highyields

knowthedifferenttypesofshockhypovolemic,septic,cardiogenic(CO,MAP,SVR)
metabolicacidosisleadstohyperkalemia
diabetesmellitusandrhizopus/mucormycosisinfections.
opticneuritisisassociatedwithmultiplesclerosis
hemolyticuremicsyndromeaftergastrointestinalillnessw/1)acuterenalfailure2)microangiopathic
hemolyticanemia3)thrombocytopenia
hypertensionismostimportantriskfactorforstrokes
ACEianddiabetesmellitus.ACEisdecreaseGFRandFF(dilatesefferentarteriole)
theophyllinetoxicitymanifestsasCNS(headache,insomnia),gastrointestinal(nausea,vomiting),
cardiac(arrhythmias)
renaltransplantdysfunctioncanbecausedbyavarietyoffactors.acuterejectionisbesttreatedw/
steroids.
thiazidediureticscausehyperglycemia,increasedLDLcholesterol,increasedtriglycerides.
hyperuricemia(gout),hypercalcemia(protectsagainstcalciumstones)
beckwithwiedemannsyndromehasmacrosomia,macroglossia,visceromegaly,omphalocele,
hypogylcemia,andhyperinsulinemia.Babieswiththyroiddisorderwillhaveumbilicalherniation.
lifestylemodificationstodecreaseBP:loseweight>fruitsandvegs>decreasesodium>exercise>
alcoholintake
hyperosmolarnonketosis(HONK)occursintype2diabetesmellitus.haveseverehyperglycemia
resultingindehydration.
SIRScriteria2ofthefollowing:1)temp>101.3or<952)pulse>903)resp>204)WBC>12kor<4k
burnpatientshaveSIRSwithhypermetabolicsyndrome
B.pertussishasburstsofwhoopingcough(loudinspiratorysound).firststageiscatarrhal(rhinorrhea
andcongestion)treatmentismacrolidemycin
osteosarcomahas"sunburst"patternandperiostealelevation(codman'striangle).increased
ALP/LDH.occursatmetaphysesoflongbones
granulosacelltumors(typeofsexcordstromalalongwithsertolileydigcell)giveprecociouspuberty
ifearly.bimodaldistribution.excessestrogen.
notnecessarytotreatasymptomaticpaget'sdisease.onlywhenhavebonepain,hypercalcemia,
neurologicaldeficits,highoutputcardiacfailure
diamondblackfananemiahaspureredcellaplasiawithshortstature,webbedneck,cleftlip,
shieldedchest,triphalangealthumbs,hypogonadism
craniopharyngiomaisasuprasellartumorleadingtobitemporalhemianopsia,headaches,and
hypopituitarism.
steroidscauseneutrophilia,lymphopenia,andeosinopenia.
familialhypocalciurichypercalcemia(FHH)willhavedecreasedurinarycalciumexcretiondespite
hypercalcemia.ThepatietwillhavenormalorhighPTH.ThePTHshouldbelow(highcalcium)but
parathyroidglandisbroken.
broca'saphasiaisexpressiveaphasiawherepatientcan'tspeakorarticulate.lesionindominant
frontallobe.willhavemotorsymptoms.
hypovolemichyponatremiaduetovolumedepletionleadingtoincreasedRAASandADH.ADHwill
contributetohyponatremia.hypovolemichyponatremia=diuretics,GI,skin
congestiveheartfailurehasbibasilarcracklesatlungbases.decreasedbreathsoundsatlungbases
couldbeduetopleuraleffusions.wheezingcanbepresentfromcardiacasthma.respiratory
alkalosis,hypoxia,hypocapnia.
S.pneumoniae,N.meningitidis,H.influenzaeforasplenics.

marfan'ssyndromeisanautosomaldominantdisorderresultingfrommutationsinfibrillin1gene.it
presentswithtallstature,longandemaciatedextremities,arachnodactyly,hypermobilityofjoints,
upwardlensdislocation.
give100%oxygenforanacuteattackofclusterheadache
patientswithsheehanssyndromepresentpostpartumwithfailuretolactateandotherfeaturesof
pituitaryhormonaldeficiency.
cysticfibrosishasawiderangeofmanifestations:anemia,heatintolerance,steatorrhea,wheezing,
recurrentinfections,hemoptysis,clubbing,rectalprolapse.+sweattesttoconfirm.
syringomyeliahasareflexicweaknessinupperextremitiesanddissociatedanesthesiainacape
distribution.thepresenceofacordcavityisthemostcharacteristicfeature.
cyclosporine/tacrolimustoxicities:nephrotoxic,gumhypertrophy,hyperkalemia,hypertension,
hirsutism,tremor.(tacrolimushasnohirsutismorgumhypertrophy)azathioprine:diarrhea,
leukopenia,hepatotoxic
mycophenolate:bonemarrowsuppression.
ulnarnerveentrapmentoccursatsitewhereulnarnerveliesatmedialepicondylargroove,inthe
elbow.decreasedsensationin4thand5thfingersandweakgripduetointerosseusmuscles.
patientreturningfromadevelopingcountrywithsymptomssuggestingmalabsorptionshouldbe
treatedw/metronidazoleforgiardiasis.pathogenesisincludesadhesivedisksandmalabsorption.
choanalatresiaappearsinaninfantwhohascyanosisduringfeedingandrelievedbycrying.cant
breathewhilemouthisclosed
patientswithpanicdisorderhaveincreasedincidenceofdepression,agoraphobia,generalized
anxietydisorderandsubstanceabuse.
understandpathophysiology,peristalsisandLEStoneindiffuseesophagealspasm(DES)/zenkers/
achalasia/scleroderma/infectiousesophagitis
totreathyperkalemiausebeta2agonist,itwillshiftpotassiumintocells.
otosclerosisinmiddleagedpeopleduetoconductivehearinglossassociatedwithbonyovergrowth
ofstapes.presbycusisinolderpatientsduetosensorineuralhearingloss
rightcoronaryarteryocclusioncancauseinferiorwallmyocardialinfarctionandposteriorwallMI.
inferiorwallMIshowsSTsegmentelevationsininferiorleads(IIIIIaVF)w/reciprocaldepressionsin
V1andV2.STsegmentdepressioninleadsV1andV2suggestaposteriorwallMI.inferiorwallMIis
associatedwithhypotension,bradycardia,andAVblocks.
tobreakbadnewsfollowsteps:1)makesurepatientiscomfortableenvironment2)askhowmuch
theyknoworwhattheythink3)askwhattheywanttoknow4)givethemawarningshot5)break
thebadnews6)giveprognosis
inhyperthyroidismgivepropanololforsymptomaticreliefuntiltheunderlyingcauseisidentifiedand
treateddefinitively.
FSGSismorecommoninafricanamericans,obesity,heroinuse,andHIV.
foraorticdissectiondoTEEorCTw/contrast
indubinjohnsonyouseeadarkgranularpigmentpresentinhepatocytesbutnotinpatientswith
rotorsyndrome.
shockliverarisesfromsepsisorischemichepaticinjury.Thereisrapidriseintransaminases
incentivespirometryhasbeenshowntobethemosteffectivemeasureindecreasingtheriskofpost
oppneumonia
inconsolidationthelungshavedullnesstopercussionandthebreathsoundsarebronchialwhich
arelouderandhaveamoreprominentexpiratorycomponent.pleuraleffusionproducesdullnessto
percussionalso,butdecreasedbreathsounds(theliquidisoutsideofthelungs)
themostimportantcomplicationofPPROMispulmonaryhypoplasia.givesteroidswhenpremature
ruptureofmembranes(PROM)occursatlessthan34weeksofgestation.
malignantotitisexternaiscausedbyPseudomonas.willhaveotorrhea,granulationtissueintheear
canal.

foractinomycesusepenicillin.anaerobicgram+branchingbacteriacausingcervicofacial,thoracicor
abdominalinfections.drainssulfurgranuleswhichappearyellow.
loopdiuretics(furosemide)causehearinglossandtinnitus.aspirinusuallycausestinnitusbutnot
hearinglossunlessthedosesareveryveryhigh.
cangethallucinationsearlyaftergivenlevodopa/carbidopa.(excessdopamine)afterseveralyears
involuntarymovementsmorelikelytooccur.
lynchsyndrome/HNPCC.atleast3relativesw/colorectalcancer,onewhois1stdegreerelative.
involvementof2ormoregenerations,atleast1casebefore50,FAPhasbeenexcluded.extracolonic
tumorsincludeendometrialcarcinomaoccuringin43%offemales
hypoxiawithrespiratoryfailure,cardiogenicshock,andDICcanoccurafteramniocentesisamniotic
fluidembolism.immediatelyintubateandmechanicallyventilateandthengiveivfluids
singlenonhealingulcerinvermilionzoneoflowerlipissquamouscellcarcinomashowingsquamous
cellswithkeratinpearls.especiallyifsunexposure.herpeticulcerwouldhealintwoweeks,wouldbe
multipleulcers,wouldshowgiantcellsontzancksmear.
mastitisassociatedwithbreastfeedingistreatedwithanalgesics,antibiotics,andcontinuationof
breastfeeding.
rheumaticfeverleadstomitralstenosisleadingtoenlargementofleftatriaandpushesupleftmain
stembronchus.willhavedyspnea,pulmonaryedema,andirritationofphrenicnerveandleftmain
stembronchus>persistentcough.Atrialfibrilationcanalsooccurand/orleftatrialenlargement
toavoidcontrastinducednephropathyadequatehydration,acetylcysteine,andnonioniccontrast.
wheneverivaccesscantbeestablishedinpediatricemergencycases,goforintraosseusaccess.then
oncehydratedgoforivaccessagain.dontgoforfemoralbecauseofperinealcontamination.
orbitalcellulitishasopthalmoplegiaandpainw/extraocularmovements,butpreseptalcellulitisdoes
not.preseptalcellulitisisamildinfectionoftheeyelidanteriortoorbitalseptum.orbitalcellulitisisa
seriousinfectionposteriortotheorbitalseptum.orbitalcellulitiscanleadtoblindnessand
intracranialinfection.
marfansfeatureswithmitralregurgitationandthromboembolicevents+downwarddislocationof
thelensishomocystinuria.autosomalrecessivecausedbycystathioninesynthasedeficiency.treat
withhighdosesofvitaminb6
whenpleuraleffusionsuspectedordiagnosed,determineiftransudateorexudate.dodiagnostic
thoracentesis.
headache,elevatedbp,renalbruitissuggestiveofrenovascularhypertensionsecondarytorenal
arterystenosis.inyoungadultscauseismostlikelyfibromusculardysplasia,inolderpatientsitsan
atheromatousplaque.treatmentisangioplastywithstentplacementforayoungperson
whenpatientpresentswithfall,stabilizeandtreatpain,thentrytouncoveretiologyoffallwith
appropriateinvestigationandassesspreoprisk.
insulinresistanceplaysacentralroleinthepathophysiologyofnonalcoholicfattyliverdiseaseby
increasingrateoflipolysisandelevatingcirculatinginsulinlevels.intrahepaticfattyacidoxidation
leadstoincreaseinoxidativestresscausingareleaseoflocalproinflammatorycytokinesliketnf
alphaandconsequentliverinflammationleadingtoincreasedtransaminaselevels.
reversibleacetylcholinesteraseinhibitorssuchasdonepezil,rivastigmine,andgalantamineareof
benefitinslowingcognitivedeclineassociatedwithalzheimersdementia.
th
th
paralysisofhandandipsilateralhornersyndromeresultfrominjuryto7 and8 cervicalnerveand
st
1 thoracicnerve,whichisarareformofbrachialpalsycalledklumpkeparalysis.duchenneerbisC5
C6waiterstip
whipplesdiseaseisamultisystemicillnesscharacterizedbyarthralgias,weightloss,fever,diarrhea,
andabdominalpain.PAS+materialinlaminapropriaofsmallintestineisfoundonbiopsy.
inapatientwith(HONK)nonketotichyperglycemiccomastartnormalsaline(0.9%)firstthen
replacewith0.45%saline.
whenpatienthascompressionofthecalsacandispresentingwithneurologicalsymptomslikelossof
bowel/bladderfunctiondoMRIbutgivesteroidswhilewaitingtoreduceriskofpermanent
neurologicaldamage.

her2isanoncogene,levelofexpressioncanbedeterminedbyFISHorimmunohistochemicalstaining
(IHC).ifitsoverexpressedcantreatwithtrastuzumab(herceptin).
sunscreensshouldbeapplied1560minbeforesunexposuretoallowenoughtimeforaprotective
filmtodevelop.sunavoidanceisthebestmethodofphotoprotection.
whenadversereactiontoDTaPvaccineoccurs,usuallyduetothepertussiscomponentofthe
vaccine.
herpeticwhitlowisacommonviralinfectionofthehand.causedbyHSV1orHSV2andisselflimiting.
healthcareworkerswhocomeintocontactwithinfectedorotrachealsecretionsareatanincreased
riskofdevelopingwhitlow.
guillainbarresyndrome(GBS)isanacuteidiopathicinflammatorydemyelinatingneuropathy.2030%
ofpatientsdevelopneuromuscularrespiratoryfailurerequiringmechanicalventilation.serial
measurementofvitalcapacityatthebedsideisthebestwaytomonitorrespiratoryfunctioninsuch
cases.
osteogenesisimperfectaiscausedbymutationsintype1collagen.itstypicalfeaturesarebluesclera
andrecurrentfractures.
prematureadrenarche(axillaryhair)andthelarche(breasts)oftenhavenoclinicalsignificance.
adrenarcheduetoprematuresecretionofandrogenbytheadrenalglands.butpubarche(pubichair)
requiresathoroughevaluationasitmaybeduetoCNSdisorderin50%ofcases.
diabetesinsipidus(ADHproblem)presentsaspolyuria,polydipsiaandexcretionofdiluteurineinthe
presenceofelevatedserumosmolality(notrespondingtoADH,concentratedplasma).primary
polydipsiahasdiluteurineanddiluteplasma.
SIADHhashyponatremia(toomuchwaterinblood),lowserumosmolality,andinappropriatelyhigh
urineosmolality(urineisveryconc)
plateletdysfunctionisthemostcommoncauseofabnormalhemostasisinpatientswithchronic
renalfailure.PT,PTTandplateletcountarenormal.BTisprolonged.DDVAPisusuallythetreatment
ofchoiceifneeded.DDVAPincreasesreleaseoffactor8:vwf.
accumulationofleukotrienesandchangedprostaglandin/leukotrienebalancetriggerscharacteristic
reactionsofbronchoconstriction,nasalpolypformationinsusceptibleindividuals.aspirinsensitivity
syndromeisapseudoallergicreaction.treatmentinvolvesavoidanceofNSAIDsanduseof
leukotrienereceptorantagonists.
giveoralisoretinointopatientswithmoderatetosevereacnethatispredominantlynodulocystic
formandtothosewhohavedevelopedscars.itgreatlydecreasessebumexcretionbutis
teratogenic.
anorexianervosaareatriskfornumerouscomplicationsincluding:miscarriage,IUGR,hyperemesis
gravidarum,prematurebirth,cesareandelivery,andpostpartumdepression.
parkinsonismgivesyouashuffling/hypokineticgait.patientappearsasifhewaschasinghiscenter
ofgravity.
friedreichataxiahasneurologicalsymptoms(gaitataxia,falls,dysarthria)resultingfrom
degenerationofthespinaltracts(spinocerebellar,posteriorcolumb,pyramidal).nonneurological
manifestationsincludeconcentrichypertrophiccardiomyopathy,diabetesandskeletaldeformities
(scoliosisandhammertoes).mostcommoncauseofdeathiscardiomyopathy.
folicaciddeficiencycanbecausedbysomedrugsthatitsabsorption(phenytoin)orantagonizeits
physiologicaleffects(methotrexate,trimethoprim)
depressedCO(normalis~5L)withanelevatedPCWP(indicatesleftatrialpressure,and/orleft
ventricularenddiastolicpressure)isindicativeofleftventricularfailure.canbeduetocardiogenic
shock.systemicvascularresistancewillbeelevatedasaresultofneurohumoralactivationintended
topreserveCO(RAAS).
asepticnecrosisofthefemoralheadisacommoncomplicationofsicklecelldisease.occlusionofthe
endarteriessupplyingthefemoralhead,bonenecrosis,andeventualcollapseoftheperiarticular
boneandcartilage.
everycaseofleukocoriaisconsideredaretinoblastomauntilprovenotherwise;refertoan
optholmologist.

cystinuriaisaninheriteddiseasecausingrecurrentrenalstoneformation.lookforapersonalhistory
ofrecurrentkidneystonesfromchildhoodanda+familyhistory.thecharacteristicstonesarehard
andradioopaque(canseethem).urinalysisshowshexagonalcrystals.theurinarycyanide
nitroprusiddetestisusedasaqualitativescreeningmeasure.
inapatientwithhepatitisc,giveimmunizationsforhepAandBifnotalreadyimmune.both
vaccinationsaresafeinpregnancy.treatmentofchronichepciscontraindicatedinpregnancy.
shouldstillbreastfeed,andcanstillhavesexw/outcondoms.
dietaryrecommendationsforpatientswithrenalcalculiare:1)decreaseddietaryproteinandoxalate
2)decreasedsodiumintake3)increasedfluidintake4)increaseddietarycalcium
antiviralmedscanreducethedurationofinfluenzasymptomsby23days.howeverthesedrugsare
onlyeffectiveifadminsteredwithin48hoursoftheonsetofillness.amantadineandrimantadineare
onlyactiveagainstinfluenzaa.neuraminidaseinhibitorszanamivirandoseltamivirareactiveagainst
bothaandb.
treatmentforTCAoverdoseincludessodiumbicarbonate.thisdrugnotonlyhelpscorrectthe
acidosisbuttonarrowtheQRScomplex.benzodiazepinesaregivenwhenpatientpresentswith
seizures.
seborrheicdermatitis(dandruff)isacommonchronicinflammatorypapulosquamousdieasethatcan
affectallagegroups.transparenttoyellowpapulesandoccasionalscalingplaquesarecharacteristic.
treatwithmoisturizers,antifungals,andtopicalsteroids.
tineaversicolorisasuperficialfungalinfectionoftheskin.characterizedbypale,velvetypinkor
whitishhypopigmentedmaculesthatdonottananddonotappearscalybutscaleonscraping.
causedmyMalasseziafurfur.KOHpreparationrevealslargeblunthyphaeandthickwalledbudding
spores(spaghettiandmeatballs).treatwithseleniumsulfideandketoconazole.
surgicalresectionfollowedbywholebrainradiationisthestandardpracticeinthemanagementof
solitarybrainmetswithstableextracranialdisease.multiplebrainmetsarebesttreatedwith
palliativewholebrainradiation.
clusterheadacheusuallypresentswithacute,severeretroorbitalpainthatwakesthepatientfrom
sleep.itmaybeaccompaniedbyrednessoftheipsilateraleye,tearing,stuffedorrunnynose,and
ipsilateralhornerssyndrome.treatmentis100%oxygen.
patientswithrenaldiseasecanhavelowlevelsoferythropoietincausingthemtohaveanemiathatis
normocyticandnormochromic.treatmentisrecombinantEPOwhichisgivenifhemoglobin<10.the
mostcommonsideeffectsareworseningofhypertension(30%)headaches(15%)andflulike
symptoms(5%)
muddybrowngranularcastacutetubularnecrosis.
RBCcastglomerulonephritis.
WBCcastinterstitialnephritisandpyelonephritis.
fattycastnephroticsyndrome.
broadandwaxycastchronicrenalfailure.
weightgainismostcommonsideeffectofolanzapine.
considerC.difficileinapatientwithdiarrheaiftheyhaverecievedantibioticsrecentlyanddevelop
nausea/vomiting/abdominalpainandelevatedWBC.cytotoxinassayinthestoolisahighlysensitive
testtodiagnosethiscondition.
mostcoloncancersdevelopfrompolyps.riskfactorsforpolypprogressinginomalignancyarevillous
adenoma,sessileadenoma,andsize>2.5cm.onlyadenomatouspolypsareclearlypremalignant,but
<1%oflesionsprogresstomalignancy.hyperplasticpolypsarenonneoplasticanddonotrequire
furtherworkup.
praderwillisyndrome(obesityhypogonadismsyndrome)hypotonia,hypogonadismandobesity.
severehypotoniaatbirthorinfancy,hyperphagia,shortstatureandmentalretardation.lesch
nyhansyndromeiscausedbyadeficiencyinHGPRT,andhasselfmutilation,mentalretardation,
hyperuricemia,andneurologicsigns.
pataussyndromescalpdefects,cleftliporpalate,microcephaly,congenitalheartdefects,flexed
fingerswithpolydactyly

edwardssyndromeischaracterizedbyclosedfists,microcephaly,prominentocciput,rockerbottom
feetandrenal/cardiacproblems.
increasedriskofsepsisforupto30yearsaftersplenectomywithencapsulatedorganisms.getanti
pneumococcal,haemophilusandmeningococcalvaccinesbeforesplenectomy,anddailyoral
penicillinprophylaxisfor35yearsaftersplenectomy.

cardiology

homocysteinecanbemetabolizedtocysteineormethylatedtoformmethionine.homocysteineto
cysteinepathwayiscatalyazedbycystathioninebetasynthaseusingcofactorb6(pyridoxine).
homocysteinetomethioninepathwayusesmethylenetetrahydrofolatereductaseandmethionine
synthasewithcobalamin(b12)ascofactor.giveb12,folate,andb6toapatientwithelevated
homocysteine.
calciumchannelblockersarecontraindicatedinmyocardialinfarctionbecausevasodilate>reflex
tachycardia
associationbetweenangiodysplasiaandaorticstenosis
endocarditiscanhavesepticembolitolungscausingnodularinfiltratewithcavitation
prolongedQRSisbradyarrhythmia,prolongedQTistachyarrhythmia(leadstotorsades)
myocardialinfarction>ventricularaneurysmdaystomonthsafter.presentslikecongestiveheart
failure,arrhythmias,mitralregurgitationand/orthrombusformation
treataorticregurgitationwithafterloadreductioncalciumchannelblockerorACEi
prinzmetalanginaoccursinyoungfemales,smokingisariskfator.transientSTelevation,treatment
withcalciumchannelblockersornitrates.betablockerandaspirinarecontraindicated
aorticdissectionleadstoaorticregurgitation,willhavenormalEKG.dxwithtransesophageal
echocardiogram
st
1 degreeheartblockiswhenPRinterval>0.2
constrictivepericarditisiswhenpericardiumisthickened.poordiastolicfilling.>JVP,ascites,
hepaticcongestion(lookslikerightsidedheartfailure).LowvoltageEKG
arrhythmiamostspecificfordigoxintoxicityisatrialtachycardiawithAVblock.increasedectopy
(tachy)andincreasedvagaltone(avblock)
leriche'ssyndromeis1)hip,thighandbuttocksclaudication2)impotence3)symmetricatrophyof
bilaterallowerextremity
cholesterolembolizationaftercardiacangiogram.canhaveincreasedeosinophilsinblood/urine.
decreasedcomplement.livedoreticularisandacuterenalfailure
stasisdermatitisiscausedbyvenousvalvularincompetenceresultinginvenoushypertension.
hemosiderindepositioncolorsthelegs.
st
best1 linediureticishydrochlorothiazide
supraventriculartachycardiaincludesmultifocalatrialtachycardia,atrialfibrillation,AVnodal
reentranttachycardia(AVNRT),atrioventricularreentranttachycardia(AVRT),junctionaltachycardia.
forPSVTs(narrowQRScomplextachycardia)usevagalmaneuversoradenosine.
Hypertrophicobstructivecardiomyopathy(HOCM)murmurwillincreaseaspreloaddecreases
(valsalva/standing)becausetheventricularcavityisasmallersize,andwillhaveincreasedoutflow
obstruction.
37dayspostMIisinterventricular/papillary/ventricularwallrupture.
infectiveendocarditisleadstotriscuspidregurgitation.holosystolicmurmurwhichincreaseswith
inspiration(decreasedintrathoracicpressure).distinguishingfeature
hypertrophicobstructivecardiomyopathyhascrescendodecrescendomurmurw/noradiationto
carotidsandisfoundinlowerleftsternalborder.ASradiatestocarotids.
hemodynamicallystablesupraventriculartachycardiashouldtryvagalmaneuverandadenosine.if
unstablethendodccardioversion.adenosinewillincreaseconductiondelaythroughtheavnode.

insystolicheartfailure:cardiacindexisdecreased(measureofcardiacoutput),totalperipheral
resistanceisincreased(neurohumoralactivationofRAAS),andleftventricularenddiastolicvolumeis
increasedbecausetheheartisnotpumpingout
hypovolemicshockwillhavedecreasedCO,decreasedPWCP,increasedSVR(raas),increasedHR
anddecreasedBP
inheartfailurethereisadecreaseofbloodgoingtokidney,activatesRAAS.angiotensin2constricts
efferentarteriole,aldosteroneabsorbsmoresodium>waterretentionandelevationoftotalbody
volume
pericardialeffusionsappearasenlarged"waterbottle"shapedcardiacsilhouette.pericardial
effusionwillhaveanonpalpablepointofmaximalimpulse,diminishedheartsounds
pericardialeffusionandcardiactamponadehave:hypotension,distendedneckveins(highint.
jugularvenouspressure),andmuffledheartsounds.willalsohavepositivehepatojugularreflexand
pulsusparadoxus.fluidaccumulationinthepericardialcavitythatincreasestheintrapericardial
pressureabovethediastolicventricularpressure.restrictsvenousreturntotheheart.decreases
diastolicfillingandlowerspreload.
infectiveendocarditiscanpresentwithsystemicarterialemboli(cns,renal,splenic),
glomerulonephritis,rothspots,oslersnodes,janewaylesions,mycoticaneurysms
dihydropyridine(dipine)calciumchannelblockerslikeamlodipinecancauseperipheraledema.
strongestinfluenceonlongtermprognosisforanSTelevationMIisthedurationoftimethatpasses
beforecoronarybloodflowisrestoredviaPTCAorfibrinolysis.
forBPcontrolweightlossismostimportantintervention.weightloss>physicalactivity>salt
restriction>alcohol
mitralregurgitationisaholosystolicmurmurradiatingtoaxilla.willhavesofts1becauseimproper
closureofthemitralvalve.
aorticregurgitationhasawidepulsepressure(systolicdiastolic)whichpatientsexperienceasa
poundingheartbeat.lyingflatbringsheartclosertochestwallandpatientsaremoreawareofthe
forcefulheartbeat.
constrictivepericarditiscausedbypericardialfibrosisandobliterationofpericardialspace.presents
likechf(fatigue,dyspneaonexertion,musclewasting,elevatedjvp,ascites,positivekussmaulssign
increasejvponinspiration),pedaledema.indevelopingcountriescanbecausedbytuberculosis.
givenitroglycerineforcardiogenicpulmonaryedema.willdecreasepreloadandrelievedyspneaand
tachycardia.cardiogenicpulmonaryedemawillhavebibasilarralesandwheezingaswell.
digoxinandfurosemide/loopdiureticsreducecongestiveheartfailuresymptomsbutdonot
improvesurvival.
patientswithahistoryofrheumaticfeverhaveanincreasedriskofrecurrentepisodesand
progressionofrheumaticheartdiseasewithrepeatedinfectionbygroupAstreptococcuspharyngitis.
needpenicillinprophylaxis.
classICantiarrhythmics(flecainide/propafenone)blocksodiumchannels.theyelongateperiodof
depolarization,andprolongtheactionpotential.slowerconductionthroughtheAVnodeandhis
purkinjesystem.classICmedshavetheslowestbindinganddissociationfromthesodiumchannel.
flecainideisaICthatdemonstratesusedependencewheretheHRincreasesflecainideseffecton
thesodiumchannels.Flecainideisstrongeratfasterheartrates.thereislesstimebetweenAPsfor
themedicationtodissociatefromitsreceptor.sotheQRScomplexwillprolongastheHRincreases.
aorticstenosisneedsechocardiogramtoconfirmdiagnosis.ifsymptomaticthentreatwithvalve
replacement.
longQTsyndromecanpresentassyncopalepisodes,hearingloss,andafamilyhistoryofsudden
cardiacdeath.treatwithbetablockers
mitralregurgitationcancauseaholosystolicmurmurthatradiatestotheaxilla.Mitralvalveprolapse
isthemostcommoncauseofmitralregurgitation.mitralregurgitationcanleadtoleftatrialdilation
andatrialfibrillation.
digoxintoxicitysideeffectsaregastrointestinal(anorexia,nausea,vomiting).verapamilincreases
digoxinconcentrationsandpredisposestotoxicity.

mitralstenosishasalouds1andamiddiastolicrumble.cancauseatrialfibrillationbecauseofleft
atrialdilation
causesofpulsusparadoxusincludecardiactamponade,tensionpneumothorax,andsevereasthma.
>10mmHgdropinsystolicbloodpressureoninspiration.
corpulmonalehashypotension,jvd,distantheartsounds,andpulsusparadoxus.elevatedjvp,
hepatomegaly,ascites,lowerextremityedemawithoutevidenceofpulmonarycongestionis
suggestiveofisolatedrightsidedheartfailure,corpulmonale.mostcommoncauseisCOPD.
inapatientwithanMIwhodevelopsaclot,doechocardiogramtoruleoutthrombusinleftventricle.
inventricularfibrillationandpulselessventriculartachycardia,defibrillationisthetreatment.
VentricularfibrillationisrecognizedonEKGbyfibrillatorywavesandabsenceofregularqrs
complexes.timetodefibiscorrelatedwithsurvival.
aCXRshouldbeobtainedinallpatientswhoundergocentralvenouscatheterizationtoconfirm
properplacementofthecathetertipbeforeadministeringdrugsorotheragentsthroughthe
catheter.
acuteMIpresentswithsubsternalchestpainwithradiationtoneck,diaphoresis,shortnessofbreath.
th
anew4 heartsoundisaclassicfindingofmyocardialinfarction.ischemicdamagemayleadto
diastolicdysfunctionandastiffenedleftventricle,resultinginanatrialgallop(4thheartsound)
abdominalultrasoundisthestudyofchoicefordiagnosisandfollowupofabdominalaortic
aneurysms.nearly100%sensitiveandspecificforthiscondition
mitralstenosisclassicallypresentsduringpregnancy.mostoftenduetorheumaticfeverandoccurs
muchmoreoftenincountrieswithlimitedaccesstoantibiotics.Thereisanincreaseinplasma
volumewithpregnancy.
anexercisestresstestwithoutimagingisthemostreasonablefirststepifbaselinerestingEKGis
normalinapatientcomplainingofexertionalcardiacpain.
ifpatientsarehemodynamicallyunstableandhavesustainedmonomorphicventriculartachycardia
(SMVT)thenelectricallycardiovert,butiftheyarestableandasymptomaticyoucangiveanti
arrhythmics(amiodarone).SMVTisawidecomplextachycardia.
inpatientswhopresentwithabdominalpainandhaveriskfactorsformyocardialinfarction,rule
outmyocardialinfarctionbeforefurthergastrointestinalworkup
coarctationoftheaortapresentswithseveresymptomatichypertension(headaches,epistaxis,and
evidenceofleftventricularhypertrophy).EKGwillshowincreasedvoltageofQRScomplexesandST
andTwavechangesinleftprecordialleads.allpatients(especiallyyoung)withsystemic
hypertensionshouldbeevaluatedforcoarctationwithsimultaneouspalpationofbrachialand
femoralpulsestoassessforbrachialfemoraldelay.alsohavesupinebilateralarm(brachial)and
pronerightand/orleftleg(popliteal)bloodpressuresmeasuredtoassessfordifferentialpressures.
coarctationmaybecongenitaloracquired(takayasu)
cardiactamponadeproducesadecreaseinCObecausethepressureexertedontheheartbythe
pericardialfluidisgreaterthanthevenouspressurethatfillstherightatriumduringdiastole.pulsus
paradoxusisafeatureoftamponadeandisdefinedasalargedecreaseinthesystolicblood
pressureoninspiration.demonstratedbylossofapalpableradialpulseduringinspiration.
Superiorvenacavasyndromeisapotentialcomplicationoflungmalignancy,andismanifestedby
headache,facialswelling,andjugularvenousengorgementwithoutperipheraledema.headaches
worsewhenleaningforwardduetodecreasedgravitationaleffectsonthebloodcolumn.jvdis
present,butthereisnoperipheraledematosuggestcardiacfailure.theprimarytreatmentis
radiationtherapyasapalliativemeasure.
EKGwithwidecomplextachycardiawithmonomorphicventriculartachycardiainastablepatientis
treatedwithamiodarone.
peripheralvasculardiseaseshouldbesuspectedinapatientwithriskfactorsforatherosclerosiswho
hasanextremitywithshiny,thin,hairlessskin,particularlyifanonhealingulcerispresent.use
anklebrachialindextoassesspvd.

septicshockhasimpairedcirculationresultingininsufficientoxygendeliverytotheperipheraltissues
andsubsequentanaerobicmetabolism.leadstoanincreaseintheproductionoflacticacidproducing
metabolicacidosis
myocarditiscanleadtothedevelopmentofdilatedcardiomyopathy.bibasilarcrackles,pitting
edema,anddisplacementofthepointofmaximalimpulse.
patientswithmitralvalveprolapsehaveaslightlyhigherriskofdevelopinginfectiveendocarditis
aftercertaininvasiveprocedures.2007AHAguidelinesforthepreventionofinfectiveendocarditisdo
notrecommendantimicrobialprophylaxisforpatientswithmitralvalveprolapseincludingthose
withregurgitation.ifyouhaveprostheticheartvalves,previoushistoryofinfectiveendocarditis,or
unrepairedcongenitalheartdiseaseyougetprophylaxis.
atrialfibrillationhasirregularlyirregularQRScomplex,absentPwaves.treatmentisratecontrolor
rythmcontrolandanticoagulation.totreatrateusebetablockerorverapamil/diliazem.
Atrialseptaldefecthaswide,fixedsplittingofs2.patientswithmoderatetoseverelefttoright
shuntsmayhaveasystolicmurmurbestheardattheupperleftsternalborderfromincreasedblood
flowacrosspulmonicvalve.
septicshockshouldbesuspectedinpatientswithhemodynamicinstabilityandevidenceofan
infection.initialtreatmentisivfluidsfollowedbyvasopressors(dopamineornorepinephrine)ifthey
donotrespondtofluids.
asmitralstenosisbecomesmoresevere,thetransvalvulargradientincreasesandcausesthe
murmurtobeheardearlierindiastoleattheapex.earlydiastolicmurmuratleftlowersternal
borderisheardinpatientswithaorticregurgitation.
systolicmurmurthatincreaseswithdecreasedpreload(standing)ismitralvalveprolapseor
hypertrophicobstructivecardiomyopathy.inmvpthereisamidsystolicclickandalatesystolic
murmurbestheardatapex.inhocmthemurmurincreaseswhenstandingbecauseoflessvenous
returnandtheleftventricularoutflowtractobstructionworsens.morecommoninyoungafrican
americans.
Hypotensioniscausedbyadecreasedleftventricularpreloadinahemothorax.(similarmechanism
astensionpneumo).hemothoraxwillhavelackofbreathsounds,anddullnesstopercussiononthe
ipsilateralsideasthehemothoraxduetoaccumulationoffluidinthepleuralspace.hemothoraxisa
potentialcomplicationofthoracentesisandshouldbesuspectedinpatientswhorapidly
reaccumulateapleuraleffusion,difficultybreathing,andhemodynamicinstabilityshortlyaftera
thoracentesis
venodilationdecreasesthepainassociatedwithacutemyocardialinfarctionbyreducingpreload,
leadingtoareductioninmyocardialoxygendemand.
aorticregurgitationisadiastolicdecrescendomurmuroverleftsternalborder.aorticregurgitation
commonlyduetoaorticrootdilationorabicuspidvalve.
flatteningofPwave,prolongedPRandQRSareconsistentwithhyperkalemia.givecalcium
gluconatetostabilizecardiaccellmembrane.hypokalemiahasuwaves,flatandbroadTwaves.
rupturedabdominalaorticaneurysmisanimportantcauseofabdominalandreferredlower
abdominalpain.patientsalsohaveatherosclerosisofothervesselssuchascoronaryorcarotid
arteries.
cyanosisinhighlyvascularizedtissueslikelipsandmucousmembranesisconsistentwitthcentral
cyanosis.peripheralcyanosisusuallyonlyinvolvesthedistalextremities.centralcyanosisiscaused
bylowarterialoxygensaturation,peripheralcyanosisisduetoincreasedoxygenextraction
(proximaltissuestakealltheoxygen,anddistalextremitiesgetnone??)secondarytosluggishblood
flow.inperipheralcyanosistheextremitiesarecoolandclammy.
lipemicserum(milkyandopalescent)alongwithpalmarxanthomasisconsistentwithsevere
hypertriglyceridemia.treatwithfibricacidderivativeslikefenofibrate.
arrhythmiahassuddenonsetsyncopewithoutaprodrome.sotalolusedtomaintainsinusrythm(in
patientswithatrialfibrillation)hasasideeffectofprolongationoftheQTintervalwhichpredisposes
totorsadesdepointes.hypokalemiaandhypomagnesemia(fromdiarrhea)arepredisposing

factors.QTintervalprolongationandPRintervalprolongation.treatwithmagnesiumsulfate(not
antiarrhythmics)initially.
wolffparkinsonwhite(wpw)synromeischaracterizedbyanaccessorypathwaybetweentheatrium
andventricleresultinginpreexcitationandincreasedriskfortachyarrhythmias.theaccessory
pathwayconductsantegrade(forward)fromatriatotheventriclesfasterthantheconduction
throughtheavnode,whichallowspartoftheventricletodepolarizeearly.shortenedPRinterval,
slurredinitialportionofQRS(deltawave)andwidenedQRScomplex.
beforeexerciseEKGwithholdmedicationsthatareantiischemicand/orslowtheheart.beta
blockersshouldbewithheld1224hoursbeforethetest.
mostcommoncauseofdeathinpatientswithacutemyocardialinfarctioniscomplexventricular
arrhythmia.acuteischemiacreatesaheterogeneityofconductioninthemyocardium.areasof
partialblockofconductionarefrequentlyformedthatpredisposethepatienttoreentrant
arrhythmia.Ventricularfibrillationisatypicalexampleofreentrantarrhythmia.
paroxysmalsupraventriculartachycardiamostcommonlyresultsfromaccessoryconduction
pathwaysthroughtheavnode.vagalmaneuversandmedicationsthatdecreaseconductionthrough
theavnode(adenosine)oftenresolvethePSVT.
pericarditispresentswithpainthatworsenswithdeepinspiration,improvedonleaningforward.
EKGfindingsshowdiffuseSTelevationwiththeexceptionofreciprocaldepressioninaVRwhereST
depressionisseen.dresslerssyndromeispericarditisoccuringweeksafteramyocardialinfarction.
NSAIDsarethemainstayoftherapyfordresslerssyndrome.
progressivedecreaseinbaroreceptorsensitivityanddefectsinthemyocardialresponsetothis
reflexarethemainreasonsforincreasedorthostatichypotensionintheelderly.(bloodpressure
drops,heartrateshouldincreasetocompensate)
screenpatientswhoare6575andwhohavesmokedcigarettesbeforewithabdominalultrasound
forabdominalaorticaneurysm.
atheroembolismresultsfromdislodgementofcholesterolplaquesfromtheaorticroot.bluetoe
syndromeinwhichembolitothepedalcirculationcausecyanoticandpainfultoeswithintactpulses
isonecommonpresentationofcatheterinducedatheroembolism.maybeaccompaniedbylivedo
reticularis(purplemottledskin),andelevationofcreatinineresultinginatheroembolismofrenal
circulation.
allpatientswhohavehadamyocardialinfarctionshouldrecievesecondaryprevention.thefollowing
nd
medicationshavebeenshowntohaveamortalitybenefitwhengivenas2 prevention:aspirin,
betablocker,ACEi,lipidloweringstatin,clopidogrel/ticlopidine(iftheyarepostpercutaneous
coronaryintervention).
digoxinisacardiacglycosidewithadverseeffectsthatincludegastrointestinaldisturbances,vision
changes,andarrhythmias.patientstakingdigoxinshouldhaveroutinemonitoringoftheirdigoxin
level.
peripheralvasculardiseasecommonlycausedbyatherosclerosis.presentswithclaudication,erectile
dysfunction,andatypicallegpainorcanbeasymptomatic.taketheanklebrachialindex(abi)using
dopplerasthefirststeptodiagnoseinhighriskofsymptomaticpatients.doexercisetestingwith
preexerciseandpostexerciseabimeasurementtoconfirmdiagnosis.
fever,chills,LUQpain,andsplenicfluidcollectionsuggestsfindingsconsistentwithinfective
endocarditiswithsepticembolitothespleen.leftsidedendocarditiscansendsepticembolito
regionsrichinbloodsupply:brain,kidneys,liver,spleen.rightsidedendocarditistendstosendseptic
pulmonaryemboli.willhaveelevatedneutrophils.
feverandanewmurmurinapatientwhomayabuseivdrugsshouldraiseconcernforendocarditis.
staphylococci(incl.MRSA)isamorecommoncauseofendocarditisinivda,thereforevancomycinis
theinitialempiricantibioticofchoice.
abdominalaorticaneurysmrupturepresentswithprofoundhypotension,abdominalorbackpain
followedbysyncope,andpossiblepulsatilemassonexamination.aaacanrupureintothe
peritoneumandcreateanaortocavalfistulawiththeinferiorvenacavaleadingtovenous

congestioninretroperitonealstructures(e.g.bladder).thefragileanddistendedveinsinthebladder
canruptureandcausegrosshematuria.
ascendingaorticaneurysmsaremostoftenduetocysticmedialnecrosisorconnectivetissue
disorders.Descending/thoracicaorticaneurysmsareusuallyduetoatherosclerosis.
diastolicdysfunctionisalsocalledheartfailurewithpreservedleftventricularejectionfraction.
systemichypertensionistheclassicalcauseofdiastolicdysfunction.treatmentiswithdiureticsand
bpcontrol.
dilatedcardiomyopathycanoccursecondarytoacuteviralmyocarditis(coxsackieb,parvob19,
hhv6,adeno,entero).viralmyocarditiscausesdilatedcardiomyopathyviadirectviraldamageandas
aresultofhumoralorcellularimmuneresponsestoviralinfections.diagnoseviaechocardogram
whichshowsdilatedventricleswithdiffusehypokinesiaresultinginalowejectionfraction.
hepatojugularreflexcanbeusedtodifferentiatebetweenheartandliverdiseaserelatedcausesof
lowerextremityedema.+hepatojugularreflexindicatesthatthevenouspressureiselevatedand
suggeststhatheartdiseaserelatededemaispresent.hepatojugularreflexisnegativeinpatients
withliverdiseaserelatededema.
coolduskyfingertipsaftervasopressorscanbetheresultofnorepinephrineinducedvasospasm.
norepinehrinehasalpha1agonistpropertieswhichcausevasoconstriction,whichisgoodwhen
tryingtoincreasethebpofhypotensivepatients,howeverinpatientswithdecreasedbloodflowit
cancauseischemiaandnecrosisofdistalfingers/toes.canalsooccurinintestines(mesenteric
ischemia)orkidney(renalfailure)
nativevalvebacterialendocarditisduetoS.viridanshighlysusceptibletopenicilliniswelltreated
withivpenicillingorivceftriaxone.donotuseoralantibioticsforsubacutebacterialendocarditis.
symptomaticsinusbradycardiashouldbetreatedwithivatropine,followedbytrancutaneous
pacing.iftheyarehemodynamicallyunstabletheuseofepinephrineisappropriate.(donoconfuse
withadenosineforPSVT!!!!!)
threemostcommoncausesofaorticstenosisare1)senilecalcificaorticstenosis,2)bicuspidaortic
valveand3)rheumaticheartdisease.bicuspidaorticvalveisthecauseofaorticstenosisinthe
majorityofpatients<70y/o.systolicmurmurinrightuppersternalborderwithradiationtothe
carotids.
aorticregurgitationcausesanearlydiastolicmurmurandcanbeassociatedwithahyperdynamic
pulse,includingboundingorwaterhammerperipheralpuses.
acutepericarditisischaracterizedbysharppleuriticchestpainthatisworseinthesupineposition
andimprovedbysittingupandlearningforward.occursinthefirstseveraldaysaftermyocardial
infarction.diffuseSTelevations,especiallywithPRdepressionsaretypicalEKGfindings.
outflowobstructioninhypertrophicobstructivecardiomyopathyresultsfrombothseptal
hypertrophyandsystolicanteriormotion(SAM)ofthemitralvalve.hocmpresentsascrescendo
decrescendomurmurinthelowerleftsternalborder.increasesduringvalsalvaduetodecreased
preloadanddecreasedfillingofleftventricle.
EKGfindingsinacutepericarditisarediffuseSTelevationanddepressionofPRsegment(exceptin
aVR).mostcommoncauseisviralinfection.canalsobecausedbyuremia(patientwithrenal
problems).treatmentofuremicpericarditisisdialysis.indicationsforhemodialysisare1)refractory
hyperkalemia2)volumeoverloadorpulmonaryedemanotrespondingtodiuretics3)refractory
metabolicacidosis(ph<7.2)4)uremicpericarditis5)uremicencephalopathyorneuropathy6)
coagulopathyduetorenalfailure
kussmaulssign(increasedjvponinspiration)isseenin:constrictivepericarditis,cardiactamponade,
rightheartfailure.hypotension,jvdandclearlungfieldspointtorightventricularinfarction.treat
withivfluidsandavoidanceofpreloadreducingmedications(nitratesanddiuretics),theyare
preloaddependent.rightheartfailure=liquids
cardiaccathistypicallydonebycannulatingthefemoralarterytoaccessthecardiacvessels.a
commoncomplicationishematomaformationinsofttissuesoftheupperthigh.ifthearterial
puncturewasdoneabovetheinguinalligament,thishematomacanextenddirectlyintothe
retroperitonealspaceandcausesignificantbleeding,withhypotensionandtachycardia.patientscan

acuteheartfailurecancausepulmonaryedemaorflashpulmonaryedemasecondarytoanterior
wallmyocardialinfarction.adiureticsuchasfurosemideisthedrugofchoiceinthissetting.
decreasesthecardiacpreloadtherebydecreasingthepulmonarycapillarypressure.alsocauses
venodilationwhichfurtherdecreasespreload.
clearlungfields,hypotension,andjugularvenousdistensioninthesettingofaninferiorwallmiare
suggestiveofarightventricularinfarct.fluidresuscitationistheappropriatemanagement,and
nitratesshouldbeavoidedbecausetheydecreasepreloadandwilllimitcardiacoutput.
anterolateralmyocardialinfarctioncancausepapillarymuscleischemiaorrupture,whichcancause
mitralregurgitation.willhavebibasilarcrackles,orthopnea.measurementofpulmonarycapillary
wedgepressure(PWCP/leftatrialpressure)withaswanganzcatheterwillrevealincreasedpressure
intheleftatrium
prematureventricularcomplexes(PVCs)arecommoninpostmyocardialinfarctionpatientsandcan
berecognizedbytheirwidenedQRS>120msec,bizzaremorphology,andcompensatorypause.no
treatmentunlesssymptomatic.
amyloidosiscanresultinarestrictivecardiomyopathywiththickenedventricularwallsand
preservedventriculardimensionsaswellasliver(clotting,bruising)andkidneys(proteinuria)
calciumgluconateisgivenforhyperkalemiatoprotecttheheart.onEKGhyperkalemiawillhave
peakedTwaves,andprolongationofPRandQRSintervalseventuallyleadingtoasinewave.sodium
bicarbisusedinTCAandaspirinoverdose.magnesiumsulfateisusedfortorsadesdepointes.a
polymorphicventriculartachycardiaassociatedwithaprolongedQTinterval.itcommonlyoccursin
patientswithlongQTsyndromeaswellaspatientswithahistoryofalcoholismandrecentintiation
offluconazoleandmoxifloxacin.
myocarditispresentsasaflulikeillnesswithfever,anorexia,lethargy,irritabilityinchildren.followed
byrespiratorydistressfromacuteheartfailure.CXRwillshowcardiomegalyandpulmonaryedema.
EKGshowslowvoltageQRSandsinustachycardia.echocardiogramshowsglobalhypokinesis,left
ventricularhypertrophy,leftventriculardysfunction,andpericardialeffusion.goldstandardis
myocardialbiopsy.
aorticstenosiscancauseanginalchestpainbecausetheleftventriclewillhypertrophyrequiring
additionaloxygen.increasedmyocardialoxygendemand
myocarditispresentslikecongestiveheartfailurewithcardiomegaly,paroxysmalnocturnal
dyspnea,dyspneaonexertion,peripheraledema,hepatomegaly,bilateralpleuraleffusions,anda
thirdheartsound.viralmyocarditisisoftenduetocoxsackiebvirus.

dermatology

senilepurpuraischaracterizedbyecchymosesthatoccuronelderlypatientsextensorsurfacesdue
toperivascularconnectivetissueatrophy.renalfailurecanalsocauseplateletdysfunction,
creatininewouldbeelevated.
basalcellcarcinomainsunexposure.nodulewithpearlyrolledbordersandtelangiectasia
actinickeratosisdescribedaserythematouspapuleswithacentralscale."sandpaperlike"texture.
sunexposedareas
stevensjohnson=erythemamultiformemajor.targetshapedmucocutaneouslesionsandsystemic
signsoftoxicity.type3hypersensitivity
escharformationcancompromisebloodflowandlymphaticcirculation.decreasedpulsesand
edema.doescharotomy.
sq.cellcarcinomawithchronicwounds.
rosaceainmiddleagedpatietnswithtelangiectasiasovercheeks,nose,andchin.flushingmade
worsebyhot/colddrinks,sun,emotion.haspapulesandpustules.txismetronidazole

porphyriacutaneatardahaspainlessblisters,photosensitivity,increasedskinfragilityondorsumof
thehands,hypertrichosis.associatedwithhepcinfection(thinkliverstuff)
tineacorporishasringshapedscalypatcheswithacentralclearingandscalyborders.treatmentis
terbinafine.
normalskin@birthwithprogressiontodry,scalyskinwithhornyplatesoverextensorsurfacesis
icythosisvulgaris.worsensinwinter.lookslikelizardyskin
allergiccontactdermatitishasvesiclesatthesiteofexposure.canbecomesecondarilyinfectedand
havepusfilledvesicles.
forSCCdoapunchbiopsytoconfirmdx
vitiligoisduetoautoimmunedestructionofmelanocytes
seborrheickeratosisisabenigngrowththatoccursinmanyplacesonthebody,butfavors
face/trunk.thelesionshaveawaxy,stuckon,wartyandwellcircumscribedappearance.actinic
keratosisisapremalignantlesionthatisdry,scaly,flatpapulewitherythematousbase.
bullouspemphigoidisautoimmuneblisteringdisordermarkedbytensebullae,urticarialplaques.igg
andc3alongbasementmembranezone.
themostcommondrugsinthetreatmentofacnetoproducephototoxicdrugreactionsarethe
tetracyclines,namelydoxycycline.sunburnreactionswitherythema,edema,andvesiclesoversun
exposedareas.
nd
squamouscellcarcinomaisthe2 mostcommonformofnonmelanomaskincancerafterbasalcell
carcinoma.exposuretosunlightisthemostimportantfactorinthedevelopmentofscc.
bestwaytopreventmalignantmelanomaiswearingprotectiveclothing.sunscreenprotectsagainst
nonmelanomaskincancerlikesq.cellcarcinoma
forbasalcellcarcinomadomohssurgery,whereinmicroscopicshavingisdonesuchthat12mmof
clearmarginsareexcised.thistechniquehasthehighestcurerateforbasalcellcancer.butis
indicatedonlyinpatientswithhighriskfeaturesorinthosewithlesionsinfunctionallycriticalareas
(perioral,nose,lips,ears)
pemphigusvulgarisisamucocutaneousblisteringdiseasethatischaracterizedbyflaccidbullaeand
intercellulariggdepositsintheepidermis.autoantibodiesareformedagainstdesmoglein,an
adhesionmolecule.bullouspemphigoidrarelyhasorallesions.(notinmucousmembranes)
dermatitisherpetiformisisassociatedwithglutensensitiveenteropathy(celiacdisease).dapsoneis
aneffectivetreatment.
mildacne(noninflammatorycomedones)aretreatedwithtopicalretinoidsfirst.topicalantibiotics
areaddedwithmildtomoderateinflammatoryacne.useoralisoretinoinforpatientswith
nodulocysticandscarringacne.
seborrheicdermatitisisacommoninflammatorydiseasethataffectsareaswithsebaceousglands,
suchasthescalp(dandruff)face(eyebrowsnasolabialfoldsandexternalearcanal/posteriorear),
chestandintertriginousareas.seborrheicdermatitisoccursinallagesbutisfoundinincreased
frequencyinpatientswithparkinsonsandhiv.pruriticerythematousplaqueswithfine,loose,
yellow,andgreasylookingscales.acnerosaceaisarosyhuewithtelangiectasiaoverthecheeks,
noseandchin.flushingoftheseareasistypicallyprecipitatedbyhotdrinks,heat,emotion,and
othercausesofrapidbodytempchanges.
atopicdermatitis(eczema)ininfancyaffectsface,scalp,andextensorsurfacesoftheextremities.
lesionsusuallybeginwithpruritisalone,andevolvetoerythematousexcoriatedpapulesand
plaquesthatmayweepandbecomesecondarilyimpetiginized.atopicdermatitisistheresultof
decreasedskinbarrierfunctionduetoimpropersynthesisofcomponentsoftheepidermalcornified
cellenvelope.allergenscanreadilyaccessdeeperlevelsoftheepidermiswheretheymaygenerate
theimmuneresopnse.thediaperregionistypicallyspared.
excisionalbiopsywithnarrowmarginsisthepreferredstudyforthediagnosisofmelanoma.ifthe
depthofthelesionis<1mmthemelanomacanbeexcisedwitha1cmtumorfreemarginandthey
havea99%5yearsurvival.tumors>1mmindepthshouldhaveasentinellymphnodestudy.donot
doexcisionwithwidemargins(like1cm)untilthediagnosisofmelanomaismade.

toxicepidermalnecrolysisisaseveremucocutaneousexfoliativedisease.erythematous
morbiliformeruptionthatrapidlyevolvesintoexfoliationoftheskin.instevenjohnsonsyndromeup
to10%ofthebodysurfaceareaisinvolved,inTEN>30%ofthebodysurfaceisinvolved.
molluscumcontagiosumcausedbypoxvirus.domeshapedlesionswithcentralumbilication.
acnefromsteroidshasnocomedonesandmonomorphouspinkpapules.adolescentacnehasboth
openandclosedcomedones.

electrolytes

chronicalcoholism>pancreatitis>malabsorption.lowvitaminDmeanswillhavelowphosphorous
andlowcalcium
malignancyisthemostcommoncauseofhypercalcemiainadmittedpatients.osteolyticmets,
secretionofpthrp,increasedvitd,andIL6
hypocalcemiacausesincreaseddeeptendonreflexes.canoccuraftermultipletransfusions.
hypermagnesemiahasdecreaseddeeptendonreflexes.
forhyperkalemia1)stabilizemembranewithcalciumgluconate2)insulin/glucoseand3)remove
frombody(kayexalate)
forapatientwithseverehypovolemichypernatremiagive0.9%saline(isotonicsaline).patientswith
lessseverehypovolemichypernatremiaaretreatedwith5%dextrosein0.45%saline
forcalciumcheckthecorrectedcalciumusing(0.8x4.0measuredalb)+measuredcalc.do
correctedcalciumtoseeifhypoalbuminemiaiscausinghypocalcemia.0.8x(4.0serumalb)+
calcium.ifthecalciumfallsinnormalrangeitsduetohypoalbuminemia
primaryhyperparathyroidismisthemostcommoncauseofhypercalcemiainambulatorypatients.in
mostcasesitsasolitaryparathyroidadenoma.
inpatientwithacutehyponatremiacorrectsodiumconcentrationwith3%saline(hypertonic).
albuterolgivenforacuteasthmaattacksmaycausehypokalemia,tremors,palpitationsand
headache.betaagonist>hypokalemia
hypokalemiahasuwavesandflatandbroadtwavesonecg,andprematureventricularbeats.
medscausinghyperkalemia:digoxin,succinylcholine,tmpsmx,aceis,nsaids,potassiumsparing
diureticslikespironolactoneandamiloride.
treathypercalcemiawithivsalinehydration(normalsaline0.9%)followedwithloopdiuretics
(furosemide)
barttersyndrome(cantabsorbNaCl)presentslikereninsecretingtumorwithveryhigh>40urine
chloride,elevatedplasmarenin/aldosterone,lowserumk,highserumbicarbonate,butinbartter/
gitelmansyndrometheserumNaisnormal,inareninsecretingtumorserumsodiumiselevated.
reninsecretingtumorswillalsocausehypertension.barttersyndromehasdefectiveNaandchloride
reabsorptioninthethickascendinglimboftheloopofhenlesoyougethypovolemia>
raas.gitelmansyndromeislikebartterbutdefectindistalconv.tubule.basicallybartter=normal
serumna+lotsofraas
asymptomatichypercalcemiaisthemostcommonpresentationforprimaryhyperparathyroidism.
24hoururinarycalciumcanhelpdistinguishprimaryhyperpth(>200mg)fromfamilialhypocalciuric
hypercalcemia(<100).bothdisordershaveelevatedserumcalciumandelevatedpth.indicationsfor
surgeryinanasymptomaticpatientare1)serumcalciumatleast1mgaboveupperlimitofnormal2)
youngage<503)bonemineraldensitylowerthant2.5atanysite4)reducedrenalfunction(egfr
<60).beforesurgerymostsurgeonsorderasestamibiscantolocalizetheadenoma.
anacuteriseinserumcalciumismostcommonlyseeninhypercalcemiaofmalignancy.primary
hyperparathyroidismdoesnotresultincalciumlevelsashighasthoseseenwithmalignancy.
siadhcauseshyponatremia(waterretention),plasmahypoosmolality(waterretention),andahigh
urineosmolality(>200)andahighurinesodiumconcentration(urinena>30meq/l)
todeterminecauseofhyponatremiacalculateserumosmolality=(2*na)+(bun/2.8)+(glucose/18)
iftheyarehypotonicandhyponatremicthenlookatvolumestatus:hypovolemic,euvolemic,or

hypervolemic.hypovolemichypotonichyponatremiacanbeduetorenalorexrarenallossesof
sodiumandwater.extrarenallosseshaveaurinena<10,(renallosseswillhaveurineNa>20)and
canbesecondarytodiarrheaandvomiting
volumeresuscitationwithnormalsalinewillcorrectcontractionalkalosis.hypokalemiashouldbe
treatedaswell.
inpatientswithmalignancy,hypercalcemiaisduetotheincreasedresorptionofboneandreleaseof
calciumfrombone.thepathologyinvolvesosteolyticmetswithlocalreleaseofcytokinesandtumor
secretionofpthrp.bisphoshonatesarethedrugofchoiceformildtomoderatehypercalcemiadue
tomalignancy.ivfluidsandfurosemideareusedinthetreatmentofhypercalcemiccrisis.
isotonicsolutionssuchasnormalsaline(0.9%)arethefluidofchoiceforinitialresuscitationinsevere
hypovolemichypernatremia.
chronicrenalfailurecanincreasepthleadingto2ndhyperparathyroidism.seenwithmoderateto
severerenalinsufficiency.serumcalciumlevelsarenormaltolowinpatientswith2ndhyperpth
becausethecauseofelevatedpthishypocalcemia.primaryhyperpthwillhaveanelevationofpth
andcalciumlevelsalongwithahistoryofrenalstonesandosteoporosis.
vigoroushydrationwithivnormalsalineisfirststepinmanagingseveresymptomatichypercalcemia
renalfailurecauseshypocalcemia.immobilizationofanindividualwithahighboneturnoverresults
inincreasedosteoclasticactivationthatcanleadtohypercalcemia.bisphosphonatetherapyin
patientswhoareimmobilizedishelpfulinreducinghypercalcemiaandpreventingosteopenia.
vomitingcausesmetabolicalkalosis(losingvolumeandlosingH+)withhypochloremiaand
hypokalemia.volumecontractioncausessecondaryhyperaldosteronismcausinghypokalemia.itwill
havelowurinechloride<20(thekidneyisreabsorbingNaCl)andchloridesensitive.
increasedextracellularpH(alkalosis)cancauseanincreaseintheaffinityofserumalbuminto
calciumcausinghypocalcemia.
siadhisacommoncomplicationoflungcancer,particularlysmallcelllungcancer.lowsodiumand
highpotassium.initialtreatmentisfluidrestriction.
addisonsdiseasehasaldosteronedeficiencyleadingtononaniongap,
hyperkalemichyponatremicmetabolicacidosis.(aldosteroneremovesh+andk+,savesna+)
salineresponsivemetabolicalkalosishasurinecl<20andistypicallyduetoconditionscausedby
hypovolemiaorgastrointestinalprotonloss.treatwithisotonicsalineinfusion.
recognizediabeticketoacidosisasmetabolicacidosis,polyuria,dehydration,decreasedlevelof
consciousness,anddiffuseabdominalpainafteraninfection.dkaischaracterizedbyanosmotic
diuresisthatreducestotalbodypotassiumstoreseventhoughserumpotassiummaybeelevated.
loopdiureticsgivehypokalemia,andalsoresultinincreaseddistalsolutedeliveryaswellas
increasedaldosteronelevel.increasedhydrogenionexcretion>metabolicalkalosis

emergency

forethyleneglycolpoisoningusefomepizole.willhavecalciumoxalatestonesinthekidneys.flank
pain,hematuria,oliguria,acuterenalfailure,aniongapmetabolicacidosis.
ironpoisoninghasacorrosiveeffectonthegimucosa.ab.pain,nausea,vomiting,diarrheaand
hematemesis.hypotensionandvenodilationleadtohypoperfusionandleadstometabolicacidosis.
ironisradioopaquesoitcanbeseeninstomachonabdominalxr.Todiagnosemeasureserumiron
levels,totreatuseivdeferoxamine
whenpatientingestsacetaminophen,beforegivingnacetylcysteinemakesureserumlevelistoxic
(checkat4hours).cangivenaceylcysteinewithin8hoursofingestion.giveactivatedcharcoalis
goodwithin4hours.
whenapatientingestslye(sodiumhydroxide)whichisastronglyalkalinesolution,mustdouppergi
endoscopytoassessextentofesophagealinjuryanddetermineifanyfurthermanagementis
needed.ifperforationissuspecteddoagastrografinstudy.

sodiumbicarbonateisusedtotreatTCApoisoning.tcaoverdosecauseshyperthermia,seizures,
hypotension,andanticholinergiceffects:dilatedpupils,flushedanddryskin,intestinalileusand
QRSprolongation.blindasbat,dryasbone,hotashare,madashatter,redasbeet.
diphenhydramineoverdosepresentswithanticholinergicsymptoms,drowsiness,andconfusion.
diphenhydramineisanantihistaminebutcangiveanticholinergiceffectsaswell.treatment
involvesgivingadministrationofphysostigmine,acholinesteraseinhibitorwhichreversesitseffecs.
forfrostbiteinjuries,besttreatmentisrapidrewarmingwithwarmwater.afterwarming,re
evaluatetheextremity.amountofdebridementisalwayslessafterrewarming.
methanolintoxicationcancausevisionlossandcoma.physicalexamwillshowopticdischyperemia,
labstudieswillshowaniongapmetabolicacidosis.increasedosmolargapisoftenseenaswell.
inheatstrokethetemperatureisusually>105F/40.5C.heatstrokeresultsfromaninsufficient
evaporativecoolingmechanism.treatmentinvolvesevaporativecoolingtoreversehyperthermia.
opioidwithdrawalpresentswithsymptomsofnausea,vomiting,abdominalpain,diarrhea,
arthralgiasandmyalgias.signsofopioidwithdrawalonexamcanincludeincreasedbowelsounds,
mydriasisandpiloerection.treatwithmethadone.C.difficileinfectionsgenerallydonotbeginuntil
510daysafterantibiotictreatmentisinitiated.
bradycardia,avblock,hypotensionanddiffusewheezingindicatebetablockeroverdose.most
commonpresentationofbetablockertoxicityisbradycardiaandhypotension,whichcanleadto
cardiogenicshock.bronchospasm(diffusewheezing)neurologicaleffects(deliriumandseizures)and
hypoglycemia.firstgiveivfluidsandatropine,thengiveglucagontoincreasecAMPandhigherlevels
ofintracellularcalciumtoaugmentcardiaccontractility.
cocainerelatedcardiacischemiaistreatedwithbenzodiazepines,nitrates,andaspirin.beta
blockersarecontraindicated.
irontabletintoxicationappearsasabdominalpainandhematemesis,hypovolemicshockand
metabolicacidosis.willappearradioopaque(cansee)onxr.givedeferoxamine.
sodiumbicarbonatenarrowsQRScomplexpreventingdevelopmentofarrhythmiainpatientswith
TCAtoxicitybyalleviatingthecardiodepressantactiononsodiumchannels.
causticpoisoningdoesnotcausealterationsinconsciousness.presentswithdysphagia,severepain,
heavysalivationandmouthburns.thedamageistheresultofnecrosisofthetissuethatlinesthe
gastrointestinaltract.inseverecasesperforationofthestomachoresophaguscanoccur,causing
peritonitisormediastinitis.
giveatropinetoreverseorganophosphatepoisoning(acetylcholineeseraseinhibitor).willhave
cholinergicexcesssoatropinecanreverse.butfirstremoveallclotheswhichmaybesoakedinthe
poisontopreventtranscutaneousabsorption.
treatcatbitesprophylacticallywithamoxicillin/clavulanate.pasteurellamulticodaisresistantto
erythromycin50%ofthetime
heatstrokeistemp>40.5C/105F.willhavehot,dryskinandhypotension.tachycardia,tachypnea
andhemoconcentration.willhavemultipleorgansystemeffects,seizures,ARDS,dic,and
hepatic/renalfailurecanoccur.

endocrine

isoniazidcauseshepatitiswithsimilarpathologicalpicturetoviralhepatitis(panlobularmononuclear
cellinfiltrationandhepaticcellnecrosis)
treatsymptomaticsyndromeofinappropriateantidiuretichormone(SIADH)withhypertonicsaline
0.3%(patientwillbehyponatremic)
hereditaryhemochromatosispatientsarevulnerabletoinfectionsofListeriamonocytogenes,
Yersiniaenterocolitica,andVibriovulnificus
corticosteroidshavemineralocorticoidlikeeffects(hypokalemia,alkalosis,hypernatremia)
inpsychogenicpolydipsia,waterdeprivationwillincreaseurineconcentration,butindiabetes
insipidus(DI)thewaterwillnotconcentrate(ADHisnotfunctioning).Thenextstepistoadminister

ADHandifitconcentratesurinethenthepatienthascentraldiabetesinsipidus,iftheurineisstillnot
concentratedthenthepatienthasnephrogenicdiabetesinsipidus.
hyperthyroidismcanhaverapidbonelossifleftunreated.ThepatientwillhaveincreasedALP
aromatasedeficiencyleadstohightestosterone,noestrogen,andvirilizationoffemales.Apatient
withcongenitaladrenalhyperplasia(CAH)willstillhaveestrogen.Aromataseconvertstestosterone
intoestrogen.
chronicsupraphysiologicaldosesofglucocorticoidssuppressCRHfromhypothalamus.Afterremoval
ofiatrogeniccorticosteroidstheHPAaxistakesafewmonthstorecover.
MEN1parathyroid,pituitary,pancreatic(insulinoma,glucagonoma).
MEN2amedullarythyroid,pheochromocytoma,parathyroid.
MEN2b/3medullarythyroid,pheochromocytoma,mucosalneuromas.AllareassociatedwiththeRET
oncogene
besttestforAddisonsiscosyntropinstimulationtest.Addison'spresentswithweakness,fatigue,
depression,increasedpigmentation(duetoincreasedACTH).Causesofaddrenalinsufficiency1)
diseasedadrenalgland2)pituitarynotreleasingACTH3)decreasedCRHbyhypothalamus
diabetesmellituscausesischemicnervedamage.somaticnerveoculomotor/CN3leadstodown
andout.
factitiousthyrotoxicosisiscausedbyingestionofexogenousthyroid,causingthethyroid
glandtoatrophy.
ifurineosmolality<300(lowconc,lotsofwater)thenyouhavecompletediabetesinsipidus.partial
diabetesinsipidusisurineosmbetween300600.patientswithpsychogenicpolydipsiahave
hyponatremia,anddiabetesinsipiduspresentswithhypernatremia.
The3maincategoriesofdiabeticretinopathyare1)simplemicroaneurysms,hemorrhages,
exudates,retinaledema2)preproliferativecottonwoolspots3)proliferativeneovascularization
Apituitaryadenoma<10mmisamicroadenoma.ifitsaprolactinoma,willhavebilateral
galactorrheaandamenorrhea.usecabergoline/bromocriptinewhicharedopamineagonists.
diabeticnephropathystartswithincreasedGFRandmicroalbuminuria.onceyouhave>300mg
protein/dayyouhavemacroproteinuriaandtheonlyinterventiontoreducethedeclineinGFRatthis
pointisintensivebloodpressurecontrol.intensiveglycemiccontrolonlylowerstheprogressionto
microalbuminuria.
hypothyroidismisassociatedwithmyopathiesincludingelevatedserumCK,myalgias,muscle
hypertrophy,proximalmyopathy,rhabdomyolysis.
tricyclicantidepressantsaredrugsofchoicefordiabeticneuropathy.Butbecausetheycanworsen
urinarysymptomsandgiveorthostatichypotensionyoucanusegabapentinasabackup.
sickeuthyroidsyndromeiswhenapatienthasabnormallylowT3inacute,severeillness.
diabeticneuropathycanleadtoadenervatedbladderleadingtooverflowincontinence.Thepatient
willpresentwithurinaryfrequency,nocturia,frequentleakageofsmallvolumesofurineandthepost
residualvolumewillbehigh.
renalfailuregiveshypocalcemia,hyperphosphatemia,andincreasedparathyroidhormonelevels.
TheGFRfallsandkidneysretainphosphatecausinghypocalcemia,leadingtohyperparathyroidism.
TSHsecretingpituitaryadenomascancauseagoiterduetotheeffectofTSHonthegrowthofthe
thyroidfollicles.ThepatientewonthaveextrathyroidalmanifestationsofGravessuchasinfiltrative
opthalmopathyandpretibialmyxedema.
connssyndrome(hyperaldosteronism)causeshypertension,mildhypernatremia,hypokalemia,and
metabolicalkalosis(excretingmoreacids).
popullary(papillary)carcinomaisthemostcommonthyroidmalignancy.
propylthiouracilandmethimazolecancauseagranulocytosis.Ifthepatientpresentswithfever,sore
throat,stopantithyroiddruganddoaCBC.ifwbc<1000permanentlystopdrug.
insulinresistanceforpatientswithcentraltypeobesityisakeypathogenicfactorinthedevelopment
oftype2diabetesmellitusandassociatedabnormalities.
Gravesopthalmopathyisduetoautoimmunelymphocyticinfiltrationoftheextraocularmuscles
resultinginfibroblastproliferation,hyaluronicaciddeposition,edemaandfibrosis

DHEASisproducedbytheadrenalglandsonly.DHEA,androstenedione,andtestosteronearemade
bytheovariesandtheadrenals.Usetodifferentiatebetween
secondary(central)hypogonadismhaslowtestosteroneandinappropriatelynormalgonadotropin
levels(FSH/LH).measureserumprolactinlevels,prolactininhibitsthereleaseofGnRH.
themostspecifictestformakingadiagnosisofacromegalyistomeasuregrowthhormone
levelsfollowinganoralglucoseload.IGF1isagoodscreeningtestforacromegaly(IGF1willbe
increasedinacromegaly),butitisanindirectmeasureofGH,andotherdiseasescanleadto
decreasedIGF1levels.
normalsalineistheinitialfluidofchoiceinahypotensive,dehydratedpatientwithdiabetes
insipidus.hypotonicfluidscanbestartedoncetheintravascularvolumeimproves.
glucagonomahasatriadof1)hyperglycemia2)necrotizingdermatitis3)weightloss.theskinlesion
iscallednecrolyticmigratoryerythema.
diabeticpatientsdevelopneuropathy.whenthesmallcolonisinvolveditusuallycausesdiarrheadue
tobacterialovergrowth,involvementofthelargecoloncausesconstipation,involvementofthe
stomachcausesgastroparesis,whichcommonlypresentsasanorexia,nausea,vomiting,and
abdominalbloatingandearlysatiety.treatwithmetoclopramide,bethanecolorerythromycin.
MEN2aconsistsofmedullarycarcinomaofthethyroid,hyperparathyroidism,and
pheochromocytoma.theserumcalcitoninleveliselevatedinpatientswithmedullarythyroid
cancer.
paraneoplasticCushingssyndromeiscausedbyectopicACTHproductionbysmallcelllung
carcinoma.Itisnotsuppressedbydexamethasoneandyougetclinicalfeaturesof
hyperpigmentationinsunexposedareas(skin,scars,palmarcreases,innersurfaceoflips,and/or
buccalmucosa),easybruising,truncalobesiy,moonfacies,buffalohump,striae,hypertension,
fatigue,glucoseintolerance,osteopenia,weakness,edema,electrolytedisturbances.
dizziness,palpitations,tremblingandsweatingwithexerciseareconsistentwithhypoglycemiain
patientswhotakeinsulinandexerciseintensely.
Cushingssyndromeiscausedbyhighlevelsofglucocorticoids/cortisol.proximalmuscleweakness,
obesity,easybruising,oilyskin,acne,hirsutism.
treatdiabeticketoacidosiswith1)aggresiverehydration,2)insulintherapyand3)potassium
repletion.
Themosteffectivetreatmentinslowingprogressionofdiabeticnephropahyismaintainingablood
pressureof<130/80withACEisorARBs.
Cushingssyndromecausessecondaryhypertension,hyperglycemia(cortisolactivatesglucagon),
hypokalemia,psychiatricproblems(sleep,depression,psychosis).
neurogenicarthropathyorcharcotsjointisacomplicationofneuropathyandrepeatedjointtrauma.
pseudohypoparathyroidismhaslowserumcalcium,highserumphosphate,andhighserumPTH.
(calciumandphosphatelevelsareasifPTHlevelsarelow,butPTHlevelsareelevated)
Xlinkedhypophosphatemicricketshavelowserumphosphateduetorenalphosphatewasting.
patientswithgeneralizedresistancetothyroidhormoneshavehighserumT4andT3levelswith
normaltomildlyelevatedTSH.patientshavefeaturesofhypothyroidismdespitehavingelevated
freethyroidhormones.
subclinicalhypothyroidismischaracterizedbymildlyelevatedTSHandnormalcirculatingthyroid
hormones.Thesepatientsdonothavefeaturesofoverthypothyroidism.
hyperlipidemia,unexplainedhyponatremia,andelevatedserummuscleenzymesareindicationsfor
thyroidfunctiontests.
somogyieffectoccurswhencounterregulatoryhormonesreacttonocturnalhypoglycemia(too
muchinsulin),therebyresultinginearlymorninghyperglycemia.thepatientwillhavelowserum
glucoseat3:00AM.inthedawnphenomenonthepatientwillhaveanincreased3:00amglucose
concentrationbecauseofthesecretionofnocturnalgrowthhormone.
hemosiderosisisthedepositionofexcessiveirontotissues.causedbyavarietyofinherited
metabolicdisorders.notconsideredtobeadistinctdiseaseentity.hemochromatosisisan
autosomalrecessivedisordercharacterizedbyincreasedskinpigmentation,diabetes,cirrhosis,and

arthralgia(pseudogout)inthelaterstages.treatmentisphlebotomyfor23yearstodepleteiron
stores,anddeferoxamineasa2ndlinetreatment.
plasmaaldosteronetoplasmareninactivityratio(PA:PRA)isusedasaninitialscreeningtestfor
primaryhyperaldosteronism.aratio>30issuggestiveofthediagnosis.
hyperpigmentationoftheskinandmucousmembranesischaracteristicofprimaryadrenocortical
deficiency,andisduetoincreasedlevelsofACTH.thisfeatureisnotseeninsecondaryadrenal
insufficiencyduetohypothalamopituitaryfailure.glucocorticoiddeficiencypresentsasweakness,
fatigue,depression,irritability,hypotension,lymphocytosis,neutropenia,andeosinophilia.
hypothyroidismpresentsascoldintolerance,constipation,dryandroughskin,bradycardia.
mineralocorticoiddeficiencypresentsashypokalemia,alkalosis,andmildhypernatremia.
whenyoufindathyroidnodule,firstdoserumTSH.ifserumTSHislow,doradionuclidethyroid
scan.ifhyperfunctioningthenevaluateforhyperthyroidism.ifnonfunctioningnodulethendo
diagnosticultrasoundofthyroid.ifnoduleissuspiciousformalignancydoFNAofnodule.iftheFNA
isbenign,routinefollowupandsurveillance.ifTSHisnormalorhighthendoultrasoundofnodule.
Steps:1)TSH,2)radionuclidescan,3)ultrasound,4)FNA
hypothyroidismleadstoaccumulationofmatrixsubstancesthroughoutthebody.ifthisoccursinthe
mediannerveandthetendonsofthecarpaltunnelthenitmaycausecarpaltunnelsyndrome.
treatdiabeticketoacidosisbygivingivnormalsalinefollowedbyregularinsulin,andpotassium.
hypertensioninpatientswiththyrotoxicosisispredominantlysystolicandcausedbyhyperdynamic
circulation.increasedtargetorgansensitivitytoendogenouscatecholaminesbyincreasingthe
expressionofadrenergicreceptorsaswell.
subacutelymphocytic(painless)thyroiditiscancausethyrotoxicosiswithreducedradioactiveiodine
uptake.othercausesofthyrotoxicosiswithreducedradioactiveiodineuptakeinclude:subacute
granulomatous(dequervain)thyroiditis,iodineinducedthyroidtoxicosis,levothyroxineoverdose,
strumaovarii.
hyperthyroidismandhypothyroidismcancauseproximalmuscleweakness.lookforadditional
symptomsofthyroiddysfunction(fatiguability,tremor,anxiety,weightchanges,menstrual)

epidemiology

matchingisfrequentlyusedincasecontrolstudiesbecauseitisanefficientmethodtocontrol
confounding.
atwosamplettestisastatisticalmethodcommonlyusedtocomparethemeansoftwogroupsof
subjects.ANOVAisusedtocomparethreeormoremeans.
cohortstudyisastudydonebasedonpresence/absenceofriskfactors.
Numberneededtotreat=1/absoluteriskreduction
thecorrelationcoefficientshowsthestrengthanddirection(positiveornegative)oflinear
associationbetweentwovariables,butitdoesntimplycausality.
afactorialdesignuses2ormoreexperimentalinterventionseachwith2ormorevariablesthatare
studiedindependently.(wtf??)
inacrosssectionalstudy,exposureandoutcomearemeasuredsimultaneouslyataparticularpoint
oftime(snapshotstudy).
iftheoutcomeofacasecontrolstudyisnotcommoninthepopulation,theoddsratioisclosetothe
relativerisk.
thepvalueistheprobabilitythattheresultofastudywasobtainedbychancealone.astudyis
statisticallysignificantwhenthepvalueis<0.05(lowerpvalueislessduetochance)
casecontrolstudiesarealsoknownasretrospectivestudies.researcherbeginswithapopulation
withacertainoutcomeandsubjectsareclassifiedascasesorcontrolsbasedonoutcomestatus.a
retrospectivecohortstudystartsatsomepointbetweentheexposureandoutcome.theresearcher
reviewspastrecords,classifiessubjectsasexposedandnotexposedandfollowsthemuntilthe
outcome.

usetestswithhighsensitivitytoscreenfordiseases.(ELISAforHIV).specificitytoconfirm(western
blot).snout.spin
chisquaretestisusedtocompareproportions.
precisionisthemeasureofrandomerror.thetightertheconfidenceinterval,themoreprecisdethe
result.increasingthesamplesizeincreasesprecision.
PPVdependsonprevalenceofdisease.NPValsodependsontheprevalenceofdisease,buthasan
inverseassociationwiththeprevalence.asprevalenceofdiseaseincreases,NPVwilldecrease.

gastroenterology

chronicpancreatitiscanleadtopancreaticcancer.Tolookforpancreaticcancerdoactscan
abdomen
zincdefhasalopecia,abnormaltaste,bullouspustulouslesions,andcanoccurintotalparaenteral
nutritionormalabsorption
acuteironintoxicationhas5phases.1)gastrointestinalphasenausea,vomiting,hematemesis,
melena,abdominalpain2)asymptomatic3)shockandmetabolicacidosis4)hepatotoxicity5)
mucosalscarringleadingtobowelobstruction
calciumchannelblockersandnitratesrelaxmyocytesinesophagus.relievesdiffuseesophageal
spasm.diagnosewithmanometry
hepatichydrothoraxisatransudativepleuraleffusioninapatientwithcirrhosis.saltrestrictionand
diuretics,andthenTIPS
crohn'sdiseasehasnoncaseatinggranulomas(pathognomonicforCD).ulcerativecolitisdoesnot.
GI,lung,breastgenerallymetstoliver.prostatemetstopelviclymphnodes.
nonbleedingvaricestreatedwithbetablockers.decreasesriskofbleedingby
bowelischemiaandinfarctionisanearlycomplicationofaaarepair.pseudomembranouscolitis
takes45daysafterantibioticusetodevelop.ischemiccolitiswillshowthickeningofthebowelwall
onCT.
inapatientwithacutepancreatitis,checkforunderlyingcause(gallstones)doRUQultrasound
inflammatoryboweldiseasealsooccursw/inflammatoryarthritis.ankylosingspondylitisisan
association.+Pancaandalsoerythemanodosum
biliarycoliccausedbyingestionoffattymeals.gallbladdercontractsandpressesgallstoneagainst
cysticductopening,increasinggallbladderpressure,causingdistensionandcolickypain.gallbladder
relaxesandstonefallsbackinduct.Biliarycolicistemporary,cholecystitisismoreconstantpain.
pyloricstricture(andgastricoutletobstruction)leadtoearlysatiety,succussionsplash,nonbilious
vomiting.
acuteappendicitisshouldhaveimmediatesurgeryifclinicaldiagnosisisclear
hematocheziaisbrightredbloodperstool.usuallyduetolowergastrointestinalbleed.do
colonoscopy,ifnegativethendolabelederythrocytescintigraphy.
laxativeabuseonbiopsywillshowdarkbrowndiscolorationofcolonwithlymphfolliclesshining
throughaspalepatches(melanosiscoli)
H.pyloriisassociatedwithgastriclymphoma/MALTomabutnotadenocarcinoma.oncediagnosisof
cancerismade,nextstepistofindextentofdisease.
inflammboweldiseasehasabimodaldistribution.erythematousmucosapossiblyw/ulcers.
ulcerativecolitishasshallowulcerscomparedtocrohn'stransmural.
persistenceofHbsAginserumfor7monthsconfirmsdiagnosisofchronichepbinfection.foracute
hepatitisuseLFTsandserologybutforchronichepatitisdoliverbiopsy.
acalculouscholecystitisisseeninseveretrauma,ischemia,postoppatients.similartocholecystitis
withthickeningofgallbladderwall,andpericholecysticfluid.
druginducedesophagitiscausedbypotassiumchloride,NSAIDs,alendronate,doxycycline.

mechanicalsmallbowelobstructionpresentswithabdominaldiscomfort,vomiting,abdominal
distention,constipation,dilatedloopsofbowelonxray.mostcommonlyb/cofadhesionsfrom
previousoperations.
painlessjaundice+conjugatedhyperbilirubinemia+elevatedALPshouldraiseconcernfor
intraabdominalmalignancythatisobstructingthebiliarysystempancreaticadenocarcinoma
chronicpancreatitisisdiagnosedwithstoolelastase.serumamylaseandlipaseconcentrationscan
benormaloronlymodestlyelevated.
acutediverticulitisisuncomplicated(75%)orcomplicated(25%).complicatedcanleadtoanabscess,
if<3cmthentreatedwithivantibiotics.butiffluidcollection>3cmthenshouldbepercutaneously
drainedviaCTguidance.ifdraindoesntworkin5daysthendebridementandsurgicaldrainagecan
beattempted.
forhepaticencephalopathyuselactulose,neomycinorrifamixin,andlaxatives.
suddenonsetepigastricpainwithairunderdiaphragmindicatesperforatedpepticulcer.canhave
diffuseabdominalpainduetoperitonitis.
primarybiliarycirrhosishassymptomsofxanthelasma,pruritis,jaundice,steatorrhea,
hepatosplenomegaly,increasedALPandserumbilirubin,and+antimitochondrialantibody.Dueto
destructionofthebileductsintheportaltriad.Treatwithursodeoxycholicacid.
lactoseintolerancehasa+hydrogenbreathtest,+stooltestforreducingsubstances,lowstoolpH
andincreasedstoolosmoticgap.
newonsetdiabetesmellitus=hemochromatosis(bronzediabetes).theycanalsohavedamageto
liver,pituitary.willpresentwithhepatomegaly,hyperpigmentation,arthropahy,restrictiveheart
failure,andhypogonadism.checkironlevels.
carcinoidsyndrometriadincludes1)diarrhea,2)flushing3)valvularheartdisease.precursorof
serotoninistryptophansopatientscangetniacindeficiency.niacindef.presentsasthe4Ds
diarrhea,dermatitis,dementia,anddeath
inpatientswithlivercirrhosisandwhohaveesophagealvaricesgivebetablockerstodecreasethe
riskofvaricealhemorrhage.
hemorrhageisthemostcommoncomplicationofpepticulcer.willpresentashematemesiswithor
withoutmelena.ifitsmassiveuppergibleedingitwillappearashematochezia(brightredbloodin
stool).
boerhaavessyndromeisspontaneousruptureoftheesophaguswhenintraabdominalpressuregoes
high.retrosternalpainandcrepitusinthesuprasternalnotcharetheresultofpneumomediastinum
whichcanoccurafterruptureofesophaguswithinthemediastinum.
duodenalulcerpresentswithepigastricpainbetteruponeating.90%infectedwithh.pylorisogive
ppi+antibiotics
echinococcusgranulosuscauseshydatidcystdiseasewhichappearsaseggshellcalcificationsonCT
scanofliver.
emphysematouscholecystitisisaformofacutecholecystitisthatarisesduetoinfectionofgall
bladderwallwithgasformingbacteria.RUQpain,nausea,vomiting,lowfever.diagnosiswith
abdominalXRdemonstratingairfluidlevelsingallbladderoranultrasoundshowingcurvilineargas
shadowinginthegallbladder.
ifhavepatientwithmigratorythrombophlebitis/Trousseausyndrometrytofindocculttumor.
GERDispresentinupto75%ofasthmapatients.patientswithadultonsetasthmaandsymptoms
thatareworseaftermeals,exercise,orlayingdownarelikelytohavegerdinduceddisease.giveppi
patientswithperniciousanemiahave1)antibodiestointrinsicfactordecreasingb12absorptionand
2)atrophicgastritiswithdecreasedproductionofintrinsicfactorbyparietalcells.atrophicgastritis
increasestheriskofintestinaltypegastriccancerandgastriccarcinoidtumors.
doanoscopyinapatientwithnoriskfactorsforcoloncancerwhohasminimalbrightredbloodper
rectum
metoclopramideisaprokineticagentusedtotreatnausea,vomiting,gastroparesis.shouldbe
monitoredcloselyfordevelopmentofdruginducedeps(dopamineantagonist)
inapatientwithcomplicatedGERD(gerd+weightloss,odynophagia,bleeding)doesophagoscopy.

vitamindoverdosegivesyouhypercalcemia.constipation,abdominalpain,polyuria,polydipsiaare
signsofhypercalcemia.
celiacspruecausesirondeficiencyanemia,andisassociatedwithdermatitisherpetiformis.
intenselyburning,pruriticpapulovesicularskindisease.granularIgAdepositsinupperdermissotest
forIgAantiendomysialantibodiesandIgG/IgAantigliadinantibodies.
cluesforlivermetsfromthecoloncanbe:abdominalpain,mildlyelevatedliverenzymes,andfirm
hepatomegaly.microcyticanemiaduetooccultgastrointestinalbleeding,andarightsidedpleural
effusioncausedbyhepatichydrothoraxduetocirrhosis.doaCToftheabdomenwithivcontrastto
evaluateformalignancy.
femalesaremoresusceptibletohepaticinjurythanmalesfromalcoholingestion.alcoholiccirrhosis
hasanincreasedratioofAST>ALT2:1
vanishingbileductsyndromeisararediseaseinvolvingprogressivedestructionoftheintrahepatic
bileducts.primarybiliarycirrhosiscausesductopeniainadultsandischaracterizedbythesame
patternofliverinjury.
spontaneousbacterialperitonitisshouldbesuspectedinanypatientwithcirrhosisandasciteswho
presentswithlowgradefever,abdominaldiscomfortoralteredmentalstatus.paracentesiswith
pmn>250and+cultureconfirmsdiagnosis.
pharyngoesophageal(zenkers)diverticulumdevelopsimmediatelyabovetheupperesophageal
sphincterbyherniatingposteriorlybetweenthefibersofcricopharyngealmuscle.motordysfunction
andincoordinationareresponsibleforthisproblem.thesurgicaltreatmentofthisdisorderincludes
excisionandfrequentlycricopharyngealmyotomy.
acholedochalcystisacongenitalabnormalityofthebiliaryductscharacterizedbythedilatationof
intraorextrahepaticbiliaryductsorboth.inchildrenincancauseabdominalpain,jaundice,and
attacksofrecurrentpancreatitis,whichmaybeevidentbyincreasesintheamylaseandlipaselevels.
allpatientswithchronicliverdiseaseshouldbeimmunizedagainsthepaandhepb.
gallstonesaremainlycholesterolstonesandmixedstones(80%).cholesterolstonesareradiolucent
(notseenonxr).
patients>55withnewonsetsymptomsofdyspepsiaandthoseofanyagewithalarmingsymptoms
(weightloss,dysphagia,persistentvomiting)shouldundergoendoscopy.otherpatientsshouldhave
eitherH.pyloriserologyorempirictreatmentwithppi.
peritonealfluidcanaccumulateduetoanumberofdiff.causesincludingportalhypertension,
trauma,infection,pancreatitis,andmalignancy.todifferentiatetransudativefromexudativeyoucan
usetheSAAAG.serumalbuminascitesalbumin.if>1.1thenitsatransudativeprocess
cirrhosis/portalhypertension,CHF,<1.1isexudativetuberculosis,pancreatitis,neoplasm
smallbowelobstructionhascolickyorparoxysmalabdominalpainwithepisodichyperactivebowel
soundsattributabletoperistalticrushes,abdominaldistension,anddiffuseabdominaltenderness.
failuretostoolorflatus(obstipation)indicatesacompletebowelobstructionhasoccurred.small
bowelobstructionalsohasnauseaandvomitingmoreoftenthanlargebowelobstruction.complete
sborequiressurgicalcorrection.patientsgetmetabolicacidosis/lacticacidosisduetoischemiaofa
strangulatedloopofsmallbowel.strangulationleadingtoischemicnecrosisandperforationofsmall
bowelisamajorlifethreateningcomplicationofsbo.whenthishappensthepatientwillhave
peritonealsigns.
inpatientsgettingtotalparenteralnutrition,thestimulusforcckreleaseisimpairedbecausethe
gastrointestinaltractisbypassed.ccknormallystimulatesgallbladdercontraction,andwhenthis
doesntoccurthereisstasisandbilesludgetendingtoformgallstonespredisposingtocholecystitis.
knowthesedrugscausingpancreatitis:1)diuretics(furosemide,thiazides),2)inflammboweldisease
drugs(sulfasalazine,5asa)3)immunosuppresants(azathioprine,lasparaginase)4)seizure/bipolar
disorder(valproicacid)5)AIDS(didanosine,pentamidine)6)antibiotics(metronidazole,
tetracycline)
perniciousanemiacanoccurinthesettingofotherautoimmunediseases.andwhiledietary
deficiencyisacommoncauseoffolatedeficiency,itusuallydoesnotcauseb12deficiency.

increasedintragastricpressureduringvomitingcancausetearsinthemucosaofthedistalesophagus
andproximalstomach.thesearecalledmalloryweisstearsandaccountfor10%ofuppergibleeds.
tearscausebleedingfromsubmucosalarteries.bleedingstopsin90%ofpatients,however
vasopressin,endoscopicinjectionorelectrocauterymayberequiredinafewcases.
spontaneousbacterialperitonitisisacommoncomplicationofascitesinwhichtheperitonealfluid
becomesinfectedbyanentericorganism.findingof>250pmnintheasciticfluidisdiagnostic.
patientswillhaveabdominalpain,ascites,tachycardia,lowgradefever.
painlessjaundiceshouldbeconsideredsecondarytopancreaticcanceruntilprovenotherwise.
elevatedALPandtotalbilirubinsuggestacholestaticpatternofjaundicewhichcouldbecausedbya
pancreaticmassobstructingthecommonbileduct.
treatalcoholwithdrawalwithbenzodiazepines.treathepaticencephalopathywithlactulose.hepatic
encephalopathypatientwillhaveacirrhoticliver(hypoalbumminemiaandincreasedINR)
hepatorenalsyndromeisadeadlycomplicationofcirrhosischaracterizedbykidneyfailurethat
doesntrespondtovolumeresuscitation.itisbesttreatedwithlivertransplantation.
cirrhosisshouldbesuspectedinanypatientwithnewascitesandpedaledemaandwithstigmataof
chronicliverdiseaselikespiderangiomata/gynecomastia.mostcommoncausesofcirrhosisare
chronicalcoholabuseandchronicviralhepatitis.
alcoholhepatitisischaracterizedbymallorybodies,infiltrationbyneutrophils,livercellnecrosis,
andperivenulardistributionofinflammation.fattyliver,alcoholhepatitis,andevenearlyfibrosisare
allpotentiallyreversibleifpatientstopsalcoholingestion.truecirrhosiswithregenerativenodulesis
irreversible.
hypertriglyceridemiaisacauseofacutepancreatitis.patientscanhaveyellowredpapulesonthe
armsandshoulders,adescriptionsuggestiveoferuptivexanthomas.doafastinglipidpaneltoseeif
thelevelsare>1000andcausingthepancreatitits.
steatorrheawithsevereintermittentepigastricpainsuggestschronicpancreatitis.#1causeisdueto
alcoholism.
portalhypertensionisthemostcommoncauseofascites.portalhypertensionisusuallydueto
cirrhosisfromchronicliverdisease(alcoholicorviral).ivdapredisposestocirrhosisbyputting
individualsatincreasedriskforchronicinfectionwithhepborc.
developmentofapalpablemassintheepigastrium4weeksafteronsetofacutepancreatitisis
suggestiveofpancreaticpseudocyst.thepseudocystiscomprisedofinflammatoryfluid,tissue,and
debristhataccumulatewithinthepancreas.whentheamylaserichfluidleaksintocirculation,
serumamylasebecomesmarkedlyelevated.ultrasoundisthepreferredmeansofimaging
pseudocysts.oftenresolvesspontaneouslysoonlydrainifitpersistsfor>6weeksis>5cmindiameter
orbecomessecondarilyinfected.pancreaticabscesspresentswithfeverandleukocytosis.tender
epigastricmass.
niacindeficiencyleadstopellagra(diarrhea,dermatitis,dementia,anddeath).patientswillhave
glossitisanddermatitisinsunexposedareasresemblingasunburn.astherashprogressestheskin
becomeshyperpigmentedandthickened.riboflavindeficiencycanleadtocheilosis,glossitis,
seborrheicdermatitis,pharyngitis,andedemaorerythemaofthemouth.
forcholelithiasisdorightupperquadrantultrasound.signsareRUQpainaftereatingandatnight.
boassignisrightsubscapularpainofbiliarycolic.
suspectceliacdiseaseinanypatientwithmalabsorptionandirondeficiencyanemia.celiacdiseaseis
associatedwithantiendomysialantibodies.willhavedeficiencyofvitA(hyperkeratosis)vitd
(osteomalacia,bonepain),vitk(easybruising),lossofsubcutaneousfat,bulkyfoulsmellingfloating
stools.
echinoccoccusinfectionsareknownashydatidcystsandcanbefoundinalmostanypartofthebody
buttheliverismostcommon.commoninareaswheresheepareraised.hydatidcystisafluidfilled
cystwithaninnergerminallayerandanouteracellularlaminatedmembrane.thegerminallayer
givesrisetonumeroussecondarydaughtercysts.eggshellcalcificationsonliver.
bacterialovergrowth,pancreaticinsuff,celiacdisease,andcrohnsdiseaseallresultinchronic
diarrheawithincreasedfecalfatcontent.dxylosetesthelpstodistinguishbetweenbacterial

overgrowthandceliacdisease.dxyloseisasimplesugar,requiresonlyanintactmucosatobe
absorbed.innormalindividualsafter25gofdxyloseitsurinaryexcretionwillbe>4.5gin5hours.in
bacterialovergrowththerewillbedecreasedexcretionofxyloseduetobacterialconsumption.in
suchcasesurinaryexcretionreturnstonormalaftertreatmentwithantibiotics.celiacdisease
damagessmallintestinalmucosa,impairingxyloseabsorption.
acutevaricealbleedingisalifethreateningemergency.thefirststepintreatmentistoestablish
vascularaccesswithtwolargeboreivneedlesoracentralline.thesecondstepistocontrolthe
bleedingitselfbyadministeringvasoconstrictorsliketerlipressin,octeotrideorsomatostatin.
labtestsusedinevaluationofliverdiseaseeitherassessliverfunctionality(PT,bilirubin,albumin,
cholesterol)orstructuralintegrityandcellularintactness(transaminases,ggt,alp).aprogressive
decreaseintransaminaselevelssignalseitherrecoveryfromliverinjuryorthatfewhepatocytesare
functional.
CTscanisthebestfordiagnosingandevaluatingtheabdomenofpatientsduringanacuteepisodeof
diverticulitis.
patientspresentingwithacuteappendicitisbutdonotseekmedicalcareuntil>48hoursafterthe
onsetofsymptomshaveahighriskofperforationintotheperitonealand
retroperitonealspacescausingperitonitisoranabscess.psoassign(flexionofhipproducing
abdominalpain)issuggestiveofapsoasabscesswhichisaknowncomplicationofaperforated
appendix.treatwithintervalappendectomy.
amoebiasisisaprotozoaldiseasecausedbyentamoebahistolytica.theprimaryinfectionisinthe
coloncausingbloodydiarrhea.howevertheamoebamaybetransportedtotheliverbyportal
circulationcausinganamoebicliverabscess.theyareusuallysingleandifitsonthesuperiorsurface
oftheliveritcancausepleuritictypepainandradiationtotheshoulder.diagnosebystoolexamfor
trophozoites,serology,andliverimaging.treatwithmetronidazole
ajejunalulcerisalmostpathgnomonicforzollingerellisonsyndrome/gastrinoma.patientsmayget
steatorrheabecauseofincreasedproductionofstomachacidinactivatespancreaticenzymes.to
testforzollingerellisondofastingserumgastrinlevels.
postcholecystectomypainmostcommonlyoccursduetooneofthreereasons:1)commonbile
ductstone2)sphincterofoddidysfunctionor3)functionalcauses.treatfunctionalpainwith
analgesicsandreassurance.
inflammboweldiseaseismostlikelyinapatientwithasubacutetochronicpresentationof
abdominalpain,tenesmus,andbloodydiarrhea.inpatientswithibdandworseningsymptoms
accompaniedbysignsofsepsis,toxicmegacolonshouldbeconsideredandanabdominalxrordered
toconfirm.
diverticulosisisthemostcommoncauseoflowergastrointestinalhemorrhage(grossbleeding)inan
elderlypatient.typicallypainless.
acuteascendingcholangitisischaracterizedbycharcotstriadof1)fever2)severejaundiceand3)
RUQabdominalpain.4)confusionand5)hypotensionmayalsobeobservedwithsuppurative
cholangitisproducingreynoldspentad.ifsymptomspersistthenthereisanindicationforurgent
biliarydecompressionpreferablybyendoscopicretrogradecholangiopancreatography(ercp).
theabsenceofperistalticwavesinthelower2/3oftheesophagusandsignificantdecreaseinlower
esophagealsphincter(LES)tonearecharacteristicforesophagealdysmotilityassociatedwith
scleroderma.diffuseesophagealspasmischaracterizedbychestpainanddysphagia,notheartburn.
manometrymayrevealperiodic,highamplitude,nonperistalticwaves.
somaticpainiswelllocalizedandintheabdomenisusuallysecondarytoperitonealinflammation.
visceralpainisvagueinlocalizationandduetomechanicalstretchingoftheabdominalviscera.
visceraisvague,peritonealisprecise
inapatientwithdirecthyperbilirubinemiathecausescanbeduetointrahepaticorextrahepatic
obstruction.hepatocellulardiseaseslikeviral/autoimmunehepatitis,alcoholichepatitis,willhave
elevatedaminotransferaseswhereasthereisadominantelevationofALPhavepredominantintraor
extrahepaticbiliaryobstruction.

thetwodrugsapprovedforchronichepatitisbareinterferonandlamivudine.chronichepb
presentswithpersistentlyelevatedaltlevels,detectableserumHbsAg,HbeAg,andHBVdna.
massivedosesofasiprinandNSAIDscancauseacuteerosivegastritisanduppergibleeding.alcohol
canaggravatethiseffect.
NASHappearshistologicallysimilartoalcoholichepatitis.impairedresponsivenessoffatcellsto
insulin,thereboycausingaccumulationoffatintheliver.steatosiscanthenprogressto
steatohepatitisandfibrosis,secondarytolipidperoxidationandoxidativestress
bacterialovergrowthisamalabsorptionsyndromewhichcanbeassociatedwithahistoryof
abdominalsurgery.physicalexamfindingsmayrevealabdominaldistentionwithidentifiable
succussionsplashfrompalpable,soft,fluidfilledloopsofbowel.
reyesyndromeoccursinchildrenwhotakeaspirin.characterizedbydiffusemitochondrialinjury
leadingtonausea,vomiting,headache,hypoglycemia,liverfailureandcnsdamage.extensivefatty
vacuolizationoftheliverwithoutinflammation.liverisenlargedbutthereisnoicterus.
inpatientswithdysphagiawherethedifferentialsarebroad,abariumesophagramisusually
performedbeforeupperendoscopy.
progestinscanhelpforcancerinducedcachexia.(pregnantwomengethungry??)
ruptureoftheesophagus(boerhaavessyndrome)occursaftersevereretchingandpresentsaschest
orepigastricpain,nausea,vomiting,fever,andunilateralpleuraleffusion.
zenkersdiverticulumoftenhavefoulsmellingbeathsecondarytopoolingofmaterialinthe
diverticulum.increasedriskforaspirationpneumonia.contrastesophagramisthediagnostictestof
choice.
treatmentforascites:saltandwaterrestriction>spironolactone>loopdiuretic>paracentesis
(checkrenalfunction)
gilbertssyndromeisafamilialdisorderofbilirubinglucuronidationwhereudpgtenzymeproduction
isreduced.manifestsasicterussecondarytoamild,unconjugatedhyperbilirubinemia(shouldbe<
34).certaineventslikefasting,hemolysis,physicalexertion,febrileillnessetcarethoughttotrigger
anexacerbation.treatmentisgenerallyunnecessary.criglernajjartype1hasseverejaundiceand
neurologicalimpairmentduetokernicterusandunconjugatedhyperbilirubinemia(2025mg/dl).
liverenzymesandhistologyarenormal.ifivphenobarbitalisgiventheserumbilirubinremains
unchanged.livertransplantisonlycure.criglernajjartype2ismilderdisordercharacterizedbylower
serumbili<20mg/dl.nokernicterus.

hematology/oncology

acutedropinhemoglobincausedbyhyperhemolyticcrisis,splenicsequestration,oraplasticcrisis
paroxysmalnocturnalhemoglobinuriacanhavehepaticveinthrombosis
warfarinactivityisincreasedbyVitE(supplements)andfoodsrichinvitaminkwilldecreaseit's
efficacy
acutegraftvshostdisease(gvhd)presentswithskin(maculopapularrash)intestines(diarrheawith
blood)andliver(abnormalLFTsandjaundice)
bronchogeniccystsarelocatedinthemiddlemediastinum.thymomaisusuallyfoundinthe
anteriormediastinum.allneurogenictumors(likeneuroblastoma)arelocatedintheposterior
mediastinum.
sicklecellpatientscangetstrokeduetoocclusionandsludginginthecerebralvessels.treatwith
exchangetransfusion
sicklecellanemiawillhavereticulocytosisduetochronicextravascularhemolysis.
mostheadandneckcancersaresq.cellcarcinomas.willhaveanormalcellcount
intumorlysissyndromeyoureleaseallthek+andphopshate.phosphatebindscalciumleadingto
hypocalcemia.
waldenstromsmacroglobulinemiacanhavedemyelinatingsensorimotorneuropathy,easybruising,
hepatosplenomegaly.

hypersegmentedneutrophilsseeninfolatedef.andb12(cobalamin)defwhichwillincrease
homocysteine.onlyb12deficiencyraisesmethylmalonicacid.
hereditaryspherocytosisleadstocholecystitisduetopigmentstones.
withchemotherapyandradiationforhodgkinsdiseasedevelopasecondarymalignancy.riskis
highestwhenchemotherapyiscombinedwithradiation.
hodgkinsdiseaseisacurablelymphomatendingtoaffectyoungerpatients.about3%ofpatients
treated
inayoungchildamicrocyticanemiaislikelytobeirondeficiencyorthallasemia.rdw(rbc
distributionwidth)cantellyouthedifferenceifits>20%thenmostlikelytobeirondeficiency
anemia.
unconjugatedbilirubinishighlyinsolubleinwater(toxic,goestobrain),doesnotgotourine.
conjugatedbilirubingoestotheurine.
hereditarytelangiectasia(oslerweberrendusyndrome)isanautosomaldominantdisorder
characterizedby1)diffusetelangiectasias2)widespreadavms3)recurrentepistaxis.inthis
syndromeavmstendtooccurinmucousmembranes,skin,gitract.theavmsinlungcanshuntblood
fromrighthearttoleftheart,causingchronichypoxemiaandreactivepolycythemia.
acutehemolytictransfusionreactiondevelopsanhouraftertransfusionstarts.lifethreatening
reactionresultingfromtransfusionofmismatchedblood,typicallyabomismatch.rapidlydevelop
fever,hemolysis,shock,anddic.delayedhemolytictransfusionresultsfromanamnesticresponseto
aminorrbcantigenwhichhasbeenpreviouslyencountered.lowgradehemolysis210daysafter
transfusion.reactiontocytokinespresentswithtransientfevers,chills,malaise.washrbcblood
products.
patientswithsicklecelldiseasehavefunctionalaspleniaby23years.needimmunizationsagainsth.
influenzaands.pnuemoniae.highgradefever,hypotension,alteredmentalstatus,elevatedwbc
withbandemiaissuggestiveofsepsis,whichismostcommonlycausedbypneumococcusinsickle
cell.
multipleepisodesofthrombosiswithoutaclearprecipitatingfactorshouldraiseconcernfor
hypercoagulabilityduetoageneticdefectinayoungerpatient,oraprimarymalignancyinanolder
patient.
anemiaofchronicdiseasehasdecreasediron,decreasedtibc(wantstobindironless),anddecreased
ironsaturationwithincreasedorelevatedferritin(storageiron)levels.
sinopulmonaryandgiinfectionswithtransfusionreactionpointtoigadeficiency.patientsform
autoantibodiestoiga.
patientswithsicklecellanemiamayexperiencepainfulvasoocclusiveepisodeswhichmaybe
triggeredbyinfection,dehydrationorhypoxia.hydroxyureaisindicatedinpatientswithfrequent
acutepainfulepisodes(>6/year).folicacidsupplementationishelpfulinpreventingaplasticcrisis.
febrilereactionisacommontransfusionreactionthatiscausedbyantibodiesinthepatientsplasma
reactingwiththedonorsleukocytes.cellwashingdecreasestheprobabilityoffebrilenonhemolytic
transfusionreaction.nohemodynamicabnormalitiesandrenaldysfunctionareusuallypresent.
acutehemolytic=abomismatch,delayedhemolytic=minorrbcantigen
inapatientwhogetshit(heparininducedthrombocytopenia)andneedstobeanticoagulatedstop
heparinimmediatelyandstartargatroban.suspectheparininducedthrombocytopeniawhen:
plateletcount<50%frombaseline,arterialorvenousthrombosis,necroticskinlesionsatheparin
injectionsites,acutesystemicreactionsafterheparin.diagnosis:serotoninreleaseassayisthegold
standard
glucose6phosphatedehydrogenasedeficiencyisanxlinkedrecessivedisordercommonlyseenin
africanamericanmen.hemolyticepisodesinresponsetooxidantdrugs,infections,orfavaeans.
heinzbodiesareseenintheperipheralbloodsmear.
howelljollybodiesarenuclearremnantswithinrbcstypicallyremovedbythespleen.theirpresence
stronglysuggestsphysicalorfunctionalhyposplenism.

patientswhodevelopseriousbleeding(e.g.intracerebralhemorrhage)duetoexcessanticoagulation
withwarfarinshouldbegivenffpfortherapidreversalofanticoagulation.vitaminkreverses
warfarinactionbuttakes812hourstobeeffective.(inreallifegiveboth)
warfarininhibitsproteincproductioninthefirstfewdaysitsgiven.>skinnecrosis.proteincis
anticoagulation.withnoproteinc>clot
HUSis
1)thrombocytopenia
2)renal
3)hemolyticanemia
(ifyouaddneuroandfeveryouhaveTTP).TreatmentforHUSisPlasmapheresis(plasmaexchange)
andsteroids,addfreshfrozenplasma
diccanpresentinapatientwithbreastcancer.labvaluesshowthrombocytopenia,decreased
fibrinogen,increasedINR,elevatedldh,elevatedreticulocytecountandbilirubin
macrocyticanemiawiththrombocytopeniaandleukopeniaaswellasneutrophilswithreduced
segmentationcanoccurinmyelodysplasticsyndromes.confirmwithbonemarrowbiopsy
patientswithasplenectomywillhavethrombocytosisb/cspleenremovesoldplateletsfromthe
circulation.
patientswithdvtinwhomanticoagulationiscontraindicatedrequiresplacementofinferiorvena
cavafiltertopreventpulmonaryembolism.
anaphylacticreactionstotransfusedbloodproductsoccurrarely,butaremorecommoninpatients
withigadeficiency.rapidonsetofsymptomswithassociatedbronchospasmandhypotensionplus
theabsenceoffeverhelptodistinguishanaphylaxisfromotherpossibletransfusionreactions.abo
mismatchingpatientshaverapidhemolysiswithmanifestationsoffever,flankpain,darkurineand
dic.amamnesticantibodyresponsetoaminorrbcantigencanleadtodelayedhemolysisseveral
daysaftertransfusion.reactiontocytokines=feverchillsmalaise.
patientswithalphathalassemiaminororbetathalassemiaminorwillhaveimpressivemicrocytosis
(mcvcanbein70s)butonlymodestanemia.reassuranceisonlyinterventionthatisneeded.patients
withthalassemiamajoraregenerallyseverelysymptomaticandtransfusiondependent.
spontaneoushemarthrosisshouldgivesuspicionforhemophiliaforwhichfactor8assayis
diagnostic.prolongedptt,normalpt,normalbt,andnormalfibrinogenlevelandlowserumfactor8
arethelabfindings.treatmentistoreplacefactor8.ifmildcantreatwithdemospressin.do
coagulationstudiestodiagnosefollowedbyfactor8and9levels.
arterial/venousthrombosisandthrombocytopeniainpatientsrecievingheparintherapyissuggestive
ofheparininducedthrombocytopenia.antibodiesagainstheparinplateletfactor4complexare
responsible.
schillingtesthelpsdifferentiatebetweendietarydeficiencyfromperniciousanemiaand
malabsorptionascausesofvitb12deficiencyandmegaloblasticanemia.giveoralradiob12and
intramuscularb12.checkurinaryexcretion.ifurinehasradioactiveb12thenabsorptionisnormal
anddietarydeficiency.iflowradioactiveb12inurinethenitsduetopoorabsorption.sodopart2
todifferentiatebetweenperniciousanemiaormalabsorption.giveradiob12withintrinsicfactorand
checkurine.lowexcretionofb12aftergivingifrulesoutperniciousanemiaandsuggests
malabsorption(pancreaticinsuffic,bacterialovergrowth,shortgutsyndrome).normalexcretion
afteraddingifsuggestsperniciousanemia.
inapatientwithadvt,treatwithheparinandwarfarinforthefirst5days.after5daysiftheinris
therapeutic(23)thentheheparinmaybediscontinuedandwarfarincontinuedfor6months.a
progressingclotinapatientwithasubtherapeuticinrrequiresbridgingheparinuntiltheinris
therapeutic.
st
ffphasalltheclottingfactorsandis1 linetreatmentforbleedingpatientswithacoagulopahy.
factor5leidenisthemostcommoninheriteddisordercausinghypercoagulabilityandpredisposition
tothromboses.

hemolyticanemiainapatientwithamalignantlymphoproliferativedisorderislikelytobeofthe
warmautoimmunetype,causedbyantirbciggantibodies.giveprednisone,ifnoteffectivethendo
splenectomy.
vitaminkdeficiencycanbeseeninapatientwhohasbeenkeptnpoforaprolongedtimeand
receivingbroadspectrumantibiotics.labsshowprolongedPTfollowedbyprolongedptt.
cysticfibrosiscanleadtoimpairedabsorptionoffatsolublevitamins.vitaminkisnecessaryforpost
translationalmodificationofseveralanticoagulantfactors:279and10aswellasproteincands.
nsaidscauseirondeficiencyanemiathroughchroniclowgradebloodlossperthegitract.anemiaof
chronicdiseasecanbeseeninrheumatoidarthritis,butnotgenerallyseeninosteoarthritis.
(osteoarthritisisnotactuallyaninflammatorycondition)
radiationtherapyisthemostappropriatemanagementforbonepaininapatientwithprostate
cancerafterandrogenablation(orchiectomy).
presenceofthrombocytopeniahasapoorprognosisincll.
stage0=lymphocytosisonly.
stage1=lymphocytosis+adenopathy.
stage2=splenomegaly
stage3=anemia
stage4=thrombocytopenia
elderlypatientwithbonepain,renalfailureandhypercalcemiahasmultiplemyelomauntilproven
otherwise.obstructionofdistalandcollectingtubulesbylargelaminatedcastscontaining
paraproteins(bencejonesprotein)causesrenalfailure.
serotoninantagoniststhatblock5ht3receptorsaredrugsofchoicefortreatingandpreventing
chemotherapyinducednauseaandvomiting.(ondansetron)
elevatedserumproteinwithnormalalbumin(gammagap)suggestsdisorderslikemultiplemyeloma,
waldenstromsmacroglobulinemia,andmonoclonalgammopathyofundeterminedsignificance.
mgusisanasymptomaticelevationofamonoclonal(m)proteinonspep.diagnosisismadeby
excludingmultiplemyeloma(anemia,pancytopenia,hypercalcemia,bonylyticslesions,andrenal
disease).mguspatientsusuallyhave<3g/dlwith<10%ofplasmacellsfoundinbonemarrow.mm
patientshave>3g/dlmproteinonspepwith>10%plasmacellsinthebonemarrow.
myeloproliferativedisordershavethejak2mutation.iftheyhavepolycythemiaverathentheepo
willbelow.willhavesymptomslikeheadache,dizziness,visualdisturbancesduetohyperviscosity.
pruritisduetoreleaseofhistamineandprosaglandins.facialplethora,hepatosplenomegaly.bcr
ablmutationisseenincmlpatients.
allisthemostcommonleukemiainchildren.mayhaveahxofviralrespiratoryinfectionor
exanthem.onphysicalexamtheremaybepallor,hepatosplenomegaly,petechiae,and/or
lymphadenopathy.diagnosisissuggestedbyanemia,thrombocytopenia,andblastcells(>25%)ona
peripheralsmear.
mmhasbackpain,anemia,renaldysfunction,andelevatedesr.hypercalcemiafrommmmay
manifestassevereconstipation,anorexia,weakness,increasedurination,orneurologic
abnormalities.
rituximabisamonoclonalantibodydirectedagainstthecd20antigenonblymphocytesthatisoften
usedtotreatpatientswithsymptomaticcll.patientswillhavesmudgecellsandcanhave
autoimmunehemolyticanemiaandimmunethrombocytopenia.
malignantmelanomametstovariableplacesinthebodyandliedormantfor1525yearsandthen
recurevenwhentheprimarytumorwasresected.malignantmelanomasareknownforcausing
bleedinginsidethemetastaticmassinthebrain.
sq.cellcarcinomaofthemucosaofthehead/neckiscommoninpeoplewithasignificanthistoryof
alcoholandtobaccouse.thefirstmanifestationmaybeapalpablecervicallymphnode.bestinitial
testispanendoscopy(tripleendoscopy=esophagoscopy,bronchoscopy,laryngoscopy)todetectthe
primarytumor.
patientswithmultiplemyelomacantmakefunctionalantibodiesandleukopeniathatdevelopsas
bonemarrowisfilledwithmalignantplasmacellssotheyareatanincreasedriskforinfection.

areciprocaltranslocationof9:22resultsinphiladelphiachromosomecontainingthebcr/ablfusion
gene.findthisincml.tyrosinekinaseinhibitorsfunctionbyinhibitingtheabnormalbcr/ablgenelike
imatinibareakeycomponentoftreatmentforcml.retinoicacidreceptorisusedtotreatacute
promyelocyticleukemia.
pthrpisproducedlocallywhenthetumormetsintothebonetoinduceboneresorption.
acutemonocytic(fabm5)leukemiahasadramaticonsetwithheadaches,fevers,weightloss,and
bleedingfromthegums/nose.+alphanaphtylesterasetestischaracteristic.acutepromyelocytic
leukemiaischaracterizedbyauerrodsincells.highincidenceofdicinthisleukemia.

infectiousdisease

serousotitismediaismostcommonmiddleearpathologyinAIDS.hivlymphadenopathyor
lymphomas.dulltympanicmembranethatishypomobile.
fordisseminatedhistoplamosischeckantigeninurineorserum.Disseminatedhistoplasmosiscan
causeoralulcers,andbonemarrow(pancytopenia)
giveallpatients>65orwithcomorbiditiespneumococcalvaccine
primaryhivassociatedthrombocytopeniaasymptomaticthrombocytopeniaispresentationin10%
ofHIVcases.Treatwithzidovudine
malignantotitisexternatreatedwithantipseudomonal(ciprofloxacin).symptomsaregranulation
tissueanddischarge
inrhinitisifyoudontfindcausebyhistoryandphysicalexamdonasalcytology.neutrophils=
infectious,eosinophils=allergic,vasomotor=noeosinophils
nasopharyngealcarcinomacanpresentw/recurrentotitismedia,recurrentepistaxis.strongly
associatedwith+serologyforEBV.mediterraneanandfareasterndescent.
necrotizingfasciitshaspurplishdiscolorationoftheskinwithgangrenouschangesandsystemic
toxicity.
themostfearedcomplicationofaretropharyngealabscessisspreadofinfectionintothe
mediastinum,whichcanleadtoacutenecrotizingmediastinitis.recenthistoryofURI,pharyngitis,
otitis,sinusitis,etc.happensinchildren.symptomsaresorethroat,dysphagia,neckstiffness,muffled
hotpotatovoice.
patientswithretropharyngealabscesscomplainofsorethroat,fever,difficultyswallowing
(dysphagia)andpainwithswallowing(odynophagia)andpainwithcertainneckmovements.treat
rapidlytopreventthespreadofinfectionintothemediastinum.
EBVDNAintheCSFisspecificforprimaryCNSlymphoma.willhaveasolitary,weaklyringenhancing
massintheperiventriculararea.
cutaneouslarvamigranscausedbyhelminthA.braziliense.foundintropicalregions.itchy,elevated
serpiginouslesions.contactbysand
progressivemultifocalleukoencephalopahy(PML)iscausedbyJCvirus.MRIwillshowmultiplenon
enhancinglesionswithnomasseffects.toxoplasmosiswillberingenhancing.CNSlymphomais
single,weaklyenhancing.
bacillaryangiomatosishasacutaneouslesionofalargepedunculatedexophyticcapsulewitha
collarette.likeacherryangioma.visceralangiomalikebloodvesselgrowths.CausedbyBartonella
henselaeinfections,foundinAIDSpatients.
herpeszosteropthalmicushasdendriformcornealuclersandconjunctivitis
nocardiaistreatedwithtmpsmx.branching,beaded,gram+partiallyacidfastpneumoniacausinga
cavitarypulmonaryinfection.
CMVretinitsinHIVpatient<50CD4.yellowishwhitepatchesofretinalopacificationandretinal
hemorrhages.
rubellahasposteriorcervicalandpost.auricularlymphadenopathyandpolyarthralgia.Rashbegins
attheheadandmovesdown.

condylomaaccuminata(anogenitalwarts)causedbyHPV.skincoloredverrucouspapilliformlesions
aroundanus.treatmentispodophyllinortrichloroaceticacid.
erythemamultiformeisanextrapulmonarymanifestationofM.pneumonia.duskyred,target
shapedskinlesions.
malariacausesanemiaandsplenomegalywithcyclicalfevers
HIVshouldgetMMRandvaricellalivevaccinesiftheirCD4is>200andnotimmunetoMMR(titers)
amoxicillinclavulanateisantibioticofchoiceforpolymicrobialhumananddogbites.
leukoplakiaisawhitishplaquethathasagranularappearanceandisnotscrapedoff.cantransform
intoSCC
epiglottitisiscausedbyH.influenzaandS.pyogenes.highgradefever,sorethroat,odynophagia,
drooling,muffledvoice,shrillonexpiration.hasthumbsign.
S.pneumoniaeisacapsularpolysaccharidevaccinethatinducesaTcellindependentBcellresponse
doaCTscantodiagnoseintraabdominalabscess.psoasabscesscanpresentw/fever,wbccount
increased,lowerabdominalorbackpain.canoccurduetoperforatedappendicitis.
forlocalimpetigo(superficial)usetopicalmupirocinororalerythromycin.notpenicillinbecauseS.
aureusisresistant
longtermsequelaeassociatedwithbacterialmeningitisinclude:1)lossofcognitivefunction2)
hearingloss3)seizures4)MR5)spasticityorparesis
mostcommoncauseofviralmeningitisarethenonpolioenteroviruseslikeechovirusand
coxsackieviruses.
ludwigsanginaisinfectionofthesubmandiblarandsublingualglands.thesourceofinfectionis
mostcommonlyaninfectedtooth.asphyxiationisthemostcommoncauseofdeath.presentswith
odynophagia,fever,dysphagia,anddrooling.
mycobacteriumaviumcomplexprophylaxisbygivingazithromycintoaidspatients.cd4<50will
havecoughandfever.forcmvinfectiongiveprophylaxiswhencd4<50andserumCMVIgGis
positiveor+biopsyforCMV.
histoplasmacapsulatumiscommonandusuallyasymptomaticinfectioninendemicareaslike
mississippi/ohio/missouririvervalleysandcentralamerica.Disseminatedgoestobones
treatmentfortoxoplasmosisissulfadiazineandpyrimethamine.
nocardiaisgram+partiallyacidfastfilamentousbranchingrodcausinglungcavities,ornodulesin
HIVpatients.treatmentistmpsmx.Disseminatestoskinandbrain
apatientfromcali/arizonawithpulmonaryinfectionandcutaneousfindingslikeerythema
multiformeanderythemanodosumhascoccidiodomycosis.
septicarthritiscanresultinrapidandpermanentjointdestruction.synovialfluidaspirationthat
shows>100kleukocytes>90%pmns,andpurulentfluidshouldpromptorthopedicconsultationfor
emergencysurgicaldrainage.
inHIVpatientsbothHSVandVZVcancausesevereacuteretinalnecrosisassociatedwithpain,
keratitis,uveitis,andfundoscopicfindingsofperipheralpalelesions.CMVretinitisispainless,not
associatedwithkeratitisorconjunctivitis,andhashemorrhagesorfluffy/granularlesionsaround
retinalvessels.
tmpsmxcancausehyperkalemia.sodoessuccinylcholine,NSAIDs,heparin,nonselectivebeta
blockers,anddigoxin.
N.gonorrheasepticarthritiscanpresentasanoligoarthritisthatisasymmetricwithtenosynovitis
andskinrash.
legionellacausesgastrointestinalsymptomswithpneumonia.abdominalpainandloosestoolsand
alsocanhavehyponatremiaandelevatedLFTs.
fulminanthepatitishasamortalityrateof>80%soputonlivertransplantlist.notsteroids,
interferonorlamivudine.
rheumaticfever:sorethroat,fever,pericarditis,erythemamarginatum,arthritis,chorea,
subcutaneousnodules.JONES(joints,heart,nodules,erythema,syndehamchorea)

trichinellacausestrichinellosisacquiredbyeatingundercookedpork.threephasedisease1)larvae
invadeintestinalwall.abdominalpain,nausea,vomiting,diarrhea.2)localandsystemic
hypersensitivityreactioncausedbylarvalmigration,hassplinterhemorrhages,conjunctivaland
retinalhemorrhages,periorbitaledemaandchemosis.3)larvaeentermusclecausingmusclepain,
tenderness,swelling,andweakness.Eosinophilia
rubellasrashiserythematousandmaculopapular.startsonfaceandprogressestotrunkand
extremities.adultwomenusuallypresentwitharthritis.occipitalandposteriorcervical
lymphadenopathyalsosuggestthisdiagnosis.
N.gonorrheaurethritisislesscommonthanchlamydialurethritis.thedischargeispurulentandnot
mucopurulentlikeitisinchlamydia.
peritonsilarabscesspresentswithsorethroat,muffledhotpotatovoiceanddeviationofthe
uvula.itsacomplicationoftonsilitis.generallyhaveunilaterallymphadenopathy.treatwithneedle
peritonsillaraspiration.
Ifpatienthasuncomplicatedpyelonephritiscanswitchtooralantibioticafter23daysofparenteral
therapy.
patientwith+PPDshouldbegivenisoniazid+pyridoxinefor9months.
blastomycosisoccursnearthegreatlakes,mississippiandohioriverbasins(wisconsin).symptomsof
lunginfectionmayresembletuberculosisandhistoplasmosis,howeveralsocausesulceratedskin
lesionsandlyticbonelesions.blaststheboneandskin
allnewlydiagnosedHIVpatientsshouldhave:CD4count,VDRL,PPD,antitoxoplasmosistiter,
pneumococcalpolysaccharidevaccineunlessCD4<200,HAV/HBVvaccinesifseronegative
patientwithheadachesandfocalneurosymptomsafteracuteotitismediaorsinusitismostlikelyhas
brainabscess.willappearasringenhancinglesiononCTorMRI
enterohemorrhagicE.coli(EHEC)causesabdominalpain,bloodydiarrhea,withnofever.itproduces
ashigatoxinthatcausesbloodydiarrhea.
invasive/disseminatedaspergillosisoccursinimmunocompromisedpatientswithfever,cough,
dyspnea,orhemoptysis.CXRwillshowacavitarylesion,andCTwillshowpulmonarynoduleswitha
halosign,orwithanaircrescent.histoplasmosiswillshowhilarlymphadenopathyand
coccidiodomycosiswillhavepulmonaryinfectionandcutaneousfindings,likeerythemamultiforme
anderythemanodosumandarthralgias.
ifawoundissevereordirty,andnotimmunizedalwaysgivetetanusdipheriatoxoid(td)andgive
tetanusimmuneglobulin(tig).howeverifimmunized<10yearsagotoxoidaloneisfine.for
minor/cleanwoundsifnotimmunizedtoxoidaloneisfine,ifimmunized<10yearsagothenno
treatment.
blastomycosisaffectslungs,skin,bones,jointsandprostate.cutaneousdiseaseiseitherverrucous
orulcerative.verrucouslesionsarepapulopustularthenbecomecrusted,heapedupandwartywith
aviolaceoushue.wetprepwillshowtheyeastformoftheorganism.
oraltmpsmxiseffectiveinpreventingpcpinfectionintransplantpatients.
doxycyclineisgoodfortreatinglymediseaseandcoexistinganaplasmaphagocytophilumhoweverin
childrendoxyiscontraindicatedsouseoralamoxicillintotreatlyme.
primaryhivinfectioncanpresentwithamononucleosislikesyndromeconsistingoffever,night
sweats,lymphadenopathy,arthralgias,anddiarrhea.
commonacutelifethreateningreactionsassociatedwithhivtherapyinclude:
didanosine(nrti)pancreatitis
abacavir(nrti)hypersensitivity/rash
anynrtilacticacidosis
anynnrti(vir)stevensjohnsonsyndrome
efavirenz(nnrti)CNS
nevirapine(nnrti)hepatotoxicity
indinavir(proteaseinhibitor)crystalinducednephrotoxicity
inpatientswithchronichepatitisc,iftheirliverenzymesarepersistentlynormalonmultiple
occasionshaveminimalhistologicalabnormalitiesanddonotneedtreatment,justfollowup.

ehrlichiosisisatypeoftickborneillnessthatiscausedbyoneofthreediff.speciesofgram
bacteria,eachwithadifferentvector.endemicinthese,southcentral,midatlantic,andupper
midwestregionsofusaswellascalifornia.clinicalfeaturesinclude:fever,malaise,myalgias,
headache,nausea,vomiting.usuallynorashhencethenamespotlessrockymountainspotted
fever.labsshowleukopeniaand/orthrombocytopeniaalongwithelevatedaminotransferases.
treatmentisdoxycycline.
inHIVpatientwithCD4>200andnoevidenceofAIDSdefiningillnessgiveMMRvaccine.
disseminatedN.gonorrheainfectionoftenpresentswithatriadof1)polyarthralgias2)
tenosynovitisand3)vesiculopustularskinlesions.
intheadultformofbotulism,thepatienteatsthetoxinandgetssymptoms.ininfantilebotulism
theinfanteatsthebacteria(infood)anditthenproducesthetoxinintheintestinaltract.blocks
AChrelease.presentswithconstipationandpoorfeeding,followedbyhypotonia,weakness,lossof
deeptendonreflexes,cranialnerveabnormalitiesandrespiratorydifficulties.signsofautonomic
dysfunctioncanoccurearlyindiseasecourse.
S.pneumoniaeisthemostcommonpathogencausingpneumoniainnursinghomepatients.
measlesischaracterizedbyaprodromeofcough,coryza,conjunctivitis,followedbykopliksspots
andmaculopapularrashinitiallyappearingonthefacecausedbyparamyxovirus.
inanimmunocompromisedpatientalesiononthefootthatiserythematousandedematousbut
laterdevelopsintoabullasurroundedbyerythemaandthenrupturesleavingapainlessulcerwitha
blackcenterisP.aeruginosa.lesioniscalledecthymagangrenosum,lookslikeanthrax.treatwith
antipseudomonalpenicillins(piperacillin/ticarcillin)
aspirationpneumoniaCXRtypicallyshowsconsolidationofthedependentlungsegments,which
includestheposteriorbasalsegmentoftherightlungifthepatientaspirateswhileinasupine
position.
CXRintuberculosiswillshowaupperlobeinfiltratewithcavitationandhilarlymphadenopathy
patientswhoareincarceratedhaveanincreasedriskfortuberculosis.tuberculosisinvolvingthe
vertebrae(Pottsdisease)typicallypresentswithchronicbackpainofinsidiousonset.epidural
abscessinlumbarregionofspinehasacuteonsetbackpainandfever.diabetics,ivda,andpatients
withrecentspinaltraumaareatincreasedrisk.S.aureusisthemostcommonetiologicalagent.treat
withvancomycinandsurgicaldrainage
rheumaticfeverislinkedtostreptococcalpharyngitis(S.pyogenes)butnotusuallyseenfollowing
impetigo.strepimpetigocanleadtoglomerulonephritis.
efavirenzisanNNRTIthatcausesCNSsideeffectsinupto50%ofpatients.
proteusisthemostlikelycauseofUTIinpatientswithalkalineurine.
legionellapneumoniaisintracellulargramorganismspreadbycoolingtowersandwatersupplies.
travelassociatedinfectioniswelldocumented.cough,fever>39C,gastrointestinalsymptomsand
confusion.diagnosebyurineantigentestingorcultureoncharcoalagar.treatwithazithromycinor
levofloxacin.alsohashyponatremiaandelevatedLFTs
recurrentpneumoniasinthesameanatomicregionofthelungsuggestsbronchialobstruction,itsa
redflagforlungcancer.whenlungcancerissuspecteddoaCTscanofthechest.bronchoscopicorCT
guidedbiopsymaythenbeperformeddependingonwhetherthelesionhasaperibronchialor
peripherallocation.
herpesmainlyaffectstemporalregionofthebrainandmaypresentacutely(<1weekduration)with
focalneurologicalfindings.CSFhaslymphocyticpleocytosis,increasederythrocytesandelevated
protein.HSVpolymerasechainreactionisthegoldstandard.
chloroquineresistantPlasmodiumfalciparumisparticularlycommoninsubsaharanafricaandindian
subcontinent.mefloquineisdrugofchoiceforchemoprophylaxis.meflyingtotravel
useamoxicillininthetreatmentofapregnantpatientorlactatingpatientswithlymedisease.
doxycyclineiscontraindicated.
suspectCMVpneumonitisinanypatientwithabonemarrowtransplant(bmt)withlungand
intestinalinvolvement.CXRwillshowmultifocaldiffusepatchyinfiltrates.CTwillshowparenchymal
opacificationormultiplesmallnodules.bronchoalveolarlavage(bal)isdiagnostic.otherthan

pneumonitisitmanifestsasupper/lowergastrointestinalulcers,bonemarrowsuppression,
arthralgias,myalgiasandesophagitis.
mostcommoncauseofdysphagia/odynophagiainHIVpatientiscandidalesophagitis.ifpersists
despitetherapy(fluconazole)theninvestigateotherpossibilities.HIVpatientswithsevere
odynophagiabutwithoutoralthrusharelikelytohaveulcerativeesophagitiscausedmost
commonlybyCMV.triadof1)focalsubsternalburningpainwithodynophagia2)evidenceof
large,shallow,superficialulcerationsand3)presenceofintranuclearandintracytoplasmic
inclusionsisdiagnosticofCMVesophagitis.treatmentisganciclovir
synovialfluidwillshowaninflammatoryprofilewithaverageleukocytecountof25,000inlyme
arthritis.
treatmucormycosiswithamphoteracinb.ifnecrotictissueispresentneedsurgicaldebridement
erysipelasisaspecifictypeofcellulitis.characterizedbyinflammationofthesuperficialdermis,
therebyproducingprominentswelling.classicfindingisasharplydemarcated,erythematous,
edematous,tenderskinlesionwithraisedborders.systemicsignsusuallypresentincludingfeverand
chills.legsaremostfrequentlyinvolvedsite.mostlikelycausativeorganismisgroupAbetahemolytic
streptococcus(S.pyogenes).
N.meningitidesvaccineshouldbegiventoapersonregardlessofHIVstatus.collegeageorlivingin
barracksordormitories,patientswhoareasplenicandthosewithtravelexposures.allHIVpatients
shouldgettdboosterevery10years.
inanHIVinfectedpatient,bloodydiarrheaandanormalstoolexamaresuspiciousforCMVcolitis.
CMVmaycauseesophagitis,gastritis,colitis,proctitisorsmallboweldisease.colonoscopywillshow
multiplemucosalerosionsandcoloniculceration.biopsywillshowthepresenceoflargecellswith
eosinophilicintranuclearandbasophilicintracytoplasmicinclusions(owlseyeeffect).treatment
ofchoiceisganciclovirorfoscarnet
treattineacorporis(ringworm)withtopicalantifungalsliketerbinafine.superficialfungalinfection
seeninhot,humidclimates.lesionsarepruritic,erythematous,scalyandhavearedringwithcentral
clearing.mostcommoninpreadolescents.diagnosedwithskinscrapingsandKOHexamination.
HIVpatientswhodevelopesophagitisarefirststartedonfluconazoledirectedagainstcandidiasis.
failuretorespondto35daycourseoforalfluconazolewarrantsfurtherinvestigationwith
endoscopy.
influenzapneumoniahassymptomsofabruptonsetoffever,chills,malaise,myalgias,cough,and
coryza.typicallyoccursinanepidemicpatterninthewinter.patientswilloftenbefebrileandamy
haveavarietyofpulmonaryfindingssuchaswheezes,crackles,andcoarsebreathsounds.
leukopeniaiscommonandproteinuriamaybepresent.CXRmayshowaninterstitialoralveolar
pattern,orbenormal.confirmwithnasalswabforinfluenzaantigenandtreatwithantiviralswithin
48hours.neuraminidaseinhibitorsoseltamivirandzanamivir.rimantadineandamantadineare
otheroptionsbutonlyworkforinfluenzaa.
acuterheumaticfeveraftergroupastreptococcalpharyngitis(S.pyogenes).majorjonescriteria
include:carditis,migratorypolyarthritis,sydenhamchorea,subcutaneousnodules,anderythema
marginatum.minorcriteriaarearthalgias,fever,elevatedacutephasereactants(CRPorESR),
prolongedPRintervalonEKG.musthave2majorcriteria,or1major+2minoralongwithpreceding
groupastrepinfection.
acommoncauseofempyemaisafterahemothorax.bloodinthechest,ifnotevacuated,canget
infected.themajorityofpatientswillpresentwithalowgradefever,dyspnea,andchestpain.
surgeryisrequiredtoremovetheclottedbloodandfibrinouspeel.
brightred,friable,exophyticnodulesinanHIVinfectedpatientaremostlikelybacillary
angiomatosis.causedbybartonella,agrambacillus.oralerythromycinisthetreatmentofchoice.
babesiosisistransmittedbytheixodestick(sametickaslymedisease).endemicinthenortheastern
us.theparasiteentersthepatientsrbcsandcauseshemolysis>jaundice,hemoglobinuria,renal
failure,death.ehrlichiosishasleukopeniaandthrombocytopenia,treatwithdoxycycline.qfeveris
causedbycoxiellaburnetii.mainsourcesofinfectionareinfectedcattle,goat,andsheep.meat

processingworkersandveterinarians.manifestationsofqfevermayincludeflulikesyndrome,
hepatitis,orpneumonia.
B.pertussiscauseswhoopingcough.itisahighlycontagiousinfectionbutitsincidencehas
dramaticallydecreasedbecauseofimmunization.usuallypresentswithsevereboutsofcoughing
spellsafteranURI.coughingspellscanbesoseverethattheycauserectalprolapse,epistaxis,and
pneumothoraces.treatwithamacrolide.
infectiousmononucleoisiscausesfever,sorethroat,jaundice,andmildhepatosplenomegaly.
symmetricallymphadenopathyinvolvingtheposteriorcervicalchainoflymphnodesmore
frequentlythantheanteriorchain.inguinalandaxillarylymphadenopathycanalsobepresent.
tonsillarexudates,tonsilitis,pharyngitisandmildpalatalpetechiaemaybefound,butalsoinstrep
pharyngitis.acomplicationofimisautoimmunehemolyticanemiaandthrombocytopenia.IgM
coldagglutininantibodieswhichleadtocomplementmediateddestructionofRBCs.
disseminatedN.gonorrheainfectionpresentswithhighfever,chills,tenosynovitis,andmigratory
polyarthritisearlyinillness.skinlesionsrangingfrom540andaremostcommonlyseenonthe
extremities.lesionsarediscretepurpuricorpustularwithhemorrhagiccomponentsandoccasionally
centralnecrosis.bloodculturesandculturesfromthecutaneouspustulesareoftennegativedueto
specificgrowthrequirementsofthestrainofN.gonorrheacausingthisdisseminatedformof
infection.nopustulesinacuteHIVsyndrome.
immunocompromisedpatientsgetshingles(herpeszoster)inanareawithconstantburningpain
withoutanyotherphysicalabnormalities.thepainoftenprecedestherashbyseveraldays,orthey
canappeartogether.therashisvesicularinadermatomalpattern.
bloodtransfusionbefore1986shouldbescreenedforHBV.1992forhepc.bforbeforehepc
(1986before1992)
cantscreenforhepatitisBusingHbsAgandantiHbsbecauseofthewindowperiod.insteaddo
IgMantiHbc.
firm,fleshcolored,domeshaped,umbilicatedpapulesaretypicalofmolluscumcontagiosum.
cellularimmunodeficiency,corticosteroiduse,andchemotherapypredisposepatientstomolluscum
contagiosum.commoninpatientswithHIV.
nailpuncturewoundresultinginosteomyelitisismostlikelyduetoP.aeruginosa
fever,headache,focalneurosigns,seizure,spasticityorsignsofincreasedICParepresentationof
brainabscess.brainabscessmorelikelytooccurinpatientswithcongenitalheartdisease,head
trauma,infectionsofjaw/mouth,infectionsofscalp/face,meningitis,cranialinstrumentation.
scabiescausedbySarcoptesscabiei.highlycontagiousdiseasepresentswithgeneralizeditchingand
pruriticpapulesoverthepenisandscrotuminmales,areolasandbreastsinfemales,andinruns
overthefingerwebs,heelsofpalms,andwristcreases.treatwith5%permethincream
postsplenectomypatientsareatanincreasedriskforsepsisfromencapsulatedorganismsdueto
impairedantibodymediatedopsonizationinphagocytosis.intracellularkillingisdefectivein
patientswithchronicgranulomatousdisease,adefectinNADPHoxidase.
aspergillosismayformacavitarylesionbecauseofdestructionoftheunderlyingpulmonary
parenchyma,anddebrisandhyphaemaycoalesceandformafungusball(aspergilloma)whichlies
freeinthecavityandmovesaroundwithpositionchange.
patientswithHIVhavea10%riskperyearofreactivatingtuberculosis.manifestsasfever,night
sweats,weightloss,fatigue,pleuriticpain,chroniccoughandhemoptysis.cxrfindingsclassically
includeanapicalcavitarylesion.coccidiodomycosisresultsinaflulikeillnesswithdyspneaanda
slightlyproductivecough.miliarypatternismostcommonlunglesion(likelittletinydots)
mildmanifestationsofadrugallergy(urticariaandpruritiswithoutsystemicsymptoms)areusually
treatedwithantihistaminesanddiscontinuationoftheaffendingdrug.rashfrom
EBVinfectiousmononoculeosiswhotakeamoxicillinispolymorphousmaculopapularanddevelops
after24hours.
secondarysyphilispresentsasadiffusemaculopapularrashinvolvingthefacetrunkextremities
palmsandsoles,inadditiontogeneralizedlymphadenopathywithsystemic/constitutional
symptoms(fever,malaise,sorethroat???wtf)

HIVpatientswithCD4counts<50requireMACprophylaxiswithazithromycinorclarithromycin.
macformac
lymphadenitisisdiagnosedwhenthelymphnodebecomestenderanderythematousinadditionto
beingenlarged.usuallycausedbybacterialinfectionwithS.aureusbeingthemostcommon
pathogenisolated.
forcommunityacquiredacutebacterialmeningitisusevancomycin+ceftriaxoneinadultsand
childrensinceitwillcoverthemostfrequentetiologicalagents:S.pneumoniae(vancomycin)H.
influenza(ceftriaxone)andN.meningitidis(ceftriaxone).addampicillintocoverL.
monocytogeneswhichcancausemeningitisinpatients>55.immunocompromisedpatientsareat
riskforlisteria.
allergicbronchopulmonaryaspergillosis(ABPA)isahypersensitivityreactiontoaspergillus
colonizationofthebronchi.itoccursmostcommonlyinpatientswithasthma/cysticfibrosis,and
presentswithfever,productivecough,eosinophiliaandhemoptysis.tuberculosiswillhavechronic
cough,hemoptysis,andintermittentfevers.CTcanshowupperlobecavitarylesions(morethan1
possible!!)withsurroundingalveolarinfiltration.
facial/opthalmicvenoussystemisvalveless,uncontrolledinfectionoftheskincanreusltin
cavernoussinusthrombosis.redflagsymptomsincludesevereheadache,bilateralperiorbital
edema,andcranialnerve3/4/5/6deficits.orbitalcellulitiscanpresentsimilarlywithfever,proptosis,
opthalmoplegia,andvisualdefects,howevertherewillnotlikelybebilateralperiorbitaledema,and
bilateralcranialnervefindings.
nocardiaisagram+partiallyacidfastfilamentousaerobethatisfoundinsoil.nocardiosismaybe
confusedwithtuberculosisoractinomycesinfection.weightloss,fever,nightsweats.coughof
purulentsputumCXRfindingsincludealveolarinfilratesandnodulesoftenwithcavitation.
disseminateddiseaseismostlikelytomanifestassubcutaneousorbrainabscessess.usuallyoccurs
inimmunocompromisedpatients.treatmentistmpsmx.
whipplediseasehasPAS+macrophage.symptomsarechronicmalabsorptivediarrhea,weightloss,
migratorynondeformingarthritis,lymphadenopathy,andlowgradefever.
treatmentforcatscratchdiseaseisazithromycin.symptomsaretenderregionallymphadenopathy
andcutaneouslesions.
usedoxycyclineorazithromycininpenicillinallergicpatientswhohavesyphilis.
givetmpsmxandsteroidsinHIVpatientswithpneumocystispneumoniaifPaO2<70mmHgorAa
gradient>35mmHg.pcpoccurswhenCD4<200.presentswithdrycough,fever,exertionaldyspnea.
andcxrusuallyshowsbilateralinterstitialinfiltrates.
instrumentationofupperairwayoresophaguscanleadtoanaerobicpneumonia.fever+foul
smellingsputum.clindamycinismostcommonlyusedforthisinfection.
inflamedfluctuantcervicallymphnodesaretypicallycausedbystreporstaphinfection.the
antibioticofchoiceisdicloxacillin.othereffectiveantibioticsarecephalexinorclindamycin.

msk/ct/rheum

fibromyalgia=paininmuscles,noweakness,noswelling.psychological,labsnormal.treatwith
tcas/amitryptiline.
systemiclupuserythematosushas90%jointinvolvementhoweverjointdeformityinvolvingthe
handsisuncommon.
formyastheniacrisis,intubateandwithdrawacetylcholinesteraseinhibitorsforafewdays
seronegativespondyloarthropathy(PAIR)likeankylosingspondylitiscauseslowerbackpainand
stiffnessinyoungmen.symptomsareworseinthemorningandimproveastheday
progresses.Patientsalsogetarthritisofperipheraljointsandanterioruveitis.willhaveelevatedESR
andnegativeRhfactor.usetnfalphaantagonists.
viralarthritissecondarytoparvoB19infectionhaspolyarticularandsymmetricarthritis.affects
MCP,PIP,wrist,ankleandresolveswithin2months.willhaveelevatedantib19IgMantibodies

patientswhohaveankylosingspondylitisfortwodecadesorlongerareatanincreasedriskof
vertebralfractureduetodecreasedbonemineraldensity.thesefracturesmayoccurwithminimal
trauma.
spondylolisthesisisadevelopmentaldisordercharacterizedbyaforwardslipofvertebraeonthe
caudalvertebrae.mostcommonlyatL4L5andL5S1.causesbackpainandneurologicaldysfunction
(urinaryincontinence).
viralarthritispresentswithsymmetricarthritisofDIP,MCPandwristlikerheumatoidarthritis,
howeveritisacuteinonset,andhasnoelevatedinflammatorymarkers.
behetssyndromeisamultisystemicinflammatorydisease.presentswithpainfuloralulcersand
genitalulcersanderythemanodosumlikelesionsoftheskin.alsocanhaveocularlesions(anterior
uveitis,opticneuritis),arthritisandCNSlesionsmimickingmultiplesclerosis(meningoencephalitis).
seeninturkish,asian,andmiddleeasternpopulations.
systemicsclerosisisaconditionaffectingeveryorgansysteminthebody.cutaneousfindingsinclude
thickeningofskinbeginninginacralsites(handandfeet)withedema,thattransitionsintodermal
sclerosiswithobliterationofskinappendages(hairfolliclesandsweatglands)andflexion
contractures.raynaudphenomenonandcalcinosiscutisarealsocommon.involvementofthe
kidneysproduceshypertension,pulmonaryarteryhypertensionresultsinrightheartfailurein
thesepatients.patientshave+antinuclearautoantibodiesand+antitopoisomerasei
bakerscystsdevelopasaresultofexcessivefluidproductionbyinflamedsynovium,asoccursin
casesofrheumatoidarthritis,osteoarthritisandcartilagetears.
ankylosingspondylitisisconfirmedbyplainfilmxraydemonstratingfusedsacroiliacjointsand/or
bamboospine.
sjgrensyndromeisautoimmuneconditionmostcommonlyaffectswomenintheir5060s.clinical
findingsincludekeratoconjunctivitis(xerophthalmia)andxerostomia.increasedincidenceofdental
caries(salivaisantimicrobialandlubricating)andwillcomplainofdifficultyswallowing.lymphocytic
infiltrationofsalivaryglandsproducesenlargementandfirmnesstopalpationoftheseglands.serum
autoantibodiesdirectedagainstantiSSA/antiRoand/orantiSSB/antiLa
osteoarthritisofthespinecancauselumbarspinalstenosis.narrowingofthelumbarspinalcanal
leadstomechanicalcompressionandischemiaofthenerveroots.showspseudoclaudication
whichislowerextremitypainwhenwalkingandprolongedstanding,especiallywalkingdownhill
(extension).tomakebetterleanforward(restingonshoppingcart,flexion).
polymyalgiarheumaticahasproximalmuscletendernessandnoelevationsofast/alt/cpk(elevated
esr).weaknessinproximalmuscleswithelevatedferritin/LDH/CPKareconsistentwithbreakdown
ofmuscletissue:polymyositis.
antismithandantidsDNAarespecificforsystemiclupuserythematosus.
treatraynaudphenomenon(coldinducedvasospasm)withcalciumchannelblockerslikenifedipine.
viralarthritiscanpresentwithsymmetricsmalljointinflammatoryarthritis.+markerssuchasana
andrheumatoidfactormayoccur.Polyarticularwithjointswellingandlowgradefever.willresolvein
lessthan2monthssotreatwithNSAIDsaloneissufficient.
systemiclupuserythematosussystemicmanifestationsincludenondeformingarthritis,oralulcers,
serositis,hematologicabnormalities,proteinuria,rash.Systemiclupuserythematosusarthritisaffects
mcpandpipcommonly??
psoriaticartritisoccursin530%ofpsoriasispatients.theclassicpresentationinvolvestheDIPjoints.
morningstiffness,deformity,dactylitis(sausagedigit)andnailinvolvementarecommon.
rheumatoidarthritispredisposestothedevelopmentofsepticarthritis.(newjointthatisverytender,
swollen)
systemiclupuserythematosuseffectsonthekidneyscanrangefromminimalmesangiallupus
nephritistoadvancedsclerosinglupusnephritisandaregradedclass14.thetreatmentsand
outcomesaredifferentdependingontheclassoflupusnephritis.renalbiopsyisrequiredinall
patientswithnewonsetlupusnephritis.

steroidinducedmyopathyisawelldescribedresultofchroniccorticosteroidusecharacterizedby
painlessproximalmuscleweakness.itwillslowlyimproveoncetheoffendingmedicationis
discontinued.
pagetsdiseaseofbone(osteitisdeformans)isassociatedwithnormalserumcalciumandphosphate
levelsandincreasedALPandurinaryhydroxyprolinelevels.
lumbarspinalstenosisismostcommonlycausedbyosteoarthritis/degenerativejointdisease.the
termneuropathicclaudicationisoftenusedtodescribelumbarstenosis.exacerbationofleg
symptomswithwalking,howeverunlikepvd,thesymptomsarepositionalandremainwhile
standingstill.painisrelievedbyflexionofthespine.diagnosebyclinicalhistoryandMRIofspine.
muscularweaknessinparaneoplasticsyndromescanbeduetoavarietyofprocessesatdifferent
levels.skinrash+weaknesssuggestsdermatomyositis.willhaveelevatedCK/aldolaselevelsand
inflammationinthemuscle
wegenersisgranulomatosiswithpolyangiitis.triadof1)systemicvasculitis2)upperandlower
airwaygranulomatousinflammationand3)glomerulonephritis.therecanbecutaneouslesions
(tendernodules,palpablepurpura,ulcerations)aswellasjointandeyelesions.treatwith
cyclophosphamide.
patientswithrheumatoidarthritisareatincreasedriskofdevelopingosteopeniaandosteoporosis.
treatpolymyalgiarheumaticawithlowdoseprednisone.Pain(notreallyweakness)andstifnessin
neck,shoulders,andpelvicgirdleinapatientover50yearsoldwithelevatedESRandmorning
stiffness>1hour.
inductionchemotherapyresultsinrapidtumorcelllysisandreleasesuricacidintothecirculation.for
preventionofgout,allopurinolandprobenecidareused,whileNSAIDsandcolchicineandsteroids
areusedduringacuteattacks.
tendernesstogentlepercussionoverthelumbarvertebraeisanimportantcluetovertebral
osteomyelitis.vertebralcompressionfracturescanalsocauselocaltendernesstopalpationbutthis
usuallyoccursinelderlypatientswithahistoryofosteomalacia/osteoporosis.MRIisthemost
sensitivestudyforvertebralosteomyelitis.
corticosteroidinducedavascularnecrosisofthefemoralheadpresentsasprogressivehipor
groinpainwithoutrestrictionofmotionrange,andnormalXRinearlystages.MRIisgoldstandard
forthediagnosisofavascularnecrosisofthehip
vertebralosteomyelitisisbestdiagnosedwithMRIofspine.Patientwillhavelowgradeeverand
elevatedESR.physicalexamwillreveallocaltendernessonpercussionoftheaffectedvertebraeand
paravertebralmuscularspasm.
thepancytopeniainsystemiclupuserythematosusisduetoformationofautoantibodiesagainst
cells.atypeoftype2hypersensitivityreaction.
commonsideeffectsofmethotrexateincludemucositis/stomatitis,nausea,abdominalpain,and
fever.canalsocausehepatotoxicityandmyelosuppression.Alsoteratogenic
reactivearthritisisatypeofseronegativespondyloarthropathy.classicreactivearthritisisatriadof
1)nongonococcalurethritis2)asymmetricoligoarthritisand3)conjunctivitis.itofteninvolvesthe
kneeandsacroiliacspine.therearealsomucocutaneouslesionsandenthesitis(achillestendon
pain).Lookforgastrointestinalinfectioninthehistoryaswell.NSAIDsarefirstlineoftherapy.cant
see/cantpee/cantclimbatree
polymyositisisaninflammatorymuscledisease.presentsw/muscleweaknessofproximalmuscles
(shoulder/hip).WillhaveelevatedESR/CPK/aldolase.treatwithhighdosecorticosteroids.
osteoarthritishassubchondralsclerosis,jointspacenarrowing,andosteophytes.itaffectsweight
bearingjointsandmanifestswithdeformityanddegenerativejointdiseaseandloosebodieson
imaging.XRwillshowlossofcartilage,osteophytedevelopmentaswell.
Paget'sdiseasecanpresentwithasymptomaticincreasedALP.duetoboneremodeling.canhave
hearingloss.treatmentisbisphosphonates
lumbosacralstrainismostcommoncauseofbackpain.afterheavyliftinginthelumbarareawithno
radiation.nosensorydeficits.

fibromyalgiaismusculoskeletalpain.patients(moreoftenwomen)willcomplainedofdisturbed
sleep,musclestiffness,labsarenormal.TCAslikeamitriptylinewillhelprestoresleepandcanbe
effectivetreatment.
trendelenburgsignisadroppingofcontralateralpelviswhenaskedtostandon1leg.indicates
glutealmuscleweakness.
forhydroxychloroquineyouhavetodoeyeexamsevery6mos.tocheckforretinopathy
cervicalspondylosisisosteoarthritisofspinalvertebrae.Willhavechronicneckpain.radiologywill
showbonyspurs(osteophytes)andscleroticfacetjoints.
inarotatorcufftear,thepatienthasapositivedroparmtestwherethearmisunabletobelowered
slowly.
hairlinefracturesarecommoninathletes,especiallyofthesecondmetatarsal.treatwithrest,
analgesia,andahardsoledshoe.
acutebackpainand+straightlegraisetestdiskherniation(sciatica).painradiatesdownposterior
surfaceofthigh.managewithNSAIDsandearlymobilization.
osteonecrosis/asepticnecrosis/avascularnecrosis/ischemicnecrosis/osteochondritisdessicansisdue
todisruptedvasculatureandboneisnotabletoremodel,leadingtotrabecularthinningand
collapse.earlyonxrayswillnotshowabnormalities.MRIisthemostsensitivetestforthiscondition.
stressfracturemostcommoninanteriortibia.xraysfrequentlynormalduringinitialeval.
mostcommoncauseofasymptomaticelevationofALPinanelderlypatientispagetsdiseaseof
bone(osteitisdeformans)
dequervaintenosynovitisisaconditionaffectingnewmotherswhoholdtheirinfantswiththumb
outstretched.theabductorpollicislongusandextensorpollicisbrevistendonsareaffected.passive
stretchingofthosetendonselicitspain.
lumbarspinalstenosishasbackpainmadeworsebyextension(narrowingthecanal)andmade
betterbyflexing(wideningthecanal).neurogenicclaudicationisthelegpainofspinalstenosis
thatcanbeconfusedwithPVDbutanklebrachialindexisnormalandsoarepulses.
posteriordislocationsoftheshouldercommonlyoccurafteratonicclonicseizurewiththepatient
holdingthearmadductedandinternallyrotated.toddsparalysisisatransientunilateralweakness
followingatonicclonicseizure.
acuteshoulderpainafterforcefulabductionandexternalrotationatglenohumeraljointsuggests
anteriorshoulderdislocationwhichcancauseaxillarynerveoraxillaryarterydamage
scaphoidfracturesarethemostcommonofthewristfallingonoutstretchedhand.immobilizewrist
for610weeks.
tearofmedialmeniscusoccursduringatwistinginjury.patientscomplainofapoppingsound
followedbyseverepainatthetimeofinjury.meniscusisnotdirectlyperfusedsoeffusiontakes
sometimetopresent.McMurrayssignisapalpableoraudiblesnapoccurringwhileslowly
extendingthelegatthekneefromfullflexionwhileapplyingtibialtorsion.
carpaltunnelsyndromepresentswithparesthesiasofthefirst3.5digitsandthenareminence
atrophy.
radialnerveismostcommonlyinjurednervewithfractureofmidshafthumerus.
pagetsdiseaseisduetoincreasedboneturnover,duetoosteoclastdysfunctioncausingincreased
bonebreakdownandacompensatoryincreaseinproduction.pelvis,skull,spineandlongbonesare
mostcommonlyinvolved.symptomsmayincludeskeletaldeformitieslikefemoralbowing.boneand
jointpainandhearinglossarelesscommonsymptoms.
lumbarspinalstenosisneurogenicclaudicationisadegenerativeconditionwherethespinalcanalis
narrowed.flexionofthespinegivespain.duetoenlargingosteophytesatthefacetjointsand
hypertrophyoftheligamentumflavum.backpainradiatingtothebuttocksandthighs.confirm
diagnosiswithMRI.
double/soapbubbleappearanceintheepiphysealendoflongboneisagiantcell
tumor/osteoclastoma.presentsin2040y/ofemaleswithkneepain.
paintopalpationofthevertebraonexamissuggestiveofspinalinfectionorlyticlesionsinthe
spine.initialtestofchoiceisaXRofthebacktolookforlyticlesionsandcompressionfractures.if

testisnondiagnosticthenMRI/CTcanbedonetoevaluatefordiscdisease,cancer,andspinal
infections.
trochantericbursitisisinflammationofthebursasurroundinginsertionofthegluteusmediusonto
thefemursgreatertrochanter.patientswiththisconditioncomplainofhippainwhenpressureis
applied(ie:sleepingonthatside)andwithexternalrotationorresistedabduction.
osgoodschlatter(tractionapophysitis)isacommoncauseofkneepain,particularlyinadolescent
maleathletes.duringperiodsofrapidgrowthwherethequadricepstendonputstractiononthe
apophysisofthetibialtuberclewherethepatellartendoninserts.worsenedbysportsthatinvolve
repetitiverunning,jumping,kneeling,anditimproveswithrest.paincanbereproducedbyextending
thekneeagainstresistance.radiographfindingsarenonspecificandincludeanteriorsofttissue
swelling,liftingoftuberclefromtheshaft,andirregularityorfragmentationofthetubercle.
femoralnervegivessensationtoanteriorthighandmedialleg.responsibleforkneeextensionand
hipflexion.
tibialnervesuppliesmusclesoftheposteriorcompartmentofthigh,posteriorcomparmentofleg,
andplantarmusclesofthefoot.
obturatornerveinnervatesthemedialcompartmentofthethigh.
supracondylarhumeralfracturesareassociatedwithbrachialarteryinjuriesresultinginthelossof
theradialpulse;assessradialpulsewhenfractureisreduced.
meniscaltearsareusuallycausedbyatwistinginjurywhenthefootisinafixedposition.kneepainis
feltinitiallybuttheswellingisworsethedayaftertheinjuryandisduetoaneffusion.confirmbest
withMRI
midshaftfractureofhumeruswilldamageradialnerve.
MRIistheinvestigationofchoicefordefiningsofttissueinjuriesoftheknee.
highsteppingorsteppagegaitisduetofootdrop.resultsfromaninabilitytodorsiflexthefoot.to
compensatepatientsmustoverlyflexthehip/kneetobringthefootforwardwitheachstep.thetoes
mayalsodragonthegroundwiththistypeofgait.mostcommonlycausedbyperipheral
neuropathy.mayalsoclassicallyresultfromtraumatothecommonperoneal/fibularnerveor
radiculopathytoanyofthespinalrootsthatcontributetothecommonperonealnerve(L4S2).may
alsobecongenitalsuchasincharcotmarietoothdisease.
osteomalaciahassymmetricallooserzonesorpseudofracturesandblurringofthespine.willhave
loworlownormalcalciumandlowphosphate,highPTHandlowvitamind.vitaminddeficiency
leadstodecreasedintestinalcalciumandphosphatereabsorption,resultinginhypocalcemiaand
hypophosphatemia.hypocalcemiathenstimulatesparathyroidgland.
vertebralcompressionfracturesalmostalwaysoccurwhenbonedemineralizationispresent.will
presentasintense,focalvertebralpainwithoutneurologicalsymptoms.occursinosteomalaciaand
osteoporosis.
spinalcordcompressioncanbecausedbycaudaequinasyndromeandresultsinabsentrectaltone,
urinaryincontinence,motor/sensorylossinextremities.itisasurgicalemergency.MRItoidentify
thesiteofcompression/fracturefollowedbysurgery.

nephrology

aceiarethemostcommoncauseofacquiredangioedema.othereffectsarecough,hyperkalemia,
andprecipitationofacuterenalfailureinpatietnswithbilateralrenalarterystenosis.angioedema
canoccuranytimetakingthemed,notjustwithinafewweeksofstarting.
type4renaltubularacidosisoccursw/diabeticnephropathyorinterstitialrenaldisease.chronic
renalfailure/uremiaisacauseofhypochloremicaniongapmetabolicacidosis.intype4can'texcrete
H+andaccumulationoforganicanions,soyougetnonaniongapmetabolicacidosis.
chronicpyelonephritisischaracterizedbyfocalparenchymalscarringandbluntingofcalices

systolicdiastolicabdominalbruitinapatientwithhypertensionandatherosclerosisisrenalartery
stenosis
normallycalciumbindsoxalateingutandpreventsreabsorption.whenhavefatmalabsorption,the
calciumisboundbyfat,andoxalateisunboundandreabsorbed,andformsstones
renalarterystenosisismostcommoncausesecondaryhypertension.
interstitialcystitisistriadof1.urinaryurgency2.urinaryfrequency3.chronicpelvicpain,relievedby
voiding.giveswbccasts.
elevationsinbun/creatinineduetoprerenalfailure,postrenalfailure,systemicsteroids,or
gastrointestinalbleeding(reabsorptionofureafromgastrointestinaltractafterbacteriabreakdown
hemoglobin)
indiabetesmellitusfirstthereisglomerularhyperfiltration.thickeningofglomerularbasement
membraneandthencomesmesangialexpansion
goodpasture'sdiseaseaffectslungsandkidneyduetoIgGantibodiesattackingcollagen.treatwith
plasmapheresis.
ultrasoundorotherimagingtechniquesareindicatedwhenpatientswithpyelonephritisdonot
respondafter4872hrsofappropriateantibiotictherapy
renalstonespresentasflankpain(LLQ,RLQ)radiatingtothegroinalongwithnauseaandvomiting.
todiagnoseusenoncontrastCTofabdomenandpelvis.
inprerenalfailureurinena<10meq/l(thekidneyisreabsorbingsalttobringinwater,sotherewill
beverylittlesaltintheurine)
amyloidwillgiverenalenlargementandhepatomegaly.suspectinpatientwithchronicdiseaselike
rheumatoidarthritis
aminoglycosideareantibioticsusedforseveregramnegativeandpotentiallynephrotoxic.amikacin
isaminoglycoside
renalpapillarynecrosisduetoNSAIDsisduetopapillaryischemiabyanalgesiamediated
vasoconstrictionofmedullarybloodvessels(vasarecta).
IgAnephropathy(bergers)ismostcommoncauseofglomerulonephritisinadults.recurrent
episodesofgrosshematuriabeginningseveraldaysafteranupperrespiratoryinfection.Inchildren
IgAnephropathyisHSPwithskinlesionsandabdominalbleeding.goodpasturesisatriadof1)pulm
hemorrhage2)prolif.glomerulonephritisand3)iggtoantigbm
largebloodonurinalysiswithlowRBCsonsedimentmicroscopyismyoglobin.duringrhabdomyolysis
myoglobincanresultintubularinjuryandacuterenalfailure.seizurescancauserhabdomyolysisdue
totonicclonicmovement.
goodpasturessyndromeiscausedbycirculatingantigbmantibodies.earlyremovalofthese
antibodiesbyemergencyplasmapheresisisimperativeinordertominimizeextentofkidney
damage.wegeners(granulomatosiswithpolyangiitis)istreatedwithacombinationof
cyclophosphamideandsteroids.
suspectmixedcryoglobulinemiainapatientwithpalpablepurpura/skinlesions,
proteinuria/hematuria.othermanifestationsincludenonspecificsystemicsymptoms,arthralgias,
hepatosplenomegaly,andhypocomplementemia.majorityofpatientshaveunderlyinghcvinfection
thestrongestpredictorofabdominalaorticaneurysmexpansionandruptureare1)largeaneurysm
diameter2)rapidrateofexpansionand3)currentcigarettesmoking.Smokingcessationhasthe
greatestlikelihoodofslowingdownAAAexpansion.
membranoproliferativeglomerulonephritis(densedepositdisease)iscausedbypersistentactivation
ofthealternativecomplementpathway.denseintramembranousdepositsthatstainforc3isa

characteristicfinding.IgGantibodies(c3nephriticfactor)directedagainstc3convertase.HBV,HCV,
lupus,cryoglobulinemia
inchronicrenalfailureareductioninGFRleadstophosphateretentionandpoorvitamind
processingresultinginhypocalcemia.stimulatestheparathyroidglandsleadingtohypertrophyand
2ndhyperparathyroidism.
diabetescancauseneurogenicbladdercausingoverflowincontinence(detrusorunderactivity).
overflowincontinenceismarkedbyurinaryfrequency,nocturia,frequentleakageofsmallvolumesof
urine,andhighpostvoidresidualurinevolumes.usecholinergicagentslikebethanechol.
mostcommoncauseofrenalfailureinmultiplemyelomaisatoxiceffectoflightchaincastsonthe
renaltubules.
initialhematuriasuggestsurethraldamage.terminalhematuriaindicatesbladderorprostatic
damage,andtotalhematuriareflectsdamageinthekidneysorureters.clotsarenotusuallyseen
withrenalcausesofhematuria.
whenpatienthasbphdourinalysistoassessforurinaryinfection,obstruction,orhematuria.
transrectalultrasoundoftheprostateisusedtohelpguideprostatebiopsy,butnotasensitive
screeningtestforprostatecancerorevaluatingbph.
totreathemolyticuremicsyndromedoplasmapheresis/FFP(plasmaexchange).
ethyleneglycolcausescalciumoxalatecrystals(rectangularenvelopeshapedcrystals)methanol
causesvisualfieldchanges(snowfieldvision)andacutepancreatitits.
cardiovasculardiseaseisthemostcommoncauseofdeathindialysispatients.approx50%ofall
deathsinthispopulation
membranousnephropathyismostcommonnephropathyassociatedwithcarcinoma,however
nephroticsyndromeisawellknowncomplicationofhodgkinslymphomaandisusuallycausedby
minimalchangedisease.
patientswithrecurrenthypercalciuricrenalstonesshouldbeadvisedtoincreasefluidintake,
sodiumrestriction,andathiazidediuretic.donotrestrictcalcium.
uricacidstonesareneedleshapedonurinalysis.ureterolithasiscancauseileus(nopropulsioninthe
GItract)duetoavagalreaction.evaluateuricacidstonesbyCToftheabdomenorivpyelography.
unilateralvaricocele(dilatedpampiniformplexus)thatfailstoemptywhenapatientisrecumbent
(lyingdown)raisesuspicionforanunderlyingmasspathologysuchasrenalcellcarcinoma.that
obstructsvenousflow.ctscanoftheabdomenisthemostsensitiveandspecifictestfordiagnosing
rcc.
renalveinthrombosisisanimportantcomplicationofnephroticsyndrome.antithrombin3/protein
C/proteinSarelostintheurineandputspatientsatriskforvenousandarterialthrombosis.presents
withsuddenonsetofabdominalpain,fever,andhematuria.itcanoccurinanyformofnephrotic
syndromebutitismostcommonwithmembranousglomerulonephritis.
hypertensioncausesintimalthickeningandarterioscleroticlesionsofafferentandefferentrenal
arteriolesandglomerularcapillarytufts.diabetesnephropathyischaracterizedbyincreased
extracellularmatrix,basementmembranethickening,mesangialexpansion,andfibrosis.
75to90%ofkidneystonesarecomposedofcalciumoxalate.calciumoxalatecrystalsareenvelope
shapedandradioopaque(canbeseenonXR)
whenkubshowsnostoneinapatientwithtypicalrenalcolicthinkofthreescenarios:1)radiolucent
stonedisease(uricacidstones),2)calciumstones<13mmand3)nonstonecauses(obstruction
byabloodclotortumor).uricacidstonesaremostcommonlyseeninpatientswithanunusuallylow
urineph.treatmentincludeshydration,alkalinizationofurine(potassiumbicarborpotassium

citrate),andlowpurinediet.uricacidstonesarehighlysolubleinalkalineurine.bringurineuptoph
>6.5
hyposthenuriaisanimpairmentinthekidneysabilitytoconcentrateurine.thisisfoundinpatients
withsicklecelldisease,andalsoinsicklecelltraitalthoughinalessseveremanner.thoughttoresult
fromRBCssicklinginthevasarectaeoftheinnermedulla.thiscanresultinnocturia.
acyclovirgivesyounephrotoxicity.willprecipitatecausingobstructionandacutekidneyinjury.
HBV,HCV,lupusisassociatedwithmembranousglomerulonephritis.FSGSisass.w/HIV,heroin,
blacks.membranoproliferativeglomerulonephritisisassw/HBV,HCV,lupus,andalso
cryoglobulinemia(proteinsinsolubleatlowtemps)andc3nephriticfactor(toomuchcomplement
pathway)
poststrepglomerulonephritispresents1020daysafterstreptococcalthroatorskininfection.
hematuria,hypertension,redcellcasts,proteinuria.willhavelowserumc3complement(immune
complexdeposition)
analgesicnephropathycausespapillarynecrosis(constrictionofvasarecta)andchronic
tubulointerstitialnephritis.
edemafromglomerulonephritisresultsfromglomerulardamageanddecreasedgfr(alsothecasein
endstagerenaldisease).asthevolumeincreasesfromthirdspacing,thegfrwilldrop,leadingto
renalsodiumretention(raas).theincreasingvolumefromraascancauseasignificantriseinbp.the
proteinuriaalsocontributestoedema.edemafromnephroticsyndromeresultsfrom
hypoalbuminemia.hypoalbuminemiadoesnotusuallycausepulmonaryedemab/calveolar
capillarieshaveahigherpermeabilitytoalbuminatbaseline(sothereislessofanoncoticpressure
difference)andgreaterlymphflowthanskeletalmuscle,protectingthelungsfromedema.
firstgenerationh1antihistaminessuchasdiphenhydraminehavesignificantanticholinergiceffects
inadditiontoantihistamineeffects.commonanticholinergicsideeffectsincludedrynessofeyes,oral
mucosaandrespiratorypassages,urinaryretentionanddysuria.urinaryretentioncausedby
anticholinergicagentsresultsfromfailureofdetrusorcontraction.
ethyleneglycolpoisoningcausesrenaltubulardamageandformationofcalciumoxalatecrystals.
methanolintoxicationcausesvisualdisturbances.willhaveametabolicacidosis(lowphlowbicarb)
renaltubularacidosisisanormalaniongapmetabolicacidosis.type1isdistalcantsecreteh+so
patientisacidotic,hypokalemia(kidneywillexcreteK+insteadofH+)andhaveelevatedurinarypH.
patientsgetnephrolithiasis.type2isproximalpatientscantabsorbbicarbinproximaltubule.Will
havelowurinepH.fanconisyndromeisacauseinchildren.type4defectinna+/k+exchangein
distaltubuleresultinginhyperkalemic,hyperchloremicacidosis.(likehavingaddisonsdisease,no
aldosteroneworking)canpresentasgrowthfailure/failuretothrive.labsshowlowbicarbwith
anincreaseincl

neurology

AlzheimersdementiahascorticalandsubcorticalatrophyonCTscan.
caudaequinasyndromeiscausedbydamagetonerveroots.Thepatientwillhavebladder/bowel
dysfunction,saddleanesthesia,decreasedAchillestendonreflex.
formigraineheadachesyoucanuseprochlorperazineasadjuvantforantiemesis.propanololisused
forforprophylaxis.
vertigoisspinningsensationaccompaniedbynausea.vertigocanbecentralorperipheral.ear
fullnessandpreferenceforhearingwithoneearovertheotherissuggestiveofaperipheralcause.
earfullnessisparticularlysuggestiveofmenieresdiseasewhichresultsfromabnormal

accumulationofendolymphwithintheinnerear.disordersofthemiddleearcancausehearingloss,
butnottypicallyvertigo
boneconduction>airconductionontherinnetestissuggestiveofconductivehearinglossandcan
becombinedwiththewebertesttoconfirmthefindings.otosclerosisisacommoncauseof
conductivehearinglossinadults,duetobonyovergrowthofstapes.ototoxicantibioticsusually
resultinsensorineuralhearingloss.
leftfrontallobeinfarctionwillgiveyoubroca'saphasiaandrightmotorproblems.ifpatienthasa
rapidheartratethatisirregular,checkforcardiacsourceofembolus.
"cerebralsaltwasting"syndromecanhappeninpeoplewithsubarachnoidhemorrhage.
1)releaseofvasopressin
2)releaseofBNP.
resultsinhyponatremia
diffuseaxonalinjuryshowsnumerousminutepunctatehemorrhageswithblurringofgreywhite
interface.
beforestartingtriptanscheckforpregnancy(contraindicated)
acutelabrynthitisandvestibularneuritisbothcausevertigo.Acutelabyrinthitishashearing
loss/tinnitusandvestibularneuritisdoesnot.
meniere'sdisease(sensorineuralhearingloss,tinnitus,vertigo)1stlinetherapyisreducedsaltdiet
noforeheadmovementmeansbellspalsy(bothupper/lower).affectsupperandlowerpartsofface.
ifcentralfacialparesis(UMNlesion)wasthecauseoffacialparalysisthenthepatientwouldbeable
tomoveforeheadbecauseofcontralateralinnervation.
ringenhancinglesiononbrainCTscanandfluidcollectioninmaxillarysinusisanabscessdueto
maxillarysinusitis.aerobicandanaerobicstreptococci(6070%)areresponsibleandalsoBacteroides
(anaerobe2040%)
hemineglectsyndromeischaracterizedbyignoringtheleftsideofaspace,andinvolvestheright
(nondominant)parietallobe.
ifpatienthasanormalneurologicexambutparesthesias,nondetectablepulses,pallorinalimb,
immediatelyanticoagulateandgetsurgicalinterventionforembolectomy.(arterialthrombosis)
anteriorcordsyndromeiscommonlyassociatedwithburstfractureofthevertebra,characterizedby
totallossofmotorfunctionbelowthelevelofthelesionwithlossofpain/tempbilateralbelowthe
lesion.intactproprioception(posterior/dorsalcolumn)
statusepilepticusisseizureactivity>510minutesnotrespondingtoantiseizuremedication.first
stepismakingsureairwayandbloodpressurearestablewithendotrachealintubation.diazepam>
phenytoin>phenobarbital
drugofchoicefortrigeminalneuralgiaiscarbamazepine.
shydragersyndrome/multiplesystematrophyhasparkinsonism+autonomicdysfunction
(orthostatics,erectiledysfunction,etc)andwidespreadneurologicalsigns(cerebellar,pyramidal,
LMN)
canhavesubclavianarterialatherosclerosiswihapreferencefortheleftarteryandmaypresentwith
vertebrobasilarinsufficiencysecondarytosubclavianstealsyndrome.
pseudotumorcerebri(idiopathicintracranialhypertension)inobesefemales.vitaminAandOCPs.
headache,blurryvision,papilledemaandcranialnervepalsies.Treatweightweightlossand
acetazolamide.
cerebellardysfunctioniscommoninchronicalcoholics.gaitinstability,difficultywithtoandfro
movements,intentiontremor.A+babinskisuggestsanuppermotorneuronlesion.
cerebellartumorsusuallyproduceipsilateralataxia,nystagmus,intentiontremors,andlossof
coordination.
thiaminedeficiencycausesWernickeswhichis1)encephalopathy/confusion,2)oculomotor
dysfunction/ophthalmoplegiaand3)ataxia.
normalpressurehydrocephalushasabnormalgait,incontinence,anddementia(wet,wacky,
wobbly).treatwithlargevolumelumbarpuncturesandvenriculoperitonealshunt.

cerebellardysfunctiongivesintentiontremor,whichgetsworseneartheendofmovement,butis
improvedbyrest,willlikelyhaveothercerebellarsigns(ataxia,etc).essentialtremorissimilar(??)
suppressedatrestandexacerbatedneartheendofamovement.
medialmedullarysyndromeisassociatedwithcontralateralspastichemiplegia,contralateral
vibratoryandproprioceptionloss,andtonguedeviationtotheinjuredside.Duetolesionofthe
anteriorspinalartery.(corticospinalfibers,dorsalcolumnmediallemniscus,CN12)
lateralmedulla/wallenbergsyndromeandhasipsilateralhorners,lossofpainandtemp.inthe
face,andcerebellarataxia.lossofpainandtemponcontralateralsideofbody.Duetolesionof
theposteriorinferiorcerebellarartery(PICA).(CN5facestuff,8ataxia,9dysphagia/gag,10)
centralcordsyndrome/syringomyeliaoccurswithhyperextensioninjuriesinelderlypatientswith
degenerativechangesinthecervicalspine.causesdamagetocorticospinaltracts(motor)andthe
decussatingfibersoflateralspinothalamictract(nociception,temperature).centralcordsyndrome
ischaracterizedbyweaknessthatismorepronouncedintheupperextremitiesthaninthelower
extremities.
Partialseizuresaresimpleorcomplex.complexpartialseizure:briefepisodesofimpaired
consciousness,failuretorespondtovariousstimuliduringtheepisode,staringspells,automatisms,
andpostictalconfusion.EEGpatternisusuallynormalormayshowbriefdischarges.
seizuresarepartialorgeneralized(generalizedistonicclonic/grandmalandabsence).
partialseizurescanbebrokendowninto
1)simplepartial(consciousnessintact)
2)complexpartial(impairedconsciousness)or
3)partialwithsecondarygeneralization.
patientswithcomplexpartialhaveautomatisms(lipsmacking,handsmoving)andpatientswhohave
partialseizuresw/secondarygeneralizationusuallyhavetonicclonicmovements.apatientwith
tonguebitingorbladder/bowelincontinencemostlikelyhascomplexpartialwithsecondary
generalization.
afterhavingasubarachnoidhemorrhagepatientsareatriskforsubsequentvasospasmofthe
arteriesatthebaseofthebrain.majorcauseofmorbidityandmortalitysousecalciumchannel
blockerslikenimodipinetopreventvasospasm.
essentialtremorhasatremorthatissuppressedatrestandmadeworseattheendofagoal
directedmovement.parkinsonsdiseasehasarestingtremormadebetterwithmovement.treat
essentialwithpropanolol/primidone
cerebralbloodflowincreaseswithhypercapnia(increasedCO2)andincreasedmetabolicdemandand
hypoxiathroughcerebralvasodilation.interventionsforloweringintracranialpressureare1)head
elevationtoincreasevenousoutflow,
2)sedationtodecreasemetabolicdemandandcontrolofhypertension
3)intravenousmannitoltoextractwateroutofbrainand
4)hyperventilationtoremoveCO2leadingtovasoconstriction.
mostcommonsiteforalacunarinfarctisposteriorinternalcapsule,producingpuremotorstroke.
lacunarinfarctsareoftennotappreciatedonnoncontrastCTobtainedduringorshortlyafterthe
event.
cerebellarhemorrhagepresentswithacuteonsetoccipitalheadache,repeatedvomitingand
gaitataxia.patientswillbehypertensive,andmighthaveCN6/abducensnerveparalysis,conjugate
deviation,coma.
hypertensiveintracranialhemorrhagesoccurmostcommonlyinthebasalganglia,thalamus,pons,
andcerebellum.patientstendtopresentinitiallywithfocalsymptomsbutcanrapidlyprogressto
signsofelevatedintracranialpressure.intracerebralhemorrhagepresentswithfocalneurological
symptomsearlybutisfollowedbyfeaturesofincreasedintracranialpressure(vomiting,headache,
bradycardia,decreasedalertness).lacunarstrokesalsooccurinhypertensivepatientsbutpresent
withseverefocalneurologicalsymptomsdependingontheaffectedarea.Lacunarstrokesdonot
causerapidlyworseningglobalneurologicsymptoms.Cerebellarsymptomsarevomiting,occipital
headache,ataxia.

neurofibromatosistype2inapatientwithbilateralacousticneuroma,cataractsandmultiplecafe
aulaitspots(hypopigmented).MRIwithgadoliniumenhancementisbestmethodtodiagnose
acousticneuromas
complexpartialseizuresoftenstareblanklyforseveralminutesandengageinautomatisms(lip
smackingorchewing).willhaveconfusionaftersuggestingapostictalstate.canhavetoddsparalysis
after,atransientpostseizureneurologicsymptom(legdragging,armweakness,etc)
theprognosisofastrocytomasismostaffectedbytumorgrade,withincreasedatypia,mitoses,
neovascularityornecrosisconveyingaworseprognosis.
flatteningofnasiolabialfoldiscausedbyabnormalfunctionofthefacialnerve/CN7.Therewillbean
inabilitytoclosetheeyeaswell.facialnervenucleusislocatedinthepons.
coadministrationoftriptansandergotaminemayresultinprolongedvasospasmdueto
overactivationof5HTreceptors.thustriptansshouldnotbegivenforatleast24hoursafter
ergotamineisgiven.
creutzfeldtjakobdiseaseshouldbesuspectedinanoldpatientwithrapidlyprogressivedementia,
myoclonus,andaperiodichighvoltagecomplexonEEG.
wernickesencephalopathypresentswiththetriadof1)confusion2)ataxia,and3)opthalmoplegia.
causedbyadeficiencyofthiamine.itsacauseofacutedeliriumand/oracuteataxiaespecially
malnourished/alcoholicpatients.
internuclearopthalmoplegiaisacharacteristicfindingofmultiplesclerosis(MS)anddueto
demyelinationofthemediallongitudinalfasciculus(MLF).
acuteattacksofmultiplesclerosis(MS)aretreatedwithintravenoussteroids.toreducefrequency
ofacuteexacerbations,useinterferon,plasmapheresis,cyclophosphamide,intravenous
immunoglobulinsandglatirameracetate
normalpressurehydrocephalusresultsfromincreasedventricularsizewithoutelevationsin
intracranialpressure.distortionofperiventricularbrainmatter.
benign/idiopathicintracranialhypertension(pseudotumorcerebri)presentswithaheadachethatis
pulsatileinnature,awakenspatientfromsleep,andisassociatedwithpulsatiletinnitus
(whooshingsoundinears).patientscancomplainofheadachesbecomingworsewithlyingflat,and
betterstandingup.visualloss,sluggishpupillaryreflexestolight,papilledemaonfundoscopyand
abducensnerve/CN6palsy.obeseyoungwomen,andcertainmedications(vitamina,OCPs).brain
MRIwillshowanemptysellaandslitlikeventricles.getlumbarpuncturewithopeningpressure(will
beelevated).treatmentinvolvesweightreductionandacetazolamide.blindnessisthemost
significantcomplicationofthisotherwisebenigncondition.
tickborneparalysisischaracterizedbyarapidlyprogressiveascendingparalysis,absenceoffever,
absenceofsensoryabnormalitiesandnormalCSFfunction.botulismpresentswithadescending
paralysisandaffectscranialnervesearly.(atickbitesatfeet,soascends)
essentialtodistinguishbetweenaseizureandasyncopalevent.aseizureresultinginlossof
consciousnesswilloftenbefollowedbyapostictalstateofcloudedsensorium,whereaspeople
rapidlyreturntotheirbaselinementalstatusafterasyncopalevent.
lewybodydementia(parkinsons+dementia)hasalterationsinconsciousness,disorganizedspeech,
visualhallucinations,extrapyramidalsymptoms.lewybodiesofeosinophilicintracytoplasmic
inclusionsrepresentingaccumulationsofalphasynucleinproteinmaybeseeninneuronsofthe
substantianigra.treatmentincludesacetylcholinesteraseinhibitorslikerivastigmine.for
hallucinationsrefractorytoACheinhibitors,atypicalantipsychoticsmaybeofbenefit.neurofibrillary
tanglesandsenileplaquesarepathologicalhallmarksofalzheimersdementia.
cerebellarhemorrhagecausesataxia,vomiting,occipitalheadache,gazepalsy,andfacialweakness.
thereisnohemiparesis.pontinehemorrhagepresentswithadeepcomaandparaplegiathat
developsinafewminutes.decerebraterigidityandnohorizonaleyemovements.
neurocardiogenicsyncope(vasovagalsyncope)ischaracterizedbynausea,diaphoresis,tachycardia
andpallorimmediatelypriortosyncopalepisode.arrhythmiasgenerallyhavenoprecedingsignsor
symptomsotherthanpalpitationsinsome.seizureshaveapostictalperiodafterasyncopalevent.

guillainbarresyndromeistreatedwithintravenousimmunoglobulinsandplasmapheresis.
ascendingparalysis,areflexia,andsensorychanges34weeksafteranupperrespiratoryinfectionor
gastroenteritisisthecommonpresentation.
riluzoleisaglutamateinhibitorthatiscurrentlyapprovedforuseinpatientswithamyotropiclateral
sclerosis(ALS).
usetrihexyphenidyl/benztropine(anticholinergic)forthetreatmentofpatientswheretremoristhe
primarysymptomofparkinsons.
anteriorcerebralarteryocclusion>contralateralweaknessaffectinglowerextremity,urinary
incontinence.
middlecerebralartery>contralateralhemiplegiaaffectsupperextremitymore,aphasia,
hemineglect.(Wernickes/Brocas)
postlimbofinternalcapsule>motorhemiparesisandvisualfield.(mostcommonlacunar)
vertebrobasilar>contralateralhemiplegiaandipsilateralcranialnerve
spinalcordcompressionischaracterizedbysignsandsymptomsofuppermotorneurondysfunction
distaltothesiteofcompression,suchasweakness,hyperreflexia,decreasedsensation,and
bowel/bladderdysfunction.cordcompressionisamedicalemergencyrequiringpromptdiagnosis
viaspinalMRI.strokedoesnothavebilaterallegweakness.
creutzfeldtjakobdiseaseincludesrapidlyprogressivedementia,myoclonus,andsharp,triphasic
synchronousdischargesoneeg.
themostcommonsiteofhypertensivehemorrhageistheputamen(35%).theinternalcapsulenext
totheputamenisalmostalwaysinvolvedleadingtohemiparesis.theeyesaredeviatedawayfrom
theparalyticside.subarachnoidhemorrhagehasasuddendramaticonsetofsevereheadache,and
usuallynofocalneurologicalsigns.
withcerebrallesions,motordeficitsareusuallyoppositethesiteofthelesionwhereasgazedeviation
isusuallytowardsthesideofthelesion.hypertensivebleedsoccurmostcommonlyinthebasal
ganglia.
primidoneisananticonvulsantagentusedtotreatbenignessentialtremors.itcanprecipitateacute
intermittentporphyria,whichcanbediagnosedbycheckingforurineporphobilinogen.symptoms
willincludeabdominalpain,neurologic,andpsychiatricabnormalities.
pronatordriftisasensitiveandspecificphysicalexamfindingforuppermotorneuronnervedamage
affectingupperextremities.closeeyesandextendarmswithpalmsup,andwilltendtopronate.
ifapatientpresentswithin45hrsaftertheonsetofanischemicstroke,thrombolytictherapywith
tpashouldbestartediftheCTscandoesnotshowhemorrhage.
anteriorcerebralarterystrokehascontralateralmotorand/orsensorymorepronouncedinthe
lowerlimb.otherfeaturesthatmaybeseenareurinaryincontinence,gaitapraxia.
middlecerebralarterycharacterizedbycontralateralmotorand/orsensorymorepronouncedin
upperlimbandhomonymoushemianopia.ifdominantlobeinvolvedmayhaveaphasia,ifnon
dominantlobeinvolvedmayhaveneglectand/oranosognosia.
posteriorcerebralarterystrokecharacterizedbyhomonymoushemianopia,hallucinations,sensory
symptoms,thirdnervepalsywithparesisofeyemovements.
hemisensorylosswithseveredysesthesiaoftheaffectedareaistypicalforathalamicstroke.
anticholinergicexcessischaracterizedbyredasabeet,dryasabone,hotasahare,blindasabat,
madasahatter,andfullasaflaskflushing,anhidrosis,hyperthermia,mydriasis/vision,
delirium/confusion,andurinaryretention/constipation.canalsocauseretroorbitalheadachedue
toprecipitationofacuteglaucoma.
glatirameracetateisalongtermdiseasemodifyingtreatmentformultiplesclerosisthatworksby
modulatingtcellmediatedautoimmunitytomyelinbasicprotein.recognizemultiplesclerosisby
periventricularwhitematter.
tonicclonicseizurescanresultinlacticacidosisduetolacticacidproductionbythemuscleand
reducedhepaticuptakeoflactate.postictallacticacidosisistransientandresolvesin6090mins.

obstetrics/gynecology

chorionicvillussamplingisdonebetween1012weeksofgestation.indicatedinwomen>35years
followinganabnormalultrasound.serumscreeningdoesnotprovideaconfirmatorydiagnosis.risks
forCVSincludefetaldeathandlimbreductiondefects.anincreaseincidenceofdistallimbreduction
defectsoccurswhentheprocedureiscarriedoutbefore910weeksgestationalage.(most
importantriskfactor)
lichensclerosischronicinflammationofanogenitalregionmostlyaffectingwomen.whitemacules
andpatcheswithanatrophic"cigarettepaper"quality.doavulvarpunchbiopsybecausethelesion
isprecancerousforsquamouscellcarcinoma.usetopicalsteroidstotreat.
patientswithpolycysticovariansyndrome(PCOS)haveincreasedriskofdyslipidemia,type2
diabetesmellitus.dofastinglipidpanelandoralglucosetolerancetest
endometritishasfever,uterinetendernessinpostpartumperiod,andfoulsmellinglochia.risk
factorsareprolongedruptureofmembranes,prolongedlabor,csection.treatmentforendometritis
isclindamycin+gentamycin.gentamycin(aminoglycoside)forgram,clindamycingivesanaerobic
coverage
transvaginalultrasoundis"goldstandard"forevaluatingcervicalincompetence
hypogonadotropichypogonadismisadecreaseinsexhormonesduetodecreasedFSH/LH.
increasedriskofosteoporosis.canbeduetostrenuousexercise,anorexia,marijuanause,stress,
starvation,depression,andchronicillness
intrauterinefetaldemisewhenthewomandoesn'tfeelanymovementsafter20weeksandcan't
hearfetalhearttonesondoppler.nextstepistodoultrasoundtoconfirm
ifpatienthashighfever,can'ttakeoralmeds(nausea/vomiting)thenhospitalizeandtreatwith
intravenouscefotetananddoxycyclineforPID.
intraductalpapillomaisabenignbreastmasspresentingaroundperimenopausalarea.
intermittentbloodydischargefromonenipple.tendtobesmall<2mm
uterinerupturehasintenseabdominalpainandvaginalbleeding.thefetalstationretracts.deliver
viaemergencycsection.
forPCOSifpatientwantstoconceivegiveclomiphenecitrate.
emergencycontraceptioniseffectiveupto120hoursafterintercourse,uselevonorgestrel(planb).
intramuscularmedroxyprogesterone(depoprovera)isamethodofbirthcontrol,notan
abortifacient.
forstoppinglactationuseicepacksandtightfittingbra.donotusebromocriptine(dopamine
agonist.stopsprolactin)
T.vaginaliscausesmalodorous,graygreen,thin,frothyvaginaldischarge.wetmountwillshow
flagellatedmotileorganisms.willalsohavevaginalpruritisandinflammation.bacterialvaginosis
(gardenerella)willnothavepruritisandinflammation.
depresseddeeptendonreflexisfirstsignofmagnesiumsulfatetoxicity.discontinueandadminister
calciumgluconate.
endometriosishaspelvicpainbeforecyclebegins.laparoscopyisgoldstandardfordiagnosing.
endometriosisleadstoincreasedriskofinfertility.Upto30%ofpeopleworkedupforinfertility
foundtohaveendometriosis.
abruptioplacentaecanpresentw/uterinetenderness,hyperactivity,andincreaseduterinetonew/
3rdtrimestervaginalbleeding.
forectopicpregnancydotransvaginalultrasoundtolocatesiteofectopicimplantation.laparoscopy
asalastresorttovisualizeectopicpregnancy,itsmoreinvasive
totreatandpreventseizuresineclampsiausemagnesiumsulfate.
renalplasmaflowandGFRincreaseinpregnancycausingadecreaseinBUN/creatinine.
missedabortioninvolvesadeadfetusstillretainedintheuterus.disappearanceofnauseaand
vomitinginearlypregnancyandarrestofuterinegrowth.

doTSH/T4foramenorrhea,aswellasFSHtoruleoutovarianfailure,prolactinfor
hyperprolactinemia.
symmetricintrauterinegrowthrestriction(IUGR)include:
chromosomalabnormalities,
congenitalanomalies(tetralogyoffallot),
congenitalinfections.
asymmetricgrowthrestrictioncausesinclude:
maternalhypertension,
preeclampsia,uterineanomalies,
maternalantiphospholipidsyndrome,
collagenvasculardisease,
maternalcigarettesmoking
iffetalmovementisdecreasedorbecomesimperceptiblebythemotherdoanonstresstest.
squamouscellcarcinomaisismostcommonvaginalcancer.vaginalbleedingandmalodorous
vaginaldischargearethemostcommonsymptoms.stageIandstageII<2cmaresurgicallyexcisedif
>2cmthenradiationtherapyisgiven.
TORCHinfectionscausemicrocephaly(symmetricIUGR).smokingcausesIUGRbutnotmicrocephaly
(asymmetricIUGR).
obesepostmenopausalwomenhavehigherestrogenlevelsbecauseofconversionofadrenal
androgenstoestrogensbyadiposetissue.
ifpatientshassuddenonsethirsutism/virilizationduringpregnancydopelvicultrasound.1)no
ovarianmassthendoabdominalCTtoruleoutadrenalmass.2)ifonultrasoundyoufindbilateral
cysticmassesthenthecaluteincysts.ruleouthighbetahcgstates.3)ifonultrasoundyoufind
bilateralsolidmassesthenmostlypregnancyluteoma.4)ifonultrasoundyoufindunilateralsolid
massthendolaparotomytoruleoutmalignancy.
normallypatientshavelowgradefeverandleukocytosisandbloodyvaginaldischargefollowingthe
delivery.ifthelochiawasfoulsmellingandtheuteruswastender,endometritis.
whenpatienthasplacentalabruptionmanageaggressivelytoensurerapidvaginaldelivery.can
causeDIC.onlydocsectionwhendeteriorationofthefetusorobstetricalcomplications.uterine
rupture>immediatecsection
Trichomonasvaginitispresentsaserythematousvaginalmucosawiththingrayishvaginaldischarge.
treatwithmetronidazoleandavoidalcohol.
menstrualdiaryforatleast3cyclesforpremenstrualsyndrome.bloating,fatigue,breasttenderness,
headaches,anxiety,moodswings,decreasedlibidoandirritability.
patientswithinevitableorincompleteabortionsshouldbehospitalized,givenivfluids,suction
curettage,andrhogamifRh.theymaygetseptic,DIC,andhemorrhage.
withafetalanomalyincompatiblewithlife,allowspontaneousdeliveryifpretermlaborwithrupture
ofmembranes.
givepulsatileGnRH(leuprolide)tosomeonewithacquiredhypogonadotropichypogonadismdueto
hypothalamicdysfunction.
copiousvaginaldischargebyitselfwithoutpruritis,burning,malodorousdischarge,erythema,edema
andfriabilityofthevaginalmucosa,tendernessofthecervix,andgreenorcurdlikevaginaldischarge
isnotconcerning.mostlikelyphysiologicalleukorrhea.
bacterialvaginosishasthingraywhitevaginaldischarge,vaginalph>4.5,+WhifftestwithKOH
prep,andcluecellswhicharevaginalepithelialcellswithadherentbacteria.nopruritisor
inflammation.Treatwithmetronidazole.
pseudohyphaeonwetmountareconsistentwithcandidavulvovaginitis.willhavepruritis,thick
whitedischargethathasacottagecheeseappearance.treatwithoralfluconazole.
after32weekswithpreterm,prematureruptureofmembranes(PPROM)itsunclearif
corticosteroidsarebeneficial,butgivepenicilliniftheirGBSstatusisunknown.
dysmenorrhea,enlargeduterus,andheavymensesisuterinefibroids.

primarydysmenorrheaiscausedbyincreasedlevelsofprostaglandinsandpresentswithlower
abdominalpainoccurringwithmenstruation.NSAIDsandOCPscanimprovethesesymptoms.
earlyfollicularphasefollowsmenstruation.cervicalmucusisthick,scant,andacidinthisphase.no
penetrationbyspermatozoa.duringovulatoryphasethecervicalmucusisprofuse,clearandthin,
andis>6.5inpHandwillstretch>6cmwhenliftedvertically.inmidandlatelutealphasesovulation
hasoccurredandthemucusbecomesthickerandinhospitabletosperm.
increaseinbloodpressurebefore20weeksofgestationisduetochronichypertensionorhmole.if
ultrasoundshowsanormalsacthenitsnothmole.hypertensionisthemostcommonlyidentified
riskfactorforplacentalabruption.
lithiuminpregnancycangiveEbsteinsanomaly:atrializedrightventricle,malformedtricuspidvalve,
andatrialseptaldefect.
fatnecrosisofthebreastassociatedwithbreasttraumaorsurgery.canmimicbreastcancerand
presentsasafixedmasswithskinornippleretraction.hascalcificationsonmammography.biopsy
showsfatglobulesandfoamyhistiocytes.
femalephenotypelackinganormalvaginaanduterusiseithermullerianagenesis,androgen
insensitivity,or5alphareductasedeficiency.inthelatter2youhaveanXYgenotype.
nd
precociouspubertyisdefinedasdevelopmentof2 sexcharacteristicsbeforeage8ingirls,9in
boys.acceleratedbonegrowthandadvancedboneagearecommon.centralcauseisresultofearly
activationofhypothalamicpituitaryovarianaxisbyGnRH.FSHandLHareelevated.inperipheral
precociouspubertytheyhavelowFSH/LHlevels,becauseofgonadal/adrenalreleaseofsex
hormones(negativefeedback).ifcentralthendiagnosewithbrainimagingCT/MRIandtreatwith
GnRHanalog(leuprolide)therapy.
uterinerupturehasintenseabdominalpainandvaginalbleedingalongwithhyperventilation,and
tachycardia.placentapreviacausespainlessvaginalbleeding,theriskfactorsarepriorcsection,
advancedmaternalage,multiparity,smoking,multiplegestation,andpreviousplacentaprevia.
asymptomaticbacteruriaprogressestopyelonephritisin3040%ofcases.
hyperemesiscanoccurwithgestationaltrophoblasticdisease,someasurebetahcg.ifbetahcgis
high,doanultrasound.hyperemesisgravidarumpresentswithketonuria.
hcgfromthesyncytiotrophoblastsismainlyresponsibleforthemaintenanceofthecorpusluteum
duringpregnancy.
inflammatorybreastcarcinomapresentsasanedematouscutaneousplaquewithapeaudorange
appearanceoverlyingabreastmass.presentswithaxillarylymphadenopathy,and25%have
metastaticdisease.clinicallyunabletodifferentiatebetweenaninfectiousprocesslikebreastabscess
soabiopsyforhistologyisneeded.
raloxifeneisaSERMthatincreasesriskofthromboembolism.decreasesriskofbreastcancerand
preventsosteoporosis.noincreasedriskofendometrialcancer.
initialmenstrualcyclesinpubertalfemalesareirregularandanovulatory.thisisduetothe
immaturityofthedevelopinghypothalamicpituitaryovarianaxisthatdoesntproduceadequate
quantitiesandproportionsofFSH/LHrequiredtoinduceovulation.
cigarettesmokingisthemostcommonpreventablecauseoffetalgrowthrestrictionintheUS.
trastuzumabwithchemotherapycanleadtocardiactoxicity.doechobeforetreatment.before
youtouchthebreasts,checkthechest!
th
majorityofbreechpositionsselfcorrectby37 weekofgestation,sothereisnoindicationto
convertuntilthen.routinelyfollowup
pagetsdiseasehasan85%chanceofhavingunderlyingbreastcancer.mostpatientswithpagets
haveanadenocarcinoma.skinbiopsytypicallydemonstrateslargecellsthatappeartobesurrounded
byclearhalos.
midcyclepain(mitelschmerz)presentsasabdominalpaininayoungfemaleinthemiddleofhercycle
withabenignhistoryandphysicalexam.
inapregnantpatientwhohassyphilisandisallergictopenicillin,dodesensitization.
galactorrheacanbeyellow,brown,orgreen.firststeptodoinpatientwithgalactorrheaistocheck
TSHandprolactinlevels.redflagsareunilateral,guaiacpositivefluidandabreastlump.

tamoxifencarriesanincreasedriskforendometrialcarcinoma.butisanantagonistatbreasttissue
andpreventionofbreastcancer.alsodecreasesriskofosteoporosis.
inpremenopausalwomenwithsimpleorcomplexhyperplasiawithoutatypiausecyclicprogestins
totreatdysfunctionaluterinebleeding(DUB).thechanceforprogressiontouterinecancerisverylow
1%and3%forsimpleandcomplexrespectively.
preeclampsiacancausecentrilobularnecrosisoftheliver,withhematomaformationandthe
formationofthrombiintheportalcapillarysystem.theseprocessescancauseswellingoftheliver
withdistentionofthehepatic(glissons)capsuleresultinginRUQpain.
pretermlaborislaboroccuring>20weeksbut<37weeksgestation.requirestheoccurrenceof
documenteduterinecontractionsatarateof4per20minormore,anddocumentedcervical
changesconsistentwithlabor.Respiratorydistresssyndrome(RDS)isacommoncomplicationin
preterminfantsasfetallungmaturityhasnotyetbeenreached.othercomplicationsinclude
intraventricularhemorrhage,sepsis,nectrotizingenterocolitisandkernicterus.themanagement
dependensonthegestationalageoffetusandpresenceorabsenceofcomorbiditiesthatposearisk
tofetusandmother.innormalpregnanciessystemiccorticosteroidsaredeliveredwhenthe
gestationalageis2434weeks.tocolysisshouldthenbeattemptedwiththegoalofmaintainingthe
pregnancyforatleast48hourstoallowthesteroidstowork.
firsttreatmentforvariabledecels(cordcompression)isgiveoxygentomotherandchangematernal
position.uterotonicdrugsneedtobediscontinuedandmaternalhypotensionevaluatedandtreated.
variabledecelsmayrequireamnioinfusion.
choriocarcinomaisametastaticformofgestationaltrophoblasticdisease.itmayoccuraftermolar
pregnancyornormalgestationandthelungsarethemostfrequentsiteofmetastaticspread.
suspectchoriocarcinomainanypostpartumwomanwithpulmonarysymptomsandmultiplenodules
onCXR.elevatedbetahcghelpstoconfirmthediagnosis.
androgeninsensitivitysyndromeischaracterizedbyadefect/absenceofandrogenreceptors
resultinginandrogenresistanceofperipheraltissues.thesepatientsareXYandhavetestes.MIFis
producedbythetestesandprohibitsformationofuterus,fallopiantubes,andupperportionofthe
vagina.breastsdevelopbecauseconversionoftestosteronetoestrogen.
stressincontinenceischaracterizedbylossofsmallamountsofurinewithincreasedintraabdominal
pressure.ineffectiveclosureofurethralsphincter.weakeningofpelvicfloormusculatureleadingto
urethralhypermobility.willshowanangle>30withacottonswabintheurethralorificeupon
increaseofinraabdominalpressure.treatwithkegelexercisesandurethropexy.useoxybutyninto
treaturgeincontinence.resultsfromdetrusorhyperactivityandischaracterizedbyasuddenurgeto
urinate.
hypotensionisacommonsideeffectofepiduralanesthesia.thecauseofhypotensionisblood
redistributiontolowerextremitiesandvenouspooling.
thyroidfunctioninpregnancyisaffectedby2separatemechanisms.1)increaseinthyroidbinding
globulin(TBG)concentrationand2)stimulationoftheTSHreceptorbychorionicgonadotropin
(hcg).anincreaseinestrogenleadstoanincreaseinTBGproduction,whichresultsinanincreasein
TBGboundT3andT4.asaresultelevatedTBGleadstoincreasedtotalT4andT3,butthefreeT4and
T3remainnormal.theelevatedlevelsofhcginpregnancycanalsocauseamildstimulationofTSH
receptor,resultinginasmallincreaseinfreeT3andT4andamilddecreaseinTSH.
infantsborntopatientswithgravesdiseasetreatedwithsurgeryareatriskforthyrotoxicosis
becauseofthepassageofthyroidstimulatingIgGacrosstheplacenta.
Chlamydiatrachomatisisthemostcommoncauseofmucopurulentcervicitis.
inapatientrecievingestrogentherapytherequirementforlthyroxineincreases.estrogenmay
causeinductionofliverenzymes,increasedlevelofTBG,andincreasedvolumeofdistributionof
thyroidhormones.
weightgainisnotassociatedwiththeuseofcombinationoralcontraceptives.
abdominalcircumferenceisthemosteffectiveparameterforestimationoffetalweightincasesof
suspectedfetalgrowthrestriction.

protractionoflaborreferstoaslowprogressionofcervicaldilatation,whereasarrestdisordersare
diagnosedwhenthecervixceasestodilateafterreachingatleast4cm.ifthemembranesarestill
intact,anamniotomyisthefirststeptopromoteprogression.
ovarianmalignancycanpresentasrightadnexalfullness,andnodularityalongtherectovaginal
septum(possibleperitonealmets).pleuraleffusioncanbeduetometastaticspreadtothepleura.
mostcommoncauseofmalignantpleuraleffusionsarebreastcancerandlungcancer.willbean
exudativeeffusion(Lightscriteria).
forLSIL/milddysplasia/CIN1doacolposcopywithatargetedbiopsy.conebiopsyisformore
aggressiveCIN.
chlamydiadoesnotinvolvethevagina,itcausescervicitisandurethritis.candidiasispresentswith
perinealitchingandathickwhitecurdlikevaginaldischargeandavaginalphof4.0.trichomonas
presentswithanelevatedvaginalphandagreenfrothymalodorousdischarge.bacterialvaginosis
cancausesimilarsymptomstocandidiasisbutthedischargeisthinnerandthevaginalphishigher
thannormal,noinflammationoritching.
treatprolactinomawithdopamineagonistlikecabergoline/bromocriptinetorestorefertility.will
havebilateralgalactorrhea.Polycysticovariansyndromewillnothavegalactorrhea.treatinfertilityof
PCOSwithGnRHanalog(leuprolide)orclomiphene.
thirdtrimesterbleedingisoftencommonlyplacentaprevia(painless)andplacentalabruption
(painful).ifhemodynamicallystable,thenextstepwouldbeatransabdominalultrasound.donotdo
bimanualexaminationorspeculumvaginalexaminationuntilplacentapreviahasbeenruledoutby
abdominalultrasound.
severaltocolyticagentscancausepulmonaryedemainrarecases.mostcommonwithbetaagonists
(terbutalineandritodrine).
reassuranceandoutpatientfollowupisstandardofcareforthreatenedabortion.(bleeding,closed
cervixbefore20weeksgestation)
oneofthesideeffectsofepiduralanesthesiaisoverflowincontinencecausedbybladder
denervation.patientcantsenseafullbladderandthenthehypotonicbladderdistendsgradually.
whenthepressurerisesaboveurethralpressuretheurineislostandpressureequalizes.transient
incontinencetreatedbyinandoutcatheterization.(samewithdiabeticneuropathy)
placentalabruptionpresentswithsuddenonsetabdominalpaininthethirdtrimesterwiththe
absenceoftrauma.bleedingisseenin80%ofcasesandinsomecasesitmayberetroplacentaland
notappearonvaginalexam.mostcommonriskfactorismaternalhypertension.
Antiphospholipidantibodysyndrome(APS)isassociatedwithfalse+VDRL,prolongedPTTand
thrombocytopenia.canpromotearterialandvenousthrombosesandresultanttendencytoward
sponaneousabortions.prophylaxiswithLMWHisrecommended.
polycysticovariansyndrome(PCOS)patientsarehyperandrogenicwomenwithadequateamountof
activeestrogens.androgensconvertedintoestrogensinperipheraltissues.theyareoligoor
anovulatoryandaredeficientinprogesteronesecretion,thustheyhaveunopposedestrogen
stimulationleavingthematariskforendometrialcancer.
duringpregnancythehigherserumconcentrationofprogesteronehasastimulatoryeffectonthe
dorsalrespiratorygroup(DRG)ofthemedullaryrespiratorycenter.bystimulatingthiscentral
respiratorycenter,highprogesteroneconcentrationsleadtotachypneaandconsequentchronicmild
respiratoryalkalosis.willhavehighpH,decreaseinPaCO2andadecreaseinHCO3tocompensate
+pregnancytestbutwithnoultrasoundfindingsofintraorexrauterinepregnancyhasadifferential
of:earlyviableintrauterinepregnancy,ectopicpregnancy,ornonviableintrauterinepregnancy.an
intrauterinepregnancyshouldbeseenwithtransvaginalultrasoundat15002000betahcg.ifthe
levelis<1000,repeatbothbetahcgandtransvaginalultrasoundin23days.
adenomyosisisthepresenceofendometrialglandsintheuterinemuscle.occursmostfrequenlyin
women>40withseveredysmenorrheaandmenorrhagia.physicalexamwillshowanenlargedand
generallysymmetricuterus.leiomyomasalsopresentsimilarlywithdysmenorrhea,menorrhagia,
andalargesibzeduterusbutitisasymmetrical/irregularlyshaped.

dysfunctionaluterinebleeding(DUB)referstoheavyvaginalbleedingthatoccursintheabsenceof
structuralororganicdisease.DUBismostoftentheresultofanovulation.treatmentdependsonthe
severityofbleeding,ifmildthengiveironsupplementation.ifmoderateandnoactivebleedingthen
addprogestin.ifmoderatewithactivebleedingorifseveregiveestrogen.inwomen>35withDUB,
endometrialbiopsyisindicated
amissedabortionisaformofspontaneousabortionthatischaracterizedbyintrauterinefetaldeath
before20weeksgestationalagewithcompleteretainedproductsofconceptionandaclosedcervix.
patientspresentwithlossofpregnancysymptomsandsomebrownvaginaldischarge.atransvaginal
ultrasoundisnecessarytoconfirmthediagnosis.themostappropriatetreatmentisremovalofPOC
fromtheuteruswithadilationandcurettage,ormedicallywithvaginalmisoprostolorexpectantly
withserialimagingtoensurecompletenaturalexpulsionofPOC.
ABOincompatibilitygenerallyoccursinagroupOmotherwithagroupAorBbaby,butABO
incompatibilitycauseslessseverehemolyticdiseaseofthenewbornthandoesRh(D)
incompatibility.affectedinfantsareusuallyasymptomaticatbirthwithabsentormildanemiaand
developneonataljaundice,whichisusuallysuccessfullytreatedwithphototherapy.
pseudocyesisisanuncommonconditioninwhichawomanpresentswithmanysignsandsymptoms
ofpregnancy(amenorrhea,enlargementofbreastsandabdomen,morningsickness,sensationof
fetalmovement,+pregnancytestreported)howeverultrasoundwillrevealanormalendometrial
stripeandthepregnancytestintheofficewillbenegative.usuallyseeninwomenwhohaveastrong
desiretobecomepregnant.formofconversiondisorderandmanagementrequirespsychiatric
evaluationandtreatment.
elevatedprolactinlevelssuppressGnRHreleasetherebysuppressingLHandFSHproductionand
ovulation.thisisthereasonforanovulationandamenorrheainlactatingmothers.
palpablebreastmassinwoman<30yearsdoanultrasound.ifsimplecystthendoneedleaspiration.
ifcomplexcyst/mass(solid)thendoimageguidedcorebiopsy.inawoman>30yearsdomammo
&ultrasound.ifsuspiciousformalignancythendocorebiopsy.
thethreehallmarkfeaturesofendometriosis(thethreeds)aredyspareunia,dysmenorrhea,and
dyschezia.definitivelydiagnosedvialaparoscopy.themostpopulartreatmentiscombinedestrogen
andprogestinpills.otherpossibilitiesincludeGnRHanalogs(leuprolide)ordanazol.
inandrogeninsensitivitysyndrome,doagonadectomyaftercompletionofpuberty.thisallowsfor
completionofbreastdevelopmentandattainmentofadultheight.immediateremovalofgonadsis
indicatedincasesofXYgonadaldysgenesis(Swyersyndrome)asmalignantchangecanoccuratany
age.
endometrialbiopsyisindicatedincasesofdysfunctionaluterinebleeding(DUB)affectingwomen>
35y/o.alsoindicatedincasesofDUBifhypertension,diabetes,orobesityarepresent.ifbiopsyis
negativethencanbetreatedwithcyclicprogestins.(ifmoderateandactivebleeding,estrogens)
rapidlydevelopinghyperandrogenismwithvirilzationishighlysuggestiveofanandrogensecreting
neoplasmoftheovaryoradrenalgland.serumtestosteroneandDHEASareveryhelpfulin
delineatingthesiteofandrogenproduction.elevatedtestosteronelevelswithnormalDHEAS
indicateanovariansource,whereaselevatedDHEASwithrelativelynormaltestosteroneindicate
anadrenalsource.rapidlydevelopingvirilizationisrareinPCOS.
LSILonpapsmeargetscolposcopy.inpostmenopausalwomanalsodoHPVtestingandrepeatpap
smearat6/12months.ifHPVisthenroutinescreening,ifHPVis+thencolposcopy.
rupturedfetalumbilicalvesselpresentswithantepartumhemorrhagewithverycharacteristicfetal
heartchangesprogressingfromtachycardiatobradycardiatoasinusoidalpattern.vasapreviaisa
rareconditionwherethefetalbloodvesselstraversethefetalmembranesacrossthelowersegment
oftheuterus(betweenthebabyandtheinternalcervicalos).thesevesselsarevulnerabletotearing
duringnaturalorartificialruptureofthemembranes.treatmentisimmediatecsection.
tmpsmxiscontraindicatedinpregnancy.totreatasymptomaticbacteriuriainapregnantwoman
useamoxicillin.
treatmentforvaginismusisrelaxation,kegelexercisestorelaxthevaginalmuscles,andinsertionof
objectsgraduallyincreasingtheirsizetoencouragedesensitization.

primaryovarianfailureresultsindecreasedestrogenlevels,increasedFSHandLHlevels.FSH:LH
ratiowillbe>1.0.FSHelevationinthesettingof>3monthsofamenorrheainawomanunderage40
confirmsthediagnosisofprematureovarianfailure.
prematureovarianfailureischaracterizedbyamenorrhea,hypoestrogenism,andelevatedserum
gonadotropinlevelsinwomenage<40years.maybeassociatedwithautoimmunedisorderssuch
ashashimotosthyroiditis,addisons,type1diabetesmellitus,andperniciousanemia.women
presentwithsigns/symptomssimilartothoseseeninmenopause.confirmdiagnosiswithincreased
serumFSH/LHlevelsanddecreasedestrogenlevels.ifwanttogetpregnantdoinvitrofertilization
becausetheylackviableoocytes.
theidealrangeofmaternalfastingglucoseisbetween7590mg/dL.treatmentisbest
accomplishedwithsubcutaneousinsulin.doesnotcrosstheplacenta.gestationaldiabetesputsbaby
atriskfor:macrosomia,hypocalcemia,hypoglycemia,hyperviscosityduetopolycythemia,
respiratorydifficulties,cardiomyopathyandcongestiveheartfailure.
mammogramforwomenevery2yearsstartingat50untiltheyare75y/o
ifpatienthasatypicalsquamouscellsofundeterminedsignificance(ASCUSonpapsmear)followed
bycolposcopyshowingCIN1thendorepeatpapsmearat6/12monthsorHPVtestingin12months.
iftwosmears,thenroutinefollowupin1year.ifASCUSorASCH(onrepeatpap)orifHPV+then
docolposcopyagain.ifcolposcopyshowspersistentCINthendiagnosticprocedure.HSIL,CIN2,and
CIN3requireexcisionaldiagnostic/treatmentmodalitylikecoldknifeconizationorLEEP.
intraamnioticinfectionshouldbesuspectedinthesettingofprolongedorprematureruptureofthe
membranes(before37weeks)whenmaternalfever,leukocytosis,anduterinetendernessor
tachycardiaaredetected.fetaltachycardiaisanotherfeatureofchorioamnionitis.themost
appropriatetreatmentofchorioamnionitisassociatedwithprematureruptureofthemembranesis
systemicbroadspectrumantibiotictherapyandexpediteddeliveryofthefetus.
DESincreasesriskofvaginaladenocarcinomainoffspring.
kallmannssyndromeconsistsofacongenitalabsenceofGnRHsecretionassociatedwithanosmia.
patientshaveanormalXXgenotypeandnormalfemaleinternalreproductiveorgans.presentwith
amenorrheaandabsentsecondarysexualcharacteristicssuchasbreastandpubichairdevelopment.
abnormaldevelopmentoftheolfactorybulbs/tractsresultsinhyposmiaoranosmia.
laborshouldbeinducedwithoutdelayinpatientswithintrauterinefetaldemisewhodevelop
coagulationabnormalities.fibrinogenandplateletlevelsinthelownormalrangecan
indicatedevelopingDIC.
screenallpregnantwomenforsyphilis,regardlessofriskfactorsforSTDs(TORCH).onlyscreenfor
chlamydiainwomen<24oratincreasedrisk(multiplesexualpartnersorhistoryofSTDs)
duringpregnancytheprimarygoalofcolposcopyistheexclusionofinvasivecervicalcancer.the
managementofwomenwithanycytologicalspecimensuggestingHSILconsistsofcolposcopyand
directedbiopsy.iftheinitialbiopsyisnegative,repeatcolposcopyandbiopsyshouldbedoneat68
weeksafterdelivery.
managementforsepticabortionis1)cervicalandbloodcultures,2)antibiotics,and3)gentlesuction
curettage.Thepatientwillbefebrile,tachycardic,hypotensive,andhavebloodypurulentvaginal
dischargefromthecervix.
contraindicationstobreastfeedingareactivedrugabuse,tuberculosis,HIVinfection.HepatitisC
isnotacontraindicationtobreastfeeding.Iftakingmetronidazolestopfor1224hours.
arrestofdilationisdefinedaslackofcervicalchangefor2hoursinnulliparious/multiparous
patients.arrestofdescentisdefinedaslackofchangeofstationfor2hoursinprimigravidpatients
and1hourinmultigravidpatients,withextrahourallowedifepiduralinplace.prominentischial
spinescanleadcephalopelvicdisproportionwhichisoneofthethreepscausingprotractionand
arrestdisorders(passenger,passage,power).doacsectionifthereisanabnormalityinthe
maternalpelvis.
progestinonlycontraceptivesarethepreferredhormonalcontraceptivesinlactatingwomenas
theydonotaffectthevolumeorcompositionofmilkproducedbythemother.theyhavenoknown
effectsontheinfantandtheydonotcarrytheriskofvenousthrombosisassociatedwith

combinationpills.lactationaloneisnotconsideredareliableformofbirthcontrolasovulationcan
resumewhileamotherisstillbreastfeeding.
corticosteroidtreatmentisnotproventohaveabenefitafter34weeksgestation.itsuseislimited
totheperiodbetween2434weeks.fetaldistress(repetitivelatedecelerations)isanindicationfor
emergentcesareansection.
ayoungwomanpresentingwithabreastlumpcanbeaskedtoreturnafterhermenstrualperiodfor
reexaminationwhichmayrevealregressionofthemassifnoobvioussignsofmalignancyare
present.
inapatientwithprimaryamenorrheadopelvicexamorultrasound:ifauterusispresent>serum
FSH.ifFSHincreased>karyotyping,ifFSHdecreased>cranialMRI.iftheuterusisabsenton
ultrasound>karyotyping.ifnormalkaryotypeandnormalfemaletestosteronelevelsthenmost
likelyabnormalmulleriandevelopment.if46XYandnormalmaletestosteronelevelsthenandrogen
insensitivitysyndrome.
csectionshouldbeperformedonwomenwithactivegenitalherpeticlesions(primaryorsecondary)
inordertoreduceriskofneonatalHSV.
lowbackpainisverycommoninthirdtrimesterofpregnancy.believedtobecausedbyincreasein
lumbarlordosisandtherelaxationoftheligamentssupportingthejointsofthepelvicgirdle.
inintrauterinefetaldemise,thereisaconcernforDIC.lowfibrinogenlevelsandlowplateletsare
indicatorsforDIC.iftheyarenotlow,youdontneedneedtodeliverthefetuspromptly.weighthe
deliveryoptions.

ophthalmology

acuteglaucomahasaninjectedeyeandamiddilatedpupil.
orbitalcellulitishasopthalmoplegia,proptosis,diplopia,painwitheyemovement.Canbecausedby
bacterialsinusitis.
agerelatedmaculardegenerationpresentswithbilaterallossofcentralvision.
vitreoushemorrhagepresentswithasuddenlossofvisionandonsetoffloaters.thefundusis
difficulttovisualizeandtherewillbefloatingdebris.
Postoperativeendopthalmitisusuallyoccurswithin6weeksofsurgery.patientshavepainand
decreasedvisualacuity.willhaveswolleneyelids,conjunctiva,hypopyon,cornealedemaand
infection.
amaurosisfugaxischaracterizedbyvisuallossthatismonocularandtransient.describedasa
curtainfallingdownsimilartocentralretinalarteryocclusion,howeveropthalmoscopyinCRAO
showspallorofopticdisc,cherryredfoveaandboxcarsegmentationofbloodinbotharteriesand
veins.inamaurosisfugaxyouseeawhiteedematousretinafollowingthedistributionoftheretinal
arterioles.
chalazionpresentsasapainfulswellingthatprogressestoanodularrubberylesion.itsachronic
granulomatousconditionthatdevelopswhenameibomianglandbecomesobstructed.persistentor
recurrentchalazionmaybeduetomeibomianglandcarcinoma.doahistopathifrecurrent.
cataractshasblurredvisionandglare.causedbythickeningofthelens.
retinaldetachmentpatientscomplainofacurtaincomingdownovermyeyesandphotopsia
(flashesoflight)andfloaters(spotsintheirvisualfield).canbeduetooculartrauma(previous
surgeryoftheeyesuchasforcataracts).opthalmoscopywillrevealagrey,elevatedretina.
spontaneoussubconjunctivalhemorrhageisabenignfinding.lookslikeeyeiscoloredbrightred.
dacrocystitisisaninfectionofthelacrimalsac.itusuallyoccursininfantsandadults>40.
characterizedbythesuddenonsetofpainandrednessinthemedialcanthalregion.sometimesa
purulentdischargeisnotedfromthepunctum.s.aureus,betahemolyticstrepareusualorganisms.
treatwithsystemicantibiotictherapy
cataractsoccurduetoopacificationofthelens.andpresentswithpainlessblurringofvision.
descriptionofaglarewhiledrivingatnightisclassicmanifestation.

angleclosureglaucomainpplage5570years.acuteonsetofsevereeyepain,blurredvision
associatedwithnauseaandvomiting.examinationrevealsaredeyewithsteamycorneaand
moderatelydilatedpupilthatisnonreactivetolight.
treatcentralretinala.occlusionwithocularmassageandhighflowoxygenadministration.will
presentwithpainlessmonocularlossofvision.fundoscopywillshowdiffuseischemicretinal
whiteningandcherryredspots.
sympatheticopthalmiaischaracterizedbydamageofoneeye(thesympatheticeye)aftera
penetratinginjurytotheothereye.itisduetoanimmunologicmechanisminvolvingtherecognition
ofhiddenantigens.
externalhordeolum(stye)isacommonstaphylococcalabscessoftheeyelid.itistreatedwithwarm
compresses.incisionanddrainageisperformedifresolutiondoesnotbegininthenext48hours.
maculardegenerationisthemostcommoncauseofblindnessinindustrializednations.activitiesthat
requirefinevisualacuityareusuallythefirstaffectedandpatientswiththisconditionmayreportthat
straightgridlinesappearcurved.
oculartonometryisthebesttestforacuteglaucoma(suddenonsetofeyepain,photophobia,and
middilatedpupil)
atropineisamuscarinicantagonist.donotgiveinapatientwithacuteglaucoma.willdilatetheeye.
insteadusemannitol,acetazolamide,pilocarpine,ortimolol.

pediatrics

henochschonleinpurpura=IgAmediatedvasculitisofsmallvesselsfollowingURI.rash,arthralgia,
abdominalpain,renaldisease.Rashonbuttocksandlegs.RelatedtoIgAnephropathy.
esophagealatresiaoccurswithtrachoesophagealfistula.airentersstomach>distendedstomach.
acidspassfistula>pneumonia
compartmentsyndrome(pallor,pain,paresthesias,poikilothermia,pulselessness,paralysis)canlead
tovolkmannsischemiccontracturewherethedeadmusclehasbeenreplacedwithfibroustissue.
kawasaki'sdiseasefeverwith
1)conjunctivitis
2)oropharyngealchanges
3)cervicaladenopathy
4)truncalrash
5)changesindistalextremities
fetalhydantoinsyndromecausedbyanticonvulsantmedications(phenytoin/carbamazepine).cleft
palate,microcephaly,digitalhypoplasia,hirsutism
laryngomalaciaiscongenitalflaccidlarynxcausesinspiratorystridor.holdchilduprightafter
feedingandnotfeedwhenlyingdown
conjunctivitsafterbirth:
1day=chemical
25days=gonorrhea
515days=chlamydia
Giveoralerythromycin(nottopical)toreduceriskofpneumonia
staphylococcalscaldedskinsyndromeprodromeoffever.erythemaandblisterswitha+nikolsky's
sign
gauchersdiseaseisadeficiencyofbetaglucosidase.ashkenazijewwithfatigue(anemia)easy
bruising(thrombocytopenia)andpathologicalfractures.radiologyshowserlenmeyerflask
deformityofdistalfemurandgauchercellswithwrinkledpaperappearance.
fanconianemiaisautosomalrecessivedisorderpresentingwithpancytopenia(macrocyticanemia)
andmorphologicalabnormalities.horseshoekidney,thumbabnormalities,shortstature,abnormal
skinpigmentation.

LAD1hasnoCD18soleukocytescan'texitvessels.nopusformation,delayedumbilicalcord
separation.recurrentinfections.increasedWBCwithhighneutrophils
epistaxis,mass,andbonyerosiononthebackofthenoseisangiofibroma
febrileseizurewhentempis>100.4andage<6associatedwithinfection
henochschonleinpurpuraseenafterURI.givesteroidsandmonitorrenalfunction.abdominalpain
>ruleoutgastrointestinalbleedingandintussusception.
duodenalatresiahasa"doublebubble"sign,jejunalatresiahasa"triplebubble"onabdominal
radiographs.willhaveairfluidlevelsandagaslesslowerabdomen.
congenitalhypothyroidismhashypotonia,largetongue,sluggishmovement,abdominalbloating,
umbilicalhernia.
todd'sparalysisisapostictalconditionwithmotorrestorationoccuringrapidlyaftertheseizure
vitaminDricketshascraniotabes(pingpongballsalloverocciput),rachiticrosary(enlargementof
costochondraljunctions),thickeningofwristandankles,cuppingandfrayingatthedistalendsof
longbones
criduchatisdeletionof5p.hypotonia,shortstature,microcephalywithprotrudingmetopicsuture,
moonlikefacies,higharchedpalate,wideandflatnasalbridges
patientswithcysticfibrosishaverecurrentpulmonaryinfectionswithHaemophilus,Pseudomonas,
Staphylococcus.youwant2drugsthatcoverpseudomonas.(penicillin/cephalosporin+
aminoglycoside)
groupbstreptococcus(S.agalactiae)ismostcommoncauseofneonatalsepsis.normalvaginalflora
inwomen.lateonsetpresentswithmeningitis
C.trachomatiscausesfollicularconjunctivitisandpannus(neovascularization)formationinthe
cornea.Lookforpneumoniaafterconjunctivitis(nofever,eosinophilia)
allchildren<24monthswithafebrileUTIshouldhavearenal/bladderultrasoundtoevaluatefor
anyanatomicabnormalities.
infectiousmononucleiosishasfever,tonsillarpharyngitis,posteriorcervicallymphadenopathy.
(streppharyngitishasanteriorcervicallymphadenopathy).Givenantibioticsaftersuspectedstrep
infection>rash
parinaud'ssyndromehasparalysisofverticalgaze.mayhavepupillarydisturbancesandeyelid
retraction.endocrinedysruptionbyinterruptinghypothalamicinhibitingpathways.duetopinealoma
orgerminoma.craniopharyngiomawillhavebitemporalhemianopsia.
at12monthschildshouldweigh3timestheirbirthweight,andtheirlengthshouldbe1.5xofinitial
length.
inforeignbodyaspirationforachildusedirectlaryngoscopywithrigidbronchoscopybecauseitis
diagnosticandtherapeutic.foresophagususeflexiblebronchoscopy.
turnersyndromehasovariandysgenesisandwillhavehighFSH/LHandlowestrogenthatgivesno
negativefeedback.
vitaminAformeaslesreducesmorbidityandmortality
posteriorurethralvalveleadstooliguria.distendedbladderfilledwithurine.mostcommoncause
ofcongenitalurethralobstruction.
umbilicalherniaduetopoorclosureatumbilicalring.softswellingcoveredbyskinthatprotrudes
whencrying,coughing,straining,andiseasilyreducible.mostdisappearspontaneouslybutifnot
thensurgeryatageof34years,orifenlarges
congenitaltoxoplasmosis:chorioretinitis,hydrocephalus,intracranialcalcifications.congenital
rubella:1)deafness,2)cataracts,3)cardiacdefects.
langerhanscellhistiocytosisisalyticboneneoplasm.painfuloverlyingboneswellingand
hypercalcemia.
serumsicknesslikereactionisahypersensitivityreactionaftercertaindrugspenicillins
cephalosporins,TMPSMX.occursaftertreatingviralinfectionwithantibioticsfever,urticaria,
lymphadenopathy,arthralgias(EBVpharyngitistreatedwithpenicillinforstreppharyngitis)
toruspalatinusbenignbonygrowthonthemidlinesutureofthehardpalate.

mostcommoncauseofsecondaryhypertensioninchildrenisfibromusculardysplasia.humor
bruitintheCVA.angiographyshows"stringofbeads"patterninrenalartery
waterhousefriderichsensyndromeischaracterizedbysuddenvasomotorcollapseandskinrashdue
toadrenalhemorrhage.(N.meningitidis)
infantswhoaresmallforgestationalageatriskfor:hypothermia,hypoglycemia,hypocalcemia,
polycythemia,meconiumaspiration.
hyalinemembranediseasepresentswithsubcostalretraction,nasalflaring,hypoxemia,tachypnea,
duskinesswithinafewminutesafterbirth.CXRwillshowfinereticulargranularityoflung
parenchyma.
prolongedlaborisariskfactorforcerebralanoxiawhichcanleadtocerebralpalsy
shortheight,higharchedpalate,widelyspacednipplesandXOisturnersyndrome.patientswith
turnerhaveahigherriskofosteoporosisbecauselowerestrogenlevels.
recurrentselflimitingepisodesofvomitingandnauseainchildrenintheabsenceofanyapparent
cause,suggestscyclicalvomiting
oralthrush,lymphadenopathy,hepatosplenomegalymaybethepresentingsymptomsofAIDSin
infants.
inaninfantwithcongenitaldiaphragmaticherniaplaceanorogastrictubetosuctionand
decompressthebowelsandpreventfurtherlungcompression.
topreventSIDSplaceinfantinsupinepositionwhilesleeping.(ontheirbacks)
breathholdingspellsareepisodesofapnea(noexternalbreathing)associatedwithlossof
consciousness.commonandselflimited.Reassuranceisallthatisneeded.
turcotssyndromeisanassociationbetweenbraintumors(medulloblastomaandglioma)andFAPor
HNPCC.
forpatientswithcysticfibrosisneeddoublecoverageofpseudomonaswhentheyhavepneumonia.
useaminoglycoside(gentamycin)+antipseudomonalpenicillin.
evenwithvaccinationover75%ofhouseholdcontactswilldevelopsymptomsofBordetellapertussis
sogiveerythromycinforprophylaxistoallhouseholdcontacts.
nursemadselbowisalsocalledsubluxedradialhead,andisoneofthemorecommoninjuriesin
children.occurswhenparentspullorliftchildrenfromthearmorhand.childkeepsarmina
pronatedposition.rotatingthehandandforearmtoasupinatedpositionwithpressureoverthe
radialheadreducestheannularligamentwithanaudibleclickandrestoresnormaluseofthe
extremity.
ingastroschisisthebowelprotrudesthroughadefectontherightoftheumbilicalcord.itsnot
coveredbyanymembrane,itlooksmattedandisnotassociatedwithanyotherabnormalities.in
omphaloceletheboweliscoveredbyanamnioperitonealmembrane,andcanbeassociatedwith
othercongenitalanomalies(chromosome13/18/21)
transientsynovitisismostcommoncauseofhippaininchildren.occursafterviralinfection.
synovialinflammationleadstopain,decreasedrangeofmotion,andlimping.theaffectedhipis
flexed,slightlyabductedandexternallyrotated.thispositionmaximizesthejointspace
inchildrenapprox60%ofCNStumorsareinfratentorialand25%aresupratentorialand15%arein
themidline.astrocytomasarethemostcommonforbothsupra/andinfratentorial.
transpositionofgreatvesselspresentswithcyanosisinthefirst24hours.aortalocatedinfrontof
pulmonaryartery,sos2aorticsoundheardbetterthans2pulmonic,andheardasasinglelouds2
withnomurmur.
severecoughingparoxysmsmayresultinsubcutaneousemphysemaduetothehighintraalveolar
pressureprovokedbythecough.pneumothoraxcanalsooccurthisway,sogetCXRtoruleout.
fragilexisaCGGtrinucleotiderepeatdisorder.largetesticles,longprominentjaw,autism,largelow
setears.
Neisseriagivesmeningitiswithpetechialorpurpuralrashonaxilla,wrists,flanks,ankles.
Wilmstumorusuallybetweenagesof25.mostcommonprimaryrenaltumorofchildhood.80%
haveasymptomaticabdominalmassthatdoesnotcrossthemidline.symptomsmaybe:
hypertension,hematuria,abdominalpain,vomiting.mayalsopresentwithlungmets.associated

withbeckwithweidemannanddenysdrashsyndromes.neuroblastoma(neuroendocrinetumor)will
presentwithfever,weightloss,hepatomegalyandhypertension,andthecrossesmidline.
tetralogyoffallothas1)overridingaorta2)rightvent.hypertrophy3)pulmonarystenosis(single
s2)and4)VSD(pansystolicmurmur)
inesodeviationwhichisatypeofstrabismus,covertheunaffectedeye.Untreateditbecomesthe
preferredeyeleadingtoblindnessofthedeviatedeye.docovertestchildfixessightonatargetand
examinercoverseyeandchecksformovement.themisalignedeyewouldshifttorefixate.
riboflavindeficiencygivesyousorethroat,hyperemicandedematousoropharyngealmucous
membranes,cheilitis,stomatitis,glossitis,normocyticnormochromicanemia,seborrheicdermatitis
andphotophobia.
epiglottitisiscausedbyHaemophilusinfluenzatypeb.presentationincludesabruptonsetoffever,
sorethroat,dysphagia,drooling.canhaveairwayobstruction,signspointingtothisincludeamuffled
hotpotatovoice.keepneckhyperextendedprovidessomerelief.
myotonicmusculardystrophyisautosomaldominanttransmission.involvesalltypesofmuscle
(smooth,striated,cardiac).slowlydevelopmuscleweaknessandwasting.upperlipwillbeinshapeof
aninvertedv.
celiacdiseasecancausekwashiorkorlikeclinicalfeaturesassociatedwithdermatitisherpetiformis
(erythematousvesiclessymmetricallydistributedoverextensorsurfacesofelbowsandknees).
hyperIgMsyndromegivesrecurrentsinopulmonaryinfectionsandpoorspecificantibodyresponses
toimmunizations.willhavehighIgMandlowotherantibodiesandBcells.
irondeficiencyanemiaiscommonininfants/toddlerswhodrinkexcessivemilk.
ifchildswallowsabatteryandxrayshowsitsintheesophagusimmediatelyremoveviaendoscopy.
edwardssyndrome(trisomy18)hasmicrognathia,microcephaly,rockerbottomfeet,overlapping
fingersandabsentpalmarcreases.mostcommoncongenitalheartproblemisVSD.
S.pneumoniaeandH.influenzaearethemostcommoncausesofacutebacterialrhinosinusitis.treat
withamoxicillin/clavulanate.
immunethrombocytopeniainchildrenafteraviralillnesspresentswithisolatedthrombocytopenia.
relativelybenignconditionandwillresolvemostofthetime.ifsymptomsaresevereandplatelets<
30kthengivecorticosteroids.
mumpsgivesbilateralparotitisandorchitisisaseriouscomplication.
cholesteatomaisanearlesionwithcontinuedeardrainagedespiteappropriateantibiotics.chronic
middleeardiseaseleadstotheformationofapocketinthetympanicmembranewhichcanfillwith
granulationtissueandskindebris.complicationsincludehearinglossandCNpalsies,vertigo,and
infections.
eczemaherpeticumisaformofprimaryHSVthatisassociatedwithatopicdermatitis.umbilicated
vesiclesoverhealingatopicdermatitisaretypical.associatedwithfeverandlymphadenopathy.
giveacyclovirassoonaspossiblebecausethisconditionislifethreatening.
neuroblastomaarisesfromneuralcrestcellswhichareprecursorcellsofsympatheticchainsand
adrenalmedulla.calcificationsandhemorrhagesareseenonXRandCTscan.levelsofserumurine
catecholaminesandtheirmetaboliteswillbeincreased.
cysticcalcifiedparasellarlesiononMRIinayoungboywhohasincreasedintracranialpressure
(headache,vomiting)bitemporalhemianopsiaisacraniopharyngioma.
vaginalforeignbodiesshouldbesuspectedinchildrenwithpurulent,foulsmellingvaginaldischarge
andbleeding,andistreatedwithirrigationwithwarmedfluids
retropharyngealabscessisadeepneckspaceinfectionseenmostcommonlyinchildrenthatages
range6mo6years.abscessformsbydirectspreadofinfectionfrompharyngitis,tonsilitis,otitis,
sinusitisorotherinfectionsofthepharynx.recenthistoryofURIfollowedbyconstitutional
symptomsandsorethroat,dysphagia,muffledorhotpotatovoice,andneckstiffness.
congenitalsyphiliscutaneouslesionsonpalms,soles,hepatosplenomegaly,jaundice,anemia,
rhinorrhea.
congenitaltoxoplasmosishaschorioretinitis,intracranialcalcifications,hydrocephalus,congenital

rubellahassensorineuralhearingloss,cataracts,heartdefects,microcephaly,congenitalCMVIUGR,
petechiaorpurpura,chorioretinitisandperiventricularcalcifications
increasedgastricresidualvolumeinpretermneonateishighlysuspiciousfornecrotizing
enterocolitis.usuallypresents310daysafterbirthandisduetobowelwallinjuryresultingfrom
perinatalasphyxia.
sepsisinaneonateoftenpresentswithhypothermia,jaundice,lethargyandpoorfeeding.doblood
culturesandalumbarpunctureforallbabiessuspectedofsepsis
recognizekawasakisdisease:
1)feverfor>5daysand4ofthefollowing:
2)bulbarconjunctivalinjection
3)desquamationoffingerandtoetips,edema
4)erythemafissuringandcrustingoflips,strawberrytongue,diffusemucosalinjectionoforpharynx
5)truncalrash
6)cervicallymphadenopathy
polycythemiainaninfantmanifestswithrespiratorydistress,poorfeedingandneurological
manifestations.decreasedpulmonarybloodflowduetohyperviscosityofthebloodleadsto
respiratorydistress.hypoglycemiaisalsoseeninpolycythemicinfants.
manageidiopathiccentralprecociouspubertywithGnRHagonist(leuprolide,relin)therapyto
preventprematurefusionofepiphysealplates,whichwouldleadtoshortstature.
jaundiceduetounconjugatedhyperbilirubinemiacanbedueto
1)increasedproductionofbilirubin(hemolysis),
2)decreasedclearanceofbilirubin(criglernajjarandgilbert)or
3)increasedenterohepaticcirculation.
inbreastfeedingjaundicethereisincreasedenterohepaticcirculationbecausetheyarenotgetting
enoughmilk.treatmentisbetterbreastfeedingtechniques.
2yearoldchildhasavocabularyof200wordswith50%oftheirspeechbeingunderstandable,three
yearoldhasavocabofaround1000wordsand75%oftheirspeechwillbeunderstandable
achildwithdilationoftheentireventricularsystemwithdistinctenlargementofthesubarachnoid
spaceoverthecerebralcortexissuggestiveofnonobstructing/communicatinghydrocephalus
secondarytosubarachnoidhemorrhage.SAHisthemostcommoncauseofcommunicating
hydrocephalus.bloodaccumulationinsubarachnoidspaceleadstodestructionofarachnoidvilliand
cisterns,blockingflowordecreasingabsorptionofCSF.SAHiscommoninprematureinfants.dandy
th
walkeranomalyshowsacysticexpansionofthe4 ventricle,andchiarimalformationreveals
protrusionofstructuresoftheposteriorfossathroughforamenmagnum.
thyroiddysgenesisisthemostcommoncauseofcongenitalhypothyroidismintheUS.
ahydroceleisafluidcollectionwithintheprocessusortunicavaginalistheperitonealprojection
thataccompaniesthetestisduringitsdescentintothescrotum.whenitfailstoobliterate,peritoneal
fluidmayaccumulatewithintheprocessusvaginaliscausingacommunicatinghydrocele.acollection
offluidwithinatunicavaginalisthathasproperlyobliterateditscommunicationwiththe
peritoneumisanoncommunicatinghydrocele.hydrocelescanbedifferentiatedfromothertesticular
massesbytransillumination(hydrocelestransilluminate).mostcasesresolvespontaneouslybythe
ageof12months.iftheydontresolvespontaneouslytheyshouldberemovedsurgicallytoreduce
theriskofinguinalhenia.
slippedcapitalfemoralepiphysis(SCFE)isdisplacementofthecapitalfemoralepiphysisfromthe
femoralneck.presentsinobesechildren1016years.insidiousonsetofdullhiporreferredknee
painandalteredgaitwithnoprecedingtrauma.patientsholdhipinpassiveexternalrotationand
exhibitdecreasedinternalrotationabductionandflexion.treatmentisimmediatesurgicalscrew
fixationtoreduceriskofavascularnecrosis.
pubertalgynecomastiaisseeninapprox50%ofadolescentboysatanaverageageof14years.itis
oftenasymmetricortransientlyunilateralandfrequentlytender.inprepubertalmalesthetesticular
sizeisnormally2cminlengthand3mLinvolume.reassuranceandwatchfulobservation.

inleggcalveperthesdiseaseyouhaveidiopathicavascularnecrosisofthefemoralcapitalepiphysis.
xraywillshowaflattenedandfragmentedleftfemoralhead.causesunilateralsubacutehippainin
amalechild(morecommonly)withprogressiveantalgicgait,thighmuscleatrophy,decreasedhip
rangeofmotion,andcollapseofipsilateralfemoralheadonplainxr.
gastroesophagealreflux(frequentvomitingafterfeeding)iscommonininfantsandcanusuallybe
managedwiththickenedfeedsandpositioning.pyloricstenosiswouldpresentwithprojectile
vomitingandfailuretothriveandsignsofdehydration.
neonataltetanusisseenindevelopingcountriesininfantsborntounimmunizedmothersfrequently
followingumbilicalstumpinfectionduetopoorobstetricprocedures,inadequatepostnatalcareor
culturalpractices.onsetiswithinfirsttwoweeksofbirthandischaracterizedbypoorsucklingand
fatigue,followedbyrigidity,spasms,andopisthotonus.
trisomy21(downssyndrome)isassociatedwithcongenitalaganglionicmegacolon(hirschsprung
disease).suspecthirschsprungdiseaseinanyneonatewithdelayedpassageofmeconiumas99%of
fullterminfantsstoolwithin48hoursofbirth.faileddevelopmentofentericnervoussystemofa
portionofthedistalgutandmostcommonlyinvolvesrectosigmoid.affectedsegmentcannotrelax
andischronicallycontracted.newbornspresentwithpoorfeeding,abdominaldistention,failureto
passmeconium,andbiliaryemesis.rectalexamproducesanexplosiveexpulsionofgasandstool
(squirtsign)fromtemporaryrelieffromtheobstruction.goldstandardisrectalbiopsy
demonstratingabsenceofganglioniccells.
intetralogyoffallot,squattingincreasessystemicvascularresistancedecreasingtherighttoleft
shuntacrosstheVSD,makingmorebloodgotothelungs.
treatintussusceptionwithanaircontrastenema.intussusceptionsarefoundattheileocolicjunction
withtheileumtelescopingintothecolon.presentswithcolickyabdominalpain,vomiting,andred
currantjellystools.sausageshapedmassisoftenpalpated.abdominalradiographswillshowair
fluidlevelsduetoobstruction.ultrasoundshowsatargetoidlesionwhereonebowelsegmentis
nestedinsideanotherbowelsegment.
suspectgrowingbonepaininachildwithnocturnalpainandnoobviousphysicalorlaboratory
finding.inallcasesthepainresolvesinthemorning.
Chlamydiaisthemostcommoncausativeagentofinfectiousneonatalconjunctivitis.chlamydial
pneumoniacandevelopininfectedinfants.(giveoral,nottopicalantibiotic)
midgutvolvuluspresentsinachild<1monthofageasbiliousvomiting,abdominaldistension,and
passageofbloodstainedstools.
anemiaofprematurityisthemostcommonanemiainprematureandlowbirthweightinfants.
diminishedRBCproducion,shortenedRBClifespan,andbloodloss.normocyticnormochromic
anemia.
constitutionalgrowthdelayisthemostcommoncauseofshortstatureandpubertaldelayin
adolescents.affectedindividualshaveanormalbirthweightandheight,butbetween6monthsand
3yearsofage,theheightandgrowthvelocityslows.around3yearsofagethechildregainsa
normalgrowthvelocity.pubertyandtheadolescentgrowthspurtaredelayed,buteventuallyoccur.
selfdestructivebehaviorisusuallyassociatedwithleschnyhansyndrome.fragilexsyndromehas
clinicalfeaturesofautism,mentalretardation,anelongatedfaceandlargetestes.
juvenilemyoclonicepilepsystartsoutwithabsenceseizuresaroundtheageof10tomyoclonic
seizuresatage15.thengeneralizedtonicclonicseizures.
viralinfectionismostcommoncauseofpharyngitisinthepediatricpopulation.lowgradefever
makesstreptococcalpharyngitisunlikely.absenceofcervicallymphadenopathymakesEBVand
groupastreptococcus(S.pyogenes)unlikely.enteroviruseslikecoxsackieavirusarecapableof
producingvesiclesonthepalateandtonsillarpillars(herpangina)
henochschonleinpurpuraisknownasleukocytoclasticvasculitis.precededbyURI.haspalpable
nonblanchingsymmetricpurpuriclesionsinthebuttocks/lowerextremities.alsojointpainwhichis
oligoarticularinthekneesandankles.abdominalpainandrenalfailure.skinbiopsyshows
leukocytoclasticvasculitisinpostcapillaryvenuleswithextensivedepositionofIgA.

coughcoryzaandconjunctivitiswithkopliksspotsinmeasles(paramyxovirus).erythematous
maculesandpapulesbeginningonthefaceandspreaddowntoinvolverestofbody.roseola
infantumisknownasexanthemsubitumor6thdisease,causedbyHHV6/HHV7.presentswithhigh
fever,periorbitaledemaandpalatalorpharyngealerythema.lasts35daysandpatientscanget
febrileseizures.skineruptsasfeversubsides.rosecoloredmaculesandpapulesthatbeginonthe
neckandtrunkandspreadtothefaceandextremities.
meconiumileusandhirschsprungdiseaseshouldbeconsideredinanyneonatewithdelayedpassage
ofmeconiumas99%ofinfantsstoolwithin48hoursofbirth.meconiumileusisobstructedatileum
withinspissated(thick,congealed)consistencyofmeconium.hirschsprungdiseaseisobstructedat
rectosigmoidjunctionwithnormalmeconiumconsistency.meconiumileusisdiagnosticforcystic
fibrosis.themeconiumwillbethickasglueanddifficulttopropel,resultinginobstructionatileum
andanarrowunderusedcolon.
achildwhoaccidentalytakesliquidalkali(ovencleaner)shouldbemanagedbyfirstensuringthereis
airwaypatency.thenextstepisdoinguppergastrointestinalendoscopytoassesstheextentof
injuryandtodictatefurthermanagement.uppergiendoscopy>gastrografinifperforationis
suspected
neonataljaundicewith(direct)conjugatedhyperbilirubinemiaissuggestiveofneonatalcholestasis.
biliaryatresiacancauseneonatalcholestasis.Willhavepalestools/darkurine.
rd
th
th
edwardssyndromepatientshaveindexdigitoverlappingthe3 andthe5 digitoverlappingthe4 ,
rockerbottomfeet,prominentocciput,micrognathiaandmicrocephaly.
VSDisapansystolicmurmurloudestatleftlowersternalborder.theycanalsohavediastolic
murmursattheapexbecauseofincreasedflowacrossthemitralvalve.(bloodfromrightventricle
returnsbacktoleftatrium)
thinkepiglottitisina37yearoldwithacuterespiratorydistress,toxicappearance,drooling,stridor
andhighgradefever.tachycardiaandtachypneaarealsopresent.managewithendotracheal
intubation,butalsosetupforpossibletracheostomy.prevaccinationitwascausedbyH.influenzae
typeb(hib)
respiratorydistresssyndrome(hyalinemembranedisease)isarespiratorysyndromecausedby
immaturelungsandsurfactantdeficiency.mostimportantriskfactorforRDSisprematurity.other
riskfactorsincludemalesex,csectionwithoutlabor,perinatalasphyxia,andmaternaldiabetes.cxr
willshowdiffusereticulogranularpatternandairbronchograms.presentswithtachypnea,
retractions,andphysicalexamwillshowsignsofdistress(grunting,retractions,tachypnea,nasal
flaring,cyanosis)
bacterialsinusitispresentswithnasaldrainage,congestion,cough.patientsappearillandhavehigh
fevers>39C/102.2Fandpurulentnasaldischarge.themostcommonpredisposingfactorforacute
bacterialsinusitisisaviralURI.contaminatingbacteriacannotbeclearedbymucociliaryclearance
duetomucosalinflammationfromviralinfection,leadingtosecondarybacterialinfection.(S.
pneumoniae,H.influenza,M.catarrhalis)
acuteotitismediacanpresentwithboggynasalmucosaandpostnasaldrip.eardrainageand
difficultyhearingarehighlysuggestiveofacuteotitismedia.confirmwithotoscopicexamination
whichtypicallyrevealserythema,retraction,ordecreasedmobilityofthetympanicmembrane.
congenitalrubellainfectionmanifestsasIUGR,deafness,cardiacmalformations(PDA,ASD),
micropthalmia,cataracts,retinopathy,hepatosplenomegaly,thrombocytopenia,andCNS
involvement.chronicinfectionmayresultingrowthretardation,radiolucentbonedisease,jaundice,
thrombocytopeniaandpurpleskinlesions(blueberrymuffinspots).classictriadis1)sensorineural
deafness2)cardiacmalformationsand3)cataracts
developmentadysplasiaofthehip(DDH)isadislocationofthefemoralheadfromtheacetalbulum.
breechpresentation,femalesex,whiteethnicity,andfamilyhistoryofDDHincreasetherisk,most
patientshavenoriskfactors.barlowandortolanimaneuversshouldbeperformedtoassessjoint
stability.inguinalskinfoldsshouldalsobeinspectedasextensionbeyondtheanalorificesuggests
dislocationoftheipsilateralfemoralhead.atage2weeks6monthsdohipultrasound.after46
monthsdoxrayofhip.showsbetterbecauseofossification.

squattingincreasessystemicperipheralresistance,decreasingtherighttoleftshunt,andimproves
thecyanosisoftetralogyoffallot(ToF).tetspellscanbebroughtonbyinfection,crying,and
exercise.severetetspellsmayprecipitateseizuresandlossofconsciousness.immediatetreatmentis
administrationofoxygenandplacingchildinakneechestposition,followedbyfluids,morphineand
propanolol.
viraluriarethemostcommonpredisposingfactorofacutebacterialrhinosinusitis.uncomplicated
acutebacterialrhinosinusitisshouldbetreatedwithoralamoxicillinclavulanicacid.featuresinclude
1)persistentsymptoms>10dayswithoutimprovementOR2)severesymptoms(fever>39C/102F),
purulentnasaldischarge,facepain>3days,OR3)worseningsymptoms>5daysafterinitially
improvingviraluri.
fetalalcoholsyndromeischaracterizedby3pathognomonicfacialdysmorphisms:1)smallpalpebral
fissures2)smoothphiltrum(verticalgrooveaboveupperlip)3)thinvermilionborder.fragilexhasa
longnarrowfacewithlargeearsandmacrocephalyandmacroorchidism.
infectionsafter6monthsofagesuggestiveofgeneticbcelldeficiencybecausethatswhen
maternalantibodylevelsstarttodrop.predisposedtorecurrentsinopulmonaryinfectionswith
encapsulatedorganismslikeH.influenzaeandS.pneumoniae.
deficiencyinIgAwhichinhabitsthegastrointestinaltractpredisposestoGiardiainfection.patients
withSCIDhavebothBandTcelldeficienciesandwouldgetbacterial,fungalandviralinfectionsas
well.
digeorge(thymichypoplasia)isaTcelldeficiencyonly,wouldgetviral/fungalinfections.
patientswithxlinkedagammaglobulinemia(brutonsagammaglobulinemia)havelowBcells(cd19
lymphocytes).patientsshouldreceiveintravenousimmunoglobulins.
neurofibromatosis1hascafeaulaitspots,axillaryfreckles,lischnodulesoftheiris,neurofibromas
andbonylesions.
sturgeweberhasportwinestainsinV1faceregion,angiomatousmalformationsofthebrain,
seizures,hemiparesis
tuberoussclerosishasashleafhypopigmentation,cardiacrhabdomyomas,kidney
angioleiomyomas,mentalretardation,retinalhamartomas,andseizures.
doguthrietest(coloration)todetectthepresenceofmetabolicproductsofphenylalanineinthe
urine.phenylketonuriahasaphenylalaninehydroxylasedeficiency,leadstotheaccumulationof
phenylalanine.urinewillhaveamousyodor,andwillbefairskinned.
friedreichataxiaisautosomalrecessiveconditioncharacterizedbyexcessivetrinucleotiderepeat
sequences.associatedwithnecrosisanddegenerationofcardiacmusclefibersleadingto
myocarditis,myocardialfibrosis,andcardiomyopathy.Twaveinversion:myocardialinfarction,
myocarditis,oldpericarditis,myocardialcontusion,digoxintoxicity.
sturgewebersyndromeisaneurocutaneoussyndromethatischaracterizedbyacongenital
unilateralcavernoushemangiomaalongthetrigeminalnervedistributionandradiographicevidence
ofintracranialcalcificationsthatresembleatramline.seizuresarethenormalneurological
presentation.
mongolianspotiscommonamongdarkskinnedraces.thecauseisentrapmentofmelanocytesin
thedermisduringtheirmigrationfromtheneuralcrestintotheepidermisinfetaldevelopment.the
lesionisablue,bluishgray,bluishgreenorblueblack,flatskinmarkignthatusuallyappearsatbirth.
mostlylocatedatbaseofspine,lowerback,andonthebuttocks.
painlessrectalbleedinginayoungchildisoftenmeckelsdiverticulum.doatechnetium99m
pertechnatescan
milkproteinintolerancemaypresentwithvomitingandbloodydiarrhea.stoolmayshowRBCsand
eosinophilsandtheremaybefamilyhistoryofanatopicdisorder.itsahypersensitivityreactionto
cowsmilkproteinsandusuallyoccursinbabieswhoarefedwithcowsmilk.howevermayoccurin
breastfedbabiesasthemothersmilkmaycontainproteinsfromingestedcowsmilk.
meconiumileusischaracterizedbybiliousvomiting,failuretopassmeconiumatbirth,historyof
polyhydramnios,familyhistoryofcysticfibrosis,andagroundglassappearanceonabdominalxr.a
possiblecomplicationofmeconiumieusisintestinalperforation.iftheperforationoccursafterbirth

pneumoperitoneumwillbeseenonabdominalxr.ifitoccursbeforebirth,intraabdominal
calcificationswillbeseen.meconiumplugsyndromeisthesamethingbutinbabieswithoutcystic
fibrosisandintestinalperforationdoesnotoccur.
ironsupplementationintheformoforalferroussaltsorironfortifiedmilkformulaiswarrantedin
prematureinfantstopreventanemiaofprematurity.
metatarsusadductusisacongenitalfootdeformity.mostfrequentinfirstborninfants;attributedto
themoldingeffectoftheprimigraviduterus.internaltibialtorsionisalsoaphysiologicalfindingin
newborns.reassuranceisallthatisneeded.knowwhentogivereassurance!
tricuspidatresia(notricuspidvalve)presentswithacyanoticinfantwithleftaxisdeviation.absent
connectionbetweentherightheartcavities,andahypoplasticorabsentrightventricle.VSD
(holosystolicmurmur)occursin90%ofcases.thereisleftventricularhypertrophyandsincetheleft
ventricleisgettingallthebloodfromtherightatrium.bloodgoesfromra>la>lv>rv>
pulmonary>backtola.treatmentisPGE1andballoonatrialseptostomy.
leggcalveperthesdiseaseischaracterizedbyosteonecrosisofthefemoralhead.typicallypresents
in410y/owithinsidiousonsethipand/orkneepainandanantalgicgait.idiopathicavascular
necrosis
thrombocytopeniawitheczemaandahistoryofbacterialinfectionsischaracteristicofwiskott
aldrichsyndrome(WAS).decreasedplateletproductionistheprimarypathophysiologiccauseof
thrombocytopeniainpatientswithwas.
idiopathicthrombocytopenicpurpura(ITP)isanimmunemediateddisordercausedbyantibodies
thatbindtoplateletsandfacilitatetheirremovalfromthecirculation.precededbyaviralinfection.
TreatITPwithsteroidsorIVIGifsevere.
vongierkesdisease(type1:glucose6phosphatasedeficiency)is34monthsofagewith
hypoglycemia,lacticacidosis,hyperuricemia,andhyperlipidemia.thecharacteristicisadolllikeface
(fatcheeks),thinextremities,shortstature,andaprotuberantabdomen(enlargedliverand
kidneys).hypoglycemicseizuresmayoccur.
pompesdisease(type2:acidmaltase)havehepatomegaly,andpresentasafloppy
babywithfeedingdifficulties,macroglossia,andheartfailureduetohypertrophiccardiomyopathy.
typeiii/glycogendebranchingenzyme,withasimilarpresentationastype1,howevertheirlab
findingsdiffer.theyhaveelevatedtransaminases,fastingketosis,andnormalbloodlactateanduric
acidconcentrations.splenomegalybutnormalkidneys.
type4isamylopectinosis.presentsinthefirst18monthsoflife
withhepatosplenomegalyandfailuretothrive.progressivecirrhosisoftheliver.
ewingssarcomaisahighlymalignanttumorfoundinthelowerextremitymoreofenthanupper.
mostcommonsitesaremetaphysisanddiaphysisoffemur,followedbytibiaandhumerus.aggresive
andmetsearlytolungsandlymphnodes.whitemalesintheir10s20s.patientsmayinitiallybe
diagnosedwithosteomyelitisbecauseofintermittentfevers,leukocytosis,anemia,andelevated
ESR.butradiologicallyischaracterizedwithalamellatedappearanceoronionskinperiosteal
reaction.lesionisusuallylytic,central,andaccompaniedbyendostealscalloping.onionskin
appearanceisoftenfollowedwithamotheatenormottledappearanceandextensionintosoft
tissue.treatmentissurgery,radiation,andmultidrugchemo.
interventricularhemorrhageiscommonlyseeninprematureandlowbirthweightinfants.bleeding
fromthegerminalmatrix.incidenceofIVHisinverselyproportionaltobirthweight.patientsmay
presentwithpallor,cyanosis,hypotension,seizures,focalneurologicalsigns,bulgingortense
fontanelle,apnea,andbradycardia.manycasesremainasymptomaticmandating
transfontanelleultrasoundforallnewbornswithpredisposingriskfactors.
childrenw/selectivemutismareverbalandtalkativeathomebutrefusetospeakinselectsettings.
erythematoxicumisabenign,selflimitedconditioninnewbornscharacterizedbyanevanescent
rashwithredhaloes,andeosinophilsintheskinlesions.erythematouspapulesandvesicles
surroundedbypatchesoferythema.
urinedipstickcanbepositiveforproteinin10%ofschoolagedchildren.canbetransient,
orthostatic,orpersistent.transientcanbecausedbyfever,exercise,seizures,stress,volume

depletion.orthostatichasincreasedproteinwhenpatientisuprightthatreturnstonormalwhen
patientisrecumbent.ifurinalysisshowsnohematuriaandisotherwisenormalrepeatdipstickx2.if
negativethenitstransientproteinuria.usuallybenigncondition.ifproteinuriapersiststhentaketo
pediatricnephrologist.
maternalHIVinfectionisabsolutecontraindicationtobreastfeeding.
hospitalizepatientswithanorexianervosawhenthereisevidenceofmedicalcomplications
(amenorrhea)and/orwhentheyweigh<75%ofavgbodyweightforagesexandheight.
scarletfevercausedbygroupastreptococcus(S.pyogenes)thatmakeserythrogenicexotoxins.may
followstreppharyngitis,woundinfections,burns,orstrepskininfection.fever,chills,abdominal
pain,pharyngitis.therashinitiallyappearsontheneck,axillae,andgroinwithin1248hoursand
generalizeswithin24hours.punctateorfinelypapulartexturewhichissometimesreadilypalpable
sandpaperlike.pharynxiserythematousswollenandmayhavegraywhiteexudates.areaaround
mouthappearspaleincomparisonwiththeextremelyredcheeksgivingtheappearanceof
circumoralpallor
slippedcapitalfemoralepiphysisischaracterizedbydisplacementoffemoralheadonthefemoral
neckduetodisruptionoftheproximalfemoralgrowthplate.seeninobeseadolescentboys.groinor
kneepainandlimping.asthehipisflexedthethighgoesintoexternalrotation.kneepainisalsoa
commonpresentation.treatwithsurgicalpinningoftheslippedepiphysisinordertodecreasethe
riskofavascularnecrosis.
nd
medulloblastomaisthe2 mostcommoninfratentorialtumorinchildrenandarisesfromthe
vermis.posteriorvermissyndromecausestruncaldysataxia.
characteristicfeaturesofneurofibromatosis1includecafeaulaitspots,macrocephaly,feeding
problems,shortstatureandlearningdisabilities.patientsmaylaterdevelopfibromas,
neurofibromasordifferenttumors.neurofibromatosistype2hasbilateralacousticneuromasand
cataracts.
reyesyndromeisseeninchildren<15yearsoldwhoweretreatedwithsalicylatesforaviral
infection.hyperammonemia,normalorslightlyelevatedbilirubinandALP,prolongedPT,
hypoglycemia,andmoderatetosevereelevationsinAST/ALT/LDH.
croupiscausedbyparainfluenzavirusandcommonlypresentsinchildren<3withhoarseness,a
barkingcough,,andvaryingdegreesofrespiratorydistress.lateralxrshows(steeplesign)subglottic
narrowing.givenebulizedepinephrinecisaboveeinalphabet.steeple(thetopofbuilding)is
abovethumb(seeninepiglottitis)
turnersyndromeshouldbeconsideredinnewbornswithawebbedneck,highpalate,shortfourth
metacarpalandnaildysplasia.lymphedemafrequentlyoccursduetoabnormaldevelopmentofthe
lymphaticsystem.
allpatientswithaclavicularfractureshouldhaveacarefulneurovascularexaminationtoruleout
injurytotheunderlyingbrachialplexusandsubclavianartery.midshaftfracture=radialnerve
epicondylarfracture=brachialarteryanteriorshoulderdislocation=axillarynerve
clubfootisinitiallymanagedwithstretchingandmanipulationofthefoot,followedbyserialplaster
casts,malleablesplints,ortaping.surgicaltreatmentisindicatedifconservativemanagementgives
unsatisfactoryresultsandispreferablyperformedbetween36monthsofage.
femaleinfants<3monthsofagesometimesdevelopvaginalspottingorbleeding.maternalestrogens
crossingplacentaenteringfetalbloodstreamcausingapubertaleffectinthenewbornwhich
disappearswhenthehormoneisclearedfromtheinfantscirculation.
ifhaveahighleadonfingerstick,doserumtestingtoconfirmforleadpoisoning.
infantwithfailuretothrive,bilateralcataracts,jaundice,hypoglycemiaandhepato/splenomegaly
mostlikelyhasgalactosemia.causedbygalactose1phosphateuridyltransferasedeficiency,leading
toelevatedlevelsofgalactose.
respiratorysyncytialvirusinfectionmayincreasetheriskofasthmalaterinlife.RSVcauses
bronchiolitis.
inpyloricstenosisamasswillnotalwaysbepalpable.doultrasoundoftheabdomentoestablish
diagnosisinaninfantwhoishavingprojectilevomitingthatisnonbilious.

niemannpicksdisease/sphingomyelinase.presentswithhypotonia,hepatosplenomegaly,cervical
lymphadenopathy,protrudingabdomenandacherryredspotonretinalexamination.
taysachsdisease/hexosaminidaseA.characterizedbyhyperacusis,MR,seizures,cherryredmacula,
butnothepatosplenomegalyorcervicallymphadenopathy.
glucocerebrosidasedeficiency/gauchersdisease.hepatosplenomegaly,anemia,leukopenia,and
thrombocytopenia,butnocherryredmacula.
galactocerebrosidase/krabbesdisease.hyperacusis,irritabilityandseizures.
(thegsdonthavecherryredmacula.Niemannpickshisnosesohehashepatosplenomegaly)
inchronicgranulomatousdiseasethereisadeficiencyoftheNADPHoxidaseenzymesoyouget
recurrentinfectionsofcatalase+organisms:S.aureus,Serratia,Burkholderia,Klebsiella,Aspergillus.
mostcommonclinicalfindingsarelymphadenopathy,hypergammaglobulinemia,
hepatosplenomegaly,anemiaofchronicdisease,chronicdiarrhea,gingivitisanddermatitis.the
diagnosiscanbemadebythenitrobluetetrazolium(nbt)testwhichwillbenegative(abnormal).
treatmentistmpsmxprophylaxisandgammainterferon.Bonemarrowtransplantcanbecurative
mccunealbrightsyndromeisarareconditioncharacterizedby1)precociouspuberty,2)cafeaulait
spotsand3)multiplebonedefects(polyostoticfibrousdysplasia).maybeassociatedwithother
endocrineabnormalitieslikehyperthyroidism,prolactin/GHsecretingpituitaryadenomas,adrenal
hypercortisolism.threePs:precociouspuberty,pigmentation,polyostoticfibrousdysplasia
bedwettingisnormalupto45years.afterthatusebedalarms,andthendesmopressin

psychiatry

pseudodementiainelderlypatientswithseveredepression.treatmentisSSRI
inquireaboutstressorsinhypochondriacs
NMShasfever,encephalopathy,autonomicinstability,wickedlyhighCK,rigidity,usebromocriptine
ordantrolene.
alcoholwithdrawalhashallucinations,hypertension,hyperthermia,agitation.treatwithlongacting
benzodiazepinessuchaschlordiazepoxide.
useSSRIasfirstlinetreatmentforOCD
schizophreniahas4types1)paranoid2)disorganized3)catatonic4)undifferentiatedandresidual
whentheyarenolongerpsychotic.
forpanicattacksusebenzodiazepineforacutetreatment,andSSRIforlongtermrelief.
delayedsleepphasesyndromeisacircadianrhythmdisordercharacterizedbyinabilitytofallasleep
atnormalbedtimes.fallasleeplate.
lithiumtoxicitypresentswithtremor,hyperreflexia,ataxia,seizures.
phenytointoxicitypresentswithhorizontalnystagmus,cerebellarataxia,andconfusion.
benzodiazepineoverdosedoesnothavenystagmus.
restlesslegsyndromepresentswithuncomfortablesensationinthelegsalleviatedbymovingyour
legs.treatedwithdopamineagonists(pramipexole/ropinerole)
inaltruismthereisnoovercompensationofthepersonsresponsewiththeoppositereactionofhow
theyactuallyfeel.reactionformationisthecompleteoppositeresponseofwhattheyactuallyfeel,
butinaltruismtheywishtohelppeopleinapositiveway.
whenpatientshaverenaldysfunctionusecarbamazepineorvalproicacidinsteadforbipolar
disorder.
antipsychoticmedslikerisperdonearedopamineantagonistsandcancausehyperprolactinemia,
leadingtosymptomssuchasgalactorrhea,gynecomastia,menstrualdysfunction,anddecreased
libido.
olanzapinecanbeusedforlongtermmaintenanceofbipolardisorder/mania.haldolcanbeusedfor
acutemania.(inpatientswithrenaldysfunctionusecarbamazepineorvalproicacid)
treatmentforadjustmentdisorderiscognitiveorpsychodynamicpsychotherapy.

theextrapyramidalsideeffectsofantipsychoticscanbetreatedwithanticholinergicslike
benztropine.
asinglemanicepisoderequireslongtermmaintenanceoflithiumforaperiodofatleast1yr.3or
morerelapsesrequirestreatmentwithlifelongmaintenancetherapy.
allatypicalantipsychotics(includingolanzapine)cancauseweightgain,hyperglycemia,dyslipidemia
andhypertension.
risperidone(atypicalantipsychotic)isadopamineandserotoninantagonistthatcancauseweight
gainandhyperprolactinemia,thelatterofwhichcanleadtoamenorrheaandgalactorrhea.
antipsychoticscausehyperprolactinemiabyblockingdopamineactivityalongthe
tuberoinfundibularpathway.(boobiesarefun)
animportantsideeffectofbuproprionisdecreasedseizurethreshold.absolutelycontraindicatedin
peoplewithseizuredisorders.individualswithanorexiaorbulimiafrequentlydevelopelectrolyte
abnormalitiesthatcanprecipitateseizures.
opioidintoxicationpresentswithmiosis,depressedmentalstatus,decreasedrespiratoryrate,
decreasedbowelsounds,hypotension,bradycardia.
socialphobiaisbesttreatedwithassertivenesstrainingandanSSRI.
st
risperidoneis1 lineatypicalantipsychoticforschizophrenia.clozapineisreservedforpatientswho
havehadserioussideeffectsfromand/orwhohavenotrespondedtotrialsofotherantipsychotics.
atypicalsworkbyblockingdopamineand5HT2receptorsandhavelessEPSeffectsbutmore
endocrineeffects(dm,weightgain).clozapinecancauseagranulocytosis.
alteredlevelsoftheneurotransmitterserotoninplayanimportantroleinthedevelopmentof
obsessivecompulsivedisorder.(ocdistreatedwithSSRI)
tourettessyndromeisbesttreatedwithtraditionalantipsychoticslikehaloperidolorpimozide.
lithiumtoxicitiesinclude:nephrogenicdiabetesinsipidus,hypothyroidism,andebsteinsanomalyin
thefetus.
SSRIsandSNRIsarethe1stlinemedicationsfortreatinggeneralizedanxietydisorder.
abruptcessationofashortactingbenzodiazepineisassociatedwithsignificantwithdrawal
symptomssuchasgeneralizedseizuresandconfusion.

pulmonary
lobarpneumonia=increasedtactilefremitus,bronchialbreathsounds,dullnesstopercussion
pleuraleffusion/hemothorax=decreasedtactilefremitus,decreasedbreathsounds,dullnessto
percussion
pneumothorax/copd=decreasedtactilefremitus,decreasedbreathsounds,hyperresonantto
percussion

inCOPDyougetchronichypoxemia>pulmonaryvasoconstriction>pulmonaryhypertension>right
ventricularhypertrophy>rightventricularfailure>hepatosplenomegaly/ascites/elevated
jvp/peripheraledema
acutepulmonaryembolismcauseshypoxiaandrespiratoryalkalosis.severeasthmaexacerbation
willcauserespiratoryacidosisduetoairtrappingandCO2retention.aspirinintoxicationcausesa
mixedrespiratoryalkalosisandmetabolicacidosis.
hypoventilationgivesrespiratoryacidosiswithhighPCO2
COtoxicitycausesaniongapmetabolicacidosis/lacticacidosis.decreaseddeliveryofO2totissues
sarcoidhasanterioruveitis(wbcinanteriorchamber),hilaradenopathyandreticulonodular
infiltrates
ARDShasintrapulmonaryshunting,andthehypoxiaistypicallyrefractorytooxygenadministration
ifmoderatetohighsuspiciousofDVT,doultrasoundfirstbeforeanticoagulation.iflowsuspicion
(wanttoruleout)doddimer.ifddimerisnegativeyoucanruleoutclot.highsensitivity.snout

S.aureuscancausepostviralURInecrotizingpulmonarybronchopneumoniawithmultiplenodular
infiltratesthatcancavitatetocausesmallabscesses.
fingerclubbingisnotassociatedwithCOPD.suspectmalignancyinCOPD+fingerclubbing
subacute<38weeksandchronic>8weekscoughseenfrequentlyinadults.1)postnasaldrip2)
GERD3)asthmacause90%ofcoughw/nopulmonarydisease.ifcoughafterURImostlikelypost
nasaldrip.treatwith1stgenantihistamine:chlorpheniramine
inaparapneumoniceffusion,ifthepH<7.2theprobabilityisveryhighthatthisfluidneedstobe
drained,itisanempyema.glucose<60isalsoanindicationforthis.
laryngealedemapresentswithacuteonsetdyspnea.duetoallergies,similartoasthmaattackbut
withdysphagia
pulmonarycontusionpresentswithtachypneatachycardia,andhypoxia.willhavedecreasedbreath
soundsonthesideofthecontusion.CXRwillrevealpatchy,irregular,alveolarinfiltrate.ABGwill
showhypoxemia.(ARDSwouldbebilateralpatchyalveolarinfiltrates)
complicationsofventilationwithhighPEEPinclude:alveolardamage,tensionpneumothoraxand
hypotension.tensionpneumothoraxwillpresentwithsuddenonsetshortnessofbreath,
hypotension,tachycardia,trachealdeviationandunilateralabsenceofbreathsounds.
asbestosisisapneumoconiosisandpresentsasdyspnea,digitalclubbingandbibasilarend
inspiratorycrackles.candevelopcorpulmonale.CXRcanshowpleuralplaques.willhavedecreased
DLCO(interstitiallungdisease)
inpatientwithacuteexacerbationofCOPDwhichisrefractorytomanagementwithoxygen,
corticosteroids,bronchodilators,trynoninvasivepositivepressureventilationbeforeyoutryto
intubateandmechanicallyventilateifthepatientisnotcrashing.
normalPCO2indicatesasevereasthmaattack.itindicatesCO2retentionbecauseofairway
obstruction(airtrapping)and/orrespiratorymusclefatigue.alsosilentlungs,cyanosis,andaltered
sensoriumindicatethis.PCO2shouldbelowbecauseofhyperventilationandrespiratoryalkalosis
rightatrialpressure>10mmhgandsystolicpressure>40mmhgareusedtodiagnosemassivePE.
septicshockhasdecreasedrightatrialpressureandwarmextremities.
sarcoidhashilaradenopathyandnoncaseatinggranulomas.treatwithsteroids.
Lightscriteria:
1)pleuralprotein/serumprotein>0.5
2)pleuralLDH/serumLDH>0.6
3)pleuralfluidLDH>2/3upperlimitofnormalforserumLDH
exudativeeffusionsaredueto:infection,malignancy,pulmonaryembolism,connectivetissue
disease,andiatrogenic
bronchoalveolarlavage(BAL)isusefulformalignancyandopportunisticinfections.>90%sensitive
forPCP,butnotasdiagnosticinotherlungdiseaseslikesarcoid,interstitialpulmonaryfibrosis,or
connectivetissuediseases.
carbonmonoxidepoisoningpresentswithheadache,nausea,dizzinessandhashighhematocritdue
tonounloadingofoxygen,sobodymakesmoreredbloodcells
hypersensitivitypneumonitisisinflammationoflungparenchymacausedbyantigenexposure.acute
episodespresentwithcough,breathlessness,fever,andmalaise.chronicexposurecancauseweight
loss,clubbing,andhoneycombingofthelung.
lowglucoseconcentrationinexudativeeffusionsisduetohighmetabolicactivityofleukocytes
withinthepleuralfluid.pH<7.2,glucose<30suggestsempyemaorrheumaticeffusion.Glucose
valuesof3050suggestsmalignancy,lupus,esophagealrupture,ortb.
cardiomyopathyduetohemochromatosiscanbereversedifcaughtearly,howeversarcoid,
sclerodermaandamyloidosiscannot.
criteriaforlongtermO2supplementationinCOPDpatientsare:PaO2<55,SaO2<88,hematocrit
>55,orevidenceofcorpulmonale.showntoprolongsurvival
acuteexacerbationofCOPDtreatedwith:inhalednebulizedbronchodilatorsandsystemicsteroids.

inanacuteCOPDexacerbationalveolarhypoventilationleadstohypoxiaandhypercapnia.avoid
sedativesastheycanexacerbatealveolarhypoventilation,whichcancauseCO2retentionleadingto
lethargy,somnolence,seizures,coma,anddeath.
antipneumococcalquinoloneslikelevofloxacinormoxifloxacinaredrugsofchoiceforinpatient
treatmentofcommunityacquiredpneumonia.foroutpatienttherapyuseazithromycinor
doxycycline.
patientswithsevereobesity(BMI>55)andalveolarhypoventilationduringwakefulnesshaveobesity
hypoventilationsyndrome(pickwickiansyndrome).ABGwillrevealrespiratoryacidosis,hypercapnia
andhypoxemia.duetoaconsequenceofdecreasedchestwallcompliance.
adenocarcinomaofthelunghastheleastassociationwithsmoking.thisisthemostcommontype
oflungcancereveninsmokers.locatedperipherallyandconsistsofcolumnarcellsgrowingalong
thesepta.itpresentsasasolitarynoduleandmaybedetectedincidentally.
largelungvolumesanddiaphragmaticflatteninginCOPDmakeitmoredifficulttodecrease
intrathoracicpressureduringinhalationandthusincreasingtheworkofbreathing.
secondarypneumothoraxshouldbesuspectedinCOPDpatientspresentingwithworseningoftheir
respiratorysymptomsandisusuallyduetodilatedalveolarblebsthatruptureairintothepleural
space.symptomsincludeacuteonsetofunilateralchestpain,shortnessofbreath,andonthe
affectedsidebreathsoundsaremarkedlyreducedandthechestishyperresonanttopercussion.
uselightscriteriatodetermineifpleuralfluidisexudateortransudate.thendetermineifthefluidis
complicatedoruncomplicated.complicatedfluidhasa+gramstain,+culture,ph<7.2,andglucose
<60andrequireschesttubedrainagebecauseitisunlikelytoresolvespontaneouslywithantibiotic
therapy.complicatedeffusionscanprogresstoempyema.infection(pneumonia)isamuchmore
likelycauseofcomplicatedparapneumoniceffusionsthanpulmonaryembolism.
thedevelopmentofclubbingandsuddenonsetjointarthropathyinachronicsmokerissuggestive
ofhypertrophicosteoarthropathy.thisconditionisoftenassociatedwithlungcancer,sodoaCXR.
massivepulmonaryembolismleadstosyncope,rightbundlebranchblockduetoacuterightheart
strain,jugulovenousdistension.rightheartstrainwillprogresstorightventriculardysfunction,
decreasedCO,leftpumpfailure,resultinginbradycardia.resultsincardiogenicshockandCNS
effectslikedilatedpupilsandunresponsivementalstatus.
suspectlungcancerinsmokerswhopresentwithhornerssyndrome.doaCXR
causesofexudativepleuraleffusion:empyema,malignancy,rheumatoidarthritis,esophageal
rupture,pancreatitis,pulmonaryinfarction,andtuberculosis.onlytbisassociatedwithaveryhigh
totalprotein,>4g/dl.
tensionpneumothoraxhaslackofbreathsoundsononeside,trachealdeviationtotheoppositeside.
leadstorapiddevelopmentofhypotensionbecauseofhighintrathoracicpressuresdecreasing
nd
venousreturn/decreasingpreload.treatmentconsistsofplacingalargeboreneedleinthe2
intercostalspaceinmidclavicularlineoftheaffectedsidetorapidlydecompressthepneumothorax
andimprovevenousreturn.
knowhowtoidentifytensionpneumoonCXR.faintwhiteline(visceralpleura)nearthemidline
beyondwhichnopulmonaryvasculatureorlungparenchymalmarkingsareapparent.alsousually
flatteningoftheipsilateralhemidiaphragm.hemothoraxandpleuraleffusionhavesimilar
appearancesoncxr:bluntingofcostophrenicangleandopacifytheentireipsilateralchest.
apicallungtumorinthoracicinletcancompresscervicalandthoracicnerverootsthatcontributeto
theulnarnervecausingpain,numbness,andweaknessinipsilateralarm.(lookforradioopaque
lesionintheapex)
granulomatosiswithpolyangiits(wegeners)isaformofgranulomatousvasculitis.renaland
pulmonarysymptomsareseenwithgoodpasturesandwegenersbutupperairwayandsinusare
onlyseenwiththelatter.canhavesystemicsymptomsofweightloss,anorexia,andarthralgiasas
well.churgstrausshasasthmaandeosinophilia.
inapatientwithrapid,ongoing,massivehemoptysis>100600mlina24hourperiod,intubatethe
patienttoprotecttheairwayandplacethebleedinglunginthedependentpositiontopreservegas
exchangeinthenonbleedinglung.thengivefluidsandperformanemergentbedsidebronchoscopy

tobothvisualizethelesionandcontrolthebleeding.intubate>fluids>bronchoscopyfor
bleedingcontrol
exudativeeffusionsarecausedbyincreasedcapillarypermeability.transudatesarecausedby
increasedhydrostaticordecreasedoncoticpressure.
patientswithobstructivesleepapneahaveepisodesofshorttermhypoxemiawhichissensedbythe
kidneysandstimulateserythropoietinproduction.thisdrivescreationofmoreRBCsandresultsin
polycythemia.
chronicandrecurrentcoughwithmucopurulentexpectorationmostlikelyduetobronchiectasis.will
haverecurrentinfectionsproducingcoughrespondingtoantibiotics.chronicbronchitishasnon
purulentexpectoration.highresolutionCTofthechestisthebestimagingmodalityfordiagnosing
bronchiectasis.
criteriaforasthma
mildintermittent:daytimesymptoms<2/week,nighttimeawakenings<2month,nolimitondaily
activitestreatmentisprnalbulterol
mildpersistent:symptoms>2days/weekbutnotdaily,nighttimeawakenings34/month,minor
limitonADLtreatmentisprnalbuterol+inhaledcorticosteroid
moderatepersistent:dailysymptoms,weeklynighttimeawakenings,moderatelimitonADLand
FEV16080%treatment:dailyinhaledcorticosteroidorcromolyn/nedocromilormethylxanthineor
antileukotriene
severepersistent:symptomsthroughouttheday,frequentnighttimeawakenings,extremelylimited
ADLs,FEV1<60%treatment:longactingbetaagonistandhighdoseinhaledcorticosteroidsand
systemiccorticosteroid
emphysemaisapathologicaldiagnosischaracterizedbypermanentanddestructiveenlargementof
airspacesdistaltotheterminalbronchioleswithlossofnormalarchitecture.patientsaregenerally
severeanddyspneic(pinkpuffers)andhavehyperinflationofthechest,decreasedvascular
markings,decreasedDLCO(duetodestructionofalveoli).panacinaremphysemaistypicalforalpha
1antitrypsindeficiency.centriacinarismorecharacteristicforCOPD.DLCOisnormalinchronic
bronchitis.chronicbronchitisisaclinicaldiagnosisofchronicproductivecoughforatleast3months
over2consecutiveyears.
mostcommonadverseeffectofinhaledcorticosteroidtherapyisoropharyngealthrush(oral
candidiasis)
fever,confusion,decreasedfoodintake,and+culturespointstowardsepsis.sepsiscancauseARDS.
ARDScauseshypoxemiarefractorytohighinspiredoxygenconcentrations.adequateoxygenationin
ARDSoftenrequirespositiveendexpiratorypressure(PEEP)deliveredviamechanicalventilation.
trytokeepinspiredO2below40%.
tensionpneumothoraxpresentswithdecreasedbreathsounds,tachypnea,trachealdeviation.treat
withneedlethoracostomyemergently.
obesityhypoventilationsyndrome(OHS)isalongtermconsequenceofsevereobesityanduntreated
obstructivesleepapnea.chronichypercapnic/hypoxicrespiratoryfailure,secondaryerythrocytosis,
andpulmonaryhypertension.willhaverespiratoryacidosis,leadingtoanincreasedbicarbonate
retentionanddecreasedchloridereabsoprtioninacompensatoryefforttomaintainanormalpH.
afixedupperairwayobstrution(suchaslaryngealedema)willshowadistinctiveflowvolumeloop.
thereisaflowlimitationwithbothinspiration(belowthehorizontalline)andexpiration(abovethe
horizontalline).lookslikeanovalsideways.
v/qmismatchcausedby:pulmonaryembolism,obstructivelungdisease,atelectasis,pulmonary
edema,pneumonia.shuntcausedbyintracardiacshunt(VSD).shuntdoesntgetbetterwithO2.(n
inshuntandninnotbetter)theybothhaveincreasedAagradient.hypoventilationanddecreased
inspiredO2donotcauseanincreasedAagradient.
inasteadyrestingstatetherespiratoryquotient(RQ)near1.0suggestscarbsarethemajornutrient
beingoxidized.whentheratiorisesitsduetoexcesscarbs.proteingivesRQof0.8andfatsgives0.7
solidsinthelungmakesoundstravelfastersoconsolidation(lobarpneumonia)hasincreasedtactile
fremitus.airorfluidoutsidethelunginterruptsthistransmissionofsound.patientswithconsolidated

lungshavebronchialbreathsoundsduetoovertransmissionofsoundoverthechestwall.breath
soundsareabsentordiminishedoverpleuraleffusion,pneumothoraxandCOPD.
movingfromsupinetosittingcanincreasetheFRCby2035%.increasingtheFRCcanhelpprevent
postopatelectasis.
inhaledantimuscarinicagentssuchasipratropiumarethemainstayofsymptommanagementin
COPD.
lungconsolidationcausesbronchialbreathsounds,dullnesstopercussion,increasedfremitus,
bronchophony,egophony,andwhisperedpectoriloquyonphysicalexam.bronchialbreathsounds
haveafullexipratoryphase.
aspirationpneumoniahasfoulsmellingsputumandiscausedbyexcessivealcoholintake.otherrisk
factorsarealteredconsciousness,dysphagia,neurologicdisorders,andsedativeprocedures.
causesofrestrictivelungdiseasesincludeinterstitiallungdisease,neuromusculardisease,alveolar
edema,pleuralfibrosisandchestwallabnormalities.restrictivepatternmaybecausedby
ankylosingspondylitis.inflammationleadstofusionofthecostovertebraljointsresultingin
restrictionofchestwallmotion.willhavenormalorincreasedFRCduetofixationofthechestwallin
aninspiratoryposition.
thenextstepininvestigationalstepofasolitarypulmonarynoduledetectedonCXRisusuallyaCT
scan.ifCTissuspiciousformalignancyorindeterminatethendofurtherinvestigationwithabiopsy
orPETscan.
carbonmonoxidepoisoningpresentswithheadache,nausea,abdominaldiscomfort.pinkishredskin
hueisnotedonexaminationanddiagnosisisconfirmedbycarboxyhemoglobinlevels.
inventilatedpatientsrespiratoryalkalosiscanresultfromhyperventilation.ifthetidalvolumeis
appropriate(6mg/klofbodyweight)therespiratoryrateshouldbelowered.reducingthetidal
volumecantriggerincreasedventilatoryrate.
COPDcanleadtocorpulmonale.willhaveelevatedJVP,hepatomegalyandperipheraledemawith
clearlungsounds.loopdiureticsareoftenusedtolowerrightventricularfillingvolumesandreduce
peripheraledema(inpatientswithCOPDexacerbations).loopdiureticscancausedecreasedCOin
patientswithcorpulmonale,leadingtoprerenalazotemia(elevatedBUN/Cr)andbicarbonatewill
godownsecondarytoametabolicacidosisfromuremia
lamberteatoncanbeassociatedwithsmallcellcarcinomaofthelung.autoantibodiestopresynaptic
voltagegatedcalciumchannels.
ARDSpatientstypicallyaregivenPEEPandhighFiO2(80%ish)butthentheventilatorsettingsshould
beadjustedtodecreaseFiO2tonontoxicvaluesslowlylowerbelow60%
theAagradientisincreasedininterstitiallungdiseaseduetoreduceddiffusioncapacityandV/Q
mismatch.CXRinidiopathicpulmonaryfibrosis(IPF)willshowairwayfibrosisgivingahoneycomb
pattern,andpulmonaryvascularcongestionmostevidentinthehilum.
uselightscriteriatodetermineiftransudateorexudate.phof7.35isconsistentwith
transudativepleuraleffusion.
pleuralplaquesareseenin50%ofasbestosiscasesonXR.helpstodistinguishfromothercasesof
pulmonaryfibrosis.mostcommonmalignancyinasbestosisisbronchogeniccarcinoma.pleural
mesotheliomacanalsooccurduetoasbestosisexposurebutithasalowerincidenceandoccursin
thepleura,notinthelungfields.

surgery

painreliefandrespiratorysupportareimportantinribfracturetraumatopreventhypoventilation
andatelectasis
bluntabdominaltraumacancausesplenicinjury.leftshoulderpain(referredfromdiaphragm,kehr's
sign).doabdominalctwithcontrast
rhinoplastycancausenasalseptumperforationleadingtoawhistlingnoisewhilebreathing.

inbluntabdominaltraumaifhemodynamicallyunstable,dofluidresuscitationandultrasound
(FAST).ifbloodfoundintraperitoneallyonFASTthendolaparotomy.
postoperativeatelectasishashypoxemiaandrespiratoryalkalosis(hyperventilation??)
inflammationofdiaphragmandperitonitisreferstotheupperleftshoulder
postopcholestasishappensinsurgerieswithhypotensionandbloodtransfusions.
1)increasedpigmentloadduetothetransfusion
2)decreasedliverfunctionduetohypotension
3)decreasedrenalbilirubinexcretionbecauseoftubularnecrosis.
AST/ALTnormaloronlymildlyelevated.ALPcanbehigh
pilonidalcystisacutepainandswellingofthemidlinesacrococcygealandsubcutaneoustissues.
whenpatienthasbluntabdominaltrauma(BAT)firststepistodetermineifneedexploratory
laparotomy.assessforintraperitonealfreefluid/hemorrhagewithFAST(focusedassessmentwith
sonography)
scaphoidfracturehaspaininanatomicalsnuffbox.cantakeupto10daystoshowfractureonxray
ifcompressedorminimallydisplaced.
supracondylarfractureofhumeruscanleadtoacutecompartmentsyndrome.commoninyoung
childrenfallingonoutstretchedhand.pain,pallor,pulselessness,paralysis,paresthesias.volkmann's
ischemiccontractureisthefinalsequenceofcomparmentsyndromewheredeadmusclehasbeen
replacedwithfibroustissue
toquicklyreversewarfarin'seffectsgiveFFP.usedinneedofsurgery.vitaminkwouldtaketoolong
becauseitworksviaposttranslationalmodifications.
prolongedplacementofcentrallinecanleadtosubclavianveinthrombosis.Thepatientwillhavea
swollenandpalearm.removecatheteranddoduplex
causesoffeverpostoparethe5Ws
1)wind(pneumonia/atelectasis)12days
2)waterUTI35days
3)walkingDVT46days
4)wound57days
5)wondermedications>7days
dehydratedandelderlypostoppatientsarepronetoacutebacterialparotitispresentingwith
painfulswellingofinvolvedparotidgland,aggravatedbychewing.mostcommoninfectiousagentis
S.aureus.topreventthiscomplicationdoadequatehydrationandoralhygiene.
motorvehicleaccidentcausessplenicrupture.willbehypotensive,tachycardic,andhaveabdominal
wallecchymoses.
foruppergastrointestinalbleedthatisongoingusepackedRBCtransfusion.inpatientwithheart
diseaseahgb>10shouldbemaintained
meniscaltearsinthekneeassociatedwithapoppingsensation.subsequentjoinswellingdevelops
graduallyinconrasttoaligamentoustearwhichisarapidjointswellingduetohemarthrosis.
inpatientswithliverdysfunctionandrenaldysfunctionuseatracuriumbecauseitisspontaneously
hydrolyzedintheplasma.succinylcholinemaycausehyperkalemiaandapneainpatientswithrenal
dysfunction.
inpulmonarycontusionpatientsdevelophypoxiaandrespiratorydistresshourslaterafter
pulmonaryedemahassetin.ifgivenlotsofIVfluidsthismayhappenquicker.CXRwillshowpatchy,
irregularalveolarinfiltrates.
transtentorialherniationoftheuncuscanoccurduringheadtraumaandleadstoipsilateral
hemiparesis,ipsilateralmydriasisandstrabismus,contralateralhemianopsia,andaltered
mentation.
acuterupturedappendicitiscancausepelvicabscess.typicallypresentsaslowerabdominalpain,
malaise,lowgradefever,andtenderpelvicmassonrectalexamination.
postopatelectasisisacommonsurgicalcomplicationresultingfromshallowbreathingandweak
coughduetopain.mostcommonondays23followingabdominal/thoracoabdominalsurgery.weak

coughpredisposestosmallairwaymucouspluggingandshallowbreathinglimitrecruitmentofalveoli
atlungbases.willbehypoxemicandhaverespiratoryalkalosis.
Inapatientwithminorheadtraumawithlossofconsciousness,thepatientcanbedischargedifCTis
normal.Justmonitorforsignsofalteredmentalstatusathome
alltraumapatientswithsuspectedspinalinjuriesshouldbehemodynamicallystabilizedandhavea
secureairwayandthenhaveaurinarycatheterplacedtoassessforurinaryretention.
allhemodynamicallyunstablepatientswithpenetratingabdominaltraumamustundergoimmediate
exploratorylaparotomytodiagnoseandtreatsourceofbleedingaswellastodiagnoseandtreat
perforationofanyabdominalviscusinanefforttopreventsepsis.
circumferentialfullthicknessburninvolvingextremitiesmaycauseaneschartoform,and
escharotomymaybenecessarytopreventvascularcompromise.willhavecompartmentsyndrome
presentinglikearterialthrombosis.(pallor,paresthesia,pain,pulseless)
fatembolismpresentswithdyspnea,confusion,andpetechiaeintheupperpartofthebodyand
occursafterlongbonefractures.
flailchestiscausedbythreeormoreadjacentribfracturesthatbreakintotwoplacesandcreatean
unstablechestwallsegmentthatmovesinaparadoxicalmotionwithrespiration.patientswithflail
chestwillremaintachypneicandhypotensivedespitecontinuousfluidresuscitation.
peripheralarteryaneurysmsmanifestasapulsatilemassthatcancompressadjacentstructuresand
resultinthrombosisandischemia.poplitealandfemoralarteryaneurysmsarethemostcommon
peripheralarteryaneurysms.
feverwithchillsanddeepabdominalpainsuggestsaretroperitonealabscess.blunt
abdominaltraumacancompressneck/bodyofpancreascausingretroperitonealabscessor
pseudocyst.abdominalCTscansdoneearlymayfailtodetectapancreaticinjury.Splenicinjury
wouldbeseenonCT,anddelayedsplenicrupturewouldcauseLUQabdominalpainandhypotension
butnosepticsigns(fever).gastricperforationmorelikelyinpenetrating(insteadofblunt)traumaand
wouldshowfreeairunderdiaphragm.
bluntaorticinjuryhasmediastinalwideningonCXR.deviationofthetracheaornasogastrictubeto
theright,ordepressionoftheleftmainstembronchusmayalsobeseen.
signsofnecrotizingsurgicalinfectionareintensepaininwound,fever,hypotensionandtachycardia,
decreasedsensitivityatedgesofwound,cloudygraydischarge,subcutaneousgaswithcrepitus.
treatmentisearlysurgicalexplorationtoassessextentofprocessanddebridethenecrotizedtissue.
positivepressuremechanicalventilationincreasesintrathoracicpressure,whichdecreasesvenous
returntotheheartanddecreasedpreload.inpatientswithhypovolemicshockthismaycause
circulatorycollapseifthepatientsintravascularvolumeisnotreplacedbeforemechanicalventilation
isattempted.
patientssufferingfromrapiddecelerationbluntchesttraumaareathighriskforaorticinjury.
findingssuggestiveofaorticinjuryincludeawidenedmediastinum,largeleftsidedhemothorax,
deviationofmediastinumanddisruptionofnormalaorticcontour.diagnosewithCTscanandtreat
withantihypertensivetherapy.
patientscangethighoutputheartfailurefromarteriovenousfistulas.symptomaticAVFcreatesan
abnormalconnectionbetweenthearterialandvenoussystemthatbypassescapillarybeds.shunting
ofalargeamountofbloodthroughthefistuladecreasessystemicvascularresistance,increases
cardiacpreload,andincreasescardiacoutput.widenedpulsepressure,strongperipheralarterial
pulsation(briskcarotidupstroke),systolicflowmurmur,tachycardia,andflushedextremities.the
leftventriclebecomeshypertrophiedandpointofmaximalimpulseisdisplacedtotheleft.
ischemiareperfusionsyndromeisaformofcompartmentsyndrome.after46hoursofischemia
tissuescansufferbothintracellularandinterstitialedemauponreperfusion.whentheextremities
areinvovledthiscreatesariskforcompartmentsyndrome.compartmentsyndromeisdefinedasan
increaseinpressurewithinanenclosedfascialspacecausingischemiaofmusclesandnerves.patients
willhaveseverepainthatisoutofproportiontothephysicalexamfindingsandcanberemembered
bythe5Ps:pain,paresthesia,pallor,pulselessness,paresis/paralysis.

incaseofamputationinjury,amputatedpartsshouldbewrappedinsalinemoistenedgauze,sealed
inaplasticbag,placedonice,andbroughtintotheED.
inflailchest,multiplecontiguousribsarefracturedresultinginanisolatedsegmentofthethoracic
wallthatexhibitsparadoxicalmotionduringnormalrespiration.theinstitutionofpositivepressure
mechanicalventilationcausestheflailsegmenttomovenormally.paincontrolandsupplemental
oxygenarethemostimportantearlystepsinmanagingflailchest.
trachealdeviationcanbecausedduetooppositesidepneumothorax,hemothorax,orsameside
lungcollapse.distendedneckveinsareduetoeitherpneumothoraxorcardiactamponade.
untreatedtensionpneumothoraxcanleadtopulselesselectricalactivity(PEA)and/orasystole.in
suspectedtensionpneumothoraxwithhemodynamicinstabilityfirstdoimmediateneedle
thoracostomypriortointubation,aspositiveventilationfollowingintubationusuallyexacerbates
anexistingpneumothorax.(samewithhypovolemicshock.positivepressuremechanicalventilation
decreasespreload,decreasesCO,soreplacevolumethendoPPV)
mostcommonandfearedcomplicationofTPNiscathetertipinfection.tpncanalsocauseelectrolyte
abnormalitiesandmetabolicdisturbances.hypokalemia,hypophosphatemiaandhypomagnesemia
whenrapidlygiveninachronicallynutrionallydeprivedpatient.knownasrefeedingsyndrome.
esophagealruptureisthemostfearedcomplicationofesophagealdilationprocedures.patientwill
havepostprocedurechestpain,hematemesis,andshortnessofbreath.anaccompanyingleftsided
pleuraleffusioniscommon.pneumomediastinumisanothertypicalCXRfindingandissuggestiveof
mediastinitiswhichisusuallycausedbyesophagealrupture.
patientswhohavehadgastricbypasssurgeryhaveahigherincidenceofdevelopinggallstonesdue
toanincreaseinbileconcentration.prophylactictreatmentwithursodeoxycholicacid
extrahepaticcholestasiscanbecausedbyobstructionofthecommonbileductbycarcinomaofthe
headofthepancreas.Thepatientwillhavepruritis,andjaundice.ERCPplacementofaCBDstent
wouldrelievetheobstructionandcholestasis.
ifthereisnoinfectionofafootulceranddoesnotinvolvebone,candebridethenecrotictissueas
sufficienttreatment
workupwidenedmediastinumonCXRwithatransesophagealechocardiographorCTscanofchest.
whenhemorrhage/hypovolemiaoccurs,tachycardiaandperipheralvascularconstrictionarethe
firstphysiologicalchanges.
tensionpneumothoraxisanemergencysituationwhichneedsimmediateneedlethoracostomy.will
haverapidonsetshortnessofbreath,tachycardia,tachypnea,hypotension,anddistensionofneck
veinsduetosuperiorvenacava(SVC)compression.
glasgowcomascalehas3components.1)eyeopening2)verbalresponse3)motorresponse
inapatientwithuppergastrointestinalbleedingwhohasadepressedlevelofconsciousnessand
ongoinghematemesis,intubatefirsttoprotecttheairway.thenendoscopictreatmentwithband
ligationorsclerotherapytostopbleeding.intubate>fluids>bronchoscopy
earlydumpingsyndromeisacommonpostgastrectomycomplication.upto50%ofpatietnswith
partialgastrectomymayexperiencethissyndrome.rapidemptyingofhypertonicgastriccontent
intotheduodenumandsmallintestine.leadstofluidshiftfromintravascularspacetothesmall
intestine,releaseofintestinalvasoactivepolypeptides,andstimulationofautonomicreflexes.treat
withdietarymodification.
persistentpneumothoraxandsignificantairleakfollowingchesttubeplacementinapatientwhohas
sustainedbluntchesttraumasuggeststracheobronchialrupture.otherfindingsinclude
pneumomediastinumandsubcutaneousemphysema.
flaccidparalysisafteraorticsurgeryisconsistentwithspinalcordischemiawithpossibleinfarction,a
rarecomplicationofvascularsurgery.thethoracicspinalcordisparticularlydependentonthese
radiculararteriesandthemostvulnerabletoinfarction.surgerytorepairthoracicand
thoracoabdominalaorticaneurysmsisthemostcommoncauseofspinalcordischemiaand
infarction.presentwithanteriorspinalarterysyndromeconsistingofflaccidparalysis,
bowel/bladderdysfunction,sexualdysfunction,possiblehypotensionandlossofdeeptendon
reflexes.

worseningchestpainaccompaniedbyshortnessofbreath,tachycardiaandtachypneaafteran
endoscopyisconcerningforiatrogenicesophagealrupture.commonradiographicfindingsincludea
pleuraleffusion,pneumomediastinumandpneumothorax.doawatersoluble(gastrografin)
esophagramtodiagnoseesophagealperforation.
anygunshotwoundbelow4thintercostalisconsideredtoinvolvetheabdomenandrequiresan
exploratorylaparotomyinunstablepatients.
patientswithesophagealperforationsmostcommonlypresentwithacuteonsetseveresubsternal
pain.physicalexamsometimesshowssubcutaneousemphysemaintheneckoracharacteristic
crunchingsoundonauscultationoftheheartduetomediastinalemphysema(hammanssign).
chestxraywillshowairintheparaspinalmuscles,awidenedmediastinum,pneumomediastinum
(mediastinalair),orpleuraleffusionswithorwithoutpneumothorax.thediagnosticstudyfor
esophagealperforationisgastrografincontrastesophagographywhichwillshowcontrastleakageat
thesiteoftheperforation.
patientswithcervicalspineinjuriesshouldfirsthavestabilizationofthecspine.orotracheal
intubationwithrapidsequenceintubationisthepreferredwaytoestablishanairwayinanapneic
patientwithacspineinjury.
acutemediastinitisisacomplicationofcardiacsurgeryusuallyduetointraoperativewound
contamination.mediastinitiscancomplicateupto5%ofsternotomies.patientstypicallypresent
postopwithfever,tachycardia,chestpain,leukocytosis,andsternalwounddrainageorpurulent
discharge.CXRwillshowawidenedmediastinuminnonpostoperativemediastinitisbutthiscanalso
beseeninpostoperativemediastinitisaftercardiacsurgery.postoperativemediastinitisrequired
drainage,surgicaldebridementandprolongedantibiotictherapy.
amortonneuromacommonlyoccursinrunnersandisamechanicallyinducedneuropathic
degenerationwithsymptomsincludingnumbnessandburningofthetoes,aching,andburninginthe
distalforefootthatradiatesforwardfromthemetatarsalheadstothethirdandfourthtoes.physical
examtypicallyshowspainbetweenthethirdandfourthtoesontheplantarsurfaceandaclicking
sensation(muldersign)whensimultaneouslypalpatingthisspaceandsqueezingthemetatarsal
joints.treatmentinvolvesusingmetatarsalsupportwithpaddedshoeinserts.dosurgeryforpeople
whereconservativetreatmentfails.
diaphragmaticruptureismorecommonontheleftsidebecausetherightsideisprotectedbythe
liver.patientstendtohaverespiratorydistressbecauseofleakageoftheintraabdominalcontents
intothechestcausingcompressionofthelungsandmediastinaldeviation.elevationofthe
hemidiaphragmonCXRmightbetheonlyabnormalfinding,butultrasoundorCTscanofthechestis
sometimesrequirediftheCXRdoesnotvisualizewell.thesmallbowelissometimespresentinthe
thoraciccavity.nasogastrictubeinpulmonarycavityindicatesadiaphragmatichernia.
dontusesuccinylcholineinapatientwithhyperkalemiaorhighriskforit(burncrushinjurypatients)
andpatientswithprolongeddemyelinationlikeguillainbarresyndrome,orwithtumorlysis
syndrome
34%ofpatientswithspinalcordinjurieswilldevelopposttraumaticsyringomyelia.whiplashis
oftentheincitinginjury.symptomsdevelopmonthstoyearslater.conditioninvolvesenlargementof
thecentralcanalofthespinalcordduetocerebrospinalfluidretention,resultinginimpaired
strengthandpain/temperaturesensationinupperextremities.MRIusedtodiagnose.(samething
ascentralcordsyndrome?)
compartmentsyndromemaybecausedbydirecttrauma(hemorrhage),prolongedcompressionof
anextremity,orafterrevascularizationofanacutelyischemiclimb.musclesoftheextremityare
encasedinfascialcompartmentsthatdonotallowforexpansionoftissue.hemorrhageoredema
withinthemusclescausesincreasedpressurewithinthenondistensiblefascialcompartment.this
increasedpressureinterfereswithperfusionbydisallowingpassageofbloodfromthearterialsystem
intothecapillarybedsoftheaffectedmuscles.thiseventuallyleadstomusclenecrosis.patientswith
compartmentsyndromeclassicalycomplainofseverepainthatisworsenedonpassiverangeof
motion,paresthesias,pallor,andparesisoftheaffectedlimb.pressures>30mmHgmayresultin
cessationofbloodflowthroughthecapillariesandshouldbetreatedemergentlybyfasciotomy.

acuteadrenalinsufficiency/addisonscancausenausea,vomiting,abdominalpain,hypoglycemia,
andhypotensionafterastressfulevent(surgicalprocedure)inapatientwhoissteroiddependent
(patientwithsystemiclupuserythematosus).
posteriorurethralinjuryisassociatedwithpelvicfractures.patientspresentwithbloodatthe
urethralmeatus,ahighridingprostate,scrotalhematoma,inabilitytovoiddespitesensinganurge
tovoid,andapalpablydistendedbladder.anteriorurethralinjurieswillnothaveahighriding
prostate.morecommonwithstraddleinjuries.
airunderdiaphragmindicatesperforatedviscus,asurgicalemergency.getasurgicalconsultfor
exploratorylaparotomy.
duodenalhematomasmostcommonlyoccurafterdirectbluntabdominaltraumaandaremore
commmoninchildren.followingtraumabloodcollectsbetweenthesubmucosalandmuscular
layersoftheduodenumcausingobstruction.mostresolvespontaneouslyin12weeksand
interventionofchoiceisnasogastricsuctionandparenteralnutrition.
postoperativeileusfollowsmostsurgerieswheretheperitonealcavityisentered.morphineand
otheropiatescompoundthisproblembydecreasinggastrointestinalmotility.signsandsymptoms
ofpostopileusincludenausea,vomiting,abdominaldistention,failuretopassflatusorstool,and
hypoactiveorabsentbowelsoundsonphysicalexam.mechanicalbowelobstructioncauses
hyperactivetinklingbowelsounds.
allpatientswithsmokeinhalationshouldbesuspectedtohaveacutecarbonmonoxidepoisoning
andtreatedwith100%oxygenviaanonrebreatherfacemask.
traumaticruptureofthediaphragmmayfollowbluntorpenetratingtrauma.XRwillshowadeviated
mediastinumwithamassintheleftlowerchest.symptomsmaybechestpainradiatingtothe
shoulder,shortnessofbreath,andabdominalpainfollowedbyrespiratorydistress.doabarium
swalloworCTscanwithoralcontrast.
immediatemanagementofsplenictraumacausedbybluntabdominalinjurydependsonpatients
hemodynamicstatusandresponsetointravenousfluids.ifunstablebutbecomesstablewithfluids
thenextbeststepisCTscan.ifstaysunstableafterfluidsthendo
exploratorylapaparotomy.hypotensionnotresponsivetofluidadministrationfollowingtraumais
suggestiveofongoingoccultbloodloss.doexploratorylaparotomytofindbleedingifabdominal
trauma
inanunstablepatientiftheFAST(focusedassessmentwithsonographyfortrauma)is
inconclusive,dodiagnosticperitoneallavage(DPL),thendolaparotomyifdeemednecessarybythe
DPL.

urology

painwithreliefofelevationofthetesticlehelpsinepididymitis.intesticulartorsionthereisalackof
acremastericreflex.
inthetreatmentofapatientwitherectiledysfunctionandBPHremembertogivesildenafiland
alphablockeratleast4hoursaparttoreduceriskofhypotension.sildenafiliscontraindicatedin
patientswithnitrates.
afterdiagnosisofsolidtesticularmasshasbeenmade(apainlesshardmassintesticle+suggestive
ultrasound)theinitialmanagementisorchiectomy.
inacuteprostatitisdoacultureofmidstreamurinesampletodirectantibiotictherapy.dont
massagetheprostateasitmayleadtobacteremia.
urgeincontinenceisknownasoveractivebladder.uninhibitedbladdercontractionsreferredtoas
detrusorinstability/hyperactivity.resultsininvoluntaryleakageofurineaccompaniedbyasevere
sensationofurgency.treatmentinvolvesbladdertrainingandestablishingavoidingschedule.can
useoxybutynin
germcelltumors(seminomaandnonseminoma)affectyoungpatientsandhaveaggressive
behavior.

nonseminomagermcelltumors(embryonalcarcinoma//yolksac//choriocarcinoma//
teratoma)typicallyproducebothafpandhcgastumormarkers.
leydigcelltumorscancauseestrogenproduction(duetoincreasedaromataseexpression)with
secondaryinhibitionofLHandFSH.leydigcelltumorisatypeoftesticularsexcordstromaltumor.
USPSTFdoesnotrecommendscreeningwithPSA,buttheamericancancersocietyandtheamerican
urologicalassociationguidelinesdisagree.discusswithpatientonacasebycasebasis.
patientswithvaricocelecomplainofadullachingpaininthetestis.varicoceleismostcommonon
theleftside.resultsfromaswellingofthepampiniformplexusofveinsandfeelslikeabagof
wormsonexam.thevalsalvamaneuverwilltypicallycausethismasstoenlarge.
cystoscopycancauseanenterococcalbacteremiainpatientswithchronicgenitourinaryinfections.
penilefracturerequiresurethralimaging(retrogradeurethrogram)andsurgicalrepair.
retrogradeurethrogramshouldbethefirststepinmanagementofsuspectedurethralinjury.foley
catheterizationinthepresenceofurethralinjurywillpredisposethepatienttoabscessformation.