ~ricasi~rcs rcspiratory burst. foscarnri is the second choice. and recurreat infections (look (usiially respiratory). . This protocol reduces mother-to-child transmission from roughly 25% 10 8% The infant rnay have a positive HIV test for 6-1 2 months because of maternal antibodies. are diarrheal infections uniquely seen in HIV-positive patients Primary immunodeficiencies: because they are rare.positivepatients z. t h r ~ m b ~ c y t o ~ ~ n i a for hleeding). in any patient who develops anaphylaxis after immunoglobnlin exposure. X-linked againmaglohulinemia (Bruton’s agammaglobulinemia): X-linked recessive disorder that affects males. you should think oflgA deficiency 2. 19. In any patient with IllV and pneumonia. nt Staphylococcus aiireiis.

red hair. Hyper IgE syndrome (Job-Ruckley syndrome): patients get recurrent staphylococcal i w fections (especially of the skin) and have extremely high IgA levels. Hypothyroidism i s often an associatcd fnding. 8. The rest of imrrrune fusictioii i s intact. and cczema. The cause i s a defect i n microtubule polymerization. Chediak-f~Iigashi syndrome: usually autosomal recessive. scalp. 10. and irail irrfc:ctions and anergy 1. Chronic mucocutaneoiis candidiasis: a cellular immunodeficiency s p t d c for Candida s p Patients have caudidal thrush. They also coninioiily liave fair skin. wjlh skin testing. . Complemcnt deficiencies: C S C 9 drficicncies cause recurrent Neisseria iiif complement cornpoixiit is low.7.0 Condida sp. Look fix giant granules in new trophils and associated oculocutaneous albinism. skin. 9.

I lurlcr’s disease. lens dislocation Huntington’s disease Familial liypercholesterolemia: look for xanthomas. Because it i s assumed that you know the inheritance pattern of tlie disease. mitral valve prolapsc. rhahdomyomas. markedly clevated ch(ilestero1 Familial polyposis coli Adult polycystic kidney discase Hereditary spherocytosis Tuhcrous sclerosis: hypopigmented skin macules. Gaucher’s discase. mental rctardation... mental retardation. central ner vous system Iramartomas. cataracts. aortic dissection. Tay4acbs disease. acoustic nelirorna Multiple endocrine neoplasia (MEN) ‘ype I and 11 syndromes @ Achondroplasia: diagrio by picture of a patient MarGn syndrome: tall patient with arachnodaccyly. renal tumors Myotonic dystrophy: muscle weakness with inability to release grip.) fibrosis .. exception is Huuter’s disease. X-linked) P m Glycogen storage discascs m Cystic (c. I’ornpc’s arid McArdlc’s disease.g. wliich is X~~linked) Miicopolysaccharidoscs (c. the following lists should come in Iiandy: Autosomal dominant: look for affected mother or father who passes the disease t o S O X of offspring: voii Willehrand disease u Neurofihroniatosis: caf6 a .Questioiis o f t e n ask you to give genetic counseling to a parent or to predict the likelihood of having a secmd a r k m l child after the first i s born with a given disease. cardiac arrhythmias Autosomal recessive: look for family liistory and unaffected parents who pass the disease t o 25% of children: gl . balding. wliicli is. seizures.g. early coronary artery disease. cxccption is Fabry’s disease. profiise peripheral nerve turnors. ~~ Spliin~olipidoses (c.l a i t spots.g.

Bipolar disorder m Iscliemic lieart disease e Alcol~olism C l ~ K ~ d ~ s o ~~d ~ ~~§ ~ a ~ i ~ o a Down syndrome (trisoiny I I ) : m o s t coinnion knowit cause of mental retardation.g. and early Al/. At hirth look fbr hypotonia. arid characteristic facics. Carrier mothers (family history in inale rclalives) who pass the gene to their sons. The major risk factor is age of the mother ( 1 / I 500 offspring of 16-year~old niotlrers.s for 4. drioclenal atresia.ook for mental retardation and self-mutilation (patients may bite off their own fingers) I Unchcnne muscular dystrophy Wiscott-Aldrich syndrome u Bruton’s m againniaglohulinernia Fragile X syndrome: second most c o m i n o ~ ~ cause of mental retardation in males (after Lbwn syndrome). Polygenic disorders: rdatives are inore likely to Irave disease. Patients have large testes. who hecoine carriers hut do not get disease. but there is no ohviolis heritable pattcrn: 81 Pyloric stenosis Cleft lip a i d o r palate ‘Type 1 dialietcs 1 Obesity * Neural tuhe defects Sdii zophreriia..and lactosecontaining foods I Amino acid disorders (e. alkaptonuria) disease m Sickle cell Children’. neonatal sepsis: avoid galactose.. 112. polycystic kidney disease nwilson’s disease m Hemochromatosis (usually) m Adrenogenital syndrome (e.heimcr’s disease. (Iongenital cardiac derects (especially ventral septal defect) are C ~ I I I X I ~ ~and. L~ paiicmts arr a t increased risk (br leukemia.m Galactosemia: look for congenital cataracts. phenylketo~inria.g. transverse palmar crease.S-year-old rnothers). 2 1 -hydroxylase deficiency) X-linked recessive: look for affected fathers to pass the gene only to their danghters. . who get the disease: Iiernophilia G-6-FD deficiency I Fabry’s disease disease m Hunter’s n Lesch-Nyhan syndrome: liypoxantliine-guanine phosphorihosyltransferase enzyme deficiency 1.

deafness. apnea. amenorrhea. widely spaced nipples.bottom feet. myelomeningocele. arid decreased IQ. rocker. m Cri Gdwchat: due to a deletion on the short arm of cliromosorne 5 . webbed neck. hypoplastic mandible. sterility (the classic prescntntion is for infertility).Genetics ~ 101 BI Edwards syndrome (trisoniy 18): more common in females than males. short stature. aTurner’s syndromr (XO instead of XX): lyrnplredema of neck at birth. small head. and lack of lreast developrnerit (due to primary ovarian failure). . Coarctation of tlic aorta is coninion. hol[)proseiicephaly (fusion of cerebral hemispheres) . look for high-pitched cry like a cat along with severe mental recardation. low-set ears. and patients may have horse-~shoc kidneys or cystic hygroma. gynecomastia. and clenclied fist with index finger overlapping third arid fburth fingers (almost pathognomonic) Patau’s syndroine (trisomy 1 3 ) : mental retardation. cardiovasciilar abnormalities. Klinefeltrr’s syndrome (XXY): call patient with microtestes (< 2 cm in length). Patients are small for their age and have mental retardation.

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At age 80 patients have h a l f the lean body mass of a 30-year-old. factors fix cerebrovascular accidcnt). wake up morc frequently during rile night. They also need more sodium. Mrdications. 10. . 7. and awaken earlier in the morning. are n ~ t o r i o culprits. Delayed orgasin i s connnon. enlarged ventricles and sulci). The inost. 6. O S ~ C O porosis.Important points: 1. the over-85 subgroup i s increasing n i o s t rapidly 2. 3. Other c a ~ ~ s e s risk iilclride HIV a i d Pick's disease. but lack of' sexual desire is not normal and should he investigated (psychological or physical causes).pseiidodcriieiitia). lahia. 4.S. brain changes (decreased weight. 3 . Atrophy of clitoris. I'iftcen pwccnt of people over age 65 srif%r fironi dementia. Look fhr psychological ( d e p physical causes. and slightly decreased ability t o learn new rnaterial. loss uf a spouse'. ~s 5.population was w c r age 6 s .c. The most c o ~ ~ ~ i canscs of nc~n dementia.g. decrcased muscle mass. Because basal rnetabolic rate depends o n lean body mass... Iriok fix a h i s tory that woiild trigger dclircssion (c. ~. elderly patients need fewer calories. viramin D (and/or calcium). Within this group.Tlicy take longcr to fall asleep (longer sleep latency) and liave less stage 3 and 4 arid rapid~eye-inovc. In 1993. advise water-solnhle lubricants. Normal changes in elderly: slightly impaired irnmune response. rapid increase in population in the U. and the patient may ejaculace (inly 1 of every 3 times that he has SCX. trririiual or debilitatiug disease). treat with estrogen cream. folate. arid vaginal tissnts may cause dyspareunia.meiitsleap. Delayed ejaculation i s common. ueiirofibrillary tail gles) a n d rnultiinfarcc (step~wisc. 12% d'tlic 1~I. arc Alzhcirncr's diseasc (gradnally progressive. Impotence and lack of sexnal desire are nor norinal arid should be investigated.. visual (presbyopia) and hearing (presbycusis) impairment. and nonhemli iron. vitamin R. Normal sexual fiinction changes in wmimi: for decrcascd lul)rication. Thc besr prophylaxis for pressure ulcers in an immobilized patient is frequent turning. incrcased far deposits. 11. llcpressiou in the clderly iuay prescnt as demnrtia (i. rspecially aiitihypertensivrs. Sleep changes: elderly people slerp less deeply. ..S. Only S'% ol'pcople over the age o f 6 5 live iii nursing Iroines. (percentage-wise) is in people over 6 5 . in order. Normal sexnal function changes in men: elderly men take longer to get an erection and have an increased refractory period (after ejaculation i t takes longer before the patient can have another erection).

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American Cancer Society guidelines for cancer screening in asymptomatic patients" Important points: .

but look for thesc abnormal lab values to show up in questions as a clue to diagProstate-specific antigen (PSA) is h ~ c o m i n g popiilar as a prostate cancer screening test. acid phosphatasc (prostate cancer). and other serum markers are not appropriate ibr screening asyiiiproriiatic patients with no physical findings. Immunizations in adults .Preventive Medicine. 11ut does not replace rcaal exam. alpha-fetoprotein (liver aiid testicular cancer). In general. uriiialysis (screening (ix urinary tract caiiccr tliar resulrs in hematuria). Epidemiology. and Biostatistics ~ 2.

are congenital abnormalities. Medicare is health insurance for people who are eligible for Social Security (primarily people > 6 5 years old as well as the perinaneiitly and totally disabled and patients with end-stage renal disease). Mathematically. Fertility rate: live births/ 1000 population of rtmales age 15-45 yr 3.They may have false negatives but do not call ~ anyone sick who is actually hcaltliy (low false-positive rate). Tests witti high specificity arc I L for diwase confirmation . Neonatal mortality rate: neonatal deaths (in tlie first 28 days)/l000 live births 5. p q d c with tlir disease may he called healthy. and sudden infant death syndrome) 7. Tests with high sensitivity are used for screening. Epidemiology.s) The perinatal mortality rate is roughly 1. Mathematically. Death rate: deaths/ IO00 population 4. Review this section of Step I material for some easy points Sensitivity: ability to detect disease.Preventive Medicine. otherwise. Infant mortality rate: deaths (from 0-1 year old)/1000 live births (tlie top three causes.negativerate). Maternal mortality rate: maternal pregnancy-related deaths (deaths during pregnancy or in the first 42 days after delivery)/ 100. Perinatal mortality rate: neonatal deaths -t stillbirths per I000 total births s The major cause is prematurity s 'The neonatal mortality rate is roughly 6/ 1000 (higher in blacks) The fetal mortality rate is roughly 9 / 1000 (higher in nonw11irt. Nursing home care is paid by Medicare only in the short term after a hospital admission. specificity i s calculatcd by dividing the number of true negativcs by the number of people without the disease. then it is paid by the patient (if the patient has IIO tnoney. acid Biostatistics 107 Per-year rates commonly used to compare groups: 1.000 live births mThe top three caiises are pulmonary embolism. Birth rate: live births/ 1000 popdation 2. low birth weight. sensitivity is calculated by dividing the number of true positives by tlie nuinher o f people with the disease. pregnancy-induced hypertension. in descending order. Specificity: ability to detect health (or nondisease). .5/1000 mA stillbirth (fetal death) i s defined as a prenatal or natal death after 20 weeks' gestation 6. Medicaid covers the indigent and poor who are deemed eligible b y the individual states. the state usually pays). The ideal confirmatory test must have high sensitivity and high specificity. and hemorrhage II Tlie rate increases with age and is higher in blacks Important points: 1.Tht:y niay have false positives but do not miss many people with the disease (low false-. 2.

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incidence may be higher than prevalence. If someoue tells you that p < 0. but any time frame can be used). p < 0. For exam. such as the flu. there i s up t o a 9. 4.-fatdiet in Japan). (2) a low p-value does not imply causation. whi. what happens to tlie incidence and prevalence? Answer: nothing happens t o incidence. for example.05 for a given set of data. mernber: ( I ) the study may still have serious flaws. the chance that the data were obtained by raudom error or chance is less than 1%. Case series simply describe the clinical presentation of people with a certain disease and may suggest tlie need for a retrospective study 5. if I tell you that the blood pressure in my controls is 180/ 100 mml-lg hm decreases to 120/70 mmHg after administration o f drug X and that p < 0.01. whereas in chronic diseases. However. An epidemic occurs when the observed incidence greatly exceeds the expected incidence. Information can then be collected about risk factors. The classic question about incidence aiid prevalence: when a disease can be treated and people can be kept alive longer but the disease cannot he cured. there is less than a 10% chance that the difference in blood pressure was due to random error or chance. vu.110 Preventive Medicine. the null liypotlirsis is that tlie drug does not woi-k. Comparison of data: 1. hut prevalence will increase as people live longer. . prevalence is greater than incidence. I n short-term diseases.Tliree points t o re^.l: samples are chosen after the fact based on presence (cases) or absence (controls) of disease. Epidemiology. p < 0. hut you connot calculate a true relative risk or measure incidence froin a retrospective study. If p c: 0. 2.cli cau be tested with a prospective study (e. I'or example. Cbi-squared test: used to compare percentages or proportions (nonnumeric data. For exdrriplc. people without lung cancer and see if the people with lung caucer smoke inore. in a e l y~ s drug study aljout hypertension. When comparing two different cultures.any dilli. there is less than a 5% chance (because O. For this reason. Prevalence survey/cross-sectioiial survey: looks at prevalence of a disease and prevalence of risk factors. diet Incidence: the nuinher of new cases of disease in a unit of time (generally 1 year. more colon cancer and higher-~fac in U.ple. you still would not use drug X.OS=S%) that these data were obtained by random error or chance. Case series: good for extremely rare diseases (as are retrospective studies)..10.g. Analysis of variance (ANOVA): used to compare three or iiiore meaos P-value: the hoard exam always coutains one or m i r e questions about the significance of the p-value.99999% cliancra that the result i s due to random crror or chance. such as diabetes mellitus. The p-value also tics iuto the null h y ~ o ~(the~ i i p t h ~ s i of no differcnni).rcm:e ~~. Incideuce rate also equals thc absolute risk (to he differentiated from relative or attributable risk).05 is corninonly used as the: c u t d f for statiscical sigrrificance. look at people with lung cancer vs. and Biostatistics 3.000000000000000001. A n odds ratio can be calculated. if I tell you that drug X call lower the l~lood pressure from 130/80 to 128/80. also called nominal data) 2. Ketrospective/case-conrn. less coloii cancer and low. Prevalence: the total number of cases of disease that exist (new or old) Important points: 1. T-test: used 1 compare 0 two means 3. and ( 3 ) a stirdy that has statistical significance does not necessarily have clinical significance.S. you may get an idea about the cause of a disease.

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Epidemiology.Preventive Medicine. . and Biostatistics ~ the saiiir patierit ~ ~ I I ~ I I I Cor IO ~ I ~ C O I I I C ''no significairce" i LI controls arid II as ferencc" in wvatecl cases. ". ptahility bias: pacicnts do 1101 admit IO rinbarrassiny hdiavior or claim to exercise inore than tlwy do t o plcasc d i e irrrcrvirwt~r~-or r y may c l a i m IO t a k r exjierimciital h iiiedications wlieii rliry spit tlicni out.

late oiiset. apathy). alogia (no speech). > 6 iiioiitlrs = scl~in~plirciiia. good sl1p~)o Seaturcs: poor preiiiorbid fiinctioning (niosr iiiiportmt). Tlicse syinptonis respond poorly t o traditioiial antipsychotics hut may respond to clozapine or rispcridonc. or widowed. iaiiiily Iiistory ofschiz(iphrenia. divorccd. hallucinations.. disorganized spwch.Schizophrenia: 1. R ~ ~ g l i 1% d p w p l e IIWP scliizoplirenia (in all ciilturcs). 5. Time period iniportatit: < I niontli ~1 acute psychotic disorder. married. tiegativc symptoms. cIilorpn. o b vioiis pr(xipitating factors. early oiiset. 2. Sanrily Iiistory o f ni(iod disorders. 'Iypical age of OIISCL: 15-25 years fix mcii (look for s o i i i e ~ n e going to rollegc and deteriorating). airliedonia. hizarrr hcliavior.. Tlie diagilostic criteria provide d u e s : delnsions. thouylit disordcr (e. grossly disougani. positivr syinptOlllS. ly .5-3 5 years fix woiiicii . poor siipjx~vt system. 1-6 months = sc1iix1pllrt~iiifhriii disortier.ed/calati. tangcnrialicy. no ctors. 2. avdition (aliatlry). Negativc syiiiptoins = flat aflect. 7. halliiciiiariolis. refusal to talk. Tliesc syiiiptonis rrspond to traditional aiitipsycliotirs (Iialoperi- doi . single. G o o d progIiosis fcaturcs: good 1)renid)id functioning ( t n o s t irirportani).mazinr) 4. poor aue~itioir. clanging). 3.iiic ticliavior. aiid negativr symptoms (flat aflect. Positivc syinptoins: dclusicms.g. avolition.

~~ 2. clozapine causes agranirlocytosis (wliitc blood cells COIIIIIS iriust b e motiitorrd). and inability to sit still. The patient also may have iiivoluntary. Acute dystonia is inost coinmoil i l l young men. high fever (np to 107"F). Most coinnionly. s h n f f h g gait. high creatine phosphokinase (often > S O O O ) . tongiiv protrusions and twisting. hut a history o f dcprcssion is common. Mania is the oiily sytnpLoin rrqiiircd fir a diagnosis of bipolar disorder. clrlovprornazine canscs janndicc arid pliotosensitivity. Individual autipsychotic side effects: tlii~iridazin~ causrs retiid pigmmt dcp(isits. choreoatlletoid rnoveirients of head.114 Psychiatry Extrapyramidal side effects: 1. and oculogyric crisis (f(irccd sustaiiied deviati(in of the head and eyes).The patient has muscle spasms or stiffiiess (e. Beta blockers can be tricd for treatment. mutism. opisthotonos. Look for ctrnstant pacing. protruding movements of the tongue. 3. common in oldcr women. which niay caiis? galactorrhea.. lirnhs. Treat b y giving antihistamines (dipbc~tliydrainine) anticholinor ergics (beiatropine. ztropine. and niyoglobinuria. I f you have 19 make a choice when thc patient develops tardive dyskinesia. Dopamine hlockadc causes increases in prolactin (dopaniinr is a pro~actin-~ilitiihitiIlg factor in the tuheroin(iiiidihu1ar tract). Bipolar dkordCI': 1. obtundation.g. Treat by giving antihistamines (diphenhydramine) or anriclioliriergics (hen. discontinue the antipsychotic aiid consider switching to clozapine. There is no known treatment for tardive dyskinesia. Parkinsonism: f i r s t f t w inonths of treatmcnt. grimacing. 'The patient has a subjective fkeling o f restlessness. Neiirolcptic malignaiit syiidroine: life-tllreatening condition that can devekip at any Lime diiring treatment. chcwirrg. agitation. finally. aiid trunk. Treatment: first discontinue antipsychotic. Acute dystonia: first few hours o r days of treatmcnt. Tardive dyskinesia: after years of treatment. alternate sitting a i d standing. the patient has pcrioral movements (darting. 5. The patient lras rigidity. administer dantrolenc (just as in malignant hyperthermia) Other antipsychotic medication pearls: 1. puckering). Akatliisia: first few days of treatment. i r n p o t " ~r i i w striral dysfunction. triliexyph~~niclyl) 4. and decrcascd libido. mask-like facies. Tlre patient has stiffness. torticollis. . triliexyphenidyl) 2. then provide sopportivc care for fkver and renal shutdown due to niyoglobiiiirria. trismus). Parkinsonism is most. sweating. cogwheel rigidity. and drooling.

7. use at thc same time as mood stahilizer. 2. and exaggerated self-importance or delusions o f grandeur. vague somatic complaints. 2. choose carhamazepine if lithium fails. insomnia). thyroid dysfimctiom. pressured speecb. 3. Suicide rates are rising the fastest in 15--24. (cornbination works hetter than 5. chronic or dehilitiating discase. tremor. history of rage or violence. 4. loss of healtti. Always ask patients about suicide (it does not make them more likely to commit silicide) If yon need to do so. anxiety. male sex (men commit suicide 3 times more often than women. Suicide: 1. Iithium causes renal dyshictioo (diabetes insipidus). . poor concentration.”Yon have t o watch for clues: change in sleep habits (classically. but women attempt it 4 times more often than men). and carhamazepine may cause hone marrow depression. prior psychiatric history. The antidepressant may hegin t o work. and leaves work early on most days. If you have to choose. Antipsychotics may he needed if the patient becomes psychotic.the pitient ~ ~ m e ~ e ~ ~ e a does iiot handle it wcll and feels “burntned out” fbr < 6 months. Patients may or rnay not have obvious precipitating factors in history. divorce or separation.“l’m depressed. the best predictor of future suicide is a p a t attempt. shopping sprees. low energy or fatigue. Bipolar I1 disorder is hypomania (mild rnania without psychosis that does not came occupational dysfunrtion) plus major depression. and central nervous system effects at toxic levels. or divorced status. Iior example. 3. 5. clioose valproic acid over carbaniazepine. The major risk factors arc age > 45 years.-year-olds. they are at increased risk of suicide. Ikprcssion is more coniinoii in females. 6. When patients come ont of a deep depression. and single. the patient gets a divorce. ~ ~ i u disorder with~d ~ ~ ~mood: when d bad situation O C C ~ T S . (no fiill. 4. . but does not m e a critrria for full-blown deprcssion. Lithiurn and valproic acid are first-line treatmerirs. seems t o cry a lot for the next few weeks. prior suicide attempts. Look for classic symptoms such as decreased need for sleep. 4. unemployment o r retirement. Cyclothymia is at least 2 years of hypomania alternating with depressed mood blown rnania or depression). decreased appetite). Choose lithium if both are options. widowed. Patients may not directly say. psychomotor retardation. If‘ valproic acid is a choice. Look for initial oiiset between 16-30 years old.~ . alcohol or substance abuse. 5. Treat with both antidepressants and psychotherapy medications alone). recent loss or separation. but the greatest risk is in people over age 65. change in appetite (classically. depression.Psychiatry 115 2.. sexual promiscuity. such as loss of loved one. 8. Valproic acid causes liver dysfunction. hospitalize acutely suicidal patients against their will. and the patient gets more energy-just enough to carry out suicide plans. unemployment or retirement. and/or anhedonia (loss of pleasure). Depression: 1.

less. patients are j u s t sewre worriers.g.. wliich may respond to bicarbonate. Intense yearning (even years aFtcr the ctcatli) aiid even searching for the d normal. 3. nonscttating) or h m x diazcpiiics (addictive. to needlrs. o r heights. It is normal to have a n illusion or hall~icinatiori about the drccased. Treat with bnspironc (noiraddictive. e. or psychosis. especially in hipolar patients. sleep disturhaii . TCAs arc dangerous in ovcrdose primarily bccausc o t cardiac arrhythmias.g. blood products. Initial grief after a I<)ss (cg. Treat with b c . Normal vs.g. no iptylinc. arid suicidal ideation arc not tlonnal cxpressioiis d grief.piiiepliriiie and serotonin. sexual dysfunction) 10.1'16 Psychiatry 6.Wberi patients cat iyrai~iinc~coiitainirig foods (especially winc and cheese). ftitiirc. psycl~omotor retardation. amxexia.'li. 8. the same syniploms as dcpression. f)iofi\cdhack. mourning. t. Tricyclic antidcpressaiits (TCAs.They also block alplia~-adrcllcrgic rccrptors (warcli fix orthostalic hypotension. carcer. inental iiiiagcry -know what rime terms ~ n r a n ) ~ ~ . tbc opposite of classic dcpr~:ssitrrr).. Patients often hyperventilate aiid are extremely anxious. feeling of nrunbness or bewildcrmcut. distress. Panic disorder: Loolc for 20-40-year-old patient who thinks that hr or she is dying or havillg a heart attack but is healthy and has a negaLive work-iir) for organic disease.. 'Ikazodone is famous hecarisc it can cairsc priapism (persistent. airiitriptylinc) preveiu rcnptakc of riort.Tliey may I)c g ~ fiw atypical dcpr ~ d hypersomnia and Iiyp liagia. hut a normal griev-~ ing person knows that it is an illusion or I~allucination. fluoxetinc. family. painfirl crection without sexual arr)iisal or desire).eat with SSRIs (e. plicnelzinr.. rnoney) at thc smit: time. possibly death. mania.~ Social phobia: a specific siniph. sedating) Simple phobias: h r example. bereavement: 1. wbiclr tecliriically i s not a tricyclic). hypomania. paroxctine) prcvcnt re. whereas a depressed person believes thal the illusion or hallucination i s real. detreascd appcLite.. crying. k t a 1)lwkers may hc irsed to rcdiirc syinptoius tJcfi)rca public appearaiic(: tiial cannot hc avoided. phol%a thai is best trcattd wit11 helraviorai therapy.tiptake of serotonin only a n d have less serious side cff (insomnia. relationships. . A comirion associatiorr is agoraphobia ( f a r of leaving the Iiotise).g. dirziiicss. 7.~ liaviorai therapy (flooding. c g . systematic deseiisitizatiorr . Generalized anxiety disorder: patit:iits worry about everything (c.. and guilt (survivor guilt) for up to 1 year--~in other words. Do iiot give MA01 at th(: same tiriic as S S I l l s o r mcperidiilt. 11. scv?re reactiorls m a y occur. Ilrioxetine). tlrcy arc signs of depression. Selective serotonin reuptakc inhibitors (SSRIs. Antidepressants can trigger i n a i i i a or hypornania. and falls) arid muscarinic receptors as well as cause se datioii arid lower tli? seizure threshold (especially bllp~. dificrrlty with conceiitratiny. 9. anilnals. death of aloved on?) may include a slatc o f s h w k . but 110 episodes of' major depression.<Jpi<Jli. they m a y get a Iiypcrtelisive crisis. . 1rany~cypn~)mine) oldcr are mcdications and not fir line ageiits. Monoamine oxidase i n h i h i t o r s (MAOls. pathologic grief.. weight l o s s . Dysthymia: depre d mood on m o s t days fbr morc than 2 years. Syrnptoins are not as dramatic as in panic disorder. 2.

&. derwcar. injcct tlieriisclvcs witli irisuliii to provokc 1iypi)glyceinia) and suhjcrt themselves to p i i c e d i i r e s tu asslime tlie role of a patient (iio fiiiancial or other sccoridary gain) 3. Scliizotygal: Iiizarre belicli (cxtrascnsory Iicrcccptioii. no Sricnds aiid iio iiitrircst in Iiaviving friends. supcrsticiori.~ 2. Persotiality disorders arc iifclong disordcrs witli iiiay be tried: iio real trcatiiimt. Paraiiuid: patients iliiiik that everyonc i s out t o get tlirm (frirtids. 3. a teciiager who tliiriks thai his or lirr iiose is t00 big when i t is of iiorinai size) Sonratoforin disorders vs.Treat with groiip therapy. Malingering: paticriis intciitionally create their illii get 011t of work) Cor secondary gain (r. Soinatofbrrii disorders: patients do not ilitcntionally crti. d iiegativc work-up. money. victim of severe accident or rapr) w h o rccurrently experiences the event in iiightiiiarcs o r Ilaslitiacks. Somatoform disorders: patients d o iiot behave inappropriately on purpose. Body dysniorphic disorder: preoccnpatkm with irriagiricd physical defect (e. 2. if y o u have to clroosc. a high-scliool girl who breaks iip w i t l i her boyfriend m a y mope aroiind the house. iise iiiiiprairriiie o r plieiielzine (MAOI) Homosexuality and homosexual experimvntati~in not coiisidcred a discasr at any age. failing grade. . Avoidaiit: patients liave n u friends tirrt waiit tlicrii. they an: arc iiorinal variants. Treat with h q u c n t return clinic visits and/or psychothcrapy 1. travels. factitious disorder vs. crying and irot wantirig t o attend school or go out wirii her friends for I week. 4.g. Soiiiatizatioir disorder: innltiplc diffetcnt c~iriiplaiiits n~riltiple in Liffercnt orgaii systems over inaiiy years with extcnsive work-ups i n tlie pasi. loss of . Adjustment disorder: normal lifi: expcrieiice ( ~ g . altliough psycbotlicrapy 1.g. job) is iiot handled wrli. 2. . For example.rdationsliip hreak-rip. Kinky faritasirs or occasional kiiiky activities (a iriaii wcaring woiiieli's i i r i . Scirizoiii: the classic loiicr. to<>) aiid oftcii start law-suits. I'actitious disorders: paticiits iiitciitionally create their illness o r syin~itoiiis (e. a rriedication. assuming iicw Multiplc personality disorder: most likely to he associated with cliiidhood scxiial ahose. 4. malingering: 1.ue sympioiiis... IJyliwlioiidriit patients kcep hclievirig t h a t tliey liavc tlic ssme [liseast. tlicy arc: afraid of rriticisin or r e j e c tioti arid avoid otlicrs (inkriority coiiiplcx). aiid Iias depression or poor cnricentration as a rcsult.Psvchiatrv 187 Posttraumatic stress disorder: look for soiii(ioiie who has beeii tlirougli a lif~!~tlireateriirig event (Vietnam veteran. illusioiis) aiid iiiaiiiier or spcaliirig hiit 110 psychosis. stocliing--aiid~ylovc (hii niiinhiicss) 3. mild h o t fetish) arc noririal.. cults. Patients oftcii are depr (xi (adjustiiicnt disorder witli depressed iiicrod) h u t do not mcrt the criteria for fii11-Mown depression. tritis to avoid thiirking ahout it. t o Dissociative fugudpsychogenic fugue: tlrc patirnt lias ariiricsia arid ideiitity. Convcrsioii disordcr: ohvioiis precipitating factor (fight with Iroyfrieiid) fidowcd by Liri cxplaiiial~lrnciinilogic syinptor~is iidrirss.

g. Obsessive-compulsive: anal-retentive. Antisocial: most frequently tested personality disorder. highly dependent on others. Note: Patients can be hospitalized against their will if they are a danger tu themselves (suicidal or nnahle to take care of themselvcs) or others (homicidal) Many d i f h e n t psychological tests are available to aid in a difficult diagnosis. 4. 7. and self-image. scored h y test giver): 1. Stanford-Binet: objective IQ test for adults. a wife stays with an abusive hushand. suicide attempts. falls). cheap. Onset risually is in adolescence or early adulthood. Patients have long criminal record (cw-men) and torture animals or set fires as children (a history of conduct disorder is required for this diagnosis). L. cataplexy (loss ormuscle tone. Narcissistic: egocentric and lacking empathy. Borderline: unstable mood. Korschacli test: subjective test in which patients describe what tlrey see in a n inkblot. 8. arid liave no remorse or conscience.’I‘hey are aggressive. 5. There are two types of tests: objective (multiple choice. 3. impulsivcriess and coiistaiit crisis (see Glenn Closc in Fatal Attraction). Obsessive-compulsive disorder: patients have recurrent thoughts or impulses (obsessions) and/or recurrent hehaviordacts (compulsions) that cause marked dysfunction in occupational and/or interpersonal lives. Dependcut: patients cannot he (or do anythi~~g) alone. hypnopompic (as patient wakes up) and hypnagogic (as patient falls asleep) hallucinations. .118 Psychiatry 5. do not pay hills or support children. scored hy a computer) and subjective (no right answer. 9. Wechsier lntelligeiice Scale for Children: objective IQ test for children (4-1 7 years d d ) . Strong association with alcoholism or drug ahuse a n d somatization disorder. attention-seeking. restricted affect.ook fix splitting (people are all good or a l l had and may frrqnently change categories). Behavioral therapy also may hc effective (e. Most patients are male. patients use others for their own gain or have a sense of entitlement. Histrionic: overly dramatic. flooding). 10. and inappropriately seductive. stuhhorn. hiria-Nebraska Neurtjpsychological Battery : assesses a wide range of cogni live fiinctiorrs and tc4ls you the patient’s cerebral dominance (left or right). Thematic Apperception Test: subjective test in which the patients descrihes what is going on in a cartoon drawing of people. Look for washing (wash hands 30 times a day) and/or checking rituals (check to see if door is locked 30 times a day). behavior. . relationships (many bisexual). Inventory: objective test dcsigned to rneasure pcrsorr- 7. Halstead-Keitan Battery: used to dcterniiiie the location arid effects of specific b r a i n lesions. they are not used fbr a straightfilrward case. 6. Treat with SSRIs or clomipramine. 13eck Ikprcssion Inventory: objective test to screen for depression 6. 2. Narcolepsy: daytime sleepiness: decreased rapid-eye-movement (REM) latency (patients go into REM as soon as they fall asleep).. micropsychotic episodcs ( I ininutcs or psychosis). the patient must be the center of attention. rules niore important than objectives. often lie. Minnesota Multiphasic: F ” r a l i 1 y ality type.Treat with amphetamines.

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No physical withdrawal syi~i~itorns notcd. talc danlagc). aggressiven .g. ccllulitis. alariiis. or hugs are crawling 011 tlic~n). N o witlidrawal synrptoiiis arc' uiotcd. corrstipalion. l'aticiits may get "flasliha(~ks" ilroritlis L )'cars o later (Iirier fi. Cocairr tcratog<. hungry (vs. [lien treat with hchavioral tlrcmpy ("gold star fix bcing good" clraris.. S y m p t o r n s i n c h d c goost4lcsli. tachycardia. drowsiiiess. d i aplioresis . IIrydr iasis. aiid irritabk!. Cocaine: l o o k for sympathetic stiinn~ali(~ri (i iisonitiia.caused or uninaskeil by iisc nf stirnulairis (e. arid suicide. ill somi. wlieii irrioxicafed). (leliriurn.7burettr's disorder teiids t o he a life. Depression in children in the elderly may p r t wit t i ucatiiieiit.king problem EiicoI"re"s/eiiuresis: not a disorder until d t w agx' 4 (etlcopresis) or 5 (emir o u s l y an iiiip(~rtaiit diagnostic point to rerneniber wlrtm tlw iiti)tlicr cornplains (nornial fiiidiiig i f the child is 3 ycars old).efkxts are similar to cocaiitc.iddicts. althouglr palicllts iiiay have are psycliohgical cravings. ai id prccpti o i i / inood [tistit rhan tioiis usually a r c visual ratlicr tli. Overdose can Iic fatal (respiratory depression). homicide. tachycardia. HiV. I'lirschsj~rung's discasc:. Srrc. psychosis. diarrhca. Withdrawal i:. or stroke).5% ofteciiagc dcatlis. ypt'rt 11 swcathig) with hyperalertness arid possiblc praiioia."Other syiriptorns include "arn(itivational syndrome" (chrouic use may c a i i s e laziness arid lack of ~ n o r i v a t i ~ ) i i tinic distortion and "muncliies" (eating hinge ).M e l l i a d i ~ r rrratmrnt soirretimes i s given fbr . trcat with rialoxom!. Important points: 1.sually taken inrraveiionsly. a i d ~:rarnping/paiii. urinary tract i r i f k t i n r i ) . wttcrcas in scliizoplirci~iatltc I ~ O darigerous ( i i r i l c s s tlw paticiit tliinks t h a t lie or she call fly and j m p s OIJIa L wiiidow). Marijuaiia is 110t a wratogcii. altlioiigh patieiits may Iiavc tcirqiorary dysplioria. possihly wirh scvere dc pressioii. and central riervoiis systcm depression. Withdrawal is not dangcrous. Metliadoiic ~r Is a longer-acting opioid that allows p a r i m t s to f i i i t c t i o n by kreping therii (111 a dirciiiic. hut patients act as tlroirgli they are going to die. analgcsia. anorcxic with intoxication). hiofwdback). Iiecomc sleepy. Overdose is i i o t daugcroiis.seh e drug is ~i. ~uydriasis. myocardial infarction. brit p s y c l i d q i c a l cravings iisually are sewre. Ikpression Ias pseiidodcmentia (cogiiitive decline). Antipsycliotirs (haloperi~ dol) are used if symptoins are swcre.g. 'The top tlirce cau of adolcscciit dcmlis in ordcr are accidents.. en presriits as irrital)le instead of depressed iiiood.eling <)I'bcirtg o n driig again. 'liigrther they acc~iiiit d h i i i i ~ fbr 7. i i o t lif& tlireatatiog.nic (vasciilar disriiptions in fetus).ni auditory. Becarr. Marijuana: most co~nmonly abused ilkgal drug. patients he fatal (arrlryrlimia.ia. On withdrawal. (br prcsiimed ADMD). and acts "weird .ure. i t is riot a first~~linc age~rt. irriosis. d ~ t l i o t l gTI~ i OIC was lakrn) o r a "had trip" (ac11LC . tlicrc arr associated morbidities or inortalities (cridocarditis. Look b r a trenager wlio lislens to rock rrlnsic. but Opioids: licroiti a i d other opioids caose e i i p l i o r i a . use is (:ontrovcrsial Its ci 11atioiis. Rule w i t physical prohlerri (e. Iinipraniiiic is n s c d only h r rcfractory cascs of erturesis. has red eyes. ~ m p l i e t a ~ ~ nclassically assticiated with psychotic syinptoiris ( p ~ i e i i t s a y appear to he es: m liill-blowii scl~izo~~lirenics). which is rcversible 2. Ovcrdosc can (iirinications ("cocaine hugs"~~--patients think t . kiw~dosc.

gradually taper the dose over several days. acting benzodiazepine. dizziness. Treat with flunrazriiil if s y n r p toms are due to benzodiazepine. Phencyclidine (PCP): LSD/muslrroom symptoms in intoxication plus confixion. asphyxiation) or cause severe permanent sequelae (central nervous system. Also look for vertical and/or horizontal nystagmus. plus possible schizophrenic-like symptoms (paranoia. liver. Benzodiazepines and harhiturates are especially cfangerous when mixed with alcohol (all three are central irervous system deprcssants). agitatiorr . Overdose may be fatal (respiratory depression). Withdrawal also may be fatal (just as with alcohol) because of seizures and/or cardiovascular collapse. Note: Caffeine can cause headaches and fatigue in withdrawal. Intoxication usually is seen in younger teenagers (1 1-15 years). kidney toxicity. gasoline. There i s no known withdrawal syndrome. slurred speech.panic reaction or dysphoria). disorganized behavior and speech). No witlidrawal symptoms are noted. . Benzodiazepinedbarbiturates: cause sedation and drowsiness as well as reduced aiixiecy and disinhibition. Inhalants (e. Treat with supportive care and uriirc acidification to hasten elimination. cardiac arrhythmias. Can he fatal in overdose (respiratory depression. glue. Overdose can he fatal (coiivnlsions. coma. ataxia. and aggressive belravior.g. varnish remover): intoxication causes euphoria. a feeling o f floating. peripheral neuropathy). respiratory arrest).Treat had trips with reassurance or henzodiazcpine/airtipsychoric medication (if needed).. 'Treat withdrawal on an inpatient hasis with a long-. and/or a sense of heightened power. auditory hallucinations.

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History may suggest a n ovulatory problein (irregular cycle length. Basal hody temperature. and/or endometrial biopsy can he done LO check fbr ovulation.13) t o fi. In the absence ofpathology. If the patient desires prrgnancy. Treat with oral contraceptives or cyclic progesteronc. 3. it i\ a 1 rrralr problem 2. lack of premenstrual syrriptorus). the risk for endornetrial cancer. endocrine disorders (thyroid. is History may suggest a tubal problem (PID. dnratiou. history and physical exam. 1. 1Jnopposcd estrogen increa. Evaluate cervical miicirs. IJse progesteronc only fur swwe bleeding.geriic. Anicnorrbea i s 1101 ~ I I C ~ I I I I I Ii n Ihard ~trairiingatlilrtes (ditc t o cxerc:ist: in~ ~ dnccd deprcssiiou ot gonadi)tropiii relrasing Iiorinrmc) . Secondary a ~ e n [ ) ~ ~ ~ i c a : in a ~)rcvionsly rncnstrrratirig. Cervical factor may be a cansc of infertility and is suggested by a history of cervicitis.lactin).. If' tlrr woinaii is liyl)[)[!str(. 4. scxrially active woman of rcproductive age.?'he priiiiary eveiit is androgen excc'ss. and/or irrft~tility PCOS is tlrc most likely cause of intertility in a woman nnder 30 with obriorinul mcnstri~ation. an re nor^ rhea. The next step is documentation of ovitlation. wlrich is'a cornhirratiou of FSIl arid L11. adrenal.h a w polycystic ovaries. L)ut t h i s approach rc-quires tlral the woman is prod ircing adcyuatc estrogen.The r a t i o of luteini~iiig borrnone (1. Multiplc ovarian cysts olicli arc seen on i~ltrasr~und. Ilistory ol' fihroids or cndoinctriosis symptoms) 5. pitr~itary/pr(. Watch for amenorrhea as a prcsciitiiig ~ .lliclc-stimnlating Ilor~nrnle(l:SI+) is greater tliaii 2: 1 . rradotropiii assay). in onc-third. Medical therapy is usually clomiphcne citrate to i n d i l c e ovulation. nmiiivasivr). the first step is semen analysis (cheap. 6. birth trauma. luteal phase progesterone Irvels. I f nothing is apparent after. Tubal/nreriiie evalua~. treat first with NSAIlIs ( h i ~lirie agents for DUB and dysrnenorrltea) 2. o Also get bernoglobin/hematocrit to make stire that the patient is not anemic from cxcc IJucommon caiises of DUB are inf'ections. Nornial semen has thc fbllowing properties: u Ejaculate volumc: > 1 1111 Sperm cmcentration: > 20 million/ml Iiiitial fbrward motility: > 50% of spernr Normal Irrorphology: > 60% of sperm 3.aparoscopy is a last r c x r t or is donc in patients with a liistory suggestive of endomctrioLysis of adhesions a n d destruction of cildometriosis lesions can restore fertility 7. or previoiis cone hiopsy.iori doiic hy a 11yster~)salpingograrn. u s e clomiphene. Always do a D&C 10 rule out endomctrial cancer in w o n ~ e r v t l i 35.coagulatio~i e f k t s . aiid do a postcoital test. If tlicsc nrctlrods rail. Important points: 1. use in vitro fertilization. Infertility: 1. the diagnosis is pregnancy rriitil prtwetl octierwisc (will1 a negative l i u m a n diorionic g . or amount of flow. previous ectopic prcynancy) or a uterine prohlein (previous l)&C may calm intraiitcririe synechiae. Polycystic ovarian syndrome (PCOS): look for lieavy womar who has Iiirsutism. and estroge~r~producirrg d neoplasni. 11two-thirds of cotiples infertility is a female Irrohlein. iisc hunran incnopausal gonadotropin (bMG). Oral contraceptives are also a first-line agent for inenorrhagia and DUB if the patie111does iiot desire pregnancy and cycles are irregular. easy.

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Culture breast milk. A discharge that i s unilateral and b1. 4.loody and/or associated with a inass slionld raise concern about possible breast cancer. 2. hut aspiration of cyst fluid and baseline inarniiiograplry are recomnended. . always consider biopsy. Fihrocystic disease: as above. Most C O I T I ~ O Iof all breast disea. 111 tlie absence of a classic bcnign prcseirtation (such as tranina t o tlie brcast with fat necrosis or hilateraliLy with prrincnstrual mastalgia). either topical or systemic. When bilateral and nonhloody. 3. cloxacillin).g. Pregnancy or oral contraceptives may . all of wliicli can cause discharge. Observe briefly if the mass i s small and seems benign clinically and the woman i s premenopansal and has no risk factors for breast cancer. L. If symptoms do not resolve. Fibroadenoma: painless. sharply circninscribed. a biopsy o f any mass. Fibrocystic disease: bilateral.. ~astitis/absces~: above. or hypothyroidism symptoms. pro biopsy. tender (especially prenicnsirually) cystic lcrions. Note: Do not do mammography in women uiider 35 (breast tissnc is too dense to give inter^. Fibroadenoma: gel baseline mammogram. Bredst mass in a woman 35 or over: 1. improves symptoms. 3. 2. which requires incision and drainage. follow-up. and start on antistaphylococcal antibiotics (e.timulate growth. I f suspicious or cancer (exceedingly rare in this age group). as . die c a t ~ s c may he a prolactinmna (check prolactin) or endocrine disorder. and/or vaginal itching. and atrophic with increased parabasal cells on cytology. Also get a hascline inammogram (See oncology chapter. dry. Excision is curative but not required. rubbery. you will never I)e faulted for doing a biopsy of' any mass. discontinue breast-feeding. assume that rile patient tias an abscess. mobile I I I ~ common benign tninor of the female breast. reast cancer: yon may not get a classic prcsentation of nipplc retractioii and/or pean d'orangc in a iiulliparoiis wornan with a strong family histary. Otlrcrwise. Observe the paticnt fbr one o r more menstrual cycles in tlie absence of symptoms. Estrogen. Watch out for cystosarcoma phylloides that niasqtleradcs as a fibroadenoma. I ieve symptoin s. J f tlie cyst fluid is iionbloody and tlie mass resolves afi. painfill. do a biopsy. the patient. Nipple discharge secDo ondary t~ carcinoma sliould contain lien~ogkihiii. Mastitidabscess: look for lactating woman with reddish. fluctuaiit mass.Gynecology 127 incontinence.er aspiration. no further work-up is needed---jrrst routiiic liillow-up. 4. niultiple.) . nceds only reassurance. Fat necrosis: as above. I Generally. If tlie fluid is hloody or the cyst recnrs quickly. In a woman 35 or older. and a baseline mammogram.ook for vaginal mucosa LO be tliin. Breast mass in a woman under 35: 1. do a biopsy to rule out cancer. thc discharge is not due to breast cancer. Progesterone for I week at the ciid of each nionth or danazol may help i o r c ~ . pretable films).. or soreness---symptoms that often are due to atrophic vaginitis i n this age group. Staphylococcal infection is by far the rriost coinmon cause. hormone thrrapies. antipsychotic medications. discrete.. menopause causes regression (estrogen-dependent) . Fat necrosis: history of trauma. Breast discharge: first get the patient's history of oral contraceptives. burning.

~~ Kmporcant points: 1. . 2. a malignant turnor . which usually are due to 21-hydroxylase deficiency (90% of cases). If the patient is postmenopausal (or over age 5 0 ) and develops a new lesion. because it increases the risk of ectopic pregnancy and PID (look for Actiiiomyces sp.est to evaluate the mass. even if it seems henign or is inapparent on physical exam. worsening of symptoins with standing. . Cystocele: bladder bulges into the upper anterior vaginal wall. which musi he ruled out. males with this disease sliow precocious sexual development. Mammography is used to detect nonpalpable breast masses (as a screening tool). Patients are female. ciriicy have salt. Oral contraceptives do not reduce transmission of sexually iransmitted diseases. A karyotype must be done. Any child with a “hiinch of grapes” protriiding from her vagina probably bas sarcoma botryoides. Symptoms: urinary urgency. An intrauterine device should be used only in older women. 2. Note: Conservative treatmeut involves pelvic strengthening exercises and/or a pessary (artificial device to provide support). Birth control: 1. Any suspicioi~s lesiori found on mammogram shoiild be biopsied. frequency. Major symptom: difficulty with defecating. Urethrocele: urethra bulges into the lower anterior vaginal wall.encral nervons systern disorder. you should proceed directly to biopsy 2. hypotension. preferably those who are monogamous. 4. Paiients with ? 1--hydroxylaseCicfi. hyperkalemia. Ambiguous genitalia: look for adrenogenital syndrome and congenital adrenal hyperplasia. Look for history of several vaginal deliveries. Surgery is used for refractory or severe cases. and resolution with lying down: 1. not to evaluate masses that are already present. Condoms are good because they prevent traiismission of sexually transmitted diseases. incontinence. 3. Rectocele: rectum bulges into the lower posterior vaginal wall.) 3. although it should be done in a woman over 3 5 tu have a baseline for filture comparison. Symptoms: urinary urgency.Important points: 1. mamrnography is a poor i. In patients wirh a clinically evident breast mass. Enterocele: loops of bowel bulge into the upper posterior vaginal wall. and elevated 17-hydroxyprogesterone. 3. Premature or precocious puherty is usually idiopathic but may he caused by a hormonesecreting tninor os c. N o patient with ambiguous genitalia should be assigned a gender until the work-up i s complete. incontinence. The best choice is oral contraceptives if the patient is a candidate and does not desire sterilization. Treat with steroids and IV fluids immediately to prevent death. Pelvic relaxation/vaginal prolapse: due to weakening of pelvic supporting ligaments. By definition. feeling of heaviness or fullness in the pelvis. backache. freqirency.-wasting (low sodium levels).

Bnt look for foreign body. if idiopathic.Gynecology I29 the patient miis1 be younger than 8 (9 for niales). treat with gonadotropin-releasing hormone analog to prevent premature epiphyseal closure and to arrest or reversr puberty until appropriate age 3.Treat underlying cause or. or candida1 infection (as a presentation d diabetes. Treatment is surgical opening of the hymen. Imperforate hymen: patient of menarche age with Irematocolpos (blood in vagina) that cannot escape (hymen bulges outward). ineastire serum glucose and/or check for glycosuria). 5. 4. 'Vaginal hleeding in the neonate is usually physiologic as a result of maternal estrogen withdrawal and resolves by itself. Most cases of vaginitis or vaginal discharge are nonspecific or physiologic. sexual abuse (especially with scxually transmitted disease). .

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Ilegar's sign (softening and c o n ihility of' thc Jowcr iitwiii(! scgiiimt). arid antibody screen: a i f i r s t visit (lor idciitiiicatiori is~~iiririrrrriizatioii) of ~iossil~lc 5 Sypliilis test: a t first visit (riiaiidated in inost slates) arid strliscqtiriit visits if the paticni is at liigli risk. visibility of gestatioilal sac aiid/or fi:tirs oii dtrasoririd. Ilrinalysis: a t f i r s t visit arid every viait (scrccn ibr precclariipsia and liactcriiiria. o h i a i i r at. first visit (otlicrwisc iiot riccrled) . good S C ~ : I Ifix rlialrctcs mcllitiis) 3. RIi type. auscrrltaiioii of fetal heart tones.tw. 2. weight gain. 110t a il'tlrr patielit is m c i i i i c (prqiiaircy may aggra~~ ~ ~~ ~ 4. all women or rt:ioiild take folatc. uiilcss slic had a noriiral I'ap sincar in past 6 ~llol~rl~s. Ideally. a n d palpati~ii~/hall~~tteriieiit of fc. M a c r o s i i i i i i a (or positivc Iii iry iiicllitns riirtil prixwi otherwise. No contra ception is I on% eflixtivc. it1 previoirs diildreri) is caused b y r t i a t c r n d diahetcs Routine laboratory tests in a pregnant patient: 1. linea nigra. Conrplctc hlood coiriit: at tirst visit t o vatc i 1). Give all Imgnaiit patients fiilate t o prcvwt neural tube defms. utcriiic co~itracticiii~. 4. Cliadwiclr's sigii (dark discoloration of the vu va arid vagirral walls). because i t is ~riost cffkctivc in thc first iriinester when iiot ~ I I O W that they are pregirank. rmiriiiiig sickness. Signs of pregnancy: anieirorrlrm. (!specially wlicn you Sactor i n poor coiiipliarxc. Pap smear: give to cvcry patirnr at first visit. 'Tlrc most c o i i i ~ i i o icaiisc (if secondary a i n e m i r r l r c a i s Ixcgiiaircy.Important points: 1. 2. Iniir i s 0ftt:ir given routincly to prcveiit 5. 3. Hlo(id rype. Alw(iys dci a prcgiiaiicy i test first wlwn a paticnt p r i t s with aiiienurrbea. cliloasiria. A woman may say that she is takiirg oral coiitraccptives and still be Imyparit. Prcgiiaiicy a l s o m i l s t h cam<' of' p r i m a r y u " o r r led. I I<iihella aurtikody s in ihc ahseiicr ( ia good vawinatioii liistory.

the products of coiiceptioii become a tumor. do at 24--28 weeks. then follow EiCG until it falls to zero. 2.. and gonorrhea cultrrrcs fbr any pregnant teenager. and high 11uirian chorionic gonadotropin IHCGj) means likely Down syndrome.132 Obstetrics 7. fktal (e. TORCH infeclions.or second-trimester bleeding with possi hle expulsion of ”grapes.g. Positive triple screen (low AFP. fetal licart rate tracing i s obtnimvi f b r 20 minutes. alcohol. R]onscress t:est (NST): with the nrother rcstiiig. or drug use. listen for feral heart toncs and evaluate iiteriiic size for any size/<late discrepancy. otherwise. If I-ICG does not fall to zero or rises. arid u~trasollnd should he donc t o evalu-~ ate fiirtlier. for head circurnferencc.. At 12 weeks’ gestation. it is often donc i n the cimt?xt of a hiophysical prolile. and femur lenglli. hypertension: diabetes mellitus. or .Tlris is ilic first screening tcst to t:valuatc felal wellLticing. Hepatitis A scrokigy. Possible explanations include intrauterine growth retardation and rr~ultiple gestation. ultrasound is most accurate at estimating fetal age (using the hiparietal diameter). ii readies the imn~bilicus. TORCH infections CO~I-. at roughly 20 weeks. A norinal strip has at least two acc:~lcrations the IIcart rate. the patient has citlrer an invasive mole or cl~oriocarcinoma. an HCG iliat does not r e t u r n to zero after delivery o r abortion or that rapidly rises during pregnancy. age > 30 years). and herpes simplex virus. Uterine size i s evaluated hy measnring the distance from t h e syinphysis pubis io tlw top (ifilic fundus in centimeters. history of prcvions prchlrrns) Ultrasound parameters m e x s u r ~ l IUGR dc rmioation jnclndc hiparjelal ciianirtt~. renal disease. cac:h of wliiclr i s at Icast 15 bpni above baseline and lasts at least I S secorrds. hypertension. tubercirlons skin k s t . cigarette. 9. Complete moles are 46 XX (all clrromosomes froni the father) and have no ft:tal tissue.Treat with uterine dilatation and curettage. cytomegakwirus.” uterine size/date discrepancy: and/or a “snow-mm” pattern on ultrasound. ruhelld.. first. low estriol.g. other (congcnital syphilis and viruses). Hydatidiform mole: i n a srnse. congenital anomalies) or placental (e. Serum alpha-fetoprotein (AFP) o r triplc screen: betwcen 16--20 weeks for older or othrr high-risk patients. Screen with fasting serum glucose and serum glucose 1 or 2.g.. and goi1orrhea cultures. thc mea surenient in cni should r:qiial the niirnlxr of wccks of gestation. yon should do Chlnmydiu sp. family history. A discrepancy greater than 2--3 i:ln is called a size/ddte discrepaocy. Look for prceclampsia before the third trirnester. Do ultrasound o n all patients who have a size/datc discrepalicy greatcr than 2--3 cm or risk factors for pregnancy problerns (e. Gross appearai~ce siiggests a hunch of grapes. snioking. the patient riceds chemotherapy (usually methoirexnte or actinomycin 1)). Between 16 and 20 weeks. lnpus erythc~~iatosos. liours after an oral glucose h a d . Glucose screen: at first visit i f the patient has risk factors ibr dialjctcs rnellitus (obcxity. lletwccn roughly 20--35 wcrks. 3. incomplete moles are usually 69 XXY a n d contain fetal tissue.g. Important points: 1. preeclampsia). 8. Chlomydio sp. the uterus enters the abdomen. abdominal circuintercncr. AI mcryprenulul viril. in either case. alcohol or drugs. MIV test. s i s t of toxoplasmosis. Intrauterine growth retardation (IUGR): defined as size below the tenth percentile for age The causes are inairy and are best understood iu hrmd terms as caused by one oCtlirce factors: maternal (e. and ultrasoiind are used only whcii the patient has a suggestive history or risk factors. lnpus erythematosus). I f asked. Evaluation of fetal well-being: 1.

g. Both preiriaturity and postmaturity increase perinatal morbidity and mortality l'roloiiged gest. labor i s induced (tg.Obstetrics 133 2. bcarthnrn. neural ~ u b e e f e c ~ s(e. I High AFP . linea nigra. the BPP often is doiic OIICC or eveii twice a wrek nntil delivery. mild ankle edema. spina bifida). aspirin and other NSAlDs should be avoi&!d in pregnancy. Contraction stress test (CST): a test fix riteroplacental dysfunction.-trimesteuahorrion i C a fetus is affecced. body rotation) in 10 minntes.. lowdose aspirin may help in subseqnent pregnancies. increased pigmcnta~ion the nipples and areolae (and M(intgomcry tubercles).nll(l( dctcct r1eural tt. diaheies mellitris. postterm pwgnancy. by oxytocin) if the cervix is favorahlc.ation is co~nmon association with anencephaly and in placental sulfatase deficiency Normal pregnancy changes: nausea a i d vomiting (morning sickncss). ease. M a l inoveiiients: fetus sliould have at least three body ~nove~nents (e. backache. hypertension.g. if gestational age is kiiowii to be accurate. Normally. history of problem pcegnaricies. ventral wall defects (e. CVS gives WOII~CII advairtagc: of first. If the cervix is not favorable or the dates are uncertain.lte defkcts. the test is positive. flexion. AFI > 25 cm = polylrydrainiiios). Alpha-fetoprotein levels: L. alcohol o r drug rise. do twice-weekly NST and BPP At 43 weeks. IUGR. ~ e r agents (see i. 1 pat ieni sbonld undergo auiniocentc:. I Fctal breathing nioveinents: fetus should have at least 30 breathing ~noveliients 1 0 in minutes..20 weeks). arid increased frequency o f nrinatioii. rniiltiple gestation. chloasma. most authorities advise induction of labor or cesarean section. yastroscliisis).. and usually a cesarean section is done.. It is as so^ tiic ciated wiili a slightly higirer miscarriage raw than aruiikx:cntc and c(. lop of next~page) ~ t ~ ~ ~ ~ ~ ~ . or inaccirrate dates.~ 1 sis (also done at 16--20 weeks) f ~ a rdefuritive diagn of chroniosonral disorders (cell ciiliure) or neural tul)e de (aniiiiolic flnid AFP) Chorionic villus sampling (CVS): c a n he donc at 9-1 2 weeks (rarlier than aniiiiocriitesis) and griierally is reserved fix women with prcvimdy a E c t e d offspring or known yenciic dis~.g. use acetaminophen instead.Tlie s n l i i of the highest vertical pocket in each quadrant i s used to deierniine whether digohydramnios or f)"lyliydramni[)s is present (AFT < 5 cm = oligoliydrainnios. hcavy of (possibly eveil painfiil) feeling of the breasts. Note: If ilie fetns scores low on the UPl: the next tc!st is the conlrdctioii stress test. and nronitor the fetal lieart strip. Generally. or inaccuraie dates. anenccplraly. Iflate decelerations are seen on the fetal beart scrip with each contraction.owAFP = Down syndrome. siriae gravidarum. 3. = d oinphaloccle. fiml demise. Note: In woiiien with anliphospholipid antibodies and previous problem pregnancies. amcnorrlica. Give oxytocin..With high-risk prcpancies (cg. maternal or plysiciaii concern). IfAPP or triple screeii i s positive (at 16-. Postterm pregxiancy: > 42 wceks' gestation.able. Riopfiysical profile (BPP): inclndes four nieasureiiieiits: NST (see above) Arniiiotic fluid index (AFI): measures vertical pockets of amniotic fluid (in cm) in each of the four quadrants.

Always r i parielit I n s check aiitihody status obi first visit il'tlic piim i n i m i n i i z a t i o i ~ Iiiscory. lc(i co1oi1 hypoplasia. 4. m CyIoiiicgalr. Ilrugs that arc gcricrally safe in ~ m ! g i i a i i c y :a c e t m i i i i o p l i e i i (1101 NSAllIs o r a s p i r i n ) . n i i c n ~ c c p b a l y .iiic. I tirst wiiriestcr (somc autlioritics rrcoinmnid alxirtioii if' t l i r n i d c o i i t r a ~ ~i sl w l l a in tlic first tririiester). cli[)rioretinitis. ancmia.. i ~ ~ i c : r ~ i p l ~ t I i a l iiiia. c c w l r a l ralcifk:atioirs. m k I m 'Hr'rprs: look tbr vesirrilar skin I r s i i m s (with ~ i i ~ s i i c i v r ' T z a is ~i ilm r s ) . Mosl TORCH i i i t r a u l c r i n e felal iiifecti(ir~s cause irit!irtal rctardatim. ski11 lcsioirs). c J ~ ibr canliovascrilar iicf clcafhrss. F i y p q l y c c n i i a aiid diahetes rncllitiis cause cardiovascular ariornalics. I .134 Obstetrics I Important points: 1. ilociisatc'. history ut i i u l ii i Ii c: rpcs lcsi oiis. I l a mstcr (liiiiljIiypoplasia and scarring of the s k i n ) aird syphilis (rliinitis. I h c k c r s . dcaiiiess. a l d insiilin.m~igoiidii: loolc fix exposirre r o cats. ]OW birth wcight . i. eyc~ rriallbriiiations. spcritic d d w r s inclridc iiitravranial calcilica tioils. . cleft lip/palatc. i i i t r o l i i r ~ i r t i ~ i iH. ventral septal i i d k t ) . Iiepat~isplciiorricgaly. '. artcriiis~is. pciiicillii~. i i c t l i y l d ~ i l~ ~ a . s a k r sliiiis.virus: iiiost coi~iiiioii. liydrala~.jaundicr. arid irracrosomia (early d i a ~ ~ tietcs) or i n i c r ~ i s o i n i a (Ioiig-sraiiding diatietcs). 11iitcliiiisoii's t 11. intrrstitial kcratitis. i i m r a l tiihc defects. ~:rphalosporiiis. arid i r i i r r o p l i t l i a l m i ~ . Iicpariii. antacids. and fiitirrc nraligiiuicics (esp 3. ~ ahc~ . caudal regression. ciiii hydroceplialus. crytlironiycin. catasxts. arrd/or KJGR: ToxcipIa.

tus. incthyscrgidej Important points: 1. indurated. a n d painfiil. ohtaiii milk for cultnrc arid seiisitivity.-feed.velop symptoms later (e. 11' the inotller gets cliickenpox in the last 5 days of pregnancy or first 2 days after delivery. l f a t tlrc timc of triic labor the motlrcr Lias iio JfSV lcsioirs. auticanct:r agt'uts. give the infant varicella zoster iiiiniuiioglohnlin. at 8. After a cesarean sectioii with a loww (Iiorizontal) iitcriiie incisiorr. Signs of placental separation: fresh show of blood from vagina. In pregnancy. 6. Breast-fecdirig is ci~ntraindicated patients with t l I V or hepatitis H a n d i n patients w h o in i i s c thc following: herr/odiazepines. If the mother lia liepatitis E. Breasts are red. learriirig disahility. Treat by stopping breasr.rnplrcnicol. and hvgiii antibiotic (~~~iiicilliriase~~rcsista:it peiiici~liii such as cloxacillin) fix 7-1 0 days wtlilc awaiting niltiire resiilts. do a cesarean section. HIV transrnission is reduced t o roughly I O % . antitliyroid mcdications. 9. iii which case iricisirjn and draiiiage a n ' ~iet:de.g. transrnissioi~ the fetirs occurs in rotrglily 25% of to cxses. rhe cmidition m a y have progressed into an ahscrss. If at the time of triic labor slir lias lesions ofHSV. pr ibc tiglrt-fitting has. 11. it i s normal t o liave some iiiscliarge (lochia).rrcd rncthod iri ohs~ciric patimts. the test revc'rts to riegativc.csi)pliagcal a. If the breast is fluctnani. I f a woiiiaii does not want to breast-lid. If a womaii does breast. clilor~. With prenatal A o v n d i n e (ALT) treatment fbr the niothcr and adiiiinistration of A%T to the infant fix 6 weeks after birth. In urrtreatcd HIV-positive patieiits. which is rcd on the f i r s t few days arid gradually iuriis to a white or yellowish~~white color by day 10. . the fundus rises and becomes firm and globular. wliicll usually dcvelops iii the f i r s t 2 montlls of breast-feeding. 3. Gcncral arresiliesia im vol vcs a higher risk o f aspiratioii aiid rcsrilting p n c n ~ i ~ o n ihcransc tlir gastr(. F:valuate infant for stapliylococcal colonization if givcri the option.. icc packs. gcsia. suspect endometritis. delay the decision or whether t c i do a cesarean section iintil the rnother goes into labor.Obstetrics 13 Note: With all io utero infections that can cause prohlen~s with the fr.d. For the first several days after delivery. opiates. Within 6 montlis. only t o dev. After a cesarean section with classical (vcrtical) uterirre ilicisioii. When rhe motlicr has genital lierpes simplex. If the lochia is foril-smelling. the noth her may he asyniptoinatic (subclinical infection) and the i n f a n t iniy even be asymptomatic at hirth. lithiurn. Breast:-feeding: 1. HlV-positive iiiothers should not hreast~~fix:d because milk can trarisriiit viriis to the hifain. treat chlamydial infection with erythromycin (not tetracycline) IO. barbiturates. t h e patient imist have arean sections fbr all fiiturc deliveries because ofthe increased rate of uterine ruptiire. ~iinhilical cord lengtliens.g. and anal-. or crgot and i t s derivatives (e. give: thc iiifaiit the first liepatitis 1\ vaccin tis B imiminogl~~biilirl hirth. . catfeeine o r tobacco (in large arnoniitsj. Wrijrrrocriptinr arid estrogens or oral contraccprivcs also may he risrd t o supprms lactation 2. inental retardatir)n j 5. often tlre patirnt has a low-grade fever. Epidural anesthesia i s the prcti. tlie paticnt may deliver fiiturc pregnancies vagirially 12.~ feeding. 3aphylococcus (iurcus almost always is t h e caiise. deliver vaginally. alcohol. watch h r rnastitis. A noiiiiifected iiifant iiuy s t i l l he 1-1IV-positive on testing hrcanse inaternal antilx~dics can cross the placenta. 7.

and HELLP syndrome (hemolysis. nullipariry. low platelets). with isoniazid to prevent nutritioiral dcfcct in her and the fetus. Make siire to give the mother vitamin B. cyanosis. headache. chronic hypertensimi. in assirme that it represents precc:lampsia and start treatment. 2.The goal of treatment is to prevent neonatal sepsis and endometritis. pulmonary edema. plus a positive sputum culture). 5. swelling or edema of hands a n d / o r face. blood pressure should increase by > 3 0 / 1 5 mriiHg over baseline). Catch it hi preeclamptic stage.Treatment is delivery if the patient is at term. 4.or m o r e proteiriuria. and black race. Eclampsia can be prevenred by regular prenatal care. treat hypertension with hydralazine or labetalol and bed rest. Marijuana aiid lysergic acid diethylamide (ISD) have not been confirmed as teratogens. headache. If tlie patient is a known recent PPD converter or lias additional risk factors (such as MIV positivity or hou iold coiitact with an active case (if tuherculosis). If preeclampsia symptoms develop before the third trimesler. I-IELLI: blood pressure > 160/ l I 0 inmHg. which may cause deafiiess arid nephrotoxicity in fetus. ~ ~ ~ depression. treat with i s o n i a d like a nonpregnant patient. visual dis-. Treat asymptomatic bacteriuria in pregnancy (20% of patients develop cystitis and/or pyelonephritis if untreated hecause progesterone decreases the tone of the ureters and the uterus compresses the ureters. Ohserve the patient carefully If the patient has severe disease (oliguria. multiple gestation. The main risk factors (in order of importance) are chronic renal disease. or progression t o eclampsia [seizures]). arid dratb. Do not try to deliver the infant until tlie motlrer is stahle (do not d o a (:mantan section whilc the mothcr is having a scimrc). Err on tlre safe side. wait tiiitil labor and give anipicillin. if the patient is CHS-positive at 26-28 weeks. . Spinal anesthesia can interfere with the mother’s ability to push a i d has a higher iilcidence ofhypotension than epidural aiiesthesia. oliguria. hut severe ankle edema or hand edema is likely to be preeclampsia. blurred vision. If the patient is premature and has mild disease. Avoid strepcomycin. treat as you would any other patient. u Mild ankle edema is normal in pregnancy. age > 40 (although the classic case is a young woman with her first child).136 Obstetrics sphincter i s relaxed in pregnancy and most patients have not been NPO. Treat group B streptococcal (GBS) carriers only during labor and delivery. deliver regardless of gestational age hecause both mother and infant may die. think of hydatiform mole and/or choriocarcinoma. iiieiital status changcs. elevated liver enzymes. u Hypertension m plus protcinuria in a pregnant patient i s preeclampsia until proved otherwise. 3. family hisrory. Pre. ~ e! I)o not rerneasure very high blood ~iressure a pregnant patient. turbances. I’reeclainpsia plus seizures = eclampsia. Toxic effects iiicliide ~ y ~ o (first sign of toxicity). urinalysis with 2-f. For example. B( . If a woman ha5 tuberculosis in pregnancy (positive purified protein derivative [PPD] test arid suspicious chest x-ray. central nervous ~ e ~ l ~ respiratory system depression. and treat appropriately. er Use magnesium sulfate fix eclauipric seizures (also lowers blood pressiire). diabetes mellitus. coma.~ eclampsia often involves right upper quadrant and epigastric pain and develops in the third trimester. Preeclampsia: look for hypertensioii (in patients with preexisting hypertension.

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trdiiiiia. 1 1 1 ~ Iiiglier tlic risk) Hleeding 15 paiderr. Uterine rupture prcdiymiiig fa<tors inclirdc prtwour iitcriiic riirgcry. Ii['lyliydrainiiio~). EXLCI\IVC 11tcr111('diitenrioii (e g . ('emcan i c t t i o i i I \ rriairdau~ry dclivcry. 011\ [)!llg lllay i i C IC'lcCl IIlOOd tiJlgWl 11111( from tlie cervical i a r i a l a r i d herald\ thc o i w t of Ialmr Tlii\ cvciit I\ i~oriiiuI aiid a ( t i a > p r i ~ . hiit you rimy try t o adiriit with l x t l ~ i i p d v i L for d rest and tocoIy\i\ i f ttic patient i s pi(wriii a i d ?table and tlic Idetdiiig \top\ 2. Petal bleeding u\iially h r n vara previa or vclairrci~toiir iiirertion il tlic cord Tlic i i i d j i x i ritk IaLtor 15 inultiple gc\tation (tlic higher the iiuiiihrr of le1 ii\er. McRohert's indneuvw with IPYF flexed on thc mdternal ahdomen and chest Angle of iiiclination of the pelvic area IS increased when the l e y s d i e flexPd IC) compared t o the lens bping extended In lithotomy 1 1 thus. goiimilica. i i t m i i e tciidcriir\r. CCIvi~al/vagiiiallcrimis cxaniplc\ i i i c l i i d c h c r p rii~iplc>x VIIII\. Byrd J l . Cervic a1 caixci iif c x t l l l \ l o n iiiay occiir 1 1 prcgnaiit paticiitt too1 1 9. cephalopelvic disproportion. Ccrvii al/vagirial ~rauiria w i i a l l y iroiri intixi( oiirw 1. aiid Iircteriii preinaturc iiipturc o iiicinhi aiics Do not forget iliac f tlic p a ~ i r i itta n Iiavc t l r i i conditrori n i t h i t visible Mcediiii: (blood coiitaiiicd hchiiid pla ceiita) I'atielitr h a w pain. ahnoimal fctal lic. a i d riicrvarcd t i t e i iiic tone with liypcrac alro I \ prcwiit Abruptio pla(eiitac iiiay caiiw tivc (oiitrat ti011 pattcrii Fetal di\ti jxodui tr enter rlic matcriial circiilalioii iriiiiatrd intravas( iilar ~ o a g i i l a t i o i~ i f U trasound detect\ oiily 2% of c a m Treat with 1V fluid$ (and blood i f iiccdcd) and rapid dclivcry (vagiiial prefcrrcd) 3. oxytocin.uated with rriatcriial hypoteii\io~i \hoLk kcla1 part\ iiray hc felt i i tlic a b or i rloiiien. Sdkurnbrit LL Ilandbook of Pregnancy dad Poimatdl C a w in Family P r d c t w Philadslphla. or the abdoininal coritour may c h d ~ i g ch a t w i t h irrinit~diatt~ laparotoiiiy aiid iiriially byrierci torny alter dclivcry 4. the shoiildrr of lhe infant may become dwngaqed 8. Abruptio placciitac prdiymriiig factor\ incliidc hypertcnriiii~ (with or witlioiil prc i&iiipria).iit\ hcbrc dclivc~y (more ~ o ~ i i i ~afteri deiivcry) ioi . (lac hycardia inilially. trauina. and the mnotl~ci cornplcwly s t a l k while the fetus \how\ wormling dI\trev. i u\e. Blceding diwrdci rarcly prw. "~lO(>dy \llOw" W l l h < ClVILal ~ f ~ ~ ~ ~ a~ i J l < ~ l l ~ . (From Ratcliffe SD. ~iolyliydrarriiiios with rapid dec oniprrwon afiw mcimbranc ruptiict~. and \houldcr dyrtocia Utcriiic riqituii\ i s ( haractrriiecl hy extieme paiii iif siiddcn o i i i c t and often aw. thcn hradycardid ar the letrit dcwinpmrat'ct) The Apt t ~ r tti po5itivc on iitrriiiia hiood and diffcreiitiatcr fctal hl niatcriiai blood Trrai with iiiiimc ii clidte cc\arcm WLI ion 5. grand miiltiparity (revcral prevrour deliveries).A. iriulti plc gestation. Hdnley p1 Uolfu. t hlainydral or ~ a n d r d a infectmil l 6.

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thcn do ciirettagc: tlic to in the operating room iiirder a n t s t h c s i a . a Irystr mriy i s usually necessary t o stop tlrc blcciling.with retained products o f corrception (wliicli i s pr~)balily [ I C most C ~ I I I ~ I I I ~cause o f ~lcluycd ~ IJI pcistpartum hrmorrhage). . I f placenta accrcta or pcrcreta is presmt (placental tissiie grciws iiito/!Iirotigli thc myorrrctriiim). reiriov~ pldceuta u~~aniially stop blceding.

-~ Obstetrics 'I .

tlic twins are rnonoi. v&mriitoiis cord iriserrion o r vasa pswia. Maternal: aiiciiiia hypertt!nsiorr. placenta previa. increased perinatal morhidity and mortality. Conlplimtions ot'multip1e gestations ((lie higtier [lrc rriiirrbcr o t k%ust. Fctal: polyhydrainuios. prematurity. If the placentas are monochorionic. you c a i i try vaginal dclivery Sbr hotlr inGiits.Multiple gestations: if sex or blood type i s different. 3. postpariurn iilcrine atony. IUGR. With vcrtcx -vcrtcx presentations.ygotic.tilc Iriyhrr t l w risk o f conditions) iiicludr tlic followiiiy: 1. abruptio placrlicae. l'li t1rrt.A--1ypingstiirlics. iurhilical cord prdapsr:. J'KOM. riialpresciiucion. do a cesarcair section.Tli lnaining 20?6 require I11. other coinhioatioii of p r . coirgen-ita1 anomalies. with a n y itations. twins arc dizygotic.s. pri~iiial lahor. poslpartiilu iirc 2.e simple taclors Mferentiate ~ n o u o r y gotic fiiom dizygotic twins i n 80% o f cases.

a ~ i m a ) l t. inany t cases or diverticulitis. in doiihl a d the paiicnt i s stahlr.le o r worsening. When you art.ncons I ~ a c t c r i aperitonitis). If the lmt'icnt is rlnsial. i o a lapartitomy Acute abdomen: ail iiiflaurctl pecito~ivuur oficn leads Localization of acute abdomen: Right ~ippi:r qiiadraiit: iliiiik of gallbladder ((.liolecystitis. q i y or lqjaroimriy.cholaugitis) o r Iivcr (abscess) 1.hccausc it signifirs '1 potent i d l y life-tlircatciiiiig coriditioii ( i r n p m a i i i (~xceptioiis u laliarotim1y an: p i i c r t a t i t i s . Right Iowt:r quadrant: think o C appendix (appeitdicitis) r~I x f i Iowcr quatlrmt: t l i i i i k i f s i g m o i d coloii (divcrticulitis) Epigastric: tlriiik of stoniach (lxrictraring ulcer) or paiimeas (paxi 147 . withhold p i n mnlicutioiis (do not iiiask synrpioms Ijcforr: i a l ahckirninal exams. a n d spoiiia.~4 rrppcr quadrant: tliirik o f s p l e e ~ j r n p t ~ ~ rwit11 Iiluni t i . The hest physical confirniations l OF p e r i t o n i t i s arc )ound Iciidcriiess a n d iiivolmtary goarding. vduntary gtlarding a n d t c i l ~ ~ derness t o p a l p i are sofier sigiis hecause boili arc often prescrit in hctiigii diseases.

Patients O~ICJI have a history of gallstones. Splenic r u ~ ~ t u liisrory of hlurrr ahdoiniiiai trannia. Krrr’s sigii. a he pa to^^ iminodiacetic acid [HIIIA~] scan) clinchcs a difficult diagnosis (iiorivis~iali~a~ioilt h e of gallhladdcr). Cliolangitis: riglit appcr quadrant pain. I i y ~ ~ o t e r ~ s i o ~ ~ / t a c l i y c a r ~ i i aa.n d ~e: sliock. sirch as postpraiidial right upper quadram colicky pain with hiriatiiig a n d l o r nausea and vomiting).g.’Ilie classic history is crampy. Hanky & Beifus. Start antibiorics. poorly 1oi:dlixd periuuihilical pain followed by nausea aiid voiniting. Treat medically with avoiilariic of oral ingmtioii (NPO) arid rn aril. [Jltrasourrd is Ihc best first ilnaginy strrcly for srispccted gallhladdcr &sea. i and patients dcvclop peritoned~siglis will1 wors(?niiigof nailsea aiid voiiiitiny. Cuiry RJ. I’or cholecystitis. wlth prrinission ) ~~~~~~~~~~1~~~~~ lower quadrant pain i n a patiwit ovw SO is divrrticulitis rinless yon have a leli good reasoii t o chink orherwise. forty. I’airi t l ~ c ilocalizes to tlic right lower quadrant. ahdoinen. I<crncinbcr positive Rovsing’s sign alld MLBurneys ) m i iisiial polnt of rnmimdl randmoss in riqlit lowor qiiadrdnl (From James rC. l’aticnts with lip iiidhrr virus inlectioo s t u ~ l di o ~ i play roiltact :.typc syrnptoins. a i d do a cholecystectoiiiy. arid jauridicc. fi-male. 1981. Petry JF Prmciples of Basic Surgical Practice Phrlndelpliin. fiwile. tiiotim. Look Ibr Murphy’s sign. Cholecystitis: thc classic patient is fat.ports. fcver a n d sliakiiig chills. Inrinunizs: all pat’icrits aftcr sl~lcriccti)ri~~y s r c t i o u ou irnrnii (sce Appendicitis: peaks i n 10-~30-ycar-oliIs. Patients who arc liurrgry and ask fix food d o not havc appeildicitis. conshirr . flatulent and JIOW fthrile (es-~ pecially with gallstones on ultrasound o r history of gallstones a n d / o r gallstonr~.Gallbladder disease: 1. Do d cholccystecti)ulyl~~ 2. I f the disease is rc:ciirreiit o r rcfractory to incdical tlrerapy.. a nuclear l~cpatohiliary/sciritigrapliystudy (c. 3.

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tlic affected par1 of' the chest wall may rriove paradosically during r Iiration (in drrriiig inspiratiom. r a ~ ~ Look ibr bowel Iicriiiated intci thc chest. Tllcvc is almost always an associatcd pnlmorrary coilciision. Fix surgically. h i c k . cornhiired with pain. Neck trauma: tlir n w k i s divided iiito thrt . Perry JI. Gct ~ Uangiiigram i S you are suspicious.or~kfir widerred mediastinum on x--raya n d a j i p p r i a t e trauma biswry. with permissiorl ) .mes f i r trauma: 3. Trear with surgical repair. may nuke rcspiratiori irradequate. intubate and givc positive p r Other injuries: '1.Pririciples of Bas16 Surgical Practice Philadt~lphia.General Surgery I ---- - Lpft m n w n pneumothorax (Froin Jdmcs LC. Hanley & Belfus. I 2. . 1987. wliich. Wlreii you arc in doubt or thc pat i m t is 11ot doing wcll. ~ i ~ rupture: ~ ~ usually occws o n the lclt becausc the liver pmtwts the right. Corry RJ. I. o i n ~ ~ icausc of immediate death aftcr an autornohile accio~i dciit o r 121 from a great height. Aortic rupture: the most c .le places. out during expiration). Hail chesc: when several adjacent ribs arc broken in mnltip1.

~ ~- Fcneral ~.Surgery 1 .

Ophthalinoloyy
_ I

'Tlrc only signs arc clevatcd iniraocnlar prcssiire (us~rally20---30 mmHg), a gradually progressive visual fitM loss, and optic ncrve changes (increased cup-lo-d doscopic cxarn) .'kcat with several difkrcnt typc:s of medications (beta blockers, prosraglarrdi t i ~laranoprost], acctazolainidc, pilocarpine) or snrgcry
2. Closed angle: presents with sriddcii ocnlar p i n , lialoes around lights, red eye, high in'urc (> 30 mrnHg), irausca arid vorniting, sudden decreased vision. arid a fixed, mirlLdilated pupil. 'rrcat immediately with pilocarpiric drops, oral glycerin, a n d acetazolamide ro break the attack.'Tlren u s e sirrgcry to prev:ventfiirtlrer attacks (periplleral iridectomy). , anticliolinevgic rrrcilicatioris iiray causc an attack of closed arrglc glau coma iii a strsccpiihle, previously untreated patient. Mrdicatious do riot causo glancoma attacks in op(mi-aiigl(: glanc(ma or patients previously treawd surgkally for closed -a~rgle glair coma.
~~~~~~~~:~~~ t points:

1. Steroids, wlictlicr topical or systcrriic, can cause glanconia a i d catara Tipica1 steroids can worsen ocirlar hcrpcs aurl fiungal i~rfcctions. board ~ w r p ( , do lint givc topical stcroids l'or iliy ii'tlre paticlit has a dendritic corneal ulcer staiiwd green by flimrcsceiri).
2. I!xposurc to ultravidct light can c a l i x keratilis (coriieal iuflarnmatioir) with rcsultarrt pain, foreign body sensation, red eye, t.caring, and dccrcascd vision. Patients have a history of welding, using a tarrtiiug bed or sunlamp, or snow-skiing ("snow-hlirrdiless"). Treat with a n eyc patch (14 liours), topical antibiotic, and possibly w i i h a n anticlrolinergic (cycloplegic agent that rcdirces pain)
3. IJveitis is c:oininon in juvcnik rheu~~iatoid arthritis (espcciaily tfic pauciarlicnlar hrIIl) Patients need periodic ophtlialinoloyic cxalnination to clrcck Ibr uveitis.

4. Cataracts are the most coniimnr calm: of a paii~less.slowly progressive loss of v i s i o n . 'Reatnient is snrgical. Cataracts in a 1lel)rldtc should make you think ofTOKC1-Li n or an inlieritd metabolic disorder (c.g., g a l a c t m " ) .
5. Know the rt:tinal and fundus clranges seen in diabetes dot^ hlot hemorrlragcs, microanc11 rysms, rieovascularizati~~n) hypertrr~siori(arteriolar iiarrvwing, copper/silvt%r and wiring, cotton wool spots, papilledema with sevcrc Iiyperterisiorr)

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Ophthalmology -

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t:r hirth uritil clip age of 7 o r 8 . the visual system is still developing afi. 3.The condition does not rex)lvc and may w i s e blindness (amblyopia) in the afkcted eyc. m i r a l l y inward) t h a t p c heyond 3 m m A s nccd o~~htliahnologic rcferral. which will not develop the proper neural connections. tlie 1 Patients iiecd biibcals or reading gla loses i t s ability i o accoininodatc. If one cyc well or Is turned outward. thc eye will iiever see well and cannot he corrected with glasses (neural rather than rrfractivc p r o hlcrn) .Oohlhalmolaav 2. Presbyopia: betwcen tlic ages oE4.0 a n d SO years. Abducens (CN 6 ) : the patient carmot look laterdly with the affected eye.or this reasoli. Tlius. tlic brain caiiliot fiise the two different images that i t sets and suppresses the had eye. Trochlear (CN 4): wlren tlic gaze is medial. byopia is a iiormal part ofaging. 15 4. 1. the patient caiiiiot look down. . visiia! scrccmirlg ~inrst dorre i l l p<!he diatric p a t i e n t s . CN 5 and I palsim also affect the eye because ofconical drying (loss ofcorocal Mink rcflcx) Children witli a “lazy eye” or strabismus (dcviatimi or tlic eye.

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X i test fix anterior cruciatc ligament (tZCI>jiiiti:gritF do the artteriiir drawer test. weakness d foot exIciisors. blood mitIlri5 and roiripltw blood cell count with diffi:rcntial i f you arc siispicious. The most com~noii a w c of osteomyelitis is Stnphylococcus i~srcus.. Aspirate thc joillt a l l d do (. Closed reduction should he done for all otlier fractures. and the paticnt has an ACL. .ook fbr de5 .5. tertiary syphilis). m Charcot joints and neuropathic joints are seen inosl cominonly'in diahetes niellitus aiid other conditions carising peripheral neuropatlry (e. cu~turt:sand scnsilivities.r. Look fbr decreased triceps reflex/strength arid weakness of foreann extension.r r o ~patients and IV drug abusers. IIcrniation affects tlie S I iicrvc root. . weakness of plantnrflexors in fbot. Surgery (discectvmy) is an iqition if conservative treatmciit fails. professional athletc) P m Extremity 2. After falling on ail outstrctclied hand. Pain in the anatomic snuff-box after trauma (fall 011 an uiitstretched hand. the test is positive. Cervical disc disease (classic syniptoni = neck pain) is less coimno~i tliaii lamliar diseasc. blood cu1tur. in sickle cell iiiserl discase. and Sulnno~icllusp. ~ ~ Septic arthritis a l s o is niost co~~~rrioiily 1..rain staill. Illc knee is placed in 90" of flexion a n d pulled fixward (like opciiing a drawer). Do x-rays fbr any (eve11minor) trauma in ncirropathic patients. 2. Lack iif proprioception causes gradual arthritis arid arthropatliy and joint deformity. tear. and pain in tlie hip or groin. If' t h i s tibia p d l s forward. wlio may IXJI k:el wen a severe fracture. Herniation a&:cts thc 1 iiervr root. Important points: 1. especially in yowig adnlts) usually is diie to a scaphoid hone fracturt.g. I. Lumbar disc herniation: coinr~io~i corrcctatile cause of low Back pain is tbc L S X I disc. titit in a scxually active adult (cspccially diie S. c hiit think or grairr~~ncgative orgairisiiis ill i r ~ i i n o n o c ~ ~ m ~ .. 3. the inost likely liacturc in older adnlts is a Colles' fracture (distal end ofradirrs). Tlic C6--C7 disc is the most c~niiiioii site. Iicriiiatioii affects tlle C7 nerve root.0 uuieus. if liri~iiiiscuorrs). IXagnosis is rnadc by CT/MRI or rnyclogram. cnlturc and sensitiv~ itics. The ITIOS~ c o m ~ n osite ~i P 'The second m o s t common site is L4-L.g. sirsliixt guiiocorci. s Conservative treatiiieiil consists of bed rest and analgesics. Aspirate t l i r joint and do Gram stain. creased biceps fernoris reflex.sarid coinplctr blood cell ixwrit with diffkrcntial i t yiiu are siapicious. Look fbr decreased ankle jerk. pain from inidgluteal area to t l ~ c posterior calf: and sciatica with the straiglit-leg raise test.Orthapedic Surgery B Compromise of hlood supply Multiple trauma (to allow mobilization at earliest possible point) function requiring perfect reductkin (c.

A hip rlisl~icatioii. Trcat with rest. thcn consider siirgvry Ask the patient to touch her toes. Pediatric hip problems (scc ahovc) give refirrcd pain t o t b r krice. hut history gives i away.The disease iisiially rcsolvcs o i i its ow~ti. a lateral ciirvatiire is sccii. you slionld he able io tell wliicli rlisordrr they had. The ~rrost ~ I I I I I I O I I causc or it patlrologic fracture is o s t c o p r o C (espr:cially in elderly. get a n aiigiograiri Orthopedic Surgery ~ 163 2. Givcn thc correct history (especially age ol'onsci o f symptoms!). lung. thin wornen). .tracttire. and NSAll~s. X-rays may hr taken. W i t h scoliosis. or prostate). (from 3.Treat with a bracc iiuless (IK: deforrni ty is sewre (wiili rapidly progressive respiratory comproniisc). It i s o f t e n bilateral and LISU ally Imseiits iii males 1&l. i Qsgood-Schlatter disease i s osteochondritis of the ti hial tuhcrcle.I I Important points: '1. Scoliosis iisiially afl'ccts prcpiihrrtal fkinalcs and is idiopathic. and telidcrriess in the knee. The most coiiiirioii typr: of bone timior is ~ ~ ~ c t a s t a t i c thc breast.S years old with p i i n . but the patient Iias 110 kn o r pain with palpation of the knee. a i d look at the spine. With a ii'ue posterior kiiee dislocation. activity rrstrictivu. 4. or iuflamination c m refer pain to tlic kiwc (c Pediatric hip problems Note: All tlirw oftlie above pediatric hip prohlcms may prcwnt iii an a d i ~ l as arthritis of the t hip. swelling.

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Epidural hematoma: diic to h l c c d i i i g fi. rhaye: diic to hlood betwtwi the a r a c l i i i o i d arid pia niater. followed hy ruptiircd b c r r y aricurysrns. other call. Subarachnoid h most co~ii~i~oii c trauma. ~ ~~~ . If thc q i i ~ ~ s t i ( iincliides a ii history of' head trauma.ive (""blown") irpilon only o i ~ e most likcly si& rqircsaits iinpiiigari<wt[if t l i ~ ipsilatcr. Mor? tliaii SO'% of patients l i m e an ipsilatcral "hlown" ptipil (. tlicy liavc cmtralatcral h e r r i i p l q i a aiid I i c i i i i s ~ : i ~ s o rdrficits. i y lilood ( w l i i t c ) Is seen i n brain par'ciirliyina arid pcrlraps in r l i e vi:iitricIcs. a l i i i o s ~ always associattd with a s k u l l h c t i i r c (classically.2nimtlis later. Of tlie dill i t iritracraiiial I i I c i ~ I stliis i s i i i o s t c o i i i ~ . fcacturc of the tcinpriral hone.do a cerebral arrgiograrii/MhlR air giograrn to l o ~ i k r ariciivysrris a i d artcrioveniins rnalfiiriria. crescent-shaped. Siirgcry i s rrv c d h r large I)lceds that arc' a( Mirr a history of traiirria. 2. lilood i s swii iir vcntriclcs a i i d around ( h i t not in) 111v hraiii/braiiistrrn.~si. Patients classically pr tlie "worst lieadache o f u i y Iik. T w ~ i ~ r l i i r cocciir iii rlic h a d gaiiglia. t h e i i i i d d e inriiiiigeal actery). h t i o i i s .I'irst do a CI'/MIU aiid . Treat w i t h s i i rgical cvacuati~iir. wliich are trcatcd with surgical clipping. tniiior.t:d a l u c i d intcrval of iiiiiiiitcs to hoiirs.il diird cranial iicr and iriipciidirrg uiical I i e r n i a t i o n diir $0 iiicrcased intracranial prcssiirt:. Awahcl paticnts 11. Treat with surgkal evacuation. lenticular-shaped.''althougli iriaiiy did hefim: I y r t w l r die Iiospital or i n d y be uiiccinscioris.and ~ihservatioii. coiriinori in a l c o l i d i c s a n d after liead trauma. 'I'llre i i i o s t bral is hypertension. I wiili e i d u r a l Iicirratoiiias.scnt iriiiriediatcly after traiiina or r i p 10 1 ~ .Treat witli stippiirt.Wlirwcvcr intracranial hemorrhage i s suspccted. see below). ciiag~~ rilopathics. fbll~i~. Oilce the patient is st. I n t ~ a ~ ~ ~ ehemorrhage: resiilts fr(im Iilr(xhig iiito the brain pareiichyina. Althong11 CT i s the test of choice. Tlic classic h i s t o r y Is a liead traiiiiia w i t h loss of coiisciousncss. a dilated. ordcr a CT w i i l i ~ i i i rcoritr. Tbc 3. ! h i d shows I up as w l i i t c aiid inay cat is(^ a riiidline shift. h c l o w ) . always coiisidrr the diagnosis o f a srihdiiral lieinatoina. 1. Do i i o ~ do luiiiliar tap oii airy p t i c i i t with a "blowii" Iiiipil. 4. l ' a i i c i i t s (ificn p r r ~ ~ ls sciits with c:~iii~ia. a i i d r d i i i n a . lrnreact.ivc sigiis d'1ii~:iiiiigitis (pmitive Kernig's and Ilriidziiiski's s i p s ) .alile. Subdural hematoma: d i r r to hlc. tlicii neiirologic d c t e r i o hy ntioii. P a h i i t s may pre.Y awakc. association bctwcc~ii polycystic kidney disease a i d h c r r y aiicurysiirs. Ilerneiiilier tlic. anticorivi~lsaiits.om m e n i i i g c a l artcrics (classically.cdiiig from vciiis that h r i d g e thc cortcx and dural siiiiisi:s. iricJridc artc~rioverioiis malfbrinations. a luiirhar tap shows grossly bloody cerebrospinal fluid. yrni may pi itatc iiiical l i c r i i i ~ t i ~ i i dt~atli.

l'n~pliylacticant iconvvulsaiits are controversial.- diabetics a t r d risrially dric to Stqhylococt.g. fractures may he ol)served and g " d 1 y b c a l on their o w n 2.erchral vasocoiistric c a n lx tried to I etioii. Surgical indications arc cimtalninatioii (clcaiiiiig a n d dcl~ridmne.. Also give strimids (provcd to i r n p r o v e o ~ s t c : o s i i c ) Sisrgery is donr fix incoinplete neurologic injury ( s m i l e residual fiirrction i s iiiaintaiild) with external cornpressiorr (e. Spinal cord trauma: o l i e n prt!st-iits with spindl shock ( k ~ s sof rcflexcs. prognosis is rrros~closcly rclatcd t o pn:trcatmeiit ~iiiii:~imr. I . respiratory irregularity). Iltlrc CT i s Iicgativc. Tlrc first steps i n tlic curcrgciicy d c p a r t i n c n t arc t o givc higlr-dosc corticosteroids and get a CT/MR[. sirrgical dccornpr'ssion rruy 1)c I ~ I ) I I < ~ . Onct: iiitohatcd. aeutc coinprcssii)n in trauma) i s oficn diie to metastatic cancer h u t also may 111: due to a primary ncoplasrn o r snhdirral or iyidiiral o r h e m a t o m a (especially after lunrhar tap or cpidural/spiilal ailcstlitsia i n a paticsit w i h a bleeding disorder or on anticoagiilatioo). Get standard trainria x-rays (ct?vical spine. I n uther words. Rarbiturate coins aird dcconrpressivc craiiiomny (bclrr lioles) are last. The first step is to piit the patient in rcvcrse Trendelenbiirg (lrcatl iip) a n d irrtuhate. If the decrease i n pressur bra1 cdcnis. l i ~ Iicmati. weakness. Increased intracranial pressure (intracranial Ilypvrtciision): n w i i i a l intrawmial p r S I S ininHg). Alternative1y. b o n e chip).ditch iiitwiircs. and hypotension). or open fracture with cerebrospinal fluid leak. Never d o a lnrnlsar tap o n aiiy paticrrl with signs o f increased iiitracranial p scan is donc first. m Cerebral perfusioii pressure eqnals blood pressiirc iniiius intracranial pressiirc. loiigcr yoii wait to t r ~ dtlrc I lie . and nlental s t a t u s clianges.nra o r si~t~driraI/e~~idural r ahsi . tliorax.rnpr(:ssii)ri and draiiiagv. t ~ l r a d traiiima also may caiise cerehral ci)ntusiori or slwar Neitlier may shuw n p o n a CT scan.its aweus). Skull fractures o f t l r c calvarium are sccn 1111 c?'scail (pr?fcrrcd) or x-ray. worse thc prognosis. Tlicn give radiotherapy t o inetastas(%froin a krrown primary that is radiosensitive.d by bilatrrally dilated a t i d Dxed piil)ils. d o not trcat hypertwsion iriitially in a paticnt witli iiicreased intracranial pressiire.iiirpingemelit oii brain pareiiclryma. bradycardia. h 1 Dolh may cause logic deficits. I~nriiserirideis also used hut less ?ffc(:tivc. pclvis) as well as acldiL tional spine x ~ ~ r a y s hased mi physical exam.1 Neurosurgery Basilar skull fracture has four classic signs: 1. the patient slrould hr Iiypervciitilatcd to rapidly lowcr tlie intracranial pressure. Cerehrospinal fluid oti:~rrhea/rIiiirorrlica: clear h i d from the ('ars or I I I I S ~ Important points: 1. I ~ J if nccded.int). Heiirotympamiiii: Idood behind tlrc cardruin 4. O t l w s y n i p t o m s include licadaclic. Raccoon eyes: periorbital ccchyrnosis 2. y o n caii p r o d to . positive nabinski's. scnsory loss). A n incrcasc is si1ggcstt. subluxation. nailsea arid vomiting. (sccii especially in . hyperteirsioii is the hody's way or tryiiig to illcrease wrehral perfiisioii. h i i k a l s o for the classic arid iinprtant Cushing's triad (increasing hlood prcssiirc. loss o fiiiotor fiiiicLioii. Othcrwisc. Spinal cord compression: salncute cornpressiou (vs. papilledema. Battle's sigii: p s t a i i r i c i i l a r 3. srirgcry is itidicated fbr dcci. This approach iiecrea iiit racranial blood vo1111iic h y iisiiig i. g?ni:rally as a dcpressed fracture. Paticrits prcseot with local s p i i i a l piii ( ~ s p i : ~ cially wirli bone riictastascs) a i d rirrrrologic d d k i t s helow tile Icsiorr (Irypcrrcllcxia.

in Meniiigocele is defined as rncniiiges outside (lie spiiial canal.. causing rnotor and sensory deficits. otherwise. scalp vein e i i g i ~ r g ~ " i i carid. Arnold-Chiari or Dandy-Walkcr syndrome). biilgirig fbntaiiellc. giving folate to potential mothers reduccs tbr incidencc of ~ i c u r atuhc deiicts. Tlrc iirost ~it includc congenital inalfi~rmations. paralysis of upward g a x . l Hydrocephalus: ill cliildrcri. il'possiblc. iiicrcased intracranial pressiire. myrloiiieiiigoccle. look for iiicrcasiirg liead circiimfercnce. usually i n the cervical or upper thoracic region. aiid treatment is siirgical ( c r e a h n of a sliunt) Neural tube defects: triariglrlar patch of hair over tlic lurnhar spine iiidicaiex spina hifida occuka. . More serious dcfccts arc obvioiis arid occur I I ~ O S ~ (:o~nnionly thc 1urnbi)sacral regioii. tui~riors. a surgical slruirt is created io d e compress the ventricles. l7ie cavitatioir in ilir cord graddually widens ti) iiivolve other tracts. Treat tlrc runderlying cause. a ineningiiis). as cerrtral iiw vous system tissiie plus rneningcs outside the spinal canal.Neurosurgery _ I 1 Syringomyelia: coiiral patliologic cavitation of tlie spinal cord. MlU is i l i e imaging study of clroice. Syringomyelia i s idiopathic but may follow trauma or coiigenital cranial base malforrnations (cg. Tlic classic prcscntaiiori i s a bilatcral Inss of p a i n and tciqmaiiire scirsatioii helow the Icsion irr the distribution i f a "cape" due t o irivolvciiient of' \Ire latcral spinotlialarnic tracts. r i d inflainnratio~r(hemorrhage. Most imporiantly.

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Nose.'I __ Ear. and rliroat Surgery - .

Otitis media: most cciisrnionly d i i e 10 Stre~i"Xiccospiecciinoniiii. hc rciriovcrd 10p c v e i i t prc:ssiirv -indrrcccl s t q i t ~ rl i r c n i s i s . Sjijgrcri's sy ndmnre. ( : o r n j ~ l ~ c a t i o r iiirci rrticl t y n i pail ic ~ i i ~ r i r l ~ r a ici rcf o r a t i u i i ( s p clisctiargc.'I'reat with Ircariiig aid or siirgcry Parotid swelling: tiic iriost ~ O I I I I ~ Xc~aI w : i s ~ n u r r i p s .?i.ctious myringitis (tympanic rr-ieIr~braiici i f ~ ~ i n r i r a i i o i is causcd h y Mycoplesrne sp. aParotid swirlling d s o may lie ii~iti.ook liir tcnderircss over affkcted siriiis. nicriiogitis. ( s rised LO wvnliiatc chrorric siirtisi~is s r i s p w t ' d c x ion oiitsidc the s i i i i i s (snggcstcd Iiy high fevcr arid cliills). l'alients have carache. srcroids niay reduce swelling. Otoscopy rcveals vesiclcs o i r t h e ty n ~ p a n i c ~ r c r i r h r a n e . fcver. Sinusitis: o f t m dire IO S. ' k I best trcatriiciii (or intmps . l l i c m o s t c o i i i m i i i i cause or scirsorineural hearing loss i n adrilrs). trcai with surgical rxcision. Treat otitis with arrtibiotics to avoid rhcsc coiirplicatioiis (aiiioxiciiliii.). 'Treat w i t l i t<ipical airtibioti<. Otic b o r ~ c s IICC~IIIC fixed loge1lic:r and inipcdc Ircaririg. a rcsuit or irrcornplnely r r s o l v d otitis) a n d can cai h c a r i i i g loss with rcsiilcant dcvclopinencal prohlerus (spcecli. tiire t o n s i l s . ~ Trcal as otitis incdia (with antibiotics). prcshyaciisis. c o g n i t i v e fiiricrions). (if the m 1rrfi. i i) S~relitncncciis prieumoniae.g c i i c r a t i ~ ) n ( spori 11s such as ccfiiroxhme or trirncttiopriiii~~sulfamethoxa-role) .s (i~eornycin. si:tIolitliiasis (inore c o i i i i i i o t ~iir i the subri~~airdil~~rilar glaii Note: After iiasal (iacti Iicinatorna. s r c ~ j i i d ~ . Maiiipirlation o f the auricle prodiicifs 110 paio. S. or viruscs. Work.~ ~ ~ tso-~c. arid Throat Suraerv 17'1 3. i r p i o 6 wccks for chniiiic cases) <?pcrativc iiitervcntiou for resistant cases (draiirage 1xiii!cdiirr. . asitiliiotics o r tyinpanostorr tuhrs. rnastoidiris ( f l II~LII~I~OI~ arid irrflarnrnacion ovcr m a s t o i d pr lrial iicrvcsVSI aiidV111. l b t i w t s p a m a y Iiavc E(ILIILSII~C!II~II~ discharge arid c i ~ i i d i r c t i v c licariiig h s . Rccurrc~n[ t i t i s iiiedia i s a cooiinm prdiatric clinical priihlcirr (as wcll as ~ir(i1ongcd o sccrc~. polymyxin R). tory otitis. a n d otlr mcocci o r staph ykicocci. Ilaeniophilus influeme. a i i d base of tlic loiigiIe as well as laryiigrrscopy. Iicadaclie.. PI. tironclioscopy. tlial the fkiintal siriuscs arc not wcll dcvckipcd until after rlrc age of' I0 years. wlriclr i n tist (whicli you s l r i m l d I)(: 10 rccogiiizc on x ~ r a y ) rirlc oiit a septal al>lc .. Man iprihliotr or tire aiiriclc ~xudiices i i n .my i s tlioirglii 10 Iiclp iii s o i i r c cast's by p r w e i i t i ~ r g hlockayc. c(!r i t i t i s rncdia ( p w t t i a i r e n l I x ~ r f b r a r i o i(if t y i i hticiits tiray gei ciiolestca~omas witli iiiargiiial perhratiims. and Moriixella CII-~ corthulis.illediripic eudoscopy with lie triple Iiiqisy Otitis externa (swimmer's ear): i i i o s t coninionly dire t u I'reri~lomonilsaerutliiii)sa. due to n c i q i l a s i i r (pleoimirpliic adciaima is I I I I O S ~ cori~rr~orr). Nose.-iipof wrknowii caircer iir tlrc neck iricliidcs rari~lorirtii(ipsy 0 1 the n a s ~ ~ p l r a r y rpala~r.Ear. erytlrernat~irrs arid bulging cyrnpaiiic mcnihrauc (light rcllcx a i d lairdmarks are d i f f i c u l t r atid votiiiiirig. arid csoplia~ gi)scopy (with biojisijcs ( i f any suspicioits i e s i o i r s ) .~ cities (~iciricillin/arrioxicilliri or erytiirornycin tiir 2 wceks. tosclcsoris: 11ie i i i o s t co11iiiion i m s e o f lirogressive corrdiictive hearing loss in adults (vs. 'TwatrncIri consists ol' prophylactic. arid pnriilctit nasal disclrarge (yellow o r grceri) d or X ray slrows i ~ p c i f i c a t i o n ' t h c sitiiis. tliv skin r i f tlic: a u d i t w y canal is ( tliernatr~us n d swollcrr. jineenmriniae. Arlcri~jidcctr.. influenme.eat with a i r t i h i . r i d thc coinplica~ion i n f e r t i l i t y i s ~~ri"mtioii of tliroiiglr i i ~ i r r ~ ~ t i i i ~ . s i n u s d > l i t c r a ~ i o i i ) lknicrrrber .

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epididymitis .Trsticiilar torsion vs.

and 2.rtility or pain (in wliicli case it i s siirgically treated) Nephrolithiasis: flank p a i n . 7 % arc oric acid S I O I I C S (look l o r history of gont o r Icukcinia).iclc(s) sonie~vlrere r ~ ~ ~ i ~ ~ ~ hetwwu thc rerial arm and the scrotuin. I'atinits undergoing dialy. d o a suprapiibic tap. first stcp is to empty the hladdcr. It gcnrrally catiscs no symptoms a n d does n o t rcqiiire trcauncrit.I~JIIS a i d dialictcs . or fear. vation.Tlre more prcnratrirr::the iisfarit. iio urination ilr past 2 4 l~(inrs). h i k fcir signs rir' iiretliral injury (Irigii~~riditig. is psychogenic. (:~yprorcliidisrni s a major risk facliir fbr tcsticular cancer ( 4 O b M d iricrcascd risk). palpatioil i i fiill h1addt. I . . I caiiccr risk). Iiiipopotence: n i o s t c o n r n i o s ~ caii ly In patients with trauma. IF any 0 1 (11 t h r d iiijury. syinjmhetics niediate cjaculatiiin.o t i m docs no^ alter rular ~:aiiccl:.ouk a i i o r i r i a l p a t t m n or iiocliiriial erections. wliicli ofttcri radiates t o the groin aud i s 1. siir#ical inlw on v c IOII (orclii(. Ireiiiatiirin. Iliabctcs nrclliLus rrray l i e a vascular (iircrcascd atlicrosclerosis) o r nrrirogciric caiist: <ifirnpotcricc. a n d stone on atidominal x ~ ~ r a y (90% of stoiics radiopaque) 2. A f c r I yaav.nd h e i r own within tlrr first year.E.Note: With acute i i r i n a r y retciitioir (pain. AIIX. lkrnernher point arid slioiit: parasymparbetics iiiciliatc crcction. a n d lxinging t l i c t i i i t o tlle s c i . IJrcthraI i t i j r i r y i s a contraindica gotrcn a rc[rogradc I tion to a I'oley catheter.?4 an: cystiiic stoiics (tliiiili d cystimiri. t11(! ' Icfi o v a t r Renal srarrsplani: a r i o j i t i o t i {or patients with end . lit. sis also xi: ~ : o r r ~ ~ ~ r o ~ i l y TJic I i i s t o r y ofieri giws yoti a clue i l the c a m e ~ifinspott~nce iii~rpoiimt. Iiy vascirlar prohlc Medicalions arc' also a com1noir culprit (especially aiitiIiyl. A varicocele i s a dilatation (if thr panrpinifiirin vciious plcxus ("bag oi' worms. am1 stress.5'% are s~r:ivitr~/rnagricsi~rrn amrnoiriiirn -ptiospliatc stoiies (I hink of iulectiiin). 7 5 % iif stom's a i r calcium ( h i k kir h y p e c c a l c e n i i a arid Iiyperparatliyr(iidisiir. ii1rr( . ncc<lr:d) ~ ~ ~ y p l ~arrcst of desccntdoi'i the tcst." i i s w ally on t i l e lcfi). does not transilluiriiriatc. S. the grcatcr the likelilrood of cryljt[irclii(lisin. ilisoppeiirs in the supine position.ci-ti:nsivcs and aiitidepr ants).us vagirialis (rciuciiiWfdrocele vs. iyiriosis) IiefilIe tryiiig t o 1x1 lilooii at tlic iiretliral incatus. Pdore: Tlii: riglit testiorilav/ovariaii vciri drains into the iiifi:rior vtmi cava.Tlre Irighcr tlir tcsticlc is f b n i r d (ttrc hrtlicr away frmi IC risk ofdevclopirig tesricirlar cariccr and the Iowcr tliii Iilwliliii~~d retaining fertility. Many ar(I tcstcs cveutiially ~lcsct.tive i o i i s or o111t-r lik tlirI:!atviiing ronditioiis (?. a i d may hc a cause of malc infi. ballottatik prostate. varicocele: hydrocelc repr bcr e111bryology?) and traiisillruninatcs.and 01). J~.. anxiety.stage rciial rlism r ~ n l r s sl i c y l i ~ v a(. inaligriaiicy)..Tlicii address the undcrlyirig cause. do not try t i l pass a l M v y catlictcr until yorr havr:: ca[lirter.r) . history i' of J W H . o r (IIICII surgery (if ~ l i c n i s u l v r sSf not. If you canirot pass the L rc!giilar I'oley catlwter.r on atxk)iiiinal exam. do lithotripsy. s n r a l l bowel bypass also incrcases oxalate absorption arid tlrus calcium storic hrmati(in).pcxy) is w a r r a i i ( d to a t t e n i p t to prrscrvc fertility as wcll as facilitate fiiturc ~ testicidar cxanrs ( h e i a u s c rii' iircrca. selcuive dysfiiirctimr (a patient fbr who has iioriiid erections whrn masturtntiiig bnt not with h i s wik). vvlicreas ilar vciri ilrairrs irrto tlic left rcrial vciii. 'lieat stoii('s with lots of hydniiion. i i m x i t i c s fix Iniii. Most sloiii's pass hy >py with htoii~:! rt:trivval. Signs a r i d synrptoiirs iirclridr scv colicky in riatiire.

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Eineigency Medicine
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A patient i s n o t crxisidcred dcad until "warm and dead"; in other words, d o I I I I ~ givc LIPre suscitation efforts until the patient has heen warmed

Hyperthermia: may he duc to Iimc srrokr. h o k for history of h a cxposiirc and high r e n i p . . awrc (> 104" F).Treat wit11 iriiiuediate cwliiig (wct hlankcts, ice, cold watrr).Tlic iiiinrcdiatc
tlircats to life are c~~nvirlsiorrs (wliicli sliouki be treatcd with ~liucpa~rr)i d cardiovascular COIL a lapse. Rule our i nft:ctioii and other classic culprits:
'1. M a l i g n a n t liy~~~rthcrirria:k for snc.ciiiylclir~lii~c h a l o ~ h m c h i or exposure. ' h a t with

clantrolene.

2. Neiiroleptic inaligiiaiu syndroine: causcd hy taking a i l antipsyclmtic. First. slop the nlcd-~
icatiori. Second, trcat with srrpport (especially lors d 1 V fluids to preveut renal s h u t d o w n froin r.l~ahdoii~yolysis) daiitrolciir:. and
3. l k o g fi:vcr: idimyircratic rcactioii to a rrictlicatir,rl h a t iisirally was starttd within tlie past

~ e a ~ ~ d r ~ ~ licsll jwatvr: is worsc thau sea water', hccaiise fr I watcr, it'aspiratcd, call wn n~ siicli p t i c ~ i t s itihcy are oai~sr hypervrhiria. electrolyte d i s t i ~ r h a i ~ u o c o ~ ~ s c i o i ~ s monitor arterial hk~od and g i f t l r t y arc conscioiis. Patients wllo drown i n cold water often do I)etter than thosc who drown in warm warcr becausr ofdrcreascd ~irctaholic rgeeds. I k a r l i usnally rrsnlts from hypoxia and/or cardiac arrest.

Milestones: t l i c w arc a inilliiin d t h e i n , hat c.orrc("xtc. on tlw c l o t i i i i ~ ( i i ionrs.'Jlic~ SiiJIowing table givcs roitgli avcragc agcs wlieii iirilesiorrcs arc acliicved.

7. F1uorid.e: start sup~'1eaieiitariorrin first tcw ycars of lice if water is inadeqiiately Ilrioridated (rare) or if i h e paticnt i s fed cxclusively from a premixed, ready-.to~ formula eat (nonfhioridaud water i s tiscd in s u c h prodrrcls). Most clrildreri nccd no sirpplerneiitatioii.

8. Vitamin D: sonic aiitlro~-ities rccmimwid that all breast-fed infants s!rould rcccive still vitamin 11; iitost r ininend i t oiily fix liiglr-risk patieiits (inadequatc rnatcimal vitaiiii 11 I1 intake, little sunlight e x p s i i r c a n d / o r dark skin, cxclusively b r c a s t ~ ~ f e t l 1)eyond 6 i n o i i t l i s of agc). Start suppleiiicrrts hy 6 rriontbs. 1'omrula-fi:d irrfaiits (10 not rcqriire v i m min 1) supplcnwits. which t l ~ fr~ r ~ n ualrcady coiitaiiis. la

. Tuberculosis: screen fix tiihcrculosis iininerliately if it is suggested b y

Iliscrry or a m w ally at airy age if risk lactors are present (HIV, incarccratioit). If ilic only risk factor i s living in a high-risk area or iinniigrant parcnts, scrccn once at 4-~.h ycars rild and one(: ai I I"-l6 years old I f n o risk factors are pr

10. Urinalysis: ~niivcrsalscr tirig i s iiot reconiint:nilcd. I k ) , lwwcvcr. sc ease wlreri a hoy . 6 years old dcv(:lo])s a urinary tract i i i k c t i o l i or a i has rcpeated ilriiiary iraci inf i o i i s . Gct a voiding cystouretlrrograiii arrd a rciial ultraS<Jlllld.

11. Immunizations: when to give irornial imnronizations i s constantly beiiig updated, s o tlie administration schedule for coirt~no~i vaccines is tisually given. Spe(:ial patient p o p with sickle cell disease splt!llcctorlly) and latioris (pnriiruo(x,ccaI vaccine fix patic~its vaccine coiitraiiidicatior~s (110 measles, rrrumps, aud ru bclla ( ~influ r .a vacciiic for pggallergic patients, i i o live vacciues t o prcynani woiiieii or i m ~ r t o n o c o r ~ i ~ i r ~ ~patients) i~iised arr high yield.

12 Other: give sexually active adolescents an annual l'ap smear arid screcii for sexually trairsinitted &ea. .Tlic first dcntal referral should hc made a r o o d 2--3 years old.

Tanner stages: Stage 1 is prcadolescent. stage 5 is adult. Increasing stages are assigned fi)r testicular and penile growth in males arid breast growth in females; pubic hair developineiit i s used fOr both sexcs. Avcragc age of piiberty (whcn the patielit first shows cliaiiges from stage 1 status) is I 1 ..S years in males (the first cv(:iit usirally is tcsticular c:nlargcsner~t) a n d 10.5 years in fciiiales (the first cveiit usrially is breast d~:vclopnier~i). Delayed puberty: n o t iciilar cnlargcntcnt in riralcs Ity agc 14, 110 Ireast ~icveloprncrtt or pubic hair i i r feniales by age 13.'l'hc i i s u a l cause i s constitutional delay. I'arents ofien ham: J. similar history JII this ~iorinal variairt. die g r o w h ciirve lags belrind otlicrs of saim: age bar is consistcirt. 1~)t:layed pthcrty i s rare1y due to primary testicular failurc (Klinefeltcr's syndrome, cryptorcliidisrii. history of chemotherapy, gonadal dysgeuesis) or ovarian failure (Twncr's syndrornc, gonadal dysgcimis) . Other rare caiiscs include hyy)oliralairiic/pituitary (icfkcts, such as
Kalhnanii's syndrome o r t i i r i ~ x .

Precocious puberty: mually idiopathic, hut may lx due to McC~mc--Rlhriglri syndrome (in fe-~ rrralcs) , ovariair ti~niors(grairdosa, tlrcca cell, o r g~~~radoblastorria) ; testicular tumors (I.eydig i c.vll), ceritral nc:rvous systciri disease or traiuna, admral neq>lasirr, or corrgcnital adrcrial !iyper.~ plasia (irides oiily; tisually 7 1 -011 deliciency). Most patierits witli air mco prccocioiis pir1)crty are given lorrg~~actiiiy, gorradotsopin. releasing I i o r r n o n ~ ~ agoriists t o s u p press progression of piibcrcy arid h i s prcvmt preinatirrr: cpipliyseal closrirt:.
Cavernous ~ ~ ~first rioticed ~ firw days aftcr birth. I.csi(itis i i i r r c~ w io ~ n a r ~ ~ ~ a ~ ~ a r i d gradtially resolve witlriri first 7. years. Thc I)(:st treatniciii is t o (ki iiotlri~iy,tmt ol)servty aiid follow rip.

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1 I _ Phaniiacoloyy Relative contraindicationsto oral contraceptives:depression. hyperteirsion. iron d 3 c i e n c y ancnria. Iiossibly hecause of the confiiundiiig lactor i i t incrcascd s c x ~ ~relaal shonld have at least t i o m and nuintier d'partncrs. i r a contraceptives should h e s t ( i p p i I nlonth btdbrc electivc siirgery arid n o t rcstartcd u i ~ t iIl niontb afier surgery 2. oligomcnorrhca. fxr:qit of t i r c ~ s cauccr durs not i in I o i i g r c r i i ~i i s c r s (coritrovcrsial. unlikely to hc askrd on hoards).ritractiptiv. benigrl liver adeiioirras. fi~nctioiialovarian cysts (often prcscc'ihed lor the previous four dfects). henign breast discme. dysmeriorrliea. weight gain. aiiniial Pap smears. uridiagi>osed amenorrhea.ftlir risks of tli r o r n h o e i ~ ~ h ~ i l os n l~ . ectopic pregnancy.rvica1 iiroplasia may I x iiicrcascd. nonctht:l . ' l l i t > risk Other benefits of oral contraceptives: 50% reduction in ovariaii con decrease ill thc iucidcrice of nienorrlragia. Side effects of oral contraceptives:glucose int~lcrat~cc (clieck fiw diabetes m e l l i t u s ailrlually in paticots at liigll risk).:s. a i d drug iiiteractions (drugs sriclr as rifarnpi II arid antiepilcptics may imlnre ~nerabolismo f oral cx~ntract~ptivcs reduce their t4ixtiveilt:ssj and Important points: 1. gallhladder disease. and ual salpi ngitis. vomiting. oral coiltraccptivr 11. ~ i r ~ m e r i s ~ ( rtensiorl. arid heavy cigarcttr srnoking midcr agv 3 5 . Bricaiise r. Irradachc. II I O bc iiicrcascd with rird ci. rnigrairrc hcadaches (may trig^ ger attacks). cdrnra (bloating). . i i i e l d s r i i a ("the mask of prrgnmcy"). depression. Ct. nausea. clrolelitliiasis.

'Trcac Note: New N ~ ~ ~ ~ ~ / p r o s t a g ~ d l r d i l l I!. hleeding. peptic ulcer disease. or 2. Generally. use of aspirin (hr priurary prcveiition of isiyocartlial infarction or stroke in a p a t i e n t with 110 dcfinite history oFrny(icardial i i r t k ~ i o ~ i . espccially in patielits who takc l h c i i r cliroiiically a n d Iiav? prwxisting renal discast'. Importarit points: 1. to depletion or gl~itatlii01rc~. GI tileeding. ~'lreriyll)iitazone can canse Eital aplastic arrmiia aiid agraiiiilocytosis and sli~iiild hc not u s e d (:hronically.l l reducitig the risk ~Eiiryocardial i iiifarclioii iii patients who liavc had a previous inyocardial iiiErrctiim a1111 paticncs with stable or uristahlc angina wlio lnv? not h a d a iny(icardial iiifarctioii. or bleeding disorder. trairsicnt ischmiic altack. Stqi aspirin 1 week hellire surgcry. Acctauiinoplicii ~ a i i s e s liver toxicity iii lrigh doscs diic will1 acctylcysteine. 9. Many also r iinrciid daily aspiriii fhr patielits with known coronary arcery diseasc. angina. . or coronary artery disease is not aiipr(ipriate. NSAIlls also may cause renal dainagc (interstitial iicpliritis a n d papillary nccriisis). Stridics Iiavc noc slrown a clear l x m f i t . cornhinatioiis lrelp to prcvent (. Give aspirin to any pa!iciit in the emergency drpxtiiwsit w i t h uiistd4e angiria. the risks of aspirin proplrylaxis may outwcigli the heiicfils. i-nyocardial iirfarc~ioii.Pharmacoloav I 7. other NSAIlls on tht' day h<~fi)re surgery. and ulcers. Other NSAILjs also cat GI ~ ~ p s c t . 8.I damage Low-dose aspirin has been prowd to he or bwiefit in rctlucing tlic risk of stroke in patielits with a transici1t isclicinic attack o r prcvious stnikt~. poorly coiitrolled I1 ypertcnsion. Always consider GI bleeding and iilcer in any patient laking aspirin or NSAID. 10. If h e I)at'ient has a history o f livcr or kidney disease. and tlirre may be a n increased risk ofheiiiorrlragic strokc and/or sudden death.

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'192 Radiology - .

t l i e L think or diabetes irisipidrrs or sickle ccll ilisrasc/irait. t i l t s i i tlic rapid plasim r c a g i i r or Viwerral Iliscase Rcsearvli I. a d o m a y cause hyperka1t:irria b y the samc rncchanisrn. ga~rima-. lipid. 14. AI kalosis may caiise hypokalemia and s p l i t m i i s of I~ypocalcciriia(peri(ira1 nuiiitincss. Waic:li S i x liypopliospliatcr~ria (iialictic k e t o a c i d o s i s .al)oratory ti'st ii (Lr syphilis may I. I-Iyperkalernia iiiay he c a w e d by a Iit"lyzec1 lilood sarrrplc or rliabd(iiriyo1ysis (due liigli intraci4ular potassiiiin (:iiii(:(~Jitrati~)rr) to 2. or prqriaiicy If tlic clcvatioir is diic ti) hiliary di sc.Important points: 1. 5. or hyperlipidciiria.. Bloiid iiri'a iritrogeii:[rcatiriiiic n t i u > 1 5 i i s u a l l y i i i i p l i c s dcliydratiiin. tetany) &e LO cellular shift. Hypiinat rciriia rriay he causcd by hyperglycenria.~N7')also slrould hc elw~tcrl. these foriris ot scconilary liyponatrciiiia will correct with correction of ttic g l u c o s e . ho~ir discasc. drugs (IHMGCoA reductase inlii1iiti)rs) or I J u r i i s ( C K ~ ~ Mi B inorc spccific for cardiac s rnuscle) . 'T'lie rrytlirocytr va~cviIiy pregiiaii iilatiolr ratc (IiSK) is a w o r t l i l test i n prqriaiicy. . rupiured tuhal pregnancy). 111 patierris witli isiistlienuria aitd I r y ~ ~ ~ i s t l ~ ' ~ ~ ~ ~ ~ ~ r i a ~ o coricimtraic urirrci~iahility ~ . brit elwation of both in the sairic patient usually is due to pancreatitis. 7. AI kaliiie phosphatase can be atcd hy biliary d as?. 83. or protcin Icvels. in 1%. ~-1yp"thyroidisiir causc elevated c l i o l c s k d can 5.. 3. renal failurc. Ilypokalcinia and/or liypiical the hypokalemia until yon co ia rrraji Ile dile to I r y ~ i ~ ~ ~ i i ~ ~ i i c s ie t canriot correct Yi u riia. liy~~crprotci~reinia. GI tract. I(SR i s V I C ~ : A high iroriiiril lrliiiid iirca iiitrog':n aiinine ratiii rnay i i i ~ d r i 1 . l!levatcd creatiiie kinase (CK) m a y he d u e t i l iriiisclc injury (striated or myocardial).glrrtarnyltrarispeptidase (GC?) arid/or 5 TIW c:leiitidase (5. Correcting liyponatrcmia aggr ivcly (cslxcially wit h hypcrtoiiic saline [ 3% cause hrainstcin danragc (cciitral poii! iire ~nyclirrolysis) I) may 4. 6.)? drrc to sy iriic I i i p n s crytlivinalo. High levels of amylase arid lipase may ha duc to s o w c i s otlier tliaii tlic pancreas (salivary glands.

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arrtlior~tics e r d t o n know. Child alxisc is susprctcd. . 2. o r li~:aItli cart. arid the olrernutive treatmenis.Tlnc patient is tlren dlowcd to rnake liis or 1icr own choice. I f the patient is an airplane pilot a r i d a p a r a n o i d . 11 the patient is b h d or has ~. 6. birt avoid active eiithaiiasia. 1. thc prnposeil tieutmeiil (it~:scriptioitof clic procediirc a m i wlix t l ~ c paticiit will expericncc). Do not h r c c a d u l t Jt!l~i)vaIi's witiiess patimts t o a pt blood products. . ( i c n t s arc m a d e t o sign arc iieitlier required iinr sufficierit f b r irdorrned COLISCII~:ihey arc.~1 colnpetcwt ptxiple dic i f tlicy want to do so. yoit have t o tcll the irntciidc~i or victim.c. Never fbrce treatincnts 011 adults o f sound iniiid.urcs. r e f h e to answer.Iniportant points: 1.Xiii iriiist rrpurt to autlioritics.o r botir. 4.~ 7. s'l'he c o u r t s inandate you to rcll. mTbc patient is a danger t o otliers.Tlie dvcrr~ncrrts I 011 hospital wards illat pa. Break co~lfidentiality oiily in rlie following situations: mThr patient asks you t o do so. YOIIliavc a duty to protect litt:. used lor inedicolcgal piir~r~isec" lawsuit pArainoia) (i. tlic risk/benelits OS tlie trratiiiciit. tlit: aotli<iritics. ue asks about a 5. halludiiaiiiig scliizoplircnic. a guar'diari (surrogate d( power OS actixirey) s h o u l d hi: appoiritcd Iiy thc coiirt. If yon caiiiiot. L>o not tell anyone hinv your patient i s doing rinlcss JIC (11' she is d care and needs to know or is an autlmri (1 family ~ncnrher. 1 f a child has a lili!-thrcacrning condition and ttic p a r e i i t s rcfuse a siinlilc. Ilespcct wislies for passive eutlranasia. (If' the ~ia~iciit that 11c or slie is goirig to kill S O I I I ~ O I I C says or liiin~ hersclf. let illem deal with it.tlic yrogiinsis (the natural i:iiiirse of thc axidition witlioiit trcatinent). curative trear~ merit (antibiotics lor meningitis).. friend wlio happens to 1 your patient. But do 1iot give the lrcatincnt uirtil y o u talk IO die courts if y(ii1 can avoid i t . your srcoiid option is to gel a court order to give the treatment. the proper Ic:t authorities know so that tlicy call take away the paiicnt's licciisc to drive.) 'Tlrc paticnt has a leportahle diseasc. 3. Wlicri tlie paticlit is incornpcteint. Inforiiied coirscri~involves giving 11ic p a t i r ~ilifbrriration about tlic diagnosis ( h i s or ller ~t conditim and what i t ~ i i c a i i s ) . .ioo niakrr. r a c( I c . first try t u persuade the parents to changc their mind.

9. 11 a patient caimot ~ : ~ ~ i n r n u i ~ i give any required eincrgerrcy care irnlcss you know cate. b i r t ii)r hoards let such rniiiors make their inatose and iio surrogate decision iiiaker has Been appiiited. Just hccausc the 15. 14.ierits under 18 do not rcquirc: parental coiiscnt io thc fbllowiiig sitnations: t h e y are ernancipaled (aiarricd. 15. Patients can he hospitalinxl against their will in psychiatry (il they arc a danger to sclf‘or otlicrs) fbr a limited tirnc. talk to your hospital cthics coinmittee. or are prqnaiit. I)r) not bide a diagnosis froi~r patients (including pediatric patients) if thcy wail1 to know the diagnosis-~-evenif the family asks you d o so. Restraints can he u s e d o i 1 an iticompcte needcd. coni^ . don’t t d l thrrn. psychotic) if 12. If tlrcy don’t want to klmw the diagnosis. evcn if the spoiisc. If thcy have a sextially transmitted disease. livirig on their pareiits o f children.” ion should not he respcctcd ~’atieiits who are suicidal iiray rcrirse all treatment. Depression always should he evaluated as a rcasrin lor the patient’s “i~~c(~mpt. 16. t l ~ i e wislics of the faiuily generally sliould he rcspeckd. Sonic states have exceptions tu 11 1 ules. ITIa pediatric crnergcricy when parents are not available. this d until tlie depression is treated 10. do not piit thc paticnt o n a ventilator.1 Fthics 8. 110 not lie to any patient liecause the family asks you to do so. hut their list! slioiild tie hrief a n d m )r violent paticnt (deliriiius. If’they want drug trcatrneiit or counseling. After 1-3 days. son. sense. want contraceptiiin.tence. or daughter snakes the request. Withdrawing and witlih~ildingcare arc no difrcrein in a legal patient is oil a respirator does not i i i e a i i that you catiiicit stop it. IJsc courts as a last resort. 17. 1. O p i o i d s arc inonly used. treat t h e l d e n t as you sce fit. In terminally ill patients.Tlie flip side also appks: do i i o l fiircc patients to r matioil against h e i r will. i f in a living will the patient says that a ventilator should not he used if tic or she i s nnalile to tireatlie iridcpendcntly. I’at. patients iisiially get a hearing to dclcrmiiie whether they have to remain in custody. that tlie paticnt docs not want it. serving in the arrricd Ibrces) ow11 arid fjiiaiicially i i ~ d e p e t l c l t ~ . If tlierc is a family disagreement or ultcrior motives are evident. This practice is lidscd on the principle o f heriefrcciicc (a principle of‘doing good fbr t l i c patient and avoidiilg harm) 11. give cnouglr medication to relieve pain.iving wills and do-mit-~resnscitate orders slioiild he respected and fbllowrd if donc corrcctly 1:or example.

thalassemia) B Malaria m i a . elrirtk of l$isicin-~Barr vi llairy ccll Icukeiitia m I k i l i l e txidics m .llieaslri ccll e Rcrd--Steriiberg cell (I Iodgkirr’s lyinpltiima) (toxic lyrrrpliocytcs. m 01 llciriz I)odics/”hitc cells” (C6PD deficiency) niriatcd intravascular coagulation. t h i s i s not always the cast:. cliroiiic lyiirpliocytic Icukemia %I pd Aiier rods (acutc myeloid leitkcrrria) I Clirimic myrlocytic lerikeiiiia Acarithixytcs (abetalipoprolcincmia) m Tbardrop cclls (myelofibrosis.Alilroiigli soiire qocseiiins witti photos cart lic iigwcd out withoui Irxiking a i tlir phoco. m a i i e i i i i a (inacrocytic. severe 1ivc:r disease) a Splierocyto ‘Targee cells (cliala. You should be ahk: to r jgnire t h e ciiiitjcs li d below Tlic Color Aelns tittll Texc of Clinical Medicitie by h r b c s and Jackson i s rcai sourcc. For i d 1 Blood smears: m Howd-Jolly bodies (asplenia/splmic bl dysfunction) f3asophilic stippling (Icad poisoiiing. tryl”’s[’gniciitr:d ncucmphils) Sicklc ccI1 diseasc Kcticulocytw c9 Aplastic ancniia (“dry” hoiie iriarrow tap) m ClicdiaB-. thromhotic tltrornliocySclris~ocyues/liehnec (:ells (d topcnic purpura. microangiopatliic licmolysis) Miiliipk: niyeloma Acritc lyinplr~~blasiic lcukeniia. fix txiartis. myelodysplasia) m Iron deficiency anemia Siderolilastic aiicrriia m I:rilatc/R.

rrigeini t ~ aarid opl1tllaltnic: involvr:nlcrit) l ileriocb~Scliiinleii piirpiira (rash) t s .~ . sliinglcs.ymc diseasc (rrytherna chronicunr migraiis) n Tirira q i i t i s I Scal. septicemia (sevcrc purpura) I.ics h i r i a s i s (skiii lindirigs a n d n a i l pitiing) m Clieilitis/storriaiitis m ‘Thxic shock ~d (tllirik of 13 vitarnitr dcficicncics) syiidroiiic:. a iiiarlicr Ibr l i y ~ i ~ ~ r c l i t i l r s t e r ~ i l ~ i i r i a ) m Roth s j x i t s BI (think of ciidomrrlitis) Herpes simplrx keratitis (dendritic iilccr sccn with hircscein. avoid stcroids) m Cawacts (had enough to iiotice with the nakcd cyc) Ortiital ~:~:llirlitis Uermatology/skin findings: Pityriasis rosea 3 Neisseria sp. I~lerpcs arid 11) (I Varicella mstt:r virus (cliir.rnic (targei Icsiorr) raslt (Iiiptis) ~1 Malar s 1felii)t.kel~pox.ropcrash (drrri~ntoiiiyositis) m m Oral hairy lculqilakia ( c a n s d hy lipstein-lhrr virns. scalded skin syndromc ~‘ihdomiiials v i a e (Cirshi iig’s syiidrime) ~!rythcriiairiargiiiatiiin (rlieurnatic fiwr) m Jancway and Osler lesions (errdocarditis) a Acantliosis m a I nigricarrs (marker for visceral malignaocy) oiidary sypliilis rash) Sypliilis (chancrc. Basal cell ~iriccr . c~mdyloma lata.~ Iirytlimia rnitltifi.1 Photos: The Glossy Book 0phIi:halmology: Kayser-Fleisclrcr ring (Wilson’s diseasc) m Bacterial cotrjunctivitis (especially in Ileotiatw) m Claucotna B (closcd~~angle attack or acute) Graves’ disease (ex[it’lrtlialrnos) m Diabetic t i i n d i i s IIyperteiisive fuiidiis $I Ceiitral retinal artery occlrrsioii (tirndus) Central rctinal veirr occlusii~n(Ibndus) Papilledcriia m Kc~iiiol)last[inia (wliitc rcllcx instead of rcd) Xant1ii:lasiira ( h n e a l arctis (iii patieiits < 5 0 .

infections [the classic cxaniple i s Coccidioides immi~is tuberculosis~].w i n e stain oii m e side of face) p Cavernous Iiernmgiornas (in clrildren.] a i t patches (nciiroiihn. ti1 Artcrial iiistiflicicircy (skin chaiigcs) 1)iahetic loot ulcers (siiiiilar in appearancc to arterial insufficiency u l V i t i ligo (associatcd with pcrnicioris anemia and hypotliyroidisin) B? Inipetigo Kaynaud's plienorncnon (fhges autoamputation: orien seen in scleroderma) RI Tmnporal arteritis (tortuoiis-1i)okiiig teinporal artery) o f t h c fingers )acviiIii (tritieroirs sclerosis) s (Iluthiirg Acii(s IC ~ ~ ~ i r d y l o n i a aciirniiiata a Mollmcum c o n ~ a g i o s u i i i Wilot's spots ( v i t a m i n A deficiency) C a f h i i .T ~ u " sign Erytlierna irriectiosruo (slapped cheek rash witli fever rcs~~lntion belorc rash appcars) just 23 Sturge-Webcr syndrome (he~nangimna. fiiirgi) 83 N o i i c w x t i n g gmniiloinas (sarcoidosis) Goodpastrrn:*s disease (linear irniniiliofl uorcsccncc in kidiicy) Gom (iicedlc~sliapccl crystals frorn a j o i n t with no hirtsfringcncc) .A l b r i g l i t syiidrtinie w i t h n i e i i l a l retarda~iori) Varicose veins Ciillm's sign C r e y . i n o s t l c s i o ~ i s rcsolvc on tbrir own) s Hirsutisiri (know conditions assticiated with it) m Rocky BI Moulrtain spotted fbver rash Pyoderma gaiigreiii)suni (I liink of iiiflanrmatory howcl disease) Erytlicirra n o d o s i r i n (think or inf~aiirniaIory bowd disease.Photos: the Glossy Book Sc]uanioris cell cancer Melanoma 1 Stasis (lcrrnatitis/v~iions irisirfficiency (skin cliangcs. g r a m positivc := blue) plus diisteriiig teiidcucics Cascating graririlorrias (trrherculosis. M c C u l i c .or sarcvidosis) or Pretibial r n y x e d a i i a (Graves' disease) Nenri~libroinatosis (skill) Kcloids (risually in hlacks) LI Allergic (ontact dermatitis I'iirca c o r p r i s aud tirica cruris Grain s t a i n (grain ircgative : rcd. o r t .malosis in patirnts with n o r m a l IQ.

Photos: Tho Flossy Book -~ - .

cubitus valgus) Horntxr's syndromc (irnilaterd ptosis and miosis and history uf beririanliydr~~sis~ Bcll's palsy (facial asymmetry) Cushing's syndroine (facies.-stagc facies) oc Spina hi fida (gross appearaiice. i r h a r deviation. scverc diseasc) m Ti. rarcly diplitlieria i n uriir~~m~~iiized paticut) Acute pharyngitis (viral or strcprocwcal) ( ynccoinastia . in sickle cell disease.nosyrrtwitis a 1~Iypertrophy of . inciiin yomy~~llocelc.Photos: the Glossy Book Scvere carotid artery stenosis on angii. ~ . simian crcase) a 'Turner's syndronle (I)orly Ilabitus. cnlta/patcli of hair) I Strawherry tongiiv (scarlet fiver and Kawasaki's disease) Acute tonsillitis (Streptococcus s p o r Epstein.grani m Shoulder m 201 separation on x. rheumatoid uodules) Ostcoartliritis (Heherdeii's and Boilchard's nodes) Gout (pclagra. (norinal finding in pubertal nialcs) (think of gonorrhea if the paticrit is srx~iallyactive) tlie Ireart (gross specinieii. wdhed neck. circeplialoccle. meniogoccleocele. boi~tonnil.ray Lytic lesions of bone on x-ray (think o f malignancy) Other photos: Rhcumatoid artliritis (swar~-ncckdrformity. widely spaced nipples.k tbr 2 L -1rydroxylase (picture deficiency) Tanner stages (male and Ii") Congeiiital syphilis (Uotciiinson's tectlr. I%arrvirus. saddle nose defbrmity) Osteomyeli tis extending to the skin (think of Stophylacoccus or Solmoncllo sp.) Sckrodcrma (late. tbrlrsll) m Goiiorrhea (yellowish discharge) a Erb's palsy (waiter's tip) Polycystic kidneys (gross appearance) BI Fetal alcohol syndrome (facies) Decubitus ulcers (hest prevention is frcqimit tirrniny ol'patient) Pse t ~ d o l r e r m a p l ~ r o t i ~ ~ s ~ n o f amhigiioiis genitalia.redefortnity. lor. tophi) Dactylitis (sickle cell disease) I h w n syndrome (facies. usually autosomal dorninant) Candida1 infection (vaginal. striae) Graves' disease (exophthalmos) m Acromegaly (facies) Peutz-Jeghers syndrome (freckling pattern on face) Achondroplasia (ovwall appearance.

short~~terin. long-term variability. a n d late and iirccl cratioiis) . early.scwre disease) m Kdryotypc showiiig Ihwir (misomy 1 I ) . or KlincfelWr's (XXY) syndrome k t a l hrart strips (noruial. Turner's (XO). variabl(:.2 Photos The Glossy Book m I)ilated cardioinyopatliy (gross spc(:imcn.

a i d right tipper quadrant pain in patients with cholangitis. Corrrvoisicr’s sign: a paillless. oil thc lefi loww quadrant prdiices pain at McJhirncy’s poiiii iii pa 3 . bradycardia. Cushirrg’s reflex: hypertrnsion. a r i d liypot<msiorii n cardiac t a m pmiadc. and irregular respiratiorrs with very liigli intrac:ranial pressiire.Bahinski’s sign: stroking tlic h o t yields extrnsion of tlie big patirrits with tipper motor i i c i i r o i i discasc. Charcot. Cullen’s sign: blrrisli discoloration of periuinhilical area due t o retropcritoncal Iiernorrliage (paiicreatitis). Leriche’s syndrome: claudication and atrophy or the buttocks with impotence (seen with aor ioilidc occlusivc disease). Kehr’s sign: p a i n in the left slioulder with a ruptured splccn. Chvostek’s sign: tapping o i l tlic facial ticrve elicits tctaiiy iii Iiypocalccmia. Brudzinski’s sign: pain 011 iicck flexion with rneniiigcal irritatimi.riad j tigiilar veiii distention. rrolani‘s &@test: a palpalhle or audible click with abdoction o f an iiilaiit’s flcxcd liip lliraiis coiig(:iiital Iiip dysplasia.’striad: fi-ver and cliills. Vrelin’s sign: elcvarioix of a paiii(ii1 tcsticltL reliwes pain in cpirlidymitis (vs. palpable gallhladdcr sliould make yoii tliink of pancreatic cancer. d o pcricardioceritesis. McBurney’ssign: teiidcmess at McBliriicy’s poiiit with appcndicilis ~ ~ 1 r ~ ~ yarrest oEiirspiraiion wlicn palpating riglit iipper qiradranr uiidcr tlrc rih cage in sign: 9 § paticiils with cliolecystitis. Grey-Turner sign: hluisli discoloratioii of flairk f r m i rctropvritoneal lirtnorrliagc (think of Honim’s sign: call paiu on rbrcrd dorsiflrxioii o f t h e fhot i n patieiitr wicli deep vein thrornlnsis. toe and fhiiiiirig of i~tliert o c s iri Beck’s t. torsion) Rovsing’s sign: jjirsliiirg ti e l i t s with appendicitis. muffled hcarc sounds. jaundice.

think of McCuneAlhright syiidrorne or tnberous sclerosis) Worst headache of patient’s lift:: subarachnoid hernorrhage a A. Symptoms.fihroinatosis (if mental retardation is present. Trousseau’s sign: pumping up a blood pressure cim‘ causes carpopedal spasm (tetariy) in hypocalccmia.ion rub: pericarditis K L I S S I ~ ~breathing: deep.n ~1 Ainhiguoos genitalia and Irypotension: 2. avoid steroids) fugax: temporary. Virchow’s triad stasis.1 . rapid hreatliing secii in ~nctaholic ~LI~ acidosis (think of diahetic ketoacidosis) Kayscr-Fleischerring: Wilson’s disease Ritot’s spots: vitamin A deficiency Dendritic corneal ulcers: herpes keratitis (seen best with iluoresceiu. painless. II g Frict. Word associations are not all 100% accurate. infection Meconium ileus: cystic fibrosis Rectal prolapsc: cystic fibrcisis I ~1 ha a Salty-tasting B bahy: cystic fibrosis Caf&au-lait spots: neur(. but they are usefd in emergencies.bdominal striae: Cusliiug’s syndrome (or possible pregnancy) Honey: infant boiulisin m m m k f t lower qiiadrarrt tcndcriiess/rehoond : divwticulitis Children who tortme animals: conduct disorder (may be antisocial as adults) Curraiit jelly stools in children: intnssoscepti~.forc biopsy co11firination to prevent blindness) Cherry -red spot on tlic macirla: Tay-Saclis disease (no heparosplem~megaly)or Nienrann-Pick disease (hepatos~ilenomegaly) Uronrc (skin) diabetes: hemochromatosis (look also for cardiac and liver dysfiiiicri(in) a m a Amaurosis m I ) Malar rash: lupus erythematosus Heliotrope rash: dermatomyositis Clue cells: Gnrdnerello sp.204 Signs. monocular hlindiiess seen in transicnt ischemic attack (watch out for temporal artcritis: if it is suspected.-Irydroxylase deficiency ~l Cat -like cry io clrildrcn: c:ri-dw chat syntlrorrie m > 10 Ib. and hypercoag~~lability (three hroad categories of risk factors for deep vein thrombosis). and Syndromes Tinel’s sign: tapping on tlic volar surface of the wrist elicits paresthesias in carpal tunucl syndrome. cndothclial damage. bahy: maternal diabetes Anaphylaxis from irnmunoglol~iilinthcrapy : IgA deficiency I’ostparturn fever iniresporrsive to hroadspeciru~nantibiotics: scpiic: p d v i c throin (give Iicparin fiir an easy cure a i r d retrospective diagnosis) h~iphlehitis m . start steroids be.

ow-grade ftwr in first 24 hours after surgery: atelectasis m Vietnam vcxeran: posttranniatic stress disorder Bilateral hilar adr:nopathy in a black patient: sarcoidosis Sudderi death in a young athlete: hypertrophic ohstructive cardiornyopatliy Practures or bruises in different stages of healing (children): child abuse Decreased breath srmids in a trauma patient: piieiiiuotliorax n Shopping sprecs: mania s Constant clcaring of throat (children): Tourettc’s syndrome Intermittent bursc o f swvaring :Totlrette’s syndrome Koilocytosis: burnan papillomavirns or cyiornegalovirus Rash afwr a q i c i l l i n or amoxicillill fix a sore tliroa~: I.pstcin-Barr virus infection Daytime sleepiness and occasioiial falling duwn (cataplcxy): narcolepsy II 8 .. $mptoffls. and Syndromes 205 I lricreascd A2 hemoglobin and anemia: tlialasscmia I-leavy young woman with papilledema and negative radiology: pseudoturnor cercbri = I.SlgnS.

.

AB or 0) ahdomirral circiiriifi'rcirce arigioteiisiii~ coilvcrting erizyine AC ACE ACE-I ACL ACTH ADW ADWD AF arrgi~~trnsin-coi7vcrtillg enzyrnc iuhihitor anterior crnciate liganieiii ad rciiocorticotropi(: hormone antidillretic hormonc . AIRCD. Abx antibiotics ARC. AHCDE abd ABG ABQ abdominal arterial hlood gas blood types (A. circulation.r~~encioii~~delicit hyperactivity disordrr amniotic fluid amniotic fluid index atria I fibrillation alpha-ictoproteiii AH afib AFP AIDS ALL ALT AMI.exposure (trauma protocol) abx. disal>ility. H. acqidred imniiiirodeficiency syndrome x u t c lymplwl>laslicleukcinia alaiiiiie arninotransferasc aiwe iriycloid Icrikeriiia air liiiiiclrar antihody ANA ANCA ~~~~A ANS AP antiircurropliil cytoplasmic antihody analysis of variaiice autoiioiiiic nervous system alitcroposlcrior adiilt respiratory d istrcss syndrornc ARDS .AAA Ab dxlominal aortic aiierirysrn aniibody airway. breatlling.

Abbreviations ARF ASA ASAP ASD AS0 acute renal failure acetylsalicylic acid (aspirin) as soon as possible atrial septal defect antistreptolysin 0 (in streptococcal infection) aspartate aminotransferase antithymocyte globuliir autosomal arteriovenous or atrioventricular arteriovmous malforrnation a1. 37" C) or complement (e. C114. CD8) carciuo~mljryoiiic anligcn ccnrigray . C4) culturr and seirsitivity Bx.. BE B BAL BM BMR BY BPD BPH BPM heats per iniiiute hiopliysical profile hilateral sdipingo-oophorect~)my bleeding time BPP BSO BT BUN hlood urea nitrogen biopsy centigrade (e.g..g.dominal x-ray AST ATG Aut AV AVM AXR AZT azidothymidine: (zidovitdiiie) beta diiriercaprol barium eiieina hone marrow basic metalmlic rate blood pressure biparictal diameter benign prostatic hyperplasia/ hypertrophy B. C l .g. bx C C&S c-section cesarean section c-spine Ca cervical spine calciu in CA cancer coronary artery disease complete hlood count cnbic centimeter coronary/carcliac care unit CAD CBC 1C ccu cn CEA CGY clristcr of ditFercntiatiort (c!.. C3.

Clostridium diff or C.. derm DES DI ~iictliylstill~estn~l diahctes iiisipidus rlisscniiriatcd intravascrrlar coqulation DIC diR difkrciitiai or difficiic (c.Abbreviations 20 CHD mronary lieart disease o r cougciiital hip dysplasia cheiriistry clieniotherapy congestive heart failurc creatine kinase chloride Chem cherxro CHI: CK C1 CEL cliroiiic lymphocytic lciikeriiia centimeter cm CMl.g. diff) digoxirr Jralangcal (joiiit) dialic~ic kctoacidmis Dig DIP DKA .atiiie pliospliokinase creatiiii ne clironic rem1 kilnre Cr CRF CRP CSF CST CT c-reactivc protein cerebrospiiial flirid contraclion s t r c s test compiitt'd tomography scan CV CVA CVP cardiovascrilar cercbrovascirlar accidciit (stroke) ccntral VCIIOIIS pressus? CVS CX cl~irioinic villus sairipliiig ciikiire CXK chest x ~ r a y dilation arid curettage didcoxyinosinc (HIV medication) drmntdogy DBrC DUI Derm. CMV chronic myelocytic (or c)tt(iiii(~gal(~virii~ cranial iicrvc ceiitral iwrvoiis systcin I I ~ ~ ~ ~ ~ ~ C I I O L I ~ ) leiikcrnia CN CNS 60 carhon m~i11oxidc cardiac output or carbon dimide COPD clrroiiic ohstructive pulinonary disease CPD CPK ~:cplralopcluic disproportion .

dl DM DMSA deciliter diabetes mellitus 2. FFP iron free erytlirocyte protoporplryri~~ forced expiratory volwric fbrccd expiratory volnsrrr in I second fresh frozcii plasma FSH follicle^ sliiirulatirlg Irorrilonr . DUB dyslirnctional urt:ririe bleeding DVT D ~ax . succirnw deoxyri t)onocleic acid do not resuscitate diagnostic peritoneal lavage DNA DNR DPI. EBL EBBNA EBV deep venous h%1hosis diagnosis estiinatcd tilood loss Iipsteiii-Rain nuclear antigen Iipst~ioAarr virus elcctrocardiograin edctate ECG EDTA EEG EF EKG ELISA electroenccphalogran~ ejection fraction electrocardiogram enlyme-linked irnrnunosorhrnt assay electrornyograrn e.3-dimereaptosuccirlic acid.xtrapyrarnidal system EMG EPS ER ERCP emergelicy room endoscopic rctrograde cholangiol~arlcreat~)~ral.hy estrogen replacerlielit therapy cxtraserisory perceptim EKT ESP ESR ESRD eryrhrocytc sediinentatiorl rate cnd-stage rcnal diseasc EtOH F FDP alcohol (ethanol) fluoride or kinale fibrin degradaLion product Fe FEP FEV FEV.

leasiug Iiormciiie gciiitoiidiiary GYN ~ylltXOlOgy r gylltWXJlOgiC O M2 W8rN liistarniiic type 2 r Iienioglohin arid ht:iiiatocrit history arid pliysical cxaiiiii~atioii hcpatitis A virus glycosylated hemoglobin hepatitis B iinmiirie globulin H&P HAV HbAlc NBIG NBcAb/Ag WBeAWAg hepalitis H core aiitibody/antigni hepatitis B “e” antibody/antigeu hepatitis I3 sarthce ancihody/antiyen NBsAb/A.~-~liy~lroxyiiidolcacetic acid I-Jiierr~o~~hilur influame t y p c h (vaccirr e) Nib HIV huniau iiiiiiioi\odefi~icrrcy virns I n i o i a n Icukorytc antigru EILA kMG Ilmiiaii i i i c i i i q m i s a l gouadotropiii . flu ~~iiemopliilu influeiii~ie Hgh 5-HIAA hcnioglohiri .LP hnnolysis.gm GDS grain glucose~ 6-phospliatase deficiency G-6-PD. low platelets hrparitis liepatitjs E v i r w WeP HEV EI. 66PD group 13 Streptococcirs gastroesopliageal ref1 ux disease glornerular filtration rate gainma-gliitarnyltrai~s~~e~iticlase GERD GFR GGT GH 61 growth Iiorinoiie gastroiiitestiiial GnRH GU goiiadotr~ipiii~~rc.g WBV hepatitis 13 virus liead circuniferencc bepatocellular carcinoma Inimari diorioiiic gonadotropin li ydroc h lori c acid NC HCC RCG NCl Wct liernatocri I Jicpatitis C virus high-dciisity lipoproteins NCV HDV hcpatitis 11 virus MBI.Abbreviatinns g. elevatcd li vcr ci~iymes.

IgE) intramnscnlar intraocular pressure iiiactivated poliovirus vaccine iii~clligencc p t i e n t c international units intrauterine device intrauterine growth retardation idiopathic thromhocytopenic purpura intraveno LIS inferior vena cava intravenous drug abuse intravenous fluids intravenous i~nmunoglohulins intravenous pyelogram juvenile rheumatoid arthritis jugular venous distcntian jugnlar venous pressurc potassiunr potassium chloridc kilogram potassium hydroxide liter Icft atrinm HTN NUS NVA Hx l&D IBD IBS ICP Ig.. 1.g. IgG.Scliiirilciii purpura NSP NSV herpes simplex virus hypertension lrernolytic uremic syndrome Iiomovanillic acid history incision and drainage inflammatory howel disease irritable howel syndrome intracranial pressure iinrnunoglobnlin (e.A LAE left atrial ciilargcrnt:nt .Abbreviations HOCM HPV hypertrophic obstructive cardion~yopatlly human papilloma virus hr HRT hour/hours hormone replacement therapy tJellocll~. IG IM IOP IPV IQ IU IUD IUGR ITP IV rvc lVDA IVP WIG IVY IRA JVD JVP K KC1 kg KOW 1. IgA. IgM.

w left ventricular hypertrophy M MA1 inale Mycobocterium avium.FT(S) LGI 1. rubella (vaccine) month /inoiitlis ..-intracrllolarc complex monoamine oxidase monoamine oxidase inhibitor riiilitary antishock trousers myelin basic protein inearl corpnscular hemoglobin concentration MA0 MAQ-I MAST MBP MCNC MCP metacarpoplialangeal (hand joint) MCV MEN niean corpuscular voluini: multiple endocrine neoplasia ine~abt>lic (e.ohernaggliitinatiori assay fix antibodies to Trymema pullidnin (tor syphilis) MI myocardial infarct milliliter millirneter r l mm ?vfMIt mo ineaslcs.Abbreviations Ib LBW pound low birth weight m LDW LDL LES T. alkalosis) nietastasis inei mets MG inyasthenia gravis MHA-TP mia. met. mumps.g.egg-CalvP-PertIies syiidroine lactate dehydrogen ax: low-density lipoprn~eins lower esopliagcai spbiiicter liver fiiiiction rest(s) lower gastroiimstinal (below the ligaineiit ofTrcitz) luteinizing hormone LH LLQ LMN LMP LOC left lower yiiadraiit Iower motor iicuro~i last nieristrrral period loss of consciousness lactated Ringer's solution lecithin:sphi ngomyelin ratio lysergic acid diethylamide l e f t upl)er quadrant left veritriclc LR L:S LSD L"Q LV LVF LVH left ventricxlar fail1.

-irrflammatory driig nonwess test nausca/vomitin g oxygen osteoarthritis oral contraceptive pill oVCrdOsc orogastric tnbe oral glucose tolerance test otitis media oral poliovirus vaccine NS NSAID NST N/V 0 2 OA OCP OD OGT OGTT OM QPV OR PAC PAN operating room prematnre atrial contraction polyarteritis nodosn Papanicolaou smear posterior cruciate ligament Jw PCL PCN PCQS penicillin polycystic ovary syn dromc phencyclidine or Pneumocystis cnriirii ~ ~ n e n m o n i a pnlmonary capillary wcdge prcssiirc patent ductus artrriosns pulmonary m h o l u s positive endkxpiratory pressirrt: PCP PCWV PDA PE PEEP .MR mental retardation magnetic rcsonance angiogram magnetic resonance imaging scan methicillin-resistant Staphylococcus ailreus iuultiple sclerosis MRA MRI MRSA MS MVP Na NEC mitral valve prolapsc sodium necroti~ing cntcrocolitis nasogastric nasogastric tuhe ammonia noii~~t-lodgkiri’s lyniplionia isophane insulin suspision NG NGT NH3 NHL NPW NPO NPV nothing by mouth negative prcdictivc value normal saline nonsteroidal anti.

Abbreviations 215 PG PI3 PID PIN prostaglandin (e. I'GF) or pliospliatidylglycerol piillmonary hypertension pelvic inflamrnatory disease pregiiaricy~iiid~iccd ypertmsion Iiy pxoxiiiial interplialairgral (joint) PIP PKU PMN PMS PO4 plieirylkeroiiriria polyiiiorp1ioiiut:Iearleukocyte premenstrual syndrome phosphate purified protein derivativc (tuhcrcnlosis skin test) preterin prmiatiirv rupture of the memhrancs jnsitive PPD PPROM VPV predictive value Prn PROM PSA as iiwdcd premature rupture of the rncinhranes prostate~spccific antigen pt/pts PT PTCA PTW PTT patien t/pat I ents prothroiiil~in tiiiir pcrcutmeoi~s translumiiial coronary angioplasty parathyroid hormone partial thrornh+. index riglit lower quadrant RNA rihoiiudeic acid MPR rapid plasrrra rcagirr test (fix syphilis) rcspiratory syncytial virus RSV riglit iipper quadrant ... P G Z .g.) REM MI.ion time PUD PVC PVD PZA peripheral vascular disease pyrazinamide right atrinm or rlreurnatoid arthritis right atrial enlargeiririit RA RAE RBI C RDW RCC radioactive iodine xed blood cells red blood cell distribution width recessive (e. autosomal rec.' rapid eye moveineiit (dream sleep) rlieoiiiatic fever Kliesus bloo&pnp antigen RI reticiilocytr.g.stin peptic ulcer disease premature ventricular contract.

Tb TBG ahdomiiial liystercctumy tuberculosis thyroid birrding gloholin tricyclic antidcpressant TCA TI! Tei tctralogy (of Falloc) tliyroid f i i n c t i o i i t m t s (asually iricarisTSH..i anlidiuretiv Ii~~rmoiic atc sccrctioii sirddcir i n f a n t (leaill synrlrotne systc:inic l u p i i s erytlicrnat~isus SCID SD SES SlADW SIDS S1. superior vena cava systeiriic ve~ious x y p i saturation o SVll Sx (Sxs) T3 symptorn (symptoms) triiod(.thyroniirr. herpes .E SOB S/P §SKI sliortness of' lhreath stat11s posr (after) serotonin-selective reuptakc inhihitm-s Stdph Stat Staphylococcus iininediatcly transmittcd diseasc s~xually Sllel'tococcus STD Sbep SVC SVO. S3. SZ. IieeT.T3 rtisin uptake) TFTS TIA tratisicirt i s c l i t m i c atcack .~ TlBC total iron-bintliiig c a p x i t y transjugular intralicpatic portosys~ernic l i i i n t s i y m p a ~ic i TIPS TM nieriihrai ie ~ TMP / SMZ TORCH r riinct hoprirn sul~arietli oxazolr I toxoplasina. S4 SBO SCD SCFE small howel o h s t s u c t i o n sickle ccll disease slippcd capital fcinoral epiphysis sevverc cointiiried irnniuiinde~cierrcy discasc sraiidard deviation socioecorioiriic st atiis syndrmnc o f ' i i i a ~ y r ~ ~ p i . thy n i x i IK total T* TAN TB. irrdcx.Abbreviations I_ I KV RVF riglit ventric:le right ventricular Liiliire right vmtricolar liypcrtrophy licart sounds 1--4 KV VW S1. cytoiiicgalovirus.T. ruhclla. other.

cardiac.tinal peptide VMA V/Q vs . tlimntbocytopeiiic piirpiira trarisiirc~liralr tiou or the prostatr t r ~ a t ~ i i i ior tberapy it UA UC UGI iiriiialysis iilccrativc coliiis upper gastroiiitestiiial (pnixirnal t o the ligainent oITreitz) iilipt:r noto or ~iciiroii upper respirawry infiction ultrasoiind UMN URI US UTI UV urinary iract infiction ultraviolet VACTHRL vertebral. limb (inalformatiwis) Vanco vancoinycin VC.~Barr Venereal Disrasc Rcscardi Laboratory test (for sypliilis) veiitriciilar fihrillatioii maxxtivc intestiiial Iwpiide pancreatic tumor that vitaiiiiu vaiiillyli~iandelic acid ..iciitilarion/pcr~iirrsioll(ratio) VDltL VIP VFib or Vfib VIPoma Vit rctes vasoactive iiicr. anal. tracheoesophageal.A virus) viral capsid aiitjgeii (in lipstcin. renal. Vc‘rSlIs vciitric&r septal dcfec~ veii~ricular tachycardia VSW VTach or Vtaclt VWR wsicourctcral reflux von Willehrand’s factor varicella zoster iiniiiunogloliulin whitc l h i d cells YWF VZIG WBC WPW Y’ W[)lff:-I’arkiiisori~Wliite syndronre yiar/ years %ollin~cr~~l~llisi~ri syndronre ZES .Abhreviatinns fPA 217 tissue plasminogcii activator TRH TSH TTP TURP TX thyroid-rel~asiiig hormone I tiyroid-stiinulating lairnione thn)rnhotic.

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2 Index .

~ Index 22 .

224 Index .