1

Paul Ciuiysek N.B.

Stavios vouyiouklis N.B.
S
iu
Euition
The
USMLE Step 2 CK
BIBLE

The Ultimate Step 2 CK Review Guide


2
Copyiight 2u14 The 0SNLE Step 2 CK BIBLE

0puateu foi 2u142u1S

All appiopiiate changes foi the BSN-S have been maue to aujust foi the new infoimation.

N0TE: This book is intenueu as a ieview book, anu in no way shoulu ieplace intense
stuuy of all mateiial piesenteu theiein.





















S
CONTENTS




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






4

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











S













Chapter 1

Surgery


6
!"#$%#

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

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



7
>/ ,3. 0.<B/2('9 0)':.9C +.';B'* ,3. ;BDDBE-/1F
Check the ulasgow coma scale
Check all oiifices foi tiauma anuoi injuiies (bleeuing)
Peifoim checks using ultiasounu, XRAY, CT
Check foi compaitment synuiome

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










8


AO?5P

The type of shock can be uiagnoseu by checking the caiuiac output (C0), the pulmonaiy
capillaiy weuge piessuie (PCWP), anu the peiipheial vasculai iesistance (PvR).
6-;;.'./,-(D 6-(1/B0-0 B; A3B<Q
BYP0v0LENIC CARBI0uENIC SEPTIC
C0 ! ! "
PCWP ! " !
PvR " " !

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


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

O7#6 !"#$%#

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


)#%#$*+*%,:
Emeigency cianiotomy essential because this is a ueauly case within a few houis








1u
A)N2)'(D O.*(,B*(
Is a low-piessuie bleeu coming fiom the biiuging veins
Theie is usually a histoiy of heau tiauma with fluctuating consciousness
!"#$%&'"':
CT showing ciescent-shapeu bleeu


)#%#$*+*%,:
If theie is miuline uisplacement anu signs of mass-effect then uo an emeigency
cianiotomy
If symptoms aie less seveie, conseivative management incluues steioius


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



11
4(0(D AQ)DD K'(<,)'.
This piesents with ecchymosis aiounu eyes, behinu the eais, oi with CSF leak
fiom the nose

!"#$%&'"':
CT scan of heau anu neck
)#%#$*+*%,:
CSF ihinoiihea will stop on its own
If facial palsy is piesent, give steioius


















12


4$"LA

C
%0
.+A;++ ,(. 9+'$(.D.+A;++ -*;(%:
Epiueimis anu supeificial ueimis
Skin is painful, ieu, anu blisteieu
Tieatment with ointments anuoi pain ielieveis

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


7;+,02+(0:
Bepenuing on seveiity, iesuscitate with fluius
Removal of eschais
Bo a CXR to iule out lung injuiies
Topical antibiotics aftei eschai iemoval
Buins that covei moie than 2u% of the bouy iequiie aumission to a buin centei










1S
A$"G>5#H #46?%7L

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









14
"-13, $++.' X)(2'(/, 5B/2-,-B/0 Y 6-;;.'./,-(,-/1

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

53BD.<90,-,-0
R0Q pain anu tenueiness
(+) Nuiphy's sign (inspiiatoiy aiiest uuiing palpation)
Peifoim an ultiasounu to uetect gallstones, a thickeneu gallblauuei wall, oi
peiicholecystic fluiu

53BD.2B<3BD-,3-(0-0
R0Q pain that is woiseneu with the ingestion of fatty foous
}aunuice is often piesent
Peifoim an ultiasounu to uetect uilatation of the common bile uuct

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

53BD(/1-,-0
A life-thieatening conuition
Piesence of Chaicot's tiiau: Fevei + }aunuice + R0Q pain
If theie is also hypotension anu mental status changes, this qualifies as Reynolu's
pentau
Peifoim anu ultiasounu anu a CT to uetect biliaiy uuct uilatation uue to gallstone
obstiuction
Confiim uiagnosis with ERCP

@/.)*B/-(
1S
Piesence of pleuiitic chest pain
Peifoim a CXR, which will show pulmonaiy infiltiates

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


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

#++./2-<-,-0
Biffuse abuominal pain that localizes to the RLQ at NcBuiney's point (2S uistance
fiom umbilicus to ASIS)
Fevei anu uiaiihea often piesent
Abuominal xiay oi CT to soliuify uiagnosis
Becision to iemove is baseu on clinical piesentation

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

A(D+-/1-,-0
Lowei abuominal pain
Puiulent vaginal uischaige
Ceivical motion tenueiness
Peifoim an ultiasounu to uetect the abscess, anu a CT to iule out othei conuitions
%.<Q.D80 6-:.',-<)D-,-0
Follows the 1-1u-1uu iule
1%-2% pievalence
1-1ucm in length
16
Su-1uu cm pioximal to ileocecal valve
Piesents with uI bleeu, small bowel obstiuction (SB0)
Technetium peitechnetate scan to uetect

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

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

@9.DB/.+3'-,-0
Classically piesents with CvA tenueiness, high fevei, anu shaking chills
Best initial uiagnostic test is a 0A anu 0iine cultuie

>/,)00)0<.+,-B/
Seen most commonly in infants between S anu 1u months of age
Piesence of cuiiant jelly stool (mix of bloou anu mucus)
vomiting, intense ciying
Infants will often pull legs into the abuomen to ielieve some pain
Baiium enema is useu foi both uiagnosis anu tieatment







17
H.;, $++.' X)(2'(/, 5B/2-,-B/0 Z 6-;;.'./,-(,-/1

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

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

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


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

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

6-:.',-<)D-,-0
Patient has LLQ pain, fevei, anu uiinaiy uigency
Biagnose with a CT scan, which shows thickening of the laige intestine wall

A-1*B-2 MBD:)D)0
Nost commonly seen in an oluei patient
Piesents with constipation, uistenueu abuomen, anu abuominal pain
Contiast enema to uiagnose, will see the classic "biiu's beak"
18

@9.DB/.+3'-,-0
Classically piesents with CvA tenueiness, high fevei, anu shaking chills



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

G7"6
Epigastiicsubsteinal buining pain
Begiee of pain changes with uiffeient positions (woise when patient is supine)
Biagnosis maue with eithei a baiium swallow, pB testing, oi uppei uI enuoscopy

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

@(/<'.(,-,-0
Epigastiic pain that iauiates to the back
Nausea anu vomiting aie usually piesent
Patient often has a histoiy of alcoholism

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





19
A)'1-<(D 5B/2-,-B/0 B; ,3. 70B+3(1)0

#<3(D(0-(
A conuition wheie the lowei esophageal sphinctei fails to ielax

-"$%' #%. -/+0,&+':
Bysphagia to B0TB soliu anu liquiu
Reguigitation of foou
!"#$%&'"':
Best initial test its the Baiium Swallow, which uemonstiates naiiowing of the
uistal esophagus
Nost accuiate test is esophageal manometiy, which will uemonstiate the lack of
peiistalsis
12*#,+*%,:
The best initial theiapy is pneumatic uilation
If pneumatic uilation is not successful, suigeiy shoulu be peifoimeu
If patient uoes not want suigeiy, can attempt to ielax the LES with injection of
botulinum toxin


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

-"$%' #%. -/+0,&+':
Bysphagia
Balitosis
!"#$%&'"':
The best initial test is the baiium swallow
12*#,+*%,:
2u
Suigical iesection of the uiveiticula is the best initial tieatment option


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

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

!"#$%&'"%$:
The best initial uiagnostic test is an enuoscopy
12*#,+*%,:
The best initial tieatment is suigical iesection as long as theie is no metastasis
Suigeiy shoulu be followeu with S-F0







21

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

!"#$%&'"':
Nanometiy is the most accuiate uiagnostic test
12*#,+*%,:
Calcium channel blockeis anu nitiates aie the tieatment option of choice


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













22
5(/<.' B; ,3. A,B*(<3

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

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

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

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

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

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




2S
9)%0+; @,;= I$%+>1 %)A(:
Baiu nouule at the umbilicus uue to metastasis
Inuicative of a veiy pooi piognosis


12*#,+*%,':
Suigeiy + chemotheiapy
Palliative caie is often the only choice if too auvanceu




















24
O.'/-(0


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

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

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


!"#$%&'"':
Nust uiffeientiate fiom a femoial heinia, which will heiniateu below the inguinal
ligament
Biagnosis is baseu on clinical examination
12*#,+*%,:
Suigical iepaii

K.*B'(D O.'/-(0
2S
Women > Nen
Bave a gieatei iisk of incaiceiation uue to the way they heiniateu
Biagnose clinically
Suigical coiiection (uo not uelay uue to iisk of incaiceiation anu subsequent
stiangulation)

M-0<.'(D O.'/-(0
This type of heinia causes intestinal obstiuction
-"$%' #%. -/+0,&+':
Abuominal pain
0bstipation (no flatulence)
!"#$%&'"':
XRAY will show aii-fluiu levels, no gas in iectum
Biffeientiate fiom auhesions
12*#,+*%,:
Suigical iepaii














26

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

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

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

12*#,+*%,:
Asymptomatic gallstones iequiie no inteivention
Chionic pain may iequiie a cholecystectomy
With an incieaseu iisk of cancei, such as in the case of a calcifieu gallblauuei wall,
cholecystectomy may be waiianteu


53BD.<90,-,-0
Is an infection of the gallblauuei that is a iesult of an obstiuction
Common causes aie: E. Coli, Enteiobactei, Enteiococcus, anu Klebsiella
Note the shauow fiom the impacteu stone.
27

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

12*#,+*%,:
Keep patient NP0, give Iv fluius, anu give antibiotics to covei giam (-) ious anu
anaeiobes
Bo not give moiphine foi pain because it causes a spasm of the sphinctei of ouui
If impiovements aie not seen, cholecystectomy may be waiianteu


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

!"#$%&'"':
0ltiasounu to uetect uilation
An ERCP can be useu aftei the pieliminaiy 0S uiagnosis
12*#,+*%,:
NP0
Iv fluius
uiam (-) antibiotics
ERCP foi uecompiession of the biliaiy tiee anu foi iemoval of the stones


53BD.2B<3BD-,3-(0-0
An obstiuction of the common bile uuct
28
-"$%' #%. -/+0,&+':
}aunuice (obstiuctive)
" Alkaline phosphatase
" Conjugateu biliiubin
!"#$%&'"':
0ltiasounu to uetect CBB obstiuction

12*#,+*%,:
Cholecystectomy


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

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

-"$%' #%. -/+0,&+':
Shaip, colicky pain
!"#$%&'"':
0S oi CT to uetect the tumoi
12*#,+*%,:
Placement of bile uuct stents
Suigeiy as a palliative option, but is not cuiative




29
A)'1-<(D 5B/2-,-B/0 B; ,3. @(/<'.(0

@(/<'.(,-,-0
Autouigestion of the pancieas by it's own enzymes
NCC is alcohol anu gallstones

-"$%' #%. -/+0,&+':
Seveie epigastiic pain that iauiates to the back
" Seium amylase anu lipase
!"#$%&'"':
Clinical suspicion + abuominal CT
Theie may be uiscoloiation of the flank (uiey Tuinei's sign) anu Cullen's sign
(bluish uiscoloiation of the peiiumbilicus)
12*#,+*%,:
NP0, Iv fluius, anu Bemeiol foi pain ielief
Be awaie of the potential foi alcohol withuiawal
3&+07";#,"&%:
Theie is a iisk foi abscesses, ienal failuie, uuouenal obstiuction, anu pancieatic
pseuuocysts



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

!"#$%&'"':
0ltiasounu
Abuominal CT
12*#,+*%,:
Suigical uiainage
Cieation of a fistula uiaining the cyst into the stomach
3&+07";#,"&%':
Infection followeu by iuptuie can cause peiitonitis


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





5(/<.' B; ,3. @(/<'.(0
Noie common in Afiican Ameiicansmalessmokeis
Nay be moie common in uiabetics
9u% aie auenocaicinomas
S1
6u% aiise fiom the heau of the pancieas

-"$%' #%. -/+0,&+':
Weight loss
Painless jaunuice
!"#$%&'"':
" biliiubin, " alkaline phosphatase, "CA19-9
CT scan
12*#,+*%,:
Although usually a teiminal uiagnosis, can uo a iesection of the pancieas, oi
Whipple's pioceuuie
The Syi suivival iate is only S%

















S2
A)'1-<(D 5B/2-,-B/0 B; ,3. A*(DD 4BE.D

A*(DD 4BE.D ?N0,')<,-B/
SB0 can be causeu by a numbei of conuitions
3#='*':
Peiitoneal auhesions
Beinias
Ciohn's uisease
Neckel's
uallstone ileus
Abuominal inflammation
-"$%' #%. -/+0,&+':
Nauseavomiting
Abuominal pain
Abuominal ciamps
Tenueinessuistention
Bypeiactive anu high-pitcheu bowel sounus
!"#$%&'"':
Abuominal xiay
Aii-fluiu levels on upiight film
92,## J$/+# 5-%0;*'0)$( K9*>)(+ F)+/L
SS
92,## J$/+# 5-%0;*'0)$( K6>;)A10 F)+/L

12*#,+*%,:
Nu tube uecompiession
NP0
Iv fluius
If only paitially obstiucteu may be able to tieat without suigeiy
If suigeiy is iequiieu, must iemove both obstiuction anu ueau bowel


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







S4
A)'1-<(D 5B/2-,-B/0 B; ,3. H('1. 4BE.D

@BD9+0
Aie neoplastic, hamaitomas, oi inflammatoiy
Neoplastic polyps aie NC auenomas
@.*%&+#' ;#% 4* ;7#''"6"*. #':
Tubulai (these have the smallest potential foi malignancy)
Tubulovillous
villous (these have the highest iisk of malignancy)

-"$%' #%. -/+0,&+':
NC piesents with inteimittent iectal bleeuing
!"#$%&'"':
Colonoscopy oi sigmoiuoscopy
12*#,+*%,:
Polypectomy


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

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



SS
6-:.',-<)DB0-0
This is the piesence of multiple false uiveiticula

-"$%' #%. -/+0,&+':
Nost people aie asymptomatic, with uiveiticula founu only on colonoscopy oi
othei visual pioceuuies
Nay have iecuiient bouts of LLQ abuominal pain
Changes in bowel habits is common
Raiely, patient may piesent with lowei uI hemoiihage
!"#$%&'"':
Colonoscopy
Baiium enema can also be useu foi uiagnosis
12*#,+*%,:
If patient is asymptomatic, the only theiapy shoulu be to inciease fibei anu
ueciease fat in the uiet
If patient has uI hemoiihage, ciiculatoiy theiapy is waiianteu (Iv fluius,
maintenance of hemouynamic stability)


6-:.',-<)D-,-0
Inflammation of the uiveiticula uue to infection
Theie aie many possible complications, such as abscess, extension into othei
tissues, oi peiitonitis

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



S6
!"#$%&'"':
CT uemonstiating euema of the laige intestine
B0 N0T peifoim a colonoscopy oi baiium enema in an acute case, this might
aggiavate the pioblem
3&+07";#,"&%':
Peifoiation
Abscesses
Fistula foimation
0bstiuctions
12*#,+*%,:
If theie is an abscess, peicutaneous uiainage is iequiieu
Nost patients aie manageu well with fluius anu antibiotics
Foi peifoiation oi obstiuction, suigeiy is iequiieu


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

-"$%' #%. -/+0,&+':
Nauseavomiting
Abuominal pain with ciamps
Abuominal uistention
!"#$%&'"':
XRAY - showing a uistenueu pioximal colon, aii-fluiu levels, anu an absence of gas
in the iectum
12*#,+*%,:
If theie is seveie pain, sepsis, fiee aii, oi signs of peiitonitis theie must be an
uigent lapaiotomy
Lapaiotomy if cecal uiametei is >12cm
S7


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

-"$%' #%. -/+0,&+':
Bigh-pitcheu bowel sounus
Bistention
Tympany
!"#$%&'"':
XRAY - "kiuney bean" appeaiance (ie. Bilateu loops of bowel with loss of haustia)
Baiium enema showing a "biiu's beak" appeaiance - points to the site of iotation
of the bowel
12*#,+*%,:
Sigmoiuoscopy oi colonoscopy acts as uiagnosis anu tieatment
If this uoesn't woik, lapaiotomy is waiianteu


5(/<.' B; ,3. 5BDB/
Colon cancei is the 2
nu
NCC of cancei ueaths
Believeu that a low-fibei, high-fat uiet incieases the iisk
Theie aie many genetic factois that contiibute to colon cancei, such as Lynch
synuiome anu BNPCC
B/%;5 -/%.2&+*:
LS 1 is an autosomal uominant pieuisposition to colon cancei that is usually iight-
siueu
LS2 is the same as LS 1 with the auuition of canceis outsiue the colon, such as in
the enuometiium, stomach, pancieas, small bowel, anu ovaiies
-;2**%"%$:
Scieening shoulu stait at 4uyi in people with no iisk factois
S8
If a family membei has hau cancei of the colon, scieening shoulu stait 1uyi piioi
to when they weie uiagnoseu (assuming this is less than 4uyi)
Shoulu have yeaily stool occult tests
Colonoscopy eveiy 1uyi
Anu a sigmoiuoscopy eveiy S-Syis

!"#$%&'"':
0btain pieopeiative CEA (allows you to follow the piogiession oi iecession of the
uisease)
Enuoscopy + baiium enema
12*#,+*%,:
Suigical iesection + LN uissection
If uisease is metastatic, auu S-F0 to the post-opeiative iegimen
C&77&:D=08
CEA levels eveiy S months foi S yeais
Peifoim a colonoscopy at 6 anu 12 months, then yeaily foi S yeais
If a iecuiience is suspecteu, a CT shoulu be peifoimeu















S9
A)'1-<(D 5B/2-,-B/0 B; ,3. ".<,)* (/2 #/)0

O.*B''3B-20
vaiicosities of the hemoiihoiual plexus
0ften ielateu to stienuous bowel movements

-"$%' #%. -/+0,&+':
Biight ieu bloou pei iectum
Itching
Buining
Palpable anal mass
Inteinal hemoiihoius aie N0T painful, while exteinal hemoiihoius ARE painful
12*#,+*%,:
0sually self-limiting
Sitz bath
Bemoiihoiual cieam
Stool softeneis to ielieve pain


!3'B*NB0.2 O.*B''3B-20
These aie not a tiue hemoiihoiu, but aie exteinal hemoiihoiual veins of the anal
canal
They aie a painful bluish elevation that lie beneath the skin
37#''"6";#,"&%':
1 hemoiihoius involve no piolapse
2 hemoiihoius classically piolapse with uefecation but ietuin without manual
ieuuction
S hemoiihoius piolapse with eithei stiaining oi uefecation anu iequiie manual
ieuuction
4 hemoiihoius aie not capable of being ieuuceu
12*#,+*%,:
Conseivative theiapies
Scleiotheiapy, iubbei banu ligation, anu suigical hemoiihoiuectomy

4u
#/(D K-00)'.
A ciack oi teai in the anal canal
0sually occuis aftei the passage of uiaiihea oi constipation

-"$%' #%. -/+0,&+':
The most common piesentation is the passage of a painful bowel movement that is
accompanieu by biight ieu bloou
!"#$%&'"':
Peifoim an anoscopy to uiagnose
12*#,+*%,:
Bulking agents anu stool softeneis aie usually all that is neeueu
If fissuies peisist uespite conseivative measuiements, a lateial inteinal
sphincteiotomy may be iequiieu

#/(D (/2 ".<,(D 5(/<.'
!(,# :,('+;:
The most common foim is squamous cell caicinoma
-"$%' #%. -/+0,&+':
Anal bleeuing, pain, anu mucus upon evacuation
!"#$%&'*:
Biopsy
12*#,+*%,:
Chemotheiapy + Rauiation

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

41
!"#$%&'"':
Colonoscopy
12*#,+*%,:
Suigeiy that spaies the sphinctei
If metastasis involveu, auuition of S-F0 chemotheiapy + iauiation























42
L7$"?A$"G7"[


!)*B'0 B; ,3. 4'(-/
0ften piesents as a 1+,.,'1+ that is seveie enough to awaken the patient uuiing
the night
4(';+,%+. )(0;,';,(),# >;+%%*;+ causing nausea, vomiting, anu Cushing's tiiau
(Biauycaiuia, hypeitension, anu Cheyne-Stokes iespiiation)
Piesence of focal ueficits
0ften piesents with a fixeu, uilateu pupil
!"#$%&'"%$ # 42#"% 7*'"&%:
The most accuiate uiagnosis comes fiom biopsy
With clinical suspicion a CT anuoi NRI can often help make the uiagnosis
12*#,+*%,:
Excision is the best tieatment foi all tumois (except piolactinoma anu lymphoma)
PR0LACTIN0NA - give biomociiptine to shiink it, then suigeiy if this uoesn't
woik
LYNPB0NA - iauiation is the tieatment of choice
If theie is metastasis of biain tumois, aujunct theiapy is iauiation

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


4S
@+.*##$-#,%0$2,:
Common in chiluien
Founu in the ceiebellum4
th
ventiicle
8;$#,'0)($2,:
Is the NC pituitaiy tumoi
Piesents with many enuociine uistuibances such as amenoiihea, impotence,
galactoiihea, anu gynecomastia.
The NC piesenting symptoms is visual uistuibance (bitempoial hemianopsia)
O=2>1$2,:
NC CNS tumoi in AIBS patients
An NRI shows a iing-enhanceu lesion
0ften confuseu with toxoplasmosis
9'1/,(($2,:
A tumoi that affects the 8
th
cianial neive
Piesents with tinnitus, loss of heaiing, anu incieaseu intiacianial piessuie



O92'B<.+3(D)0
An inciease in CSF causes an enlaigement of the ventiicles

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

44
Tieatment:
If possible, tieat the unueilying cause
If not possible, a shunt shoulu be placeu (usually uiaineu into peiitoneum)

























4S



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

#/.)'90*0
Is a uilatation of an aiteiy to gieatei than two times its noimal uiametei
"Tiue" aneuiysms involve all S layeis of the vessel, anu aie causeu most commonly
by atheioscleiosis anu congenital uisoiueis
"False" aneuiysms aie coveieu only by the auventitia of the vessel, anu aie most
commonly causeu by tiauma

-"$%' #%. -/+0,&+':
uastiicepigastiic uiscomfoit
Back pain
Commonly in the abuomen (abuominal aoita aneuiysms)
Also commonly in the peiipheial vessels
3&+07";#,"&%':
A iuptuie of an abuominal aneuiysm is an emeigency
Piesents with abuominal pain, a pulsatile abuominal mass, anu seveie hypotension
!"#$%&'"':
0ltiasounu can help uetect aneuiysms
CT is the best test to ueteimine size
The most accuiate test is the aoitogiam
12*#,+*%,:
Contiol bloou piessuie
46
Reuuce iisk factois
Suigeiy iecommenueu if aneuiysms aie >Scm
@.'-+3.'(D M(0<)D(' 6-0.(0. \@M6^
Bue to atheioscleiosis

-"$%' #%. -/+0,&+':
Piesents with clauuication
Patient may have smooth anu shiny skin with a loss of haii in the affecteu aiea
!"#$%&'"':
Ankle:Biachial Inuex (ABI) is the best initial test - noimal test is % u.9
The most accuiate test is an angiogiaphy
12*#,+*%,:
Lifestyle mouifications such as cessation of smoking anu incoipoiation of exeicise
Contiol lipius with an LBL <1uu
Contiol bloou piessuie
Baily aspiiin
Suigeiy is iequiieu if theie is pain at iest, neciosis, intiactable clauuication,
anuoi a non-healing infection













47
#B',-< 6-00.<,-B/
Is a uissection of the thoiacic aoita
Piesents with intense "teaiing" pain that iauiates to the back
Theie is a uiffeience in bloou piessuies between the iight anu left aim

!"#$%&'"':
The best initial test is a CXR - showing a wiuening of the meuiastinum
The most accuiate test is the CT angiogiaphy
12*#,+*%,:
0igent bloou piessuie contiol with #-blockeis followeu by nitiopiussiue to
maintain a uecieaseu bloou piessuie
0igent EKu anu CXR
Then get a TEE oi CT
Suigical coiiection is necessaiy, otheiwise this is iapiuly fatal.









48
A)N<D(:-(/ A,.(D A9/2'B*.
An occlusion of the subclavian aiteiy leaus to a uecieaseu bloou flow uistal to the
obstiuction
The veitebial aiteiy "steals" the bloou uue to ietiogiaue flow
Patient expeiiences clauuication of the aim, nausea, syncope, anu supiaclaviculai
biuit
!"#$%&'*:
Angiogiaphy
Bopplei ultiasounu
NRI
12*#,+*%,:
Caiotiu-subclavian bypass


5('B,-2 M(0<)D(' 6-0.(0.
Is an atheioscleiotic plaque in the caiotiu aiteiies
-"$%' #%. -/+0,&+':
Patient may piesent with a TIA
Amauiosis fugax (blinuness in one eye)
Caiotiu biuit
!"#$%&'"':
Angiogiaphy
12*#,+*%,:
Beciease the mouifiable iisk factois
Aspiiin
0thei anticoagulation meuications
Suigeiy is waiianteu if theie is stenosis >7u%, if patient has iecuiiing TIA's, oi if
they have suffeieu fiom a pievious ceiebiovasculai acciuent





49
A)'1-<(D 5B/2-,-B/0 B; ,3. $'-/('9 A90,.*

!.0,-<)D(' !B'0-B/
0sually occuis in a youngei patient
Acute euema anu seveie testiculai pain
Patient usually expeiiences nausea anu vomiting uue to the uegiee of the pain
ABSENCE of the ciemasteiic ieflex
Piesence of sciotal swelling
Testicle may have a hoiizontal lie
!"#$%&'"':
0ltiasounu to assess aiteiial patency
0pon elevation of the teste, the pain is not alleviateu
12*#,+*%,:
1
st
step is to secuie the ciiculation
2
nu
step is to evaluate the neeu foi excision of the testicle if it is ueau

7+-2-29*-,-0
0nilateial pain of the testicle
Bysuiia
Painful anu swollen epiuiuymus
Less common in piepubeital chiluien as opposeu to toision
!"#$%&'"':
Swab foi Chlamyuia anu uonoiihea
12*#,+*%,:
NSAIBs anu antibiotics

@'B0,(,. 5(/<.'
0bstiuctive symptoms
Rock-haiu nouule in the piostate
!"#$%&'"':
PSA
Seium phosphatase
Azotemia
Su
Tiansiectal ultiasounu

12*#,+*%,:
The only suigical iequiiement is a iauical piostatectomy in veiy seveie cases -
iisk of incontinence anuoi impotence






















S1
?',3B+.2-< <B/2-,-B/0 '._)-'-/1 0)'1.'9

P/.. >/W)'-.0
>%;7=.*:
Anteiioi ciuciate ligament teais
Posteiioi ciuciate ligament teais
Collateial ligament teais
Neniscus teais

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

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

E&',*2"&2 32=;"#,* B"$#+*%, ,*#2':
Injuiy usually occuis when the knee is flexeu
"Posteiioi uiessei uiawei sign"
NRI is the test of choice to ueteimine seveiity of the injuiy
Tieatment is eithei with conseivative measuies, oi if seveie with aithioscopic
iepaii
S2
7+,; $& 01+ 8:O




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

)*%"';=' ,*#2':
0ften seen in oluei patients anu is uue to uegeneiation
Injuiy is most commonly seen in the meuial meniscus anu is much moie common
in men
Biagnose with NcNuiiay's test
NRI to ueteimine the seveiity of the injuiy
Tieatment is usually iest alone, if seveie can tieat with aithioscopic suigeiy
SS
@+.),# 2+()%'*% 0+,;



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

-"$%' #%. -/+0,&+'8
Pain anu tenueiness of the ueltoiu with movement
Pain ovei the anteiioi aspect of the humeial heau
Neei's sign (+) - pain eliciteu when the aim is foicefully elevateu foiwaiu
!"#$%&'"':
Clinical suspicion
NRI is useu foi confiimation
12*#,+*%,:
NSAIBs
Steioius injections
Foi seveie uiseases that aie not successfully tieateu with steioius, aithioscopic
suigeiy is helpful


S4
6-0DB<(,-B/ B; ,3. A3B)D2.'
Is most commonly an anteiioi uislocation
Posteiioi uislocation seen when patient is electiocuteu anuoi expeiiences a
status epilepticus seizuie
!(0+;)$; .)%#$',0)$( $& 01+ 1*2+;*%
-"$%' #%. -/+0,&+':
Immobility
Extieme pain
12*#,+*%,:
Tiaction-counteitiaction techniques to put the bone back in the socket
Immobilization peiiou (2-6 weeks)












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

6-0DB<(,-B/0
Bislocations iequiie emeigency ieuuction unuei seuation
Risk of injuiy to sciatic neive
Avasculai neciosis is a seveie complication

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


I'-0, >/W)'-.0
5BDD.08 K'(<,)'.:
This is a fiactuie to the uistal iauius
0ccuis aftei falling on an outstietcheu hanu
Biagnose with B & P anu xiay
Tieat with cast immobilization foi 2-4 wk
S6
:$##+%G &;,'0*;+


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







S7
5('+(D !)//.D A9/2'B*.
Piesents with pain, numbness, tingling of the hanus along the uistiibution of the
meuian neive

!"#$%&'"':
Pathognomonic sign is "Tinel's Sign", wheie tapping ovei the palmai aspect of the
wiist elicits shooting pains
"Phalen's test" is also uiagnostic
12*#,+*%,:
Tieat by avoiuance of aggiavating activity, use
wiist splints which holu the wiist in %#)A10
+Q0+(%)$(
Seveie cases shoulu fiist be manageu with steioiu
injection in the caipal tunnel, if no tieatment suigeiy is peifoimeu














I'-0, A+D-/,0F
OBD20 ,3. E'-0,
-/ ( +B0-,-B/ B;
`0D-13,
.V,./0-B/8
S8
!3. 4'.(0,

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







S9
5(/<.' "-0Q0
The #1 iisk factoi foi bieast cancei is genuei
(Female >>> Nale)
In women, age is the #1 factoi foi bieast cancei
iisk
Late menopause incieases the iisk of bieast cancei
(aftei Suyi)
If less than 11yi at menaiche, the iisk of bieast
cancei is incieaseu
If >Suyi at fiist piegnancy, the iisk foi bieast
cancei incieases

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
















O-0,B'9 B;
K-N'B(2./B*(
(/2JB'
K-N'B<90,-<
2-0.(0. 2B.0 /B,
-/<'.(0. ,3. '-0Q
B; 1.,,-/1 N'.(0,
<(/<.'
6u
!)*B'0 B; ,3. 4'.(0,

%(**B1'(*
All women >4uyi (contioveisial as to age to
stait) shoulu have yeaily mammogiams
Not effective in young patients because the
bieast tissue is too uense
K-N'B(2./B*(
The classic piesentation is a fiim, non-tenuei,
mobile bieast nouule
Nost commonly seen in teens anu youngei
women


!"#$%&'"':
Bieast exam
FNA
Follow-up clinical bieast exam in 6 weeks
12*#,+*%,:
Not iequiieu as this conuition is not a cancei
piecuisoi anu often uisappeais on its own





I3./ ,B +.';B'*
<.',(-/ ,.0,0
+.',(-/-/1 ,B N'.(0,
*(00.0F
A palpable mass that
feels cystic always
iequiies an ultiasounu
fiist.
A palpable mass that
uoesn't feel cystic
iequiies a FNA (aftei an
0S oi insteau of an 0S).
Any FNA that ieveals
bloouy fluiu iequiies
cytology.
Always uo a
mammogiam in patients
>4uyi who piesent with
almost all pathologies of
the bieast.
A biopsy is iequiieu
when a cyst iecuis moie
than 2 times within 4
weeks, when theie is
bloouy fluiu, when theie
aie signs of
inflammatoiy bieast
uisease, anu when a
mass uoes not uisappeai
with FNA.
61
K-N'B<90,-< 6-0.(0.
This piesents with multiplebilateial painful lumps in the bieast that vaiy in pain
with the menstiual cycle
Is the most commonly seen bieast tumoi in women between SS-Suyi of age

!"#$%&'"':
Fine-neeule aspiiation to uiain fluiu, anu it will collapse aftei the FNA
12*#,+*%,:
0CP's can help pievent this fiom occuiiing



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

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



62
!"#$%&'"':
Bistology shows pucheu-out aieas in uucts anu haphazaiu cells along the papillae
12*#,+*%,:
Suigical excision ensuiing clean maigins
Post-opeiative iauiation is iecommenueu to ueciease the iisk of iecuiience (Can
give Tamoxifen in auuition to iauiation oi insteau of iauiation)

HBN)D(' 5('<-/B*( >/ A-,) \H5>A^
In contiast to BCIS, this is not piecanceious, it uoes howevei inciease the iisk of
futuie invasive uuctal caicinoma
!"#$%&'"':
Baiu to uiagnose with mammogiam
Cannot be uetecteu clinically
The histology shows mucinous cells in the classic "saw-tooth" pattein
12*#,+*%,:
Tamoxifen alone is useu foi tieatment














6S
>/:(0-:. 4'.(0, 5(/<.'0

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

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

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

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

4"5#a (/2 4"5#R
Testing foi these genes shoulu be peifoimeu if theie is a histoiy of the following:
Family histoiy of eaily-onset bieast cancei
Family histoiy of male bieast cancei
Past histoiy of bieast anuoi ovaiian cancei in that patient
Ashkenazi }ewish heiitage
64

















6S


Chapter 2

Obstetrics









66


!.'*-/BDB1-.0
uiaviuty = total numbei of piegnancies
Paiity = numbei of biiths with a gestational age >24 weeks
Teim ueliveiy = ueliveiy aftei S7 weeks of gestation
Piematuie ueliveiy = ueliveiy of infant between 2u anu S7 weeks

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

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

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

6"$G 5#!7G?">7A 6$">LG @"7GL#L5[
5(,.1B'9 6.0<'-+,-B/
# %.2-<(,-B/ 3(0 /B, 03BE/ (/ -/<'.(0. -/ '-0Q ;B' N-',3 2.;.<,0 -/ 3)*(/
0,)2-.0=
4 #/-*(D 0,)2-.0 3(:. /B, 2.*B/0,'(,.2 ( '-0QC (/2 ,3.'. ('. /B (2._)(,.
0,)2-.0 -/ 3)*(/0C ?" (/-*(D 0,)2-.0 3(:. 03BE/ ( '-0QC N), ,3. '-0Q 3(0
/B, N../ 0../ -/ 3)*(/0=
5 #/-*(D 0,)2-.0 3(:. 03BE/ (2:.'0. .;;.<,0C N), /B 0,)2-.0 ('. (:(-D(ND.
-/ 3)*(/0C ?" 0,)2-.0 -/ 3)*(/0 (/2 (/-*(D0 ('. /B, (:(-D(ND.=
6 %.2-<(,-B/0 ('. (00B<-(,.2 E-,3 N-',3 2.;.<,0 -/ 3)*(/0b 3BE.:.'C
67
+B,./,-(D N./.;-,0 -/ '('. <(0.0 *(9 B),E.-13 ,3.-' Q/BE/ '-0Q0=
c %.2-<(,-B/0 ('. <B/,'(-/2-<(,.2 -/ 3)*(/ +'.1/(/<9 N.<()0. B; Q/BE/
;.,(D (N/B'*(D-,-.0 ,3(, 3(:. N../ 2.*B/0,'(,.2 -/ NB,3 3)*(/ (/2
(/-*(D 0,)2-.0=


5?%%?L !7"#!?G7LA >L @"7GL#L5[
6')1 4-',3 6.;.<,
H-,3-)* 7N0,.-/80 (/B*(D9 \0-/1D.Y<3(*N.'.2 '-13, 0-2. B; 3.(',^=
5('N(*(T.+-/.C
M(D+'B(,.
L.)'(D ,)N. 2.;.<,0=
".,-/B-2 #<-2 5LA 2.;.<,0C <'(/-B;(<-(D 2.;.<,0C <('2-B:(0<)D(' 2.;.<,0=
#57 >/3-N-,B'0 6.<'.(0.2 0Q)DD B00-;-<(,-B/C './(D ,)N)D. 2901./.0-0C './(D
;(-D)'. -/ /.B/(,.=
?'(D
39+B1D9<.*-<0
L.B/(,(D 39+B1D9<.*-(
I(';('-/ 5LA d AQ.D.,(D 2.;.<,0
LA#>60 L.<'B,-T-/1 ./,.'B<BD-,-0C <B/0,'-<,-B/ B; 2)<,)0 (',.'-B0-0=


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

Recommenu:
68
Folic aciu
Iion
Nulti-vitamin
2S-SS lb weight gain uuiing piegnancy

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

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




A75?L6 !">%7A!7" "?$!>L7 !7A!A
" NS-AFP:
Neuial tube uefect (NTB), vential
wall uefect, twin piegnancy,
placental bleeuing, ienal uisease,
saciococcygeal teiatoma.
! NS-AFP:
Tiisomy 21, Tiisomy 18
U !3. *B0,
<B**B/ <()0. B;
-/(<<)'(,. D(N
'.0)D,0 -0 2(,-/1
.''B'=

69
A<'../-/1 !.0, 6-(1/B0,-<
A-1/-;-<(/<.
L.V, A,.+ -/ %1*,
6-(N.,.0 a3' eS1 ?G!!
\RfYRg EQ0^
#N/ -;
hafS*1J2H
>; iC +.';B'* j3'
aSS1 ?G!!
#/.*-( 545 *.(0)'.2
N.,E../ RfYRg
E..Q0=
ON kaS1J2H l
(/.*-(

>'B/
0)++D.*./,(,-B/
#,9+-<(D
(/,-NB2-.0
>/2-'.<, 5BB*N0
,.0,
@.';B'*.2 -/
"3\Y^ EB*./
DBBQ-/1 ;B'
(/,-NB2-.0 \(/,-Y
6 #N^ N.;B'.
1-:-/1 "3BG#%
"3BG#% /B,
-/2-<(,.2 -/ "3 \Y^
EB*./ E3B 3(:.
2.:.DB+.2 (/,-Y6
(/,-NB2-.0
G4A 0<'../-/1 M(1-/(D (/2 '.<,(D
<)D,)'. ;B' 1'B)+
4 0,'.+ (, jeYjm
E..Q0=
\i^ G4A -0 ( 3-13
'-0Q ;B' 0.+0-0 -/
/.ENB'/0=
n,'.(, E-,3
-/,'(+(',)* >M
(/,-N-B,-<0o=
>MF
@./ G
5D-/2(*9<-/
7'9,3'B*9<-/ -/
@5L (DD.'1-<
+(,-./,=

j
'2
,'-*.0,.'F
See patient eveiy 4 weeks until week S2, eveiy 2 weeks fiom week S2-S6, then eveiy
week until ueliveiy.
Assess:
Inquiie about pieteim laboi |vaginal bleeus, contiactions, iuptuie of membianesj.
Inquiie about piegnancy-inuuceu hypeitension.
Scieen foi gioup B stieptococcus at SS-S7 weeks.
uive RhouAN at 28-Su weeks if inuicateu
71+ &$##$/)(A ,(0)+2+0)'% ,;+ %,&+ 0$ *%+ .*;)(A >;+A(,('=<
Boxylamine
!3. <B/;-'*(,B'9 ,.0, ;B' 2-(N.,.0 -/ +'.1/(/<9 -0 ,3. j3' aSS1 B'(D
1D)<B0. ,BD.'(/<. ,.0, \?G!!^=
Plasma glucose >12SmguL at beginning of test = BN
Abnoimal plasma glucose is >14umguL at 1hi, >1SSmguL at 2hi, anu
>18umguL at Shi.
If 1 post glucose loau measuiement is abnoimal, impaiieu glucose
toleiance is the uiagnosis.
If 2 oi moie post glucose loau measuiements aie abnoimal, gestational
uiabetes is the uiagnosis.
7u
Netoclopiamiue
0nuansetion
Piomethazine
Pyiiuoxine























71
!3. 5B*+D-<(,.2 @'.1/(/<9

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



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

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

72
S. Peicieta - placenta penetiates entiie myometiium to uteiine seiosa

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

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









7S

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







74
V=>+;0+(%)$( )( 8;+A(,('=
Bypeitension in piegnancy pieuisposes both the mothei anu fetus to seiious conuitions.
A 4@ B; % afSJpS uuiing piegnancy can be classifieu as chionic hypeitension oi
gestational hypeitension.
Bypeitension accompanieu by signs anu symptoms of enu-oigan uamage oi
neuiological sequelae is uiagnoseu as +'..<D(*+0-(, .<D(*+0-(, oi O7HH@
09/2'B*..
Sustaineu hypeitension may cause fetal giowth iestiiction anu hypoxia, anu
inciease the iisk of (N')+,-B +D(<./,(.

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

S,;()(A 9)A(% $& 8;++'#,2>%),<
Ballmaik symptoms incluue:
Beauache
Epigastiic pain
visual changesuistuibances
Signs:
Pulmonaiy euema
0liguiia
Labs:
Thiombocytopenia
Elevateu livei enzymes





7S
6-0.(0. 53('(<,.'-0,-<0
Pieeclampsia BTN (>14u9u oi " systolic BP
>Su mmBg oi uiastolic BP >1S
mmBg compaieu to pievious BP).
New onset pioteinuiia anuoi
euema.
Commonly aiounu week 2u
Seveie Pieeclampsia SBP >16u mmBg oi BBP >11u
mmBg.
Significant pioteinuiia (>1g24hi
uiine collection oi >1+ on uip)
CNS uistuibances such as
heauache oi visual uistuibance
Pulmonaiy euema
R0Q pain
Eclampsia C0Nv0LSI0NS
2S% occui befoie laboi, Su%
uuiing laboi, 2S% in fiist 72hi
post-paitum

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

7;+,02+(0:
BP goal is 14u-1Su mmBg (systole) anu 9u-1uu mmBg (uiastole).
Bon't tieat unless BP is >16u1uu mmBg

)#"%,*%#%;* 15*2#0/8
Fiist line theiapy - Nethyluopa
Seconu line theiapy - #-blockeis such as labetalol
* #-blockei use in piegnancy can cause I0uR
76

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

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



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

@,(,A+2+(0:
Immeuiate ueliveiy at any gestational age
Iv coiticosteioius if platelets aie <1uu,uuumm^S both antepaitum anu
postpaitum, continuing until platelets aie >1uu,uuumm^S anu livei functions
noimalize
uive platelet tiansfusion if platelets uiop below 2u,uuumm^S oi platelet count
less than Su,uuumm^S if C-section will be peifoimeu
Iv Nagnesium Sulfate foi seizuie piophylaxis
Steioius foi fetal lung matuiity.

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

77




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

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

@)D*B/('9 -
Nucosal hypeiemia causes nasal stuffiness anu nasal hypeisecietion
Biaphiagm elevates uue to uteius expansion
Tiual volume anu minute ventilation " Su-4u%
Functional iesiuual capacity anu iesiuual volume ! 2u%
Bypeiventilation that allows foi a piessuie giauient so mateinal u2 can tiansfei to
fetus
Respiiatoiy iate, vital capacity, inspiiatoiy ieseive all iemain unchangeu.


78
G> -
! uI motility
! esophageal sphinctei tone (leaus to uERB)
" alkaline phosphatase
Bemoiihoius causeu by constipation anu " venous piessuie uue to enlaiging
uteius compiession on IvC

"./(D -
! blauuei tone uue to piogesteione pieuisposes to uiinaiy stasis anu
0TI'spyelonephiitis
uFR " by Su%, thus glucose excietion without incieaseu piotein loss
Seium cieatinine anu B0N ueciease

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

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



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

5('2-(< #N/B'*(D-,-.0
Beait uisoiueis account foi up to 1u% of mateinal obstetiic ueaths
Women with veiy high-iisk uisoiueis shoulu be auviseu against piegnancy uue to
incieaseu iisk of ueath
79
Caiuiovasculai physiological changes may unmask anu woisen unueilying
conuitions, seen maximally between 28-S4 weeks gestation.
@.'-+(',)* 5('2-B*9B+(,39
Fiom the 8
th
month until S months post-paitum, heait failuie without iuentifiable
cause is possible
Risk factois incluue multipaiity, age ovei Su, histoiy of multiple gestations, anu
pieeclampsia
S-yi moitality iate is Su%

%(/(1-/1 0+.<-;-< <('2-(< <B/2-,-B/0
?*#2, C#"7=2*8
Loop uiuietics, nitiates, anu # - blockeis
Bigoxin may impiove symptoms but uoes not impiove outcome.
Nevei use ACEI's in piegnancy
@225/,5+"#':
Rate contiol as with non-piegnant patients
Nevei give waifaiin oi amiouaione
I%.&;#2.","' E2&05/7#K"'8
Same as in non-piegnant patient
Baily piophylaxis in patient with iheumatic heait uisease
L#7G=7#2 !"'*#'*8
Reguigitant lesions uo not iequiie theiapy
Stenotic lesions have incieaseu iisk of mateinal anu fetal moitality
Nitial stenosis has incieaseu iisk of pulmonaiy euema anu Afib.



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

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

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

6-(N.,.0 -/ @'.1/(/<9
The taiget values foi fasting bloou sugai aie between 9umguL anu 12umguL 1hi
aftei eating.
Insulin-uepenuent BN iequiies insulin anu is safe thiough piegnancy
uestational BN is manageu solely thiough uiet
0ial hypoglycemics aie contiainuicateu anu shoulu also be avoiueu if
bieastfeeuing, since it can cause hypoglycemia.
O&=,"%* +&%",&2"%$ ,*',' .=2"%$ 02*$%#%;/8
Nonthly sonogiams
Nonthly biophysical piofiles
BbA1c each tiimestei
Tiiple maikei scieen at 16-18 weeks
assessing NTB's.
At S2 weeks stait weekly non-stiess tests
anu amniotic fluiu inuex
If gestational BN, uo a 2hi 7Sg 0uTT at 6-12 weeks postpaitum to see if uiabetes
has iesolveu
BbA1c > 8.S in the fiist
tiimestei is stiongly
associateu with congenital
malfoimations, especially
neuial tube uefects!
81

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

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






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


@;=,* C#,,/ B"G*2 &6 E2*$%#%;/8
82
A iaie conuition causeu by uisoiueieu metabolism of fatty acius by the fetal
mitochonuiia.
Causes BTN, pioteinuiia, anu euema that can mimic pieeclampsia.
Biagnosis:
" livei enzymes (ALT, AST, uuT)
Bypeibiliiubinemia
BIC
Bypoglycemia
Incieaseu seium ammonia
Tieatment:
Emeigency situation iequiies IC0 aumission anu aggiessive Iv fluius + immeuiate
ueliveiy






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

(+) uiine cultuie
B0RNINu
FREQ0ENCY
0RuENCY
N0 fevei
(+) uiine cultuie
B0RNINu
FREQ0ENCY
0RuENCY
FEvER + CvA
TENBERNESS
Tieatment 0utpatient
Nitiofuiantoin is
the B0C
0utpatient
Nitiofuiantoin is
the B0C
Aumission, give:
Iv hyuiation
Iv cephalospoiin's
uive tocolytics
Possible
Complications
Acute
pyelonephiitis if
untieateu in
appioximately
Su%
Acute
pyelonephiitis if
untieateu in
appioximately
Su%
Pieteim laboi anu
ueliveiy.
Seveie cases may
piogiess to sepsis,
anemia, anu
pulmonaiy
uysfunction

8S

7<,B+-< @'.1/(/<9J!)N(D @'.1/(/<9
The eailiei the age of gestation the less theie is a iisk of complications.
P
',
,2"+*',*28
B&C is the most common 1
st
tiimestei pioceuuie.
uive piophylactic antibiotics
Peifoim unuei twilight anesthesia + paiaveitebial block
Can peifoim meuical aboition as an alteinative to B&C with use of oial
mifepiistone (piogesteione antagonist), anu oial misopiostol (piostaglanuin E1).
* Nust be peifoimeu within 6S of onset of amenoiihea.
3&+07";#,"&%':
Enuometiitis (iaiely)
Retaineu piouucts of conception (P0Cs)

Q
%.
,2"+*',*28
B&C is the most common 2
nu
tiimestei pioceuuie.
Foi moie auvanceu piegnancies, an "intact B&C" can be useu.
3&+07";#,"&%':
Retaineu placenta is the most common immeuiate complication
Ceivical tiaumaceivical insufficiency is the most common uelayeu complication


#NB',-B/

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

I;,&0"; E2*$%#%;/8
Implantation outsiue of the uteiine cavity
84
PIB incieases the iisk
Risk factois:
Pievious ectopic piegnancy
Bistoiy of gonoiihea, Chlamyuia, PIB, salpingitis
Auvanceu mateinal age (>SS)
> S piioi piegnancies
Biffeiential ux of ectopic piegnancy:
0vaiian toision
Enuometiiosis
Suigical abuomen
Aboition
Salpingitis
Ruptuieu ovaiian cyst
Biagnosing:
(+) #-hCB + 0S to ueteimine intia vs. extia uteiine piegnancy
Low piogesteione level is suggestive of a non-viable piegnancy that may be
locateu outsiue of the uteiine cavity
Tieatment:
Lapaioscopic iemoval, tubes usually heal on theii own
Nethotiexate eaily, especially if size is <S.Scm in uiametei + no caiuiac activity on
0S
Rh negative women shoulu ieceive RhouAN
Seiial #-hCB must be uone to ensuie success of teimination

!9+.0 B; #NB',-B/0
!3'.(,./ >/.:-,(ND. 5B*+D.,.2 >/<B*+D.,. %-00.2 ".<)''=
vaginal
bleeuing in
fiist 2u wk
without
passage of
tissues oi
R0N.
Ceivix is
closeu.

0ccuis in
2S% of
piegnancies
.
Thieateneu
aboition
with uilateu
ceivical os
anuoi
iuptuie of
membianes
(R0N).

Piegnancy
loss is
unavoiuable
.

A
uocumenteu
piegnancy
that
spontaneousl
y aboits all
piouucts of
conception
(P0Cs).

Nust uo
pathology
iepoit of
P0Cs.
Ciamping,
bleeuing,
uilateu ceivix
with passage
of tissue into
vagina oi
enuoceivical
canal.

Cuiettage
often
iequiieu.

Rh (-) pt
P0Cs uo not
get fully
expelleu.

No uteiine
giowth, no
fetal heait
tones,
cessation of
piegnancy
symptoms.

Evacuation
of uteius
%2
consecutive
oi total of S
spontaneous
aboitions.

Nay be ut
chiomosoma
l anomaly.

Tieat with
ceivical (1S-
16wk)
ciiclage until
8S

Biagnose
with
ultiasounu.

If no
caiuiac
activity by
week 9
consiuei a
B&C.



Tieat with
suigical
evacuation
+ aumin of
RhouAN if
mothei is
Rh (-).

Pt may
iequiie
auuitional
cuiettage if
P0Cs aie not
completely
evacuateu.

RhouAN to
Rh (-)
women.
iequiies
RhouAN.

Bemouynami
c stabilization
may be
iequiieu.
aftei
confiimeu
fetal ueath.

BIC is iaie
complication
.

RhouAN is
Rh (-)
laboi oi
R0N occuis
(S6-S7wk).



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

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

-/++*,2"; >RAO8
Fetal Causes:
! giowth potential
0S shows a ! in all measuiements
Etiology:
T0RCB infection
Aneuploiuy
Stiuctuial anomalies such as: caiuiac, neuiological.
0ltiasounu:
! in all measuiements (symmetiic)
Biagnosing:
Kaiyotype
86
Scieen foi fetal infection
Betaileu sonogiam

@'/++*,2"; >RAO8
1. Nateinal Causes:
! placental peifusion
Etiology:
Bypeitension
Nalnutiition
ET0B, tobacco, illicit uiugs
0ltiasounu:
! abuomen measuiements with noimal heau measuiements
Biagnosing:
Seiial sonogiams
NST
AFI (often !, especially with seveie uteioplacental insufficiency).
Biophysical piofile


2. Placental Causes:
! placental peifusion
Etiology:
Infaiction
Twin-twin tiansfusion
Abiuption
velamentous coiu inseition
0ltiasounu:
! abuomen measuiements with noimal heau measuiements
Biagnosing:
Seiial sonogiams
NST
AFI (often !, especially with seveie uteioplacental insufficiency).
Biophysical piofile
87

%(<'B0B*-(
Inuicateu by fetal weight >9u-9S peicentile foi gestation age oi biith weight of
4uuu-4Suug.
Risk Factois:
uestational Biabetes Nellitus
Piolongeu gestation
0besity
Incieaseu piegnancy weight gain
Nultipaiity
Nale fetus

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


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










88
K.,(D #00.00*./, (/2 >/,'(+(',)* A)':.-DD(/<.

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

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

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


F"&05/'";#7 02&6"7*8
Neasuies:
Fetal bieathing
Fetal bieathing
Fetal tone
Qualitative amniotic fluiu volume
Reactive fetal heait iate
89
All measuies fiom u-2, a scoie of 8-1u is noimal, scoie of 6 iequiies fuithei
evaluation, scoie of & 4 usually iequiies immeuiate inteivention

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

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









9u
@;;*7*2#,"&%'8
7('D9 2.<.D.'(,-B/0 - ! FBR miiioiing contiaction, uue to piessuie on fetal heau (vagal
neive stimulation), is physiologic anu not haimful to fetus.



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



91
H(,. 2.<.D.'(,-B/0 - begin aftei contiaction has staiteu, uips aftei peak of contiaction,
anu ietuins to baseline aftei contiaction is ovei. vieweu as uangeious anu is associateu
with placental insufficiency.

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

** Repetitive late ueceleiations iequiie inteivention

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

92
12*#,+*%,V@G&".#%;*8
uive RhouAN within 72hi of ueliveiy to pievent an antibouy iesponse in the
mothei.
uiven at 28 weeks as well, can fuithei ieuuce iisks by u.2%
Impoitant to test fathei foi Rh status, if he is Rh (+), auministei RhouAN both at
28 weeks of gestation + at 72hi aftei ueliveiy.
W,5*2 ,"+*' +#,*2%#7D6*,#7 47&&. ;#% +"K8
Buiing amniocentesis
Aftei an aboition
Aftei an ectopic piegnancy tieatment


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

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








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

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

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

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





j= %(/(1.*./, B; H(NB'
94
!=2"%$ 6"2', ',#$*8
Continuous FBR monitoiing
Continuous monitoiing of uteiine activity with exteinal tocouynamometei anu
intiauteiine piessuie cathetei
Analgesia anuoi anesthetic given, most commonly when ieaching the active stage
of laboi.
!=2"%$ '*;&%. ',#$*8
At this stage mateinal pushing can acceleiate ueliveiy
Episiotomy uone at this stage (if peifoimeu at all)
Bulb anu suction aftei ueliveiy of the heau
Shoulueis ueliveieu aftei heau
0mbilical bloou sent foi AB0 anu Rh testing
!=2"%$ ,5"2. ',#$*8
Beliveiy of placenta
!=2"%$ 6&=2,5 ',#$*8
Evaluation of ceivix, vagina, vulva, peiineum, anu uiethial aiea foi laceiations
anuoi tiaumatic injuiy

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

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

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

j= @(00(1. -

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



9S
H(NB' 0,(1. 6.;-/-,-B/ 6)'(,-B/ #N/B'*(D-,-.0
A,(1. a Z H(,./,
@3(0.
\7;;(<.*./,^
4.1-/0 E-,3 B/0.,
B; '.1)D(' ),.'-/.
<B/,'(<,-B/0=

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

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

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

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

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

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

7/20 (, aS<*
2-D(,-B/=

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

ha=e<*J3'
\*)D,-+('(^
#<,-:. @3(0.
+'BDB/1 B' (''.0,F

5.':-V 2-D(,.2 %
j<*

@'BDB/1(,-B/F
<.':-<(D 2-D(,-B/
B; ka=R<*J3'
\+'-*-^ B'
ka=e<*J3'
\*)D,-^

5()0.F +(00./1.'
(N/B'*(D-,9

%1*,F
>; 39+B,B/-<
<B/,'(<,-B/F >M
BV9,B<-/
>; 39+.',B/-<
<B/,'(<,-B/F
*B'+3-/.
0.2(,-B/
>; (2._)(,.
<B/,'(<,-B/0 2B
.*.'1./<9 5Y
0.<,-B/
A,(1. R Z 6.0<./, 4.1-/0 E3./
aS<* 2-D(,.2=

7/20 E3./ N(N9
-0 2.D-:.'.2
kR3' -; +'-*-
ka 3' -; *)D,-
#22-,-B/(D 3B)' -;
1-:./ .+-2)'(D
A.<B/2 0,(1.
(''.0,F
K(-D)'. ,B 2.D-:.'
E-,3-/ R3'\@^ B'
a3'\%^
96
5()0.F
(N/B'*(D-,9 E-,3
+(00./1.'C +.D:-0C
B' +BE.'
%1*,F
K.,(D 3.(2 /B,
./1(1.2 \2B
.*.'1./<9 5Y
0.<,-B/^
K.,(D 3.(2
./1(1.2 \;B'<.+0
B' :(<))*
.V,'(<,-B/^
A,(1. j Z
7V+)D0-B/
4.1-/0 E-,3 N(N9
2.D-:.'9 (/2 ./20
E-,3 +D(<./,(D
2.D-:.'9
kjS *-/),.0 @'BDB/1.2 0,(1. -;
+D(<./,( ,(Q.0
DB/1.' ,3(/ jS
*-/),.0 ,B
2.D-:.'=
%1*,F >M
BV9,B<-/C *(/)(D
'.*B:(D=
O90,.'.<,B*9 -;
,3.0. ;(-D=















97
@'BDB/1(,-B/ 6-0B'2.'0
Bystocia can be uiviueu into piolongeu latent phase anu piolongeu active phase
1. Piolongeu latent phase
Latent phase >2uhi in piimigiaviu oi >14hi in multigiaviu
Nay be uue to ineffective uteiine contiactions, uispiopoition between pelvis anu
fetus, anu even excessive anesthesia


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

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

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


>%.";#,"&%' 6&2 "%.=;,"&%8
Suspecteu fetal compiomise
Fetal ueath
Piegnancy inuuceu hypeitension
Past uate piegnancy
Nateinal meuical complication
Piematuie iuptuie of membianes (PR0N)
98

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

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



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

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


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

R4:: Nost commonly associateu with placental abiuption, seveie pieeclampsia, amniotic
fluiu embolism, oi piolongeu ietention of a ueau fetus.
99

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

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


@'.*(,)'. ")+,)'. B; %.*N'(/.0 \@"?%^
Ruptuie of choiioamniotic membiane befoie the onset of laboi
0ccuis in 1u%-1S% of all piegnancies
Laboi usually follows in 9u% of patients within 24his
PR0N at & 26 wks of gestation is associateu with pulmonaiy hypoplasia
!"#$%&'"%$:
Peifoim vaginal exam with testing of non-bloouy fluiu
Nitiazine test: tests pB
Fein test: amniotic fluiu placeu on sliue, looking foi bianching fein leaf pattein
when sliue uiies
0S confiims uiagnosis: finus oligohyuiamnios
12*#,+*%,:
If an intiauteiine infection is suspecteu, give bioau-spectium antibiotics,
otheiwise tieat as a pieteim laboi.



@B0,+(',)* 5B/,'(<.+,-B/
F2*#',6**."%$:
Bieastfeeuing pioviues contiaception foi S months because of tempoiaiy
anovulation
1uu
3&+4"%*. *',2&$*%D02&$*',"% 6&2+=7#,"&%'8
0CP, patch, oi vaginal iing
Not staiteu until S weeks postpaitum to pievent hypeicaogulable state anu iisk
BvT
Not useu in bieastfeeuing women because they uiminish lactation
!"#052#$+ #%.V&2 >R! 07#;*+*%,8
Befeiieu until 6 weeks post-paitum
E2&$*',"% ;&%,2#;*0,"&%8
Nini-pill, Bepo-Pioveia
Can be safely useu while bieastfeeuing anu staiteu immeuiately aftei piegnancy

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

a $!>

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

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

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

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










1u1
@.'-/(,(D >/;.<,-B/0

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

Su% of women have asymptomatic vaginal colonization with uBS
veitical tiansmission can cause pneumonia anu sepsis of the neonate within
houis of biith
Noitality iate is as high as Su%
12*#,+*%,8
Intiapaitum Iv penicillin u
In patient with PCN alleigy, use Iv clinuamycin, eiythiomycin, oi cefazolin


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

Causeu by Toxoplasma gonuii paiasite
Is most commonly causeu by the hanuling of cat feces anuoi littei uuiing
piegnancy
Nay be causeu by uiinking iaw goat milk oi eating iaw meat
veitical tiansmission will only occui with piimaiy infection of the mothei
Nost seiious infection iesults fiom infection in the fiist tiimestei
-/+0,&+':
Nost common piesentation is a mononucleosis-type synuiome + the piesence of a
cat in the householu
0n 0S, theie may be intiauteiine giowth ietaiuation

I3./ ('. (/,-N-B,-<0 1-:./s
1. When uBS (+) uiine, ceivical,
oi vaginal cultuie at any time
in piegnancy.
2. Piesence of high-iisk factois
such as:
Piolongeu PR0N
Pieteim ueliveiy
Piesence of mateinal fevei
Any pievious baby who
expeiienceu uBS sepsis
I3./ ('. (/,-N-B,-<0 /B, 1-:./s
1. With planneu C-section, when
theie is no iuptuie of
membianes.
2. Cultuie (-) in this piegnancy
but with (+) cultuie in pievious
piegnancy
1u2
E2*G*%,"&%:
Avoiu hanuling cat feces, iaw goat milk, anu
unueicookeu meat
If infecteu, mothei shoulu take spiiamycin to
pievent veitical tiansmission
12*#,+*%,:
Aftei seiologic confiimation, give pyiimethamine
anu sulfauiazine.

j= M('-<.DD(

Piimaiy vaiicella infection in mothei causes tiansplacental infection 2S%-4u% of
the time.
uieatest iisk to fetus is poseu if a iash appeais in the mothei fiom S uays
antepaitum anu 2 uays postpaitum.
A neonatal infection piesents with limb hypoplasia, miciocephaly,
miciophthalmia, choiioietinitis, cataiacts, anu "zigzag" skin lesions
E2*G*%,"%$ L#2";*77# "%6*;,"&%8
Non-piegnant women shoulu ieceive vaccination
Post-exposuie piophylaxis within 96his of exposuie with vZv immunoglobulin
12*#,+*%,:
Nateinal vaiicella - anti-vaiicella antibouies to mothei anu neonate
Congenital vaiicella - anti-vaiicella antibouies + Iv acyclovii to neonate

f= ")N.DD(

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


E2*G*%,"&%:
Peifoim a fiist tiimestei scieening
Bave mothei avoiu any infecteu inuiviuuals
5D(00-< <B/1./-,(D ,'-(2F
a= O92'B<.+3(D)0
R= >/,'(<'(/-(D
<(D<-;-<(,-B/0
j= 53B'-B'.,-/-,-0
"$47HH#:
"Bluebeiiy Nuffin" iash
Beafness
PBA
Cataiacts
Retaiuation
Bepatosplenomegaly
Thiombocytopenia
1uS
Immunize seionegative women aftei ueliveiy
** Theie is no post-exposuie piophylaxis available


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

Is the most common congenital viius in the 0SA.
CNv is the most common cause of sensoiineuial ueafness in chiluien
CNv is spieau by bouy fluiu secietions
Nost infections piouuce a mononucleosis-like synuiome
Appioximately 1u% of infants aie symptomatic at biith
-/+0,&+' "% %*&%#,*8
I0uR
Piematuiity
Niciocephaly
}aunuice
Petechiae
Bepatosplenomegaly
Peiiventiiculai calcifications
Choiioietinitis
Pneumonitis
!"#$%&'"%$ 3)L8
viial cultuie within 2 weeks of biith
PCR
E2*G*%,"&%:
0niveisal piecautions with avoiuance of bouy fluius
Avoiu tiansfusion with CNv-positive bloou
12*#,+*%,:
uanciclovii (pievents heaiing loss but uoes not cuie infection)


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

Contact with lesions is the most common cause
of tiansmission
uieatest iisk of infection in the S
iu
tiimestei
CNv
I0uR
Piematuiity
Niciocephaly
}aunuice
Bepatosplenomegaly
Petechiae
Peiiventiiculai
calcifications
Choiioietinitis
Pneumonitis
# /.B/(,(D
-/;.<,-B/ (<_)-'.2
2)'-/1 2.D-:.'9 3(0
( eSt *B',(D-,9
'(,.=
1u4
Su% iisk of tiansplacental infection with piimaiy infection
-/+0,&+'F
Fevei + malaise + uiffuse genital lesions
If infant suivives, they may uevelop meningoencephalitis, mental ietaiuation,
pneumonia, hepatosplenomegaly, jaunuice, anu petechiae.
!"#$%&'"'F
\i^ BSv cultuie fiom vesicle fluiu oi ulcei oi BSv PCR of mateinal bloou
Pievention
A C-section is manuatoiy if mothei has active genital BSv lesions at time of laboi.
It is contiainuicateu to use fetal scalp electioues foi monitoiing; they inciease iisk
of BSv tiansmission.
Avoiu stanuaiu piecautions such as sex with outbieak
12*#,+*%,:
Acyclovii foi piimaiy infection uuiing piegnancy

m= O>M

The majoi ioute of veitical tiansmission is contact with infecteu genital secietions
at time of vaginal ueliveiy.
Without tieatment veitical tiansmission iate is 2S%-Su%
Elective C-section is most beneficial in women with low CB4+ counts anu high RNA
viial loaus (>1uuu).
All neonates of BIv + motheis will test positive uue to the tiansplacental passage
of Igu
E2*G*%,"&% #%. 12*#,+*%,8
Tiiple-uiug theiapy staiting at 14 weeks anu continuing thioughout the
piegnancy.
Iv intiapaitum ziuovuuine (AZT)
uive infant oial ziuovuuine foi 6 weeks post-ueliveiy
Piophylax infant foi PCP with TNP-SNX aftei the 6 weeks of ziuovuuine theiapy
Scheuule a C-section at S8 weeks unless the viial loau is <1uuu viial copiesml
Nothei cannot bieastfeeu because BIv passes thiough bieast milk
Avoiu all invasive pioceuuies such as aitificial R0N anu fetal scalp electioues

g= A9+3-D-0

1uS
Tiansplacental infection is moie likely in piimaiy anu seconuaiy infection, anu
less likely in teitiaiy infection
I#27/D#;Z="2*. TP
',
,2"+*',*2U ;&%$*%",#7 '/05"7"' "%;7=.*' ,5* 6&77&:"%$ '/+0,&+'8
Byuiops fetalis
Naculopapulai oi vesiculai iash
Laige anu swollen placenta
Anemia, thiombocytopenia, anu hepatosplenomegaly
Theie is a Su% peiinatal moitality iate
B#,*D#;Z="2*. ;&%$*%",#7 '/05"7"' "' ."#$%&'*. #6,*2 Q /*#2' &6 #$*< "%;7=.*' ,5* 6&77&:"%$8
Butchinson teeth
"Sabei" shins
"Sauule" nose
Beafness (CN8 palsy)
"Nulbeiiy" molais
!"#$%&'"':
vBRL oi RPR scieen in fiist tiimestei
Confiim a positive test with FTA-ABS oi NBA-TP
12*#,+*%,:
Benzathine penicillin IN (1 time foi infecteu motheis)
If PCN alleigy: Besensitization followeu by full uose benzathing PCN


9. O.+(,-,-0 B
Neonatal infection fiom piimaiy infection in the S
iu
tiimestei oi ingestion of
infecteu genital secietions
8u% of infecteu neonates will uevelop chionic hepatitis
E2*G*%,"&%:
Bep B infection is not an inuication foi C-section
Avoiu invasive pioceuuies
Aftei neonate ieceives immunization anu hep B immunoglobulin, can be bieastfeu
>++=%"J#,"&%:
BBsAg-negative - give active immunization uuiing piegnancy
# 5Y0.<,-B/ <(//B,
+'.:./, :.',-<(D
,'(/0*-00-B/ B;
09+3-D-0= >, E-DD N.
,'(/0*-,,.2 ,3'B)13
,3. +D(<./,( N.;B'.
N-',3=
Aftei any (+) syphilis scieen, FTA-ABS oi NBA-TP is uone as confiimatoiy tests.
1u6
Postexposuie piophylaxis foi the mothei - BBIu
12*#,+*%,:
Bepatitis immunization + BBIu in neonate
Chionic BBv can be tieateu with inteifeion oi lamivuuine

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










1u7


Chapter 3

Gynecology






1u8
4./-1/ G9/.<BDB19

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

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

1u9
KBDD-<)D('J@'BD-;.'(,-:.
@3(0.
?:)D(,B'9 @3(0. H),.(DJA.<'.,B'9 @3(0.
Bay 1-1S Bay 1S-17 Bay 1S - Bay 1 of menses
Estiauiol-inuuceu
negative feeuback on FSB
anu positive feeuback on
LB in anteiioi pituitaiy
leaus to LB suige on uays
11-1S.
Bominant follicle
secietion of estiauiol
leaus to positive feeuback
to anteiioi pituitaiy FSB
anu LB, ovulation will
occui within Su-S6his
aftei LB suige, small FSB
suige also occuis at time
of LB suige.
Naikeu by change fiom
estiauiol to piogesteione
pieuominance, coipus
luteal piogesteione acts
on hypothalamus, causing
negative feeuback on FSB
anu LB, iesulting in
uecieaseu basal levels
piioi to next cycle, if
feitilization anu
implantation uo not occui
theie will be a iapiu
ueciease in piogesteione.


5B/,'(<.+,-B/:
0ial contiaceptives that combine piogestin anu estiogen
Estiogen suppiesses FSB, which pievents selection anu matuiation of a uominant
follicle.
Piogestin woiks by suppiessing LB, which inhibits ovulation. It also thickens
ceivical mucosa, which fuithei pievents the ability of semen to pass into the
uteius.
Togethei, they inhibit piegnancy by thinning the enuometiial lining anu iesulting
in light oi misses menses.
Phasic vs. Nonophasic Pills:
Phasic pills vaiy the iatio of estiogen anu piogestin. This uecieases the uose of
hoimone given but it incieases the iisk of bieakthiough bleeuing
Nonophasic pills uelivei a constant uose of estiogen anu piogestin thioughout the
month
** Following cessation of 0CP's, feitilization usually iesumes immeuiately. A small
peicentage of useis will expeiience a peiiou of infeitility, known as "postpill amenoiihea"





11u
#2:(/,(1.0 (/2 6-0(2:(/,(1.0 B; ?5@80
#6M#L!#G7A 6>A#6M#L!#G7A
Reliable with failuie iate of <1%
Piotective against ovaiian anu
enuometiial cancei
Becieases inciuence of PIB anu
ectopic piegnancies
Nakes menses moie pieuictable
anu less painfullightei.
Nust be taken uaily close to the
same time
No STB piotection
0p to Su% bieakthiough bleeuing
Nay cause uepiession, weight
gain, hypeitension, acne, bloating,
anu weight gain

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

E#0 -+*#2 37#''"6";#,"&%'8
1. >/,.'*.2-(,. 0*.(': Atypical squamous cells of unueteimineu significance
(ASC0S)

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




111
IB'Q)+ B; (/ (N/B'*(D @(+

A,.+ -/ ,3. IB'Q)+ I3./ -0 ,3-0 0,.+
E(''(/,.2
L.V, A,.+ -/
*(/(1.*./,
".+.(,.2 @#@ #;,.' ;-'0, #A5$A ;-/2 ".+.(, .:.'9 fYq
*B/,30 )/,-D ,3.'. ('. R
<B/0.<),-:. /.1(,-:.
@(+ 0*.('0
O@M 6L# ,.0,-/1 #;,.' ;-'0, #A5$A -0
;B)/2
>; O@M aq B' ag
-2./,-;-.2 +.';B'*
<BD+B0<B+9
5BD+B0<B+9 (/2
.<,B<.':-<(D N-B+09
#N/B'*(D @(+ 0*.('
!EB #A5$A @(+ 0*.('0
5BD+B0<B+9C
#N/B'*(D D.0-B/0 0./,
;B' <9,BDB19
7/2B<.':-<(D <)'.,,(1.
\755^
#DD /B/Y+'.1/(/,
+(,-./,0 03BE-/1 (/
(N/B'*(D @(+ 0*.('0
LB/Y+'.1/(/, +,0
)/2.'1B-/1 <BD+B0<B+9
;B' (N/B'*(D @(+
'._)-'. 755 ,B ')D. B),
./2B<.':-<(D D.0-B/0
5B/. 4-B+09 I3./ @(+ 0*.(' -0
EB'0. ,3(/ N-B+09
0)11.0,.2C
I3./ 755 -0 (N/B'*(DC
I-,3 ./2B<.':-<(D
D.0-B/C
I3./ N-B+09 03BE0
*-<'B-/:(0-:.
<('<-/B*( B; <.':-V



%(/(1.*./, B; (N/B'*(D 3-0,BDB19
A,.+ -/ %(/(1.*./, 5B/2-,-B/ E(''(/,-/1
,3-0 0,.+
LB,.0J6.,(-D0
?N0.':. (/2 ;BDDBEY)+ 5>LaC 5>L R B' j (;,.'
.V<-0-B/ B' (ND(,-B/
KBDDBEY)+ ,.0,0 _fYq
*B/,30 ;B' R 9.('0
#ND(,-B/ 5>LR B' 5>Lj !3-0 -0F <'9B,3.'(+9C
D(0.' :(+B'-T(,-B/C
.D.<,'B;)D1)'(,-B/
7V<-0-B/(D +'B<.2)'.0 5>LR B' 5>Lj H77@ (/2 5BD2YQ/-;.
<BDB/-T(,-B/
O90,.'.<,B*9 ".<)''./, 5>LRJj

M(1-/-,-0
112
The most common piesenting symptom is uischaige
Always iule out chemical oi alleigic causes
Su% of cases aie uue to uaiuneiella
2S% uue to Tiichomonas
2S% uue to Canuiua
Biffeientiating between the uiffeient causes of vaginitis
5(/2-2( !'-<3B*B/(0 G('2/.'.DD(
M(1-/(D +O 4-S >6 >S
?2B' N0NE RANCIB "Fishy" on K0B
6-0<3('1. Cottage Cheese-
like
uieen, fiothy vaiiable
A-JAV Itching, buining,
swollen
Seveie itching vaiiable, none
%-<'B0<B+9 Pseuuohyphae Notile 0iganisms Clue cells
!'.(,*./, Fluconazole Netioniuazole Netioniuazole

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










11S
!'-<3B*B/(0 Z %B,-D. ?'1(/-0*0


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



7/2B*.,'-B0-0
Enuometiial tissue outsiue of the uteius, most commonly founu in the ovaiies.
Affects appioximately 1%-2% of women
Appioximately Su% of infeitile women have enuometiiosis
-"$%' [ -/+0,&+'8
The S B's ! Byspaieunia, Bysmenoiihea, Byschezia
Nay also have pelvic pain, infeitility, pain on iectovaginal exam.

!"#$%&'"':
visualization via lapaioscopy oi lapaiotomy with histological confiimation.
114
12*#,+*%,':
1. NSAIB's fiist
2. 0CP's
S. Testosteione (Banazol - AE: hiisutism, acne)
4. unRB analog (gives best iesult but causes menopausal symptoms within S-6
months)
Recuiience aftei cessation of meuical tieatment is common, uefinitive tieatment is
hysteiectomy.



















11S
".+'B2)<,-:. 7/2B<'-/BDB19

#*./B''3.(
Piimaiy ! woman has nevei menstiuateu
Seconuaiy ! menstiual ageu woman who has not menstiuateu in 6 months
Nost common cause of amenoiihea is piegnancy
Eveiy evaluation must by excluuing piegnancy (uiine #-hCu)
The most common cause of seconuaiy amenoiihea is Asheiman's synuiome
(scaiiing of the uteiine cavity aftei B&C)
Bypothalamic ueficiency is a cause of amenoiihea (excessive weight loss,
excessive exeicise, psychogenic, uiug use)
Pituitaiy uysfunction: fiom ! hypothalamic pulsatile ielease of unRB oi !
pituitaiy ielease of FSB oi LB
WG#2"#% ./'6=%;,"&%8
Follicles aie exhausteu of FSB anuoi LB 0R aie iesistant to stimulation
3#='*':
Inheiiteu uisoiueis such as Tuinei's synuiome
Piematuie menopause
Autoimmune ovaiian failuie
Chemotheiapies
Tieatment:
If hypothalamic ! tieat unueilying cause anu inuuce ovulation with
gonauotiopins
Tumois ! Biomociiptine to shiink tumoi anuoi excision
uenital tiact obstiuction ! suigeiy
0vaiian uysfunction ! Exogenous estiogen ieplacement

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




116


V=>$01,#,2)' :,*%+%: Stiess, Anxiety, Anoiexia, Anu Excessive Exeicise
8)0*)0,;= :,*%+%: Auenoma
5?,;),( :,*%+%< Eaily menopause, iesistant ovaiy synuiome
3(.$2+0;),# :,*%+%: Asheiman's synuiome
#N/B'*(D ND..2-/1 -/ ( '.+'B2)<,-:. (1. EB*(/
With the piesence of abnoimal bleeuing, fiist thing is to iule out "PAB:
117
P! piegnancy
A! anatomical abnoimalities
B! uysfunctional uteiine bleeuing

690;)/<,-B/(D $,.'-/. 4D..2-/1 \6$4^F
Anatomic menstiuation without anatomic lesions of the uteius
Is most commonly uue to chionic estiogen stimulation
Abnoimal bleeuing is uefineu as bleeuing at inteivals <21 uays oi >S6 uays, lasting
>7 uays, oi bloou volume loss >8uml
!"#$%&'"':
R0 anatomic causes (fibioius, ceivical oi vaginal lesions, infections, ceivical
anuoi enuometiial cancei)
Evaluate factois that can affect the hypothalamus-pituitaiy axis (stiess, excessive
exeicise, weight changes, systemic uisease, coagulopathies, piegnancies)
12*#,+*%,:
uive piogesteione fiom uay 14-2S of menstiual cycle
Biith contiol pills aie an alteinative

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









118
6-;;.'./,-(,-/1 <()0.0 B; O-'0),-0* (/2 M-'-D-T(,-B/
6-0.(0. 53('(<,.'-0,-<0 !'.(,*./,
@BD9<90,-< ?:('-(/
6-0.(0.
!3. ra <()0. B;
(/2'B1./ .V<.00 (/2
3-'0),-0*=

Relateu to LB
oveipiouuction.

SiSx: amenoiihea oi
oligomenoiihea,
infeitility, hiisutism, acne.

Anemia

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

Weight loss.

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

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

Labs: !LBFSB,
"""Testosteione.
Remove affecteu ovaiy
5B/1./-,(D #2'./(D
O9+.'+D(0-(
NC uue to 21-$
hyuioxylase uefect.

AR pattein.

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

" LBFSB, " BBEA (BBEA
helps ueteimine auienal
souice).
ulucocoiticoius can
suppiess auienal
anuiogen piouuction.



119
%./B+()0.
The cessation of menses occuis on aveiage at S1yi of age.
Cycles no longei associateu with pie-menstiual symptoms, no longei iegulai oi
pieuictable.
-"$%' #%. '/+0,&+'8
Acute onset of hot-flashessweating that cease acutely (within S-S minutes)
Noou uistuibances
Sleep uistuibances
vaginal uiyness (leaus to uyspaieunia)
0steopoiosis
!"#$%&'"':
Iiiegulai menstiual cycles aie most obvious foi uiagnosis
Piesence of hot flashes suggest menopause
" levels of FSB (>SumI0ml)
12*#,+*%,:
1
st
line tieatment is estiogen ieplacement theiapy (continuous estiogen with
cyclic piogestin to allow withuiawal bleeuing oi uaily aumin of both estiogen anu
piogestin, which wont cause wu bleeuing).
Raloxifene: a 2
nu
geneiation tamoxifen-like uiug (mixeu estiogen
agonistantagonist). Shown to pievent osteopoiosis, uecieases LBL, uecieases
iisk of bieast cancei.
Calcium supplementation is not a substitute foi estiogen ieplacement

>/;.',-D-,9
Befineu as 1yi of fiequent, unpiotecteu inteicouise without piegnancy.
6u% female cause, 4u% male cause
?&: ,& #002&#;5 "%6*2,"7",/8
a
0,
A,.+: Semen Analysis (volume, motility, # active speim)
If this is founu to be abnoimal, attempt Intiauteiine Insemination (I0I) oi
Intiacytoplastic Speim Injection (ICSI)
If semen analysis is noimal, consiuei female factois.

R
/2
A,.+: Test ceivical mucus to see if it softens (uone aiounu time of ovulation - known
as "spinnbaikeit".
V$/ 0$ 0+%0<
12u
Patient comes in aftei inteicouise
With help of speculum get enuoceivical mucus
Put mucus on a glass sliue anu covei with anothei sliue
Attempt to pull sliues apait (shoulu be able to sepaiate at least 6cm befoie mucus
bieaks - which inuicates soft anu favoiable mucus)
If sliue bieaks too eaily, mucus is "hostile"
Also want to check foi "mucus feining" on micioscopy

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

Next: If Speim is 0K anu Nucus is 0K..
j
'2
A,.+F Check 0vulation
Check basal bouy tempeiatuie (" 1ueg uue to piogesteione spike)
A sign of piegnancy is the lack of bouy tempeiatuie iising
Bo an enuometiial biopsy
Bay 22 is the highest uay of seium piogesteione
LB suige - theie aie stiips that can measuie LB, if + patient will ovulate within 24-
48his
If you finu a pioblem with ovulation, give feitility uiugs.

12*#,+*%,:
a
0,
! 5H?%>6 (fools the pituitaiy into secieting lots of FSB anu LB)
0R
R
/2
! @7"G#L?H (concentiateu amounts of FSB anu LB fiom uiine of menopausal
women).

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

If semen is noimal.
If mucus is noimal.
121
If ovulation is noimal.
L7c! A!7@: Look foi tubal factois (blockage uue to PIB) - histoiy of chionic pain, T0A,
ectopic piegnancy, infeitility
@.';B'*: Bysteio-Salpingogiam to help uiagnose a blockage
IF theie is a tubal pioblem, theie aie 2 choices:
1. Tuboplasty (cuts out the obstiuction)
2. In vitio Feitilization (uone in a lab, then put zygote into uteius)

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

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




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

122
GB/(2(D 6901./.0-0 \!)'/.'80 09/2'B*.^
Absence of seconuaiy sexual chaiacteiistics
Kaiyotype ieveals the absence of one of the X chiomosomes (4S, X).
Elevateu FSB
Lack of a seconu X chiomosome leaus to lack of ovaiian follicle uevelopment,
leauing to "stieak gonaus".
)#%#$*+*%,:
Estiogen anu piogesteione ieplacement to help uevelopment of seconuaiy sexual
chaiacteiistics.


















12S
$'B19/.<BDB19


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

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

Begiees of piolapse:
1
st
uegiee ! piolapse is above intioitus
2
nu
uegiee ! goes to the intioitus
S
iu
uegiee ! goes past intioitus

:=%0$'+#+:
Blauuei piolapse into the vagina uue to excessive pelvic ielaxation
Seveie cases can cause stiess incontinence
Q ,/0*' &6 "%;&%,"%*%;*8
1. Stiess Incontinence ! the most common type (causeu by pelvic flooi injuiies)
2. Neuiogenic Incontinence ! uigeoveiflow incontinence (causeu by ! inneivation
anu contiol of blauuei function, iesulting in involuntaiy blauuei contiaction
(uiges) oi blauuei atony (oveiflow).

124

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

12*#,+*%,':
Stiess Incontinence ! 1
st
- attempt kegel exeicises, 2
nu
- suigeiy (colpoiaphy)
Neuiogenic ! Anti-spasmotics, anti-cholineigics

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











12S
G9/.<BDB1-< ?/<BDB19

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

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

O"'9 6#;,&2'8
0nopposeu postmenopausal estiogen ieplacement theiapy
Nenopause aftei S2yi of age
0besity
Nullipaiity
PC0S
Biabetes
Chionic anovulation
-"$%' [ -/+0,&+'8
Abnoimal uteiine bleeuing, especially if woman is postmenopausal
All women >SSyi with abnoimal bleeuing iequiies an enuometiial sampling foi
histologic examination.
!"#$%&'"':
Pap smeai not ieliable
Bimanual exam foi masses, nouules, inuuiation, anu immobility
Enuometiial biopsy by enuoceivical cuiettage, B&C, hysteioscopy with uiiect
biopsies.
12*#,+*%,:
4& %)2>#+ $; '$2>#+Q 1=>+;>#,%), - give piogesteione to ieveise hypeiplastic
piocess piomoteu by estiogen (Pioveia foi 1u uays)
!0=>)',# 1=>+;>#,%), - hysteiectomy because of likelihoou that invasive
caicinoma will ensue
126
3(.$2+0;),# ',;')($2, ! Total abuominal hysteiectomy + bilateial salpingo-
oophoiectomy + lymph noue uissection, aujuvant exteinal-beam iauiation,
tieatment foi iecuiience is high-uose piogestin's.
E2&$%&'"':
Bistologic giaue is the most impoitant factoi in oveiall piognosis.
Bepth of myometiial invasion is 2
nu
most impoitant factoi in oveiall piognosis
u1 - highly uiffeientiateu
u2 - moueiately uiffeientiateu
uS - soliu oi completely unuiffeientiateu
u1 tumoi that uoesn't invaue the myometiium has a 9S% S-yi suivival
uS tumoi with ueep myometiial invasion has ~2u% S-yi suivival


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

-"$%' [ -/+0,&+'8
Nenoiihagia
Pelvic pain anu piessuie (misuiagnoseu as uysmenoiiheal)
Enlaigeu, fiim, asymmetiic, non-tenuei uteius
!"#$%&'"%$ C"42&".'8
0S initially, confiim with tissue sample by eithei B&C oi biopsy (especially in
postmenopausal women).
12*#,+*%,':
Nilu symptoms only iequiie ie-assuiance anu obseivation
Estiogen inhibitois such as unRB agonists can shiink the uteius, which help to
cieate a simplei suigical pioceuuie.
Suigeiy ! myomectomy iecommenueu in young patients who want to pieseive
feitility.
Bysteiectomy is uefinitive tieatment that shoulu be ieseiveu foi symptomatic
women who have no uesiie foi chiluien anuoi any moie chiluien.

127
#2./B*9B0-0
Abnoimal location of enuometiial glanus anu stioma within the myometiium of
the uteiine wall
When symptomatic is causes uysmenoiiheal anu menoiihagia.
0teius feels soft, globulai, tenuei, anu symmetiical.
0nlike leiomyomas, theie is no change with high oi low estiogen states.

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

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

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

O-0,BDB19 Is uefinitive uiagnosis Is uefinitive uiagnosis





H.-B*9B0('<B*(
A iaie cancei that accounts foi appioximately S% of uteiine canceis

-"$%' [ -/+0,&+'8
Saicoma ! postmenopausal bleeuing, pelvic pain, incieasing vaginal uischaige
128

12*#,+*%,:
Bysteiectomy with intiaopeitive LN biopsy
Suigical staging is an impoitant aspect
Aujunctive theiapies have minimal oveiall benefit
** 0nly Su% of patients suivive S yi


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


!"#$%&'"':
Ceivical Biopsy! most commonly is SCC
Next step ! metastatic woikup (pelvic exam, CXR, Iv pyelogiam, cystoscopy, anu
sigmoiuoscopy).
** Imaging stuuies not iequiieu (invasive ceivical cancei is the only gynecological cancei
that uoes not get stageu clinically).
)#%#$*+*%,:
Nanagement is simple hysteiectomy oi mouifieu iauical hysteiectomy + LN
uissection. Suivival <4u% at Syi.
Aujuvant theiapy such as iauiation anu chemo is given when any of the following
conuitions aie piesent: Nets to LN's, tumoi >4cm, + maigins, local iecuiience

?:('-(/ L.B+D(0*0
F*%"$% ;/','8
Functional giowth iesulting fiom failuie of noimal iuptuie of follicle
Benign tumois aie moie common than malignant tumois
Risk of malignancy incieases with age
129
-"$%' [ -/+0,&+'8
Pelvic painpiessuie
Acute anu seveie pain when cyst iuptuies
3&%6"2+ !"#$%&'"' ! With 0S
4./-1/ L.B+D(0*0
L.B+D(0* 53('(<,.'-0,-<0 !'.(,*./,
7+-,3.D-(D 5.DD Seious cystauenoma is the
most common type.
0sually benign
(malignancy iisk incieases
when bilateial).

0theis: mucinous,
enuometiioiu, Biennei
tumoi (all iaiely
malignant).

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

Almost nevei malignant.

Contains tissues fiom all S
geim layeis.

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

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

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

Seitoli-Leyuig makes
anuiogens (viiilization in
females)

Excision
1Su

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

Seious
cystauenocaicinoma is the
most common type (often
uevelops fiom a benign
piecuisoi).
Excision
ueim Cell Is the most common
ovaiian cancei in women
<2uyi.

Piouuces hCu oi AFP,
which aie useful as tumoi
maikeis.

Subtypes incluue:
uysgeiminomas anu
immatuie teiatomas.
1
st
- Rauiation
2
nu
- Chemotheiapy
>8u% S-yi suivival
Stiomal Cell uianulosa cells make
estiogen (enuometiiosis).

Seitoli-Leyuiu cell tumoi
makes anuiogens
Total hysteiectomy +
oophoiectomy.


1S1
M)D:(' (/2 M(1-/(D 5(/<.'0
F*#?,; 4(0;,+>)01+#),# X+$>#,%), KF4XL<
vIN 1 & 2 ! chaiacteiizeu by milumoueiate uysplasia, " iisk of piogiessing to auvanceu
stages anu then caicinoma.
vIN S = caicinoma in situ
-"$%' [ -/+0,&+'8
Piuiitis
Piesence of iaiseu lesions
Iiiitation
!"#$%&'"':
Biopsy iequiieu foi a uefinitive uiagnosis
!"66*2*%,"#7 ."#$%&'"'8
Nalignant melanoma anu Paget's uisease
12*#,+*%,:
Foi vIN 1 anu 2 ! local excision
Foi vIN S ! wiue excision

F*#?,; :,('+;<
9u% aie squamous cell canceis
Nost often this piesents in postmenopausal women
-"$%' [ -/+0,&+'8
Piuiitis (may piesent with oi without an ulceiative lesion)
12*#,+*%,:
Excision
** Syi suivival iate ianges fiom 7u%-9u% uepenuing on LN involvement.
** With the piesence of ueep pelvic noues, suivival iate uiops to 2u%




1S2
F,A)(,# ',;')($2, )( %)0* ,(. ',;')($2,<
7u% of patients with vaginal CIS have pievious genital tiact neoplasm
12*#,+*%,:
Rauiation
Suigeiy ieseiveu foi extensive uisease


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

!"#$%&'"%$8
0S ieveals homogenous intiauteiine echoes without a gestational sac oi fetal paits
(looks like a "snowstoim")
Nanagement:
uet a baseline quantitative #-hCu
uet a CXR to iule out lung NETS
B&C to evacuate the uteiine contents
Place the patient on 0CP's so that theie will be no confusion between a iising #-
hCu titei fiom iecuiient uisease anu noimal piegnancy
1SS

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

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












1S4

!3. 4'.(0,


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

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

>/,'(2)<,(D @(+-DDB*(
Piesents commonly with seious bloouy nipple uischaige
Nultiple nouules in youngei patients anu solitaiy giowth in peiimenopausal
patients
1SS
Theie is an incieaseu cancei iisk with multiple papillomas, but no incieaseu
cancei iisk with solitaiy pipillomas
6)<,(D 5('<-/B*( -/ A-,) \65>A^
0sually seen on mammogiaphy but not clinically palpable
Is a piemalignancy that will leau to invasive uuctal cancei
Bistology shows haphazaiu cells along papillae, puncheu-out aieas in uucts, with
cells infiltiating open spaces.
12*#,+*%,:
Nass excision ensuiing cleai maigins.
If maigins aie not cleai must excise again with wiuei maigins.
uive post-op iauiation to pievent iecuiiences.

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

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

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

1S6

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

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


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

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

M",5 ."';5#2$*8
Next step is a mammogiam to look foi unueilying masses anuoi calcifications
If mammogiaphy gives a uefinitive uiagnosis, excision of uuct is iecommenueu
Foi nipple uischaige, nevei base uiagnosis on cytology


1S7
%(0,(D1-(:
Is cyclical oi noncyclical bieast pain that isn't causeu by lumps
Tieat with uanazol (inuuces amenoiihea)

G9/.<B*(0,-(:
Enlaigement of the male bieast, both unilateial anu bilateial
No lobules
Is causeu by an imbalance in estiogens anu anuiogens, most often occuiiing
uuiing pubeity
Nay be seen in hypeiestiogen states (ciiihosis, uiugs inhibiting estiogen
bieakuown ! ET0B, maiijuana, heioin)


5(/<.' "-0Q0 B; 4'.(0, 5(/<.'0F
#1 iisk factoi is genuei (females make up 99% of bieast canceis)
In women, age is the #1 factoi
Nenaiche < 11yi is a iisk factoi foi bieast cancei
Women who aie nullipaious at >Suyi have an incieaseu iisk
9S% of bieast cancei is N0T familial
Baving a fiist uegiee ielative with a hx of bieast cancei incieases the iisk of bieast
cancei
Autosomal uominant conuitions that have incieaseu iisk, such as BRCA-1, BRCA-2
Piioi cancei in the opposite bieast
Cancei of the bieast occuis most commonly in the uppei anu outei quauiant of the
bieast.

M5#, ,& .& 6&2 ;*2,#"% 42*#', +#''*'X
S1+( 0$ .$ ,( *#0;,%$*(. K69L ! this is the fiist step when finuing a palpable mass that
feels cystic on physical exam.
S1+( 0$ .$ &)(+ (++.#+ ,%>);,0)$( KEX!L ! this is often the fiist step when finuing a
palpable mass, anu may be uone eithei aftei an 0S oi insteau of an 0S.
S1+( 0$ .$ +)01+; 2,22$A;,>1= K)& >0 [\U=;L ,(. -)$>%= K$; -)$>%= %$#+#= )& >0 )%
]\U=;L<
! If cyst iecuis moie than twice in 4-6 months
! If theie is bloouy fluiu on aspiiation
1S8
! If mass uoesn't appeai completely with a FNA
! Theie is bloouy nipple uischaige
! Theie is euema of the skin anu eiythema that suggests inflammatoiy bieast caicinoma
(excisional biopsy)
S1+( 0$ $;.+; &$; '=0$#$A= ! any aspiiate with gioss bloou must be senu foi cytology
S1+( 0$ $-%+;?+ ,(. ;+>+,0 ,( +Q,2 /)01)( ^D_ /++B% ! whenevei a cyst uisappeais
with aspiiation, anu the fluiu is cleai, anuoi when the neeule biopsy anu imaging stuuies
aie negative.
When shoulu aujuvant theiapy be incluueu in the management ! 0se aujuvant theiapy
in all hoimone ieceptoi (+) tumois iegaiuless of any othei factois.


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



!(*BV-;./:
Competitively binus to estiogen ieceptois
Piouuces a Su% ueciease in iecuiience anu a 2S% ueciease in moitality
Excellent foi both pie anu post-op patients


1S9
#'B*(,(0. >/3-N-,B'0F
Incluue uiugs such as: Anastiazole, Exemestane, anu Letiozole
These block the peiipheial piouuction of estiogen
These aie the stanuaiu of caie in hoimone ieceptoi (+) women who aie
menopausal (moie effective than tamoxifen)
Will inciease the iisk of osteopoiosis

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

"" iisk of cancei of the enuometiium

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

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





14u



Chapter 4

Pediatrics





141


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


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




142

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

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

0nilateial ieu
foimations on
heau anu neck
(unilateial anu
peimanent)
Poit Wine
Stain
Nay be
associateu with
Stuige-Webei
synuiome
Pulseu lasei
theiapy.
If Stuige-
Webei must
evaluate foi
glaucoma anu
give anti-
convulsives

Bluishgiay
macules on
lowei back
anuoi
posteiioi thigh
(most
commonly)
Nongolian
Spots
Rule out chilu
abuse, usually
faue within
fiist few yeais
of life

Fiim, yellow-
white
papulespustule
s with
eiythematous
base, peaks on
2
nu
uay of life
Eiythema
Toxicum
None None, is self-
limiteu

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

Befect in the iiis Coloboma of
the Iiis
Associateu
with othei
CBARuE
uefects
Scieen foi
CBARuE
synuiome
14S

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

A mass lateial to
the miuline
Bianchial Cleft
Cyst
Is a iemnant of
embiyonic
uevelopment
associateu with
infections
Suigical
iemoval

A miuline mass
that iises when
swallowing
Thyioglossal
Buct Cyst
Nay have
ectopic
thyioiu,
associateu with
infections
Suigical
iemoval

A piotiusion of
uI contents
thiough
umbilicus
containeu
within a sac
0mphalocele Associateu
with
chiomosomal
uisoiueis anu
othei
malfoimations
Scieen foi
tiisomies.

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


Rectus
abuominus
weakness that
allows bulging
of fetal anu
infant umbilical
coiu
Beinia
(umbilical)
Congenital
hypothyioiuis
m
This may
close
spontaneously
.

Scieen foi
hypothyioiu
with TSB
scieen.

Sciotal swelling
that can be
tiansilluminateu
Byuiocele Associateu
with an
inguinal heinia
Biffeientiate
fiom inguinal
heinia by
shining
flashlight

Absence of
teste(s) in
sciotum
Ciyptoichiuis
m
Associateu
with cancei of
the teste(s)
Suigical
iemoval by
1yi
144

0pening of the
uiethia on
uoisum of the
penis
Epispauias 0iinaiy
incontinence
Evaluate foi
blauuei
extiophy

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

Reuucible
sciotal swelling
Inguinal
Beinia
Suigical
coiiection













6.:.DB+*./,(D %-D.0,B/.0
Bevelopmental milestones show up ovei anu ovei again on the boaiu exams. By
memoiizing the impoitant milestones you aie going to get 2-S easy points on the CK
exam. Nilestones iefei to both infant anu auolescent (pubeity) milestones.
14S


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

2 months Bolus heau up Swipes at
objects
Coos Social smile
4 months Rolls fiont to
back
G'(0+0
?NW.<,0
0iients to
voice
Laughs
6 months Rolls fiom
back to fiont,
0-,0 )+'-13,
Tiansfeis
objects
Babbles 6.:.DB+0
0,'(/1.'
(/V-.,9C 0D..+0
(DD /-13,
9 months Ciawls, pulls
to a stanu
@-/<.' 1'(0+C
eats with
fingeis
LB/Y0+.<-;-<
EB'20
Waves gooubye,
iesponus to name
12 months A,(/20 B/
BE/
%(,)'.
+-/<.' 1'(0+
A+.<-;-<
EB'20
u*(*(v
Recognizes
pictuies in a
bookmagazine
1S months I(DQ0 0ses a cup Speaks 4-6
woius
!3'BE0 ,.*+.'
,(/,')*
18 months Thiows a ball,
walks up the
staiis
0ses spoon foi
soliu foous
Names
common
objects
4.1-/0 ,B-D.,
,'(-/-/1
24 months Staits iunning,
can go up anu
uown staiis
0ses spoon foi
semi-solius
A+.(Q0 RY
EB'2
0./,./<.
Can follow a 2-
step commanu
S6 months Can iiue a
tiicycle
Can eat neatly
with utensils
A+.(Q0 jY
EB'2
0./,./<.
Knows fiist anu
last names



E=4*2,/:
The milestones of pubeity aie as follows anu aie baseu on population aveiages:
%#H7A K7%#H7A
Testiculai enlaigement - 11.S yis Bieast buus - 1u.S yis
uenitals inciease in size Pubic Baii uiowth Begins
Pubic Baii uiowth Begins Lineai uiowth Spuit - 12 yis
Peak uiowth Spuit - 1S.S yis Nenaiche - 12.S yis
146



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

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

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

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

M&29=0 6&2 '='0*;,*. ;5"7. #4='*8
147
PTPTTBT
Full skeletal suivey foi bieaks
If injuiies aie seveie, get a CT oi NRI + a thoiough eye exam
If injuiy is to the abuomen, get an abuominal CT, check foi bloou in the stool anu
uiine, anu check livei anu pancieatic enzymes

12*#,+*%,:
1
st
- Auuiess meuical anuoi suigical issues befoie all else
2
nu
- Repoit abuse to chilu piotective seivices (CPS)


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


O-13Y9-.D2 G'BE,3 d 6.:.DB+*./, K(<,0
The height of a chilu at 2 yeais of age noimally coiielates with the final auult
height peicentile.
148
By 6 months of age the biith weight shoulu uouble, anu by 1 yeai the biith weight
shoulu tiiple.
The absolute best inuicatoi foi malnutiition is a chilu who is <S
th
peicentile foi
height anu weight.
Skeletal anu sexual matuiity aie ielateu moie than it is ielateu to chionological
age.
The NCC of failuie to thiive (FTT) in all age gioups is psychosocial uepiivation.
In patients with genetic shoit statuie oi constitutional uelay, biith weight is
noimal.
Patients with both genetic shoit statuie anu constitutional uelay have a giowth
pattein that is below anu paiallel to the noimal giowth cuive.


>/;.<,-B)0 6-0.(0.0 Z !3. !B"5OA
In geneial, all will have: jaunuice, I0uR, mental ietaiuation, anu hepatosplenomegaly.
Look foi things that stanu out with each infection
Bisease Chaiacteiistics
Toxoplasmosis Acquiieu by mothei thiough pooily ingesteu meat
Acquiieu when mothei hanules cat feces thiough littei
box
1S of motheis tiansmit anu 1S of infants aie affecteu
Causes: -/,'(<.'.N'(D <(D<-;-<(,-B/0, I0uR, seveie
mental ietaiuation, 392'B<.+3(D)0, choiioietinitis,
epilepsy, hepatosplenomegaly
If infecteu ! uo ultiasounu to finu any majoi anomalies
Rubella When acquiieu in 1
st
tiimestei theie is an 8u% chance of
tiansmission
When acquiieu in 2
nu
tiimestei theie is a Su% chance of
tiansmission
When acquiieu in S
iu
tiimestei theie is a S% chance of
tiansmission
Signs & Symptoms - <(,('(<,0, I0uR, bluebeiiy muffin
iash, glaucoma, choiioietinitis, PBA, pulmonaiy
stenosis, #A6C MA6C *9B<('2-,-0, heaiing loss, mental
ietaiuation, 2.(;/.00
Biagnosis - confiim with >1% iubella antibouy in
neonate's seium.
Tieat - goal is univeisal pievention by immunizing all
chiluien, theie's no theiapy foi active infection
Cytomegaloviius
(CNv)
Affects 1% of all biiths anu is the most common
congenital infection
Infection is often asymptomatic
Appiox 1% iisk of tiansplacental tiansmission, anu
149
appiox 1u% of infecteu infants manifest uefects
Congenital uefects - miciochephaly, +.'-:./,'-<)D('
-/,'(<'(/-(D <(D<-;-<(,-B/0, I0Ru, choiioietinitis, seveie
mental ietaiuation, 0./0B'-/.)'(D 3.('-/1 DB00
Tiansmission is thiough bouy fluius
6-(1/B0. E-,3 )'-/. 5%M <)D,)'.
Beipes Simplex
viius
vaginal ueliveiy uuiing active infection = appiox Su%
get infecteu
C-section is iequiieu if active infection
a
0,
E..Q Z +/.)*B/-( (/2 03B<Q
R
/2
E..Q Z 0Q-/ :.0-<D.0C Q.'(,B<B/W)/<,-:-,-0
I..Q jYf Z (<),. *./-/1B./<.+3(D-,-0
Tieat - acyclovii ! significantly uecieases moitality
Syphilis Theie is almost a 1uu% tiansmission iate, occuis mostly
aftei 1
st
tiimestei
4u% ueath iate (fetal anu peiinatal)
Nanifests eaily (fiist 2 yeais), then late (within next 2
uecaues)
SignsSymptoms of eaily infection - jaunuice, incieaseu
LFTs, hemolytic anemia, iash that is followeu by
2.0_)(*(,-B/ B; ,3. 3(/20 (/2 ;..,, 0/);;D.0 (bloou-
tingeu nasal secietions), B0,.B<3B/2'-,-0, sattle nose.
Late symptoms - Butchinson teeth (uppei 2 incisois get
notcheu), mulbeiiy molais, bone thickening (fiontal
bossing), sabei shins (anteiioi bowing of tibia)
4.0, -/-,-(D ,.0, Z M6"H 0<'../-/1
%B0, 0+.<-;-< ,.0, Z >1%YK!#Y#4A
Tieat - Penicillin u foi 1u-14 uays



>/;(/, 4B,)D-0*
An acute anu flacciu paialysis causeu by C. Botulinum.
Iiieveisible blocks ielease of Ach
Causeu by the ingestion of iaw honey
-"$%'V-/+0,&+'8
Constipation
Lethaigy
Weak ciy
Pooi feeuing
Bypotonia
Biooling
1Su
! suck ieflexes
! spontaneous movements
!"#$%&'"': Baseu on PE anu the acute onset of flacciu paialysis
12*#,+*%,: Suppoitive caie + intubation

5B**B/ M-'(D 7V(/,3.*0
6-0.(0. A-1/0 (/2 A9*+,B*0
Neasles (Rubeola)
Paiamyxoviius
Begins at haiiline then moves uownwaiu, is an
eiythematous maculopapulai iash that eiupts S
uays aftei piouiome.
Pathognomonic "Koplik spots" often uisappeai
befoie iash staits (white spots on buccal mucosa)
Biagnosis - cough, coiyza, conjunctivitis (SC's)
Rubella (ueiman
measles) Togaviius
Suboccipital lymphauenopathy*
A maculopapulai iash staits on the face then
geneializes
Rash lasts appioximately S uays
Soft palate may show ieu spots of vaiious sizes
Banu, foot, & mouth
uisease (Coxsackie A)
Patient has vesiculai iash on the hanus anu feet +
ulceiations in the mouth
Rash lasts appioximately 1 week
Is contagious by contact
Roseola Infantum
(BBv-6)
Acute fevei lasts 1-S uays, but chilu shows no
physical symptoms anu uoes not feel ill
0nce fevei uiops, a maculopapulai iash appeais
ovei the whole bouy (lasts 24his)
Eiythema Infectiosum
(S
th
uisease - Paivo
B19)
"Slappeu cheek" synuiome
An eiythematous maculopapulai iash spieaus
fiom the aims to the tiunklegs, foims "ieticulai"
pattein
Bangeious if pt has sickle cell uisease uue to
tenuency to foim aplastic ciisis
vaiicella (chicken pox) Bighly contagious, teaiuiop vesicles that bieak anu
ciust ovei.
Staits on face anu tiunk then spieaus
Contagious until ciusting ovei




1S1






M(<<-/(,-B/0
This uiagiam is the typical vaccination iecommenuation foi chiluien fiom u-6yi olu










1S2





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

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

Symptoms
woisen at
night
Nothing
neeueu foi
uiagnosis but
a neck-x-iay
shoulu be hau
1. Bumiuifieu u2
2. Nebulizeu epi
+ steioius

Spontaneously
iesolves
within 1 wk.

Always be
waiy of the
possibility of
epiglottis
Epiglottitis
(Bib, S.
pyogenes, s.
pneumo, anu
mycoplasma)
Acute onset of
muffleu voice,
uiooling, high
fevei,
uysphagia,
anu
inspiiatoiy
stiiuoi.

Patient will
lean foiwaiu
to ease
bieathing
%.2-<(D
7*.'1./<9

Ngmt baseu
on clinical ux,
stabilize fiist
then uo
woikup:

Woikup:
Neck xiay
looking foi
thumbpiint
sign.

Bloou
cultuies

Epiglottic
swab cultuie

1. Aumit to
hospital
2. Anesthesia
anu ENT
consult
S. Intubation
4. Ceftiiaxone +
steioius
S. Bouseholu
contacts
shoulu get
Rifampin if
patient is
B.Influenza
+ve
Without
piompt
tieatment
aiiway
obstiuction
can leau to
ueath
Bacteiial
Tiacheitis (S.
Chilu usually
<Syi, aftei a
Bx is clinical
but also uo a
Antistaph Ab's, if
seveie intubate
Aiiway
obstiuction is
1SS
Auieus) viial 0RI gets
cough that
sounus
"Biassy", has
high fevei,
iespiiatoiy
uistiess B0T
no signs oi
symptoms of
seveiity of
epiglottitis
laiyngoscopy
anu CXR

CXR looking
foi sub-glottic
naiiowing

Bloou cult +
thioat cult.
a life-thieat
complication


?,-,-0 %.2-(
Common in chiluien anu often piecipitateu by an 0RI
Conuitions that uisiupt piopei Eustachian tube uiainage leau to chionic 0N
NCC aie: stiep pneumonia, B. Infl, Noiaxella, oi viial causes
-"$%' #%. -/+0,&+'8
Eiythema anu ! motility of tympanic membiane
! heaiing
Eai piessuie
Bulging tympanic membiane with visualization of fluiu behinu TN
12*#,+*%,8
P
',
7"%* ! Amoxicillin
Q
%.
7"%* ! Amoxicillin + Clavulinic Aciu (augmentin)
** Foi iecuiiing 0N, ENT consult anu tubes may neeu to be inseiteu

4'B/<3-BD-,-0
Classically piesents as chilu <2yi with the following:
Nilu 0RI
Fevei
Paioxysmal wheezing cough
Tachypnea
Byspnea
Wheezing anu piolongeu expiiations
3&++&% ;#='*' #2*8
1S4
RSv (in up to Su%)
Paiainfluenza viius
Auenoviius

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

!"#$%&'"':
Bx is clinically baseu.
Best initial test ! CXR looking foi hypeiinflation + patchy atelectasis
Nost specific test ! Immunofluoiescence of nasophaiyngeal swab

12*#,+*%,:
Nostly suppoitive
If tachypnea is seveie hospitalize anu give tiial of nebulizeu #-agonists


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

F);,#:
Tachypnea is the most consistent finuing in viial pneumonia
0RI symptoms
Low giaue fevei

J,'0+;),#:
Acute onset with suuuen shaking chills
1SS
Bigh giaue fevei
Cough
Chest pain (pleuiitis- pain with iespiiation)
Biminisheu bieath sounus
Bullness to peicussion of the lung fielus

:1#,2=.),#:
Nost common finuing aie a "staccato cough" anu "peiipheial eosinophilia"
No fevei oi wheezing
Nay be conjunctivitis

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

12*#,+*%,:
Nilu cases can be manageu on an outpatient basis, Amoxicillin is the best choice.
Augmenting may also be useu
Seveie cases iequiie hospitalization anu aie tieateu with Iv ceftiiaxone
If pneumonia is of viial oiigin, witholu Ab's unless patient ueteiioiates.
Chlamyuia oi Nycoplasma tieateu with eiythiomycin






1S6

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

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

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

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

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

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

0sually no tenueiness,
waimth, oi swelling

Rest + analgesia foi S-S
uays
1S7
`;,= is noimal

R),A($%+: technetium
scan that shows "
epiphyseal uptake
#0.+,-< M(0<)D('
L.<'B0-0
H.11Y5(D:.Y@.',3.0 2V
Beau of femui
4-9yi olu
Boys Sx moie than
giils

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

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

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

RQ: technetium scan
shows ! uptake in
epiphysis
! weight beaiing on
affecteu siue ovei long
teim
AD-++.2 5(+-,(D K.*B'(D
7+-+390-0 \A5K7^
NC in obese males
8-17yi
2u%-Su% bilateial
8u% occui slowly
anu piogiessively
wheie 2u% occui
acutely anu
associateu with
tiauma

9)Y9Q: uull, aching pain in
Suigical pinning
1S8
hipknee, pain with
activity

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

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

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

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










1S9

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

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

16u

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

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

3&+07";#,"&%':
1u%-4u% of untieateu cases show uilationaneuiysm of the coionaiy aiteiies

12*#,+*%,:
IvIu to pievent coionaiy vasculitis + high-uose aspiiin
Bo not give steioius as this will exaceibate the conuition

E2&$%&'"':
With iesponse to IvIu + aspiiin is iapiu anu 2S become afebiile within 1 uay.
Always ie-evaluate in 1 week, iepeat ECB0 at S-6wk post illness
If no fuithei abn on ECB0 then no fuithei imaging is necessaiy


161

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


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

12*#,+*%,:
Self-limiteu anu iaiely piogiesses to glomeiulonephiitis


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

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

162



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

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

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

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
















16S


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

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












164

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

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

81=%)$#$A)' P,*(.)'+<
Clinically benign conuition that occuis between 24-48hi aftei biith
Chaiacteiizeu by unconjugateu hypeibiliiubinemia
Cause is incieaseu biliiubin piouuction + a ielative ueficiency in glucuionyl
tiansfeiase in the immatuie livei
12*#,+*%,:
None iequiieu

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

M&29=0 6&2 0#,5&7&$"; ]#=%.";*8
Total anu uiiect biliiubin
Biiect Coomb's test
Bloou type of infant anu mothei (AB0 oi Rh incompatibility)
16S
CBC, ietic #, peiipheial smeai (assessing foi hemolysis)
0A anu uiine cultuie (if elevateu is uiiect biliiubin - assess foi sepsis)
>6 02&7&%$*. ^Q :**9'< .& ,5* 6&77&:"%$8
If " conjugateu biliiubin
Initial uiagnostic tests ! LFT's
Nost specific test ! 0S anu livei biopsy
If no elevation of unconjugateu biliiubin
0TI oi othei type of infection
Biliiubin conjugation abnoimalities (uilbeits, Ciiglei-Najjai)
Bemolysis
Intiinsic ieu cell membiane uefect oi enzyme uefect (spheiocytosis, elliptocytosis,
u6PB uef, pyiuvate kinase ueficiency)
12*#,+*%,:
When biliiubin is >1u-12 mguL ! phototheiapy
Exchange tiansfusion if encephalopathy is suspecteu oi theie is failuie of
impiovement with phototheiapy


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


:$(P*A,0+. V=>+;-)#);*-)(+2),
Infectious causes aie ! sepsis, ToRCB's, hepatitis, syphilis, listeiia infection
Netabolic causes aie ! galactosemia, $1-antitiypsin uef
Congenital causes aie ! extiahepatic biliaiy atiesia, Bubin-}ohnson synuiome,
Rotoi synuiome
12*#,+*%,:
166
0v light to bieak uown biliiubin pigments
0igent tieatment is impeiative in oiuei to pievent keinicteius inuuceu mental
ietaiuation
3&+07";#,"&%':
0v light can cause uiaiihea, ueimatitis, uehyuiation, anu uamage to the ietina (be
cautious of these auveise effects)


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

-"$%' #%. -/+0,&+'8
Alteinates an asymptomatic inteival with abiupt onset of vomiting, ueliiium,
stupoi, abnoimal LFT's
Rapiu piogiession to seizuies, coma, anu ueath
!"#$%&'"':
Significantly elevateu livei enzymes
12*#,+*%,:
0igent ICP management with mannitol anu fluiu iestiiction
ulucose auministiation uue to iapiu uepletion of stoies
E2&$%&'"'8
Bau if seium ammonia levels aie incieaseu Sfolu, anu if theie is a uecieaseu PT
level that W0NT iesponu to vitamin K
If uisease is milu the iecoveiy is usually goou anu iapiu
A seveie uisease can iesult in peimanent neuio uefects



A.-T)'.0
In the newboin, seizuies may piesent as jitteis with iepetitive sucking
movements, tongue thiusting, anu apneic spells.
167
Bloou counts anu chemistiies aie often WNL
Neonatal seizuies can be uiagnoseu by the piesence of oculai ueviation anu failuie
of jitteis to subsiue with stimulus
!"#$%&'"':
EEu - often noimal
CBC + chemistiy panel ! often the cause is hypoglycemia in case of uBN
Amino aciu assay looking foi inboin eiiois of metabolism
Total coiu bloou IgN to look foi ToRCB infections
0iine cultuies
LP if suspecteu meningitis
0S of heau if infant is pieteim ! looking foi bleeuing
12*#,+*%,:
1
st
line B0C is Phenobaibital
Peisistent seizuie not iesponsive to Phenobaibital - give Phenytoin


E+-;)#+ 9+)b*;+%
0sually between Smnt - Syi
A fevei is piesent with no othei signs of infection
Is the NC convulsive uisoiuei in chiluien anu iaiely uevelops into epilepsy
Seizuie occuis uuiing tempeiatuie iise (% 1u2F) but not at its peak
-"$%' #%. -/+0,&+'8
NC is a tonic-clonic seizuie that iaiely last moie than 1umin + a uiowsy postictal
peiiou is common
Seizuie lasting >1Smin is usually uue to an infectious piocess
!"#$%&'"':
Clinical uiagnosis is usually all that is neeueu
Routine labs only iequiieu to iuentify a souice of the fevei
LP to iule out meningitis (only if suspecteu)
12*#,+*%,:
Contiol fevei with antipyietics
Reassuie paientscounsel
Always uo a caieful evaluation foi the souice of the fevei
** Su%-Su% of chiluien expeiience iecuiient febiile seizuies

168
G./.,-< (/2 5B/1./-,(D 6-0B'2.'0

E,)#*;+ 0$ 71;)?+
Is the failuie of chiluien to giow anu uevelop at an appiopiiate iate
Nay be uue to inauequate caloiies oi inability to absoib the caloiies
Nay be iuiopathic oi uue to othei uiseases
Factois such as 0&G*2,/, 6#+"7/ 02&47*+', %*&%#,#7 02&47*+', anu +#,*2%#7
.*02*''"&n shoulu all be incluueu in uiagnosis
!"#$%&'"':
Requiies S ciiteiia foi a FTT uiagnosis:
1. Chilu <2yi with weight <S
th
peicentile foi age on >1 occasion
2. Chilu <2yi whose weight is <8u% of iueal foi age
S. Chilu <2yi whose weight ciosses 2 majoi peicentiles uownwaiu on a stanuaiuizeu
giowth chait
IK;*0,"&%':
uenetically shoit statuie
Small foi gestational age chiluien
Pieteim infants
veiy lean (be caieful heie)
" height with a !weight gain (causes an oveiweight chilu - caieful attention foi
this uiagnosis)
12*#,+*%,:
0iganic causes ! tieat unueilying conuition + supplement with sufficient caloiies
Iuiopathic causes ! euucate paient on nutiition anu obseive paient while feeuing
0luei infantschiluien ! offei solius befoie liquius, ! mealtime uistiactions, have chilu
eat with otheis, nevei foice-feeu
** Nonitoi closely foi weight gain with auequate caloiie consumption

E2&$%&'"':
In the 1
st
yeai of life the px is pooi since the biain uevelops eaily in life
1S of chiluien with nonoiganic failuie to thiive aie uevelopmentally uelayeu

:;,()$&,'),# !-($;2,#)0)+%
169
The miluest foim of cianiofacial abnoimality is the "bifiu uvula", anu has no
clinical significance

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

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

)#;2&$7&''"#:
Is a congenitally enlaigeu tongue
Seen in conuitions such as Bown's synuiome, hypothyioiuism, anu gigantism
Can be acquiieu latei in life via aciomegaly anuoi amyloiuosis
Is N0T glossitis, which is fiom a B-vitamin ueficiency
Tieatment is aimeu at tieating the unueilying cause








17u
!;($#.D:1),;) @,#&$;2,0)$(
A congenital uisoiuei wheie the ceiebellum is cauually uisplaceu, the meuulla is
elongateu anu passes into the foiamen magnum.

-"$%' #%. -/+0,&+'8
Flatteneu skull base
Byuiocephalus
Aqueuuct stenosis
E2&$%&'"':
Beath usually as neonate of touulei

X+*;,# 7*-+ R+&+'0%
Associateu with incieaseu $-fetopiotein in the mateinal seium
vERY PREvENTABLE with F0LATE supplementation
-"$%' #%. -/+0,&+':
Spina bifiua (failuie of posteiioi veitebial aiches to close)
Neningocele (lack of veitebiae coveiing the lumbai spinal coiu)
12*#,+*%,:
Pievention is key (folic aciu supplementation)
Neuio ueficits iemain






171
E+0,# !#'$1$# 9=(.;$2+
In chiluien boin to alcoholic motheis, oi motheis who consumeu excessive alcohol
uuiing piegnancy
-"$%' #%. '/+0,&+'8
Chaiacteiistic facial abnoimalities anu uevelopmental uelays
ASB
Niciocephaly
Smooth filtium of uppei lip
12*#,+*%,:
Cessation of ET0B consumption when piegnant

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


:$(A+()0,# V+,;0 R)%+,%+%
!9R8
0ften asymptomatic anu founu on ioutine physicals
Can pieuispose to CBF in the 2
nu
anu S
iu
uecaues of life
Nay also pieuispose to stiokes (uue to an embolus bypass tiact)
-"$%' #%. -/+0,&+'8
Niusystolic ejection muimui
Louu S1
Wiue fixeu-split S2
!"#$%&'"':
172
Echocaiuiogiaphy
12*#,+*%,:
Suigical patching
Tieatment is moie impoitant foi females because they have an inciease in
caiuiovasculai stiess uuiing piegnancy


F+(0;)'*#,; 9+>0,# R+&+'0 KF9RL
Is the NC congenital heait uefect
Su% of these vSB's close spontaneously by 2yi of age
-"$%' #%. -/+0,&+'8
Small uefects may be asymptomatic
Laige uefects can cause CBF
Can cause uelayeuuecieaseu uevelopment anu giowth
Bolosystolic muimui heaiu ovei the entiie piecoiuium anu maximally at the 4
th

left inteicostal space
I"'*%+*%$*2N' 3&+07*K8
A iight to left shunt seconuaiy to pulmonaiy hypeitension
Rv hypeitiophy causes a flow ieveisal thiough the shunt, iesulting in a R! L
shunt
uet cyanosis seconuaiy to lack of bloou flow to the lungs
!"#$%&'"':
Echocaiuiogiaphy
12*#,+*%,:
Simple uefects iequiie complete closuie







17S
7+0;,#$A= $& E,##$0
Foui uefects make up this tetialogy, they aie:
1. vSB
2. Pulmonaiy outflow obstiuction
S. Rv hypeitiophy
4. 0veiiiuing aoita
-"$%' #%. -/+0,&+'8
Cyanosis uevelops within fiist 6 months of life (not piesent at biith)
"Tet Spells" aie acute cyanosis accompanieu by panic, wheie chilu goes into a
squatting position because it helps impiove bloou flow to the lungs
!"#$%&'"':
Echo
CXR shows "boot-shapeu" contoui of the heait uue to Rv enlaigement
12*#,+*%,:
Suigical iepaii of vSB anu pulmonaiy outflow tiacts


7;,(%>$%)0)$( $& 01+ N;+,0 !;0+;)+%
Aoita comes off the iight ventiicle
Pulmonaiy aiteiy comes off left ventiicle
Without a peisistent Av communication this conuition is incompatible with life.
Thus iequiies a PBA oi peisistent foiamen ovale.
-"$%' #%. -/+0,&+'8
Naikeu cyanosis at biith
Eaily clubbing of the uigits
CXR shows an enlaigeu egg-shapeu heait anu an inciease in pulmonaiy
vasculatuie
!"#$%&'"':
Echo
12*#,+*%,:
Suigical switching of the aiteiial ioots to noimal positions with iepaii of
communication uefect
E2&$%&'"':
174
Without tieatment is fatal within seveial months of biith




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

-"$%' #%. -/+0,&+'8
Noimal BP in aims with uecieaseu BP in legs
Continuous muimui ovei collateial vessels in the back
The classic XRAY shows "iib notching"
!"#$%&'"':
Confiim with CT oi aoitogiam
12*#,+*%,:
Suigical iesection of coaictation anu ieanastomosis

8,0+(0 R*'0*% !;0+;)$%*% K8R!L
" inciuence with piematuie biiths
Pt pieuisposeu to enuocaiuitis anu PvB's
-"$%' #%. -/+0,&+'8
Continuous machineiy muimui that's best heaiu at 2
nu
left inteispace
Wiue pulse piessuie
Bypoxia
!"#$%&'"':
Echo oi caiuiac catheteiization
12*#,+*%,:
Inuomethacin inuuces closuie (blocks piostaglanuins) foi chiluien
0luei chiluien usually iequiie suigical iepaii

17S

G./.,-< #/B*(D-.0
5B/2-,-B/ 5D(00-< K.(,)'.0 IB'Q)+J#00B<-(,-B/0
Bown's Synuiome (tiisomy
21)

Incieaseu iisk when
mateinal age is >SSyi
Epicanthal folus
Slanteu palpebial
fissuies
Speckling of iiis
Late fontanel closuie
Nental ietaiuation
Beaiing exam
ECB0: vSB, ASB, PBS
uI: TEF, uuouenal
atiesia
TSB foi
hypothyioiuism
ALL, uecieaseu iisk
with incieasing age
Euwaius synuiome (tiisomy
18)
Low-set, malfoimeu
eais
Niciocephaly
Niciognathia
Clencheu hanu
Rockei-bottom feet
0mphalocele
ECB0: vSB, ASB, PBS
Renal 0S: polycystic
kiuneys, ectopic oi
uouble uietei
Nost pts uon't
suivive 1
st
yi
Patau Synuiome (tiisomy
1S)
Niuface uefects
Eye uefect
Befective foiebiain
uevelopment
Niciocephaly
Niciophthalmia
Cleft lip anu palate
ECB0: vSB, PBA,
ASB
Renal 0S: polycystic
kiuneys
Single umbilical
aiteiy
WAuR synuiome 1. Wilm's
2. Aniiiuia
S. u0 anomalies
4. Retaiuation (mental)
The piesence of
aniiiuia shoulu aleit
foi the woikup foi
WAuR
Klinefeltei (XXY)
1Suu males
Low IQ
uynecomastia
Behavioial pioblems
Longslim limbs
Testosteione levels:
hypogonauism anu
hypogenitalism
Testosteione
ieplacement at 11-
12 yi of age
Tuinei's synuiome (Xu)
A spoiauic conuition with no
mateinal age association
Small-statuieu
female
Low IQ
uonaual uysgenesis
Webbeu neck
Bioau chest
Wiue-spaceu nipples
Renal 0S: hoiseshoe
kiuney, uouble ienal
pelvis
Caiuiac: bicuspiu
aoitic valve,
coaictation of the
aoita
Thyioiu function:
piimaiy
hypothyioiuism
Supplement with
estiogen, uB, anu
anabolic steioius

176
Fiagile X Synuiome
Niciocephaly in
eaily chiluhoou
Laige eais
Laige testes
Is the NCC of mental
ietaiuation in boys

Ass'u with ABBB
Beckwith-Wieuemann
synuiome
Nulti-oigan
enlaigement
Naciosomia
Nacioglossia
Pancieatic beta cell
hypeiplasia
Laige kiuneys
Neonatal
polycythemia
Incieaseu iisk of abu
tumois
0S anu seium AFP q
6mnth up until 6yi of
age - looking foi
Wilm's tumoi
Piauei-Willi
(ueletion at 1Sq11q1S -
pateinally ueiiveu)
0besity
Bypeiphagia
Small genitalia
Nental ietaiuation
Noibiu obesity
uecieases life-span
Angelman synuiome (aka
"happy puppet" synuiome).
(ueletion at 1Sq11q1S
mateinally ueiiveu)
Nental ietaiuation
Inappiopiiate
laughtei
Absence of speech
Ataxiajeiky aim
movements
Recuiient seizuies
Epilepsy uevelops in
8u%
Pieiie-Robin
(ass'u with FAS anu
Euwaius)
Nanuibulai
hypoplasia
Cleft palate
Aiiway obstiuction
possible ovei fiist 4
wks of life, thus
monitoi aiiway









177
!'()*( (/2 >/,BV-<(,-B/

@B-0B/-/10
A-1/0JA9*+,B*0 @B00-ND. !BV-/0
Lethaigy & Coma ET0B, seuatives, naicotics, antihistamines,
neuioleptics, anti-uepiessants
Seizuies Theophylline, cocaine, amphetamines, anti-
uepiessants, antisphychotics, pesticiues
Bypotension 0iganophosphate pesticiues, #-blockeis
Aiihythmia TCA's, cocaine, uigitalis, quiniuine
Bypeitheimia Salicylates, anticholineigics

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


















178
#2BD.0<./<.

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









179

Chapter 5

Biostats









18u
Success in answeiing the biostatistics questions comes fiom not only memoiizing the
following chaits, but actually unueistanuing them. If you can giasp what is happening
you will not have any issues in this section.



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

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

5..% M,0)$ ! |(a X u) (b X c)j
181
Compaies the inciuence of uisease in people exposeu X inciuence of non-uisease in people
not exposeu, uiviueu by the inciuence of people unexposeu anu inciuence of non-uisease
in those exposeu.
0R >1 = the factoi being stuuieu is a iisk factoi foi the outcome
0R < 1 = the factoi being stuuieu is a piotective factoi in iespect to the outcome
0R = 1 = no significant uiffeience in outcome in eithei exposeu oi unexposeu gioup
M+#,0)?+ M)%B ! |a(a+b) c(c+u)j
Compaies uisease iisk in people exposeu to a ceitain factoi with uisease iisk in people
who have not been exposeu
!00;)-*0,-#+ M)%B ! |a(a+b) - c(c+u)j
The attiibutable iisk is the # of cases attiibutable to one iisk factoi

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


NEAN - the aveiage value
NEBIAN - the miuule value
N0BE - the most common value

182
+vE SKEW
A +ve skeweu giaph means the 2+,([2+.),([2$.+

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




N0 BISEASE BISEASE
18S
This chait iepiesents sensitivity & specificity
If the cutoff point foi a uisease is moveu fiom false (+) ! false (-), theie will be an
" in the # of positive iesults. Thus an " in sensitivity (TP", FP", FN!, PPv!j
If the cutoff point is iaiseu fiom the false (-) ! false (+), this will " specificity
|TN", FP"j


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

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


184




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


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







18S
A,)29 !9+.0
:,%+D:$(0;$#Y3Q>+;)2+(0,# ! Is the golu stanuaiu, compaies 2 equal gioups wheie one
has a changeu vaiiable
8;$%>+'0)?+ ! Also known as: 3&5&2,< W4'*2G#,"&%#7< >%;".*%;*. Takes a sample anu
uiviues it into 2 gioups baseu on piesence oi absence of iisk factoi, anu follows ovei time
to see what uevelops. ** These aie time consuming anu expensive.
M+0;$%>+'0)?+ ! Chooses a population (aftei the fact) baseu on the piesence oi absence
of a iisk factoi. ** Costs less, less time consuming, bettei foi iaie uiseases.
:,%+ 9+;)+% ! uesciibes the clinical piesentation of people with a ceitain uisease
:;$%%D9+'0)$(,#Y8;+?,#+('+! This stuuy looks at the pievalence of uisease anu the
pievalence of iisk factois. Takes sample fiom a population at one point in time. This
compaies 2 uiffeient cultuies.

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


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






186
!9+.0 B; 4-(0
9+#+'0)$( J),%: Bias type uue to mannei in which people aie selecteu, oi fiom selective
losses fiom follow-up
5-%+;?+; d @+,%*;+2+(0 J),%: Bistoition of measuiement of association by
misclassifying exposeu, unexposeu, anuoi uiseasesnon-uiseaseu subjects.
M+',## J),%: Results fiom the inaccuiate iecall of past exposuie by people in the stuuy
V,/01$;(+ 3&&+'0: Patients change theii behavioi because they know they aie being
stuuieu
:$(&$*(.)(A: Is bias that iesults when the exposeuisease ielationship is mixeu with the
effect of extianeous factois. (ex. Stuuy of the association of smoking anu ciiihosis, anu
finu that theie is a stiong association. Then the uivision of uiinkeis anu non-uiinkeis
finus theie's no association of smoking to ciiihosis. In this case, alcohol is the
confounuei). * Natching is an effective way of contiolling confounuing
O+,. 7)2+ J),%: Refeis to the chionology of the uiagnosis anu tieatment between
uiffeient cases. (ex. Testing of platelet inhibitois in pilots vs autowoikeis, not faii
because pilots aie unueigoing constant health scieening)
!.2)%%)$( M,0+ J),%: Refeis to uistoition in iisk iatio uue to uiffeient hospitals
aumission of cases
6(,''+>0,-)#)0= J),%: 0ccuis when paiticipants puiposely give uesiiable iesponses
which leau to









187


Chapter 6

Psychiatry






188






>L!"?6$5!>?L !?
@A[5O>#!">5 %76>5>L7











189

19u
!?@>5AF

S*: '/',*+ &6
;#,*$&2"J#,"&%

A&#7 &6 >%,*2G"*:"%$

)*%,#7 -,#,=' IK#+

!"#$%&',"; 1*',' &6 E'/;5"#,2/

191


5#!7G?">]#!>?L



The BSN-v has eliminateu the olu 'axis system' foi categoiizing
psychiatiy illness. We now use a non-axial uocumentation of uiagnosis.
The new appioach combines the foimei axis' I, II, anu III with sepaiate
notations foi psychosocial anu contextual factois (olu Axis Iv) anu
Bisability (0lu Axis v). 0n top of that, a stiategy has been uevelopeu to
paitially eliminate a uiagnosis of 'not otheiwise specifieu, oi N0S',
wheieby clinicians iate uisoiueis along a sliuing scale oi 'continuum' of
seveiity. This stiategy allows physicians to cieate moie appiopiiate
tieatment plans foi theii patients.


>L!7"M>7I !75OL>X$7A



The goal of all psychiatiic inteiview techniques is to gain youi patient's
tiust anu builu iappoit. With tiust anu iappoit, a patient will open up
with infoimation to help you make a uiagnosis. This is iueal as we neeu
a goou psychiatiic histoiy, peisonal histoiy, social histoiy, anu uiug &
alcohol histoiy in oiuei to make the best possible uiagnosis foi oui
patients.
192



The following is a look at the moie commonly useu inteiview
techniques, as well as the main puipose they seive in psychiatiy.
19S
"(++B', 4)-D2-/1 !.<3/-_).0F

32>,01= !! Expiesses unueistanuing of the patient's situation.
9*>>$;0 !! Expiesses concein anu inteiest foi the patient.
F,#).,0)$( !! Expiesses the value of youi patient's feelings.


>/;B'*(,-B/ G(,3.'-/1 !.<3/-_).0F

E,')#)0,0)$( !! Encouiages a patient to uig ueepei anu elaboiate on
theii answeis.
5>+(DDD+(.+. c*+%0)$( !! To help obtain as much infoimation without
leauing oi closing potential aieas of exploiation.
M+&#+'0)$( !! Encouiages a patient to expanu on theii answeis by
ieviewing a pievious iesponse.
9)#+('+ !! Belps to encouiage youi patient's iesponsiveness.



>/;B'*(,-B/ 5D('-;9-/1 !.<3/-_).0F

5B/;'B/,(,-B/ !! Pointing out inconsistencies in the patient's
iesponses anuoi bouy language.
R);+'0 e*+%0)$( !! Belps to elicit infoimation as quickly as possible.
M+',>)0*#,0)$( !! Belps summaiize the infoimation obtaineu uuiing
inteiviews to ensuie complete unueistanuing.
194
!O7 %7L!#H A!#!$A 7c#%



Is a thoiough suivey that helps to assess the patient's cuiient level of
mental functioning. With the NSE we can assess many chaiacteiistics,
incluuing all of the following:
!! ueneial piesentation

!! Sensoiium & Cognition

!! Speech

!! Noou & Affect

!! Thought

!! Peiceptual Abilities

!! }uugment & Insight

!! Reliability

!! Impulse Contiol






19S
!O7 %>L> %7L!#H A!#!$A 7c#%



Is a fastei, moie supeificial means by which we can assess a patient's
cuiient level of mental functioning. The following ciiteiia aie useu to
peifoim the NNSE:
!! 5;)+(0,0)$( (have the patient name the cuiient location anu time) -

Naximum scoie of 1u

!! O,(A*,A+ (have the patient name the object you aie holuing) -
Naximum scoie of 8
196
!! !00+(0)$( d :,#'*#,0)$( (have the patient subtiact 7 fiom 1uu anu
continue subtiacting 7's as long as they can) - Naximum scoie of S
!! M+A)%0;,0)$( (have the patient iepeat the names of thiee objects) -

Naximum scoie of S

!! M+',## (iecall the name of the thiee objects above) - Naximum scoie
of S
!! :$(%0;*'0)$( (copy this uesign - show them a tiiangle) - Naximum

scoie of 1






6>#GL?A!>5 !7A!A $A76 >L @A[5O>#!"[



We use psychological tests to assess a patient's cognitive function, level
of achievement, peisonality, anu psychopathology. Each test is slightly
uiffeient, anu on a laigei scale is useu to gathei infoimation eithei
objectively oi piojectively.


?NW.<,-:. ,.0,0 !! baseu on questions with eithei a coiiect oi incoiiect
answei.
197
@'BW.<,-:. ,.0,0 !! baseu on the psychiatiist's inteipietation of the
answeis given.


Below is a list of the main tests useu in psychiatiy.
198
>L!7HH>G7L57 !7A!A



S+'1%#+; !.*#0 4(0+##)A+(0 9',#+ M+?)%+.KS!49DDDML< Is the most
commonly useu intelligence test.
S+'1%#+; 4(0+##)A+('+ 9',#+ &$; :1)#.;+( M+?)%+. KS49:DDDML< Is useu to

measuie intelligence in chiluien 6---16.S yeais of age.

S+'1%#+; 8;+%'1$$# ,(. 8;)2,;= 9',#+ $& 4(0+##)A+('+ KS8994L< Is
useu to test intelligence in chiluien 4---6.S yeais of age.





#5O>7M7%7L! !7A!A



8+,-$.= 4(.)?).*,# !'1)+?+2+(0 7+%0< 0seu in school systems to
evaluate achievement in specific subject aieas.
S).+DDDM,(A+ !'1)+?+2+(0 7+%0 KSM!7L< 0seu clinically to evaluate

aiithmetic, ieauing, anu spelling skills.



199



@7"A?L#H>![ !7A!A



M$;%'1,'1 7+%0< Piojective tests in which patients inteipiet ink---blots.
@)((+%$0, @*#0)>1,%)' 8+;%$(,#)0= 4(?+(0$;= K@@84DDDTL< 0bjective
test in which the patient answeis S66 tiue oi false questions about
themselves.
9+(0+('+ :$2>#+0)$( 7+%0 K9:7L< Piojective tests in which patients
complete sentences.
2uu
71+2,0)' !>>+;'+>0)$( 7+%0 K7!7L< Piojective test in which patients
cieate scenaiios baseu on thiity pictuies of ambiguous situations.





L7$"?@A[5O?H?G>5#H !7A!A



V,#%0+,.DDDM+)0,( J,00+;= KVMJL< To uetect anu localize biain lesions
anu ueteimine theii effects.
J+(.+; F)%*,#DDD@$0$; N+%0,#0 7+%0< To scieen visual anu motoi ability
thiough iepiouuction of uesigns.
O*;),DDDX+-;,%B, X+*;$>%='1$#$A)',# J,00+;= KOXXJL< 0seu to
ueteimine left oi iight ceiebial uominance anu to iuentify specific types
of biain uysfunction.
2u1
























47O#M>?"#H d 5?GL>!>M7
!O7"#@[
2u2
!?@>5AF
-/',*+"; !*'*%'","J#,"&%
3&$%","G* 15*2#0/
F"&6**.4#;9
C7&&."%$ @G*2'"G*
3&%.","&%"%$ 1&9*%
I;&%&+/
2uS
47O#M>?"#H #L6 5?GL>!>M7 !O7"#@>7A



A90,.*-< 6.0./0-,-T(,-B/ !! Is useu in the tieatment of phobias.

!! In this technique, the feaieu objectsituation is paiieu with a ielaxing
stimulus, with the goal of piovoking a ielaxeu iesponse whenevei the
feaieu object is encounteieu.


5B1/-,-:. !3.'(+9 !! Is useu to tieat milumoueiate uepiession,
somatofoim uisoiueis, anu eating uisoiueis.
!! Patients aie encouiageu to iuentify the negative thoughts they have

about themselves, anu aie taught to ieplace those feelings with positive,
self---ieassuiing thoughts about themselves.


4-B;..2N(<Q !! Is useu to tieat heauaches, hypeitension, asthma,
Raynauu's uisease, chionic pain, fecal incontinence, anu TN}.
!! Patients aie given ongoing physiologic infoimation so they can
consciously contiol behaviois with the goal of achieving theii uesiieu
goal.


KDBB2-/1 !! Is useu I the tieatment of phobias.
2u4

!! Patients aie exposeu to laige levels of theii feaieu objectsituation as
a way of uecieasing theii sensitivity to it.


#:.'0-:. 5B/2-,-B/-/1 !! Is useu in the tieatment of auuictions.

!! The paiiing of a pleasuiable yet uestiuctive stimulus is paiieu with a
painful stimulus, leauing to the cessation of the pleasuiable behavioi.
2uS
!BQ./ 7<B/B*9 !! Is useu in helping to inciease the positive behavioi
of a patient who is eithei seveiely uisoiganizeu anuoi mentally
ietaiueu.
!! Reinfoicing a uesiiable behavioi by offeiing a iewaiu foi peifoiming
that behavioi.
2u6





















A$4A!#L57 #4$A7
2u7
!?@>5AF

>+0&2,#%, !*6"%","&%' 37#''*' &6
-=4',#%;*' &6 @4='* 3&++&%7/
R'*.V@4='*. -=4',#%;*' -/+0,&+'
&6 M",5.2#:#7 !"#$%&'"%$
-=4',#%;* @4='* )#%#$*+*%, &6
-=4',#%;* @4='*
2u8


>%@?"!#L! 67K>L>!>?LA






A)N0,(/<. #N)0.: Besciibes a pattein of abnoimal use that eventually
leaus to impaiiment of functioning (social, physical, occupational).


A)N0,(/<. 6.+./2./<.: Besciibes a pattein of abuse that leaus to
patteins of toleiance, compulsive use, anu withuiawal.


A)N0,(/<. !BD.'(/<.: A physiological auaptation that leaus to an
incieaseu neeu in oiuei to expeiience the same iesult.
!! Theie is a phenomenon known as ';$%%DDD0$#+;,('+, wheieby the
auaptation to one uiug causes toleiance of anothei (ex. Alcohol anu
Benzouiazepines).


A)N0,(/<. I-,32'(E(D: A physiological uevelopment of symptoms that
occui once a substance has been stoppeu aftei piolongeu use anu
uepenuence.
2u9
5H#AA7A ?K 5?%%?LH[ #4$A76 A$4A!#L57A



The commonly abuseu substances fall unuei one of foui categoiies,
incluuing:
!! Stimulants

!! Naicotics

!! Seuatives

!! Ballucinogens



A,-*)D(/,0: Aie substances that stimulate the CNS. Leau to a wiue---

vaiiety of symptoms, incluuing:

!! Agitation, hypeiactivity, tachycaiuia, loss of appetite, incieaseu levels
of concentiation.
!! Anothei name foi cocaine is 'ciack', which is smokeu.

!! Amphetamines such as Nethylpheniuate aie wiuely piesciibeu foi

ABBB.

!! Commonly abuseu foims of !2>1+0,2)(+ incluue
21u

)*,5#+05*,#+"%* (Speeu) anu )!)@ (Ecstacy).



5B**B/ 0,-*)D(/,0 -/<D)2.F

!! :,&&+)(+ (The most commonly useu substance woiluwiue)

!! :$',)(+ (Can be snoiteu anuoi smokeu) - Inciease ielease of
ceitain neuiotiansmitteis anuoi ueciease ie---uptake. Specifically
blocks BA ie---uptake.
!! !2>1+0,2)(+% (Commonly useu by people who want to inciease
aleitness anuoi concentiation)
211
!! X)'$0)(+ (Founu mainly in cigaiettes, is the most common cause of
pieventable ueciease in lifespan).





L('<B,-<0: Belong to the opioiu class of uiugs, aie commonly abuseu
anu aie commonly useu in pain---management.
!! Incluue a wiue---vaiiety of pain---ielieving uiugs such as )&205"%*,

3&.*"%*, WK/;&.&%*, etc (ie. 0piates)

!! Cause iespiiatoiy uepiession, euphoiia, anu miosis.






A.2(,-:.0: Aie a class of uiugs that leau to uepiession of the cential
neivous system, causeu by an inciease in the inhibitoiy
neuiotiansmittei uABA. The main seuatives incluue Alcohol,
Benzouiazepines, anu Baibituiates.
!! Cause iespiiatoiy uepiession (Nost woiiisome with Baibituiates).

!! Bisinhibition.

!! Bepiession of emotions.
212

!! Sloweu mentation anu physical peifoimance.



5B**B/ A.2(,-:.0 -/<D)2.:

!! !#'$1$# (Noou initially elevates, then CNS uepiession begins.
Associateu with thiamine ueficiency anu a ueciease in life---expectancy in
long---teim useis).
!! J,;-)0*;,0+% (Bighly auuictive, cause uepiession of iespiiation,
anxiolysis, uangeious when combineu with alcohol).
21S
!! J+(b$.),b+>)(+% (Bighly auuictive, cause uepiession of iespiiation,
anxiolysis, uangeious when combineu with alcohol).





O(DD)<-/B1./0: Leau to symptoms of hallucinations, thought to be
ielateu to the inciease of available Seiotonin.
!! visual uistuibanceshallucinations.

!! Auuitoiy uistuibanceshallucinations.

!! Panic attacks aie common.

!! Alteieuuistoiteu peiception of ieality.

!! Psychosis



5B**B/ O(DD)<-/B1./0 -/<D)2.:

!! O=%+;A)' ,'). .)+01=#,2).+ KO9RL - Causes alteiation in peiception
of visual anuoi auuitoiy peiception. Flashbacks aie a common finuing
in long---teim LSB useis.
!! 81+('='#).)(+ K8:8L - Causes euphoiia, amnesia, violent behavioi,

uistoition of peiception, hypeitension, hypeitheimia, nystagmus.
214
A[%@!?%A ?K I>!O6"#I#H



A,-*)D(/,0: Withuiawal symptoms will be the opposite of the
symptoms seen uuiing intoxication.
!! Bepiession of moou anuoi eneigy levels.

!! Nalaise

!! Fatigue

!! Incieaseu appetite

!! Beauache

!! Niosis






L('<B,-<0: Withuiawal symptoms will be the opposite of the symptoms
seen uuiing intoxication.
!! Biaphoiesis

!! Anxiety

21S
!! Paiasympathetic oveistimulation (sweating, iunny nose, uiaiihea, uI

ciamping).

!! Nyuiiasis
216
A.2(,-:.0: Withuiawal symptoms will be the opposite of the symptoms
seen uuiing intoxication.
!! Tiemoi

!! Anxiety

!! Tactile hallucinations

!! Seizuies

!! Beliiium






O(DD)<-/B1./0: Theie aie usually no withuiawal symptoms seen in
patients who have stoppeu using a hallucinogen.











217
%#L#G7%7L! ?K A$4A!#L57 #4$A7



Biagnosing uiug use anuoi abuse is a simple mattei of unueistanuing
the main finuings mentioneu pieviously anu keeping a close eye out foi
them. Ceitain featuies aie unique to paiticulai uiugs, which shoulu be
well---known. The main laboiatoiy finuings foi each class of uiug is
outlineu below, which aie veiy impoitant in making a uefinitive
uiagnosis.
218
H(NB'(,B'9 ;-/2-/10:



!#'$1$#: Bloou---alcohol levels aie elevateu.

!2>1+0,2)(+%: Remain in the bloou foi 24---48hi.

:$',)(+: The metabolite benzoylecgonine iemains in the system foi up
to twelve uays.
O9R: 0iine will be positive foi LSB.

8:8: Will iemain in the uiine foi up to one week. CPK levels also tenu to
be elevateu.
@,;)P*,(,: Can iemain in the uiine foi up to one month in chionic

useis.





219
%#L#G7%7L!
#D<B3BD:

422+.),0+ !! Thiamine IN until levels aie appiopiiately ieplenisheu.
:1;$()' !! uioup theiapy (Alcoholics Anonymous) is the best stiategy
foi most alcoholics.


4./TB2-(T.+-/.0J4('N-,)'(,.0:

422+.),0+ !! Bospitalize in anticipation of seizuie, Flumazenil to
ieveise effects.
:1;$()' !! Behavioial mouification.
22u
5(;;.-/.:

422+.),0+ !! No tieatment is iequiieu immeuiately, howevei tapeiing
uosages will help pievent a withuiawal heauache.
:1;$()' !! Acetaminophen foi heauache as neeueu.






5B<(-/.:

422+.),0+ !! Benzouiazepine, anti---psychotics, anu pieventative
management.
:1;$()' !! Nanage withuiawal symptoms with Besipiamine.



O(DD)<-/B1./0:

422+.),0+ !! Benzouiazepines, anti---psychotics.

:1;$()' !! No long---teim management is necessaiy.



%('-W)(/(:

422+.),0+ !! Benzouiazepines foi agitation.
221

:1;$()' !! Behavioial mouificationtheiapy.



L-<B,-/.:

422+.),0+ !! uum, patch, suppoit.

:1;$()' !! Suppoit gioups, Bupiopion.
222






















5?GL>!>M7 6>A?"67"A
22S
!?@>5AF
!*7"2"=+
!*+*%,"#
@7J5*"+*2N' !*+*%,"#
224


?M7"M>7I



Cognitive uisoiueis aie chaiacteiizeu by ueficits in noimal mental
functioning, incluuing:


!! @+2$;= #$%%

!! 42>,);+. P*.A2+(0

!! R)%$;)+(0,0)$(

!! R+';+,%+. 2+(0,# ,'c*)0=

!! !#0+;+. 2$$.

!! !(Q)+0=

!! 8,;,($), d 8%='1$%)%







22S

67H7">$%



Is chaiacteiizeu by a patient's fluctuation of consciousness, oiientation,
anu attention. This is uue to some oiganic pioblem that affects the CNS.
Initially a patient will uisoiient to time, place, anu peison. Theie aie
foui common causes of ueliiium, which aie:


!! R;*A *%+ (Alcohol, PCP, Seuatives)

!! :X9 )(P*;)+% (Tiauma, Neningitis)

!! 9=%0+2)' .)%+,%+ (Any oigan)
226
!! R;*A /)01.;,/,# (Withuiawal fiom seuatives most commonly)

5B**B/ ;-/2-/10 -/<D)2. ( +(,-./, E3B .V+.'-./<.0:



!! Bypeiactive oi Bypoactive behaviois

!! Confusion

!! Anxiety

!! Autonomic uysfunction

!! Sleep uistuibances






6-;;.'./,-(D 6-(1/B0-0:



Nany conuitions may mimic ueliiium, incluuing:

!! Bepiession

!! Bementia

227
!! Psychosis






@'B1/B0-0: Whenevei theie is a tieatable unueilying conuition that is
tieatable, the piognosis is goou. 0ntieatable conuitions anuoi causes
usually leau to a woiseneu piognosis. Any untieateu cases may woisen
anu piogiess to uementia anuoi ueath.
228


67%7L!>#



Is chaiacteiizeu by a giauual loss of memoiy anu cognitive function.
Theie aie many possible causes of uementia, ianging fiom tieatable
uiseases such as uepiession all the way to teiminal illnesses such as
Buntington's uisease, Paikinson's uisease, anu BIv.


>*+B',(/, >/;B'*(,-B/F

!! Bementia is most common in the elueily population (affects >2u% of
those 8uyi of age oi gieatei).
!! Noie than half of all uementia cases aie a iesult of Alzheimei's

uementia.

!! vasculai uementia is also a common cause of uementia (Is the 2
nu


NCC).



@'BN(ND. 5()0.0F

!! uenetics plays an impoitant iole in Alzheimei's uementia.
229

!! vasculai uisoiueis play an impoitant iole in uementia.

!! BIv infection plays an impoitant iole in uementia.
2Su


#H]O7>%7"8A 67%7L!>#



Patients with Alzheimei's uementia piesent with significant memoiy
loss anu uifficulty in communication, all while noimal levels of
consciousness aie seen. Peisonality changes aie quite eviuent, anu
usually take place in the foim of excessive angei, paianoia, anu
uepiession. It is impoitant to iealize that with age comes a noimal
ueciease in cognitive function anu abilities, howevei these inuiviuuals
uo not expeiience an inability to function on a uay---to---uay basis.
Alzheimei's uementia patients will not only lose theii memoiy anu
cognition, but will have a uecieaseu ability to function on theii own on a
uay---to---uay basis. 0n a final note, it is impoitant to iealize that uementia
in the eluei population often looks just like Alzheimei's uementia, so a
close examination anu family questioning shoulu be unueitaken.


%(/(1.*./, B; #DT3.-*.'80 6.*./,-(F



!! 7,';)(+, which is a cholinesteiase inhibitoi, has been shown to
impiove cognition anu uelay the onset of symptoms in appioximately
one quaitei of all patients.
!! It is impoitant to manage all anxiety anuoi moou uisoiueis
2S1

phaimacologically.

!! O)&+%0=#+ 2$.)&)',0)$(% such as uiet, nutiition, living---aiiangements,
anu exeicise shoulu all be auuiesseu.
2S2
@'B1/B0-0F



!! 0pon onset of symptoms, the aveiage age of suivival is
appioximately eight yeais.
2SS
























G7L67" 6[A@O?">#




2S4
G7L67" 6[A@O?">#



This is a new class of uiagnosis foi the BSN-v. Theie is gieat emphasis
of the concept of uenuei Incongiuence iathei than simple 'cioss-
genuei iuentification'. It was confiimeu that genuei iuentity uisoiuei
(a BSN-Iv classification) was neithei a sexual uysfunction noi a
paiaphilia.

In oiuei to uiagnose uenuei Bysphoiia, a gioup of physicians
(Enuociinologist, Sexual health expeit) must take pait in management
of the patient. Theie aie sepaiate ciiteiia foi chiluien, auolescents,
anu auults, wheie a chilu with a stiong uesiie to be of the opposite
genuei oi an insistence that heshe is of the opposite genuei is
necessaiy, but not sufficient enough to make a uiagnosis. This means
that uiagnosis of a chilu is much moie iestiictive anu conseivative than
it will be in an auolescent oi auult.





2SS

















2S6










%??6 6>A?"67"A
2S7
!?@>5AF

)#]&2 !*02*''"G* !"'&2.*2
F"0&7#2 !"'&2.*2
!/',5/+"; !"'&2.*2
3/;7&,5/+"; !"'&2.*2
2S8
%#w?" 67@"7AA>M7 6>A?"67"



Najoi uepiession is chaiacteiizeu by episoues of seveiely uepiesseu
moou, lasting foi at least two weeks at a time. The majoi symptoms of
uepiession aie a loss of inteiest in things usually enjoyable to a peison.
Lifetime pievalence foi men is S---12% anu foi females is 1u---2u%.
Biagnosis iequiies a majoi uepiessive episoue that lasts at least two
weeks.


While that is the majoi finuing, theie aie a vaiiety of possible signs anu
symptoms associateu with uepiession, incluuing:


A - AD..+ 2-0,)'N(/<.0 (Bypeisomnia, Byposomnia) - often patients
will complain of eaily---moining awakening anu the inability to fall back
asleep.
> - >/,.'.0, DB00 (Loss of usual inteiests. Loss of ability to feel pleasuie
is known as 'Anheuonia').
G - G)-D, (Patients often feel excessive guilt ovei things out of theii
contiol oi things they shoulun't feel guilty about).
7 - 7/.'19 DB00 (Patients have a noticeable ueciease in eneigy).

5 - 5B/<./,'(,-B/ (Patients lose theii ability to concentiate).

2S9
# - #++.,-,. <3(/1.0 (A ueciease in appetite is moie common,
although often patients will have hypeiphagia uuiing uepiessive
episoues).
@ - @09<3B*B,B' (<,-:-,9 (Nainly a loss of cognitive functioning).
24u
A - A)-<-2(D -2.(,-B/ (As many as 6S% of patients who aie uepiesseu
will consiuei haiming themselves, with appioximately 1u---1S%
attempting suiciue).

6.+'.00-B/ (D0B +'.0./,0 E-,3 ,3. ;BDDBE-/1 '.D(,.2 09*+,B*0F



8%='1$%)% !! Bepiession in auuition to psychosis, incluues uelusions
anuoi hallucinations in iaie ciicumstances.
9$2,0)' 9=2>0$2% !! Patients will complain of a iange of inteinal
pains, which can leau to the onset of hypochonuiiasis.


9+,%$(,# !&&+'0)?+ R)%$;.+;: A common sub---type of uepiession that is
limiteu to the wintei season. These patients iesponu veiy well to
exposuie to ultiaviolet light.





6.+'.00-B/ -0 B;,./ 0../ <B/<)''./,D9 E-,3 B,3.' *.2-<(D -00).0C
-/<D)2-/1F


3(.$';)(+ .)%$;.+;%: Thyioiu uisoiueis (hypothyioiuism) look like
241
uepiession.
X*0;)0)$(,# .+&)')+(')+%: Biets low in healthy fats can pieuispose a
patient to uepiession.
X+*;$#$A)' .)%$;.+;%: Paikinson's uisease, Buntington's uisease, anu
othei neuiologic uiseases tenu to leau to uepiession. Not only is theie
an unueilying oiganic cause, but patients who aie awaie of the seveiity
of theii uisease tenu to become uepiesseu.
242
81,;2,'$#$A=: Nany uiffeient uiugs tenu to cause uepiession (Beta
blockeis, Anti---hypeitensives)
F);,# )##(+%%+%: BIvAIBS, influenza, etc.

8%='1),0;)' .)%$;.+;%: Schizophienia, anxiety, uiug use anu abuse, anu
othei somatofoim uisoiueis aie common causes of uepiession.

Beieavement. commonly oveilaps with NBB. Beieavement will
typically last 1-2 yeais, anu is iecognizeu as a seveie psychosocial
stiessoi that may piecipitate NBB in those who aie susceptible (ie.
Family histoiy oi histoiy of NBB)





%(/(1.*./, B; 6.+'.00-B/: Touay, the gioup of SSRI's aie the 1
st
line
in phaimacologic management of majoi uepiession. In auuition to
meuication, psychotheiapy is a majoi pait of theiapy.


99M4G% !! The main siue---effects associateu with SSRI's aie a uecieaseu
sex---uiive anu anoigasmia.
V+0+;$'='#)' ,(0)DDD.+>;+%%,(0% !! Stiongly anti---cholineigic anu
seuative.
@!54G% !! Less favoieu because theie is a high---iisk of hypeitensive
24S
ciisis (When patient eats foous high in tyiamine - wine, cheese, ieu
meat).


Refiactoiy cases oi cases that aie not iesponsive to meuication shoulu
be consiueieu foi ETC, which is an inuuction of a geneializeu seizuie
that lasts 2S---6u seconus.


9).+DDD+&&+'0% $& 37: !! Retiogiaue amnesia, lasting no moie than six
months.
:$(0;,)(.)',0)$( !! Incieaseu intiacianial piessuie.
244
?,3.' -*+B',(/, -/;B'*(,-B/ '.1('2-/1 2.+'.00-B/F



!! If untieateu, majoi uepiessive episoues will usually iesolve within
six months.
!! Risk of suiciue is gieatest when patient has staiteu taking anti---

uepiessants, because they stait to gain the eneigy to take action.

!! It is within a physicians juiisuiction to aumit a patient who is suspect
of having suiciual iueation, who is unable to take caie of himheiself, oi
uoesn't have a piopei suppoit system to caie foi them.







4>@?H#" 6>A?"67"



Bipolai 1 uisoiuei is chaiacteiizeu by alteinating episoues of mania anu
majoi uepiession. Bipolai 2 uisoiuei is chaiacteiizeu by alteinating
episoues of hypomania anu majoi uepiession. 0ften times, patients will
piesent while in the uepiessive phase of bipolai uisoiuei. Taking anti---
uepiessants with bipolai uisoiuei will often piecipitate the manic phase
24S
of the uisease. 0ntieateu manic episoues will usually iesolve within
thiee months.
246
A-1/0 d A9*+,B*0 B; *(/-( -/<D)2.:



!! Incieaseu eneigy

!! Lack of neeu to sleep

!! Feeling of gianuiosity

!! Racing thoughts

!! Loss of inhibitions



This is a uangeious state because patients tenu to act iecklessly, often
spenuing absuiu amounts of money anuoi engaging in sexually iisky
behaviois.





%(/(1.*./, B; 4-+BD(' 6-0B'2.':



!! Lithium, Caibamazepine, anu valpioic Aciu aie effective uiugs.

247
!! Lithium has a veiy small theiapeutic winuow, thus we have to
constantly check bloou---Lithium levels.
!! Nain siue---effect of Lithium is nephiogenic uiabetes insipiuus.
248
6[A!O[%># d 5[5H?!O[%>#



R=%01=2), is chaiacteiizeu by milu to moueiate uepiession, most of the
time, with no fiim beginning oi enu.
:='#$01=2), is chaiacteiizeu by episoues of hypomania anu

milumoueiative uepiession.



** These conuition cannot be uiagnoseu until symptoms have been
piesent foi at least two yeais.


%(/(1.*./,:

R=%01=2), !! The tieatment of choice is theiapy (Cognitive anuoi

Psychotheiapy).

:='#$01=2), !! Psychotheipy + Anti---uepiessants aie the tieatment
mouality of choice.
249




















#Lc>7![ 6>A?"67"A
2Su
!?@>5AF
A*%*2#7"J*. @%K"*,/ !"'&2.*2
E#%"; !"'&2.*2
E5&4"#'

W4'*''"G*DDD3&+0=7'"G* !"'&2.*2


E&',DDD12#=+#,"; -,2*'' !"'&2.*2

-*0#2#,"&% @%K"*,/ !"'&2.*2

-*7*;,"G* )=,"'+
2S1
?M7"M>7I ?K #Lc>7![ 6>A?"67"A



Anxiety uisoiueis aie chaiacteiizeu by an outwaiu manifestation of
inteinal feai, exhibiteu by both physical anu emotional symptoms.
:$22$( 2,()&+%0,0)$(% $& ,(Q)+0=f ;+A,;.#+%% $& 0=>+f )('#*.+ 01+
&$##$/)(A<


!! Tiemoi

!! Biaphoiesis

!! Tachycaiuiatachypnea

!! Bizziness

!! Nyuiiasis

!! Syncope

!! Neuiopathies

!! uI uistuibances



5B**B/ <()0.0 B; (/V-.,9 -/<D)2.F

2S2
!! Neuiotiansmittei abnoimality (uABA, S---BT, NE, E)

!! Nutiitional abnoimalities

!! Substance useabuse

!! Enuociine uisoiueis

!! Bypoglycemia
2SS
!3. *(-/ (/V-.,9 2-0B'2.'0C (<<B'2-/1 ,B ,3. 6A%YYY>M -/<D)2.F

a W N+(+;,#)b+. !(Q)+0= R)%$;.+;

R W 8,()' .)%$;.+;

j W 81$-),%

f W 5-%+%%)?+DDD:$2>*#%)?+ .)%$;.+;

e W 8$%0DDD0;,*2,0)' %0;+%% .)%$;.+;






G7L7"#H>]76 #Lc>7![ 6>A?"67"



ueneializeu anxiety uisoiuei is chaiacteiizeu by symptoms of anxiety
that last at least six months. These patients uo not have any paiticulai
souice of anxiety, but aie anxious about all aspects of life. uAB is moie
common in women, with half of all cases beginning in chiluhoou anuoi
auolescence.


Balf of all patients with uAB will uisplay chionic symptoms that iise anu
fall thioughout theii lives. The othei half of patients typically iesolve
2S4
within a few yeais of having the uisease. 0ne of the most woiiisome
complications of uAB is the patient's iisk of becoming auuicteu to
Benzouiazepines, which aie a staple in patient management.
2SS
@#L>5 6>A?"67"



Panic uisoiuei is chaiacteiizeu by panic attacks that occui at ianuom
times. Patients often uesciibe these attacks as heait---attack---like, wheie
an impenuing feai of ueath is a main symptom. These attacks occui
appioximately twice pei week anu last appioximately ten to thiity
minutes. No longei uo we associateu panic attacks with agoiaphobia.


!3. ;BDDBE-/1 ('. ,3. -*+B',(/, <3('(<,.'-0,-<0 B; +(/-< 2-0B'2.'F

!! Nean age of onset is twenty---five, moie common in females.

!! Theie is a stiong genetic component to the uisoiuei.

!! Is usually chionic, although stiessful times of life may piesent with
moie episoues.


%(/(1.*./,:

!! Acute tieatment may involve benzouiazepines.

!! Chionic tieatment involves SSRI's.

!! Cognitive theiapy is a staple of effective tieatment.
2S6
@O?4>#A



The two main phobias incluue 'Specific Phobia' anu 'Social Phobia'. A
specific phobia is an iiiational feai of a known object anuoi situation
(ex. Spiueis, Beights). Since the specificity of the phobia is known,
patients will go to gieat lengths to avoiu the tiiggei. Social phobia, on
the othei hanu, is an exaggeiateu feai of social anuoi enviionmental
situations. Because the patient feais being in public, they tenu to avoiu
going into public places oi social situations.

INP0RTANT: The BSN-v states that patients uo not have to iecognize
the iiiationality of theii phobia in oiuei to make a uiagnosis.


!! Specific phobias aie seen in S---1u% of the population, anu is seen
equally in men anu women.
!! Those with phobias often incui iepeicussions such as loss of job,
failing out of school, anu failuie to keep fiienus.
!! Tieatment of phobias is exposuie theiapy, wheieby we intiouuce a

patient to the subject of feai anu uesensitize them of the feai.




2S7


?4A7AA>M7YYY5?%@$HA>M7 6>A?"67"



0bsessive---compulsive uisoiuei (0CB) is chaiacteiizeu by a iepetitive,
intiusive feeling, thoughts, anu obsessions, which leau to a builu---up of
anxiety that is only ielieveu by peifoiming a iepetitive action. This
uisoiuei most commonly begins in chiluhoou, anu is seen in 2---S% of the
geneial population. Theie is a stiong genetic component.
2S8
5B**B/ BN0.00-B/0 0../ -/ ?56 -/<D)2.F

!! Counting

!! Checking anu ie---checking

!! Becontamination

!! 0iuei



A majoi key to uiagnosing a patient with 0CB is that they have insight to
the iiiationality of theii uisease. Those with 0CB peisonality uisoiuei
uo not see iiiationality with theii behavioi.





@B,./,-(D 5()0.0 B; ?56:

!! Seiotonin is thought to be stiongly linkeu to 0CB, anu as such, SSRI's
aie an effective tieatment mouality. 0thei anti---uepiessants acting on S---
BT will also help patients with 0CB.
!! 0ften times, a life---stiessoi is a common piecipitant of 0CB.



2S9
>*+B',(/, H-/Q0:

!! Bepiession is commonly seen in 0CB patients.

!! 0CB is commonly associateu with othei behavioial uisoiueis such as:

@%&2*K"#, F=7"+"#, @%K"*,/ ."'&2.*2', anu W3! 0*2'&%#7",/ ."'&2.*2.

OB('2-/1 2-0B'2.' (newly auueu to BSN-v), uesciibeu as peisistent
uifficulty uiscaiuing oi paiting with possessions uue to a peiceiveu neeu to
save them. Seveie uistiess is associateu with uiscaiuing items.



@'B1/B0-0 !! Tieatment will significantly impiove SS% of patients,
moueiately impiove Su%, anu likely be ineffective in the iemaining.
Foi those patients who uo not see impiovement with tieatment, fuithei
ueteiioiation will likely occui.
26u
@?A!YYY!"#$%#!>5 A!"7AA 6>A?"67"



Post---tiaumatic stiess uisoiuei (PTSB) is seen aftei a tiaumatic event
has taken place. These events aie often life---thieatening oi life---alteiing.
Recuiiing memoiies anuoi uieams of the event(s) leau to the
uevelopment of the uisoiuei. Biagnosis can only be maue when
symptoms aie piesent foi at least one month, beginning at least 4
weeks aftei the tiaumatic event.

4@85M7!X7 94R3DX5739: Acute Stiess Bisoiuei & Aujustment
uisoiuei (these aie closely ielateu to PTSB, thus shoulu be consiueieu
as pait of the oveiall uiscussion).

!'*0+ 90;+%% R)%$;.+;: Refeis to the symptoms following a tiaumatic
event fiom 2 uays - 4 weeks post-tiauma (iemembei PTSB uiagnosis is
maue 4 weeks aftei the tiaumatic event).
!.P*%02+(0 R)%$;.+;: Consiueieu a 'stiess iesponse synuiome'. This is
now consiueieu a conceptual fiamewoik foi a gioup of uisoiueis that
iepiesent a simple iesponse to life stiessois (tiaumatic oi non-
tiaumatic).


6A%YM 0)11.0, f *(WB' 09*+,B* <D)0,.'0 ;B' @!A6F

261
Cg M+D+Q>+;)+(')(A 01+ +?+(0 K%>$(0,(+$*% 2+2$;)+% $& 01+ +?+(0L
Tg V+)A10+(+. ,;$*%,# K%#++> .)%0*;-,('+f ,AA;+%%)?+(+%%Y;+'B#+%%(+%%L
ag !?$).,('+ K+Q0+;(,# ;+2)(.+;% $& 01+ +?+(0%L
\g X+A,0)?+ 01$*A10% d 2$$.Y&++#)(A%













%(/(1.*./,:

!! SSRI's

!! Benzouiazepines acutely (not a long---teim solution, they have
incieaseu iisk of abuse).
!! uioup theiapy



@'B1/B0-0 !! Balf of patients will continually have symptoms, while the
othei half will iecovei completely within appioximately thiee months.
262

A7@#"#!>?L #Lc>7![



** This is now categoiizeu as a iegulai anxiety uisoiuei (not isolateu to
peuiatiics)

When patients aie attacheu to theii paients beyonu what is consiueieu
noimal, sepaiation anxiety is uiagnoseu. The woiiy expeiienceu is that
something teiiible will happen to the main caiegiveis (usually the
paients).


@,)( 9)A(% d 9=2>0$2%:

!! Tiouble sleeping at night (ie. Nightmaies, insomnia)
26S
!! Somatic symptoms when sepaiateu fiom caiegiveis (ie. Nausea,
vomiting, Biaiihea, etc)


@,(,A+2+(0: Besensitization theiapy, exposing them to the pioblem
anu uecieasing theii woiiy.



A7H75!>M7 %$!>A%

Noveu into the categoiy of 'Anxiety Bisoiueis' with the BSN-v.
Chaiacteiizeu by a suuuen incapability to speak in someone who can
otheiwise speak noimally. Commonly chiluien will iemain silent uespite
incieasing theii iisk of social isolation, shame, oi punishment.

$0)(DD9 <BY.V-0,0 E-,3 B,3.' <B/2-,-B/0 0)<3 (0F
! Shyness
! Social anxiety

53('(<,.'-0,-<0 B; A.D.<,-:. *),-0*F
! Failuie to speak in social situations (ongoing basis)
264
! At least 1 month in uuiation
! Inteifeies with occupational oi euucational expeiiences
! Not uue to lack of language compiehension, knowleuge, etc.
! Boes not impiove with age (typically)



%(/(1.*./,:

E$; =$*(A+; '1)#.;+(<
! Stimulus fauing is commonly employeu
26S




















A5O>]?@O"7L>#
266
!?@>5AF
35#2#;,*2"',";'
-"$%' [ -/+0,&+'
-=4DDD1/0*'
!"66*2*%,"#7 !"#$%&'"'
)#%#$*+*%,
)*.";#,"&% -".*DDDI66*;,'
267
5O#"#5!7">A!>5A



Schizophienia is one of the most uebilitating mental uisoiueis we ueal
with in psychiatiy. It is chaiacteiizeu by patteins of uistuibing
thoughts, behaviois, anu speech. Patients tenu to show a loss of touch
with ieality when unueigoing a psychotic episoue, yet can uemonstiate
being in touch with ieality uuiing the piouiomal anu iesiuual phases.
0ften times, schizophienic patients aie those in society with a stiange
appeaiance, pooi giooming, anu social withuiawal.


#<<B'2-/1 ,B ,3. 6A%YMC ,3. <'-,.'-( ;B' 2-(1/B0-0 -/<D)2.F

Abnoimalities in one oi moie of the following five uomains:

1. Belusions
2. Ballucinations
S. Bisoiganizeu thinking
4. uiossly uisoiganizeu oi abnoimal motoi behavioi
S. Negative symptoms






268
@'B2'B*(D A-1/0 d A9*+,B*0F

!! Social withuiawal fiom fiienus, family, anu social activities.

!! Behavioi is quiet, passive, iiiitable, angiy.

!! Physical complaints aie common.

!! New inteiests in things such as: O*7"$"&%, E5"7&'&05/, the W;;=7,.



@B0-,-:. :0= L.1(,-:. A9*+,B*0F

8$%)0)?+ 9=2>0$2% !! aie symptoms uemonstiating excessive
functioning, such as Belusions, Ballucinations, Agitation, Stiange
Behavioi, excessive talking. Positive symptoms iesponu exceptionally
well to tiauitional anti---psychotic tieatment iegiments.
269
X+A,0)?+ 9=2>0$2% !! aie ueficits in functioning anu incluue things
such as Thought Blocking, Flatteneu Affect, Pooi uiooming,
Amotivation, Social Withuiawal, Cognitive Bistuibances. Negative
symptoms aie not as iesponsive to tiauitional tieatment moualities, but
uo iesponu well to atypical anti---psychotics such as Rispeiiuone,
Clozapine, 0lanzapine, anu Quetiapine.







A-1/0 d A9*+,B*0 B; @09<3B0-0F Buiing an acute psychotic phase,
thought uisoiuei is seen in auuition to alteiations in E*2;*0,"&%, ,5&=$5,
;&%,*%,, ,5&=$5, 02&;*''*', anu 6&2+ &6 ,5&=$5,, which incluue:


R+#*%)$(% !! Falsely helu beliefs that uo not follow logic oi ieason, aie
not shaieu by society as a whole. The most common type is a '.*7='"&%
&6 0*2'*;=,"&%'.
3'1$#,#), !! Nimicking woius spoken by anothei peison.

V,##*')(,0)$(% !! False sensoiy peiceptions of auuitoiy oi visual
stimuli. Nay also be tactile, gustatoiy, olfactoiy, oi visceial
hallucinations.
4.+,% $& M+&+;+('+ !! Is a falsely helu belief that one is the subject of
27u
attention by otheis (often believe they aie the subject of meuia
sciutiny).
42>,);+. !-%0;,'0)$( !-)#)0= !! Bifficulty in uiffeientiating the

qualities of objects oi ielations uespite noimal intelligence.
271
O$$%+ !%%$'),0)$(% !! Shifting of iueas fiom one subject to anothei in
an unielateu oi paitially ielateu fashion.
O$%% $& 3A$ J$*(.,;)+% !! Lack of knowing wheie one's minu anu bouy

enu anu those of otheis begin (feel as though they aie 'one' with otheis).
X+$#$A)%2% !! Invention of new woius that aie nonsensical.
7,(A+(0),#)0= !! Tuining a logical iesponse into a long, uiawn---out,
pointless tangent.
71$*A10 J#$'B)(A !! Acute stoppage in the noimal thinking piocess
because of an onset of hallucinations.
8+;%+?+;,0)$( !! Repeating a thought ovei anu ovei.

S$;. 9,#,. !! Saying combinations of woius that have no ielation to
one---anothei.





A$4YYY![@7A



Theie aie five main sub---types of schizophienia, which incluue:

!! @('(/B-2 |uelusions of peisecution, seen in oluei patients, has bettei
functioning patient than the othei sub---typesj.
272
!! $/2-;;.'./,-(,.2 |contains chaiacteiistics of moie than one sub---

typej.

!! 5(,(,B/-< |bizaiie postuiing, stupoi, muteness, extieme excitabilityj.

!! 6-0B'1(/-T.2 |pooily oiganizeu, inappiopiiate emotional iesponses,
uisinhibition, seen moie commonly in those < 2S yeais of agej.
!! ".0-2)(D |pievious schizophienic episoue with iesiuual but non---

psychotic symptomsj.
27S
6>KK7"7L!>#H 6>#GL?A>A



It is impoitant to unueistanu the list of potential causes of psychosis, as
they shoulu be iuleu out befoie making a uiagnosis of schizophienia.
The list below outlines the possible causes anuoi alteinate uiagnoses
of schizophienia.


4'-.; @09<3B,-< 6-0B'2.' !! Symptoms of psychosis that occui foi
moie than one uay but less than one month.
A<3-TB+3'./-;B'* 6-0B'2.' !! Psychosis anuoi iesiuual symptoms

that last anywheie between one month anu six months.
A<3-TB(;;.<,-:. 6-0B'2.' !! A moou uisoiuei + symptoms of
schizophienia (note: Noou uisoiuei must be piesent foi the
majoiity of the uisoiuei's uuiation)
6.D)0-B/(D 6-0B'2.' !! Fixeu, long---teim non---bizaiie oi bizaiie
uelusions anuoi thought uisoiueis.
A<3-TB-2 @.'0B/(D-,9 6-0B'2.' !! Patient is socially withuiawn but
theie aie no symptoms of psychosis.
A<3-TB,9+(D @.'0B/(D-,9 6-0B'2.' !! 0uu behavioi anu thought
patteins without psychosis.
@09<3B0-0 2). ,B *.2-<(D <B/2-,-B/ !! Symptoms of psychosis that
occui as a iesult of an unueilying meuical illness.
274
4B'2.'D-/. @.'0B/(D-,9 6-0B'2.' !! Seveie moou swings, angei,

uissociation, low---level psychosis that lasts veiy little time.

6')1YYY-/2)<.2 @09<3B0-0 !! Seen commonly with LBS, PCP, cocaine,
amphetamines.
27S
%#L#G7%7L!



Nanagement foi schizophienia is best appioacheu with
phaimacological anu psychological meuiums. Phaimacological
tieatment involves using typical anuoi atypical anti---psychotic agents.
The mechanism of action of these uiugs involves loweiing Bopamine
levels in the biain.


!9+-<(D #/,-YYY+09<3B,-<0: Woik by blocking the B2 ieceptois.

!! Classic examples aie Balopeiiuol anu Chloipiomazine.

!! Balopeiiuol has the highest tenuency of causing extiapyiamiual siue---

effects.

!! Long---teim management must incluue psychotheiapy.

!! Impiovement is seen in appioximately 7u% of all patients.

!! Typicals aie most effective against positive symptoms of
schizophienia.


#,9+-<(D #/,-YYY+09<3B,-<0: Woik by blocking the B4 ieceptoi anu acting
on the Seiotonin levels in the biain.
276
!! Clozapine is the uiug least likely to cause extiapyiamiual siue---effects.

!! Clozapine has a tenuency to suppiess the bone maiiow, thus we me
keep an eye on the CBC to ensuie agianulocytosis hasn't occuiieu.
!! 0thei atypical anti---psychotics aie Rispeiiuone, Quetiapine, anu

0lanzapine, they cause fewei hematologic anu neuiologic effects.
277
Some patients aie non---compliant, which makes them iueal canuiuates
foi long---acting uepot foims of the meuication. These aie auministeieu
eveiy foui weeks intiamusculaily.





%76>5#!>?L A>67YYY7KK75!A



O-13YYY+B,./<9 2')10 (namely Baluol anu othei typicals), tenu to cause
gieatei extiapyiamiual siue effects. Examples aie below:


!B,01)%),: is a subjective feeling of iestlessness.

!'*0+ .=%0$(),: is slow anu piolongeu muscle spasms.

8%+*.$>,;B)(%$()%2: Paikinson---like movements.

7,;.)?+ R=%B)(+%),: Wiithing movements of the heau, neck, anu
tongue.
X+*;$#+>0)' 2,#)A(,(0 %=(.;$2+: Bigh fevei, confusion, uiaphoiesis,
hypeitension, musculai iigiuity, ienal failuie.


278
HBEYYY+B,./<9 2')10 (namely Chloipiomazine), tenu to cause less
extiapyiamiual siue---effects anu tenu to cause moie anticholineigic siue---
effects anu anti---histamine effects.


0thei common siue---effects:

!! Weight gain

!! Seuation

!! }aunuice (causeu by hepatic pioblems)
279
!! Enuociine abnoimalities

!! ualactoiihea

!! Impotence

!! Amenoiihea

!! Becieaseu sex---uiive

!! Bematologic uysfunction (Agianulocytosis, leukopenia)

!! Photosensitivity

!! Blue---giay skin uiscoloiation (causeu by Chloipiomazine)

!! 0phthalmologic effects causeu by Thioiiuazine anu Chloipiomazine






@"?GL?A>A



Typically, schizophienia is a life---long uisease that waxes anu wanes.



28u
8;$A($%)% )% -+00+; /1+(<

!! 0nset is latei in life

!! Patient has goou social ielationships, incluuing maiiiage

!! Bas moou symptoms

!! Female genuei

!! Bas positive symptoms

!! Bas few ielapses
281




















6>AA?5>#!>M7 6>A?"67"A
282
!?@>5AF
!"''&;"#,"G* @+%*'"#
!"''&;"#,"G* C=$=*
!"''&;"#,"G* >.*%,",/ !"'&2.*2
!*0*2'&%#7"J#,"&% !"'&2.*2
28S
6>AA?5>#!>M7 #%L7A>#



Chaiacteiizeu by an inability to iecall impoitant infoimation about
oneself. Is an uncommon conuition that is seen moie commonly in
women anuoi young auults. 0ften, if the amnesia began aftei a
stiessful event, it iesolves ovei time. A 'Bissociative Fugue' is now
a specifiei of uissociative amnesia, anu not it's own sepaiate
uiagnosis.


%(/(1.*./,: Attempt at uncoveiing the stiessoi oi tiauma that

causeu the amnesia in auuition to long---teim psychotheiapy to ueal with
any unueilying issues.





6>AA?5>#!>M7 K$G$7



Chaiacteiizeu by an inability to iemembei impoitant infoimation about
oneself, in auuition to leaving home anu taking on a new iuentity. The
patient is unawaie of the new assumeu iuentity. Is iaie anu is
associateu with a histoiy of excessive alcohol use. Is now a specifiei of
284
uissociative amnesia, anu not an actual uiagnosis in anu of itself.





6>AA?5>#!>M7 >67L!>![ 6>A?"67"



Chaiacteiizeu by having at least two uiffeient peisonalities, also known
as 'Nultiple Peisonality'. The majoiity of patients aie women, wheie
one peisonality is the uominant peisonality. This conuition is usually
28S
associateu with some unueilying stiuggle anuoi eaily tiaumatic event
in theii life. Is often associateu with chiluhoou sexual abuseincest.
Iuentity tiansitions may be obseiveu by otheis anuoi self-iepoiteu,
which is a new uiagnostic factoi in the BSN-v. Look foi gaps in this
patient's eveiyuay life, not only with iespect to tiaumatic events that
piecipitateu the uisoiuei.





67@7"A?L#H>]#!>?L 6>A?"67"



Chaiacteiizeu by iecuiiing anu peisisting feelings of uetachment fiom
self, social situation, oi enviionment. This uisoiuei often occuis in
patients with othei psychiatiic conuitions such as uepiession, anxiety,
histiionic peisonality uisoiuei, boiueiline peisonality uisoiuei, anu
schizophienia.
286
























A?%#!>5 A[%@!?%
6>A?"67"
287
!?@>5AF

-&+#,"; -/+0,&+ [
O*7#,*. !"'&2.*2'
288
A?%#!>5 A[%@!?% 6>A?"67"



Somatic symptom uisoiuei (SSB) is chaiacteiizeu by uistiessing
symptoms oi symptoms that leau to significant uisiuption of noimal
eveiyuay functioning. They may also leau to uispiopoitionate
thoughts, feelings, anu behaviois iegaiuing those symptoms. The
patient must be peisistently symptomatic foi at least 6 months to
make a uiagnosis of SSB.

Pieviously, somatization uisoiuei, hypochonuiiasis, pain uisoiuei,
anu unuiffeientiateu pain uisoiuei fell into the 'Somatofoim uisoiuei'
categoiy - these have all been iemoveu with the BSN-v. Nany of the
finuings associateu with these olu uisoiueis aie now going to piompt
a uiagnosis of SSB. No longei aie a vaiiety of complaints fiom 4
uiffeient systems iequiieu as pait of the uiagnosis, iathei the somatic
symptoms must be uistiessing anu uisiuptive to uaily life.

Anothei key change to this categoiy is the fact that pieviously the
symptoms of somatofoim uisoiueis weie iequiieu to be 'meuically
unexplainable', wheie theii symptoms coulu not be linkeu to any
oiganic cause. Now, symptoms may oi may not be meuically
explainable.


289


6-(1/B0,-< 5'-,.'-(F
! 0ne oi moie somatic symptoms that aie eithei uistiessing oi iesult
in significant uay-to-uay impaiiment
! Excessive thoughts, feeling, oi behaviois ielateu to the somatic
symptoms oi associateu health conceins as manifesteu by at least one
of the following: 1. Bispiopoitionate anu peisistent thoughts about
the seiiousness of one's symptoms. 2. Peisistent high level of anxiety
about health oi symptoms. S. Excessive time anu eneigy uevoteu to
the symptoms oi health conceins.
! The same symptoms neeu not be piesent continuously, but
symptoms must be peisistent in some foim oi anothei foi at least 6
months



%(/(1.*./,:

!! Inuiviuual anuoi gioup theiapy, in auuition to ielaxation
techniques, aie the most effective moualities of tieatment -
phaimacological measuies aie usually not the fiist line of tieatment.



29u







O[@?5O?L6">#A>A d >HHL7AA #Lc>7![ 6>A?"67"

Since hypochonuiiasis is no longei an inuiviuual uisoiuei, patients
aie now uiagnoseu with 'Somatic Symptom Bisoiuei'. The main
ieasons foi the change aie that labeling a patient as a hypochonuiiac
often uisiupteu a stiong patient-physician ielationship.


5?LM7"A>?L 6>A?"67"
(Functional Neuiological Symptom Bisoiuei)

6-(1/B0,-< <'-,.'-( B; KLA6 -0 (0 ;BDDBE0F
! 0ne oi moie symptoms of alteieu voluntaiy motoi oi sensoiy
function
291
! Incompatibility between the symptoms anu iecognizeu
neuiomeuical conuitions
! Symptoms oi ueficit not bettei explaineu by anothei meuical oi
mental uisoiuei
! Causes significant uistiess oi impaiiment in social, occupational,
oi othei functional aieas.

A+.<-;-< 09*+,B*0 *(9 -/<D)2.F
! Weakness oi paialysis
! Abnoimal movement (tiemoi, myoclonus, gait uisoiuei)
! Swallowing symptoms
! Speech symptoms (sluiieu speech, uysphonia)
! Seizuies
! Sensoiy loss anesthesia
! Special sensoiy ueficits (olfactoiy, auuitoiy, visual)


#<),. :0= @.'0-0,./,F Acute when symptoms last < 6 months,
peisistent if symptoms last > 6 months.
! Also impoitant to specify whethei a psychological stiessoi is
piesent
292



K#5!>!>?$A 6>A?"67"



Patients with factitious uisoiuei aie pietenuing to have an illness
anuoi inuucing an illness in oiuei to obtain meuical attention.
Factitious uisoiuei imposeu on anothei (pieviously known as
'Factitious uisoiuei by pioxy') is seen whenevei a caiegivei, often a
paient, fakes oi inuuces an illness in a chilu so they can obtain meuical
attention. Those in the meuical fielu aie most likely to fake an illness
because they know the main signs anu symptoms, with the most
commonly fakeu symptoms being uI, u0, caiuiac, oi ueimatological.


!! Factitious uisoiuei imposeu on anothei is always consiueieu chilu
abuse, anu thus must be iepoiteu to the appiopiiate authoiities.
!! 0ften, patients have a histoiy of illness that iesulteu in theii
enjoyment of being caieu foi.
!! School, woik, anuoi ielationships often suffei as a iesult of the
patient's pieoccupation with the illness.

! Willingness to unueigo invasive anu unnecessaiy pioceuuies oi
meuications in oiuei to confiim the seiiousness of the illness.
29S


@#>L 6>A?"67"

The new ciiteiia foi pain uisoiuei take into account patients who
have puiely psychological pain, patients who have meuical causes
of pain, anuoi a combination of both. Because it is often uifficult to
ueteimine whethei pain is psychological oi not, we no longei class
them sepaiately.
294






29S



























#6w$A!%7L! 6>A?"67"
296
!?@>5AF
35#2#;,*2"',";'
-=4DDD1/0*'
)#%#$*+*%,
297
5O#"#5!7">A!>5A



Aujustment uisoiuei is seen whenevei someone iesponus in a negative
way to a change in theii life. Those who unueigo some soit of stiessful
event will expeiience eithei a noimal giief ieaction oi a malauaptive
ieaction.


LB'*(D G'-.; !! Is the noimal iesponse seen whenevei someone
unueigoes a change anuoi stiessful event in life. Patients in this
categoiy can function noimally.
%(D(2(+,-:. ".0+B/0. !! Leaus to an aujustment uisoiuei, acute
stiess uisoiuei, oi biief psychotic uisoiuei. Patients in this categoiy
cannot function noimally.





#2W)0,*./, 6-0B'2.' !! In the BSN-v, this categoiy has been
ieconceptualizeu as a stiess-iesponse synuiome. It is no longei a stiict
uiagnosis, iathei a uiagnosis exploieu when a patient uoesn't meet the
full set of ciiteiion foi othei uisoiueis. Typically a patient with an
aujustment uisoiuei expiesses a uepiesseu moou, symptoms of anxiety,
oi conuuct uistuibances.

298

LB'*(D ".0+B/0. !! Seen when psychological uiscomfoit follows a
stiessoi, howevei no impaiiment is seen in one's life.


LB'*(D G'-.; ".(<,-B/ !! A stiong emotional iesponse aftei a loss of
something oi someone veiy close to them.
299
#<),. A,'.00 6-0B'2.' !! A uisoiuei wheieby theie aie multiple
psychological symptoms seen within the month of the stiessoi (2
uays - 4 weeks). These symptoms last two uays to foui weeks aftei
stiessoi, aftei which a uiagnosis of PTSB shoulu be exploieu.

".(<,-:. #,,(<3*./, 6-0B'2.' ! Theie aie 2 sub-uivisions of
ieactive attachment uisoiuei, which is baseu upon olu BSN-Iv sub-
types: Reactive attachment uisoiuei anu Bisinhibiteu social
engagement uisoiuei.
M+,'0)?+ !00,'12+(0 R)%$;.+;: incompletely foimeu piefeiieu
attachments to caiegiving auults. Patients uemonstiate a uampeneu
positive affect towaius caiegivei.
R)%)(1)-)0+. 9$'),# 3(A,A+2+(0 R)%$;.+;: moie closely iesembles
ABBB, wheieby chiluien typically have bonueu attachments to
caiegiveis.


Suu






%#L#G7%7L!



Suppoitive theiapy is the management of choice, helping the patient
auapt to the stiessful even as well as give them tools to cope with the
new changes. uioup theiapy is often effective, as it gives those with the
uisoiuei an empathetic enviionment (highly effective). Anytime
patients suffei fiom anxiety, uepiession, oi insomnia in auuition to the
aujustment uisoiuei, it is iecommenueu to tieat phaimacologically.


91$;0DDD0+;2 !! Lasts no longei than six months aftei the stiessoi.
O$(ADDD0+;2 !! Lasts longei than six months aftei the onset of the
stiessoi.
Su1
























>%@$HA7 5?L!"?H 6>A?"67"A
Su2
!?@>5AF
>%,*2+",,*%, IK07&'"G* !"'&2.*2
_7*0,&+#%"#
E/2&+#%"#
12";5&,"77&+#%"#
E#,5&7&$";#7 A#+47"%$
>%,*2%*, A#+"%$ !VW
SuS
>L!7"%>!!7L! 7c@H?A>M7 6>A?"67"



Is a uisoiuei chaiacteiizeu by a peiiou wheieby the patient loses self---
contiol anu attacks anothei peison. Theie is usually no cause foi these
attacks. Is seen moie commonly in men as a iesult of a ueciease in
seiotoneigic activity.


!! Tieat with SSRI's

!! 0sually woisens until miuule---age is ieacheu

!! Patients often have unhealthy ielationships






PH7@!?%#L>#



Is a uisoiuei wheie patients have the impulse to take things without
paying foi them. The action is not uone in angei oi uefiance, but is uue
to the lack of impulse contiol.

Su4

!! Seen most commonly in those with concuiient bulimia neivosa (up
to of patients).
!! 0sually uue to a uysfunctional upbiinging.

!! SSRI's anu aveisive conuitioning aie the tieatment moualities of
choice.
!! The conuition is chionic anu usually enus only when a patient is

caught anu incaiceiateu.
SuS
@["?%#L>#



Chaiacteiizeu by one's impulse to stait fiies (iepetitively). A patient's
uesiie to stait fiies often puts them into caieeis wheieby they have easy
access to fiies.


!! Is moie common in males.

!! 0sually seen in those with chiluhoou pioblems.

!! SSRI's aie the management of choice

!! When staiteu in chiluhoou theie is a goou piognosis, when staiteu in
auulthoou theie is a pooi piognosis.





!">5O?!>HH?%#L>#



Chaiacteiizeu by a patient's impulse to pull out theii haii, iesulting in
haii loss.

Su6

!! Noie common in females.

!! 0sually onset in chiluhoou.

!! Piecipitateu by stiess anuoi uepiession.

!! SSRI's aie the management of choice.

!! Is usually a chionic conuition.
Su7
@#!O?H?G>5#H G#%4H>LG



AKA "uambling Bisoiuei". Chaiacteiizeu by an oveiwhelming neeu to
gamble. This usually leaus to loss of financial stability anu theiefoie
tiouble with family, fiienus, anu woik.


!! Associateu with a tioubleu chiluhoou, ABBB as a chilu, anu majoi
uepiessive uisoiuei.
!! Is usually chionic anu lifelong.

!! uamblei's anonymous is the tieatment mouality of choice.



>L!7"L7! #66>5!>?L 6>A?"67"



INP0RTANT N0TE: Inteinet auuiction uisoiuei is not listeu in the BSN-v,
although it is cuiiently a topic of stuuy among the behavioialpsychiatiic
woilu, anu will likely be incluueu in the next ielease.
Su8






















K??6 #L6 7#!>LG 6>A?"67"A
Su9
!?@>5AF
@G&".#%, V
O*',2";,"G* C&&.
>%,#9* !"'&2.*2

@%&2*K"# S*2G&'#

F=7"+"# S*2G&'#

W4*'",/
S1u
>%@?"!#L! 5O#"#5!7">A!>5A



The BSN-v has maue significant changes to the foou & eating uisoiueis
umbiella because many patients weie uiagnoseu in the past with 'N0S'
conuitions, as they uiu not fit into an Anoiexia oi Bulimia Neivosa
uiagnosis. It was founu that many of the N0S patients actually hau a
Binge-Eating uisoiuei, anu thus it has been auueu to the spectium of
foou & eating uisoiueis. Patients with eating uisoiueis often have
paiticulai patteins of behavioi, which aie impoitant foi physicians to
iecognize. Some of the impoitant behavioial chaiacteiistics incluue:


!! They have a noimal appetite.

!! They go to extieme measuies to avoiu gaining weight.

!! They have uistoitions of theii bouy image.

!! Females almost always have menstiual iiiegulaiities uue to the
suppiession of the hypothalamic---pituitaiy axis.





Eating Bisoiuei Infoimation:

S11
!! They aie almost always seen in females (1u:1 F:N).

!! The most likely time of onset is late auolescence.

!! Those who aie highei achieveis aie most likely to uevelop an eating
uisoiuei.
!! Eating uisoiueis aie iaie in societies wheie foou is not abunuant.

!! 0nset usually follows a stiessful event in one's life.
S12

4>LG7 7#!>LG 6>A?"67"F
Pieviously known as an eating oiuei not otheiwise specifieu, the
uiagnosis is often times now a binge-eating uisoiuei. It is uefineu by
iecuiiing episoues of eating laige amounts of foou in a shoit peiiou of
time (gieatei than the aveiage peison woulu consume), even when the
patient is not hungiy.

The conuition is associateu with maikeu peisonal uistiess. Anu while it
is a much less commonly uiagnoseu conuition, it can be quite seveie
anu leaus to significant physical anu psychological tiauma.

6-(1/B0,-< <'-,.'-(:
! Noie than one binge-eating session pei week ovei a S-month peiiou
! Significant uistiess encounteieu aftei each episoue

%(/(1.*./,: Talk Theiapy






S1S
#L?"7c>#
L7"M?A#



Patients have an oveiwhelming feai of gaining weight, thus they take to
extiaoiuinaiy measuies in oiuei to lose weight oi avoiu gaining weight.
Patients have abnoimal views of eating, usually taking ouu behaviois
when faceu with foou (cutting into small pieces, uiviuing foou gioups,
etc).


@390-<(D 53('(<,.'-0,-<0 B; #/B'.V-(F

!! Lanugo (thin haii all ovei the bouy).

!! Loss of > 1S% of bouyweight.

!! Amenoiihea.

!! Netabolic aciuosis.

!! Anemia



%(/(1.*./,:

!! Initial management involves helping iestoie the patient's
electiolytes.
S14
!! Family theiapy may be neeueu if theie aie family uynamic pioblems.

!! uaining weight to biing them to a healthy bouyweight is iequiieu.

!! Behavioial theiapy is the coineistone of management.



#/B'.V-( `'.YYY;..2-/18 A9/2'B*.F

!! Seen 2---S weeks aftei initial management, patients piesent with
seveie hypophosphatemia
!! uive Iv phosphate ieplacement.
S1S
4$H>%># L7"M?A#



A uisease wheieby patients binge (eat excessively) anu puige (vomit
aftei meal), in oiuei to maintain a low bouyweight. Nost of the time,
bingeing is uone in seciet. Patients have a pooi self---image anu aie
oveily conceineu about weight gain.


>*+B',(/, 53('(<,.'-0,-<0 B; 4)D-*-( L.':B0(F

!! Patients usually have a ielatively noimal bouyweight.

!! Knuckle abiasions, enamel eiosions, anu esophageal uamage is
commonly seen in these patients.
!! Paiotiu glanu inflammation is common.

!! Electiolyte abnoimalities.

!! Nenstiual abnoimalities.



%(/(1.*./,:

!! Behavioial theiapy is the coineistone of management.

!! Family theiapy may be iequiieu if theie aie family uynamic
S16
pioblems.
!! SSRI's aie also commonly useu to suppiess the uiges to binge anu
puige.
S17
?47A>![



0besity is an epiuemic in Noith Ameiica, with moie than 2S% of all
people being oveiweight. 0besity is uefineu as a bouyweight that is >
twenty pounus oveiweight.


>/<'.(0.2 "-0Q0 #00B<-(,.2 I-,3 ?N.0-,9F

!! Bypeitension

!! Caiuiovasculai uisease

!! Biabetes

!! Nusculoskeletal issues



** 0besity is moie common in those in lowei socioeconomic classes.



%(/(1.*./,:

!! Commeicial uiets aie usually only effective in the shoit---teim, with
most people ie---gaining all lost weight within five yeais.
S18
!! Long---teim weight loss is best achieveu with a sensible uiet anu
exeicise plan.
S19






















@7"A?L#H>![ 6>A?"67"A
S2u
!?@>5AF

37=',*2 @ E*2'&%#7",/ !"'&2.*2'
37=',*2 F E*2'&%#7",/ !"'&2.*2'
37=',*2 3 E*2'&%#7",/ !"'&2.*2'
S21
>L!"?6$5!>?L



A peisonality uisoiuei is uiagnoseu whenevei someone's pattein(s) of
behavioi aie beyonu what society ueems as noimal behavioi. Those
with peisonality uisoiueis will make othei people uncomfoitable in
some way oi anothei, at which point tieatment is usually sought.


53('(<,.'-0,-<0 B; @.'0B/(D-,9 6-0B'2.'0F

!! Patients usually have little insight into theii uisoiuei.

!! Patients only seek help when they aie piompteu to uo so by otheis.

!! Patients uo not have uisabling symptoms, just uistuibing symptoms.

!! Bisoiueis must be piesent by eaily auulthoou






5H$A!7" # @7"A?L#H>![ 6>A?"67"A



These uisoiueis encompass behavioial patteins that aie peculiai,
S22
feaiing of social ielationships, anu usually have a familiai oi genetic
association with psychotic illness.


@('(/B-2 !! Aie uistiustful anu suspicious of otheis, anu attiibute the
iesponsibility foi theii own pioblems to otheis.
A<3-TB-2 !! Patients have a long---stanuing pattein of voluntaiy social
withuiawal, theie is no psychosis seen.
A<3-TB,9+(D !! Patients have an ouupeculiai appeaiance, have an ouu
thought patteinbehavioi, anu have magical thinking.
S2S
5H$A!7" 4 @7"A?L#H>![ 6>A?"67"A



Patients with Clustei B peisonality uisoiueis aie oveily emotional,
uiamatic, anu behave in an inconsistent pattein.


O-0,'-B/-< !! Patients aie emotional, sexually piovocative, anu
theatiical. They have tiouble maintaining intimate ielationships uue to
this unstable behavioi.
L('<-00-0,-< !! Patients have a sense of entitlement anu believe they aie
bettei than otheis. They uon't empathize with otheis anu always put
the blame on otheis. They aie oveily sensitive to ciiticism.

#/,-0B<-(D !! Patients uo not confoim to social noims, often bieaking
the law, haiming otheis, anu lacking any iemoise foi these behaviois.
Conuuct uisoiuei is a pie---cuisoi to antisocial peisonality uisoiuei.
4B'2.'D-/. !! Patients behave eiiatically anu with impulse. They often
engage in self---haiming behaviois anu expeiience episoues of sub---
psychotic behavioi.

L?!7: 5>>$%)0)$(,# .+&),(0 .)%$;.+;, while often uiscusseu alongsiue
anti-social peisonality uisoiuei, is not a piecuisoi to its uevelopment.
The chaiacteiistics of 0BB incluue: Angiyiiiitable moou,
aigumentativeuefiant behavioi, anu vinuictiveness (Thus, the
S24
conuition consists of both emotional anu behavioial symptoms)



























S2S








5H$A!7" 5 @7"A?L#H>![ 6>A?"67"A



Patients with Clustei C peisonality uisoiueis aie oveily feaiful oi
anxious.


#:B-2(/, !! Patients aie oveily sensitive to iejection, socially
withuiawn, anu have excessive feelings of infeiioiity.
S26
6.+./2./, !! Patients will allow otheis to make uecisions foi them,
anu often won't uo anything without consent fiom anothei. 0ften theii
self---confiuence is veiy low.
?N0.00-:.YYY5B*+)D0-:. !! Patient is oveily conceineu with oiuei anu
cleanliness. Patients feel as though things must always be peifect, anu
become annoyeu when they aien't. They aie also veiy stubboin.





%(/(1.*./,:

!! The only peisonality uisoiuei in which we use meuications is
Boiueiline peisonality uisoiuei, wheie anti---psychotics anu anti---
uepiessants aie commonly helpful.
!! Neuications can be useu when patients aie oveily anxious anuoi
uepiesseu.
!! Psychotheiapy is useful foi patients with peisonality uisoiueis.

!! Peisonality uisoiueis aie usually life---long anu aie non---cuiative.
S27





















G7">#!">5 @A[5O>#!"[
5?L6>!>?L
S28
!?@>5AF @$"%$V35#%$*' &6
>%;2*#'*. @$* !*#,5 &
F*2*#G*+*%,
!*02*''"&% "% ,5* I7.*27/
S29
#G>LG



O)&+ 3Q>+'0,('=:

!! The aveiage lifespan in the 0niteu States is 7S.S yeais.

!! Women life appioximately seven yeais longei than men.

!! Caucasians tenu to live between six to eight yeais longei than Afiican

Ameiicans.

!! The most impoitant factoi affecting life expectancy is genetics.






71)(A% 01,0 '1,(A+ /)01 )(';+,%+. ,A+:

!! Bloou flow uecieases (to biain, heait, kiuneys, uI tiact).

!! Bone mineial uensity uecieases (mainly in post---menopausal
women).
!! vision anu heaiing acquity uecieases.

!! Taste sensation uiminishes.
SSu

!! Fatty accumulation incieases.

!! Nuscle mass uecieases.

!! Tempeiatuie iegulation is uiminisheu.

!! Biain sizeweight uecieases.

!! Nemoiy capabilities ueciease.

!! Plaques uevelop in the biain (woise in uementia).
SS1
71)(A% 01,0 0+(. 0$ #+(A01+( #)&+%>,(:

!! Euucation (those with moie euucation tenu to live longei anu stave---

off uementia).

!! Naiiiage.

!! Continueu physical fitness.






67#!O #L6 47"7#M7%7L!



Beieavement is a peison's emotional iesponse to the loss of a loveu one.
Theie aie five unique stages to the piocess of giieving, all of which aie
eventually encounteieu uuiing the giieving piocess. All stages aie not
necessaiily expeiienceu in the paiticulai oiuei mentioneu below:


6./-(D: Patient's iefusal to accept what has happeneu.

#/1.': Patient uemonstiates feelings of angei, which may be uiiecteu
towaius themselves oi otheis.
SS2
4('1(-/-/1: Naking a ueal with a supeinatuial powei in oiuei to
ieveise the pioblem (unuoing).
6.+'.00-B/: Noimal uepiessive symptoms being.

#<<.+,(/<.: Peison accepts the situation.
SSS
Theie is often times an oveilap between noimal giief anu uepiession. It
is impoitant to exploie the patient's iesponse to the loss anu ueteimine
if they aie in fact expeiiencing noimal giief oi pathological giief.


X$;2,# N;)+&<

!! Sauness without uepiessive symptoms.

!! Nilu weight loss, sleep uistuibances, anu guilt.

!! Illusions of seeing the ueceaseu.

!! Patients make an attempt to ietuin to noimal activities of life.

!! Seveie symptoms iesolve within two months.



** uioup theiapy is a gieat stiategy foi helping the giieving to cope with
theii loss.


8,01$#$A)',# N;)+&<

!! Bepiessive symptoms

!! Significant weight loss, sleep uistuibance, anu guilt.

SS4
!! Consiueisattempts suiciue.

!! Symptoms last foi moie than two months.

!! Noueiate symptoms may last moie than one yeai.
SSS
67@"7AA>?L >L !O7 7H67"H[



Bepiession is the most common moou uisoiuei seen in the elueily
population. 0ften times, uepiession in the elueily is a iesult of the
losses acquiieu with olu age, such as:


!! !*#,5 &6 # 7&G*. &%* T!*02*''"&% #' # 2*'=7, &6 .*#,5 &6 # 7&G*. &%* 7#',"%$
PDQ /*#2' "' %&: :5#, "' 2*Z="2*. ,& +#9* # ."#$%&'"' &6 4*2*#G*+*%,U

!! !"+"%"'5*. 5*#7,5.

!! B&'' &6 ,5*"2 #4"7",/ ,& :&29 (Eithei ietiiement oi foiceu ietiiement).



Bepiession in the elueily often looks just like Alzheimei's uementia,
theiefoie it is impoitant to always inquiie about uepiession befoie
jumping to a conclusion of Alzheimei's uisease. Beliiium is also
commonly seen in the elueily, which is often a iesult of conuitions such
as:


!! S=,2","&%#7 .*6";"*%;"*'

!! E5/'";#7 "77%*''

SS6
!! )*.";#,"&% '".*DDD*66*;,'
SS7
@,(,A+2+(0 $& .+>;+%%)$( )( 01+ +#.+;#=<



!! SSRI's aie safe anu effective foi the tieatment of uepiession.

!! TCA's aie useu in iefiactoiy cases, howevei it is impoitant to have
patients use anticholineigic meuications at nighttime, as to pievent falls
associateu with the siue---effects.
!! NA0I's aie not geneially inuicateu in the elueily population because

of the incieaseu iisk of hypeitensive ciisis.
SS8





















6>A?"67"A ?K AH77@
SS9
!?@>5AF

S&2+#7 -7**0

3&++&% 3#='*' &6 -7**0 !"'&2.*2
3&++&% -7**0 !"'&2.*2'
E*."#,2"; -7**0 !"'&2.*2'
B*'' 3&++&% -7**0 !"'&2.*2'
S4u
L?"%#H AH77@



Theie aie a few impoitant stages of sleep, which aie uiviueu into thiee
geneial sections. The awake phase, the non---uieaming stages of sleep,
anu the uieaming phase of sleep. The EEu is the iueal tool useu foi
chaiacteiizing the uiffeient phases of sleep, which aie outlineu below.


A,(1.F @:#9*

!! Beta waves, associateu with active mental concentiation.

!! Alpha waves, associateu with eyes closeu while awake.



A,(1. aF 15*,# :#G*'

!! Appioximately five---peicent of time is spent in this stage.

!! Is the lightest stage of sleep.

!! Respiiation, pulse, anu bloou piessuie ueciease.

!! Nay see episouic bouy movements in this stage.



S41
A,(1. RF -7**0 '0"%.7*' [ _DDD;&+07*K*'

!! Appioximately foity---five peicent of time is spent in this stage (the
gieatest amount of time in any stage).


A,(1. j d fF !*7,# :#G*'

!! Consiueieu 'slow---wave' sleep stage.

!! Appioximately twenty---five peicent of time is spent in this stage.

!! Is the ueepest, most ielaxing stage of sleep.
S42
!! Is a common stage of ceitain uisoiueis (Sleepwalking, Enuiesis,
Night Teiiois).


A,(1.: OI)

!! Appioximately twenty---five peicent of time is spent in this stage.

!! Time spent in REN uecieases with age, uecieases with ET0B

intoxication.

!! Is the uieaming phase.

!! Incieaseu pulse, bloou piessuie, anu iespiiation.

!! Complete ielaxation of skeletal muscle.

!! Penile anu clitoial tumescence occuis in this stage.

!! REN latency (time until fiist REN cycle) takes ninety---minutes on
aveiage.
!! REN peiious occui foi ten to twenty minutes eveiy ninety---minutes
thioughout the night.
!! "REN iebounu" is a phenomenon wheieby a peison lacking REN

sleep with catch---up the following night.
S4S
E2&0*2 '7**0 2*Z="2*' "%;2*#'*. 7*G*7' &6 ;*2,#"% %*=2&,2#%'+",,*2'<
"%;7=."%$8


A.'B,B/-/: Incieaseu S---BT is neeueu to inciease the time spent
sleeping as well as uelta wave sleep.
6B+(*-/.: Incieaseu uopamine levels tenu to ueciease sleep time.
LB'.+-/.+3'-/.: Incieaseu NE will ueciease the total sleep time anu
the oveiall time spent in REN sleep.





5?%%?L 5#$A7A ?K AH77@ 6>A?"67"A



The two main categoiical causes of sleeping uisoiueis incluue Physical
causes anu Psychological causes.


@390-<(D 5()0.0:

!! )*.";#7 ;&%.","&%' (Enuociine uisoiueis, pain uisoiueis).

!! M",5.2#:#7 &6 '*.#,"G*' (ET0B, benzouiazepines, opiates).

S44
!! IK;*''"G* ='* &6 ',"+=7#%,' (Caffeine, Amphetamines).



@09<3BDB1-<(D 5()0.0:

!! F"0&7#2 ."'&2.*2

!! )#]&2 .*02*''"G* ."'&2.*2

!! @%K"*,/ ."'&2.*2' (specific, geneial)
S4S
5?%%?L AH77@ 6>A?"67"A



Theie aie two main categoiies of sleep uisoiueis, they incluue:

!! R=%%$2(),%

!! 8,;,%$2(),%



6900B*/-(0: Aie chaiacteiizeu by uisiuption in the quality anu
quantity of sleep. Najoi uyssomnias incluue:
!! 4(%$2(), (Tiouble falling anu staying asleep)

!! Bifficulty falling asleep at least Sxweek foi 1 month

!! 0ften a sign of impenuing uepiessionanxiety

!! V=>+;%$2($#+%'+('+ .)%$;.+; (excessive sleepiness uespite at least 7hi
of sleep anuoi piolongeu sleep time (>9hi) that is non-iestoiative anuoi
uifficulty being fully awake aftei abiupt awakening.

!! X,;'$#+>%= (Expeiience sleep attacks - Sxweek foi at least S months)

!! Shoit REN latency

!! Bypnagogichypnopompic hallucinations

S46
!! Sleep paialysis (lasts foi a few seconus)

!! 9#++> ,>(+, (Cential anu 0bstiuctive)

!! Cential is causeu by a lack of iespiiatoiy uiive (elueily)

!! 0bstiuctive (most common) uue to obstiuction


! 9#++>DM+#,0+. V=>$?+(0)#,0)$( (episoues of uecieaseu iespiiation
associateu with elevateu levels of Cu2)

! :);',.),( M1=012 9#++>DS,B+ R)%$;.+;% (peisistent oi iecuiiing
pattein of sleep uisiuption that is piimaiily uue to an alteiation of the
ciicauian system oi to a misalignment between the enuogenous ciicauian
ihythm anu the sleep-wake scheuule iequiieu by an inuiviuual's physical
enviionment oi socialpiofessional scheuule)
S47
@('(0B*/-(0: Aie chaiacteiizeu by physiological oi behavioial
changes associateu with a lack of sleep. Najoi paiasomnias incluue:
!! 9#++>/,#B)(A (Begins in chiluhoou, no conscious iecollection of

walking while sleeping)

!! 9#++> 0+;;$;% (Awakening with teiioi, no iecollection)

!! X)A102,;+ .)%$;.+;% (Repetitive, fiightening uieams that
cause nighttime awakening)
! X$(DM3@ %#++> ,;$*%,# .)%$;.+; (iecuiiing episoues of
incomplete awakening, often accompanieu by sleepwalking
anuoi sleep teiiois)
! M3@ 9#++> J+1,?)$; R)%$;.+; (iepeateu episoues of aiousal
uuiing sleep associateu with vocalization anuoi complex motoi
behaviois)
! M+%0#+%% O+A 9=(.;$2+ (uige to move the legs, usually
accompanieu by oi in iesponse to uncomfoitable anu unpleasant
sensations in the legs)
! 9*-%0,('+Y@+.)',0)$(D4(.*'+. 9#++> R)%$;.+; (Seveie anu
obvious sleep uistuibance occuiiing uuiing oi soon aftei
substance intoxication oi aftei withuiawal fiom exposuie to a
meuication - N0TE: The substance must be one capable of
causing a uistuibance)
! 501+; 9>+')&)+. 4(%$2(), R)%$;.+; (any situation that is
chaiacteiistic of insomnia uisoiuei, leauing to impaiieu social oi
S48
occupational uistuibances, yet not meeting the full ciiteiia of
othei insomnia uisoiueis)
! 6(%>+')&)+. 4(%$2(), R)%$;.+; (any situation chaiacteiistic
of insomnia that uoesn't meet the full ciiteiia foi insomnia
uisoiuei oi any of the uisoiueis in the sleep-wake uisoiuei
uiagnostic class.
S49

H7AA 5?%%?L AH77@ 6>A?"67"A
%./0,')(DYYY#00B<-(,.2 A9/2'B*.:

!! Bypeisomnia that occuis pie---menstiually.



5-'<(2-(/ "39,3* AD..+ 6-0B'2.':

!! Sleepawake patteins that occui at inappiopiiate times of the uay.



PD.-/.YYYH.:-/ A9/2'B*.:

!! Recuiiing peiious of hypeisomnia anu hypeiphagia that last one to
thiee weeks.
!! Seen most commonly in auolescent boys.



AD..+ 6')/Q.//.00:

!! A genetic conuition wheieby patients have significant tiouble waking
up, uespite getting auequate sleep.
SSu





















7!O>5A d H7G#H
%#!!7"A >L @A[5O>#!"[
SS1
!?@>5AF
3&%6".*%,"#7",/
>%6&2+*. 3&%'*%,
>+0#"2*. E5/'";"#%
O*0&2,#47* >77%*''*'
I,5";' [ @>!-V?>L
@.G#%;*. !"2*;,"G*'
O"$5, 1& !"*
)#702#;,";*
SS2
5?LK>67L!>#H>![



Physicians aie iequiieu to keep confiuentiality in the majoiity of cases,
howevei aie not iequiieu to uo so when the thieat of haiu is maue to
themselves oi otheis.


:$(&).+(0),#)0= ',( -+ -;$B+( )( 01+ &$##$/)(A ');'*2%0,('+%<

!! If you suspect the patient may attempt suiciue (always ask a patient if
they aie consiueiing suiciue).
!! If you suspect chilu oi eluei abuse.

!! If you suspect oi heai that theie is a thieat to anothei's safety.



4& =$* &++# 01,0 =$* 2*%0 -;+,B '$(&).+(0),#)0=f 0,B+ 01+ &$##$/)(A
,'0)$(%<
!! Notify the appiopiiate authoiities.

!! Aumit the patient to the appiopiiate hospital setting.

!! Ensuie that anybouy who is in uangei is notifieu (Taiasoff uecision)



SSS



>LK?"%76 5?LA7L!



Infoimeu consent iequiies you to infoim youi patient of a few specifics
befoie they can give you consent to a pioceuuie.


8,0)+(0% 2*%0 -+ )(&$;2+. $& 01+ &$##$/)(A<

!! The conuition at hanu.
SS4
!! The iueal tieatment anu any alteinative tieatments.

!! Benefits anuoi iisks of the pioceuuie as well as the benefits anuoi
iisks of not having the pioceuuie.
!! The expecteu outcome if consent is not given.

!! That the patient can ieveise hishei uecision at any time befoie the
stait of the pioceuuie.


42>$;0,(0 7$ H++> 4( @)(.<

!! Shoulu always get wiitten consent via signatuie.

!! Any finuings uuiing suigeiy that aie non---emeigency iequiie anothei
infoimeu consent.
!! Family membeis cannot give consent unless they aie the immeuiate

next of kin (in cases wheie the patient cannot give consent).

!! You aie not obligeu to give any infoimation to family membeis

(ieveiseu if the patient gives consent).






SSS
>/;B'*.2 5B/0./, >/ !3. 5(0. ?; %-/B'0F

!! The piimaiy caiegiveipaient is the only peison who can give
consent to the management of a minoi.
!! If a minoi is at iisk of uangei anu the paientscaiegivei cannot be
locateu, you can pioceeu without consent.
!! When a paientguaiuian iefuses to allow life---sustaining tieatment
foi a minoi, you can get a couit oiuei in oiuei to pioceeu (ie. If they
iefuse tieatment foi ieligious ieasons).
SS6
S1+( )% 8,;+(0,# :$(%+(0 X$0 M+c*);+.Z

!! Foi contiaceptive piesciiptions.

!! Foi STB management.

!! When theie is an emeigency.

!! Foi the management of uiug anuoi ET0B uepenuence.

!! Foi the caie of a piegnancy.



S1,0 :$(%0)0*0+% !( 32,(')>,0+. @)($;Z

!! They aie maiiieu.

!! They aie caiing foi theii own chilu.

!! They aie suppoiting themselves financially.

!! They aie eniolleu in the militaiy.








SS7
# 5#A7 ?K #L >%@#>"76 @O[A>5>#L



Theie aie commonly encounteieu situations wheieby a colleague is
incapacitateu in some way, shape, oi foim. Some of the most common
ways you might encountei an impaiieu physician aie:
!! Nental Illness

!! Physical Illness

!! BiugET0B Abuse

!! Age---ielateu Illness
SS8
S1,0 )% ;+c*);+. $& =$* /1+( , '$##+,A*+ )% )2>,);+.Z

As a licenseu physician in the 0niteu States, you aie legally anu ethically
obligateu to iepoit this peison. The two main ieasons why this is a
necessity aie:
!! To ensuie no patient is at iisk of negligence.

!! To ensuie the physician gets the appiopiiate help.
























SS9
"7@?"!#4H7 6>A7#A7A




S6u
Hepatitis C,acute

Hepatitis C,past or present

H VInfection (AIDS has been reclassified as H V Stage III}
Innuenza -associated pediatric mortality
Invasive Pneumococcal Disease

Legionellosis
Listeriosis
Lyme disease
Malaria
Measles
Meningococcal disease

Mumps

Novel innuenza A virus infections

Pertussis Plague
Poliomyelitis,paralytic
Poliovirus infection,nonparalytic

Psittacosis Q
fever
Rabies,animal
Rabies,human
Rubella
Rubella,congenital syndrome

Salmonellosis

Severe Acute Respiratory Syndrome-Associated Coronavirus Disease
S61




O)%0 '$*;0+%= $& 01+ :R:f TUCT X,0)$(,##= M+>$;0,-#+ R)%+,%+%g
S62
7!O>5A d #>6AJO>M



Bue to the significant moitality associateu with acquiiing BIvAIBS,
theie aie often issues faceu when a physician is not comfoitable in
inteiacting with this patient. The following is a list of common
scenaiios that will help claiify what is anu is not expecteu of a physician.



! >1=%)'),( ;+&*%+% 0$ 0;+,0 ,( V4FDDD>$%)0)?+ >,0)+(0Z 4% 01)% +01)',##=
;)A10Z
!! No, ethical piinciples manuate that a physician tieats this patient

uespite the iisks poseu.



! >1=%)'),( )% >;)'B+. -= 01+ %,2+ (++.#+ 01,0 /+(0 )(0$ ,( V4FDDD

>$%)0)?+ >,0)+(0g 4% )0 ;)A10 &$; 1)2Y1+; 0$ .+2,(. ,( V4F 0+%0Z

!! Yes, the physician shoulu be testeu in oiuei to maintain theii safety
anu the safety of otheis. This is howevei not a legal iequiiement.


h$*; '$##+,A*+ )% V4FDDD>$%)0)?+f %1$*#. =$* -+ ;+&+;;)(A >,0)+(0% 0$
S6S
01)% V4FDDD>$%)0)?+ >1=%)'),(Z
!! Yes, as long as the physician is competent anu is taking the
appiopiiate piotective piecautions then theie is no ethical uilemma in
this situation.
S64
h$*; V4FDDD>$%)0)?+ >,0)+(0 )% >*00)(A 1+; 1*%-,(. ,0 ;)%B $& )(&+'0)$(f
%1$*#. =$* 0+## 1)2Z
!! Yes, if a patient is having unpiotecteu sex in this situation then it is

youi iesponsibility to infoim him of his wife's BIv status. If conuoms
aie being useu then you aie not obligateu to say anything. Initially, you
shoulu tiy to convince youi BIv---positive patient to uisclose hei BIv
status to hei husbanu.




#6M#L576 6>"75!>M7A



The @.G#%;*. !"2*;,"G* is a legal statement of instiuction, inuicating
what shoulu be uone in the case of an emeigency situation. Two foims
of the auvanceu uiiective incluue the B"G"%$ M"77 anu the !=2#47* E&:*2
&6 @,,&2%*/.


O)?)(A S)##<

!! A uocument wheieby the patient states what heshe wishes to be
uone in case heshe becomes unable to give uiiections.
!! If a living will is in place, no othei peison's wishes can oveiiule the
S6S
wants anu wishes of the patient's living will.


R*;,-#+ 8$/+; $& !00$;(+=<

!! A uocument wheieby a patient uesignates anothei peison to
iepiesent them in case theie is a neeu foi meuical uecisions.
S66
!! In case of BPA, nobouy else can act as the uecision---makei except that
peison who is uesignateu.




!O7 ">GO! !? 6>7



The iight to uie is a tiicky issue because sometimes the iules uo not
quite make sense to all physicians. Bowevei, theie aie a few cleai cut
iules that can make the topic much easiei to unueistanu.


!! A patient who is competent has the iight to iefuse lifesaving
tieatment foi himheiself, foi any ieason, even if ueath is likely to
occui.
!! A paientguaiuianpiimaiy caiegivei cannot iefuse tieatment foi a
minoi unuei theii caie, foi any ieason. In an emeigency situation, a
physician has the iight to act in the minoi's best inteiest without
peimission fiom the caiegivei oi the couits. In a non---emeigency
situation, a couit---oiuei must be obtaineu befoie tieatment is initiateu.
!! A piegnant woman has the iight to iefuse any anu all tieatment, even
if that means the fetus will be injuieu oi uie. The patient must be
competent in oiuei to make this uecision.
!! A competent patient has the iight to stop aitificial life---suppoit, even
S67
if this will iesult in ueath.
S68
42>$;0,(0 #+A,# )%%*+% ,% )0 >+;0,)(% 0$ ;)A10 0$ #)&+<



!! In oiuei to be ueemeu legally competent to accept oi iefuse meuical
tieatment, a patient must fiist fully unueistanu the iisksbenefits of the
tieatment, as well as the likely outcome that woulu iesult if they iefuseu
the tieatment.
!! Ninois aie not ueemeu competent unless they aie emancipateu.

!! When a patient's competence is in question, a juuge will have to make
the final uecision as to whethei they aie in fact competent oi not.
!! Nental ietaiuation anuoi othei illnesses uo not always immeuiately

ueem a patient incompetent to make theii own uecisions.








%#H@"#5!>57



0ccuis whenevei a physician causes haim to a patient as a iesult of not
following the stanuaius of piactice. The foui B's of malpiactice aie as
S69
follows:
!! R+;+#)'0)$( (A ueviation fiom noimal stanuaiu of caie).

!! R*0= (0f an establisheu uoctoi---patient ielationship).

!! R,2,A+% (Injuiy causeu by physician's negligence).

!! R);+'0#= (Neaning uamages aie not causeu by othei factois).
All CWRO !N' must be met in oiuei to ensuie a successful lawsuit.
S7u
!% , ;+%*#0 $& , 2,#>;,'0)'+ %*)0<

!! Patients ieceive Compensation oi Punitive uamages as a iesult of a
successful lawsuit.
!! Compensation is the most common type of awaiu, which is a financial
ieimbuisement.
!! Punitive uamages aie punishments given to the physician on behalf
of the patient's lawsuit. This is not a financial gain, but iathei is a way
to uemonstiate the physician's caielessness anu set an example foi the
iest of the meuical community.





A7c$#H "7H#!>?LAO>@A I>!O # @#!>7L!



Is always inappiopiiate anu a violation of the ethical stanuaius a
physician is supposeu to live by, whethei a cuiient oi past patient.


!! Sometimes a ielationship is not in violation of ethics if an acceptable
time fiame has passeu fiom the last time you saw the patient
piofessionally (Set by meuical boaius).
!! The majoiity of cases biought upon by patients with the complaint of
S71
an inappiopiiate sexual encountei uo not ieceive compensatoiy
uamages.
S72





















#4$A7 d L7GH75!
S7S
!?@>5AF




53-D2 #N)0.F
-*K=#7 @4='*
E5/'";#7 @4='*
I+&,"&%#7 S*$7*;,



7D2.'D9 #N)0.F
E5/'";#7 @4='*
S*$7*;,



6B*.0,-< #N)0.F
E5/'";#7 @4='*
I+&,"&%#7 @4='*
-*K=#7 @4='*
S74
5O>H6 #4$A7



The main types of chilu abuse incluue: Sexual, Physical, anu Emotional

Neglect.



A7c$#H #4$A7F

!! The majoiity of the time, the abusei is male.

!! The majoiity of the time, the abusei is well---known to the chilu anu
family (< S% of cases aie stiangeis).
!! The majoiity of sexual abuse cases aie nine to twelve yeais of age.

!! Twenty---five peicent of cases aie youngei than eight yeais of age.

!! Twenty---five peicent of females anu twelve peicent of males iepoit
sexual abuse at some point thioughout theii lives.


3?).+('+ $& !-*%e:

!! Tiauma to the analgenital iegion.

!! Piesence of STB (get a swab).
S7S

!! Piecocious sexual behavioi with otheis.

!! Knowleuge about specific sexual acts.

!! Recuiiing 0TI's.

!! Piesence of anxiety, uepiession, oi othei emotional uisoiueis.



:$22$( :1,;,'0+;)%0)'% $& 01+ !-*%+;<

!! They usually have substance abuse pioblem.

!! Commonly have pioblems in theii own maiiiage.

!! Commonly have uepenuent peisonality uisoiuei.
S76
!! 0ften have a peuophilia uisoiuei.



h$*; M$#+ ,% , 81=%)'),(<

!! It is manuatoiy that you iepoit all cases anu suspecteu cases.

!! You aie alloweu to aumit a chilu if you feel they aie at iisk of fuithei
abuse.
!! You aie not obligeu to tell the paients you suspect abuse of any king.





@390-<(D #N)0. d L.1D.<,F

!! Chiluien with some soit of peiceiveu pioblem aie moie commonly
physically abuseu (emotionalmoouetc).
!! Two---thousanu to foui---thousanu cases of abuse iesult in ueath,

annually.

!! The majoiity of abuseu chiluien aie youngei than fifteen yeais of age.



3?).+('+ $& !-*%+<
S77

!! Chilu is lacking in peisonal caie (uisheveleu haii anu clothes, iashes
in uiapei, etc).
!! Chilu appeais malnouiisheu anuoi is not gaining weight

appiopiiately.

!! Cigaiette buins.

!! Fiactuies at uiffeient stages of healing.

!! Spiial fiactuies anuoi chip fiactuies.

!! Immeision buins.

!! Belt maiks.
S78
!! Signs of physical iestiaint on wiists anuoi ankles.



:1,;,'0+;)%0)'% $& ,( !-*%+. :1)#.<

!! They have a histoiy of low biith---weight anuoi piematuiity.

!! They have a histoiy of hypeiactivity oi ABBB.

!! They aie colicky.



:$22$( :1,;,'0+;)%0)'% $& 01+ !-*%+;<

!! They live in poveity.

!! They have a histoiy of substanceET0B abuse.

!! They have a histoiy of being abuseu in some capacity themselves.

!! They have a histoiy of social isolation.








S79
@O[A>5#H #4$A7 d L7GH75! ?K 7H67"H[F

!! Bementia is often a common finuing in abuseu oi neglecteu elueily.

!! The most common abusei of the elueily is a spouse.

!! The majoiity of cases uo not get iepoiteu.



9)A(% $& 3#.+; !-*%+<

!! Signs of pooi peisonal caie.

!! Signs of malnouiishment.

!! Biuising.

!! Physical signs of iestiaint.

!! Fiactuies at uiffeient stages of healing.
S8u
h$*; M$#+ ,% , 81=%)'),( 4( 3#.+; !-*%+<

!! You aie obligeu to iepoit all cases of elueily abuse anu just as with
chilu abuse, you can aumit a patient if you suspect they aie in uangei.





6?%7A!>5 #4$A7F

!! The majoiity of uomestic abuse cases aie not iepoiteu.

!! The majoiity of the time the male is the abusei.

!! It is often uifficult to convince someone that leaving the paitnei is
theii best choice, mainly because they aie:
!! Bepenuent on the spouse (financially, emotionally)

!! They blame themselves

!! They have low self---esteem

!! They have nowheie else to go






S81
:1,;,'0+;)%0)'% $& 01+ !-*%+;<

!! 0ften has a uiug anuoi ET0B pioblem.

!! Is impulsive anu uoesn't toleiate stiess well.

!! Bas a histoiy of uisplacing feelings.

!! Abusei usually has low self---esteem.



71+;+ )% , '$22$( '='#+ $& ,-*%+ %++(f )0 )('#*.+%<

!! Theie is a builuup of tension in the abusei.

!! Theie is abusive behavioi (veibal, Physical).

!! The abusei is apologetic, uemonstiates loving behavioi towaius the
victim, anu is foigiven.
S82


h$*; M$#+ ,% , 81=%)'),( )( R$2+%0)' !-*%+<

!! Pioviue suppoit.

!! Biscuss options foi safety.

!! You aie not iequiieu to iepoit uomestic abuse to the authoiities.






A7c$#H #4$A7 \"#@7^F

Any type of sexual contact without mutual consent is uefineu as sexual
abuse. Theie is no legal iequiiement foi penetiation to occui in oiuei
to make a case foi iape.


:1,;,'0+;)%0)'% $& M,>)%0<

!! The majoiity aie youngei than twenty---five yeais of age.

!! They aie usually of the same iace as the victim.

!! Biugs anuoi ET0B aie a pait of a thiiu of all iape cases.

S8S


h$*; M$#+ ,% , 81=%)'),( )( M,>+ :,%+%< Theie aie thiee stages you
have to go thiough with youi patient:


ra Z >**.2-(,.D9 #;,.' !3. >/<-2./,

!! uet a thoiough histoiy

!! Peifoim a geneial physical examination

!! uet the appiopiiate laboiatoiy tests

!! Consiuei antibiotics anuoi aboitificants if necessaiy

!! Suggest youi patient contact the piopei authoiities
S84


rR Z !EB !B A.:./ 6(90 H(,.'

!! Biscuss emotional anu physical state of the patient

!! uet a piegnancy test

!! Allow youi patient to communicate theii feelings

!! uet a psychiatiic consult foi youi patient

!! Fuithei uiscuss legal implications of the case



rj Z A-V I..Q0 #;,.' >/<-2./,

!! Peifoim anothei physical exam

!! Bo a follow---up laboiatoiy panel

!! Consiuei senuing the patient to counseling if neeueu



32$0)$(,# :$(%+c*+('+%<

!! 0ften times youi patient will uevelop post---tiaumatic stiess uisoiuei.

S8S
!! Counseling in a gioup setting is the most effective foim of tieatment.
S86




















@76>#!">5
@A[5O>#!"[
S87



!?@>5AF

S&2+#7 !*G*7&0+*%,
E*2G#'"G* !*G*7&0+*%,#7 !"'&2.*2'
!*02*''"&%
-*0#2#,"&% @%K"*,/
W00&'","&%#7 !*6"#%, !"'&2.*2
3&%.=;, !"'&2.*2
@,,*%,"&%DDD!*6";", ?/0*2#;,"G",/ !"'&2.*2

1&=2*,,*N' !"'&2.*2
S88
L?"%#H 67M7H?@%7L!



Noimal uevelopment is not an exact science, but on aveiage these aie
the ages by which chiluien have ieacheu milestones. The main
uevelopmental milestones fall unuei the following categoiies:


!! SocialEmotional

!! LanguageCommunication

!! Cognitive (leaining, pioblem---solving skills, thinking)

!! NovementPhysical Bevelopment



I. ,(Q. ( DBBQ (, ,3.0. *-D.0,B/.0 (, ,3. ;BDDBE-/1 (1. 1'B)+0:

!! 2 months

!! 4 months

!! 6 months

!! 9 months

!! 12 months (1 yeai)
S89

!! 18 months

!! 24 months (2 yeais)

!! S6 months (S yeais)

!! 48 months (4 yeais)

!! 6u months (S yeais)
S9u
# 67!#>H76 H??P #! 67M7H?@%7L!#H %>H7A!?L7A



7S5 @5X7V9



AB<-(DJ7*B,-B/(DF

!! Smiling begins

!! Begins puiposeful eye contact with paients



H(/1)(1.J5B**)/-<(,-B/F

!! Coos

!! uuigles

!! Tuins heau towaius sounus



5B1/-,-:.F

!! Facial iecognition

S91
!! Recognizes people



%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Bolus heau up

!! Pushes bouy up when lying on stomach

!! Aim anu leg movement is moie cooiuinateu
S92
E56M @5X7V9



AB<-(DJ7*B,-B/(DF

!! Smiles at people

!! Enjoys playing

!! Nimics facial movement anu expiession



H(/1)(1.J5B**)/-<(,-B/F

!! Babbles

!! Tiies to imitate sounus

!! Tiies to communicate with unique sounus



5B1/-,-:.F

!! Bemonstiates emotion

!! Can ieach foi objects single---hanueu

S9S
!! Begins to uevelop smooth hanu---eye co---oiuination

!! Can follow objects visually

!! Pays gieatei attention to facial uetails

!! Recognizes familiai faces



%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Bolus heau up unsuppoiteu

!! Rolls fiom fiont to back

!! Begins playing with toys

!! Biings hanu to mouth

!! Can push onto elbows fiom lying on stomach
S94
94` @5X7V9



AB<-(DJ7*B,-B/(DF

!! Becomes awaie of stiangeis

!! Plays with otheis

!! Can iesponu to othei people's emotions

!! Recognizes self in ieflection



H(/1)(1.J5B**)/-<(,-B/F

!! Responus to noise by making it's own noise

!! Can stiing vowels togethei when cooing

!! Responus to own name

!! Bemonstiates joy anuoi uispleasuie

!! Begins to use consonants in sounus



S9S
5B1/-,-:.F

!! Cuiiosity about things neaiby

!! Passes object fiom one hanu to the othei



%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Can ioll ovei in both uiiections

!! Can sit up without suppoit

!! Can suppoit own weight on legs

!! Rocking back anu foith seen
S96
X4X3 @5X7V9



AB<-(DJ7*B,-B/(DF

!! Feai of stiangeis

!! Bevelops clinginess to familiai auults

!! Bas favoiite toys



H(/1)(1.J5B**)/-<(,-B/F

!! Will unueistanu the woiu 'N0'

!! Nakes seveial uiffeient sounus

!! Copies the sounus anu gestuies of otheis

!! Points at things



5B1/-,-:.F

!! 0nueistanu when things aie hiuuen

S97
!! Plays 'peek a boo'

!! Noves things smoothly fiom one hanu to the othei

!! Bas well---uevelopeu pincei giasp



%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Stanus up while holuing onto something

!! Can get into the sitting position anu stay theie without suppoit

!! Can pull to a stanu

!! Ciawls quickly
S98
7S3OF3 @5X7V9



AB<-(DJ7*B,-B/(DF

!! Ciies when paients leave

!! Bas both favoiite objects anuoi people in theii life

!! Shows feai in ceitain situations

!! Repeats sounus anu actions

!! Belps uiess by assisting you

!! Plays 'peek a boo' anu 'pat---a---cake' well



H(/1)(1.J5B**)/-<(,-B/F

!! Responus to simple spoken iequests

!! Shakes heau 'N0' oi waves gooubye

!! Same 'mama', 'uaua', anu 'uh oh'

!! Changes the tone of veibal expiession

S99
!! Tiies to mimic woius



5B1/-,-:.F

!! Exploies uiffeientnew things

!! Copies gestuies

!! Biinks fiom cup

!! Biushes haii

!! Can poke with inuex fingei

!! Follows simple uiiections

!! Can iecognize objectspeople in a pictuie

!! Recognizes people
4uu


%B:.*./,J@390-<(D 6.:.DB+*./,F

!! uets into sitting position without help

!! Bemonstiates 'ciuising' (walks while holuing onto objects)

!! Nay stanu alone

!! Can take a few steps without holuing onto objects
4u1
34NV733X @5X7V9



AB<-(DJ7*B,-B/(DF

!! Banus things to otheis while playing

!! Tempei tantiums stait

!! Afiaiu of stiangeis

!! 0nueistanus concept of playing 'pietenu'

!! Is affectionate towaius familiai people

!! Clings to caiegiveis in unfamiliai situations

!! Points things out to othei people

!! Will exploie new spaces when paients aie close



H(/1)(1.J5B**)/-<(,-B/F

!! Can say seveial single woius togethei

!! Says 'N0'

4u2
!! Shakes heau 'N0'

!! Points to things they want



5B1/-,-:.F

!! Knows what most objects aie

!! Pietenus to caie foi stuffeu animalsuollsetc

!! Can point out ceitain bouypaits

!! Can sciibble

!! Can follow a one---step veibal commanu
4uS
%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Can walk alone

!! Staits walking up steps

!! Staits to iun

!! Can help unuiess self

!! Can uiink fiom a cup

!! Can eat with a spoon
4u4
7S3X7hDDDE56M @5X7V9 KT h3!M9L



AB<-(DJ7*B,-B/(DF

!! uets exciteu when othei chiluien aie aiounu

!! Shows moie inuepenuence

!! Copies otheis

!! Nay stait to incluue othei chiluien in theii play



H(/1)(1.J5B**)/-<(,-B/F

!! Can point things out when nameu

!! Knows most familiai bouy paits

!! Says a 2---4 woiu sentence

!! Can follow simple instiuctions

!! Can iepeat woius oveiheaiu in conveisation

!! Can point to things in a book

4uS


5B1/-,-:.F

!! Begins to soit shapes anu colois

!! Completes a full sentence

!! Plays make---believe games

!! Can builu a towei of foui oi moie blocks

!! Staits using a uominant hanu

!! Can follow two---step instiuctions
4u6
%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Can kick a ball

!! Begins to iun

!! Can climb onto anu off of fuinituie without help

!! Walks up anu uown staiis holuing on

!! Thiows ball oveihanu

!! Can copy stiaight lines anu ciicles

!! Can stanu on tiptoes
4u7
7V4M7hDDD94` @5X7V9 Ka h3!M9L



AB<-(DJ7*B,-B/(DF

!! Nimics auults

!! Shows affecting to familiai people

!! Plays togethei with otheis (takes tuins playing)

!! Can uemonstiate empathy

!! 0nueistanus concepts such as 'mine', 'heis', 'ouis'

!! Bemonstiates a vaiiety of emotions

!! Can sepaiate fiom paients without becoming oveily emotional

!! Bevelops ioutines in uaily living

!! Can uiess anu unuiess themselves



H(/1)(1.J5B**)/-<(,-B/F

!! Can follow two anu thiee---step instiuctions

4u8
!! Can name most familiai objects

!! Can say fiist name, age, anu sex

!! Can get theii point acioss somewhat in conveisation

!! Can speak in two to thiee---woiu sentences



5B1/-,-:.F

!! Can uo a thieefoui piece puzzle

!! Can tuin pages one at a time

!! Can sciew anu unsciew lius

!! Can copy a ciicle with a pencil oi ciayon

!! Can builu a towei of > six blocks
4u9


%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Climbs staiis easily one step at a time

!! Runs easily

!! Can peual a tiicycle
41u
E5M7hDDD34NV7 @5X7V9 K\ h3!M9L



AB<-(DJ7*B,-B/(DF

!! Cieative make---believe play

!! Can behave co---opeiatively with otheis

!! Piefeis gioup play as opposeu to inuiviuual play

!! Likes to tiy new things



H(/1)(1.J5B**)/-<(,-B/F

!! 0nueistanus the basic iules of giammai

!! Can sing basic songs fiom nuiseiy ihymes

!! Can tell stoiies

!! Can tell you theii fiist anu last name



5B1/-,-:.F

411
!! Can name colois anu numbeis

!! Can use scissois

!! Can uiaw a peison with two to thiee bouy paits

!! Can play basic boaiu oi caiu games

!! Can uiaw capital letteis

!! 0nueistanus time

!! Can iecall paits of a stoiy



%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Can stanu up on one foot

!! Can catch a bouncing ball
412
94`7h @5X7V9 Ki h3!M9L



AB<-(DJ7*B,-B/(DF

!! Wants to mimic theii fiienus

!! Can follow anuoi agiee with iules

!! Can show concein foi otheis

!! Is genuei awaie

!! Knows the uiffeience between ieal anu make---believe

!! Can sign anu uance

!! Bemonstiates moie inuepenuence



H(/1)(1.J5B**)/-<(,-B/F

!! Speaks in a cleai mannei

!! Can tell a stoiy with full sentences

!! Can use piopei veib tense

41S
!! Knows auuiess



5B1/-,-:.F

!! Can count ten oi moie objects

!! Can piint some letteis anu numbeis

!! Can copy geometiic shapes

!! Can uiaw a bouy with six bouy paits



%B:.*./,J@390-<(D 6.:.DB+*./,F

!! Stanus on one foot foi ten oi moie seconus

!! Can hop anu skip
414
!! Can uo a someisault

!! Can use all utensils to eat

!! Can use the toilet inuepenuently

!! Can swing anu climb



* Bevelopmental milestones couitesy of CBC
41S
@7"M#A>M7 67M7H?@%7L!#H 6>A?"67"A



The peivasive uevelopmental uisoiueis aie chaiacteiizeu by a chilu's
failuie to uevelop anuoi the eaily iecession of noimal social anu
language skills foi theii age. The loss of these skills is lifelong anu
subsequently theie is a uecieaseu capacity to function noimally.


The common peivasive uevelopmental uisoiueis incluue:

!! Austism

!! Aspeigei's

!! Rett uisoiuei






#$!>A%: Is chaiacteiizeu by pioblems with communication anu
foimation of social ielationships. 0ften chiluien engage in iepetitive
anuoi self---uestiuctive behavioi.
!! 2S of patients with Autism have below noimal intelligence (IQ <7u)

!! 0ften times, patients have above---aveiage abilities (ie. Excel in playing
416
the piano)


:1,;,'0+;)%0)'% d 8;$A($%)%:

!! 0nset is befoie thiee yeais of age

!! Is much moie common in males

!! If seen in a female, cases is often much moie seveie

!! The majoiity of patients iemain impaiieu into auulthoou, with a veiy
small numbei able to live inuepenuently.
417
#A@7"G7"8A: Patients have seveie pioblems in foiming social
ielationships. Patients tenu to have iepetitive behaviois anu
clumsiness. They have little to no uelay in language uevelopment, anu
cognitive uevelopment is usually noimal.


:1,;,'0+;)%0)'% d 8;$A($%)%:

!! 0nset is usually between thiee to five yeais of age

!! Is moie common in males than females

!! The piognosis is much bettei foi Aspeigei's than it is foi Autism.






"7!!8A 6>A?"67": Is only seen in giils. Patients have a peiiou of
completely noimal functioning, followeu by a iapiu uecline in social
skills.


:1,;,'0+;)%0)'% d 8;$A($%)%:

!! 0nset befoie foui yeais of age

!! Patients uemonstiate a classic 'hanu---wiinging' motion
418

!! Patients aie mentally ietaiueu

!! This conuition piogiessive with age, with a slight impiovement in
social skills as patient ages
419
5O>H6O??6 67@"7AA>?L



Bepiession seen in chiluien often times piesents itself in a uiffeient
mannei than uepiession in auults. While some chiluien may show the
same signs anu symptoms, often theie aie unique finuings in uiffeient
age gioups:


8;+%'1$$#+;%: Nay uemonstiate hypeiactivity anuoi aggiession.
!.$#+%'+(0%: Nay uemonstiate iiiitability, boieuom, oi antisocial
behavioi.


%(/(1.*./,: Examine the chilu's social situation (ie. Check foi family
stiessois, check foi stiessois at school)
!! Antiuepiessants aie not always useu foi chiluhoou uepiession, as
theie is an incieaseu iisk of suiciual iueation in this population.









42u
A7@#"#!>?L #Lc>7![



** This is now categoiizeu as a iegulai anxiety uisoiuei (not isolateu to
peuiatiics)

When patients aie attacheu to theii paients beyonu what is consiueieu
noimal, sepaiation anxiety is uiagnoseu. The woiiy expeiienceu is that
something teiiible will happen to the main caiegiveis (usually the
paients).



@,)( 9)A(% d 9=2>0$2%:

!! Tiouble sleeping at night (ie. Nightmaies, insomnia)
421
!! Somatic symptoms when sepaiateu fiom caiegiveis (ie. Nausea,
vomiting, Biaiihea, etc)


@,(,A+2+(0: Besensitization theiapy, exposing them to the pioblem
anu uecieasing theii woiiy.



?@@?A>!>?L#H 67K>#L! 6>A?"67"



The chilu engages in behavioi that is aigumentative, angiy, anu
iesentful. This behavioi is uiiecteu towaius people who aie in an
authoiitative iole.


42>$;0,(0: The behavioi uisplayeu, while uistuibing at times, uoes not
violate any social noims as uoes the behavioi seen in conuuct uisoiuei.


!! Seen most commonly in chiluien between six anu eighteen yeais of
age.
!! 0ppositional uefiant uisoiuei is not a pie---cuisoi to antisocial

peisonality uisoiuei.
422

!! Befoie pubeity, the conuition is moie common in boys, while post---

pubeity theie is an equal iatio of male to female.
42S
5?L6$5! 6>A?"67"



Chiluien engage in behaviois that aie consiueieu to be uangeious anu
against the noimal behavioi accepteu by society. A majoi factoi in
uiagnosing is the lack of iemoise felt by the chilu.


71+ &$##$/)(A -+1,?)$;,# 0;,)0% ,;+ '$22$(#= %++(:

!! Piopeity uestiuction

!! Aggiession towaius people anu animals

!! Stealing

!! Lying

!! Fiie---setting

!! Running away fiom home

!! Skipping school



!3.'. ('. 2-;;.'./, ;B'*0 N(0.2 B/ ,3. (1. B; B/0.,:
35"7.5&&.DDD&%'*, ,/0*: 0nset is befoie ten yeais of age.
424
@.&7*';*%,DDD&%'*, ,/0*: 0nset is aftei ten yeais of age.
* 0veiall, onset must be seen befoie eighteen yeais of age foi the

appiopiiate uiagnosis.

** This IS a pie---cuisoi to antisocial peisonality uisoiuei.
42S
#!!7L!>?LYYY67K>5>![ O[@7"#5!>M>![ 6>A?"67"



ABBB is a uisoiuei wheieby the chilu has a gioup of behavioial
pioblems that aie seen in moie than one setting (ie. At school anu at
home).


71+ 2,)( '1,;,'0+;)%0)'% ,%%$'),0+. /)01 !RVR ,;+:

!! Bypeiactivity

!! Limiteu attention span

!! Impulsiveness

!! Iiiitability

!! Emotional outbuists



4( $;.+; 0$ 2,B+ ,( ,>>;$>;),0+ .),A($%)%f B++> 01+ &$##$/)(A )(
2)(.:
!! Age of onset befoie seven yeais of age.

!! Symptoms lasting foi at least six months.

426
!! Is five times moie common in boys.



@'B1/B0-0: Appioximately one in five will maintain the uisoiuei into
auulthoou.
!! ABBB in auulthoou leaus to an incieaseu iisk of mooupeisonality

uisoiueis.



%(/(1.*./,: The 1
st
line meuication of choice is Nethylpheniuate.

!! In chiluien, stimulating the CNS incieases theii ability to concentiate.
427
!?$"7!!78A 6>A?"67"



Is a uisoiuei chaiacteiizeu by involuntaiy movements anu vocalizations
(tics). Patients typically have seveial motoi tics in auuition to at least
one vocal tic. Touiette's commonly begins befoie the age of eighteen,
with the onset of motoi tics beginning as eaily as eight yeais of age.
Theie is no cessation of signs anu symptoms of the uisoiuei.


:,*%+: Bysfunctional iegulation of uopamine in the cauuate nucleus.



3Q,2>#+% $& 2$0$; 0)'%:

!! Blinking

!! Lip smacking

!! uiimacing



3Q,2>#+% $& ?$',# 0)'%<

!! Piofanity

428
!! uiunting

!! Baiking



@,(,A+2+(0:

!! Balopeiiuol is the mainstay of tieatment.

!! Pimoziue is also an effective agent
429




















@A[5O>#!">5
@O#"%#5?H?G[
4Su

!?@>5AF

@%,"DDD@%K"*,/ )*.";#,"&%'
@%,"DDD!*02*''#%, )*.";#,"&%'
@%,"DDDE'/;5&,"; )*.";#,"&%'
@%,"DDD)#%"# )*.";#,"&%'
4S1
#L!>YYY#Lc>7![ %76>5#!>?A



!! The two main categoiies of anti---anxiety meuications incluue:
Benzouiazepines anu Non---Benzouiazepines.


4./TB2-(T.+-/.0:

!! Rapiu onset of action.

!! Biffeient agents have shoit, inteimeuiate, anu long uuiations of
action.
!! The benzouiazepines aie inuicateu foi othei conuitions such as sleep

uisoiueis.

!! Bave a high iisk of abuse



LB/YYY4./TB2-(T.+-/.0:

!! Zolpiuem is an imiuazopyiiuine that is useu to inuuce iapiu sleep, is
not a benzouiazepine.
!! Buspiione is a goou anti---anxiety uiug that is less seuating anu less

4S2
likely to leau to uiug uepenuenceabusewithuiawal (longei onset of
action than benzouiazepines).
4SS






4./TB2-(T.+-/.0























LB/YYY4./TB2-(T.+-/.0
4S4

#L!>YYY67@"7AA#L! %76>5#!>?LA

The main categoiies of anti---uepiessant meuications incluue:

!! Selective Seiotonin Receptoi Blockeis (SSRI)

!! Beteiocyclic Agents

!! Nonoamine 0xiuase Inhibitois (NA0Is)

AA">0:

!! Nain action is the inhibition of seiotonin ie---uptake.

!! They have limiteu effect on othei catecholamines like NE, E, BA, anu

Ach.

!! These aie much safei anu have fewei siue---effects as compaieu to the
othei classes of anti---uepiessants.
4SS
O.,.'B<9<D-< #1./,0:

!! Theii main action is the inhibition oi ie---uptake of NE anu S---BT.

!! Stiong anticholineigic action

!! Bighly seuative

!! Commonly cause weight gain




4S6
%B/B(*-/. ?V-2(0. >/3-N-,B'0F

!! Iiieveisible inhibition of NA0, leaus to the inciease in available NE

anu S---BT in the synapse.

!! Can leau to hypeitensive ciisis when combineu with foous high in

Tyiamine (cheese, wine, beei, some meatsfish).

!! Combining NA0 with SSRI can leau to Seiotonin---synuiome

(hypeitheimia, convulsions, coma, anu even ueath).




4S7
#L!>YYY@A[5O?!>5 %76>5#!>?LA



The anti---psychotic meuications woik by uecieasing the amount of
uopamine available. The two main categoiies of meuications incluue
the 'typicals' anu 'atypicals'.


7=>)',#% !! Aie stiongei anu uemonstiate gieatei siue---effects than the
atypicals.
!0=>)',#% !! Aie weakei anu have fewei siue---effects than the typicals.



4S8

4S9
#L!>YYY%#L># %76>5#!>?LA



Anti---mania uiugs aie useu to contiol the symptoms of mania, which is a
main finuing of bipolai uisoiuei. Biugs aie useu as acute aboitificants
anu chionic moou---stabilizeis.



44u




















441






















7G? 67K7LA7A
442
# H>A! ?K 67K7LA7 %75O#L>A%A



The following is a list of the most commonly encounteieu uefense
mechanisms.


!#0;*)%2: Assisting otheis to avoiu negative feelings.

#<,-/1 ?),: Behaving in an outwaiu, attention---seeking mannei.
R)%>#,'+2+(0: Noving one emotion fiom an unacceptable situation to
one that you finu moie toleiable.
R+(),#: Refusing to accept ieality because it is unbeaiable.

R)%%$'),0)$(: Nentally sepaiating pait of the peisonality, oi mentally
uistancing oneself fiom otheis.
R)%>#,'+2+(0: Noving one's emotions fiom a peisonally unacceptable
situation to a moie beaiable one.
V*2$;: 0sing a sense of humoi to covei one's uiscomfoit about a

paiticulai situation.

4.+(0)&)',0)$(: To pattein one's behavioi aftei someone moie
poweiful.
4(0+##+'0*,#)b,0)$(: 0sing one's highei intellect to avoiu expeiiencing

44S
emotions.

4%$#,0)$( $& !&&+'0: Failuie to expeiience any feelings when a stiessful
event is expeiienceu.
8;$P+'0)$(: Putting one's feelings onto anothei peison.
M,0)$(,#)b,0)$(: Changing one's peiception in oiuei to make negative
expeiience seem moie positive.
444


M+,'0)$( E$;2,0)$(: Changing one's attituue to the opposite in
oiuei to avoiu an unacceptable emotion.
M+A;+%%)$(: Reveiting to behaviois typical of a youngei peison.

9>#)00)(A: Putting people into uiffeient yet absolute
categoiies. 9*-#)2,0)$(: Is the expiession of an impulse in a
socially accepteu fashion.
9*>>;+%%)$(: Noving one's unacceptable emotions out of one's

conscious awaieness.

6(.$)(A: Believing one can change an outcome by auopting a
moie acceptable behavioi.













44S










Chapter 7

Cardiovascular




446



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

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

)#]&2 O"'9 C#;,&2'8
Biabetes
Smoking
Bypeitension (BTN)
Bypeicholesteiolemia
Family histoiy
Age
)"%&2 O"'9 C#;,&2'8
0besity
Lack of estiogen (this is why it occuis in men moie than women)
The #1 pieventable RF is smoking

A,(ND. #/1-/(
Chest pain that occuis with activity
Causeu by atheioscleiosis, wheieby the supply of u2 iequiieu by the heait is
not met
-"$%' #%. -/+0,&+'8
Chest pain that may iauiate to the left aim, jaw, anu back.
Relieveu by iest anu nitioglyceiin
EKu will show ST-segment uepiession anu T-wave inveision
!"#$%&'"':
Naue by clinical piesentation anu baseu on symptoms
447




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

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


$/0,(ND. #/1-/(
Symptoms aie similai to angina but occui moie fiequently anu without any
ielation to exeitionactivity, occuiiing at iest
0nstable angina = ischemia
0nstable angina anu non-ST-elevation NI aie a closely ielateu
EKu uuiing ischemia usually shows ST-segment uepiession oi T-wave
inveision
LABS aie (+) foi caiuiac enzymes
448




12*#,+*%,:
Baseu on the likelihoou that it will piogiess to a potentially fatal outcome (ie.
Risk of iecuiient unstable angina, infaiction, oi ueath Su uays aftei
piesentation).

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

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

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

!"#$%&'"':
EKu will show ST elevation anu Q waves

449


Caiuiac enzymes elevateu (CK-NB, tioponin I) - CK-NB noimalizes within
72hi

12*#,+*%,:
Re-establish vessel patency
#1

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

E&',D)> !"';5#2$* >%',2=;,"&%'8
ASA
#-blockei
Statin
ACEI











4Su




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

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

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

4S1


-"$%' #%. -/+0,&+'8
Chest uiscomfoit
Palpitations
Tachycaiuia,
Bypotension + syncope
12*#,+*%,:
Contiol iate with #-blockeis, CCB's, anu uigoxin (not acutely)
If fibiillations last >24hi then shoulu anticoagulate with waifaiin foi at least
S weeks befoie caiuioveision (pievents embolisms)
If you cannot conveit to noimal sinus ihythm, the patient will iequiie long-
teim anticoagulation. 1
st
line is waifaiin, 2
nu
line is aspiiin
Caiuioveision to conveit to noimal ihythm:
1
st
line ! Iv piocainamiue, sotalol, amiouaione
Electiical ! shock of 1uu-2uu} followeu by S6u}
#,'-(D KD),,.'
Less stable than Afib
The iate is slowei than that of atiial fibiillation (appioximately 2Su-
SSubpm)
ventiiculai iate in atiial fluttei is at iisk of going too fast, thus atiial fluttei is
consiueieu to be moie uangeious (meuically slowing this iate can cause a
paiauoxical inciease in ventiiculai iates)
Classic ihythm is an atiial fluttei iate of Suubpm with a 2:1 block iesulting in
a ventiiculai iate of 1Subpm
Signs anu symptoms similai to those of atiial fibiillation
Complications incluue syncope, embolization, ischemia, heait failuie
Classic EKu finuing is a "sawtooth" pattein:


12*#,+*%,:
If patient is stable, slow the ventiiculai iate with CCB's oi #-blockeis (avoiu
piocainamiue because it can iesult in incieaseu ventiiculai iate as the atiial
iate slows uown)
If caiuioveision is going to take place be suie to anticoagulate foi S weeks
4S2


If patient is unstable must caiuioveit ! stait at only Su} because is easiei to
conveit to noimal sinus ihythm than atiial fibiillation

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

12*#,+*%,:
veiapamil
Tieat any unueilying conuition




A)+'(:./,'-<)D(' !(<39<('2-(
Nany tachyaiihythmias oiiginating above the ventiicle
Pacemakei may be in atiium oi Av junction, having multiple pacemakeis
active at any one time
Biffeientiating fiom ventiiculai aiihythmia may be uifficult if theie is also
the piesence of a bunule bianch block
12*#,+*%,:
veiy uepenuent on etiology
Nay neeu to coiiect electiolyte imbalance
Nay neeu to coiiect ventiiculai iate |uigoxin, CCB, #-blockeis, auenosine
(bieaks 9u% of SvT)j
If unstable iequiies caiuioveision
4SS


Caiotiu massage if patient has paioxysmal SvT


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



12*#,+*%,:
If hypotensive oi no pulse existent uo emeigency uefibiillation (2uu, then
Suu, then S6u})
If patient is asymptomatic anu not hypotensive, the fiist line tieatment is
amiouaione oi liuocaine because it can conveit ihythm back to noimal

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


-"$%' #%. -/+0,&+'8
Syncope
4S4


Seveie hypotension
Suuuen ueath

12*#,+*%,:
1
st
line - Emeigent caiuioveision is the piimaiy theiapy (2uu-Suu-S6u}),
which conveits to noimal ihythm almost 9S% of the time
Chest compiessions iaiely woik
2
nu
line - Amiouaione oi liuocaine
If tieatment isn't given in a timely mattei, patient expeiiences failuie of
caiuiac output anu this piogiesses to ueath.
















4SS


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

!*6"%","&%:
- CBF occuis when the caiuiac output is insufficient to met systemic uemanus
- Nay be iight-siueu, left-siueu, oi both
3#='*':
- valvulai uiseases
- NI
- Bypeitension
- PE
- Anemia
- Caiuiomyopathy
- Euocaiuitis
- Thyiotoxicosis

-"$%' #%. -/+0,&+'8
O+&0D%).+.: signs anu symptoms aie uue to ! C0 anu " caiuiac piessuies
- Paioxysmal noctuinal uyspnea
- Exeitional uyspnea
- 0ithopnea
- Caiuiomegaly
- SS gallop
- Renal hypopeifusion (leaus to souium ietention anu woiseneu CBF)
M)A10D%).+.: signs anu symptoms aie uue to pooling upstieam of the iight heait
- " }vP
- Euema
- Bepatic congestion
- Atiial fibiillation (incieases iisk of embolization)
- Fatigue
- Cyanosis
- Weight loss
Biagnose with echocaiuiogiam
12*#,+*%,:
C
%0
#)(+ ;+A)2+( ! ACEI, #-blockeis, fuiosemiue anu spiionolactone, anu uigoxin
If patient cannot toleiate ACEI, tiy hyuialazine + isosoibiue uinitiate
4S6



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













4S7


5('2-B*9B+(,3-.0

6-D(,.2 O9+.','B+3-< ".0,'-<,-:.
5()0. Ischmia, infections,
metabolic
conuitions, uiugs
uenetic myosin
uisoiuei
Amyloiuosis,
scleioueima,
hemochiomotosis,
glycogen stoiage
uisease,
saicoiuosis
A-1/0 d
A9*+,B*0
Right anu left siueu
heait failuie, SS
gallop, %=%0$#)'
.=%&*('0)$(
Exeitional
syncope, angina,
LvB, .),%0$#)'
.=%&*('0)$(
Pulmonaiy BTN,
S4 gallop, ! QRS
uysfunction
@'B1/B0-0 Su% Syi suivival
iate
S% annual
moitality iate
Su% S-yi suivival
!'.(,*./, Stop offenuing
agents, tx is similai
to CBF tieatment
#-blockeis anu
uiuietics
Biuietics anu
coiiection of
unueilying cause
Biagnosis foi each is echocaiuiogiaphy












4S8


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

E2*'*%,#,"&%:
- valvulai heait uiseases all piesent with shoitness of bieath as the chief
complaint
- 0ften woisens with exeitionexeicise
5D). ,B 6-(1/B0-0 6-(1/B0-0
[B)/1 ;.*(D. (/2JB' 1./.'(D
+B+)D(,-B/
%-D,'(D M(D:. @'BD(+0. \%M@^
O.(D,39 9B)/1 (,3D.,. >2-B+(,3-< O9+.','B+3-< A)N(B',-<
A,./B0-0 \/BE <(DD.2F O9+.','B+3-<
BN0,')<,-:. <('2-B*9B+(,39 O?%5^
>**-1'(/,C +'.1/(/, %-,'(D A,./B0-0
!)'/.'80 09/2'B*. 4-<)0+-2 (B',-< :(D:.
@(D+-,(,-B/0C (,9+-<(D <3.0, +(-/ /B,
(00B<-(,.2 E-,3 .V.',-B/
%-,'(D M(D:. @'BD(+0.

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

)=2+=2':
Systolic:
- Nost commonly seen in aoitic stenosis, mitial ieguigitation, NvP, anu B0CN
Biastolic:
- Nost commonly seen with aoitic ieguigitation anu mitial stenosis.

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



4S9


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

)=2+=2 "%,*%'",/8
IvI ! only heaiu with special maneuveis (valsalva)
IIvI anu IIIvI ! majoiity of muimuis
IvvI ! thiill piesent
vvI ! can be heaiu with stethoscope paitially off of the chest
vIvI ! can be heaiu without a stethoscope
!"#$%&'"':
- Best initial uiagnostic test foi valvulai lesions is
echocaiuiogiam
- The most accuiate test is left heait catheteiization
12*#,+*%,:
M+A*;A)0,(0 #+%)$(% ! best tieateu with vasouilatoi theiapy
(ACEI, ARB)
90+($0)' #+%)$(% ! best tieateu with anatomic iepaii (mitial
stenosis iequiies balloon valvuloplasty, seveie aoitic stenosis
iequiies suigical ieplacement)


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

E2&$%&'"':
- If coionaiy uisease is piesent then S-Syi is avg suivival
- If syncope is piesent then 2-S yi avg suivival
- If CBF piesent then 1.S-2yi avg suivival
A tiick to know
what type of
theiapy you shoulu
use:
If the valsalva
maneuvei
impioves the
muimui, use
uiuietics.
If amyl nitiate
impioves the
muimui, ACEI is
inuicateu.
46u


!"#$%&'"':
- TTE is the best initial uiagnosis
- TEE is moie accuiate
- Left heait catheteiization is the most accuiate
- EKu anu CXR will show LvB
12*#,+*%,:
- Biuietics aie the best initial theiapy but uo not altei the long-teim
piognosis, anu special attention must be paiu since ovei-uiuiesis is a possibility
- Tieatment of choice is valve ieplacement

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

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

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





461


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

-"$%' #%. -/+0,&+':
- Bysphagia (laige left atiium compiesses esophagus)
- Boaiseness (piessuie on iecuiient laiyngeal neive)
- Atiial fibiillation
E5/'";#7 IK#+8
- Biastolic iumble aftei an opening snap
!"#$%&'"':
- TTE is best initial uiagnostic test
- TEE is moie accuiate
- Left heait cath is most accuiate
- EKu anuoi CXR showing left atiial hypeitiophy
12*#,+*%,:
- Best initial theiapy is uiuietics, howevei they uo not altei piogiession of
the uisease
- Balloon valvuloplasty is the most effective theiapy (all piegnant women
must have this pioceuuie uone)

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

E5/'";#7 *K#+ 6"%."%$'8
- Bolosystolic muimui that obscuies both S1 anu S2
- Best heaiu at the apex, iauiates to the axilla
!"#$%&'"':
- TTE is best initial test
- TEE is moie accuiate
462


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



















46S


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

@.'-<('2-,-0
- Pleuiitic chest pain
- Relieveu by leaning foiwaiu
- Pain often uesciibeu as shaip anu biief

-"$%' #%. -/+0,&+'8
- Fiiction iub is commonly founu
- No othei peitinent physical finuings
!"#$%&'"':
- Best initial test is the EKu
- Biffuse ST-segment elevation
- PR-segment uepiession is pathognomonic but is not always piesent
12*#,+*%,:
- Best initial theiapy is NSAIB's
- Patient shoulu ietuin in 1-2 uays, if the pain is gone they aie cuieu
- If pain peisists aftei 2 uays of NSAIB tieatment, pieunisone oially is
tieatment











464


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

!"#$%&'"':
- Echo is the most accuiate uiagnostic test
- Eailiest finuing is usually collapse of the iight atiium anu ventiicle
- EKu shows low voltage anu electiical alteinans
- Right heait catheteiization will show equalization of all piessuies in the
heait uuiing uiastole
12*#,+*%,:
- Best initial theiapy is a peiicaiuiocentesis
- Nost effective long-teim theiapy is peiicaiuial winuow placement


5B/0,'-<,-:. @.'-<('2-,-0
- Piesents with S0B
- Euema
- }vB
- Ascites
- Bepatosplenomegaly
R%"Z=* 6*#,=2*' &6 ;&%',2";,"G* 0*2";#2.","'8
- A peiicaiuial knock, which is an extia uiastolic sounu fiom the heait hitting
the calcifieu peiicaiuium
!"#$%&'"':
- CXR showing calcification
- Low voltage EKu
- Thickeneu peiicaiuium on CT
12*#,+*%,:
- Biuietics aie the best initial theiapy
- Peiicaiuial stiipping is the most effective theiapy

46S



Chapter 8

Endocrine









466


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

@'BD(<,-/B*(
Piolactin-secieting tumoi
Always think of this when theie is visual uistuibances

-"$%' #%. -/+0,&+'8
Nen:
Impotence
Becieaseu libiuo
uynecomastia
Nost often men also piesent with heauache anu visual uistuibacnes
Women:
Amenoiihea
ualactoiihea
Both in the absence of piegnancy
!"#$%&'"':
Rule out piegnancy
Rule out uiugs such as: Netoclopiomiue, Phenothiazines, anuoi TCA
NRI to confiim piesence of tumoi
12*#,+*%,:
1
st
line tieatment is a uopamine agonist such as biomociiptine (most
piolactinomas iesponu to BA agonists)
If meuical theiapy uoesn't woik, suigical iemoval is uone






467


#<'B*.1(D9
Excess piouuction of uB uue to a uB-piouucing auenoma in the pituitaiy

-"$%' #%. -/+0,&+'8
Enlaigement of the heau, hanus, feet, nose, anu jaw
Nay be enlaigement of the sweat that can cause intense sweating
}oint abnoimalities (excess giowth of aiticulai caitilage)
Amenoiihea
Caiuiomegaly anu hypeitension
Colonic polyps
Biabetes also common because insulin is antagonizeu by uB
!"#$%&'"':
Best initial test is IuF (confiims uiagnosis of aciomegaly)
Nost accuiate test is auministiation of glucose (noimally shoulu suppiess
uB, if it suppiesses uB then this excluues aciomegaly)
NRI uone aftei theie is a ieason foi uoing so
12*#,+*%,:
Tiansphenoiual iemoval
BA agonist to inhibit uB ielease
0ctieotiue has some meiit in pieventing uB ielease
Pegvisomant ! a uB ieceptoi antagonist









468


6-(N.,.0

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

-"$%' #%. -/+0,&+'8
Polyuiia, polyphagia, polyuipsia
Weight loss
BKA ! emeigency
!"#$%&'"':
Ranuom plasma glucose >2uu with symptoms 0R
Two measuiement of fasting glucose >12S
2hi oial glucose toleiant test >2uu with oi without symptoms
12*#,+*%,:
Insulin ieplacement
3&+07";#,"&%':
BKA
-"$%' #%. -/+0,&+' &6 !_@8
Bypeiglycemia >2Su
Bypeikalemia (uue to tianscellulai shift out of the cell in exchange foi B+)
Low pB
Elevateu levels of acetone, acetoacetate, anu #-hyuioxybutyiic aciu
Incieaseu anion gap
RH! 0;+,02+(0<
1
st
! Iv fluius
2
nu
! potassium ieplacement(hypei becomes hypo as BKA is tieateu), insulin
ieplacement
S
iu
! auuition of glucose to insulin uiip when pt becomes noimoglycemic (keep
giving insulin until ketones aie gone)
** insulin is given oiiginally to shut uown ketogenesis, not ueciease glucose, thus
keep giving insulin until ketones aie gone uespite noimal glucose.
469



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

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

Biagnosis: same as type 1
12*#,+*%,:
FIRST tieatment is always uiet anu lifestyle mouifications
0ial hypoglycemics foi milumoueiate uisease
1
st
line ! metfoimin (biguaniue), its N0A is blocking gluconeogenesis
2
nu
line ! sulfonyluiea (glybuiiue), N0A is " #-cell insulin secietion
S
iu
line ! Thiazoliuineuiones (pioglitazone), N0A is incieasing tissue
sensitivity to insulin
If oial uiugs uon't woik, patient may iequiie insulin
Lifelong cases most usually will iequiie insulin tieatment
ACEI's impoitant because they slow uown the piogiession of uiabetic
nephiopathy

)&%",&2"%$ !) :",5 ?4@P;8
BbA1c allows us to get a measuie of the aveiage glucose level ovei the past S
months
Tight glucose contiol is uiiectly iesponsible foi uecieasing complications anu
moitality in both types of insulin
An BbA1c <7 oi 8 is iecommenueu (this # is always uecieasing)
47u



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

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


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

6-(N.,.0 !9+. a !9+. R
?/0., }uvenilechiluhoou Auult (incieasingly
471


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





















472


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

5)03-/180 A9/2'B*.
Theie aie S souices of Cushing's uisease, they aie listeu in this table along with
peitinent infoimation
@-,)-,('9 !)*B' 7<,B+-< #5!O
@'B2)<,-B/
#2'./(D #2./B*(
#5!O Bigh Bigh Low
O-13Y2B0.
2.V(*.,3(0B/.
Suppiession No suppiession No suppiession
A+.<-;-< ,.0, NRI, petiosal vein
sampling
Scan the chest anu
abuomen
Scan the auienals
!'.(,*./, Removal Removal Removal

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

!"#$%&'"':
1. 1mg oveinight uexamethasone suppiession test: noimally a peison will
suppiess the 8am level of coitisol if given uexa at 11pm the pievious night. A
noimal test (suppiession) will iule out hypeicoitisolism of all kinus. ** a test
may be elevateu uue to othei factois such as uepiession, alcoholism, oi
excessive stiess
47S


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


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

12*#,+*%,:
Removal of whatevei is causing the pioblem, iuentifieu by NRI oi abuominal
scan (uepenuing on the location of the pioblem)


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

!..)%$(G% .)%+,%+<
NC is autoimmune uisoiuei
Wateihouse-Fiiueiichsen may be cause, which is hemoiihagic neciosis of the
auienal meuulla uuiing the couise of meningococcemia
-"$%' #%. -/+0,&+'8
Fatigue
Anoiexia
Byponatiemia + hypeikalemia
Bypotension
Nauseavomiting
Constipation
Bypeipigmentation (only in piimaiy case)
474


!"#$%&'"':
" ACTB anu ! coitisol (in iesponse to ACTB)
Bypeipigmentation
If cause is seconuaiy, then coitisol will " in iesponse to ACTB
12*#,+*%,:
Foi acute Auuison's give fluius + hyuiocoitisone
Foi stable patient give pieunisone
If patients uo not iesponu to above tieatments, give fluuiocoitisone (highest
# of mineialocoiticoius)


#2'./(D 5B',-<(D O9+.';)/<,-B/
C V=>+;,#.$%0+;$()%2 K:$((G% 9=(.;$2+L<
Nost commonly uue to an auenoma oi hypeiplasia of the zona glomeiulosa
of the auienal glanu
-"$%' #%. -/+0,&+'8
Bypeitension
"Na+
"Cl-
!K+
! ienin
!"#$%&'"':
" aluosteione
! ienin
CT showing auienal lesion
12*#,+*%,:
If auenoma ! suigical iesection
If hypeiplasia ! spiionolactone




47S


T V=>+;,#.$%0+;$()%2<
Incieaseu ienin piouuction 2 to uecieaseu ienal bloouflow(CBF, shock,
ienal aiteiy stenosis)
!"#$%&'"':
" ienin (this is useu to uiffeientiate between 1 anu 2 causes
12*#,+*%,:
Tieat unueilying cause
Tieat BTN

@3.B<'B*B<9,B*(
E#,"*%, 02*'*%,' :",58
Episouic BTN
Beauache
Palpitations
Tachycaiuia
Biaphoiesis
!"#$%&'"':
Best initial tests ! high plasma anu uiinaiy catecholamineplasma-fiee
metanephiine anu vNA levels
Nost accuiate tests ! CT oi NRI of auienal glanus
12*#,+*%,:
1
st
- phenoxybenzamine to contiol BP
2
nu
- piopianolol (only aftei $-blockaue with phenoxybenzamine)
S
iu
- suigical iesection







476


Nale uonaual Bisoiueis
6-0.(0. 53('(<,.'-0,-<0 Tieatment
Klinfeltei's
Synuiome
XXY inheiitance with vaiiable expiessivity
Biagnosis usually at pubeity when no viiilization
Tall with small testes anu gynocomastia
Becieaseu testosteione
" LBFSB (no feeuback)
Bx with buccal smeai showing baii bouy
Testosteione
Supplements
XXY synuiome Nilu mental ietaiuation, acne, violent, antisocial
behavioi
Biagnose with kaiyotype analysis
None
Testiculai
feminization
synuiome
Befect in BBT ieceptoi
Female exteinal genitalia with steiile, unuescenueu
testes
Patient appeais female but is steiile with blinu
vagina
TestosteioneestiogenLB aie all elevateu
No tx
Remove
testes
S-$-ieuuctase
ueficiency
Ambiguous genitalia until pubeity
At pubeity a buist of testosteione oveicomes the lack
of BBT (masculinizing exteinal genitalia)
Testosteione anu estiogen aie noimal
Biagnosis is by genetic testing
Testosteione
Congenital
auienal
hypeiplasia
A uefect in the steioiu synthesis pathway causes
viiilization of females oi failuie to viiilize in males
21-$-hyuioxylase ueficiency causes 9S% of all CAB
cases
seveie uisease piesents in infancy with ambiguous
genitalia anu excess salt loss
less seveie ! minimal viiilization anu salt loss
Boimone
ieplacement
Piauei-Willi
synuiome
pateinal impiinting
shoit limbs, floppy baby
hypeiphagia ( obesity ! incieases eaily ueath
likelihoou)
mental ietaiuation
classically have almonu-shapeu eyes with stiabismus
uiagnosis is genetic analysis
None
Kallmann's
synuiome
AB hypogonauism with anosmia
Becieaseu piouuction anu secietion of unRB by
hypothalamus
Biagnosis maue by finuing uecieaseu ciiculating LB
anu FSB
Pulsatile
unRB





477



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

The clinical uiffeiences between hypeithyioiuism anu hypothyioiuism
BYP0TBYR0IBISN BYPERTBYR0IBISN
Weight uain Loss
Intoleiance Colu Beat
Baii Couise Fine
Skin Biy Noist
Nental Bepiesseu Anxious
Beait Biauycaiuia Tachycaiuia
Nuscle Weak Weak
Reflexes Biminisheu
Fatigue Yes Yes
Nenstiual Changes Yes Yes

O9+B,39'B-2-0*
Nost commonly fiom 'buinout' Bashimoto's thiyoiuitis.
Patient is fatigueu
Poveity of movement
uaining weight

!"#$%&'"':
" TSB
! T4
12*#,+*%,:
Thyioxine
T4(conveiteu in the tissue to TS as neeueu)

O9+.',39'B-2-0*
" T4 levels
! TSB
4 foims of hypeithyioiuism: uiaves(NC), Silent, Subacute, Pituitaiy auenoma
478




N;,?+G% R)%+,%+<
Bas many finuings that aie unique to this type of hypeithyioiuism:
Exophthalmos anu pioptosis
Beimopathy (ieuness anu thickeneu skin below the knee)
0nycolysis (sepeiation of the nail fiom the nailbeu)
RAI0 is elevateu
12*#,+*%,:
PT0 oi methimazole is given acutely to biing the glanu unuei contiol
Aftei glanu is contiolleu, use iauioactive iouine ablation
Piopianolol useu to tieat sympathetic symptoms

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

9*-,'*0+ 71=;$).)0)%F
A conuition of viial etiology
ulanu is tenuei
!"#$%&'"':
TSB low
T4 incieaseu
RAI0 low
12*#,+*%,:
Aspiiin to ielieve the pain

479




8)0*)0,;= !.+($2,<
Raie conuition
Is the only hypeithyioiu uisoiuei with an elevateu TSB
!"#$%&'"':
NRI of biain
12*#,+*%,:
Removal of auenoma

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

71=;$). 90$;2:
This is an emeigency situation wheie theie is seveie ielease of thyioiu
hoimones fiom the thyioiu glanu
Causes symptoms of extieme sympathetic stimulation (tiemoi, tachycaiuia,
uiaphoiesis, etc)
12*#,+*%,:
1
st
! give iouine to block the uptake of iouine into the glanu
2
nu
! give PT0 oi methimazole to block thyioxine piouuction
S
iu
! uexamethasone to block the peiipheial conveiion of T4! TS
4
th
! block sympathetic effects with piopianolol

@=Q+.+2, :$2,:
An emeigency hypothyioiu conuition
Nay be spontaneous oi ppte by colu conuitions, infections, seuative uiugs,
iespiiatoiy failuie
48u


-"$%' #%. -/+0,&+'8
Bypoventilation
Bypotension
Stupoi
Coma
Seizuies
12*#,+*%,:
Levothyioxine
Coitisone
Intubate


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

bianchial pouch
Secietes calcitonin
@%#07#',"; ;#%;*2:
Teiiible piognosis
Bas a u% S-yi suivival iate
481




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









482




Chapter 9

Infectious
Disease




48S


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

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

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









484


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








48S


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













486


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

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










487



Chapter 10

Allergies









488


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

#/(+39D(V-0

Is a typ1 hypeisensitivity ieaction
Bue to piefoimeu IgE antibouies that cause the immeuiate ielease of
vasoactive amines such as histamines anu leukotiienes.
Commonly seen aftei bee stings anu ingestion of meuications such as
penicillin anu sulfa uiugs
8;+%+(0,0)$(:
Symptoms uevelop acutely anu aie often veiy uiamatic
Bifficulty bieathing
Bypotension + tachycaiuia
0iticaiia
Angioeuema

7;+,02+(0Y@,(,A+2+(0<
Secuie aiiway
uive subcutaneous epinephiine
If these aien't available give coiticosteioius
uive antihistamines foi cutaneous ieactions




489



#/1-B.2.*(

Is most commonly causeu by a ueficiency of C1 esteiase inhibitoi
8;+%+(0,0)$(:
Biffuse swelling of the eyelius, lips, anu aiiway
0sually occuis aftei milu facial tiauma oi ingestion of ceitain meuications
(often ace inhibitois)
Theie is usually a family histoiy
C4 levels aie low
7;+,02+(0Y@,(,A+2+(0:
Secuie aiiway
uive subcutaneous epinephiine
Nanage exactly like anaphylaxis



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

An alleigic ieaction that is veiy common
Recuiiing nasal stuffiness, itching, ihinoiihea, anu sneezing
7;+,02+(0Y@,(,A+2+(0:
The main tieatment shoulu be avoiuance of the alleigen
Keep aii clean
Close winuows anu keep aii-conuitioning iunning uuiing summei months
Non-seuating antihistamines such as loiatauine aie veiy effective anu can be
useu continually
Nasal saline spiaysnetti pot aie effective at washing out the nasal cavity



49u




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

>1# 6.;-<-./<9
Is the most common piimaiy immunoueficiency, anu it is often asymptomatic
Causes iecuiient iespiiatoiy anu uI infections
Someone ieceiving bloou piouucts may uevelop anaphylaxis, which shoulu
make you think of an IgA ueficiency
Nevei give these patients immunoglobulin's
12*#,+*%,:
Nanage anu tieat infections as they aiise

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

5B**B/ M('-(ND. >**)/B2.;-<-./<9
Is a conuition that piesents in both men anu women
0sually only piesents when they aie auults
Patient piesents with iecuiient sinopulmonaiy infections
Nay get spiue-like abuominal uisoiueis (malabsoibtion, uiaiihea,
steatoiihea)
!"#$%&'"':
Igu levels aie low
12*#,+*%,:
Infusions of IvIu is iequiieu since Igu levels aie low
491




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

I-0QB,,Y#D2'-<3 A9/2'B*.
An x-linkeu iecessive uisoiuei affecting only males
Theie is a classic tiiau of eczema, iecuiiing infections, anu thiombocytopenia

53.2-(QYO-1(03- A9/2'B*.
Bue to a uefect in miciotubule polymeiization
uiant gianules in neutiophils
0culocutaneous albinism
Recuiiing infections

53'B/-< G'(/)DB*(,B)0 6-0.(0.
0sually an x-linkeu iecessive uisoiuei affecting males
Theie is a uefect in NABPB oxiuase, causing iecuiiing infections uue to
catalase (+) oiganisms (Staph, Pseuuomonas,etc)
Biagnostic test involves nitioblue tetiazolium uye (noimally gets ieuuceu by
gianulocytes) - measuies iespiiatoiy buist, which is lacking in these
patients




492




Chapter 11

Pulmonary




49S






O9+BV.*-(

Theie aie S causes of hypoxemia:
1. Bypoventilation
2. Biffusion Impaiiment
S. vQ mismatch
4. ! Fiu2
S. Shunt

Beie is an algoiithm figuiing out the cause of hypoxemia


494


-"$%' #%. -/+0,&+':
Tachycaiuia, uyspnea
Clubbing anu cyanosis
Ciackles anu iales
12*#,+*%,:
Tieatment iequiies tieating the cuiient hypoxemia anu the tieatment of
unueilying uisoiueis
" Pau2
u2 by nasal cannula, oi CPAP, oi intubation if necessaiy
If theie is a shunt, the hypoxemia will not impiove by incieasing the FI02



















49S




5?@680

1. Emphysema
2. Chionic Bionchitis
S. Asthma
4. Bionchiectasis

7*+390.*(
Is aii space uilation with alveolai wall uestiuction
The most common cause of emphysema is smoking
If a young patient gets this, consiuei an alpha-1-antitiypsin ueficiency

32>1=%+2, W X$0)'+ O*(A V=>+;)(&#,0)$(

-"$%' #%. -/+0,&+':
Baiiel chest
Bypeiventilation
Puiseu lip bieathing
Known as the "pink puffeis"
!"#$%&'"':
Clinical uiagnosis + CXR showing hypeiinflation of the lungs
496


12*#,+*%,:
Acute episoues iequiie:
u2 anu an ABu
CXR
Albuteiol (inhaleu)
Steioius foi acute uesatuiations
ABvISE PATIENT T0 ST0P SN0KINu
Chionic management of C0PB:
Ipiatiopium inhalei
Albuteiol inhalei
Yeaily influenza vaccination
Pneumococcal vaccine
F0TBER SN0KINu CESSATI0N ABvISINu
Long-teim u2 theiapy if Pu2 is <SS% oi the u2 satuiation is <88%


53'B/-< 4'B/<3-,-0
Piesents as a piouuctive cough on most uays foi % S months in a iow foi %
2yis
Known as the "blue bloatei"
-"$%' #%. -/+0,&+':
Similai to emphysema howevei hypoxia is moie seveie
RvB + pulmonaiy BTN
Neck vein uistention
Bepatomegaly
!"#$%&'"':
Biagnosis is laigely clinical
Can confiim with a lung biopsy that shows an incieaseu Reiu inuex, which is
a glanuulai layei that is >Su% of the total thickness of the bionchial wall.
12*#,+*%,:
u2
Bionchouilatois

497





#0,3*(
Piesents with S0B anu expiiatoiy wheezing
Seveie cases may piesent with the use of accessoiy muscles
Causeu by bionchial hypeiiesponsiveness that is ieveisible
-"$%' #%. -/+0,&+':
Expiiatoiy wheezing anu uyspnea
0nset is often physical activity
Conuition is ieveisible with bionchouilatois such as albuteiol
!"#$%&'"':
Bighly clinical
Check foi a FEv inciease of moie than 1u%
Complication incluues status asthmaticus, which is iefiactoiy attacks that
last foi uays anu aie fatal
12*#,+*%,:
Tieatment with #2-agonists such as albuteiol
Long-teim contiol involves auuition of inhaleu steioiu (if patient isn't
expeiiencing enough contiol with albuteiol)
If albuteiol + steioius aie not enough, auuition of a long-acting #-agonist
such as salmuteiol may help
Last iesoit in long-teim management (iefiactoiy to these pievious
tieatments) is oial steioius








498





4'B/<3-.<,(0-0
Bue to an anatomic uefect that causes peimanent uilation of the bionchioles
Patient expeiiences iecuiiing lung infections that piouuce massive amounts
of sputum
Patient often has uigital clubbing as well
!"#$%&'"':
The most accuiate uiagnostic test is the high-iesolution CT scan, which will
show thickeneu bionchial walls anu uilateu aiiways
CXR will show the classic "tiam-tiack maikings"
12*#,+*%,:
Nust tieat infections as they aiise because theie is no cuiative theiapy
Antibiotic theiapy foi iecuiiing infections
Chest physiotheiapy can be helpful in ieleasing anu eliminating sputum
Long-teim "cuie" is a lung-tiansplant













499





".0,'-<,-:. H)/1 6-0.(0.0

1. Inteistitial Fibiosis
2. Paienchymal uisease
S. Extiapulmonaiy uisease
4. Pleuial effusion


>/,.'0,-,-(D K-N'B0-0
Bue to chionic insult to the lung tissue by things such as asbestos, chionic
infections, oiganic uusts
Biagnosis maue by a CXR, which shows a "honeycomb" pattein of the lung
12*#,+*%,:
u2, PEEP, steioius if theie is collagen vasculai uisease

@('./<39*(D 6-0.(0.
Paienchymal uiseases aie causeu by things such as infections (TB),
inflammation (saicoiuosis), uiugs, toxicchionic inhalation of offenuing
agents (asbestos), anu it may be iuiopathic
Patient piesents with a uiy cough, S0B, anu chionic hypoxia
-"$%' #%. -/+0,&+':
"velcio" iales
Clubbing
!"#$%&'"':
CXR oi high-iesolution CT
Lung biopsy
PFT (all measuiements aie uecieaseu piopoitionately)
12*#,+*%,:
Suu


If inflammatoiy, steioius can help
Theie aie no uefinitive cuies foi othei foims of paienchymal uisease


7V,'(+)D*B/('9 6-0.(0.
Anything that affects the musculatuie iesponsible foi aiuing in bieathing can
cause pioblems
Nultiple scleiosis, ALS, uuillain-Baiie, spinal coiu tiauma
Anything that piesses on the uiaphiagm can also cause tiouble, such as
piegnancy anu obesity
Nanagementtieatment is suppoitive only


@D.)'(D 7;;)0-B/
Fluiu in the pleuial space
-"$%' #%. -/+0,&+'8
Becieaseu bieath sounus
Bullness to peicussion
Becieaseu tactile fiemitus

!"#$%&'"':
The best initial uiagnostic test is a CXR (lateial uecubiuus shows fiee flowing
fluius)
Nost accuiate test is thoiacentesis (can show which type of fluiu it is)

12*#,+*%,:
Small effusions usually iesoib spontaneously
Biuietics can be useu if causing iespiiatoiy pioblems
If effusion is laige, inseit a chest tube foi uiaining



Su1






@)D*B/('9 7*NBD-0*

Patient piesents with a suuuen onset of shoitness of bieath
Lungs aie cleai
The iisk factois foi PE aie usually telltale in the questions:
1. Immobility (Long aiiplane iiue)
2. Tiauma (Bioken bone)
S. Suigeiy (Especially ieplacement of joints in the leg)
4. Nalignancies
S. Thiombophilias

!"#$%&'"':
A CXR shoulu be uone anu is usually noimal. Nay show a weuge-shapeu
infaict (laige PE), atelectasis is a common finuing
EKu often shows non-specific ST-T wave elevations
Best test to confiim uiagnosis of PE is the spiial-CT anu shoulu be uone if the
xiay is abnoimal
If the xiay is noimal but you aie still suspicious, a vQ scan shoulu be
peifoimeu (the less noimal the xiay the less accuiate the vQ scan will be)
Bopplei exam is only 7u% sensitive, thus many PE's aie misseu with this test.
The benefit of the Bopplei is that if it B0ES uetect a PE, it is 1uu% accuiate
B-uimei is a highly sensitive test but it has low specificity. This is the best
test to use if the patient has a low piobability of having a PE anu you want a
single test to iule out a PE





Su2






@)D*B/('9 O9+.',./0-B/

Pulmonaiy hypeitension is uefineu as hypeitension that is % that of the systemic
piessuie. Noimally it shoulu be appioximately 18 that of the systemic piessuie
Active pulmonaiy hypeitension means it is piimaiily a uisease of the lung
Passive pulmonaiy hypeitension means it is seconuaiy to a conuition of the
heait
E2"+#2/ !"'*#'*:
Iuiopathic, which occuis commonly in young women
Inteistitial iestiictive uiseases
0bstiuctive pulmonaiy uiseases
-*;&%.#2/ !"'*#'*:
Seen in heait uisease
Commonly seen in patients with BIvAIBS

-"$%' #%. -/+0,&+':
Tiicuspiu ieguigitation
Louu P2
Right ventiiculai heave
Raynauu's phenomenon
!"#$%&'"':
Best initial test is the TTE, which will show RvB anu an enlaigeu iight atiium
Nost accuiate test is iight heait catheteiization with incieaseu pulmonaiy
aiteiy piessuie
EKu will likely show iight-axis ueviation


SuS


12*#,+*%,:
u2
Piostaglanuins
Enuothelin inhibitois that pievent giowth of the vasculatuie of the
pulmonaiy system

!)N.'<)DB0-0

1 TB affects the lowei lobes anu is usually asymptomatic
It occuis in specific gioups such as immigiants, BIv+ patients, homeless
patients, anu alcoholics.
-"$%' #%. -/+0,&+':
Night sweats
Fevei
Cough
Sputum
Weight loss
!"#$%&'"':
CXR is the best initial uiagnostic test
Bo an aciu-fast stain of the sputum to confiim uiagnosis
12*#,+*%,:
Tieatment with 4 anti-TB meuications shoulu be staiteu with six months of
theiapy being the stanuaiu of caie
Isoniaziu (6 months), Rifampin (6 months), Pyiizinamiue (2 months), anu
Ethambutol (2 months)
Bo LFT's because these meuications can cause livei toxicity (stop all
meuications if tiansaminase levels ieach Sx the uppei limit of noimal)
A+.<-;-< !BV-<-,-.0 <()0.2 N9 !4 2')10:
Isoniaziu ! peiipheial neuiopathy, auu B6
Rifampin ! ieuoiange coloieu bouy secietions
Pyiazinamiue ! hypeiuiicemia
Ethambutol ! optic neuiitis

Su4







!3. @@6 ,.0,
A scieening test foi those in iisk gioups.
7+%0)(A ';)0+;), )% ,% &$##$/%<
Smm: close contacts, BIv+, steioiu useis
1umm: foi those who aie in the "high-iisk" gioups mentioneu above
1Smm: those with no incieaseu iisk
If PPB is positive, uo the following:
1. CXR
2. If CXR is abnoimal, uo a sputum stain
S. If sputum stain is positive, stait 4-uiug theiapy













SuS



5(/<.'0 B; ,3. H)/1

Lung canceis account foi the most cancei ueaths anu aie the 2
nu
most
commonly uiagnoseu cancei
XRAY is N0T a goou scieening tool because by the time they aie seen
metastasis has occuiieu
Common signs anu symptoms: Cough, hemoptysis, hoaiseness, weight loss,
fatigue, iecuiient pneumonia
71+ &$##$/)(A 0,-#+ .+2$(%0;,0+% 01+ '$22$( '1,;,'0+;)%0)'% $& .)&&+;+(0 0=>+%
$& #*(A ',('+;%
5#L57" ![@7 5O#"#5!7">A!>5A
Auenocaicinoma Is the most common lung cancei in non-
smokeis (>+;)>1+;= ,(. %*->#+*;,)
CEA (+), anu is useu to follow tieatment
Bionchoalveolai caicinoma A subtype of auenocaicinoma that is not
ielateu to smoking
Piesents in the >+;)>1+;= of the lung
Laige Cell caicinoma In >+;)>1+;=
Is highly anaplastic anu has a pooi
piognosis
Squamous cell caicinoma Aiises fiom -;$('1*% ,(. )% , '+(0;,#
hilai mass
Stiongly linkeu to smoking
PTBiP ielease causes hypeicalcemia
Small cell caicinoma :+(0;,# 1)#,; location
Stiong link to smoking
Secietion of ABB anu ACTB causes
multiple enuociine pioblems
Tieat with iauiation + chemotheiapy
Nay cause Lambeit-Eaton synuiome
Bionchial caicinoiu tumoi 9+';+0+% %+;$0$()(
Causes iecuiient uiaiihea, flushing of
the skin, asthmatic wheezing
Nanage with a S-BT antagonist
Lymphoangio-leiomyomatosis Is a %2$$01D2*%'#+ neoplasm
Nost commonly seen in menstiuating
women
Piesents classically with pneumothoiax
Tieat with eithei piogesteione oi a lung
tiansplant

Su6


Tieat small cell caicinoma with a combination of iauiation anu chemotheiapy
Tieat all othei types with local iesection + iauiation (non-metastatic), anu iauiation
+ chemo if metastatic

A)+.'-B' A)D<)0 !)*B'
Also known as "Pancoast tumoi", which causes the following:
1. V$;(+;G% %=(.;$2+ - Ptosis, Anhyuiosis, Nyosis because it uamages the
sympathetic ceivical ganglion in the lowei neck, ANB
2. 9*>+;)$; F+(, :,?, 9=(.;$2+ - obstiuction of the SvC causes facial
swelling, cyanosis, anu uilation of veins of the heau anu neck



















Su7




Chapter 12

GI








Su8




70B+3(1.(D 6-0B'2.'0

The only two esophageal uisoiueis that iequiie an enuoscopy aie 5#L57" anu
4(''.,,80 .0B+3(1)0, both which iequiie a biopsy to know the uiagnosis.



6[A@O#G>#

#<3(D(0-(
Bysphagia to both solius anu liquius in a young non-smokei.
Nay be foou ieguigitation, anu aspiiation of pieviously eaten foou.
Involves a failuie of the gastioesophageal sphinctei to ielax, no mucosal
abnoimalities

!"#$%&'"':
Best initial test is the baiium swallow
Nost accuiate test is an esophageal manometiy

12*#,+*%,:
Best Initial tieatment is pneumatic uilation, if iepeateuly unsuccessful uo
suigeiy.
If patient iefuses suigeiy, we can give them an injection of botulinum toxin.




Su9



70B+3(1.(D 5(/<.'

Piesents w the following:
1. Bysphagia: fiist to solius then to liquius
2. Nay have heme (+) stool anuoi anemia
S. 0ften pts aie >Suyi anu aie smokeisalcohol uiinkeis.


!"#$%&'"':

Best initial test is an enuoscopy
If enuoscopy is not an option, uo a baiium swallow



12*#,+*%,:

Best initial theiapy is a suigical iesection (if no local oi uistant metastasis)
Follow suigeiy w chemo-baseu SF0



"-/10 (/2 E.N0

Also known as peptic stiictuies.
Can be causeu by iepetitive exposuie of the esophagus to acius, iesulting in
scaiiing anu stiictuie foimation.
Pievious use of scleiosing agents foi vaiiceal bleeuing can also cause
stiictuies(this is why banuing is the supeiioi pioceuuie).

S1u



!"#$%&'"':
Best initial uiagnostic test is a baiium stuuy

Following aie the uiff kinus of stiictuies:

1. 8#*22+;DF)(%$( %=(.;$2+: is a pioximal stiictuie founu in association
with iion ueficiency anemia. Is moie common in miuule-ageu women anu is
associateu with squamous cell esophageal cancei

Best initial theiapy is iion ieplacement

2. 9'1,0bB)G% ;)(A%< is a uistal iing of the esophagus that piesents w
inteimittent symptoms of uysphagia

Best initial theiapy is pneumatic uilation

S. 8+>0)' %0;)'0*;+< iesults fiom aciu ieflux. Tieat with pneumatic uilation



]./Q.'80 6-:.',-<)D)*

Look for pt w/ dysphagia w/ horribly bad breath. There is food rotting in the back of the
esophagus from dilation of the posterior pharyngeal constrictor muscles.

Diagnosis:

Best initial test is a baiium stuuy
Best initial theiapy is suigical iesection



S11



A+(0,-< 6-0B'2.'0
Biffuse esophageal spasm anu "nutciackei esophagus" aie essentially same
uisease.
Look foi case of seveie chest pain, often wo iisk factois foi Ischemic heait
uisease.
Nay occui aftei uiinking a colu beveiage.
Pain is always piesent, but uysphagia isn't always piesent.
All caiuiac tests aie noimal

!"#$%&'"':
Nost accuiate uiagnostic test is manometiy
Baiium stuuies may show a coiksciew pattein, but only uuiing an episoue of
spasm

12*#,+*%,:
Calcium channel blockeis anu nitiates aie the best tieatment options



70B+3(1-,-0

Esophagitis presents with odynophagia as the food rubs against the esophagus.

!"#$%&'"':
IF patient is BIv (-), uo an enuoscopy fiist
IF patient is BIv (+), has a CB4 count <1uu give fluconazole.. only uo
enuoscopy if the patient uoesn't iesponse to fluconazle.


5(/2-2( 70B+3(1-,-0
Causes 9u% of esophagitis in BIv (+) patients
The othei common cause is pill esophagitis, wheie ceitain pills can cause
esophagitis in the patient.
S12



12*#,+*%,:
Bave pt sit upiight when taking the pills
Bave patient uiink moie watei anu iemain upiight foi Su minutes aftei
swallowing.
.

%(DDB'9YI.-00 ,.('
Is an upper GI bleed with violent retching and vomiting of any cause.
Theie may be hematemesis oi black stool on exam oi in the histoiy

12*#,+*%,:
Nost cases iesolve spontaneously, if bleeuing peisists, injection of
epinephiine can be useu to stop the bleeuing.


G7"6

Patient presents with a history of epigastric pain that is associated with substernal chest
pain and possibly a metallic taste in the mouth.

Signs and Symptoms (on top of the classic presenting ones)

Soie thioat
Netallic oi bittei taste
Boaiseness
Chionic cough
Wheezing

N0TE: As many as 2u% of people who have a chionic cough aie suffeiing as a iesult
of uERB
!"#$%&'"':
PPI aumin is both uiagnostic anu theiapeutic.
Fuithei testing such as 24hi pB monitoiing shoulu only be uone if theie is no
iesponse to PPIs anu the uiagnosis still is not cleai
S1S



12*#,+*%,:Nilu uisease shoulu be contiolleu w lifestyle mouifications such as:
Weight Loss
Sleeping in an upiight position, oi at least somewhat angleu in beu
Smoking cessation
Limiting alcohol, caffeine, chocolate, anu peppeimint ingestion
Avoiuance of foou anu uiink within 2-S houis of going to beu

If those uon't woik then PPIs aie the next best theiapy foi uERB. They shoulu
contiol 9u-9S% of cases.

If theie is no impiovement then a tiial of B2-blockeis shoulu be tiieu (many auveise
effects with these)


4(''.,, 70B+3(1)0
Is a metaplasia fiom squamous to columnai cells

!"#$%&'"':
Peifoim enuoscopy when theie is weight loss, anemia, anuoi bloou in the
stool, anu in anyone who has chionic symptoms of ieflux uisease foi moie
than Syis.

K>L6>LG ?L 7L6?A5?@[ %#L#G7%7L!
Baiiett esophagus PPI anu iepeat enuoscopy eveiy 2-S
yeais
Low-giaue uysplasia PPI anu iepeat enuoscopy in S-6 months
Bigh-giaue uysplasia Bistal esophagectomy



S14



7+-1(0,'-< @(-/
Any pt >4Syi w peisistent epigastiic pain anuoi uiscomfoit shoulu ieceive an
uppei enuoscopy. This is essential to excluue the possibility of gastiic cancei


Non-Ulcer Dyspepsia:

Is the NCC of epigastiic uiscomfoit
Can only be concluueu aftei enuoscopy has excluueu an ulcei uisease, gastiic
cancei, anu gastiitis

12*#,+*%,:
Consists of symptomatic theiapy w B2 blockeis, liquiu antacius, oi PPIs.



@.+,-< $D<.' 6-0.(0.
Bue to hypeisecietion of aciu
Can be eithei uuouenal ulcei(B0) oi gastiic ulcei(u0) uiseases
B. Pyloii is the NCC of ulceis, 2
nu
NCC is NSAIBs, heau tiauma, buins,
intubation, Ciohn's uisease, anu ZES.
0sually, foou impioves the pain of a uuouenal ulcei anu makes the pain of a
gastiic ulcei woise
If the pt is above 4S anu has epigastiic pain, you must scope to excluue
gastiic cancei.



G(0,'-,-0

Not due to hypersecretion of acid, as in PUD.
Can be associated with H.Pylori, if this is present treat w/ PPI and 2 antibiotics.
S1S


uastiitis can also be "atiophic" fiom peinicious anemia anu is often
associateu with a ueficiency of vitamin B12

7+%0)(A &$; Vg 8=#$;)<
)&', #;;=2#,* ,*',8
Enuoscopy with biopsy (if this is uone no fuithei testing is iequiieu)
-*2&7&$/ is veiy sensitive but not specific, if the seiology is negative, this
excluues B. Pyloii.
A positive test can't uistinguish between new anu pievious infection.

F2*#,5 ,*',"%$ #%. ',&&7 #%,"$*% ,*',"%$8
These aie not stanuaiu oi ioutinely useu. They can howevei uistinguish
between new anu olu uisease.

12*#,"%$ ?\ E/7&2"8
Tieat this bacteiia with PPI anu claiithiomycin + amoxicillin.
0NLY tieat if its associateu with gastiitis oi ulcei uisease.

Theie is no neeu foi ioutine post-tieatment testing of B Pyloii. theie is no benefit in
tieating B. Pyloii that is associateu with non-ulcei uyspepsia.

>6 ,5* ,2*#,+*%, &6 ?\E/&7"2 .&*'%N, '=;;**.< ,2/ ,5* 6&77&:"%$8

1. Repeat tieatment with 2 new antibiotics anu PPI : 0se metioniuazole +
tetiacycline insteau
2. If iepeat tieatment fails, evaluate foi ZES (uastiinoma).




A,'.00 $D<.' @'B+39D(V-0:

S16


Routine prophylactic use of a PPI or H2 blocker or sucralfate should only be used if one
of the following is present:

1. Beau tiauma
2. Intubation anu mechanical ventilation
S. Buins
4. Coagulopathy anu steioiu use in combo

**NSAIB oi steioiu use alone is not an inuication foi ioutine stiess ulcei piophylaxis


]BDD-/1.'Y7DD-0B/ A9/2'B*.\]7A^ B' G(0,'-/B*(

ZES is diagnosed by finding an elevated gastrin level and an elevated gastric acid output.

**remember that everyone on a H2 blocker or PPI has an elevated gastrin level.

M5*% ,& ,*', ,5* $#',2"% #%. $#',2"; #;". &=,0=,X

When any of the following aie piesent:
1. laige ulcei >1cm
2. multiple ulceis
S. uistal location neai the ligament of Tieitz
4. iecuiient oi peisistent uespite B. Pyloii tieatment

*if the gastrin and acid output level are both elevated, then localization of the gastrinoma
is next.

!"#$%&'"'8
Nost accuiate is an enuoscopic ultiasounu
Nucleai somatostatin scan is also veiy sensitive because ZES patients have a
high numbei of somatostatin ieceptois

12*#,+*%,8
Local uisease iequiies suigical iesection
Netastatic uisease iequiies the patient be on lifelong PPIs
S17






>/;D(**(,B'9 4BE.D 6-0.(0.\>46^

Both Crohns and ulcerative colitis can present with fever, abdominal pain,
diarrhea, blood in stool, and weight loss.

0C pies most often with abuominal pain anu bloouy uiaiihea

IK,2#"%,*',"%#7 +#%"6*',#,"&%' &6 >F! #2*8
}oint pain
Eye finuings
Skin finuings
Scleiosing cholangitis

C*#,=2*' +&2* ;&++&% ,& 32&5%N' ."'*#'* #2*8
Nasses
Skip lesions
Involvement of uppei uI tiact
Peiianal uisease
Tiansmuial gianulomas
Fistulae
Bypocalcemia fiom fat malabsoibtion
0bstiuction
Calcium oxalate kiuney stones
Cholesteiol gall stones
vitamin B12 malabsoibtion fiom teiminal ileum involvement

!"#$%&'"'8
Enuoscopy is best initial test
Baiium stuuies aie also goou uiagnostic tests


S18


5'B3/80 Naikeis:
Antisacchaiomyces ceievesiae(ASCA) : positive
Antineutiophil cytoplasmic antibouy(ANCA) : negative

$5 Naikeis:
ASCA: negative
ANCA: positive

12*#,+*%,:
Best initial tieatment foi both is mesalamine
Steioius aie useful in acute cases
Suigeiy is iequiieu if theie is no ielief fiom these tieatment moualities

















S19





6>#""O7#

Infectious Diarrhea

The presence of blood indicates a pathogenic invader, which may include any of the
following:

Campylobacter - Is the MCC of food poisoning.

Salmonella - Transmitted by chicken and eggs

Vibrio Parahemolyticus Associated with infected seafood

E. Coli There are many different types, which include:

E. Coli 0157:H7 ! MC associated with haemolytic uremic syndrome(via effects
of verotoxin). Look for undercooked beef in the history.
Vibrio vulnificus: Look for shellfish in a person w/ liver disease
Shigella: Secretes Shiga toxin, which is also associated with reactive arthritis
Yersinia: Rodents are natural reservoirs, transmission via veggies, milk-derived
products, and meat
Amebic: Perform three ova & stool parasite exams or serologic testing. Treat
with metronidazole


Diagnosis:

Best initial test ! fecal leukocytes

Most accurate test ! stool culture


Treatment:

Mild disease! Keep the patient hydrated, this usually resolves on its own

Severe disease ! Fluoroquinolones are the treatment of choice. Severe disease is
defined as presence of any of the following (Blood, fever, abdominal pain, hypotension
and tachycardia)
S2u









Non-Bloody Diarrhea:

Non-bloody diarrhea may still be d/t the above pathogens, which can all present
with non-bloody diarrhea.
NO BLOOD in diarrhea will exclude all of the following, which never have
blood:


1. Viruses ! Rotavirus, Norwalk virus (Norovirus)
2. Giardia ! Camping/hiking. Look for bloating/flatus/steatorrhea, stool ELISA is
diagnostic test of choice, treatment involves metronidazole.
3. Staph Aureus ! Presents with vomiting in addition to diarrhea. This resolves
spontaneously
4. Bacillus Cereus ! Is associated with eating refried rice. This resolves
spontaneously
5. Cryptosporidiosis! HIV (+) patient with a CD4 count <100. Diagnosis with
acid-fast stain. There is no proven treatment except to raise the CD4 count w/
antiretroviral therapy.
6. Scombroid! Histamine fish poisoning, has fastest onset of poisoning, which is
around 10 min after eating infected tuna, mackerel, or mahi-mahi. Patient has
vomiting, diarrhea, wheezing, and flushing. Treatment involves giving the
patients antihistamines such as diphenhydramine.




Antibiotics Associated Diarrhea (C. Difficile)

Develops several days to weeks after use of antibiotics such as Clindamycin, which is
the most common cause. There can be both blood and fecal leukocytes with C.Difficile-
related colitis.


Diagnosis:

Best initial test is a stool toxin assay.

Treatment:

S21


The best initial therapy is metronidazole






Chronic Diarrhea

The most common cause of chronic diarrhea is lactose intolerance


Diagnosis:

Removal of milk products will both allow for diagnosis and treatment































S22









MALABSORBTION


Diarrhea caused by malabsorption is always associated with weight loss
Fat malabsorption is associated with steatorrhea, which leads to oily/greasy stools
that float on the water in the toilet and are foul smelling

The common causes of fat malabsorption are as follows:

1. Celiac Disease
2. Tropical Sprue
3. Chronic Pancreatitis
4. Whipples Disease


All forms of malabsorption are associated with:

Hypocalcemia from vitamin D deficiency, which may lead to osteoporosis
Oxalate overabsorption and oxalate kidney stones
Easy bruising and elevated PT/INR due to vitamin K malabsorbtion
Vitamin B12 malabsorption from either destruction of terminal ileum or loss of
pancreatic enzymes that are necessary for B12 absorption


Diagnosis:

The best initial test is the sudan stain
The most sensitive is a 72-hr fecal fat test



Celiac Disease

Presents with iron malabsorption and microcytic anemia


Diagnosis:

S2S


Best initial diagnostic test is checking for antigliadin, antiendomyseal, and
antitissue transglutaminase antibodies
The most accurate test is a small bowel biopsy

*bowel wall biopsy is always necessary even w/ antibody confirmation, in order to
exclude bowel wall lymphomas.


Treatment:

Elimination of oats, wheat, barley from the diet




Tropical Sprue

Patient will have a history of being in a tropical location, and presents the same way as
celiac disease.

Diagnosis:

Small bowel biopsy is the best test to perform

Treatment:
Tetracycline or TMP-SMX for 3-6 months





Whipples Disease

A GI infection presenting with arthralgias, rash, diarrhea, and anemia


Diagnosis:

The most accurate test is a small bowel biopsy that shows PAS (+) organisms
Can also do a PCR of the stool looking for T. Whippelii

Treatment:

Penicillin, Tetracycline, or TMP-SMX for 12 months


S24










Chronic Pancreatitis

History of alcoholism is usually present
Lipase and amylase levels are likely normal since these wont drop until the
pancrease is calcified and fibrosed.
Fat soluble vitamins are not absorbed


Diagnosis:

The best initial test is an abdominal XRAY or a CT without contrast
The most accurate testis secretin stimulation testing (normal person releases large
amount of bicarbonate-rich pancreatic fluid).

Treatment:

Involves the administration of pancreatic enzymes by mouth.





Irritable Bowel Syndrome

Syndrome where the patient experiences an alteration in bowel habits
(constipation alternating with diarrhea)
Pain is usually relieved after a bowel movement


Diagnosis:

Testing may include colonoscopy, xrays, blood tests, but all are negative

Treatment:

The best initial treatment is fiber supplementation, which helps by bulking the
stool and relieving pain
If fiber doesnt work, can add antispasmotic agents to try and relax the bowel
S2S


If these fail to work, TCAs can be tried







COLON CANCER


Hamartomas and hyperplastic polyps are benign
Dysplastic polyps are malignant

** The most important thing to know for colon cancer screening is when and what to do
for the patient


Diagnostic Testing:

General Population:

1. Begin screening at 50yr
2. Colonoscopy q10yrs
3. Sigmoidoscopy q 3-5yrs
4. Fecal occult blood testing yearly
5. Barium enema

The best method of screening for colon cancer is performing a colonoscopy every 10yrs

One family member with colon cancer requires colonoscopy starting at 40yr or 10yr
before age of family member who had cancer.

Three family member, two generations, one premature(<50) require a colonoscopy every
1-2yr starting at 25yrs. This is a lynch syndrome or HNPCC











S26










Familial Adenomatous Polyposis(FAP)

Start screening sigmoidsocopies at age 12
Perform colectomy if polyps are found




Gardners syndrome

This presents with benign bone tumors known as osteomas, as well as other soft
tissue tumors. There is no additional screening indicated for Gardners syndrome




Peutz-Jeghers Syndrome

This presents with a patient who has melanotic spots on the
There are hamartomatous polyps throughout the small bowel and colon
There is a lifetime risk of colon cancer is 10%.
No extra screening recommended




Juvenile Polyposis

There are multiple extra hamartomas in the bowel.
No increased risk of colon cancer from hamartomas
No extra screening recommended
If dysplastic polyps are found, perform repeat colonoscopy in 3-5 years

GENERAL
POPULATION
SINGLE
FAMILY
MEMBER
WITH COLON
CANCER
THREE
FAMILY
MEMBERS
WITH
CANCER
FAP GARDNERS,
PEUTZ-
JEGHERS, JP
S27


Start at 50, then
q10yr
Start at 40yr or
10yr earlier
than when
diagnosed
Colonoscopy
q1-2yr at 25yr
Sigmoidoscopy
q102 yr starting
at 12yr
No xtra
screening
recommended



DIVERTICULAR DISEASE


Includes Diverticulosis and Diverticulitis


Diverticulosis

Incredibly common in older Americans and it most commonly caused by a low-fiber,
high-fat diet

Signs and Symptoms:

LLQ abdominal pain
Lower GI bleed

Diagnosis:

The most accurate test is a colonoscopy
Best diagnostic test is an abdominal CT scan

Treatment:

High-fiber diet low in saturated fats




Diverticulitis

Is a complication of diverticulosis and presents with:

LLQ abdominal pain
Tenderness
Fever
Elevated white cell count in blood

Treatment:

S28


Involves the use of antibiotics. Metronidazole and ciprofloxacin most commonly
used.





Gastrointestinal Bleeding


Red blood ! lower GI bleed, rarely a very acute upper GI bleed can be red blood

Black stool ! upper GI bleed (Proximal to Ligament of Trietz). Black stool usually is
100ml or more blood.

Heme (+) brown stool ! can occur from as little as 5-10ml of blood loss

Coffee ground emesis ! needs very little gastric, esophageal, or duodenal blood loss, as
little as 5-10ml.

**The most important thing to do in acute GI bleeding is to determine if there is
hemodynamic instability



Treatment for GI bleeds:

IV fluids if it is a large bleed
Correction of anemia or other lab abnormalities




Variceal Bleeding

Look for alcoholic with hematemesis and/or liver disease
Other clues are the presentation of splenomegaly, low platelets, and spider
angiomas or gynecomastia

Diagnosis:

Endoscopy

Treatment:

First thing to do is add octreotide which decreases portal hypertension
S29


2
nd
thing to do is an upper GI to band the variceals
If banding fails, a shunt between the portal vein and the hepatic vein should be
done





Sources of Bleeding

Upper GI:

Ulcer disease
Esophagitis
Gastritis
Duodenitis
Varices
Cancer

Lower GI:

Angiodysplasia
Diverticular disease
Polyps
Ischemic colitis
IBD
Cancer

Diagnosing sources of bleeding:

Technetium bleeding scan (tagged red cells) detects source of bleed
Angiography is an excellent preoperative test because it localizes the site of
resection
Capsule endoscopy should be done when the other methods fail. This is a small
camera that is swallowed and allows for visualization of the small intestine




Acute Mesenteric Ischemia

Presents with a sudden onset of severe abdominal pain with a normal appearing exam (ie.
The pain is out of proportion to the findings on exam)

Diagnosis:
SSu



The most accurate test is an angiography

Treatment:

Surgical resection of ischemic bowel


Other GI Conditions



Constipation

Initial management of constipation is hydration and fiber supplements

There is usually no clear etiology, for clinical purpose must know possible causes and be
able to treat underlying reason.

1. Dehydration: look for signs of dehydration, BUN:Cr of >20:1
2. CCBs
3. Narcotic medication use/sedatives
4. Hypothyroidism: TSH, T4
5. Diabetes
6. Ferrous sulphate iron replacement
7. Anticholinergic medications



Dumping syndrome

This is a rare disorder related to prior gastric surgery (Often for ulcer disease)
This is a disorder where stomach contents are quickly passed through to the
intestine, and it then draws fluid into the GI, causing an initial HYPERglycemia
follow by a reactive HYPOglycemia


Signs and Symptoms:

Shaking chills
Diaphoresis
Weakness
Hypotension
Hyperglycemia


SS1


Treatment:

Small and frequent meals






Diabetic Gastroparesis

Longstanding DM impairs neural supply of bowel, there is impairment of normal
motility.
Patient will present with bloating and constipation as well as diarrhea


Diagnosis:

Clinical + history of diabetes

Treatment:

Erythromycin (increases motilin in the gut, thus increasing motility) and
metoclopramide.




Acute Pancreatitis

Presents (classically) as severe midepigastric pain and tenderness that is associated with
alcoholism and/or gallstones


Diagnosis:

Lipase (more specific) and amylase

Treatment:

Keep patient NPO
Give IV fluids
Give pain medications



SS2










ACUTE HEPATITIS:


All pts present in a very similar way:

1. Jaundice
2. Fatigue
3. Weight loss
4. Dark urine from bilirubin in the urine

*Hepatitis B and C are more likely to pres with serum-sickness phenomenom like joint
pain, urticaria, and fever.

No definitive treatment is available for any form of acute hepatitis.

Diagnosis:

Conjugated bilirubin levels (will be elevated)
Viral Hepatitis gives elevated ALT level
Drug-induced hepatitis is associated with increased levels of AST
In pregnancy, if a patient gets hepatitis E this can be fatal
Most accurate tests for hep A, C, D, and E, the confirmatory test is serology
IgM levels acutely rise, and IgG levels rise in the recovery phase.
Surface antigens, core antibody, e-antigen, or surface antibodies are only
associated w/ hepatitis B.




Hepatitis B testing:

The first test to become abnormal in acute hep B infection is the surface antigen.
Elevation in ALT, e-antigen, and symptoms all occur after the appearance of
hepatitis B surface antigen.
Chronic hep B gives the same serologic pattern as acute hep B, but it is based on
persistence of the surface antigen beyond six months.

SSS


*Tests for active viral replication: hep B DNA polymerase = e-antigen = hep B PCR
for DNA, all equal the same thing.







Hepatitis C testing:

Best initial test is hep C antibody, this wont tell the level of activity of the virus
Most accurate test Hep C PCR for RNA, also is the most accurate way of testing
response to therapy
Liver biopsy is the most accurate for finding out the severity of the disease


Treatment of Chronic Hepatitis

Chronic hep B: The pt w/ surface antigen, e-antigen, and DNA polymerase or PCR for
DNA is the pt most likely to benefit from antiviral therapy. Look for >6mnth of positive
serology

Treat chronic hep B w/ following single agents:
1. Lamivudine
2. Adefovir
3. Entecavir
4. Telbivudine
5. Interferon (has the most adverse effects)

Chronic hep C: Combine interferon with ribavirin (MC adverse effect is anemia)



Vaccination:

Hep A and B vaccination is now universally done in children.

For adults the strongest indication for both types are the following:

1. Chronic liver disease
2. Household contacts
3. MSM (men who have sex with men)
4. Blood product recipients on a chronic basis
5. Injection drug users

SS4


Specific indications:

HEP A ! travelers
HEP B ! health care workers and pts on dialysis.

*there is no vaccine or postexposure prophylaxis for hep C



CIRRHOSIS


No matter what the cause may be, it will have a number of features:

1. Edema due to low oncotic pressure (treat with spironolactone + diuretics)
2. Gynecomastia
3. Palmar erythema
4. Splenomegaly
5. Thrombocytopenia due to splenic sequestration
6. Encephalopathy, which should be treated with lactulose
7. Ascites - Treat with spironolactone
8. Esphageal varices - Propranolol will prevent bleeding, perform banding if bleed
continues.

Ascites:

Perform paracentesis for all pts with ascites if a new ascites, pain, fever, or tenderness are
present.

Diagnosis:

Test the fluid albumin level
SAAG > 1.1 is consistent with portal hypertension from cirrhosis













SSS











CHRONIC LIVER DISEASE (Cause of cirrhosis)


Alcoholic cirrhosis

Is a diagnosis of exlusion. Must exclude all other causes of cirrhosis and look for a
history of longstanding alcohol abuse. Treat as described above for cirrhosis





Primary Biliary Cirrhosis

Presents most commonly in a middle-aged woman complaining of itching. Xanthalasmas
may be found on exam. Also look for a history of other autoimmune disorders


Diagnosis:

The best initial test is elevated alkaline phosphatase + normal bilirubin level
The most accurate test is presence of antimitochondrial antibody

Treatment:

Ursodeoxycholic acid






Primary Sclerosing Cholangitis:

80% of those with PSC also have IBD


SS6


Signs and Symptoms:

Urticaria
Elevated bilirubin levels
Elevated alkaline phosphatase

Diagnosis:

Most accurate test is ERCP
Anti-smooth muscle antibody, and (+) ANCA
Treatment:

Ursodeoxycholic acid









Wilsons Disease

Involves cirrhosis and liver disease in a person with a choreiform movement disorder
and neuropsychiatric abnormalities.


Signs and Symptoms:

Extrapyrimidal symptoms
Mania/depression
Kayser-Fleischer rings around the cornea is pathognomonic for Wilsons disease

Diagnosis:

Decreased serum ceruloplasmin

Treatment:

Penicillamine




Hemochromatosis
SS7



Most often from a genetic disorder resulting in overabsorbtion of iron
Iron deposits throughout the body, most commonly in the liver.


Signs and Symptoms:

Darkening of the skin (Bronze diabetes)
Arthralgia
Cardiomyopathies (Restrictive)
Infertility
Hepatoma


Diagnosis:

Best initial test is serum study showing elevated serum iron and ferritin with a low
TIBC. Iron saturation will be grossly elevated
The most accurate test is a MRI or liver biopsy

Treatment:

Phlebotomy




Autoimmune Hepatitis

Most often presentation is a young woman who has another autoimmune disease

Diagnosis:

Best initial test is ANA and anti-smooth muscle antibodies
The most accurate test is a biopsy of the liver

Treatment:

Prednisone





Nonalcoholic steatohepatitis (NASH)

SS8


Strong association with obesity, diabetes, and hyperlipidemia

Diagnosis:

Best initial test is liver studies that show ALT>AST
The most accurate test is a liver biopsy that shows fatty infiltration



Treatment:

Management of the underlying condition







SS9




Chapter 13

Nephrology





S4u


"./(D !)N)D(' (/2 >/,.'0,-,-(D 6-0B'2.'0

6')1 >/2)<.2 >/,.'0,-,-(D L.+3'-,-0
Classic uiugs causing inteistitial nephiitis incluue PCN, NSAIBs,
Sulfonamiues, anu uiuietics.
-"$%' #%. -/+0,&+':
Rash
Bematuiia
0liguiia
Fevei
Eosinophilia
Eosinophiliuiia is iaie but is pathognomonic foi hypeisensitivity Alleigic
Inteistitial Nephiitis
!"#$%&'"':
Biagnosis is mainly clinical, iemoval of offenuing agent + impiovement helps
to confiim uiagnosis
Tieatment:
Removal of offenuing agent
Steioius can help


#<),. "./(D K(-D)'.
Piesents with " azotemia
" B0N & Cieatinine
Causeu by eithei pieienal, ienal, oi postienal azotemia
8;+;+(,# E,)#*;+:
Bypopeifusion will leau to ienal failuie
volume uepletion, sepsis, heatstioke, buins, hypotension
4(0;)(%)' M+(,# E,)#*;+F
ATN is the most common cause
Renal ischemia also a possibility

S41


8$%0;+(,# E,)#*;+F
Is uue to obstiuction seconuaiy to eithei BPB, ienal calculi, anuoi
blauueipelvic tumois

Test Pieienal Postienal Renal
0iine 0smolality >Suu <SSu <SSu
0iine Souium <2u >4u >2u
FENa <1% >4% >2%
B0NCieatinine >2u >1S <1S

12*#,+*%,:
Iv fluius to maintain uiine output
Biuietics to pievent fluiu oveiloau
Close monitoiing of electiolyte abnoimalities
Bialyze with seveie electiolyte abnoimalities, uniesponsive metabolic
aciuosis, uiemia, anu toxic ingestion


#<),. !)N)D(' L.<'B0-0
Fiom eithei hypopeifusion that leaus to tissue ueath oi fiom insult uue to
vaiious toxic injuiies
Is the most common cause of acute ienal failuie
12*#,+*%,:
Remove cause
uive Iv fluius to maintain uiinaiy output
Closely monitoi electiolytes
uive uiuietics as neeueu to pievent fluiu oveiloau


"./(D !)N)D. K)/<,-B/(D 6-0B'2.'0
1. Renal Tubulai Aciuosis
2. Biabetes Insipiuus
S. Synuiome of Inappiopiiate Antiuiuietic Boimone
S42



M+(,# 7*-*#,; !').$%)%:
Type Chaiacteiistic 0iinaiy pB
Type I A uefect of the uistal
tubule (B+ giauient)
>S.S
Type II Pioximal tubule fails to
iesoib BC0S
>S.S eaily then <S.S as the
aciuosis woisens
Type Iv ! Aluosteione (leauing to
hypei K+ anu hypei Cl-

Fiom ! secietion seen in
BN, inteistitial nephiitis,
ACEI's, hepaiin, anu
NSAIB use.

Nay also be uue to
aluosteione iesistance
fiom sickle cell oi uiinaiy
obstiuction
<S.S


R),-+0+% 4(%)>).*%:
Theie is cential anu nephiogenic types of BI, both:
! secietion of ABB if it is cential uiabetes insipiuus, anu an ABB iesistance if
it is nephiogenic
-"$%' #%. -/+0,&+' &6 4&,5:
Polyuiia
Polyuypsia
Noctuiia
0iine osmolality & 2uu anu seium osmolality % Suu
5./,'(D 6>F
Is eithei iuiopathic (Piimaiy) oi causeu by insult to biain (Seconuaiy)
Tieat this with BBAvP nasal spiay
L.+3'B1./-< 6>:
Is an x-linkeu uisease anu may be seconuaiy to sickle cell, pyelonephiitis,
nephiosis, amyloiuosis, multiple myeloma uiugs
S4S


Tieat by incieasing watei intake anu iestiicting souium intake

!"#$%&'"':
With BBAvP auministiation, cential BI will have a fast ueciease in uiine
output, while nephiogenic BI will have no change in uiine volume
With BBAvP auministiation, cential BI shows an acute inciease in uiine
osmolality, wheie nephiogenic BI shows no change in osmolality
Tieat cential BI with BBAvP oi vasopiessin
Tieat nephiogenic BI by coiiecting the unueilying cause (electiolyte
imbalances).


9=(.;$2+ $& 4(,>>;$>;),0+ !(0).)*;+0)' V$;2$(+ K94!RVL<
Theie aie many possible causes of SIABB:
3S- ."'*#'*: tiauma, tumois, hyuiocephalus
E=7+&%#2/ ."'*#'*': pneumonia, Small cell caicinoma of lung, abscess, C0PB
I%.&;2"%* ."'*#'*: hypothyioiuism, Conn's synuiome
!2=$': NSAIBs, chemotheiapy, uiuietics, phenothiazine, oial hypoglycemics

!"#$%&'"': piesence of hyponatiemia with a uiine osmolality of >Suummolkg
12*#,+*%,: this conuition is usually self-limiting, iesistant cases may iequiie
uemeclocycline which inuuces nephiogenic BI


:1;$()' M+(,# E,)#*;+<
Always associateu with ienal azotemia
35#2#;,*2"J*. 4/8
Azotemia
Aciuosis
Bypeikalemia
Bypocalcemia uue to lack of vitamin B piouuction
S44


Anemia (lack of eiythiopoietin piouuction)
Bypeitension uue to RAAS pathway activation

-"$%' #%. -/+0,&+':
Nausea anu vomiting
Anoiexia
Bementia
Convulsions
Coma
PLT uysfunction (leaus to bleeuing)
!"#$%&'"':
Renal ultiasounu showing small kiuneys if failuie is chionic
Piesence of anemia uue to lack of EP0 piouuction
12*#,+*%,:
Restiict both watei anu salt
Pievent fluiu oveiloau with uiuietics
If theie aie seveie electiolyte uistuibances oi aciu-base pioblems go into
uialysis













S4S


GDB*.')D(' 6-0.(0.0

L.+3'-,-< (/2 L.+3'B,-< A9/2'B*.0F
L.+3'B,-<F !*6"%*. 4/ ! hypeipioteinuiia, hypopioteinemia, hypeilipiuemia,
euema
Pioteinuiia >S.Sguay
Patient has geneializeu euema
Bypeicoagulation
! albumin
Bypeilipiuemia
!"#$%&'"':
J+%0 )()0),# 0+%0 is a uiinalysis showing significantly incieaseu levels of
piotein
Next best step is a spot-uiine test foi a piotein: cieatinine >S.S:1
24-hi uiine piotein collection >S.Sg
@$%0 ,''*;,0+ 0+%0 ! Renal biopsy
![@7 ?K L7@O"?!>5 6>A7#A7 5?%%?L 5O#"#5!7">A!>5AJ!c
Ninimal Change Bisease This is seen in young chiluien.
Tieat with pieunisone
Focal Segmental ulomeiuloscleiosis Similai in piesentation to NCB but
occuis in auults.
Nost commonly iuiopathic.
Commonly piesents in young
hypeitensive males.
Tieat with pieunisone anu
cyclophosphamiue
Nembianous ulomeiulonephiitis Is the most common 1 cause of
nephiitic synuiome in auults.
A slowly piogiessive uisoiuei.
Nany causes: BBv, BCv, syphilis, ceitain
uiugs, malignancies, SLE.
Tieat with pieunisone +
cyclophosphamiue.
Su% of cases piogiess to enu-stage ienal
failuie
Nembianopiolifeiative
ulomeiulonephiitis
Type 1 is slowly piogiessive while Type
2 is aggiessive.
Autoantibouy against CS conveitase
(!CS levels)
Tieat with pieunisone, plasmaphaiesis.
S46


12*#,+*%,:
Piotein anu salt iestiiction
BNu-CoA ieuuctase inhibitoi foi hypeilipiuemia

L.+3'-,-<:
This happens when theie is uiffuse glomeiulai inflammation
-"$%' #%. -/+0,&+':
Theie is an acute-onset of hematuiia
0liguiia
Bypeitension
Euema
!uFR
" Bun:Ci
![@7 ?K L7@O">!>5 6>A7#A7 5?%%?L 5O#"#5!7">A!>5AJ!c
Post-stieptococcal ulomeiulonephiitis An acute conuition.
Classically occuis aftei Stiep Pyogenes
infection.
Immunofluoiescence shows coaise
gianulai Igu oi CS ueposits.
Labs show incieaseu ieu cells anu casts,
! seium CS, " AS0 titei.
Rapiuly Piogiessive ulomeiulonephiitis
(Ciescentic)
A nephiitic conuition that piogiesses
iapiuly to ienal failuie.
uooupastuie's uisease is in this categoiy.
Immunofluoiescence shows smooth anu
lineai Igu ueposits.
Tieat with pieunisone anu
plasmaphaiesis.
Beigei's Bisease (IgA nephiopathy) Nost common type of nephiopathy.
IgA ueposits in mesangium.
Piesents with iecuiient hematuiia +
low-giaue pioteinuiia.
0sually haimless, howevei 1 in 4 may
piogiess to ienal failuie.
Tieat with pieunisone
Benoch-Schonlein Puipuia Always in chiluien, is an IgA
nephiopathy.
Piesents with abuominal pain, uI bleeu,
vomiting, anu hematuiia.
Classically finu palpable puipuia on
S47


buttocks anu legs
Is a self-limiting uisease that iequiies no
steioius.
Nultiple Nyeloma Theie is an incieaseu light-chain
piouuction.
Finu Bence-}ones piotein in uiine.
Bypeicalcemia seen.
Patient becomes succeptible to
encapsulateu bacteiia because theie is a
uefect in noimal antibouy piouuction.
Tieatment must be on the unueilying
myeloma.




















S48


A90,.*-< GDB*.')DB/.+3'B+(,3-.0F
6>A7#A7 5O#"#5!7">A!>5 L7@O"?@#!O[
Biabetes Nellitus Is the NCC of ESRB.
Eaily manifestation is micioalbuminuiia
(give ACEI's, stiict glycemic contiol).

BIv NC seen when BIv is acquiieu by Iv
uiug use.
Piesents as focal segmental
glomeiulonephiitis.
Eaily tieatment with antiietioviial
Renal Amyloiuosis Biagnose with biiefiingence on congo
ieu stain.
Tieat with a tiansplant

H$@$A
Type 1 No ienal involvement
Type 2 Is a mesangial uisease with focal
segmental glomeiulai pattein.
Tieatment isn't typically iequiieu
Type S Is a focal piolifeiative uisease.
Tieat aggiessively with pieunisone anu
cyclophosphamiue
Type 4 Biffuse piolifeiative uisease.
Combination of both nephiitic anu
nephiitic uisease.
Wiie-loop abnoimality on LN
Tieat with pieunisone anu
cyclophosphamiue
Type S Is a membianous uisease that is
inuistinguishable fiom othei piimaiy
membianous uiseases.
Tieat with pieunisone







S49


"./(D #',.'9 A,./B0-0

Piesents with suuuen onset of hypeitension along with hypokalemia
Abuominal biuit heaiu with stethoscope
Can be causeu by plaque, fibiomusculai uysplasia
!"#$%&'"':
J+%0 )()0),# 0+%0 is a ienal ultiasounu with Bopplei
If small kiuneys aie then seen, uo an NRA
The 2$%0 ,''*;,0+ 0+%0 is a ienal angiogiam
12*#,+*%,:
Angioplasty anu stenting

















SSu



?N0,')<,-B/ B; ,3. $'-/('9 !'(<,

BPB anu stones aie the NCC in auults
Theie is an incieaseu iisk of stasis thus incieasing the iisks of 0TI's
Piesent with uiinaiy colic, intense pain that iauiates fiom the back aiounu to
the pelvis anu the gioin
L.+3'BD-,3-(0-0:
3#7;"=+ E/2&05&'05#,*:
8S% of stones aie calcium pyiophosphate
Aie iauiopaque anu associateu with hypeicalcemia
Su% of time it's associateu with hypeicalciuiia
Tieat calcium stones with hyuiation anu loop uiuietics (L00PS eliminate
calcium)
@++&%"=+ )#%$*'"=+ E5&'05#,* T-,2=G",*U8
2
nu
NCC of stones
Aie iauiopaque
0sually causeu by uiease (+) Pioteus oi Staph Sapiophyticus
Nay foim laige staghoin calculi
Tieatment involves taking caie of the unueilying infection

R2"; @;". -,&%*':
0ften seconuaiy to gout oi conuitions that cause incieaseu cell tuinovei,
such as myelopiolifeiative uisease
Tieat by alkalinizing the uiine anuoi tieating any unueilying conuitions







SS1



P-2/.9 !)*B'0

The most common ienal malignancy is './(D <.DD <('<-/B*(, which occuis
NC in males fiom Su-7uyi of age
Piesents with hematuiia, flank pain, fevei, palpable mass, anu seconuaiy
polycythemia
Tieatment involves inteileukin anu iesection
The most common chiluhoou ienal malignancy is I-D*80 ,)*B', which
occuis NC between 2-4yi olu
Piesents with a palpable flank mass
Pait of WAuR complex (Wilms, Aniiiuia, u0 malfoimation, Retaiuation -
mental anu motoi)
12*#,+*%,:
Removal of kiuney plus chemotheiapy anuoi iauiation
















SS2





Chapter 14

Hematology

SSS




#/.*-(0:


@)#. 0$ 2$.+;,0+ ,(+2), >;+%+(0% /)01<
Fatigue, palloi, pale conjunctiva, flow muimui

9+?+;+ ,(+2), >;+%+(0% /)01<
S0B, light-heaueuness, confusion

!"#$%&'"':
The most ieliable test foi iion ueficiency anemia is seium feiiitin, which will
be uecieaseu.
If a patient has iion-ueficiency anemia anu uoes not iesponu to tieatment, uo
hemoglobin electiophoiesis to look foi an $ oi # thalassemia

O!J9 &$; %*%>+'0+. ,(+2),%<

1. Iion stuuies (most imp)
2. CBC w peiipheial smeai (paying attention to NCv, NCBC)
S. B12folate(B12 = neuiopathies, folate = no neuiopathies)
4. RBW (newei smallei RBCs cause change in RBW)
S. Reticulocyte count (ueteimines whethei site of pioblem is bone maiiow
synthesis of new RBCs)
6. LBB, biliiubin, haptoglobin (all ueteimine whethei hemolysis is in play)
7. TSB with T4 (see whethei hypothyioiuism is cause of fatigue)
8. CXRbloou cultuie0A foi suspecteu sickle cell uisease


SS4







>'B/ 2.;-<-./<9 #/.*-(
-"$%' #%. -/+0,&+'F
Fatigue
Palloi
Pale conjunctiva
Low feiiitin, low iion, incieaseu TIBC


!"#$%&'"':
Best uiagnostic test foi iion-ueficiency anemia is iion stuuies
The most accuiate test is a bone maiiow biopsy

12*#,+*%,:
0ial feiious sulfate supplement






SSS


#/.*-( B; 53'B/-< 6-0.(0.

-"$%' #%. -/+0,&+'F
Same signs anu symptoms with the auuition of a histoiy of chionic
inflammatoiy uisoiuei oi autoimmune uisoiuei



!"#$%&'"':
Best uiagnostic test is iion stuuies (will come back noimal)

12*#,+*%,:
Coiiect the unueilying uisease


!3(D(00.*-(
-"$%' #%. -/+0,&+':
Small NCv
Piesence of taiget cells
veiy othei symptoms

!"#$%&'"':
Best initial test is an iion stuuy
The most accuiate test is hemoglobin electiophoiesis
Beta-thalassemia has elevateu BgA2 anu BgF
Alpha-thalassemia has noimal levels

Theie is no tieatment foi these conuitions



SS6




A-2.'BND(0,-< #/.*-(


-"$%' #%. -/+0,&+':
Patient has a histoiy of alcohol abuse, exposuie to leau, oi the use of
isoniaziu (INB)

!"#$%&'"':
Best initial test is iion stuuies
The most accuiate test is the Piussian blue stain

Tieatment:
Ninoi cases iequiie only pyiiuoxine ieplacement
Seveie cases iequiie the iemoval of exposuie to toxin








SS7




%(<'B<9,-< #/.*-(

Piesents similaiy to miciocytic anemia with fatigue, palloi, light-heaueuness,
but is causeu by a ueficiency of eithei vitamin B12 oi folic aciu




M-,(*-/ 4aR 6.;-<-./<9F
-"$%' #%. -/+0,&+':
Paiasthesias
Peiipheial neuiopathies
Bementia is the least common occuiience

!"#$%&'"':
CBC with peiipheial smeai, paying special attention to neutiophils
Neutiophils aie laige anu hypeisegmenteu
B12 ueficiency can also cause glossitis anu uiaiihea

12*#,+*%,:
Replace eithei folate oi vitamin B12


SS8


L?!7:
Appiox Su% of B12 ueficiencies show noimal B12 levels because tianscobalamine
is an acute phase ieactant which elevates with any foim of stiess. Thus is you
suspect B12 ueficiency anu levels aie noimal, get a methylmalonic aciu level.

Aftei finuing low B12 oi elevevateu methylmalonic aciu, the -+%0 '$(&);2,0$;= 0+%0
"' antipaiietal cell antibouies oi anti-intiinsic factoi antibouies (both confiim
peinicious anemia as the cause of B12 uef).

12*#,+*%,8
Replace B12 oi folate


** Folate ueficiency is most commonly causeu by a pooi uiet, classically uesciibeu as
a "tea anu toast uiet". Folate stoies ueplete within S months, thus with pooi uiets
this can be seen quickly. Tieat this with uiet mouifications anu immeuiate folate
ieplacement.




Sickle Cell Anemia



Patient piesents with extieme pain in the chest, back, anu thighs
When a patient piesents with a sickle cell ciisis, give immeuiate oxygen,
noimal saline, anu analgesics.
SS9


If patient piesents with these symptoms + fevei, give Iv antibiotics as well




S1+( 0$ .$ +Q'1,(A+ 0;,(%&*%)$( )( %)'B#+ '+## >0Z
1. Piesence of visual uistuibances uue to ietinal infaict.
2. Pulmonaiy infaict leauing to pleuiitic pain anu abnoimal xiay.
S. Piiapism uue to infaict of piosthetic plexus of veins.
4. Stioke

S1,0 ',*%+% %*..+( .;$>% )( 1+2,0$';)0 )( %)'B#+ '+## >0Z
Eithei uue to a folate ueficiency oi paivo B19 viius, which causes an aplastic
ciisis
- All Sickle cell pts shoulu be on folate supplements, thus if that's the case it is
uue to paivo B19
- Bo a PCR foi BNA of paivo B19

12*#,+*%,
Tiansfusion anu IvIu


S1,0 %1$*#. ,## %)'B#+ '+## >,0)+(0% /1$ ,;+ -+)(A .)%'1,;A+. -+ A)?+(Z
Folate ieplacement
Pneumococcal vaccine
Byuioxyuiea (This incieases hemoglobin F, stops sickling of cells, anu
pievents fuithei ciises)






S6u



O.*BD9,-< #/.*-(

All foims of hemolytic anemia piesent with a suuuen onset of weakness anu fatigue
that is associateu with anemia.

Aie piematuie uestiuction of ieu bloou cells
Bone maiiow iesponus appiopiiately by incieasing eiythiopoiesis anu thus
theie is an inciease in ieticulocyte count
If bone maiiow uoesn't woik piopeily, anemia will ensue

?*+&7/'"' :"77 '5&: ,5* 6&77&:"%$:

1. Incieaseu inuiiect biliiubin (uets ieleaseu with RBC uestiuction)
2. Incieaseu ieticulocyte count (Beteimines bones maiiow's ability to make
new RBCs)
S. Incieaseu LBB
4. Becieaseu haptoglobin (oiueieu to uistinguish between anemia anu
hemolytic anemia)


>%,2#G#';=7#2 5*+&7/'"' :"77 #7'& '5&: ,5* 6&77&:"%$8

1. Abnoimal peiipheial smeai (Schistocytes, helmet cells, fiagmenteu cells)
2. Bemoglobinuiia
S. Bemosiueiinuiia (Netabolic, oxiuizeu piouuct oi hemoglobin in uiine).

:,*%+%: Factois exteinal to RBC uefects 0R intiinsic RBC uefects

P\ C#;,&2' *K,*2%#7 ,& OF3 .*6*;,' T)&', ;#'*' #;Z="2*.U

Immune hemolysis
Nechanical hemolysis (causeu by piosthetic heait valves)
Neuications, buins, anu toxins
S61




Q\ ?*+&7/'"' .=* ,& "%,2"%'"; OF3 .*6*;,' T)&', ;#'*' "%5*2",*.U

Causeu by sickle cell uisease, hemoglobin uisease, thalassemias
Nembiane uefects such as heieuitaiy spheiocytosis, paioxysmal noctuinal
hemoglobinopathy
Enzyme uefects such as u6PB ueficiency anu pyiuvate kinase ueficiency




Autoimmune Hemolysis

Patient often has a histoiy of autoimmune uiseases, canceis, oi meuication
use

!"#$%&'"'8
Nost accuiate test is Coomb's test
Look foi an incieaseu LBB anu incieaseu ieticulocyte count
Look at the peiipheial smeai foi spheiocytes

12*#,+*%,:
The best initial theiapy is pieunisone
With no iesponse to pieunisone, IvIu can stop acute episoues
With iecuiiing episoues of hemolysis, a splenectomy is most effective

*N0TE: waim antibouies aie the cause heie, which aie always Igu. 5(#= 4AN
;+%>$(.% 0$ %0+;$).% ,(. %>#+(+'0$2=g




S62





5BD2Y>/2)<.2 O.*BD90-0 \5BD2 (11D),-/-/0)
Coomb's test is negative
Theie is often a mycoplasma oi EBv infection
Theie is no iesponse to steioius, splenectomy, oi IvIu
























S6S




O.*BD90-0 2). ,B -/,'-/0-< 2.;.<,0

GD)<B0.YqY@3B0+3(,. 2.392'B1./(0. 2.;-<-./<9
Piesents with a seveie anu acute onset of hemolysis
Is an x-linkeu uisoiuei, thus seen in males
Nost commonly theie is a histoiy of sulfa uiugs, piimaquine, oi uapsone use
Ingestion of fava beans is classically askeu on boaiu exams

!"#$%&'"'8
The best initial test is the peripheral smear that shows Heinz bodies and bite cells
The most accurate diagnostic test is a glucose-6-phosphate level. The problem
with this test is that it will only show up after 2 months, and is not a good test
early on in an acute haemolytic episode

12*#,+*%,:
Avoiuance of oxiuative stiess



@9'):(,. P-/(0. 6.;-<-./<9
Piesents the same way as u6PB ueficiency, but the cause is unknown







S64





O.'.2-,('9 A+3.'B<9,B0-0
-"$%' #%. -/+0,&+'8
}aunuince in chiluhoou
Splenomegaly
Biliiubin gallstones
Recuiient episoues

9>1+;$'=0+%

!"#$%&'"':
The most accuiate anu best initial test is the osmotic fiagility test
Peiipheial smeai showing spheiocytes

12*#,+*%,:
Folic aciu supplementation
Splenectomy foi seveie uisease




O.*BD9,-< $'.*-< A9/2'B*. \O$A^
O$A in kius, theie is usually a histoiy of E.Coli u1S7:B7
S6S



-"$%' #%. -/+0,&+:
Acute ienal failuie
Abuominal pain
Bloouy uiaiihea
Seizuies

12*#,+*%,:
Bialysis in chiluien, auults this isn't useful anu theie is a much pooiei
piognosis



!3'B*NB,-< !3'B*NB<9,B+./-< @)'+)'( \!!@^
Is an iuiopathic uisease that is often seen in BIv patients

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

71+;+ )% , >+(0,. $&<
Baemolytic anemia
Renal failuie
Fevei
Thiombocytopenia
Neuiological uiseases

12*#,+*%,<
Plasma exchange until symptoms subsiue
Without tieatment this is fatal




S66







@('BV90*(D LB<,)'/(D 3.*B1DBN-/)'-( \@LO^

Piesents with iecuiiing episoues of uaik uiine, mostly seen in the moining.

-"$%' #%. -/+0,&+'8
Pancytopenia
Recuiiing episoues of uaik uiine in the moining
Poital vein thiombosis is a complication that leaus to ueath
Nay piogiess to cause aplastic anemia anuoi ANL

!"#$%&'"'8
The most accuiate test is the piesence of uecay acceleiating factoi antibouy

12*#,+*%,8
Pieunisone oi othei steioius




Methemoglobinemia

Bloou lockeu in the oxiuizeu state cannot pick up anu tianspoit oxygen.
Patient will piesent with shoitness of bieath with no ieason

-"$%' #%. -/+0,&+':
S67


S0B with no known cause (Theie will be cleai lungs on exam with a noimal
CXR)
Bloou (if seen) will have a biownish appeaiance, which inuicates it is lockeu
in the oxiuizeu state.


!"#$%&'"':
Look foi exposuie to uiugs like nitioglyceiin, amyl nitiate, oi nitiopiussiue
CXR anu PE show no ieason foi S0B
Look foi a histoiy of anesthetic use

Tieatment:
uive methylene blue




Transfusion Reactions

1. #4? -/<B*+(,-N-D-,9 ! piesents with acute symptoms of hemolysis while
the tiansfusion is happening. Ex: uuiing a tiansfusion, a patient becomes
hypotensive anu tachycaiuic. She has back anu chest pain, anu theie is uaik
uiine. LBB anu biliiubin aie elevateu, anu haptoglobin aie low.
2. !'(/0;)0-B/ '.D(,.2 (<),. D)/1 -/W)'9\D.)QB(11D),-/(,-B/ 'V/^ !
piesents with acute S0B fiom antibouies in the uonoi bloou against iecipient
white cells.
S. >1# 6.;-<-./<9 ! piesents with anaphylaxis. In futuie use uonation fiom
IgA ueficient uonoi oi washeu ieu cells.
4. K.N'-D. /B/3.*BD9,-< 'V/ ! iesults in a small iise in tempeiatuie anu
neeus no theiapy, the ieaction is against the uonoi's white cell antigens.
Pievent by using filteieu bloou tiansfusion in futuie.
S. %-/B' NDBB2 1'B)+ -/<B*+(,-N-D-,9 ! iesults in uelayeu jaunuice, no
theiapy neeueu.




S68



Leukemia

Acute leukemias present with signs of pancytopenia, such as fatigue, bleeding, and
infections from non-functional white blood cells.



Acute Myelogenous Leukemia

A0ER R0BS
Nostly occuiiing in auults (up to 8u%)


!"#$%&'"':
The best initial test is peiipheial smeai showing blasts

Tieatment:
Best initial theiapy foi ANL is 4.,;*-)')( (oi uaunoiubicin) anu '=0$%)(+
,;,-)($%).+




Acute Lymphoblastic Leukemia

The most common malignancy in chiluien
Is the leukemia most iesponsive to theiapy
Is a neoplasm of eaily lymphocytic B cell piecuisois
Bistology ieveals pieuominance of lymphocytes
Pooi piognosis when age < 2 oi > 9, WBC's >1u^S, oi CNS involvement

!"#$%&'"'8
The best initial test is peiipheial smeai showing blasts

12*#,+*%,8
>2(')N-<-/ + <9,B0-/. ('(N-/B0-2. + -/,'(,3.<(D *.,3B,'.V(,..
S69



#<),. @'B*9.DB<9,-< H.)Q.*-(\%j^

This leukemia is associateu with uisseminateu intiavasculai coagulopathy

12*#,+*%,:
>2(')N-<-/ + <9,B0-/. ('(N-/B0-2. + (DD ,'(/0 '.,-/B-< (<-2\#!"#^




53'B/-< %9.DB1./B)0 H.)Q.*-(\5%H^

-"$%' #%. -/+0,&+'8
Elevated white cells that are predominantly neutrophils
Splenomegaly is frequent.
Untreated CML has the highest risk of transformation into acute leukemia of all
forms of myeloproliferative disorders.
#00B<-(,.2 E-,3 @3-D(2.D+3-( 53'B*B0B*.

!"#$%&'"'8
Best initial test is H.)QB<9,. (DQ(D-/. +3B0+3(,(0. 0<B'. \H#@ 0<B'.). An
elevateu PNN count with low LAP scoie is CNL. Reactive high white counts
fiom infection give an elevateu LAP scoie, LAP is up in noimal cells, not CNL.
The most accuiate test is finuing the Philauelphia Chiomosome

12*#,+*%,8
Best initial tieatment is Imatinib (uleevec)
Bone maiiow tiansplant is the only cuie foi CNL, but is nevei the best initial
theiapy, because Imatinib leaus to 9u% hematologic iemission with no majoi
auveise effects.

S7u




53'B/-< H9*+3B<9,-< H.)Q.*-(\5HH^
Seen in people oluei then Suyi of age

-"$%' #%. -/+0,&+':
0ften asymptomatic
0iganomegaly
Baemolytic anemia
Thiombocytopenia

!"#$%&'"':
Best initial test is the peiipheial smeai showing 'smuuge cells'

12*#,+*%,8
At stages u anu 1, theie is no tieatment iequiieu
At auvanceu stages give fluuaiabine oi chloiambucil




Hairy Cell Leukemia

Seen in miuule-ageu people anu piesents with massive splenomegaly anu
pancytopenia

!"#$%&'"':
The Nost accuiate test is the taitiate iesistant aciu phosphatase(TRAP)
smeai showing haiiy cells

12*#,+*%,:
The best initial theiapy foi Baiiy Cell leukemia is clauiibine oi 2-CBA

S71





Myelofibrosis

Piesents similaily to haiiy cell leukemia except theie will be a noimal TRAP
level
The key uiagnostic featuie is the "teai-uiop" shapeu cells on peiipheial
smeai
Theie is no specific theiapy foi myelofibiosis




Polycythemia Vera (Erythrocytosis)

This piesents with heauache, bluiieu vision, uizziness, anu fatigue. All uue to
thickeneu bloou

-"$%' #%. -/+0,&+':
Eveiything above
Piuiitis following hot showeis oi baths uue to histamine ielease
Splenomegaly

!"#$%&'"':
veiy high hematociit with a low NCv
uet an ABu to iule out oi in hypoxia as a cause of eiythiocytosis

12*#,+*%,:
The best initial theiapy is phlebotomy
Byuioxyuiea can be given to lowei the cell count
uive uaily aspiiin



S72




PLASMA CELL DISORDERS



Multiple Myeloma

This conuition piesents most commonly with bone pain uue to fiactuies occuiiing
fiom noimal use

!"#$%&'"'8
The most specific test is a bone maiiow biopsy
Skeletal suivey to uetect puncheu out osteolytic lesions
Seium piotein electiophoiesis(SPEP) to look foi elevateu monoclonal
antibouy (usually Igu)
0iine piotein electiophoiesis(0PEP) to uetects Bence-}ones pioteins
Peiipheial smeai showing "iouleaux" foimation of bloou cells.
Elevateu calcium levels uue to osteolytic lesions
Beta 2 micioglobulin level is a piognostic inuicatoi
B0N anu Cieatinine to uetect ienal insufficiency


12*#,+*%,:
Steioius anu Nelphalan
The most effective theiapy is bone maiiow tiansplant
Tieat all unueilying co-moibiuities





S7S







Waldenstroms Macroglobulinemia

This is a hypeiviscosity of the bloou uue to oveipiouuction of IgN

-"$%' #%. -/+0,&+':
Bluiieu vision
Confusion
Beauache
Enlaigeu lymph noues
Splenomegaly

!"#$%&'"':
The best initial test is the seium viscosity (incieaseu significantly) anu SPEP
foi IgN levels
Theie will be no specific finuing on the CBC

12*#,+*%,:
Plasmaphaiesis is the best initial theiapy
Can also give fluuaiabine oi chloiambucil




Aplastic Anemia

Piesents as pancytopenia with no iuentifiable etiology.
If pt is < Su anu has a match, best theiapy is BN tiansplantation.
If BN tiansplant isn't an option (>Su), give antithymocyte globulin anu
cyclospoiine.


S74





LYMPHOMAS


Present with enlarged lymph nodes that are most commonly seen in the cervical area

Hodgkins disease occurs in a bimodal age distribution (young and old), and is
characterized by Reed-Sternberg cells

Reed-Sternberg Cell

Non-Bougkin's uisease is commonly seen in BIv patients

!"#$%&'"':
The best initial uiagnostic test foi both types of lymphomas is lymph noue
biopsy

0nce excisional biopsy shows abnoimal aichitectuie, fuithei testing to ueteimine
stage of the lymphoma neeus to be uone.

1. Stage 1 ! single lymph noue gioup
2. Stage 2 ! 2 LN gioups on one siue of uiaphiagm
S. Stage S! LN involvement on both siues of uiaphiagm
4. Stage 4! wiuespieau uisease


?! #%. S?B 02*'*%, :",5 ',#$*' #' 6&77&:'8
S7S



BB - 8u-9u% pies w stage 1 anu 2
NBL - 8u-9u% pies w stages S anu 4

?&: ,& ',#$*: CXR, CT with contiast (Chestabuomenpelvisheau), anu BN biopsy.

12*#,+*%,:

1. O$',#)b+. .)%+,%+ (stage 1,2) without "B"
symptoms is tieateu pieuominantly with
iauiation.
2. @$;+ ,.?,('+. %0,A+% S,4 is tieateu with
chemotheiapy.


-0*;"6"; ,2*#,+*%,':
1. BB: ABvB (auiiamycin|uoxoiubicinj, bleomycin, vinblastine, uacaibazine)

2. NBL: CB0P (cyclophosphamiue, hyuioxyauiiamycin, oncovin|vinciistinej,
anu pieunisone)

* Also test foi anti-CB2u antigen anu if piesent, auu Rituximab, which auus
efficacy to CB0P.








J 9h@875@9<

Aie systemic symptoms
such as:

FEvER
NIuBT SWEATS
WEIuBT L0SS
S76





COAGULATION DISORDERS

MB/ I-DD.N'(/280 2-0.(0. \MI6^

Is uue to platelet uysfunction, not a lowei numbei of platelets

Bleeding from PLT dysfunction, superficial bleeds from skin and mucosal
surfaces, such as gingival, gums, and vagina.
Epistaxis common
Bleeuing often woiseneu with use of aspiiin
PLT count is noimal

!"#$%&'"'8
J+%0 )()0),# 0+%0 is platelet function test
The 2$%0 ,''*;,0+ 0+%0 is a iistocetin cofactoi assay anu a vWF level (If vWF
is noimal, iistocetin tells you if it is woiking piopeily)

12*#,+*%,':
Fiist line tieatment is uesmopiessin oi BBAvP, which causes the ielease of
subenuothelial stoies of vWF anu co-factoi vIII
If uesmopiessin uoesn't woik, give factoi vIII ieplacement


@D(,.D.,Y,9+. ND..2-/1 <()0.0: petechiae, epistaxis, puipuia, gingival, gums,
vaginal
K(<,B'Y,9+. ND..2-/1 <()0.0: hemaithioses, hematoma

>2-B+(,3-< !3'B*NB<9,B+./-< @)'+)'( \>!@^

S77


ITP is a uiagnosis of exclusion that piesents with platelet-type bleeuing anu a
platelet count of < Su,uuu


!"#$%&'"':
Peifoim a sonogiam to assess the size of the spleen
Check foi anti-platelet antibouies
Bone maiiow biopsy looking foi megakaiyocytes
Antibouies to glycopiotein IIbIIIa ieceptois

12*#,+*%,8
With milu ITP (platelets of ~ 2u,uuu) give pieunisone
With seveie ITP (platelets of < 2u,uuu) give Iv immunoglobulins, which is the
fastest way to inciease the platelet count
NEvER tiansfuse platelets because this exaceibates the conuition



Uremia-Induced PLT dysfunction

This piesents as platelet-type bleeuing in a patient with ienal failuie, wheie ienal
failuie causes uiemia, which pievents the uegianulation of platelets anu thus stops
them fiom woiking

-"$%' #%. -/+0,&+':
Platelet type bleeuing

!"#$%&'"':
Ristocetin anu vWF levels (noimal)
Check platelet levels (They will be noimal)
Look foi ienal failuie (This is the key to uiagnosing)

12*#,+*%,:
S78


Besmopiessin



O.+('-/Y>/2)<.2 !3'B*NB<9,B+./-( \O>!^

A conuition wheie platelets uiop at least Su% a few uays aftei the use of hepaiin

-"$%' #%. -/+0,&+':
The most common clinical manifestation is thiombosis, wheie venous
thiombosis is the most common type

!"#$%&'"':
The best initial uiagnostic test is platelet factoi 4 antibouies
0thei impoitant test is hepaiin-inuuceu anti-platelet antibouies

12*#,+*%,:
The best initial theiapy is to stop hepaiin anu use uiiect thiombin inhibitoi
such as "aigatioban" oi "lepiiuuin".











S79





Chapter 15

Rheumatology



S8u



"3.)*(,B-2 #',3'-,-0

An autoimmune uisease piesents most commonly in females > Su.

}oint pain anu moining stiffness that is symmetiical anu in multiple joints of
the hanus.
Lasts longei than 1hi in the moining with symptomatic episoues going on foi
at least 6 weeks.
0ften a piouiome of fatigue anu malaise, but this isn't enough foi a cleai ux.

!"#$%&'"' "' 4#'*. &% 5#G"%$ ` &2 +&2* &6 ,5* 6&77&:"%$8

Noining stiffness lasting moie than 1hi
Wiist anu fingei involvement
Swelling of at least S joints
Symmetiic involvement
Rheumatoiu nouules
Xiay abn's showing eiosions
(+) iheumatoiu factoi

Rheumatoiu aithiitis is a gioup of physical finuings, joint pioblems, anu lab tests.
Theie is no single uiagnostic ciiteiia to confiim the uiagnosis, noi is theie one single
theiapy to contiol anu tieat the uisease.

!"#$%&'"'8
The single most accuiate lab test is the anticitiullinateu cyclic peptiue (anti-
CCP)
Noimocytic, noimochiomic anemia is veiy chaiacteiistic of iheumatoiu
aithiitis

a&"%, C"%."%$':
NCP swelling anu pain
Boutonieiie uefoimity: flexion of PIP w hypeiextension of the BIP
Swan neck uefoimity
S81


Bakei's cyst
C1C2 ceivical spine subluxation
Knee: although knee is commonly involveu, multiple small joints aie involveu
moie commonly ovei time.


12*#,+*%,:
NSAIBs anu Bisease mouifying anti-iheumatic uiugs(BNARBS)
Steioius can be useu acutely to help contiol the uisease while BNARBs take
effect, but they aie only useu as a biiuge to BNARB theiapy, not useu long-
teim



A.'B/.1(,-:. A+B/29DB(',3'B+(,3-.0
1. Ankylosing sponuylitis
2. Reactive aithiitis (Reiteis synuiome)
S. Psoiiatic aithiitis
4. }uvenile RA


71)% A;$*> $& )(&#,22,0$;= '$(.)0)$(% ,## 01+ &$##$/)(A '1,;,'0+;)%0)'%<
Negative foi RF
Pieuilection foi the spine
SI joint involvement
Associateu with BLA B27




#/Q9DB0-/1 A+B/29D-,-0\#A^
AS piesents in a young male (<4u) w spine oi back stiffness.
Peiipheial joint involvement is less common
S82


Pain is woise at night anu ielieveu by leaning foiwaiu, which can leau to
kyphosis anu uiminisheu chest expansion.
Raie finuings incluue: uveitis anu aoititis.

!"#$%&'"':
The best initial test is an xiay
The most accuiate test is an NRI

12*#,+*%,:
S-@>!-
Sulfasalazine
Biological agents (Infliximab, Aualimumab)




".(<,-:. #',3'-,-0\;B'*.'D9 ".-,.'80 09/2'B*.^F
Piesents with asymmetiic aithiitis anu a histoiy of uiethiitis oi uI infection.
Patient may have constitutional symptoms such as fevei, malaise, anu weight
loss.

!"#$%&'"':
Clinical uiagnosis baseu on the piesence of the classic tiiau of uiethiitis,
conjunctivitis, anu aithiitis

Tieatment:
NSAIBs





S8S




@0B'-(,-< #',3'-,-0F
Piesents as joint involvement with a histoiy of psoiiasis.
Rheumatoiu factoi (-)
SI joint is involveu.

_*/ 6*#,=2*' &6 ,5"' ."'*#'* #2*8
Pitting of the nails
Involvement of the uistal inteiphalangeal joints
"Sausage-shapeu" uigits

12*#,+*%,8
Initial tieatment shoulu be with NSAIBs
If this isn't woiking, auu biological agents such as Infliximab
If these uon't woik, tiy methotiexate




w):./-D. "# \(Q( (2)D, B/0., A,-DD80 2-0.(0.^
Theie is no specific uiagnostic test.
aO@ "' ;5#2#;,*2"J*. 4/ ,5* 6&77&:"%$8
Feiiitin levels aie high
WBC count is elevateu
RF (-) anu ANA (-)

Tieatment:
NSAIBs
If uniesponsive to NSAIBs, give methotiexate


S84






I3-++D.80 6-0.(0.
Causes uiaiihea anu fat malabsoibtion, anu is most commonly piesenteu
with joint pain
The most specific test foi uiagnosis is a biopsy of the bowel

12*#,+*%,F
TNPSNX




?0,.B(',3'-,-0
0steoaithiitis is the most common joint abnoimality anu is associateu with
excessive joint usage anu incieaseu age

-"$%' #%. -/+0,&+'8
Noining stiffness lasting < Su minutes
}oint ciepitus seen
Affects the uistal inteiphalangeal joint (wheieas RA uoes not)
Bebeiuen's noues aie seen as BIP osteophytes
Bouchaiu's noues aie seen as PIP osteophytes

!"#$%&'"'8
The best initial uiagnostic test is an xiay of the joint

12*#,+*%,8
NSAIBs
S8S


ulucosamine sulphate anu chonuioitin sulphate aie useu to slow joint
ueteiioiation.




0A RA
Noining Stiffness <Sumin >1hi
BIP YES N0
PIP YES YES
NCP N0 YES
RF, anti-CCP N0 YES
}oint fluiu <2uuu Suuu-Suuuu














S86







AH7
Classically, a iash + joint pain + fatigue = Lupus
Theie aie 11 ciiteiia foi L0P0S, 4 must be piesent to make the uiagnosis.
AP>L - Nalai Rash
- Photosensitivity iash
- 0ial ulceis iash
- Biscoiu iash
#',3'(D1-(0 Piesent in 9u% of pts
4DBB2 Leukopenia, thiombocytopenia,
hemolysis. Any bloou involvement
counts as 1 ciiteiia.
"./(D vaiies fiom benign pioteinuiia to ESRB.
5.'.N'(D Behavioi changes, stioke, seizuie,
meningitis
A.'B0-,-0 Peiicaiuitis, pleuiitic chest pain,
pulmonaiy BTN, pneumonia,
myocaiuitis.
A.'BDB19 - ANA (9S% sensitive)
- BS-BNA (6u% sensitive)
Each of the seiologic abn's count as 1
ciiteiia. If peison has joint pain,
iash, anu both ANA anu BS BNA, the
pt has 4 ciiteiia.


!"#$%&'"'8
The best initial uiagnostic test is the ANA
The most specific test is the anti-us BNA oi anti-Smith antibouy
S87




V$/ 0$ &$##$/ 01+ %+?+;)0= $& , #*>*% &#,;+D*>Z
1. Complement levels will uiop in flaie-up
2. anti-us BNA will iise in flaie up


12*#,+*%,V)#%#$*+*%,8
Foi acute flaie-ups give pieunisone anu othei glucocoiticoius
uive NSAIBs foi joint pain
If theie is no iesponse to those meuications, antimalaiials anu
hyuiochloioquine will woik
Foi seveie uisease that iecuis give cyclophosphamiue anu azthiopiine



6')1Y-/2)<.2 H)+)0
The most likely causes of uiug-inuuceu lupus aie hyuialazine, piocainamiue, anu
isoniaziu

!"#$%&'"':
Theie will be anti-histone antibouies
Theie is nevei ienal oi CNS involvement
Theie aie noimal levels of complement anu anti-us BNA antibouies



AWB'1./80 09/2'B*.
Seen most commonly in women (9x gieatei in women than men)

-"$%' #%. -/+0,&+':
S88


Biy eyes, uiy mouth
Theie is a sensation of sanu unuei the eyes
Bysgeusia is common
Commonly a loss of teeth uue to the lack of auequate saliva



!"#$%&'"':
The most accuiate test is a lip biopsy
The Schiimei test is will show inauequate laciimation
Commonly see "anti-Ro oi anti-La antibouies

12*#,+*%,:
Pilocaipine to inciease Ach anu thus inciease laciimation anu salivaiy
secietions




A<D.'B2.'*(
Patient has tight skin, heaitbuin, anu Raynauu's phenomenon

-"$%' #%. -/+0,&+':
9B)( &)(.)(A% incluue a tight, fibious thickening that causes tight anu
immobile fingeis as well as a tight face
I$)(0 8,)( that is milu anu symmetiical
M,=(,*.G% 81+($2+($(, may iesult in ulceiations


A<D.'B2.'*( <(/ +'.0./, 2-;;)0.D9 E-,3 ,3. ;BDDBE-/1F

O*(A%: fibiosis anu pulmonaiy BTN(the leauing causes of ueath in this uisease)
S89



N4: Wiue mouth colonic uiveiticula anu esophageal uysmotility, leauing to ieflux anu
Baiiett's esophagusg 1S% of pts get piimaiy biliaiy ciiihosis

V+,;t: Restiictive caiuiomyopathy

M+(,#: may leau to malignant BTN.


Diagnosis:

Theie is not a single best uiagnostic test
Though not specific, ANA is seen in 9S% of cases

12*#,+*%,:
Theie is no tieatment that slows the piogiession oi tieats this conuition
If theie is ienal involvement give ACEIs
If theie is pulmonaiy hypeitension, give Bosentan anu piostacyclin analogs
Foi Raynauu's give calcium channel blockeis





7B0-/B+3-D-< K(0<--,-0
Is similai in piesentation to scleioueima but theie is no Raynauu's, noi is theie any
of the othei systemic finuings

-"$%' #%. -/+0,&+':
Thickeneu skin similai to scleioueima
Naikeu eosinophilia gives the appeaiance of peau u'oiange

S9u


12*#,+*%,:
Nanage this conuition with coiticosteioius





@BD9*9B0-,-0\@%^ (/2 6.'*(,B*9B0-,-0\6%^

In both conditions, the patient cannot get up from a seated position without using the
arms. There can also be muscle pain and tenderness.

E$; >$#=2=$%)0)%! Weakness + incieaseu CPK + incieaseu aluolase
E$; .+;2,0$2=$%)0)% ! Weakness + incieaseu CPK + incieaseu aluolase + skin
iash.

!"#$%&'"':
Clinical
Shoulu oiuei LFT's anu ANA

Tieatment:
Coiticosteioius



K-N'B*9(D1-(
A pain synuiome seen mostly in females that piesents with aching muscles,
stiffness, tiiggei points foi pain, anu sleep that isn't iefieshing

Signs anu Symptoms:
S91


Nuscle aches
Nuscle stiffness
Bepiession anuoi anxiety
Extieme sensitivity anu pain to tiiggei points on the bouy

!"#$%&'"'8

Noimal bloou tests anu no objective eviuence of uisease

12*#,+*%,V)#%#$*+*%,8

Exeicise can help ielieve some pain anu stiffness
TCA's can be given









@BD9*9(D1-( "3.)*(,-<( \@%"^

Seen most commonly in those > Suyi


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

S92


Patient oluei than Suyi with significant pain anu stiffness of the pioximal
muscles (shoulueis, pelvic giiule)
Stiffness is usually woise in the moining anu is usually moie localizeu to the
muscles
Patient may have fevei, malaise, anu weight loss

!"#$%&'"':
CBC will likely show noimocytic anemia
Nuscle biopsy anu labs aie all noimal
Lack of muscle atiophy

12*#,+*%,: Steioius

Following explains uiffeience between chionic fatigue, fibiomyalgia, anu PNR
53'B/-< ;(,-1).
09/2'B*.
K-N'B*9(D1-( @BD9*9(D1-(
'3.)*(,-<(
Fatiguemalaise +++++ >6mnth ++ ++
Noniefieshing
sleep
+++++ ++ No
Tiiggei points N0 YES N0
Bloou tests All noimal All noimal Inci ESR
Tieatment None Pain ielief Pieunisone



M(<)D-,-0
Common featuies among uiffeient types of vasculitis incluue:
Fatigue, malaise, wt loss
Fevei
Skin lesions such as palpable puipuia anu iash
}oint pain
Neuiopathy

S9S


3&++&% 7#4 6"%."%$'8
Noimocytic anemia
Elevateu ESR
Thiombocytosis




!"#$%&'"'8
The most accuiate test is a biopsy


12*#,+*%,8
The best initial theiapy is steioius

! If steioius aien't effective, alteinate anuoi auuitional theiapies aie the following

Cyclophosphamie
Azathiopiine6-meicaptopuiine
Nethotiexate


@BD9(',.'-,-0 LB2B0( \@#L^

PAN has all the featuies of vasculitis uesciibeu above, what uiffeientiates it is the
unique featuies that accompany PAN.

Abuominal pain (6S%)
Renal involvement (6S%)
Testiculai involve(SS%)
Peiicaiuitis(SS%)
BTN(Su%)

S94


!"#$%&'"'8
The best initial test is angiogiaphy of the abuominal vessels
The most accuiate test is a biopsy of the muscles, suial neive, anu skin

12*#,+*%,:
Pieunisone anu Cyclophosphamiue


I.1./.'80 G'(/)DB*(,B0-0
A disorder that like PAN can affect the majority of the body. Look for the addition of
upper and lower respiratory findings and the presence of c-ANCA

Diagnosis:

The most accurate diagnostic test is a biopsy
Upper and lower respiratory findings
Presence of c-ANCA

Treatment:

Treatment involves Prednisone and Cyclophosphamide




53)'1YA,'()00
Can affect any oigan in the bouy, but the key to making its uiagnosis is
piesence of ?,%'*#)0)%f +$%)($>1)#),f ,(. ,%012,g
P-ANCA anu anti-myelopeioxiuase can be positive too, but these finuings
aien't as unique as the piesence of eosinophilia.
Nost accuiate test is biopsy

12*#,+*%,:
Steioius

S9S








!.*+B'(D #',.'-,-0
A type of giant cell arteritis, related to PMR.

Signs and Symptoms:

Fever
Malaise
Fatigue
Weight loss
Headache
Visual disturbances
Jaw claudication

Diagnosis:

Elevation of ESR
Clinical findings

Treatment:

Steroids




!(Q(9(0)80 #',.'-,-0
Seen in young asian females

-"$%' #%. -/+0,&+':
S96


Bimishes pulses
vasculitis commonly seen befoie loss of pulse
Patient often gets TIA anuoi stioke causeu by the vasculai occlusion

!"#$%&'"':
NRA oi aiteiiogiaphy


12*#,+*%,:
Steioius


5'9B1DBN)D-/.*-(
Is similai to to vasculitis synuiomes, the uiffeience is the association with hepatitis
C anu kiuney involvement
12*#, with inteifeion anu iibaviiin


4.3<., 6-0.(0.

This condition presents in pts of Middle Eastern or Asian ancestry.

Signs and Symptoms:
0ial anu genital ulceis
0culai involvement that can leau to blinuness
Skin lesions: "patheigy" which is hypeiieactivity to neeule sticks, iesulting in
steiile skin abscesses.

!"#$%&'"'8
Theie is no specific test foi uiagnosis, we must use the featuies seen above

12*#,+*%,8
Pieunisone anu colchisine
S97





>LKH#%76 w?>L!A


The key to uiagnosing inflameu joints is to look at the fluiu within the joint. It is the
most accuiate uiagnostic test foi gout, pseuuogout, anu septic aithiitis

9=($?),# &#*). '+## '$*(0
LB'*(D >/;D(**(,B'9\1B),J+0.)2B1B),^ >/;.<,-B)0
<2uuu WBC's 2uuu-Suuuu WBC's >Suuuu WBC's



GB),

Look for a man with a sudden onset of severe pain in the toe at night. The toe will be
red, swollen, and tender.

Things that precipitate a gouty reaction are:

Alcohol ingestion
Thiazide diuretics
Nicotinic acid
Foods high in protein


!"#$%&'"':
The best initial test is aspiiation of the joint fluiu
The most accuiate test is light exam of the fluiu showing negatively
biiefiingent neeule-shapeu ciystals

S98


12*#,+*%,:
The best initial theiapy foi an acute gouty attack is NSAIBs.
uive colchisine within 24hi of the attack
Allopuiinol is best as piophylaxis anu pievention of futuie attacks, which
woiks by ieuucing the levels of uiic aciu




@0.)2B1B), \5(D<-)* @9'B+3B0+3(,. 6.+B0-,-B/ 6-0.(0.^
Involves most commonly the wiist anu knees, but uoesn't involve the toes
0nset is much slowei than gout, anu uoesn't acutely attack the patient

!"#$%&'"':
Aspiiation of joint fluiu shows positively biiefiingent ihomboiu-shapeu
ciystals

12*#,+*%,:
NSAIBs aie the best initial theiapy
Can give colchisine, but is not as effective heie as it is in gout



A.+,-< #',3'-,-0
Any aithiitic oi piosthetic joint put patient at iisk of septic aithiitis
With incieaseu joint abnoimality comes incieaseu iisk of sepsis

)&2* 2"'9 6#;,&2' 6&2 '*0,"; #2,52","'8
0steoaithiitis is moie of a iisk than having noimal joints
RA is moie of a iisk than osteoaithiitis
Piosthetic joints aie moie of a iisk than anything else.

-"$%' #%. -/+0,&+':
S99


Reu, swollen, tenuei, immobile joint


Nost common causes of septic aithiitis:
Staph auieus (4u%)
Stiep (Su%)
uiam-ve bacilli (2u%)

**Septic aithiitis iequiies consult w oithopaeuic suigeon.

!"#$%&'"'8
The best initial test is aithiocentesis showing > Su,uuu WBC
The most accuiate test is a cultuie of the fluiu

12*#,+*%,8
Empiiic Iv antibiotics such as Ceftiiaxone anu vancomycin once suspecteu



@(1.,80 6-0.(0. B; 4B/.
A conuition with pain, stiffness, aching, anu fiactuies associateu with softening of
the bones.

-"$%' #%. -/+0,&+':
Stiffness
Pain
Fiactuies
Bowing of the tibias

!"#$%&'"':
The best initial test is foi the elevation of alkaline phosphatase
The most accuiate test is xiay of the bones
6uu



12*#,+*%,:
Best tieateu with bisphosphonates anu calcitonin


* In cases of Paget's, osteolytic lesions will be founu initially. These may be ieplaceu
with osteoblastic lesions

** If you see osteolytic think Paget's oi osteopoiosis

*** If you see osteoblastic, think about metastatic piostate cancei in uiffeiential.


4(Q.'80 590,
A posteiioi heiniation of the synovium of the knee

-"$%' #%. -/+0,&+'8
Patient often has osteoaithiitis
Palpation of the sac in the posteiium of the knee
Swelling of the calf is common (excluue a BvT when you see this)

12*#,+*%,:
NSAIBS aie mainstay of tieatment
Seveie cases may iequiie steioiu injections






6u1





@D(/,(' K(0<--,-0 (/2 !('0(D !)//.D A9/2'B*.

E$##$/)(A 0,-#+ '$2>,;+% 01+ 0/$ '$(.)0)$(%<
Plantai Fasciitis Taisal tunnel synuiome
Pain on bottom of foot Pain on bottom of foot
veiy seveie in moining, bettei w
walking a few steps
Noie painful w use; may have sole
numbness
Stietch the foot anu calf Avoiu boots anu high heels; may neeu
steioiu injection
Resolves spontaneously ovei time Nay neeu suigical ielease















6u2



Chapter 16

Neurology









6uS


A,'BQ.0 (/2 !>#

90;$B+%:

Stiokes occui foi gieatei % 24hi anu have peimanent iesiuual neuiological
ueficits.
Causeu by ischemia most commonly, anu hemoiihagic.
Ischemic stiokes occui fiom emboli oi thiombosis, which occui moie acutely

74!:

Piesents the same as a stioke except it lasts <24hi.
Commonly piesents with a loss of vision in only one eye (Amauiosis fugax),
uue to emboli in the fiist bianch off of the caiotiu (0phthalmic aiteiy)
TIA's aie always uue to emboli oi thiombosis, nevei hemoiihage


!"#$%&'"%$:

The best initial test is always a CT of the heau without contiast

12*#,+*%,:

If possible, give thiombolytics within Shis of the onset of symptoms anu the
CT has iuleu out hemoiihage
Aspiiin is the best initial theiapy foi those who come in too late foi
thiombosis
If patient is alieauy on aspiiin, can give uipyiiuamole (Clopiuogiel is an
alteinative)


j 71+;+ )% ($ '#+,; +?).+('+ 01,0 1+>,;)( -+(+&)0% , %0;$B+

6u4


#',.'-.0 (/2 ,3.-' (00B<-(,.2 09*+,B*0 -/ 0,'BQ.F

57"74"#H #"!7"[ A[%@!?%A
Anteiioi ceiebial aiteiy -piofounu lowei extiemity weakness
- milu uppei extieme weakness
- peisonality changes
- uiinaiy incontinence
Niuule ceiebial aiteiy - piofounu uppei extiemity
weakness
- aphasia
- apiaxianeglect
- eyes ueviate towaius lesion siue*
Posteiioi ceiebial aiteiy - contialateial homonymous
hemianopia w maculai spaiing
- piosopagnosia(cant iecognize
faces)
veitebiobasilai aiteiy - veitigo
- Nv
- veitical nystagmus
- Bysaithiia anu uystonia
- Sensoiy changes in facescalp
- Ataxia
- Labile bloou piessuie
Lacunai infaict - must be absence of coitical
ueficits**
- Paikinson signs
- Bemipaiesis(most notable in
face)
- Sensoiy ueficits
- Possible bulbai signs
0phthalmic aiteiy - amauiosis fugax


C=2,5*2 +#%#$*+*%, &6 # -,2&9* &2 1>@8

Aftei all initial managements aie implementeu, uo the following:

6uS


Echocaiuiogiam
Caiotiu Bopplei
EKu anu Boltei monitoi if the EKu comes back noimal

b&=%$ 0,' cde/2 :",5 %& '"$%"6";#%, 0#', +*.";#7 5"',&2/ T!)< ?1SU '5&=7. 5#G*
6&77&:"%$ .&%*8

1. Seuimentaion iate
2. vBRL oi RPR
S. ANA, usBNA
4. Piotein C, piotein S, factoi v leiuen mutation, antiphospholipiu synuiomes

* The youngei the patient, the moie likely the cause of stioke is a vasculitis oi
hypeicoagulable state.

:$(0;$# V7Xf R@f ,(. 1=>+;#)>).+2), )( 01)% >0<

N$,#%<

BTN: <1Su8u
BN: same tight glycemic contiol as gen pop'n
Bypeilipiuemia: LBL<1uu



74!:

Same management as pei stioke, except thiombolytics aien't inuicateu because the
auministiation of thiombolytics aie to iesolve symptoms, so if symptoms aie
iesolveu they aien't necessaiy.


6u6



SEIZURES

Foi seizuie uisoiueis, the only cleai uiagnostic ciiteiia is foi a patient unueigoing
status epilepticus.

15*2#0/ 6&2 ',#,=' "' #' 6&77&:'8
1. Benzouiazepine such as Ativan (Loiazepam)
2. If seizuie peisists, auu fosphenytoin
S. If seizuie peisists, auu phenobaibitol
4. If seizuie peisists, give geneial anesthetic such as pentobaibital.

!"#$%&'"' "% # 0#,"*%, 5#G"%$ # '*"J=2*8
0igent CT of the heau
0iine toxicology secieen
Chemistiy panel
Calcium levels
Nagnesium levels


C=2,5*2 +#%#$*+*%,:
If initial tests uon't give cleai cause, uo an EEu (shoulun't be uone fiist).

Neuiology consult iequiieu in any patient having oi who hau a seizuie.


B&%$D,*2+ ,2*#,+*%, &6 6"2',D,"+* '*"J=2*':
If patient only hau 1 seizuie, chionic theiapy is not iequiieu unless theie is a
stiong family histoiy, an abnoimal EEu, oi status epilepticus


352&%"; #%,"*0"7*0,"; ,5*2#0/8
Theie is no single agent consiueieu to be the best theiapy.
6u7



C
%0
#)(+ 01+;,>)+% )('#*.+<
valpioate, caibamazepine, phenytoin, anu levetiiacetam aie all equal in
efficacy.
Lamotiigine has same efficacy but can cause steven-johnson synuiome.

R
/2
D-/. ,3.'(+-.0F
uabapentin anu phenobaibitol


E$; ,-%+('+Y>+0)0 2,# %+)b*;+%:
Ethosuxamiue is best.
















6u8



@('Q-/0B/80 6-0.(0.

Is a gait uisoiuei with the following finuings:
Cogwheel iigiuity
Resting tiemoi
Nask-like facies
0ithostasis
Intact cognition anu memoiy

!"#$%&'"':
Theie is no specific test to make the uiagnosis of PB, iathei the clinical
finuings aie what is useu to make the uiagnosis

12*#,+*%,:
@)#. %=2>0$2%F

In a patient < 6uyi of age ! Anticholineigics such as Benztiopine oi
Byuioxyzine
In a patient > 6uyi of age ! Amantauine (0luei patients commonly uevelop
bau ieaction fiom anticholineigic meuications)

9+?+;+ %=2>0$2%F
Leveuopacaibiuopa have the gieatest efficacy but has an "on-off"
phenomenon with uneven long-teim effects anu moie siue effects
Bopamine agonists such as Piamipiexole, Ropineiole, anu Cabeigoline aie
less efficacious but have fewei siue effects


** If these meuication uon't woik, use C0NT inhibitois (Tolcapone, Entacapone)
which inhibit metabolism of uopamine, which extenus the effect of uopamine-baseu
meuication. Can also tiy NA0I's.


6u9



TREMOR

!9+. B; ,'.*B' ".0,-/1 ,'.*B' >/,./,-B/ ,'.*B' !'.*B' (, '.0,
(/2 E-,3
-/,./,-B/
6-(1/B0-0 Paikinsons Ceiebellai uisoiuei Essential tiemoi
!'.(,*./, Amantauine Tieat etiology Piopianolol



MULTIPLE SCLEROSIS

Nultiple Scleiosis piesents with abnoimalities of any pait of the CNS. The
symptoms impiove anu iesolve, only to have anothei uefect uevelop months oi
yeais latei.


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

The most common abnoimality is optic neuiitis
Theie is commonly fatigue, hypeiieflexia, spasticity, anu
uepiession
Theie is also commonly optic neuiitis


!"#$%&'"'F
The best initial uiagnostic test is an NRI
The most accuiate test is also the NRI
If the NRI uoesn't give you the uiagnosis, uo a lumbai tap

12*#,+*%,:
%)D,-+D.
A<D.'B0-0F

uA>Lv

1. Scanning
speech
2. Intention
tiemoi
S. Nystagmu
s
61u


Steioius aie the best initial theiapy to iesolve an acute exaceibation
ulatiiamei anu beta-inteifeion can both ueciease the piogiession of NS
Can give Amantauine to combat fatigue anu Baclofen to combat spasticity





DEMENTIA

#DT3.-*.'0 6-0.(0.
Is a slow piogiessive loss of memoiy exclusively in pts > 6Syis of age
!"#$%&'"'8
Anybouy with memoiy lost iequiies a CT of the heau, a TSB level, anu an
RPRvBRL
With Alzheimei's uisease you will only see uiffuse anu symmetiical atiophy

12*#,+*%,
Anticholinesteiase inhibitois aie the stanuaiu theiapy of choice


K'B/,B,.*+B'(D 6.*./,-( \@-<Q 6-0.(0.^
Peisonality anu behavioui become abnoimal fiist, then memoiy loss
afteiwaius.
Beau CT oi NRI shows focal atiophy of fiontal anu tempoial lobes
Tieat this like Alzheimei's, but uo not expect the same type of iesponse

5'.),T;.D2Yw(QBN 6-0.(0. \5w6^
Causeu by piions, which aie tiansmissible piotein paiticles.
Nanifests as iapiuly piogiessive uementia anu piesence of myoclonus.
This piesents in those youngei than the Alzheimei's patient
EEu will be abnoimal
Nost accuiate test is biain biopsy
611


CSF: shows 14-S-S piotein, the piesence of this will spaie the patient a biain
biopsy.


H.E9 4B29 6.*./,-(:
Is Paikinson's uisease + uementia.


LB'*(D @'.00)'. O92'B<.+3(D)0:
This conuition geneially piesents in oluei males, but it can affect women as
well.
It piesents as a peison with incontinence, with gait abnoimalities, anu with
cognitive impaiiment

!"#$%&'"':
Biagnosis shoulu incluue a heau CT anu a lumbai punctuie

12*#,+*%,:
Shunt placement




O)/,-/1,B/80 6-0.(0.J53B'.(
Piesents in young patients (usually in Su's)
Theie is usually a family histoiy

-/+0,&+'8
Bementia
Peisonality changes anu psychological uistuibance
Choieic movements

612


!"#$%&'"':
Specific genetic testing will show that inheiitance is autosomal uominant

Tieatment:
Theie is no tieatment























61S




HEADACHE

%-1'(-/.: 6u% aie unilateial, often tiiggeieu by: cheese, caffeine, menses, 0CP's

Bo a CT oi NRI if BA has any of the following:
Suuuen anuoi seveie
0nset aftei 4uyi
Associateu with any neuiological finuings
Nay be pieceeueu by an auia anuoi scotomata (Baik spots in visual fielu),
anu abnoimal smells

12*#,+*%,8
The best initial aboitive theiapy is sumatiiptan oi eigotamine
Piophylactic theiapy takes 4-6wks to woik, if patient gets foui oi moie BA
pei month, piophylax with piopianolol.
Alteinate piophylactics with CCBs, TCA's, oi SSRI.

5D)0,.': 1ux moie fiequent in men than women. Aie exclusively unilateial w
ieuness anu teaiing of the eye anu ihinoiihea.

Tieatment:
The best aboitive theiapy is 1uu% u2.
This tieatment is unique to clustei BA's.
Sumatiiptan can also be useu in same way as is in migiaines.

Piophylactic theiapy: theie is none because these BA's aie numeious but shoit anu
intense, anu the "clustei" woulu be ovei by the time the piophylaxis kickeu in.




614





O# !9+. %>G"#>L7 5H$A!7"
uenuei Nen 1ux moie than
women
Piesentation 0nilateial oi bilateial,
auia
0nly unilateial,
teaiingieuness of eye
Aboitive Sumatiiptan Sumatiiptan, Special:
1uu%u2
Piophylactic Piopianolol none

* Sumatiiptan is similai to SBT, anu woiks by causing vasoconstiiction in ceiebial
aiteiies.




!.*+B'(D #',.'-,-0
Patient will piesent with tenueiness ovei the tempoial aiea anu may also complain
of jaw clauuication

!"#$%&'"':
Fiist check the ESR
The most accuiate test is a biopsy of the tempoial aiteiy

12*#,+*%,:
uive steioius immeuiately, uo not uelay if this is suspecteu


61S




@0.)2B,)*B' 5.'.N'-
This piesents most commonly in a youngei woman with a heauache anu
uouble vision, papilleuema
CTNRI show up noimal
vitamin A use is often the cause

!"#$%&'"':
LP is the most accuiate test because it shows an elevateu opening piessuie

Tieatment:
Involves weight loss
Acetazolamiue can also be given



6-TT-/.00JM.',-1B
All pts with veitigo will have a subjective sensation of the ioom spinning
aiounu them.
0ften associateu with nausea anu vomiting
All pts with veitigo will have nystagmus
ueneially all patients wtih veitigo shoulu have NRI of the inteinal auuitoiy
canal.








616




E$##$/)(A 0,-#+ %*22,;)b+% >;+% $& , (*2-+; $& ?+;0)A$D',*%)(A '$(.)0)$(%<
6-0.(0. 53('(<,.'-0,-<0 O.('-/1 HB00J !-//-,)0
4@M Changes w position N0
M.0,-N)D(' /.)'-,-0 veitigo occuis wo
position change
N0
H(N9'-/,3-,-0 Acute YES
%./-.'.80 2-0.(0. Chionic YES
#<B)0,-< /.)'B*( Ataxia YES
@.'-D9*+3 ;-0,)D( Bx of tiaum YES


4@M
veitigo alone w no loss of heaiing,no tinnitus, no ataxia.
Positive uix-hallpike maneuvei
Tieat with meclizine(antiveit)



M.0,-N)D(' L.)'B/-,-0
An iuiopathic inflammation of the vestibulai poition of CN8.
No heaiing loss oi tinnitus because only vestibibulai poition is affecteu.
Nost likely to be a viial cause
Not ielateu to change in position
Tieat with meclizine




617




H(N9'-/,3-,-0
Is inflammation of the cochleai poition of the innei eai.
Theie is heaiing loss as well as tinnitus.
Is acute anu self-limiteu
Tieat with meclizine



%./-.'.80 6-0.(0.
Same pies as labyiinthitis (veitigo, tinnitus, heaiing loss) but menieie's is
chionic with iemitting anu ielapsing episoues.
Tieat with salt iestiiction anu uiuietics.



#<B)0,-< L.)'B*(
A tumoi of CN8 that can be ielateu to neuiofibiomatosis (von
Recklinghaus's).
Piesents with ataxia in auuition to heaiing loss, tinnitus, anu veitigo.

!"#$%&'"'8
NRI of inteinal auuitoiy canal

12*#,+*%,:
Suigical iesection.





618




@.'-D9*+3(,-< K-0,)D(
Beau tiauma oi any foim of baiotiaumas to the eai may iuptuie the
tympanic membiane anu leau to a peiilymph fistula.




Wernicke-Korsakoff Syndrome

Piesents with the following:
1. Bistoiy of chionic heavy ET0B use
2. Confusion with confabulation
S. Ataxia
4. Nemoiy loss
S. uaze palsy anuoi ophthalmoplegia
6. Nystagmus

!"#$%&'"':
Bo a heau CT
vitamin B12 level
TSBT4 level
RPRvBRL
Piesence of memoiy loss

12*#,+*%,:
1
st
give thiamine then give glucose.








619




5LA >LK75!>?LA

0ften when a CNS infection is suspecteu, a heau CT shoulu be peifoimeu befoie the
LP.

This is the case in the following ciicumstances:
A histoiy of CSN uisease
Focal neuiological ueficits
Piesence of papilleuema
Seizuies
Alteieu consciousness
Significant uelay in ability to peifoim LP

** If these aie piesent, get bloou cultuies anu stait empiiic antibiotics befoie
oiueiing CT.

:9E<
uetting CSF is the most accuiate test foi bacteiia meningitis, but cannot wait
foi cultuie to stait theiapy.
uiam stain: only Su% sensitive, thus if (-) cannot excluue anything. Is highly
specific though, so if (+) it is likely to be bacteiia meningitis. Ie. uoou spec
bau sensitivity
uiam (+) uiplococci: pneumococcus
uiam (+) bacilli: listeiia
uiam (-) uiplococci: neisseiia
uiam (-) pleomoiphic, coccobacillaiy oiganisms: hemophilus


8;$0+)(: An elevateu piotein level in CSF is of maiginal uiagnostic benefit. Elevateu
piotein is non-specific because any foim of CSN infection can elevate the CSF
piotein. Bowevei, a noimal CSF piotein excluues bacteiial meningitis.

62u


N#*'$%+: Levels below 6u% of seium levels is consistent w bacteiial meningitis

:+## '$*(0< This is best initial test foi the uiagnosis of meningitis. If thousanus of
PNN's aie piesent stait Iv ceftiiaxone, vancomycin, anu steioius. Thousanu of
PNN's is bacteiial meningitis until pioven otheiwise.



5'9+,B<B<<)0 (fungal meningitis)

Look foi BIv(+) patient with <1uuCB4 cells.
This infection is slowei than bacteiial meningitis anu may not give seveie
meningeal signs (neck stiffness, photophobia, anu high fevei, all at same
time).

!"#$%&'"':
The best initial test is the Inuia ink stain
The most accuiate test is the ciyptococcal antigen

12*#,+*%,8
The best initial theiapy is Amphoteiicin

*follow Amphoteiicin with oial Fluconazole (continueu inuefinitely until the CB4
count iaises), once CB4 count >1uu, fluconazole can be uiscontinueu.







621




H9*. 6-0.(0.
Patient usually lives in Connecticut aiea anu has a histoiy of camping, hiking, oi
being in tall giass. The tick exposuie is iaiely iemembeieu by the patient.

!"#$%&'"':
A cential cleaiing taiget iash is pathognomonic
Theie is a histoiy of joint pain
Bell's palsy

12*#,+*%,:
0ial uoxycycline
If theie is caiuiac involvement tieat with Iv ceftiiaxone



"B<Q9 %B)/,(-/ A+B,,.2 K.:.' \"%AK)
Look foi campeihikei with a iash that staiteu on wiists anu ankles anu moveu
centially.

-"$%' #%. -/+0,&+'8
Fevei, heauache, anu malaise always pieceue the iash

!"#$%&'"'8
0ial Boxycylcine is the most effective theiapy.




622






!4 %./-/1-,-0
This is an extiemely uifficult uiagnosis to pinpoint
Look foi an immigiant with a histoiy of lung TB
Piesents slowly ovei weeks to months (If acute then not TB meningitis)

!"#$%&'"'8
Bas a veiy high CSF piotein levels
Aciu fast stain of CSF is not accuiate, neeu thiee high-volume centiifugeu
samples if going to uo aciu-fast stain.

12*#,+*%,8
RIPE tieatment as with TB, only uiff is shoulu auu steioius anu extenu the
length of theiapy foi meningitis when compaieu to the pulmonaiy uisease.



M-'(D %./-/1-,-0
viial meningitis is in geneial a uiagnosis of exclusion.
Theie is lymphocytic pleocytosis in the CSF.
Theie is no specific theiapy foi viial meningitis.



H-0,.'-( %./-/1-,-0
Look foi elueily, neonatal, anu BIv (+) patients anu those who have no
spleen, aie on steioius, oi aie immunocompiimiseu with leukemia oi
lymphoma.

62S


* Auu Ampicillin to iegimen of vancomycin + ceftiiaxone when Listeiia is suspecteu.
Such as if theie is lymphocytosis in the CSF.


L.-00.'-( %./-/1-,-2.0
Look foi patients who aie auolescents, in the militaiy, aie asplenic, oi who
have teiminal complement ueficiency.

12*#,+*%, "' #' 6&77&:':
8,0)+(0 ! Respiiatoiy isolation
:#$%+ '$(0,'0%! Stait piophylaxis with iifampin oi cipiofloxacin.
Close contacts aie: householu membeis, people who shaie utensils, cups, kisses.
M$*0)(+ '$(0,'0%! Routine school anu woik contacts uo not neeu to ieceive
piophylaxis.






ENCEPHALITIS

Look foi a patient with a fevei anu alteieu mental status ovei a few houis.
Almost all encephalitis in the 0S is fiom heipes, the patient uoes not have to
iecall a past histoiy of heipes in oiuei to make this uiagnosis

E3F3M k :5XE6945X = Encephalitis

!"#$%&'"':
The best uiagnostic test is a CT scan of the heau
The most accuiate test is a PCR of the CSF

12*#,+*%,:
624


The best initial theiapy is acyclovii
Foi acyclovii-iesistant patients give foscainet



BRAIN ABSCESS

Pies with a fevei, heauache, anu focal neuiological ueficits
CT finus a "iing" aka contiast enhanceu lesion
Finuing a iing means eithei cancei oi infection.

Consiuei BIv status in context of biain abscess as follows:

BIv negative patient ! biain biopsy is the next step
BIv positive patient ! Tieatment foi toxoplasmosis with pyiimethamine
anu sulfauiazine foi 2wks anu iepeat the heau CT




@'B1'.00-:. %)D,-;B<(D H.)QB./<.+3(DB+(,39 (PNL)
These biain lesions in BIv(+) patients aie not associateu with iing
enhancement oi mass effect.
Theie is no specific theiapy.
Tieat the BIv anu iaise the CB4, when the BIv is impioveu, the lesions will
uisappeai.



L.)'B<90,-<.'<B0-0
Look foi a patient fiom Nexico with a seizuie
Beau CT shows multiple 1cm cystic lesions, ovei time lesions will calcify.

!"#$%&'"':
62S


Confiim with seiology


12*#,+*%,:
When still active anu uncalcifieu, the lesions aie tieateu with Albenuazole,
use steioius to pievent a ieaction to uying paiasites.





O.(2 !'()*( (/2 >/,'(<'(/-(D O.*B''3(1.

Any heau tiauma iesulting in a loss of consciousness oi alteieu mental status shoulu
leau to CT of heau without contiast

5B/<)00-B/ 5B/,)0-B/ A)N2)'(D
3.*=
7+-2)'(D 3.*=
Focal ueficit Nevei Raiely Yes oi no Yes oi no
Beau CT Noimal Ecchymosis Ciescent shape Lens shapeu


!'.(,*./, ;B' :('-B)0 3.(2 ,'()*(0 ('. (0 ;BDDBE0:

1. :$('*%%)$(: None
2. :$(0*%)$(: Aumit patient, vast majoiity get no tieatment
S. 9*-.*;,# ,(. 3>).*;,# V+2,0$2,%: Laige ones uiaineu, small ones left
alone to ieabsoib on theii own.
4. O,;A+ )(0;,';,(),# 1+2$;;1,A+ /)01 2,%% +&&+'0: 1.
Intubatehypeiventilate to ueciease ICP, 2. Beciease PCu2 to 2S-Su, which
constiicts ceiebial bloou vessels, S. auministei Nannitol as an osmotic
uiuietic to ueciease ICP, 4. Peifoim suigical evacuation.
626





A)N('(<3/B-2 O.*B''3(1.\A#O^
Look foi the following symptoms:
Suuuen, seveie heauache
Stiff neck
Photophobia
L0C in Su% of patients
Focal neuiological ueficits in Su% of patients
SAB is like suuuen onset of meningitis with a L0C but without fevei.


!"#$%&'"'8
The best initial test is a heau CT without contiast. It is 9S% sensitive, if
conclusive, no neeu to uo an LP
The most accuiate uiagnostic test is an LP, but not necessaiy if CT shows
bloou.

12*#,+*%,8
Peifoim angiogiaphy to ueteimine site of bleeu
Suigically clip oi embolize the site of bleeuing (If patient ie-bleeus theie is a
Su% change of ueath).
Inseit a vetiiculopeiotoneal shunt if hyuiocephalus uevelops
Piesciibe nimouipine oially; which is a CCB that pievents stioke.

** When SAB occuis, an intense vasospasm can leau to non-hemoiihagic
stioke(thus CCB useu).






627





SPINE DISORDERS
Lumbosacial
stiain
Coiu compiession Epiuuial abscess Spinal stenosis
Nontenuei Tenuei Tenuei anu fevei Pain on walking
uownhill.



A9'-/1B*9.D-(
Is a uefective fluiu cavity in the centei of the coiu fiom tiauma, tumois, oi
congenital pioblem.
Piesents with a loss of sensation of pain anu tenueiness in a cape-like
uistiibution ovei the neck, shoulueis, anu uown both aims.

!"#$%&'"':
NRI

12*#,+*%,:
Suigical coiiection



5B'2 5B*+'.00-B/
Netastatic cancei piesses on the coiu, iesulting in pain anu tenueiness of the
spine.
Lumbosacial stiain uoesn't give tenueiness of the spine itself.

!"#$%&'"':
The best initial test is an NRI
628


The most accuiate uiagnostic test is a biopsy, only uone if uiagnosis is not
cleai fiom the histoiy




Spinal Epidural Abscess

Piesents with back pain wth tenueiness anu fevei
Scan spine with an NRI
uive antibiotics against staphylococcus such as oxacillin oi nafcillin
Laige abscesss iequiie suigical uiainage.




A+-/(D A,./B0-0
Piesents with leg pain on walking anu can look like peiipheial aiteiial
uisease
Pulses will be intact in spinal stenosis
Pain woisens when patient leans backwaius anuoi walks in a uownwaiu
uiiection, while it impioves when walking in an upwaiu uiiection
Biagnose with an NRI anu tieat with suigical uecompiession



#/,.'-B' A+-/(D #',.'9 >/;('<,-B/
All sensation is lost except position anu vibiatoiy sense, which tiavel uown
the posteiioi column of the spinal coiu
No specific theiapy can coiiect this pioblem




629


4'BE/YA._)('2 A9/2'B*.
This iesults fiom tiaumatic injuiy to the spine, such as that fiom a knife
wounu.
Patient loses ipsilateial position, vibiatoiy sense, contialateial pain anu
tempeiatuie


** The most uigent management in coiu compiession is the auministiation of
steioius as soon as possible anu to ielieve piessuie on the coiu. Imaging stuuies aie
uone aftei auministiation of steioius.




AMYOTROPHIC LATERAL SCLEROSIS

Is an iuiopathic uisoiuei of both uppei anu lowei motoi neuions.
Tieateu with iiluzole, a unique agent that blocks the accumulation of
glutamate

$%L 0-1/0 H%L 0-1/0
Bypeiieflexia
0pgoing toes on plantai ieflex
Spasticity
Weakness
Wasting
Fasciculations
weakness








6Su




PERIPHERAL NEUROPATHIES


6-(N.,.0
Biabetes is the most common cause of peiipheial neuiopathies
Specific testing is not necessaiy in most cases.

12*#,+*%,:
uabapentin oi Piegabalin aie useful in tieating neuiopathies.
TCA's aie less effective anu have moie siue effects

5('+(D !)//.D A9/2'B*.
Look foi pain anu weakness of fiist thiee uigits of hanu
Symptoms may woisen with iepetitive use.
Initial mgmt is a splint.
Steioiu injections may be useu if splints pioviue no ielief
If these uon't woik, can peifoim suigeiy to ielieve the pain


"(2-(D L.':. @(D09
Aka Saturday night palsy, results from falling asleep or passing out with
pressure on arms underneath the body or outstretched, perhaps draped over back
of a chair (classic presentation on exam question)
Results in wrist drop, resolves on its own.



@.'B/.(D L.':. @(D09
Results fiom high boots piessing at the back of the knee.
Results in foot uiop anu inability to eveit the foot.
This palsy will iesolve on its own

6S1




5Lm +(D09 \4.DD80 +(D09^
Results in hemi-facial paialysis of both uppei anu lowei halves of face.
Thought to be uue to a viius
Theie may also be a loss of taste in anteiioi 2S of tongue, hypeiaccusis, anu
the inability to close the eye at night.

12*#,+*%,:
Steioius anu acyclovii oi valcyclovii shoulu be given



".;D.V 09*+(,3.,-< 290,'B+39 \<3'B/-< '.1-B/(D +(-/ 09/2'B*.^
0ccuis in a patient with a pievious injuiy to the extiemity
Light tough such as fiom a sheet touching the foot, iesults in extieme pain
that is "buining" in quality

12*#,+*%,:
NSAIBs
uabapentin
0ccasionally a neive block may be uone if the pievious methous uon't woik
Suigical sympathectomy may be necessaiy when iefiactoiy




".0,D.00 H.1 A9/2'B*.
0ncomfoitable feeling in the legs which patient tiies to "shake off", which
biings only tempoiaiy ielief

12*#,+*%,:
6S2


Piamipexole oi iopineiole.



G)-DD(-/Y4(''. 09/2'B*.
Ascenuing paialysis, thought to be causeu by a viial infection.
0sually piesents weeks aftei a iespiiatoiy infection

)#%#$*+*%,V12*#,+*%,8
Fiist step is to take a peak inspiiatoiy piessuie, which can tell if the pt will
unueigo iespiiatoiy failuie.
Seconu step is to give IvIu's anuoi peifoim plasmaphaiesis.


MYASTHENIA GRAVIS

Classically piesents with weakness of the muscles of mastication, making it
haiu to finish meals
Bluiiy vision fiom uiplopia iesults fiom inability to focus the eyes on a single
taiget.
Classically the patient iepoits uiooping of the eyelius as the uay piogiesses.

!"#$%&'"':
The best initial test is testing foi anti-acetylcholine ieceptoi
antibouies(ACBR)
The most accuiate test is ;7"%";#7 02*'*%,#,"&% #%. @3?O, which is moie
sensitive anu specific that tensilon test.

12*#,+*%,:
The best initial theiapy is @9'-2B0,-1*-/. oi L.B0,-1*-/.
Thymectomy can be peifoimeu if pyiiuostigmine oi neostigmine uon't woik
patients < 6u yi of age shoulu unueigo thymectomy.
uive E2*.%"'&%* if thymectomy uoesn't woik, oi if theie aie no iesponses to
pyiiuostigmine oi neostigmine, then pieunisone shoulu be staiteu.
!b,01)$>;)(+ #%. '='#$%>$;)(+ aie useu to tiy to keep the patient off of long-
teim steioius.
6SS













Chapter 17

Oncology

6S4


4'.(0, 5(/<.' A<'../-/1

Scieening mammogiaphy as follows:
Stait at 4u
Between 4u-Su anu eveiy 1-2yis
At Su, stait uoing them eveiy yeai


S1+( , 2,22$A;,2 %1$/% ,( ,-($;2,#)0=Z
1
st
thing is to uo a biopsy(shows CA anu piesence of esetiogen anuoi
piogesteione ieceptois)

S1,0 )% 01+ %+(0)(+# ($.+s
It is the fiist noue uetecteu in the opeiative fielu, uetecteu by uye.
If this noue is fiee of CA, then axillaiy noue uissection is not necessaiy, if the
noue is canceious, axillaiy lymph noue biopsy is iequiieu

J+%0 )()0),# 01+;,>= &$; -;+,%0 ',('+;s
Lumpectomy with iauiation tieatment(equal to mouifieu iauical
mastectomy)
If theie is piesence of estiogen oi piogesteione ieceptoi (+), use tamoxifen
oi ialoxifene
Aujuvant chemotheiapy useu whenevei the axillaiy noues aie (+) 0R the
cancei is >1cm in size.


V$;2$(,# 4(1)-)0)$( 71+;,>=F
!(*BV-;./ anu '(DBV-;./. useu if eithei piogesteione oi esteiogen
ieceptois aie positive. They SERNs (selective esteiogen ieceptoi
mouulatois). #2:.'0. ".(<,-B/0: BvT, hot flashes,enuometiial CA.
These aie uiffeient fiom ('B*(,(0. -/3-N-,B'0, which uo not leau to BvT,
but cause osteopoiosis uue to antagonistic activity in the bone.


6SS



!.P*?,(0 :1+2$01+;,>=< >0 (++'B+'-(,. E3./C
1. Cancei is in the axilla
2. Cancei laigei than 1cm
S. Noie efficacious when pt still menstiuation, because BR-ca wont be
contiolleu with estiogen antagonists such as tamoxifen.

7M!976l6@!J: is a monoclonal antibouy against bieast CA antigen "BER-2NE0",
useful in metastatic uisease, has mouest activity with few auveise ieactions

E2"+#2/ E2*G*%,#,"G* 15*2#0/: 0se Tamoxifen in any patient with multiple 1
st

uegiee ielatives (mom, sistei) with bieast CA



COLON CANCER

The most imp thing is scieening scheuule anu inuicatois..

Colon cancei is tieateu with suigical iesection of the colon anu
chemotheiapy centeieu aiounu a S-F0 iegimen.

M$*0)(+ &$; %';++()(AF
1. Colonoscopy starting at 50, the every 10yrs. If single family member has it, get
colonoscopy 10yrs earlier than the age at which that person was diagnosed. Three
family members get colonoscopy at 25yr, then every 10yr. FAP do screening
sigmoidoscopy at 12yr, then every 1-2yr.
2. ?<<)D, NDBB2 ,.0,-/1 staiting at Suyi, then eveiy yeai theieaftei.
S. A-1*B-2B0<B+9 anu 2B)ND. <B/,'(0, N('-)* enema at Su, then q S-Syi.





6S6



LUNG CANCER

Remember that small cell carcinoma releases ectopic ACTH, Squamous cell carcinoma
releases PTH-like hormone.

Theie is no scieening test foi lung cancei
Excisional biopsy shoulu be uone on solitaiy lung nouules in pts who aie
smokeis with nouule >1cm.
Calcifications usually go against malignancy, but if theie is histoiy of
smoking, a patient >Suyi, anu nouule >1cm, excision is waiianteu.

O*(A ',('+; 01+;,>=: The most imp issue in tieatment is whethei the uisease is
localizeu enough to be suigically iesecteu. Suigeiy cannot be uone is any of the
following aie piesent:
1. Bilateial uisease
2. Nets
S. Nalignant pleuial effusion
4. Involvement of aoita, vena cava, oi heait
S. Lesions within 1-2cm of caiina.

*** 92,##D'+## #*(A ',('+; is non-iesectable because >9S% of time is has one of
these featuies.

CERVICAL CANCER

Stait pap smeais at 21, oi Syis aftei onset of sexual activity
Bo pap smeais eveiy S yis until age 6S. Stop at 6S unless theie has been no
pievious scieening.
Auministei BPv quauiivalent vaccine to all women 1S-26yi

C&77&:"%$ =0 #% #4%&2+#7 0#0 '+*#2:
1. An abnoimal pap smeai with low-giaue oi high-giaue uysplasia shoulu be
followeu by colposcopy anu biopsy.
2. A pap smeai showing atypical squamous cells of unueteimineu significance
(ASC0S), uo BPv testing. If BPv (+), pioceeu to colposcopy, if BPv (-), uo
iepeat pap in 6mnth
S. 0nce pap smeai noimal, ietuin to ioutine testing
6S7



* Pap smeais lowei moitality in scieen populations, but still not as much as
mammogiaphy because inciuence of ceivical CA is less than that of bieast cancei.



PROSTATE CANCER

No pioven scieening methou that loweis moitality iate. PSA anu BRE not
pioven to lowei moitality.
Bo not ioutinely offei these tests, howevei if pt asks foi them, you shoulu
peifoim.

12*#,"%$ 02&',#,* ;#%;*2:
1. O$',#)b+.: Suigeiy anu eithei exteinal iauiation oi implanteu iauioactive
pellets (neaily equal in efficacy)

2. @+0,%0,0)': Anuiogen blockaue is stanuaiu of caie, use flutamiue
(testosteione ieceptoi blockei) ANB leupioliue oi goseielin (uNRB
agonists).

* Theie is no goou chemotheiapy foi metastatic piostate cancei, tieatment is
hoimonal in natuie.
*Remembei the S-alpha-ieuuctase inhibitoi finasteiiue is useu foi BPB, not
cancei

A man with piostate cancei piesents with seveie, suuuen back pain. NRI shows
coiu compiession, anu he's staiteu on steioius. S1,0G% 01+ (+Q0 -+%0 %0+> )(
2A20Z
KH$!#%>67 (to block tempoiaiy flaie up in anuiogen levels that accompanies
uNRB agonist tieatment



6S8



OVARIAN CANCER

Key feats aie women >Su with incieasing abuominal giith at same time as weight
loss.

!"#$%&',"; ,*',"%$:
Theie's no ioutine scieening test
CA12S is a maikei of piogiession anu iesponse to theiapy, not a uiagnostic
test

12*#,+*%,:
Treatment is surgical debulking followed by chemotherapy, even in cases of local
metastatic disease.
Ovarian ca is unique in that surgical resection is beneficial even when theres a
large volume of tumor spread through the pelvis and abdomen. If possible,
removing all visible tumors helps.



TESTICULAR CANCER

Presents with painless scrotal lump in a man <35yr.
Is extiemely cuiable with a 9u-9S% Syi suivival iate.
NEvER uo a biopsy of the testicle.

!"#$%&',"; 1*',"%$8
An inguinal orchiectomy of the affected testicle, never do biopsy.
Measure AFP, LDH, and bHCG
Stage with CT of abdomen and pelvis.

12*#,+*%,:
1. O$',# .)%+,%+: Rauiation
2. S).+%>;+,. .)%+,%+: Chemotheiapy, which is cuiative of even metastasis in
testiculai cancei.

6S9


U?; (DD ,.0,-<)D(' <(/<.'0C pet ('. 1.'* <.DD ,)*B'0 \0.*-/B*( (/2 /B/Y
0.*-/B*(^=

*AFP secieteu only by nonseminomas.

*Neasuie AFP, LBB, anu bBCu.




SOME EXTRA PREVENTATIVE MEDICINE

92$B)(A '+%%,0)$(:
Scieen all anu auvise against smoking
Nost effective methous aie use of oial meus such as Bupiopiion anu
vaienicline.
Less effective aie nicotine patch anu gum (which shoulu be tiieu fiist).

*With bupiopiion, patient shoulu slowly ueciease cigaiettes 2wks aftei staiting
theiapy. 0se bupiopiion in conjunction with counselling anu nicotine ieplacement.

5%0+$>$;$%)%! Scieen all women with BEXA scan at 6Syi of age.

!!!! All men about 6Syi who weie evei smokeis shoulu be scieeneu once w an
ultiasounu.

R@! No iecommenuation foi ioutine uiabetes scieening

V7X! All pts shoulu be scieeneu at eveiy visit.

V=>+;#)>).+2),! Nen >SS, Women >4S
64u







Chaptei 18

Beimatology






641



6%)(A 7$>)',# 90+;$).%
Potency Neuication 0se
Low 1% hyuiocoitisone Face, genitalia, anu skin
Noueiate u.1% tiiamcinolone BouyExtiemities, face,
genitalia, anu skin folus
Bigh Fluocinoniue Foi thick skin.
Nevei on face
veiy Bigh Bifloiasone Thick skin oi seveie bouy
neeus


#</.
An infection of the pilosebaceous glanu causeu by the bacteiia
Piopionibacteiium acnes
!:X3
-"$%' #%. -/+0,&+'8
Blackheaus (open comeuones) anu whiteheaus (closeu comeuones)

12*#,+*%,:
Nilu uisease shoulu be manageu with topical antibiotics such as clinuamycin,
eiythiomycin, in auuition to benzoyl peioxiue
Noueiate uisease shoulu combine benzoyl peioxiue with ietinoius
Seveie uisease shoulu be manageu with oial antibiotics anu oial ietinoic aciu
ueiivatives

642




4(<,.'-(D >/;.<,-B/0 B; ,3. AQ-/

>*+.,-1B
A supeificial skin infection limiteu to the epiueimis
42>+0)A$

Is often uesciibeu as being "honey-coloieu", "wheeping", oi "oozing"
0sually causeu by 90,>1=#$'$''*%, but may also be uue to 90;+> 8=$A+(+%
12*#,+*%,:
Nupiiocin (A topical antibiotic) anuoi antistaphylococcal oial antibiotics


7'90-+.D(0
A skin infection of the epiueimis anu the ueimis, which is usually causeu by Stiep
Pyogenes. This conuition is often uesciibeu as being biight ieu, angiy, anu swollen.
64S


3;=%)>+#,%
With eiysipelas may come fevei anu chills
12*#,+*%,:
Penicillin u oi ampicillin if uiagnosis is Stieptococcus


5.DD)D-,-0
An infection causeu by Staphylococcus anu Stieptococcus that infects the ueimis
anu the subcutaneous tissues. Nanageu with antistaph uiugs such as oxacillin anu
nafcillin.
:+##*#)0)%


644



KBDD-<)D-,-0
An infection of the haii follicle, may piogiess to a woise infection calleu a fuiuncle.
0sually causeu by staphylococcus, if acquiieu fiom a hot-tub it can be uue to
Pseuuomonas, fungi, oi viius
Look foi this aiounu the beaiu aiea wheie theie aie accumulations of pus-like
mateiial.
E$##)'*#)0)%

12*#,+*%,:
Local caie anu topical mupiiocin
Seveie cases that piogiess iequiie systemic antistaphylococcal antibiotics












64S



L.<'B,-T-/1 K(0<--,-0
Is a seveie, life-thieatening skin infection. It begins as a cellulitis that uissects into
the fascial planes of the skin. NCC by stiep anu Clostiiuium
E2*'*%,#,"&%:
Bigh fevei
Extieme pain that is woise than it looks
Bullae
Ciepitus
X+';$0)b)(A E,%'))0)%
!"#$%&'"':
CT oi NRI looking foi aii in the tissue anuoi neciosis
Elevateu cieatine phosphokinase

)#%#$*+*%,V12*#,+*%,8
Suigical uebiiuement
Combination beta lactambeta lactamase meuications
If it is causeu by Stiep Pyogenes, give clinuamycin + PCN








646



A<('D., K.:.'
Is causeu by Stiep Pyogenes, anu looks like a combination of a iash anu goosebumps
9',;#+0 E+?+;

-"$%' #%. -/+0,&+'F
Rough skin
Stiawbeiiy tongue
Beefy-ieu phaiynx
Rash is most intense in the axilla anu gioin (In the cieaseu aieas of skin)
Besquamation of hanus anu feet occuis as iash iesolves
Nay have fevei, chills, soie thioat, ceivical auenopathy
ulomeiulonephiitis is a complication

12*#,+*%,:
Penicillin








647



5B**B/ 6.'*(,BDB1-< 6-0B'2.'0

7<T.*(
Is a supeificial, itchy, eiythematous lesion
The iash uevelops aftei itching
Commonly seen on the flexoi suifaces
Biagosis is clinical
3'b+2,
12*#,+*%,F Avoiuance of iiiitants anu tiiggeis, keep skins moistuiizeu,
antihistaminessteioius aie goou foi ielief fiom inflammation anu itching
Theie aie many vaiiations of Eczema, incluuing:
1. !0$>)' R+;2,0)0)% - this is the classic wheie itching causes a iash
2. :$(0,'0 .+;2,0)0)% - an itchy iash at the site of contact, classically causeu by
contact with nickel, chemicals, oi poison plants
S. 9+-$;;1+)' .+;2,0)0)% - scaling anu flaking in aieas of sebaceous glanus






648




@0B'-(0-0
Piesents as pink plaques with silvei scaling
0ccuis on the extensoi suifaces such as the elbows anu knees
Theie is often pitting of the fingeinails
The classic finuing is known as "Auspitz Sign", which is pinpoint bleeuing
when the scale is iemoveu
This is uiagnoseu clinically
8%$;),0)' 8#,c*+
12*#,+*%,:
C
%0
#)(+ is Topical steioius
T
(.
#)(+ is 0vA light anu may be useu as an aujunctpiophylactic
a
;.
#)(+ is methotiexate anu clyclospoiin


$',-<('-(
Is a conuition causeu by mast cell uegianulation anu histamine ielease
Piesents with the classic "wheals" that aie intensely itchy
"Beimogiaphism" is seen wheie you can wiite a woiu with youi fingei on
the skin anu it will iemain
Nost lesions aie IgE-meuiateu (thus a type 1 sensitivity)
Biagnose this conuition by sciapings
649


6;0)',;),
12*#,+*%,:
Avoiu tiiggeis
uive antihistaminessteioius
This can possibly affect the iespiiatoiy tiact which woulu then involve
secuiing an aiiway


M-,-D-1B
Theie is a loss of melanocytes in uisciete aieas of the skin
Boiueis aie shaiply uemaicateu
0sually seen in uaikei patients
Possibly autoimmune in natuie
F)0)#)A$
12*#,+*%,:
Nini-giafting can iestoie pigment to aieas wheie it is lacking
6Su


#DN-/-0*
Failuie of melanocytes to piouuce pigment, uue to a tyiosine ueficiency
Patient has white skin, iiis tianslucency, uecieaseu ietinal pigment,
nystagmus, anu stiabismus
Avoiu sun exposuie anu use sunscieen all the time
Theie is an incieaseu iisk of skin cancei uue to lack of piotection fiom the
sun
!#-)()%2















6S1


4D-0,.'-/1 6-0B'2.'0

@.*+3-1)0 M)D1('-0
A iaie autoimmune uisoiuei affecting people between 2u-4uyi of age
Bullae slough off easily anu leave laige uenuueu aieas of skin, this is know as
"Nikolsky's sign", this pieuisposes to an incieaseu iisk of infection
Fatal conuition if not manageu piopeily
8+2>1)A*% F*#A,;)%
!"#$%&'"':
Immunofluoiescence of the suiiounuing epiueimal cells shows a
"tombstone" fluoiescent pattein
12*#,+*%,:
Bigh-uose oial steioius






6S2


4)DDB)0 @.*+3-1B-2
An autoimmune conuition that affects mostly the elueily
Less seveie than pemphigus vulgaiis
Piesents with haiu anu tense bullae that uo not iuptuie easily
Piognosis is much bettei than that of pemphigus vulgaiis
J*##$*% 8+2>1)A$).
!"#$%&'"':
Skin biopsy showing a lineai banu along the basement membiane on
immunofluoiescence
Incieaseu eosinophils founu in the ueimis
12*#,+*%,:
0ial steioius


7'9,3.*( %)D,-;B'*.
Is a hypeisensitivity ieaction to uiugs, infections, oi systemic uisoiueis
Piesents with uiffuse anu eiythematous taiget lesions that aie highly
uiffeiing in shape
3;=01+2, @*#0)&$;2+
!"#$%&'"'F
Is clinical but a histoiy of heipes infection makes this a likely uiagnosis
6SS


12*#,+*%,:
Stop offenuing causes anu tieat if theie is a histoiy of heipes with acyclovii


@B'+39'-( 5),(/.( !('2(
An autosomal uisoiuei of impaiieu heme synthesis
uet blisteis on sun-exposeu aieas of the face anu hanus
Biffeientiate this poiphyiia by the absence of abuominal pain
8$;>1=;), :*0,(+, 7,;.,
!"#$%&'"':
Woou's lamp of uiine, wheie the uiine fluoiesces with an oiange-pink coloi
uue to the incieaseu levels of uiopoiphyiins
12*#,+*%,:
Sunscieens useu libeially
Phlebotomy
Chloioquine
Avoiuance of alcohol





6S4



@('(0-,-< >/;.<,-B/0 B; ,3. AQ-/

A<(N-.0
Piesents as seveiely itchy papules anu buiiows that aie locateu along the
webs of the fingeis
Bighly contagious
9',-)+% )(&+'0)$(
!"#$%&'"':
Iuentify the Saicoptes Scabiei mite fiom a skin sciaping unuei the
micioscope
12*#,+*%,:
Peimethiin S% cieate to the entiie bouy foi those infecteu anu close contacts
foi 8-1uhi, iepeateu in anothei week
Wash all linens anu beuuing in hot watei the same uay as cieam application


@.2-<)DB0-0 5(+-,-0 \O.(2 H-<.^
Itching anu swelling of the scalp
Common in school-ageu chiluien
!"#$%&'"':
Nicioscopic exam of the haii shaft will show lice attacheu to shaft
12*#,+*%,:
6SS


Peimethiin shampoo oi gel to the scalp
Repeat applications aie commonly iequiieu
@.2-<)DB0-0 @)N-0 \5'(N0^
Extiemely itchy papules in the pubic iegion
Nay also be along the axilla, buttocks, eyelashes, eyebiows, anu peiiumbilical
aiea
!"#$%&'"':
Nicioscopic iuentification of lice
12*#,+*%,:
Peimethiin shampoo left on foi 1u minutes, anu iepeateu again within a
week

5),(/.B)0 H(':( %-1'(/0
Is a snake-like, thieau-like lesion that maiks the buiiow of the nematoue
laivae
0ften seen on the hanus, back, feet, anu buttocks
Is causeu by hookwoims, namely ! Ancylostoma, Necatai, anu Stiongyloiues
:*0,(+$*% O,;?, @)A;,(%
!"#$%&'"':
A histoiy of skin being exposeu to moist soil oi sanu
Piesence of classic lesion
12*#,+*%,:
Iveimectin oially oi Thiabenuazole topically

6S6




K)/1(D 5),(/.B)0 6-0B'2.'0

6-0.(0. A-1/0 (/2
A9*+,B*0
6-(1/B0-0 !'.(,*./
,

!-/.( Itchy, scaly,
well
uemaicateu
plaques.

Black uots
seen on scalp
K0B Piep Topical
Antifungal
s

5(/2-2( Itchy, scaly
plaques,
usually in
skin folu
aieas
K0B piep
showing
buuuing
yeasts +
pseuuohyph
ae
Topical
Nystatis
oi 0ial
Fluconazo
le

!-/.(
M.'0-<BDB'
Pityiospoiu
m 0vale.

Shaiply
uemaicateu
hypopigment
eu macules
on face anu
tiunk in the
summei.

Nacules uo
not tan
K0B piep
shows the
classic
"Spaghetti
anu
meatball
appeaiance"
Selenium
Sulfiue
shampoo
on
affecteu
aiea foi 7
uays.

6S7


?/9<3B*9<B
0-0
Thickeneu,
yellowing of
the
fingeinails
anu toenails.
Clinical
anuoi K0B
piep
Fluconazo
le oi
Itiaconazo
le


AQ-/ 5(/<.'

5(/<.' !9+. >*(1. A-1/0 (/2
A9*+,B*0
!'.(,*./, @'B1/B0-0
Nalignant
Nelanoma

Seen NC in
light-skin
people with
incieaseu sun
exposuie.
Fits all
ABCBE
ciiteiia
Excision +
chemotheiapy
if theie is
metastasis
Pooi with
metastasis
Squamous
Cells
Caicinoma

Common in
elueily.

0n sun
exposeu
aieas.

0lceiations
anu ciusteu
Excision +
iauiation
Noueiate
piognosis
(bettei than
melanoma
but woise
than basal
cell)
Basal Cell
Caicinoma

NC anu looks
like a peaily
papule with
tianslucent
boiueis
Excision uieat
piognosis -
almost nevei
metastasizes
6S8


Kaposi's
Saicoma

Reupuiple
plaques.

Causeu by
BBv8.

Almost
exlusively in
AIBS patient
Chemotheiapy
anu BIv
meuications
uoou unless
theie is
associateu
oigan uamage
Cutaneous T-
cell
Lymphoma

Total bouy
iash that is
veiy itchy
Rauiation,
chemotheiapy
7-1u yi
suivival with
no tieatment.







6S9




Chapter 19

High-Yield
Preventative
Medicine







66u


Female patients > 6S yis of age shoulu ieceive a one-time BEXA bone scan
foi osteopoiosis
Any female who is at least 6uyi olu anu has 1 iisk factoi foi osteopoiosis
The T-scoie is useu to assess bone uensity
A T-scoie between |-1.S to -2.Sj is consiueieu to be osteopenia
A T-scoie < -2.S is osteopoiosis
A patient with a T-scoie of <-1.S plus iisk factois foi osteopoiosis (smoking,
pooi calcium vitamin B levels, lack of weight beaiing exeicise in the histoiy,
use of alcohol), shoulu ieceive pieventative meuications, such as oial
bisphosphonates oi Raloxifene
Raloxifene is the only SERN that is FBA appioveu to pievent osteopoiosis
Kius with cystic fibiosis shoulu ieceive noimal vaccinations in auuition to a
few auuitions ! yeaily influenza, pneumococcal boosteis
Patients with an egg alleigy shoulu avoiu the influenza anu yellow fevei
vaccines, anu shoulu be cautious with NNR as well
The 1
st
step in management of incieaseu LBL is lifestyle management, if LBL
>1uumguL anu the patient has iisk factois, they shoulu be staiteu on
lifestyle mouifications + statin uiugs
The uiug of choice foi incieasing the BBL is uemfibiozel anu nicotinic acius
It is iecommenueu that any male who is an active smokei oi foimei smokei
anu ageu between 6S-7S be given a one-time abuominal ultiasounu to
evaluate foi a AAA
Patients with a chionic livei uisease shoulu ieceive a numbei of vaccines
(Tetanus eveiy 1uyis + Bep A&B yeaily, anu pneumococcal vaccine)

Auult vaccine Recommenuations:
Tetanus anu Biptheiia eveiy 1uyis aftei 18yis of age
Influenza to all auults >Suyi oi to auults with chionic uiseases (BN, CBF, etc)
Pneumococcal vaccine given to all auults >6Syi of age oi to auults with
chionic uiseases

Scieening foi ceivical cancei with a pap smeai shoulu stait at 21yi of age oi
Syis aftei the onset of sexual activity (whichevei comes fiist)
If 2-S noimal pap smeais aie uone in a iow anu the woman is in a
monogamous ielationship, you can inciease the time between pap smeais to
eveiy 2-S yeais.
Scieening can stop at 7uyis of age
Bupiopion is FBA appioveu foi smoking cessation anu must be useu in
conjunction with counseling anu nicotine ieplacement
Bepatitis A vaccine is given to men who have sex with men
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Neningococcal vaccine is given to those who live in close quaiteis with
otheis
Routine cholesteiol scieening shoulu begin in patients at iisk at SSyi of age
in men anu 4Syi of age in women, then eveiy Syis aftei that
The most common vaccine-pieventable uisease is hepatitis A
When CB4 count uiops below 2uu2Su, stait PCP piophylaxis with TNP-SNX
When CB4 count uiops below Su, piophylax foi mycobacteiium avium
complex with amoxicillin
Routine scieening foi Chlamyuia is now iecommenueu foi all sexually active
females who aie & 24 yis of age
Nammogiams shoulu be uone eveiy 1-2 yis staiting at 4uyi in females with
an aveiage iisk of bieast cancei. Theie is no cleai time when they shoulu
stop, but it shoulu be no soonei than 7uyi of age
Pneumococcal vaccine is a capsulai polysacchaiiue of the 2S most common
types of pneumococcus, which yielu a B-cell iesponse only, it is T-cell
inuepenuent
Any female with a histoiy of being tieateu foi CIN2S shoulu have pap
smeais with oi without colposcopy anu cuiettage eveiy 6 months until thiee
negative iesults aie obtaineu (patients may iesume stanuaiu scieen aftei
meeting this milestone)