High-yield Shelf Notes

HIGH-YIELD SHELF NOTES

Surgery Psychiatry Obstetrics/gynecology Medicine Pediatrics

Young Kim, UCCOM c/o 2013 [email protected]

2 – 26 27 – 51 52 – 92 93 – 150 151 – 170

SURGERY

Surgery – Preoperative Care

––––––––––––––––– CV ISSUES ––––––––––––––––– Goldman’s index: cardiac risk factors in surgery – JVD (#1), recent MI (#2), PVCs and arrhythmias, age >70, emergency surgery, aortic stenosis JVD: indicates CHF, #1 CV risk factor overall, give β-blockers, Ca2+-channel blockers, digitalis, and diuretics if possible before surgery MI: previous MI increases risk of post-op MI, so consult cards and order a stress test

Previous coronary angioplasty: high risk (33%) of coronary restenosis, so stress test is indicated; if angioplasty is recent, delay surgery for several weeks

Delirium in liver failure: possible causes include CNS abnormality, electrolyte imbalance, GI bleeding, sepsis, or bacterial peritonitis; evaluate for mental status change, and tap the ascites

Angina: indicates coronary artery disease, evaluate for possible coronary revascularization

Ascitic leakage: high risk of bacterial peritonitis; manage by sending fluid to lab, giving IV antibiotics, and urgent hernia repair

AFib: give anticoagulation and β-blockers, and cardiovert them to normal sinus rhythm Carotid bruit: indicates carotid stenosis; indicated for CEA if high grade (>70%) stenosis

MI within 30 days: very high risk, delay surgery Family Hx of MI: get a concentrated cardiac FHx, EKG, and exercise stress test to assess risk factors ↑cholesterol: increased risk of coronary artery disease, but do not postpone surgery

Previous stroke: order a carotid duplex study, in order to assess the carotid arteries

Hemorrhoids: suspect portal HTN in pt with cirrhosis + hemorrhoids, high risk of hemorrhage Malnutrition: indicated by recent weight loss (#1) or albumin <3.0 (#2); give 7-10 days of pre-op nutritional support ideally ––––––––––––––––– GU ISSUES –––––––––––––––––

Gangrenous toe: peripheral revascularization is more urgent than a full cardiac work-up

Dysuria: get urinalysis and urine culture; if positive for UTI, delay surgery until resolved

––––––––––––– RESPIRATORY ISSUES –––––––––––– Premature ventricular contractions: at risk of arrhythmia due to ventricular dysfunction, indicated for stress test and echo Ejection fraction: SV/EDV; normal EF >67%, an EF<35% increases risk of operative MI Diabetes: should be NPO 8 hours before surgery, administer IVF with D5, check glucose morning of surgery; if glucose >250 → 2/3 of insulin, if glucose <250 → 1/2 of insulin Hyperglycemia: ideal glucose is 100-250, delay surgery until glucose is under control Diabetic coma: absolute contraindication to surgery; give IVF, correct acidosis and glucose ↓hct: important to determine underlying cause of anemia, consider possible colorectal cancer

Smoking: up to 6× risk for post-op complications due to compromised ventilation, must quit smoking for 2 months before surgery COPD: give bronchodilators and try to improve pulmonary status as much as possible Severe COPD: very high risk for acute pulmonary failure with surgery; teach patient about incentive spirometry, give bronchodilators, and mobilize post-op to prevent atelectasis Green sputum: give oral antibiotics, and schedule surgery after Tx is complete

Chronic renal failure: delay surgery until pt is stable, dialysis started, and any other problems resolved CRF × K+ measurement: needs to be obtained immediately before surgery, since CRF can result in rapid electrolyte imbalances CRF × operative bleeding: renal failure causes platelet dysfunction secondary to uremia; give desmopressin or FFP, but not platelets CRF × operative hypotension: many possible causes, consider glucocorticoid (aldosterone) deficiency in a pt who has taken steroids before Kidney transplant pt: require perioperative steroids

Bloody sputum: indicates active infection or lung cancer; requires a full work-up including CXR, CT scan, and bronchoscopy

Post-op hyperkalemia: check EKG for peaked T waves, Tx C BIG K DIe – calcium gluconate, bicarbinsulin-glucose, kayexalate, and dialysis

–––––––––––– HEPATOBILIARY ISSUES ––––––––––– ↑hct: either hypovolemia or polycythemia; if hypovolemic → delay until hydrated, if polycythemic → important to determine underlying cause

Acute cholecystitis: presents as fever, RUQ pain, WBC>15; get U/S → IVF, abx, lap chole w/in 72 hours

Obesity: higher risk of HTN, cardiovascular disease, post-op atelectasis, type 2 diabetes, DVTs; require DVT prophylaxis and aggressive post-op pulmonary care for preventing atelectasis

Child’s classification: stratifies risk of surgery in pts with liver failure; measures 3 labs (albumin, bilirubin, PT) and 3 clinical findings (encephalopathy, ascites, nutrition)

HTN: diastolic BP >110 is high risk of CV complications, β-blockers reduce overall risk

–––––––––––––– VALVULAR ISSUES –––––––––––––

Child’s group A: 0-5% mortality Child’s group B: 10-15% mortality

Atherosclerosis: can present as acute coronary syndome or peripheral vascular disease, always evaluate pt’s cardiac risk factors CV evaluation: EKG (and compare to old EKG), persantine thallium stress test, dobutamine echo

Child’s group C: >25% mortality; not good surgical candidates until Child’s status is improved Alcohol use: delay surgery until pt has undergone withdrawal, since post-op withdrawal syndrome has a high risk of morbidity/mortality

LBBB: indicates underlying ischemic heart disease RBBB: indicates significant pulmonary disease, but can be normal in up to 10% of pts Previous CABG: decreases cardiac risk if performed 6 months to 5 years before surgery, effect on cardiac risk unclear if >5 years

Liver failure: make sure the pt is in a compensated state, abstain from alcohol for 6-12 weeks, control ascites, normalize nutrition status and coagulation factors Pressure necrosis on hernia: high risk of rupture with a high mortality rate, requires urgent repair

Mitral stenosis: elevated LA pressure can lead to cor pulmonale (PH+RVH); management includes cards consult, prophyactic abx for endocarditis, can go to surgery if stable Mitral stenosis × CHF: high risk of mortality; requires extensive cardiac work-up, EKG, echo, and operative monitoring of cardiac status Aortic stenosis: Sx triad of angina, dyspnea, syncope, and high possibility of sudden death; requires cardiac work-up and operative monitoring Endocarditis prophylaxis: recommended for GI procedures, GU procedures, and HEENT procedures Cardiomyopathy: high risk of arrhythmias, CHF, heart failure, and sudden death; manage with cards consult and full cardiac work-up –––––––––––––––––– GI ISSUES ––––––––––––––––– Bowel prep: decreases fecal mass and bacterial content in the colon → prevents colon surgery

Surgery – Preoperative Care

complications; put pt on clears day before surgery, NPO at midnight, and give a cathartic agent GoLYTELY: an isotonic formula that causes no change in electrolyte or water balance; fluid remains in colon and causes a “volume washout” Fleet’s Phospho-Soda: a sugar-rich, hypertonic formula that works by drawing fluid into the GI tract; risks include dehydration, metabolic acidosis (loss of bicarb); avoid in diabetics Magnesium citrate: an osmotic agent that draws fluid into GI tract (mag is poorly absorbed); risks include dehydration and hypermagnesemia; avoid in renal failure –––––––––––––––– OTHER ISSUES ––––––––––––––– Anesthesia of choice: multiple factors involved, so it’s best to consult an anesthesiologist Local anesthesia: ↓systemic effects, ↑pain Spinal anesthesia: ↓pulmonary complications, ↓control over cardiac or vascular mechanisms General anesthesia: ↑physiologic control, ↑pulmonary complications, ↓HR/BP Aspirin use: stop aspirin use 7-10 days prior to surgery, will affect platelet aggregation NSAIDs use: stop NSAIDs 2 days prior, will affect platelet aggregation Cellulitis: active infections are associated with higher risk of post-op wound infections; delay surgery until infection is resolved

Surgery – Postoperative Care

––––––––––––––– POST-OP FLUIDS –––––––––––––– Post-op fluid management: replace blood lost during surgery + provide maintenance IVF + make up for fluid loss in drains/NG tubes/fistulas Surgical blood loss: replace in a 3:1 ratio with IVF (e.g. replace 500mL blood loss with 1.5L NS or LR) Maintenance IVF: administer D5½NS+KCl, using the 100/50/20 rule for daily fluid requirements, or 4/2/1 rule for hourly fluids Drains/NG tubes/fistulas: fluid loss should be replaced milliliter for milliliter with regard to specific electrolyte content Third space: fluid sequestered into ISF due to inflammation or injury, mobilized 3-5 days after recovery → requires decrease in IVF rate ––––––––– OPERATIVE COMPLICATIONS –––––––– Malignant hyperthermia: T>104 following anesthesia w/ high risk of myoglobinuria; Tx dantrolene, 100% O2, and cooling blankets Bacteremia: T>104 and chills within 1 hour of an invasive procedure; get blood Cx ×3 and start empiric abx Aspiration: complication of awake intubations; leads to sudden death, chemical pneumonitis, or secondary pneumonia

toilet and incentive spirometry (can develop into pneumonia on POD #3 if left untreated)

volume depletion (slow) or altered MS (rapid); give D5½NS to correct imbalance

UTI: Dx urinalysis and urine Cx, Tx abx

Hyponatremia: due to SIADH or isotonic fluid loss w/ free water resorption, presents as coma and convusions; Tx water restriction and LR/NS

Urosepsis: UTI + septic shock; presents as cloudy urine, fever, hypotension, and ∆mental status; Dx urinalysis and urine Cx, Tx empiric abx + IVF DVT: Dx doppler studies, Tx heparin Wound infection: Dx examine wound site for erythema and fluctuance; if cellulitis → abx only, if abscess → drain pus and BID dressing changes IV infection: Tx remove catheter and inflammation should resolve, all IV sites should be rotated every 4 days for prevention Suppurative phlebitis: infected thrombus at site of venipuncture; Tx remove catheter and surgical excision of infected vein to the first non-infected branch, leave wound open, and give IV abx GI fistula: causes leakage of GI contents from wound site; Tx NPO, TPN, and protect abdominal wall until body can heal itself Non-healing fistula: factors that prevent healing are FRIEND – foreign body, radiation, infection, epithelialization, neoplasm, distal obstruction Fistula × peritonitis: requires surgical exploration Fistula × abscess: requires percutaneous drainage

Aspiration management: prevent via NPO and antacids before intubating, Tx BAL and bronchodilators (steroids are useless) Tension PTX: complication of intubation in weak or traumatized lungs, presents as “difficulty to bag”, progressive hypotension and JVD; Tx emergent needle decompression + chest tube

Post-op chest pain: consider MI or massive PE MI: presents as chest pain +/- other classic signs; Dx CK-MB or troponin I, treat the complications Massive PE: presents as chest pain, hypoxia, and prominent JVD; Dx V-Q scan, Tx heparin → IVC filter if PE recur while anticoagulated

––––––––––– POST-OP COMPLICATIONS –––––––––– Normal urine output: at least 0.5-1 mL/kg/hr Post-op urine retention: presents as a need to void, but inability to do so; Tx straight cath at 6 shours post-op and Foley after 2nd straight cath

ARDS: presents as hypoxia due to septic shock, Tx intubation w/ high PEEP and permissive hypercarbia, then look for source of sepsis Delirium tremens: presents as hallucinations in an alcoholic POD #2-3, prevention is key and Tx is controversial (benzodiazepines if choice is given)

UOP = 0: most likely a kinked or plugged Foley UOP < 0.5: either fluid deficit (bleeding out) or acute renal failure; give a bolus of 500mL IVF and if UOP responds, then it’s due to fluid deficit Post-op hematuria: consider bladder overdistention, cancer, infection, kidney stones, trauma, prostatitis, and cyclophosphamide; get urology consult Post-op fever: consider the five Ws – wind (atelectasis POD #1), water (UTI POD #3), walking (DVT POD #5), wound infection (POD #7+), wonder drug (drug-induced fever) Atelectasis: partial lung collapse, Dx bilateral inspiratory crackles, prevent with pulmonary

Hypokalemia: due to diarrhea or vomiting, give K+ at a rate of <10 mEq/hr

Hepatic encephalopathy: presents as coma in a liver failure pt s/p TIPS due to NH4+ toxicity Wound dehiscence: presents as salmon-colored fluid soaking dressings s/p open laparatomy POD #5; stabilize wound site, surgical closure at a later date Evisceration: dehiscence + intestines spilling out; keep pt in bed and cover bowel w/ sterile dressings, emergency surgical closure necessary ––––––––––– FLUIDS & ELECTROLYTES –––––––––– Hypernatremia: every 3 Na+ over 140 indicates 1L water loss (e.g. Na+ 146 = 2L water loss), presents as

Hyperkalemia: due to renal failure, aldosterone blockers, or release from dead tissue (crush injury, ischemic bowel, etc.); Tx C BIG K DIe – calcium gluconate, bicarb-insulin-glucose, kayexalate, and dialysis Metabolic acidosis: pH<7.4 + HCO3<24, Tx correct underlying problem (e.g. fluid resuscitation) Metabolic alkalosis: pH>7.4 + HCO3>24, Tx KCl Respiratory acidosis: pH<7.4 + CO2>40 due to hypoventilation, Tx mechanical ventilation Respiratory alkalosis: pH>7.4 + CO2<40 due to hyperventilation caused by pain, fever, sepsis or early ARDS; Tx correct underlying problem

Surgery – Wound Healing

––––––––––––––– WOUND HEALING ––––––––––––– Primary intention: close approximation of wound edges via sutures or staples Primary intention timing: epithelialized by POD #2, max collagen in 5-7 days, avoid weight-lifting for 4-6 weeks, complete healing by 6 months (only 60-80% of original strength) Secondary intention: contamined wounds left open to prevent abscess formation; granulation tissue forms first, then contraction via myofibroblasts, then finally a delayed epithelialization Third intention: wound initially left open, then delayed primary closure afterwards Secondary/tertiary intention timing: much more delayed than healing by primary intention Healing growth factors: PDGF, TGF-β, FGF, EGF Suture knot: hard, knot-like structure below wound site; absorbable sutures will resolve with time, nonabsorbable sutures can be taken out under lido/epi Stitch abscess: infected suture that intermittently drains pus, should be taken out under lido/epi Incisional hernia: presents as bulging at wound site with increased abd pressure (e.g. coughing), needs to be repaired surgically Red/sensitive scar: assuming no wound infection, it could be completely normal; observe for 6 months before considering surgical revision Hypertrophic scar: raised scar within site of incision; observe until scar is stable, then steroids + excision Keloid: raised scar that extends beyond site of incision; will grow back if excised –––––––––––––– WOUND INFECTION –––––––––––– Wound infection: red and tender area on incision site; Tx drainage and BID wet-to-dry dressing changes, no antibiotics unless cellulitis is spreading Post-infection management: observation is slow and can result in contractions; other options include skin grafting (must have <105 bacteria per gram of tissue) or healing by third intention Wound types: clean, clean-contaminated, contaminated, infected Clean wounds: no entry into GI, GU, or respiratory tracts; <1% infection rate, Tx primary closure Clean-contamined wounds: enters GI, GU, or respiratory tract in a controlled manner; <10% infection rate, Tx primary closure Contaminated wounds: major wound contamination (e.g. bowel spillage or stab wounds); Tx secondary closure

Prophylactic abx: recommended for any cleancontaminated or contaminated procedures, insertion of prosthetic material, immunosuppression, or poor blood supply; give single dose 1 hour pre-op and single dose post-op

Surgery – Cardiothoracic Surgery

–––––––––––––––– LUNG CANCERS ––––––––––––––

–––––––––––––––– LUNG DISEASES ––––––––––––––

Coin lesion: solitary pulmonary nodule on CXR; DDx primary lung cancer, granuloma (TB or fungal), hamartoma, metastatic cancers

Pleural effusion: fluid build-up in pleural space, cancer in older pt until proven otherwise; DDx CHF, bronchogenic carcinoma, mesothelioma, empyema, pneumonia, TB effusions

Coin lesion management: first thing is always to get an older CXR for comparison studies → if suspicious, sputum cytology and CT scan

Pleural effusion management: get thoracentesis and culture pleural fluid, and a pleural biopsy

Off-bypass coronary surgery: grafting of ITA or GSV to coronary arteries without bypass in order to avoid complications of bypass (e.g. general inflammatory response); reserved for high-risk pts Dilated cardiomyopathy: dilation of myocardium causes systolic dysfunction leading to progressive dyspnea and fatigue, often preceded by viral URI DCM Px: 1/3 recover, 1/3 stay the same, 1/3 die

Benign coin lesions: calcification = granuloma, bull’s-eye shape, popcorn shape = hamartoma, air-crescent sign = aspergilloma, Southwest region = coccidioidomycosis, Ohio river valley = histoplasmosis Indeterminate coin lesions: resection indicated Malignant coin lesions: spiculations or 20+ packyear smoking = primary lung cancer, multiple lesions = metastatic cancer; resection indicated Lung cancer management: first thing is always CXR → if suspicious, sputum cytology and CT scan → if still suspicious, bronchoscopy and mediastinoscopy w/ biopsy (“tissue is the issue”) NSCLC staging: stage I is local, stage II involves hilar LN, stage III involves distal LN, stage IV is metastatic cancer NSCLC Tx: stage I/II → first get spirometry and V/Q scans to see if pt is a surgical candidate, then do pneumonectomy or sleeve lobectomy; stage III/IV → chemotherapy and radiation Surgery contraindications: FEV1 <800mL, mediastinal LN involvement, distal metastases SCLC staging: limited stage involves ipsilateral lung only, extensive stage involves contralateral lung SCLC Tx: chemotherapy and radiation Pancoast tumor: superior sulcus tumor at the apex of the lung; presents as Horner syndrome – ipsilateral ptosis, miosis, anhidrosis, flushing due to loss of sympathetic tone (invades superior cervical ganglia)

Spontaneous PTX: rupture of apical blebs in healthy young people causes sudden chest pain and dyspnea; Tx thoracostomy on water-seal drainage Recurrent/persistent PTX: indicated for thorascopic excision of blebs, and pleurodesis (either scraping or talc application) causing pleural adhesions Bilateral PTX: dangerous situation, indicated for pleurodesis to prevent future recurrences Empyema: collection of pus within pleural cavity; presents with cough, fever, chest pain, and pleural effusion on CT scan; MCC is Staph aureus Empyema Tx: initiate appropriate antibiotics, insert chest tube, evacuate pus collection, then re-expand the lung ––––––––––––––– HEART DISEASES –––––––––––––– Unstable angina: progressive ischemia of myocardium resulting in increasing angina at rest and an ischemic EKG pattern Unstable angina management: cardiac catheter and evaluate for potential revascularization, Tx bypass or angioplasty Ejection fraction: SV/EDV; normal EF is 67%, EF <50% is abnormal, EF <35% is high-risk for operative MI Coronary artery disease: blockage of coronary arteries, high risk of sudden death due to ventricular arrhythmias; Tx bypass or angioplasty

Bronchial adenoma: tumors that arise from within bronchi and cause obstruction; MC lung cancer in a nonsmoker under 30 y/o, Sx hemoptysis and atelectasis, Dx CT scan and bronchoscopy (beware of possibility of bleeding)

Heart transplant: remove donor heart and isolate in hypothermic cardioplegia solution, remove recipient heart on bypass, suture donor heart in recipient; MCC of death are infection due to immunosuppression, and accelerated coronary artery atherosclerosis Constrictive pericarditis: presents as dyspnea, hepatomegaly, and ascites due to diastolic failure; Dx cardiac cath shows “square root sign”, Tx surgical correction ––––––––––––– VALVULAR DISEASES –––––––––––– Valvular disease management: first detected on auscultation → get an echocardiogram Valve replacement: mechanical valves (durable but require anticoagulation) and porcine valves (nonthrombogenic but will deteriorate over time) Aortic stenosis: angina, dyspnea, syncope, and high risk of sudden death; Dx harsh mid-systolic murmur, MCC is congenital bicuspid aortic valve with dystrophic calcification, Tx valve replacement when symptomatic Aortic regurgitation: presents as loud, blowing diastolic murmur and bounding pulses; if chronic → valve replacement when symptomatic, if acute → emergent valve replacement and long-term abx

Left main disease: blockage of only LCA, worst Px Three-vessel disease: blockage of LAD/RCA/LCX

Pancoast tumor Tx: two stages – irradiation for 6 weeks to shrink tumor, then surgical resection

DCM Tx: β-blockers will improve heart function, but heart transplant is indicated (requires chronic immunosuppression)

Mitral stenosis: presents as dyspnea and fatigue, caused by rheumatic fever, results in cor pulmonale (RVH+PH) and AFib; Tx valve repair or replacement

Coronary artery bypass: open via median sternotomy, isolate internal thoracic artery (best choice) or greater saphenous vein, put on bypass and stop the heart, sew grafts to arteries, restart the heart and close up

Mitral regurgitation: presents as dyspnea and fatigue, caused by MVP, Dx high-pitched holosystolic murmur; Tx annuloplasty (preferred) or valve replacement

CABG mortality: 3% overall, greater in high-risk pts but they benefit the most from the surgery

Mitral prolapse: eccentric closure of mitral leaflets; common in women, precedes severe disease in men

Bronchial adenoma Tx: lobectomy is curative Mesothelioma: cancer arising from pleural mesothelium, shipyards and asbestos exposure are risk factors, Dx CT scan shows thick pleural walls Mesothelioma Px: not responsive to medical therapy, most pts have <1 year to live w/o surgery Mesothelioma Tx: extrapleural pneumonectomy is curative, but high rate of morbidity/mortality

Coronary angioplasty: insertion of stent to prolong patency of clogged coronary arteries, 33% rate of restenosis in 1 year Cardioplegia solution: solution used to stop heart mid-diastole to protect it from ischemia and provide a motionless field; often used with hypothermia to prolong time of safe ischemia (up to 2.5 hours)

––––––––––– MEDIASTINAL DISEASES ––––––––––– Anterior mediastinal mass: thymomas, lymphomas, teratomas, other metastatic germ cell neoplasms Thymoma: often presents with progressive muscle weakness secondary to myasthenia gravis, Tx surgical removal via median sternotomy Lymphoma: Tx radiation and chemotherapy

Surgery – Cardiothoracic Surgery

Teratoma: contains hair and teeth, Tx surgical removal via median sternotomy Middle mediastinal mass: lymphomas, bronchogenic cysts, pericardial cysts Bronchogenic cysts: develop from foregut remnants, Tx surgical removal via thoracotomy Pericardial cysts: typical water bottle appearance, Tx surgical removal via thoracotomy Posterior mediastinal mass: neurogenic tumors (MCC is neurilemoma) Neurilemoma: dumbbell-shaped tumor found adjacent to vertebral bodies, develops from nerves and nerve sheathes, Tx surgical removal via thoracotomy

Surgery – Vascular Surgery

–––––––––––––– CAROTID DISEASES ––––––––––––– Atherosclerosis: systemic disease that has multiple manifestations (stroke, TIA, CAD, MI, mesenteric ischemia, AAA, PVD); presence of any one of these should raise suspicion for the others Stroke: a neurologic deficit that doesn’t resolve within 24 hours, Tx t-PA only within 3 hours Stroke management: carotid duplex study, observation for improvement; CEA is not indicated until pt has stabilized Transient ischemic attack: brief neurologic deficit that fully resolves within 24 hours; due to thromboembolus from internal carotid arteries

Ankle-brachial index: ratio of BP in arm vs. leg; ABI >1.0 is normal, ischemic ABI is 0.6-0.8 (claudication) or 0.3-0.5 (rest pain) Doppler tracing: normally triphasic due to systolic flow → elastic recoil → diastolic flow; ischemic signal is either biphasic (mild) or monophasic (severe) Claudication: exercise-induced ischemia that causes reversible calf pain, MCC is an atherosclerotic SFA Claudication management: if mild → not indicated for surgery, so exercise and lifestyle changes are recommended; if severe → get Doppler tracing, then arteriogram to localize Claudication Px: 1/3 improve on a non-op exercise program, 1/3 stay the same, 1/3 get worse

TIA management: physical exam (check carotid bruids, neuro, cardiovascular) + carotid duplex; Tx aspirin or carotid endarterectomy

Aortoiliac stenosis: presents as triad of claudication + absent femoral pulse + impotence

TIA × amaurosis fugax: emboli from carotid travels to retina causing transient blindness; Dx fundoscopic exam reveals Hollenhorst plaque, a bright shiny spot in a retinal artery

Aortoiliac stenosis Tx: depends on case; bilateral loss of femoral pulse → aortofemoral bypass graft, single segment iliac stenosis → angioplasty, high risk pt → lifestyle changes

TIA × aphasia: emboli from left carotid travels to speech center located in left hemisphere

Severe claudication: presents as claudication + rest pain or foot ulcers, common in diabetics; get a vascular work-up and arteriogram to determine level of occlusion, and assess general medical status

CEA: indicated for >70% carotid stenosis with either neurologic sx or asymptomatic bruits; complications include 1-3% risk of perioperative stroke, or injury to facial, vagus, or hypoglossal nerves Post-CEA management: start aspirin, encourage lifestyle modifications (e.g. diet and exercise, quit smoking) since patient is still high-risk for MI Asymptomatic carotid bruit: get a carotid duplex study, indicated for CEA if >70% stenosis –––––––––––– PERIPHERAL DISEASES ––––––––––– Subclavian steal syndrome: presents as nothing at rest, but arm claudication and CNS sx with arm activity due to subclavian artery atherosclerosis; Dx arteriogram, Tx bypass surgery Arterial embolus: presents as the 6 P’s – pain, pallor, parasthesias, poikilothermia, pulselessness, paralysis; clot source is usually Afib or recent MI Embolus Tx: requires urgent revascularization within 6 hours; give heparin and go to OR for balloon catheter embolectomy +/- fasciotomy Embolus post-op: start warfarin for anticoagulation, then get CT scan or aortography to search for source of emboli Compartment syndrome: revascularization of acutely ischemic limb results in ischemia-reperfusion injury, causing muscle edema within fascial compartment and the 6 P’s Compartment syndrome Tx: fasciotomy

AAA: presents as painless pulsatile abdominal mass; management is getting ultrasound and CT scan, then elective graft repair if aorta is >5 cm AAA repair post-op: major fluid shifts (third-space loss on POD#1/2, third-space mobilization on POD#3), cardiac problems due to aortic clamping, and impotence due to damage of hypogastric circulation or autonomic nerves around IMA Ruptured AAA: presents as pulsatile mass, back and abdominal pain, and hypotension; if unstable → OR, if stable → get CT scan or ultrasound, then OR Ruptured AAA repair: clamp aorta at level of diaphragm to stop bleeding, then proceed with repair; 80% risk of death by bleeding out in the OR AAA repair × bloody diarrhea: indicates ischemic colitis due to interrupted IMA; Dx sigmoidoscopy, Tx bowel rest if limited to mucosa, colectomy and colostomy if full-thickness involvement AAA repair × delayed fever: indicates vascular graft infection via S. aureus or S. epidermidis; Dx CT scan, Tx graft removal, debridement, and IV antibiotics AAA repair × UGI bleed: indicates aortoduodenal fistula, usually a small bleed followed 1-2 days later by massive bleeding; Dx CT scan, Tx graft removal and GI repair

SFA stenosis Tx: reverse GSV to SFA graft Iliac stenosis Tx: surgical revascularization or balloon dilation SFA + iliac stenosis Tx: both of the above, either at the same time or sequentially (iliac first) SFA + popliteal stenosis Tx: femoropopliteal bypass to the best artery continuous with the foot, failure likely in distal and severe disease Multiple obstructions Tx: reconstruction may not be possible, limb amputation indicated Bypass pre-op: 10% risk of MI, arrhythmias, or heart failure; requires evaluation of cardiac status (get dipyridamole-thallium scintigraphy to rule out CAD) Pre-op reveals <30% ejection fraction: high risk of post-op heart failure Pre-op reveals CAD: cancel or delay surgery, perform a less invasive procedure, pre-op CABG or PTCA, or intensive intraoperative monitoring

Mesenteric ischemia: presents as postprandial abd pain, weight loss, and multiple abd bruits due to atherosclerosis of celiac trunk or SMA Mesenteric ischemia management: Dx mesenteric angiogram, Tx revascularization; follow-up with aspirin and evaluation for other atherosclerotic diseases Aortic dissection: presents as acute onset tearing chest/back pain due to severe HTN (200/140), CXR shows widened mediastinum Aortic dissection management: Dx MRI, spiral CT, transesophageal echo, or arteriography; if ascending aorta → go to OR for surgical repair, if descending aorta → β-blockers –––––––––––––– VENOUS DISEASES ––––––––––––– Deep venous thrombosis: presents as acute onset dull leg pain, unilateral swelling, and Homans’ sign DVT risk factors: Virchow’s triad – stasis, endothelial damage, and hypercoagulability

Pre-op reveals recent MI: delay surgery for 3 mo Bypass post-op: daily duplex studies to check for graft stenosis, give aspirin, educate on lipid control and foot care; MCC death is CAD Trash foot: post-op embolization of atherosclerotic debris following bypass results in cyanotic toe; Tx heparinization of clot and long-term aspirin use –––––––––––– ABDOMINAL DISEASES –––––––––––

DVT management: Dx duplex ultrasound, Tx therapeutic heparin or LMWH, followed by longterm warfarin therapy (follow INR) Post-thrombotic syndrome: occurs in 10% of DVT pts, presents as severe leg edema and ulceration around ankle area due to chronic venous HTN

Surgery – Vascular Surgery

Post-thrombotic syndrome management: prevention via chronic use of support hose, heal ulcers if they’ve already developed DVT prophylaxis: indicated if pt is at risk for DVT; includes leg compression devices and subcutaneous low-dose heparin DVT prophylaxis for hip fx: fondaparinux and leg compression devices Pulmonary embolus: presents as acute onset chest pain, dyspnea, and hyperventilation (↓PCO2), due to DVT embolization into lung → wedge-shaped area of lung infarction, S1Q3T3 on EKG PE management: get EKG to rule out MI, ABGs (shows ↓PCO2), CXR, and pulse oximeter; mismatch on a V/Q scan is diagnostic, Tx identical to DVT Tx Recurrent PE: due to failure of heparin therapy; indicated for IVC interruption with a metal filter Anticoagulation: therapeutic/high-dose heparin or LMWH for Tx DVT/PE, low-dose for prophylaxis; IVC filters when anticoagulation fails or is contraindicated Anticoagulation × HIT: rare heparin side-effects include thrombocytopenia and paradoxical arterial clots, d/c heparin immediately Anticoagulation × skin necroses: rare side-effect of warfarin therapy, start warfarin along with heparin to prevent this from happening Anticoagulation × UGI bleed: life-threatening condition that requires immediate d/c, give pt a metal filter instead for PE prophylaxis Phlegmasia cerulea dolens: presents as acute onset leg edema with pain and cyanosis due to venous outflow obstruction, high risk of nerve damage and venous gangrene PCD management: elevate leg and immediate anticoagulation, then order duplex ultrasound and pelvic CT scan to confirm the Dx –––––––––– OTHER VASCULAR DISEASES ––––––––– Temporal arteritis: presents as severe, unilateral headache, visual changes, and nodularity of temporal artery; give high-dose steroids right away to prevent blindness

Surgery – Upper GI Surgery

–––––––––––– ESOPHAGEAL CANCERS ––––––––––– Dysphagia: management includes barium swallow and esophagoscopy w/ biopsy; DDx achalasia, Zenker diverticulum, esophageal cancers, strictures Esophageal cancer: SCC in upper 2/3 due to cigs and EtOH, adenocarcinoma in lower 1/3 due to Barrett’s, Sx progressive dysphagia and weight loss EC management: esophagoscopy and biopsy, then staging via endoscopic ultrasound and CT scan, then specific Tx EC staging: stage I invades submucosa only, stage II invades muscularis +/- LN, stage III invades adventitia + adjacent structures, stage IV is metastatic EC prevalence: adeno MC in US, SCC elsewhere EC Tx: upper 1/3 – chemo and radiation only; middle 1/3 – chemo and radiation to shrink the tumor, then esophagectomy; lower 1/3 – esophagectomy and proximal gastrectomy; never operate on stage IV cancer Advanced esophageal cancer: Sx severe dysphagia and chronic cough (due to aspiration from TE fistula), management is palliative care b/c surgery won’t help

Pain × PMHx: gallstones or alcoholism = acute pancreatitis (order amylase/lipase levels), NSAIDs or steroid use = PUD Esophageal varices: present as UGIB due to portal HTN, often alongside coagulopathy (liver failure) EV management: band the bleeding varices, correct any coagulopathy, IV octreotide to lower portal pressure → if bleeding continues, repeat endoscopic banding → if bleeding continues, TIPS or gastric balloon tamponade EV follow-up: β-blockers to lessen chance of rebleeding; good liver function → elective TIPS, bad liver function → liver transplant Mallory-Weiss syndrome: presents as UGIB due to retching lacerating the lower esophagus, bleeding usually stops spontaneously Boerhaave syndrome: presents as epigastric pain and fever due to retching perforating the esophagus; Dx contrast swallow, Tx emergent surgical repair Instrumental perforation: presents as retrosternal pain, fever, and pneumomediastinum s/p upper GI endoscopy; Dx contrast swallow, Tx surgical repair GERD: presents as heartburn, regurgitation, waterbrash (sour taste), dysphagia, cough

––––––––––– ESOPHAGEAL DISEASES ––––––––––– Zenker diverticulum: pulsion diverticulum that develops at upper esophagus due to abnormal coordination of cricopharyngeal constriction; Sx dysphagia, regurgitation, and bad breath Zenker management: Dx barium swallow, Tx cricopharyngeus myotomy Traction diverticulum: diverticulum at middle esophagus due to LN traction, indicates cancer Esophageal motility disorders: achalasia (only one treated surgically), nutcracker esophagus, spasms, hypertensive LES Achalasia: hypertonic and non-relaxing LES w/ poorly relaxing esophagus, Sx dysphagia of liquids > solids Achalasia management: Dx bird’s beak on barium swallow and ↑LES pressure on manometry, Tx Heller myotomy Nutcracker esophagus: painful swallowing due to high amplitude action potentials, Tx nifedipine Diffuse esophageal spasms: uncoordinated 3° peristalsis, Tx medically Hypertensive LES: high LES pressure at baseline but relaxes with swallow, Tx medically Acute epigastric pain: DDx acute pancreatitis, GERD, PUD (gastric ulcers or duodenal ulcers), cholelithiasis, gastroenteritis

GERD Tx: PPIs → if it persists after six weeks, do EGD w/ biopsy to see what’s going on Normal EGD: PPIs or elective lap Nissen Esophagitis: multiple, nonulcerating erosions in stomach; mild to moderate esophagitis → PPIs for 8-12 weeks, severe esophagitis → lap Nissen, uncontrollable bleeding esophagitis → subtotal gastrectomy Barrett esophagus: intestinal metaplasia of esophageal epithelium; no dysplasia → Tx PPIs or lap Nissen; low-grade dysplasia → Tx lap Nissen + annual surveillance; high-grade dysplasia → Tx esophagectomy Lap Nissen fundoplication: wraps fundus of stomach around LES to keep it in abdominal cavity (must check for intact esophageal peristalsis first); contraindicated in morbidly obese (gastric bypass instead) Hiatal hernia: hernia from abdominal cavity, through diaphragm, into chest cavity Type 1 hiatal hernia: sliding hernia, risk of reflux esophagitis, Tx PPIs Type 2 hiatal hernia: paraesophageal hernia, risk of incarceration/strangulation, Tx surgical repair Type 3 hiatal hernia: presence of both types 1+2, Tx surgical repair –––––––– GASTRIC/DUODENAL DISEASES –––––––– Peptic ulcer disease: gastric ulcers, duodenal ulcers

PUD surgery indications: intractability, perforation, obstruction, bleeding Duodenal ulcers: caused by ↑acid secretion; most commonly in 1st part of duodenum, DU in 2nd-4th part indicates Zollinger-Ellison syndrome (gastrinoma) DU types: posterior ulcers bleed due to gastroduodenal artery, anterior ulcers perforate DU Tx: triple therapy → if ulcer persists, surgery is indicated (HSV > TV+P >> TV+A), also get serum gastrin levels to rule out Z-E syndrome Perforated DU: CXR shows free air under diaphragm; use omentum to patch the ulcer (Graham patch), then stop acid w/ PPIs or HSV Perforated DU × sepsis: complete Graham patch as soon as possible, give PPIs and IV abx, then monitor in ICU and plan surgery for a later date Bleeding DU: due to posterior ulceration into GDA; Tx oversew the ulcer, then stop acid w/ PPIs Gastric ulcers: caused by ↓mucosal protection; type I – lesser curvature at incisure, type II – duodenum and stomach, type III – pylorus, type IV – GE junction GU Tx: PPIs → if ulcer persists after six weeks, do endoscopy and multiple marginal biopsies for possibility of gastric cancer; if ulcer persists after 18 weeks, surgery is indicated GU surgery: wedge resection or distal gastrectomy (due to possibility of cancer), TV+P for types II and III due to ↑acid production Bleeding GU: Tx excision rather than oversewing Gastric cancers: lymphoma, adenocarcinoma, GIST (e.g. sarcomas and lipomas) Gastric adenocarcinoma: often spreads to left supraclavicular (Virchow’s) node and ovaries; Tx proximal → total gastrectomy, if distal → distal gastrectomy w/ anastomosis; take out D1 LN at lesser curvature Linitis plastica: infiltrating carcinoma with desmoplastic reaction causing stomach to look fixed and rigid; Tx total gastrectomy w/ splenectomy Gastric lymphoma: first determine cancer stage (CT scan, LN biopsy, and bone marrow Bx); Tx partial thickness → radiation, full thickness → surgical resection GIST: any soft tissue tumor of stomach; Tx wedge resection w/ 1 cm negative margins (no LN) Gastric varices: present as UGIB due to portal HTN, Tx uncontrollable bleeding w/ TIPS or splenectomy instead of banding

Surgery – Pancreatic/Hepatic Surgery

––––––––––––– GB/BILIARY DISEASES ––––––––––––

–––––––––––––––––– JAUNDICE –––––––––––––––––

Biliary disease progression: cholelithiasis → biliary colic → acute cholecystitis; choledocholithiasis → ascending cholangitis or gallstone pancreatitis

Jaundice: elevated bilirubin and yellowing of skin; three types – hemolytic, obstructive, hepatocellular

Cholelithiasis: presents as nausea, vomiting, RUQ pain w/o fever; only 15-20% are symptomatic Cholelithiasis in pregnancy: manage non-op if possible (hydration and pain meds), elective lap chole can be done after delivery Biliary colic: fatty meal → CCK release → gall bladder contraction against non-lodged stone resulting in transient RUQ pain for <6 hours; labs are usually normal if episode has passed Cholecystitis: presents as fever, WBC>15, RUQ pain >6 hours; MC bacteria are E. coli, Bacteroides fragilis, Klebsiella, Enterococcus Cholecystitis management: Dx abdominal U/S, order CBC and LFTs, Tx lap chole within 72 hrs

––––––––––––––– LIVER DISEASES –––––––––––––– Hemolytic jaundice: ↑bilirubin (direct <20%), search for what’s killing the RBCs Hepatocellular jaundice: ↑bilirubin (direct 20-50%) and ↑AST/ALT, consider HBV/HCV and alcoholism Obstructive jaundice: ↑bilirubin (direct >50%) and ↑alk phos, caused by CBD stones and cancers Painless jaundice: caused by biliary obstructive tumors (ampullary cancer, duodenal cancer, cholangiocarcinoma, pancreatic adenocarcinoma) Painless jaundice management: Dx CT scan then ERCP, Tx Whipple if no mets or local invasion Painless jaundice × occult bleed: indicates ampullary cancer, get CT scan then Whipple –––––––––––– PANCREATIC DISEASES –––––––––––

Cholecystitis in elderly: elderly pts respond to sepsis with hypothermia and ↓WBC Cholecystitis antibiotics: ciprofloxacin (Cipro) and metronidazole (Flagyl) to cover GNR and anaerobes; abx not indicated for cholelithiasis Cholecystectomy indications: symptomatic cholelithiasis, acute cholecystitis, and cholangitis; do not operate on asx stones Cholecystectomy complications: nicking the CBD (jaundice) or right hepatic artery (hepatitis) Post-op biliary leak: presents as Charcot’s triad; get an U/S and HIDA scan → Tx biliary drainage and temporary stent during ERCP Post-op obstruction: presents as Charcot’s triad due to stricture or retained stone; get an U/S and HIDA scan → Tx biliary drainage and choledochojejunostomy Choledocholithiasis: presents as transient jaundice and ↑alk phos; Dx U/S shows dilated bile ducts +/ERCP, Tx lap chole w/ CBD exploration Acute cholangitis: presents as Charcot’s triad (jaundice, fever, RUQ pain) or Reynold’s pentad (shock, ∆MS) due to choledocholithiasis Acute cholangitis management: IVF, antibiotics, and U/S → ERCP to decompress biliary tree → finally lap chole w/ CBD exploration GB polyps: <2 cm observe, >2 cm take it out due to risk of adenocarcinoma GB adenocarcinoma: presents as mass in GB fossa; Dx CT scan, Tx open chole + hilar LN resection + liver resection w/ negative margins Porcelain GB: dystrophic calcification of GB has 50% risk of adenocarcinoma, take it out

Chronic pancreatitis: presents as constant epigastric pain, steatorrhea, and diabetes in a chronic alcoholic; Tx insulin and pancreatic enzyme replacement

Pancreatic head mass: check for metastases, then perform Whipple if no mets Pancreatic adenocarcinoma: presents as obstructive jaundice, get a CT scan; cancer in head → Tx Whipple, in body or tail → distal pancreatectomy, mets or local invasion → palliative care (no surgery) Acute pancreatitis: presents as epigastric pain boring through to the back w/ ↑lipase/amylase; amylase levels do not correlate with severity Pancreatitis causes: I GET SMASHED – Idiopathic, Gallstones (#1), EtOH (#2), Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hypertriglyceridemia (#3), Hypercalcemia, ERCP, Drugs Edematous pancreatitis: get amylase/lipase, then NPO, IVF, pain meds Hemorrhagic pancreatitis: presents as MSOF, ARDS, and hemodynamic instability; send to ICU for resuscitation and serial CTs Ischemic pancreatitis: Dx no blood flow to pancreas on contrast CT, Tx IV abx and resection Gallstone pancreatitis: if amylase returns to normal → lap chole + cholangiogram; if complicated → ERCP to remove stone Pancreatic abscess: presents as septic shock 2 weeks after acute pancreatitis; Dx dynamic CT scan, Tx perc drain + antibiotics Pseudocyst: abdominal pain and early satiety 5 weeks after acute pancreatitis, Tx cystogastrostomy only if it’s symptomatic and has been present for 6+ weeks (must get Bx w/ frozen epithelial section and see no epithelial lining before the ostomy since epithelium indicates cancer)

Liver cyst: simple cyst, leave it alone Echinococcal cyst: multilocular cyst w/ calcified walls due to parasite Echinococcus granulosus; inject hypertonic saline inside cyst and carefully excise it Liver abscess: multiple/small bacterial abscesses → IV antibiotics; single/large bacterial abscess → perc drain; amebic abscess (Mexicans) → metronidazole Liver cancers: hepatic adenoma, focal nodular hyperplasia, hemangioma, hepatoma Hepatic adenoma: often presents as hypovolemic shock and distended abdomen, related to OCPs and anabolic steroid abuse; Tx d/c OCP → if it persists, resect due to possibility of rupture FNH: Dx central stellate scar or sunburst pattern on CT scan, no OCP relationship, leave alone even if symptomatic Hemangioma: leave alone even if symptomatic, never spontaneously rupture, do not needle biopsy due to possibility of rupture Hepatoma: presents as vague RUQ pain and mass related to HBV/HCV and cirrhosis w/ ↑αFP; Dx CT scan then Tx resection w/ negative margins indicated as long as there’s no mets Portal HTN: Sx esophageal varices, caput medusa, hemorrhoids; Tx TIPS (connect portal vein to hepatic vein to relieve pressure) as a “bridge to liver txp”

Surgery – Lower GI Surgery

––––––––––– SMALL BOWEL DISEASES ––––––––––– Small bowel obstruction: presents as colicky abd pain, nausea/vomiting, and constipation; MCC are adhesions from previous surgery and hernias SBO management: get KUB → Dx air-fluid levels and dilated loops; Tx NPO, NG suction, IVF, and initially observation SBO × electrolyte imbalance: “hypokalemic, hypochloremic metabolic alkalosis” due to emesis SBO × bloody diarrhea: indicates obstructive tumor or ischemic bowel; Dx sigmoidoscopy → observe if mucosal, resection if full-thickness SBO × flatus: indicates partial SBO since gas can get through, more likely to resolve w/o surgery SBO × diarrhea: indicates partial SBO due to fecal impaction and severe constipation

Mesenteric ischemia × peritonitis: presents as rebound tenderness, ↑WBC, fever, or metabolic acidosis due to necrotic bowel; ex lap indicated Mesenteric ischemia × AFib: indicates emboli shooting from left atrium to celiac trunk or SMA Mesenteric ischemia × ↑hct: polycythemia due to severe dehydration requires IV fluid resuscitation Mesenteric ischemia × CHF: ischemia may be secondary to a low-flow, nonocclusive state; indicated for mesenteric vasodilation and improve cardiac output Mesenteric ischemia × aortic dissection: dissected aorta can occlude mesenteric vessels; Dx angiography, Tx surgical repair Mesenteric ischemia × ↓BP: either ischemic bowel causing septic shock, or hypotension causing low-flow, nonocclusive ischemia

SBO × inguinal hernia: requires urgent hernia repair to relieve strangulation

Left colon necrosis: bowel resection → anastomosis if stable, otherwise colostomy and Hartmann pouch

SBO × melanoma: melanoma is the MC tumor that metastasizes to intestine, surgery indicated since these don’t resolve spontaneously

Long segment necrosis: bowel resection → small bowel syndrome requiring chronic TPN or transplant

SBO × other cancers: surgery indicated since these don’t resolve spontaneously SBO × peritonitis: presents as rebound tenderness, ↑WBC, fever, or metabolic acidosis due to necrotic bowel; indicated for ex lap SBO × adhesions: indicated for ex lap → lysis of adhesions SBO × closed loop obstruction: usually due to adhesive band occluding two segments of bowel; indicated for ex lap → lysis of adhesions, resection of any dead bowel, and “second look” operation if bowel viability is indeterminate SBO × pneumoperitoneum: indicates perforation due to ischemic or overdistended bowel; indicated for ex lap → dead bowel resection Nicked bowel during LOA: small hole → primary repair, large or multiple holes → bowel resection; high risk of leakage and EC fistula formation Uncertain about SBO: get an upper GI series w/ small bowel follow-through, barium contrast will stop at site of obstruction if SBO exists Mesenteric ischemia: presents as postprandial abd pain, weight loss, SBO, and multiple abd bruits usually due to atherosclerosis of celiac trunk or SMA Mesenteric ischemia management: Dx mesenteric angiogram, Tx revascularization; follow-up with aspirin and evaluation for other atherosclerotic diseases

Short segment necrosis: bowel resection → anastomosis, “second look” operation if bowel viability is indeterminate Small punctate necroses: indicates multiple small emboli or low-flow state; bowel resection → anastomosis, “second look” operation if bowel viability is indeterminate Bowel ischemia but no necrosis: try to revascularize the bowel via removing or bypassing the occlusion Low-flow but no necrosis: non-op management of hemodynamic status, surgery should be avoided

Crohn’s × rectal disease: rare, indicated for subtotal colectomy and ileostomy Ulcerative colitis: inflammatory disease involving rectum and continuous proximal extension, Bx shows mucosal involvement + crypt abscesses + pseudopolyps, Dx lead pipe sign on CT scan UC management: IV steroids and 5-ASA (sulfsalazine) for acute flare-ups, annual colonoscopy for possibility of cancer UC × severe dysplasia: total proctocolectomy, ileal pouch formation, and ileo-anal anastomosis; no further cancer surveillance needed Pouchitis: presents as fever, bloody diarrhea, and pain on defecation s/p ileal pouch formation for UC; Tx metronidazole Toxic megacolon: presents as fever, bloody diarrhea, pain, and abdominal distention in a pt w/ UC TM management: get KUB for confirmation, then NPO, IVF, NG suction, IV steroids and abx; improves → no surgery, stays the same or gets worse → surgery necessary TM × perforation: shows free air on upright CXR, indicated for total colectomy and ileostomy w/ Hartmann pouch TM × impending perforation: shows pneumatosis on CT scan, indicated for surgery (see above) ––––––––––––––– APPENDICITIS ––––––––––––––– Appendicitis: presents as RLQ pain, low grade fever and leukocytosis; MCC lymphoid hyperplasia Appendicitis management: get CT scan or U/S (U/S is cheaper); if uncomplicated → app’y, if abscess (↑↑fever/↑↑WBC) → perc drain, interval app’y

––––––– INFLAMMATORY BOWEL DISEASE ––––––– Inflammatory bowel disease: Crohn’s disease and ulcerative colitis; presents as crampy abdominal pain, bloody diarrhea, and recent weight loss IBD management: colonoscopy to determine if it’s UC, Crohn’s, or something else → abdominal CT scan for confirmation of IBD Crohn’s disease: inflammatory disease involving full GI tract with skip lesions (terminal ileum is MC site), Bx shows full thickness + noncaseating granulomas + creeping fat, Dx terminal ileum string sign on CT scan Crohn’s management: IV steroids and 5-ASA (sulfsalazine) for acute flare-ups Crohn’s × SBO: due to stenotic terminal ileum; manage with NPO, TPN, and observation → if it fails to resolve, surgical stricturoplasty indicated Crohn’s × perianal disease: metronidazole

Appendicitis in kids: children with appendicitis present more often with a ruptured appendix Appendicitis in elderly: older pts usually don’t have classic presentation of appendicitis, but rather vague abdominal complaints, sepsis, altered MS, or failure to thrive Appendicitis in pregnancy: enlarged uterus can push appendix upwards → RUQ pain; appy can be performed safely w/o risk to mom or child RLQ pain × dysuria: indicates appendicits, UTI, or appendiceal abscess next to bladder RLQ pain × minimal dysuria: likely appendicitis RLQ pain × hematuria: indicates severe UTI or a kidney stone RLQ pain × h/o PID: could be appendicitis, recurrent PID, or an ectopic; PID confirmed by cervical or adnexal tenderness, or cervical discharge (get gyn consult and stain discharge)

Surgery – Lower GI Surgery

RLQ pain × h/o gastroenteritis: could be appendicitis but likely gastroenteritis RLQ pain × R pelvic tenderness: likely retrocecal appendicitis, go to the OR RLQ pain × BPH Sx: likely bladder outlet obstruction due to enlarged prostate, Tx Foley catheter RLQ pain × h/o IBD: IBD can present similarly to appendicitis, get colonoscopy and CT scan and manage appropriately RLQ pain × crampy pain/diarrhea: indicates IBD, constipation, or cancer rather than appendicitis RLQ pain × corticosteroids: steroids can mask all Sx of inflammation, be cautious since most steroid pts won’t present until perforation occurs App’y findings: inflamed appendix, perforated appendix, normal appendix, inflamed cecum, fecalith, carcinoid tumor, other tumors Inflamed appendix: take it out Normal appendix: take it out anyways unless cecum is inflamed, check other areas for abnormalities (terminal ileum for Crohn’s or Meckel’s, perforated gastric or duodenal ulcer, ovaries, etc.) Inflamed appendix/cecum: take them both out via right colectomy

Diverticulitis complications: abscess (Tx perc drain), obstructions, fistula (pneumaturia or fecaluria, Tx surgical separation of colon from bladder) ––––––––––– LARGE BOWEL DISEASES –––––––––– Pseudomembranous colitis: watery diarrhea and ↑↑WBC due to clindamycin-related C. diff overgrowth; Dx stool toxin or colonoscopy, Tx stop clindamycin and start metronidazole or vancomycin

Perforated appendix: take it out, I/D the abscess, and leave a drain in to prevent wound infection Appendiceal carcinoid: <2cm appendectomy, >2cm right hemicolectomy; can present w/ carcinoid syndrome due to liver metastasis Terminal ileal carcinoid: resection and check the rest of bowel for other carcinoids; can present w/ carcinoid syndrome due to liver metastasis ––––––––––––––– DIVERTICULITIS ––––––––––––––– Diverticulosis: presents as LGIB, 85% stop spontaneously, may develop into diverticulitis Diverticulitis: presents like left-sided appendicitis, get CT scan and manage non-op if possible (IVF, NPO, IV antibiotics) even with signs of LLQ peritonitis

Polyps: tubular/pedunculated have a stalk, sessile/villous are flattened; progression from polyp to cancer takes ~10 years Pedunculated polyp: polypectomy w/ biopsy → if dysplasia is not localized to head of polyp, then segmental colectomy Sessile polyp: biopsy → if any high grade dysplasia, then colectomy Benign polyps: juvenile, Peutz-Jeghers, inflammatory, hyperplastic; leave these alone Colon cancer: left side obstructs, right side bleeds; Dx “apple core” lesion on barium enema, 99% garden variety (∆MCC, ∆DCC, ∆RAS, ∆p53) and 1% familial inheritance (FAP, HNPCC)

Stage III: LN involvement, Tx colectomy and chemo (5-FU + levimasole, only stage that chemo will improve survival rates) Stage IV: distal metastasis, Tx palliative chemo unless there is a resectable mass in liver or lung Colectomy: requires 12-14 LN removal for adequate procedure; requires pre-op bowel prep and abx Post-op wound infection: open fascia to make sure it’s intact, then local wound care Post-op feculent leak: indicates anastomotic leak, get abd CT scan to check for undrained collection, then NPO/IVF is sufficient for most cases Post-op feculent vomit: indicates either post-op ileus (due to leakage) or mechanical obstruction; Tx NPO/IVF and NG tube Post-op abscess: Dx CT scan, Tx perc drain

Diverticulitis f/u: colonoscopy to confirm presence of diverticula and absence of cancer Surgery indications: uncontained perforation that presents as 4-quadrant peritonitis or pneumoperitoneum (air under diaphragm) Elective surgery indications: recurrent episodes (2x in 6 months, 3x in a year)

HNPCC: ∆MLH or ∆MSH mismatch repair genes → microsatellite instability, Tx total abdominal colectomy + ileorectal anastomosis Colon cancer recurrence: f/u with colonoscopy, CEA marker, CXR for lung mets, and LFTs for liver mets –––––––––––– ANORECTAL DISEASES –––––––––––

Colon cancer screening: anyone above 50 y/o should get yearly fecal occult blood test (flex sig and colonoscopy also used, but less commonly)

Stage I/II: localized cancer, Tx colectomy Inflamed appendix + fecalith: confirms appendicitis

FAP pts should always get upper endoscopy and remove the duodenal polyps

Post-op constipation: indicates either stricture or cancer recurrence; Dx colonoscopy FAP: ∆APC on chromosome 5p, autosomal dominant, presents as >100 polyps in colon; Tx either total proctocolectomy, or total abdominal colectomy + strip anal mucosa + ileoanal anastomosis Gardner syndrome: FAP + polyps in stomach (not premalignant) and duodenum (premalignant);

All anorectal diseases: first step in management is to scope and rule out cancer Hemorrhoids: presents as blood streaks in stool and extreme pain (external); Tx scope to r/o cancer → fiber/stool softeners → if it keeps bleeding, excision or banding Non-healing hemorrhoids: indicates anal canal cancer; Tx chemoradiation (5-FU) → APR if it persists or recurs LAR vs. APR: LAR is low anterior resection (high in rectum), APR is abdominoperineal resection (low in rectum) Rectal cancer: Dx colonoscopy to r/o cancer, then endoscopic U/S for staging → Tx depends on stage Rectal cancer T1: transanal resection Rectal cancer >T1: neoadjuvant chemoradiation for 6 weeks to shrink the tumor → then LAR with 2cm distal margins → APR if margins not possible Anal cancer: presentation is non-specific (bleeding, pain, drainage, itching) and requires biopsy Small anal cancer: Tx resection w/ negative margins Large anal cancer: often mistaken as “nonhealing hemorrhoids”, Tx chemoradiation (Nigro protocol) → APR if it persists or recurs Perirectal abscess: Tx I&D → 40% will develop a fistula according to Goodsall’s rule (anterior straight tract, posterior curved tract) → Tx fistulotomy Pilonidal abscess: abscess in sacrococcygeal area of lower back, Tx I&D and removal of hair Anal fissure: presents as pain and blood with BM due to increased sphincter tone; Tx fiber/stool softeners → if it won’t heal, botox → still won’t heal, lateral internal sphincterotomy Recurring anal fissure: probably Crohn’s; biopsy first for possible cancer, then Tx metronidazole if biopsy reveals Crohn’s Rectal prolapse: presents as rectal protrusion following defecation; internal prolapse → high-fiber diet to normalize BM, external/bleeding prolapse → rectopexy or LAR

Surgery – Lower GI Surgery

–––––––––––––––– GI BLEEDING –––––––––––––––– Hematemesis: bloody vomiting, always UGIB Melena: coffee ground blood in stool, usually UGIB but can also be from ascending colon Hematochezia: BRBPR, can be either UGIB or LGIB; NG tube aspirate/lavage → LGIB if –blood/+bile, UGIB if +blood, indeterminate if –blood/–bile UGIB: GI bleeding proximal to Ligament of Treitz, management is EGD UGIB in ICU pt: most likely a stress ulcer LGIB: GI bleeding distal to Ligament of Treitz, 85% stop spontaneously; MCC are AVM, diverticulosis, and colon cancer LGIB management: must localize site of bleeding w/ tagged RBCs (<1 cc/min) or angiography (>1 cc/min); if not currently bleeding, get upper and lower endoscopy since localization won’t help LGIB surgery indications: “hemodynamic instability despite transfusion”, loss of 4-6 units in 24 hrs or 8-10 units in 48 hrs LGIB scenario: GI bleed stops spontaneously → get colonoscopy to determine cause and rule out possibility of colon cancer → coagulate if AVM, leave alone if diverticulosis LGIB scenario: unstable patient, massive BRBPR, no imaging to localize site of bleeding → total colectomy since 85% of bleeding is from the colon LGIB in kids: indicates Meckel’s diverticulum, Dx technetium uptake into ectopic gastric mucosa Dx tagged RBCs: sensitive for LGIB at 0.1 cc/min, but not specific for localizing site of LGIB; bladder always lights up first so ignore that part Dx angiogram: less sensitive for LGIB at 1.0 cc/min, but more specific for localizing site of LGIB; allows for smaller LGI resection in surgery if necessary ––––––––––––– OTHER GI DISEASES –––––––––––– Sigmoid volvulus: twisting of sigmoid colon around mesentery results in closed-loop obstruction; Tx “detorse” the colon via rigid scope and rectal tube, then elective sigmoid colectomy Cecal volvulus: twisting of cecum; Tx right colectomy since detorsion usually won’t work Ogilvie’s syndrome: pseudoobstruction and massive colon dilation w/o mechanical obstruction; Tx endoscopic decompression or neostigmine if >11 cm due to possibility of cecal perforation Constipation: do a rectal exam to make sure stool isn’t impacted, then give enemas from below

Surgery – Endocrine Surgery

–––––––––––––– THYROID DISEASES––––––––––––– Thyroid embryology: derivative of foramen cecum from the base of the tongue Thyroglossal duct cyst: remnant of thyroglossal duct as a mobile midline neck mass, Dx at 1-2 yo due to neck fat, Tx Sistrunk operation (take out cyst, trunk, and medial portion of hyoid bone) Thyroid nodule management: first get TSH levels → if euthyroid, get FNA for cancer Dx; otherwise, work up for hypo- or hyperthyroidism Risk of malignancy: solid nodules, cold nodules (lack of radioiodine uptake), size > 1.5 cm Colloid nodule: benign nodule, manage medically Hyperthyroidism: Graves’ disease (most common), toxic adenoma (#2), toxic multinodular goiter (#3)

Papillary cancer Tx: total thyroidectomy w/ central LN excision → modified radical neck dissection if LN are positive for cancer

DiGeorge syndrome: congenital absence of both 3rd and 4th branchial pouches → hypocalcemia, thymic aplasia

Follicular cancer: endemic to iodine-deficient regions, hematogenous spread, 2nd best Px

PTH: secreted from chief cells; three functions – renal ↑Ca++/↓P, bone ↑Ca++/↑P, stimulates 1αhydroxylase to activate vitamin D for indirect GI resorption of Ca++

Follicular cancer Tx: hemilobectomy with biopsy because 80% are benign adenomas and 20% are malignant carcinomas, total thyroidectomy if Bx reveals malignant carcinoma Medullary cancer: AD inheritance with MEN2A/2B syndromes, Δret proto-oncogene, both lymphatic and hematogenous spread, Bx amyloid deposits, 3rd best Px Medullary cancer Tx: total thyroidectomy for both cancer and ret+ prophylaxis w/ central LN excision → modified radical neck dissection if LN are positive for cancer

Graves’ disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing exophthalmos, pretibial myxedema, and hyperthyroidism; more common in women

Anaplastic cancer: rare, worst Px

Graves’ disease Tx: oral radioiodine (no surgical risks) or surgery (won’t become hypothyroid)

Thyroid lymphoma: associated w/ chronic Hashimoto’s thyroiditis, Tx radiation therapy

Thyroid storm Tx: β-blockers, antithyroid drugs

Post-thyroidectomy f/u: take patient off T4 for 6 weeks (use T3 instead for its shorter T½), increase TSH level, and make sure total thyroidectomy was performed; give radioactive iodine exam after 6 weeks to check if any metastases will light up

Antithyroid drugs: propylthiouracil (PTU) and methimazole block peroxidase, PTU also blocks peripheral conversion of T4 to T3 Toxic adenoma: Dx hot nodule on scan with peripheral suppression, Tx lobectomy if >2 cm, radio-iodine if <2 cm

Anaplastic cancer Tx: palliative (e.g. tracheostomy)

Positive for metastases: get CT scan, macro → excision, micro → oral radio-iodine therapy Papillary cancer f/u: follow thyroglobulin levels

Toxic multinodular goiter: Tx surgical excision if >2cm, radio-iodine if <2 cm Hypothyroidism: chronic/Hashimoto thyroiditis (most common), subacute/De Quervain thyroiditis, acute bacterial thyroiditis Hashimoto thyroiditis: autoimmune disease with lymphocytic infiltration, Tx Synthroid Hashimoto thyroiditis antibodies: anti-TSH, anti-microsomal, anti-thyroglobulin, antiperoxidase De Quervain thyroiditis: subacute, painful granulomatous inflammation following viral URI, Tx observation (condition will self-resolve) Acute thyroiditis: painful, swollen, tender thyroid mass due to Staph/Strep infection, Tx I&D Thyroid cancers: 80% papillary, 10% follicular, 4% medullary, 1% anaplastic; FNA can be used to Dx papillary and medullary but not follicular (must see capsular invasion to DDx adenoma vs. carcinoma) Papillary cancer: associated with radiation, lymphatic spread, best Px overall, Bx shows Orphan Annie nuclei with psamomma bodies

Follicular cancer f/u: follow thyroglobulin levels Medullary cancer f/u: 24-hour urine for VMA or metanephrines (MEN syndrome can present with pheochromocytoma), follow calcitonin levels Modified radical neck dissection: like radical neck dissection, but spares sternocleidomastoid muscle, CN XI, and internal jugular vein Thyroid cancer Px: MACIS system – Metastasis (nonlymph nodal), Age (<45 is better), Completeness of resection, Invasion, Size (>2 cm has worse Px) Thyroid surgery risk factors: superior laryngeal nerve (soft/deep voice), recurrent laryngeal nerve (hoarseness unilateral, dyspnea bilateral), parathyroid glands (hypoparathyroidism)

Osteitis fibrosa cystica: rapid, painful loss of bone due to HPTH; “moth eaten skull” Calciphylaxis: calcium deposition in soft tissue due to HPTH Multiple myeloma: punched-out lesions of bone due to a B-cell neoplasm Hypercalcemia Sx: kidney stones, painful bones, abdominal groans (peptic ulcers, pancreatitis, cholelithiasis), psychic overtones (↓mental status) Hypercalcemia DDx: parathyroid adenoma (MCC outpatient), metastases to bone (MCC inpatient) 1° HPTH: ↑PTH/↑Ca++/↓P, most sensitive test is Cl:P ratio >33:1; causes include 90% adenoma, 9% hyperplasia, 1% carcinoma 1° HPTH management: straight to surgery if symptomatic (4-gland exploration or minimally invasive surgery), no imaging necessary 4-gland exploration: open exploration of neck area; adenoma → take it out; hyperplasia → take 3½ glands out, or take all 4 out and autotransplant ½ gland back in; carcinoma → en bloc resection of parathyroid and ipsi thyroid lobe Minimally invasive surgery: needs positive Sestamibi scan pre-op, big/abnormal gland during exploration, and intra-operative decrease in PTH levels by >50% following excision 2° HPTH: ↑↑PTH/↓Ca++/↑P, due to renal failure 2° HPTH management: medical management, 3½ gland excision if complications exist 3° HPTH: ↑PTH/↑Ca++/↓P, found in renal transplant pts whose parathyroid glands work autonomously 3° HPTH management: 3½ gland excision if HPTH persists for 1 year following transplant Sestamibi scan: “lighting up” in parathyroid gland is 85% accurate for Dx parathyroid adenoma

––––––––––––– PARATHYROID DISEASES –––––––––

Hypercalcemic crisis: Ca++>15 indicating carcinoma; Tx flush with NS, then drain with furosemide (Lasix), then treat the underlying cause

Parathyroid glands: 30-50 mg each, brownish-yellow color, sinks in water (to differentiate from fat)

Parathyroid nodule: probably a thyroid nodule, unless Ca++ ~15 indicating parathyroid carcinoma

Parathyroid embryology: 3rd branchial pouch becomes inferior glands and thymus, 4th becomes superior glands

2nd operation s/p adenoma removal: requires localization studies, don’t just go back in there

Surgery – Endocrine Surgery

Missing parathyroid glands: check thymus (MC location/15%), up and down neck, open carotid sheath, retro-esophageal area, esophageal groove, and inside the thyroid gland itself Median sternotomy: only indicated if pt is in a lifethreatening hypercalcemic crisis –––––– MULTIPLE ENDOCRINE NEOPLASIA –––––– MEN1 (Wermer): pituitary adenoma, pancreatic endocrine cancer (MC gastrinoma), parathyroid hyperplasia MEN1 Tx: excise parathyroid first since hypercalcemia can cause ↑gastrin levels; if Z-E can’t be controlled w/ PPIs → total gastrectomy since MEN gastrinomas are multifocal

Pituitary Cushing: due to ↑ACTH secretion, suppressable by high dose dexamethasone; Dx MRI, Tx transsphenoid hypophysectomy Adrenal Cushing: due to ↑cortisol secretion (causes ↓ACTH); Dx CT scan, Tx adrenalectomy Ectopic Cushing: due to ↑ACTH secretion usually from SCLC, not suppressable by high dose dexa Adrenal gland tumors: aldosteronoma, cortisoloma, sex hormone-secreting tumor, pheochromocytoma, incidentaloma Aldosteronoma: presents as ↑Na, ↓K, ↓H, ↓renin; Dx CT scan for mass (if no mass present or ↑renin, think RA stenosis), Tx adrenalectomy (adenoma) or aldactone (hyperplasia)

MEN2A (Sipple): parathyroid hyperplasia, pheochromocytoma, thyroid medullary cancer

Cortisoloma: presents as adrenal Cushing’s, Tx adrenalectomy

MEN2B: pheochromocytoma, thyroid medullary cancer, mucosal neuromas, Marfanoid habitus

Sex hormone-secreting tumor: Tx adrenalectomy

MEN2A/2B Tx: excise pheochromocytoma first since it can be life-threatening Gastrinoma: give PPIs → if acid persists, get serum gastrin levels → <200 absent, >500 present, 200-500 indeterminate and requires secretin stimulation test → if paradoxical ↑gastrin w/ secretin, present → get CT scan to localize and cut it out VIPoma: presents as “rice water” diarrhea; get CT scan to localize and cut it out Insulinoma: presents as hypoglycemia, Dx ↑Cpeptide levels or monitored fasting (to see if they’re “faking it”); get CT scan and cut it out Glucagonoma: presents as new-onset diabetes and migratory rash from lower body upwards, Dx glucose challenge test; get CT scan and cut it out Metastatic glucagonoma: give somatostatin and streptozocin since surgery is contraindicated Nesidioblastosis: presents as hypersecretion of insulin in a newborn; Tx 95% pancreatectomy –––––––––– OTHER ENDOCRINE DISEASES ––––––––– Pituitary adenoma: prolactinoma (#1), null cell tumor (#2), ACTH (#3), GH (#4); may present as bitemporal hemianopsia ◐◑ due to optic chiasm compression Prolactinoma: presents with galactorrhea and amenorrhea, Tx bromocriptine Null cell tumor: doesn’t secrete anything Cushing syndrome: presents as truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, and immunosuppression due to ↑cortisol Cushing causes: MCC is exogenous steroid use; intrinsic causes include pituitary adenoma, adrenal adenoma, and ectopic secretion of ACTH

Pheochromocytoma: presents with HA, HTN, palpitations, etc.; Dx 24 hour urinary VMA or metanephrines, Tx α-blockers (phenoxybenzamine) then β-blockers then adrenalectomy Intraoperative hypotension: give IVF Incidentaloma: make sure it’s not secreting hormones then work-up based on size; <5 cm → leave alone, >5 cm → resection + check other organs since adrenals are common site of metastasis Aortic coarctation: presents as HTN in arms but normal BP in legs; get CXR (scalloping of ribs) then confirm w/ spiral CT, then surgical correction Renovascular HTN: presents as HTN + abd bruits, secondary to fibromuscular dysplasia (young women) or atherosclerosis (old men) of the renal arteries; get a doppler of renal vessels, then either balloon dilation or surgical correction

Surgery – Skin/Soft Tissue Surgery

––––––––––––––– SKIN CANCERS ––––––––––––––– Skin cancers: basal cell carcinoma (50%), squamous cell carcinoma (25%), malignant melanoma (15%); management is full-thickness incisional biopsy at border of the lesion Basal cell carcinoma: raised waxy lesion or nonhealing ulcer in upper face, doesn’t spread; Tx local excision w/ 1 mm margins Squamous cell carcinoma: non-healing ulcer in lower face, spreads to LN; Tx local excision w/ 1 cm margins and LN excision SCC risk factors: draining fistulas, arsenic exposure Keratoacanthoma: variant of SCC that grows rapidly and then dies off spontaneously Dysplastic nevus: atypical mole, precursor of malignant melanomas, requires close observation Melanoma: ABCDE – Asymmetric, irregular Borders, different Colors, Diameter >5mm, Evolving; Px related to depth, highly metastatic and will be found in weird places Ulcerated melanoma: 1/3 reduction in survival Depth <0.75 mm: Tx excision w/ 1 cm margin, good prognosis Depth 0.76-3.99 mm: Tx excision w/ 2 cm margin, palpable LN → removal, no palpable LN → sentinel LN biopsy w/ elective removal Depth >4 mm: Tx excision w/ 2 cm margin, remove palpable LN, pt will likely die from mets Melanoma × LN involvement: remove regional LN, then complete staging for mets (CXR, CT scan, LFTs, brain MRI) Melanoma × metastases: Tx radiation and chemotherapy (interferons)

–––––––––––––––– SARCOMAS –––––––––––––––– Sarcomas: present as firm, painless masses; Px depends on size, grade, and distant metastases (no LN since sarcomas spread hematogenously) Sarcoma management: Dx incisional biopsy parallel to resection margins, chest CT for mets, Tx resection w/ 1 cm negative margins High-grade sarcomas: Tx radical amputation w/ post-op radiation therapy

McVay repair w/ relaxing incision: cut transversus abdominis aponeurosis to relax tension on sutures

Sarcoma × liver mets: biopsy for confirmation → Tx hepatic wedge resection or formal lobectomy

Lichtenstein repair: tension-free repair w/ mesh; fixes direct, indirect, and femoral hernias

––––––––––––––––– HERNIAS –––––––––––––––––

TAPP and TEP: TransAbdominal PrePeritoneal and Totally ExtraPeritoneal lap procedures; have steep learning curve and unproven results

Hernia surgery indications: all abdominal hernias due to possibility of strangulation, except sliding esophageal hernias (Tx PPIs) and umbilical hernias in pts <2 yo (simple observation) Umbilical hernia management: <2cm watch, >2cm fix, fix if it doesn’t regress before kindergarten regardless Hernia × SBO: presents as abdominal distention, nausea, and vomiting due to incarcerated or strangulated hernia; Tx emergent hernia repair Hernia × strangulation: presents as firm/tender mass w/ fever, ↑WBC, metabolic acidosis; Tx emergent hernia repair Indirect hernia: through internal ring lateral to inferior epigastrics vessels, due to patent processus vaginalis; most common hernia overall (even in women and elderly) Indirect hernia in kids: high incidence of bilaterality, repair is limited to high ligation of sac w/o abdominal wall repair

Acral lentiginous melanoma: melanoma on pale areas of dark-skinned pts (sole of feet, palm of hand), worst prognosis due to depth

Femoral hernia: below inguinal ligament into femoral triangle, more common in women, highest risk of strangulation (50% of all strangulations)

Subungual melanoma: melanoma under fingernail or toenail, Tx DIP amputation

Sliding hernia: involves other viscera as part of the hernia wall (e.g. bladder, cecum, sigmoid colon), important to recognize sliding hernias as not to injure any contained structures

Melanoma × SBO: presents as abd distention, nausea and vomiting due to metastatic melanoma in peritoneal cavity; Tx ex lap w/ excision

McVay repair: Cooper’s ligament to conjoint tendon; fixes direct, indirect, and femoral hernias

Shouldice repair: inguinal ligament to reinforced transversalis fascia in two layers

Direct hernia: medial to inferior epigastric vessels, due to weakening abdominal wall; more common in elderly

Melanoma in anus: all mucosal melanomas have bad prognosis, Tx APR w/ palpable LN excision

Bassini repair: inguinal ligament to conjoint tendon, high tension, fixes direct and indirect hernias

Sarcoma × lung mets: get chest CT to characterize lesion and look for others → needle biopsy for confirmation → Tx thoracic wedge resection

Lentigo maligna melanoma: superficial, spreading melanoma on the face, good prognosis overall, Tx excision w/ narrow margin

Melanoma on face: Tx excision w/ smaller margins for cosmetic purposes, consult plastic surgery

Hernia surgery types: open (Bassini, McVay, Shouldice, Lichtenstein), laparoscopic (TAPP, TEP)

Ventral hernia: hernia through incision site at linea alba; Tx primary closure (small) or mesh repair (large) Rare hernia causes: anything that increases abdominal pressure – obesity, COPD, ascites, BPH causing bladder obstruction, constipation, ascites; these require further evaluation before surgery

Hernia surgery complications: damage to genital branch of genitofemoral nerve, ilioinguinal, iliohypogastric, or lateral femoral cutaneous nerves causing pain and sensory defects Hernia surgery post-op: avoid lifting for 6 weeks so incision site has time to regain strength

Surgery – Breast Surgery

–––––––––––– BREAST MANAGEMENT –––––––––––

–––––––– MALIGNANT BREAST DISEASES –––––––

Breast cancer screening: monthly self-exam, yearly breast exam, yearly mammogram if >40 y/o (earlier if there is a strong family Hx)

Breast cancer buzzwords: family history, ill-defined or fixed mass, skin or nipple retraction, peau d’orange, nipple eczema, and palpable axillary LN

Breast mass on exam: first, get mammogram to characterize mass and rule out other masses → get core needle biopsy → excisional biopsy if needle inadequate

Breast cancer Tx: identical for all cancers (except inflammatory, LCIS, DCIS); depends on cancer stage

Abnormality on mammogram: ‘probably benign’ → follow-up; ‘suspicious’ → core needle biopsy, excisional biopsy if needle inadequate

Stage I-II: lumpectomy w/ 1 cm negative margins + axillary LN samping + post-op radiation; or modified radical mastectomy Stage III-IV: systemic chemotherapy

Breast cancer risk factors: family Hx (#1), BRCA1 and BRCA2 genes, old age

Axillary LN involvement: Tx chemotherapy if premenopausal, tamoxifen if post-menopausal

MC breast masses: <25 fibroadenoma, 25-50 fibrocystic change, >50 infiltrating ductal carcinoma

Breast cancer × pregnancy: work-up and Tx is identical, except no chemo during 1st trimester and no radiation anytime; if stage III or IV, chemoradiation is essential and abortion may be necessary

–––––––––– BENIGN BREAST DISEASES ––––––––– Fibroadenoma: firm, mobile, rubbery mass in young women; Dx FNA and U/S, Tx elective removal Giant juvenile fibroadenoma: seen in teens with rapid breast growth; Tx excision to avoid breast deformity Phyllodes tumor: huge, benign tumors that distort the breast; Dx core or incisional biopsy since FNA is insufficient, Tx excision w/ negative margins

Breast cancer × men: work-up and Tx is identical Paget’s disease: presents as “crusty” nipple eczema, indicates underlying infiltrating ductal carcinoma Inflammatory cancer: resembles cellulitis w/ peau d’orange, “tumor cells in dermal lymphatics”, Tx requires pre-op chemo DCIS: Tx simple mastectomy

Fibrocystic change: multiple, bilateral lumps that vary with menstrual cycle; if dominant or persistent lump → aspiration → excisional biopsy if mass recurs or persists Sclerosing adenosis: Tx careful observation or prophylactic bilateral simple mastectomy; not precancerous, but is a risk factor of cancers Atypical ductal hyperplasia: Tx excision; not precancerous, but high risk of becoming a cancer Intraductal papilloma: presents as bloody nipple discharge; Tx galactogram/ductogram-guided excision (due to small risk of carcinoma) Acute mastitis: breastfeeding women get Staph/Strep infection through cracks in nipple w/ yellowish discharge, Tx antibiotics and warm compresses, may develop into breast abscess Breast abscess: pus pocket in lactating women; Tx I&D and biopsy to rule out possible cancer

LCIS: Tx careful observation or prophylactic bilateral simple mastectomy; not precancerous, but is a risk factor of breast cancers –––––––– POST-SURGERY COMPLICATIONS ––––––– Small ipsilateral nodule: local recurrence until proven otherwise, work-up like any other mass Contralateral finding: most likely a new primary cancer, work-up like any other mass Elevated LFTs: indicates liver mets, get abd CT scan Back pain: indicates bone mets, get bone scan then X-ray Pathologic fracture: indicates bone mets, get bone scan then X-ray Sensorimotor defects: indicates spine mets, get MRI Severe headache: indicates brain mets, get MRI

Periductal mastitis: subareolar infection in smokers, both males and females affected Gynecomastia: breast tissue hypertrophy in males; common in puberty (will resolve spontaneously) and older men (excision if it doesn’t regress on its own) Dystrophic calcification: presents as breast lump following trauma, but work up as a cancer until proven otherwise (trick question!)

New-onset seizures: indicates brain mets, get MRI New-onset coma: indicates acute hypercalcemia due to bone mets, get a renal panel for confirmation

Surgery – Acute/Critical Care Surgery

–––––––––––– TRAUMA EVALUATION –––––––––––– Evaluation of trauma pt: primary survey, get an “ample” Hx, secondary survey Primary survey: initial evaluation of trauma pt; ABCDE – airway, breathing, circulation, disability (neurological), environment/exposure

C-spine injury: suspected with neurological Sx, radiological abnormalities, or C-spine tenderness; intubation requires extreme caution

Stab × hemiparesis: suggests injury to the carotid artery; get angiogram and either vascular or neurosurg consult

Priapism: indicates fresh spinal cord injury; check for anal sphincter tone, bradycardia, and possibly neurogenic shock

Neck GSW: exploration of neck is mandatory in zone 2, observe if stable in zones 1+3

––––––––––––––– HEAD TRAUMA ––––––––––––––– Ample Hx: things to ask a trauma pt – allergies, meds, previous illnesses, last meal, events surrounding injury Secondary survey: full inspection of trauma pt following clearance of life-threatening issues, continual reassessment is necessary for changes Airway: determine if airway is clear, quickest way to evaluate is to see if pt can talk; use intubation, cricothyroidotomy, or tracheostomy if obstructed Blunt trauma to neck: consider possibility of laryngeal edema developing into airway obstruction Breathing: evaluate via lung auscultation, CXR, and pulse oximetry Circulation: stop external hemorrhage, 2 large-bore IV lines (14 or 16-gauge) w/ 2L crystalloid, followed by packed RBC (type O–) if necessary Cardiac tamponade: presents with Beck’s triad – JVD, muffled heart sounds, hypotension; Tx subxiphoid pericardiocentesis and go to OR Hypovolemic shock: class I <15% and lactic acid; class II 15-30% and ↑HR; class III 30-40% and ↓BP; class IV >40% with lethargy and anuria Hypovolemic shock Tx: 2 large-bore IV lines and 2L crystalloid infusion, resuscitation measured by urine output, HR, BP, and mental status Hypovolemic shock Tx unresponsive: search for underlying cause, ex lap or thoracotomy may be indicated for continuous internal bleeding Closed head injury: brain edema and ischemia causes Cushing reflex – peripheral vasoconstriction (↑BP), bradycardia (↓HR), and respiratory depression (↓RR) Circulation × pregnancy: ↑HR is normal and may not indicate shock, ↓hct of 31-35% is normal, best evaluated laying on her left side Disability: evaluate with GCS; 15 max, ≤8 coma, 3 nearly dead Disability × awake: stabilize C-spine, palpate posterior neck for tenderness, assess extremities for motor/sensory function, and get lateral Cspine imaging Disability × comatose: C-spine cannot be cleared, so precautions must continue

Head trauma evaluation: begin with primary survey (ABCs) → rapid neuro exam if stable → if any neuro sx, get head CT and neurosurg consult Rapid neuro exam: check pupils, cranial nerves, peripheral motor/sensory function, and rate level of consciousness via GCS EDH: head CT shows convex lens hematoma; presents as LOC → lucid interval → LOC → ipsilateral fixed/dilated pupil, Tx craniotomy SDH: head CT shows crescent moon hematoma, high risk for brain herniation; Tx head elevation, hyperventilate, sedate, mannitol + furosemide Diffuse axonal injury: head CT shows blurred gray-white junction and small punctate hemorrhages; management is prevention of ↑ICP Head trauma × hypovolemic shock: look for another source of bleeding Basal skull fx: raccoon eyes, hemotympanum, otorrhea, rhinorrhea, ecchymosis behind the ear (Battle’s sign); neurosurg consult is indicated ––––––––––––––– NECK TRAUMA ––––––––––––––– Neck stab wound: begin with primary survey (ABCs), then careful exam for injured structures Surgery indications: expanding hematoma, deteriorating vital signs, coughing blood, subcutaneous emphysema, all GSW and stab wounds in zone 2 (zones 1+3 can be observed if stable) Stab × zone 1: below cricoid (includes lung); observation and pre-op angiogram if stable, otherwise exploration of neck is necessary Stab × zone 2: between mandible and cricoid; exploration of neck is mandatory Stab × zone 3: above mandible; observation and pre-op angiogram if stable, otherwise exploration of neck is necessary Stab × dysphagia: suggests injury to the esophagus, Dx esophagoscopy or barium swallow Stab × hoarseness: suggests injury to the airway, larynx (voicebox), or recurrent laryngeal nerve; Dx laryngoscopy or exploration

Neck blunt trauma: at risk of carotid dissection (Tx anticoagulation) or laryngeal edema (Tx intubation) ––––––––––––––– SPINAL TRAUMA –––––––––––––– Spinal cord injury management: get MRI to look at spinal cord, then immediate high-dose steroids Hemisection syndrome: always due to stab wounds in posterior neck area, presents as ipsi DCML/motor loss and contra ACL loss Anterior cord syndrome: usually seen w/ vertebral burst fractures, presents as bilateral ALS/motor loss but intact DCML Central cord syndrome: usually seen w/ whiplash (e.g. rear end collisions), presents as UE burning pain and paralysis, but LE nerves intact ––––––––––––––– CHEST TRAUMA –––––––––––––– Rib fx: painful breathing leads to shallow breaths → atelectasis → pneumonia, Tx local nerve block Chest stab wounds: suspect HTX or PTX, chest tube insertion is indicated Infraclavicular stab wounds: suspect injury to subclavicular artery or vein, Dx angiogram if pt is stable or urgent exploration if unstable Nipple-level stab wounds: suspect additional injury to diaphragm/abdominal organs, ex lap indicated for abdominal organ damage PTX: air in pleural space; insert a finger to make sure of pleural space, then insert a chest tube, remove when lung is fully inflated and no air leak present Small PTX: simple observation is okay if it’s asymptomatic, no free fluid present, not expanding, and no other significant injuries Sucking chest wound: seal with occlusive dressing, insert chest tube in different location Nonfunctioning chest tube: chest tube is in the wrong location or not working properly; reposition or replace chest tube Continuous air leak into chest tube: major airway injury with disruption of bronchus or trachea Tension PTX: mediastinal shift, hypotension, JVD, absent breath sounds, and hyperresonant to percussion; Tx emergent needle aspiration and chest tube insertion (do not wait for CXR or ABG) HTX: blood in pleural space, go to OR if chest tube drains 1.5L or >200 mL/hr for 3 hours

Surgery – Acute/Critical Care Surgery

HTX × hypotension: suspect blood loss in left chest, indicated for left chest tube insertion Thoracic GSW: GSW is managed differently due to unpredictable path of bullets vs. knife, mark both entrance/exit sites and get imaging Thoracic blunt trauma: suspect HPTX, chest tube insertion is indicated; emergent thoracotomy if >1.5L or >200mL/hr blood is extracted from tube Aortic transection: presents as widened mediastinum on CXR, confirm w/ aortic angiography or chest CT → go to OR if transected Flail chest: presents w/ paradoxic chest wall movements due to multiple rib fx, suspect lung contusions and aortic transection; manage by inserting bilateral chest tubes and serial ABGs Pulmonary contusions: presents as deteriorating ABGs and “white out” of lungs on CXR; Tx colloid (not crystalloid) + diuretics + fluid restriction Ruptured diaphragm: CXR reveals stomach in left chest; rapid eval of non-abd injuries → go to OR

Trauma × perforated viscera: CXR reveals free air in abdomen; rapid eval of non-abd injuries → repair perforated viscera in the OR Trauma × hypotensive w/o hemorrhage: indicated for FAST or DPL → ex lap in OR if positive; CT scan inappropriate for unstable pts Trauma × hypotensive w/ pelvic fx: suspect vascular injury from branch of internal iliac, Dx FAST, Tx control by embolization

Air embolus: presents as sudden death in an intubated/respirator pt; management is immediate Trendelenburg position + cardiac massage Fat embolus: presents as RDS and petechiae in neck/axilla due to bone marrow embolization from long bone fx; management is respiratory support ––––––––––––– ABDOMINAL TRAUMA ––––––––––– Abdominal GSW: mandatory OR for ex lap for all GSW below nipple level Abdominal stab wound: mandatory OR if stab wound penetrates peritoneum (e.g. protruding viscera, peritonitis, hemodynamic instability); otherwise, digital exploration and observation Abdominal blunt trauma: mandatory OR if signs of peritonitis or hemodynamic instability despite transfusion; otherwise, CT scan can be done safely before proceeding Trauma × flat/nontender abd: observe if no mechanism, imaging if mechanism exists

Dx CT scan: useful for stable pts, avoid in unstable or severely injured pts Splenic laceration: ex lap if unstable, preserve spleen if possible to avoid post-splenectomy sepsis, avoid blood transfusion if possible, splenectomy requires vaccination for SHiN bacteria

Mesentery injury: difficult to detect on CT so mechanism must evoke suspicion, co-exists with bowel injury since mesentery is tougher than bowel Renal laceration: stable → angiography and planned operative repair; unstable → IV pyelo to detect if two kidneys present, then OR for nephrectomy Hematoma in SMA region: suggests major injury to abd aorta, major aortic branches, pancreas, or duodenum; stable → angiography and assessment before operation, unstable → urgent ex lap Pancreatic transection: mandatory ex lap; minor injury → debride and drain, major injury → resection of devitalized pancreatic tissue and repair of duodenal injury Duodenal hematoma: common in kids hitting abd on bicycle handlebars, hematoma causes GI obstruction; Tx NPO/IVF, will resolve spontaneously in 5-7 days

↓CO/↑CVP: cardiogenic shock (e.g. CHF, MI, tension PTX, pericardial tamponade)

Retroperitoneal zones: central is zone 1, flank is zone 2, pelvis is zone 3 Surgery indications: all zone 1 hematomas, zone 2 and 3 hematomas only if penetrating trauma Zone 1 (central hematoma): may involve injury to major vascular structure, indicated for ex lap Zone 2 (flank hematoma): no exploration warranted unless penetrating trauma, because peritoneum will tamponade bleeding Zone 3 (pelvic hematoma): no exploration warranted unless penetrating trauma, because peritoneum will tamponade bleeding ––––––––––––– UROLOGIC TRAUMA –––––––––––– Urologic surgery indications: all GSW, stab wounds, and other penetrating injuries Urethral injury: presents as blood on meatus, scrotal hematoma, and “high-riding” prostate; get a retrograde urethrogram and suprapubic catheter instead of Foley (may compound injury) Bladder injury: associated w/ seatbelt trauma in adults; get a retrograde cystogram and post-void films, then surgical repair Renal injury: associated w/ blunt trauma to back and lower rib fx; get CT scan, manage non-op if possible Scrotal hematoma: manage non-op unless testicle is ruptured (seen on U/S)

Blood in ex lap: stop bleeding by packing all four quadrants with gauze packs → attack injuries in order of severity and attempt hemostasis → inspect remainder of abd contents and repair injuries

Penis fx: associated w/ cowgirl sex; insert a suprapubic catheter then repair surgically

Triad of death: acidosis, coagulopathy, hypothermia

Penetrating limb trauma: no vascular injury → give tetanus PPx and clean wound; vascular injury present → arteriogram if stable, OR if unstable

Trauma × severe abd pain: suspect peritoneal irritation due to blood or intestinal contents, Dx FAST or CT → indicated for ex lap if positive

Hemorrhage × hypothermia: can lead to coagulopathy due to platelet dysfunction and PT/PTT prolongation; rewarming indicated

Trauma × tire mark across abd: indicates severe direct trauma, high suspicion of internal injury

Hemorrhage × low platelets: loss of platelets due to hemorrhage puts pt at risk for coagulopathy; platelet transfusion indicated

Trauma × coma: abd imaging mandatory since physical exam is impossible on a comatose pt

↓CO/↓CVP: hypovolemic shock, neurogenic shock (e.g. spinal cord trauma, anaphylaxis)

––––––––– RETROPERITONEAL TRAUMA –––––––– Dx DPL/FAST: diagnostic peritoneal lavage (DPL) or ultrasound (FAST) useful for quick Dx of internal free fluid → positive DPL/FAST is indicated for ex lap; may be false negative in retroperitoneal injuries

Liver laceration: ex lap if unstable, observe if stable Ruptured trachea/bronchi: presents as continuous air leak into chest tube and subcutaneous emphysema; go to OR

Hemorrhage × abd distention: bleeding into abd cavity can lead to abd compartment syndrome, which can cause decreased renal blood flow (oliguria) and dyspnea (elevated diaphragm)

Hemorrhage × metabolic acidosis: results from decreased tissue perfusion causing lactic acidosis; crystalloid infusion indicated

–––––––––––––––– LIMB TRAUMA –––––––––––––––

Combined limb trauma: order of repair is bone first, then vascular repair, nerve last; fasciotomy required to prevent compartment syndrome Limb GSW: may require extensive debridements and amputation if unsalvageable Crushing limb trauma: high risk of myoglobinuria leading to acute renal failure; Tx IV fluids + mannitol + acetazolamide to maintain a high urine output

Surgery – Acute/Critical Care Surgery

––––––––––––––––––– BURNS –––––––––––––––––– Burn assessment: determine depth of burn, type of burn, and body surface area (%BSA) burned First-degree burns: epidermis only, painful Second-degree burns: extends into dermis, causes pain and blistering, may develop into third-degree burns w/o proper management Third-degree burns: full thickness, painless Burn management: tetanus PPx, IV pain meds, topical agents (silver sulfadiazine is default, mafenide acetate for deep penetration, triple abx ointment for the eyes) Rule of 9’s: estimates %BSA burned; head and upper extremities are 9% each; anterior trunk, posterior trunk, and lower extremities are 18% each; and perineum is the last 1% Parkland formula: estimates fluid replacement in burn victims, LR volume = %BSA × kg × 4mL/kg; give 50%LR in first 8 hours, 50%LR in next 16 hours Fluid for infants: 20 mL/kg if BSA>20% Chemical burns: alkaline burns are worse than acids Chemical burn management: massive tap water irrigation, don’t try acid-base neutralization, except in ingestion – orange juice for alkali, milk for acids Electrical burns: may appear benign on surface, but masks large amounts of interior damage to muscles, nerves, and vessels; at risk of cardiac injury (arrhythmias) and muscle injury (myoglobinuria) Electrical burn management: IV fluids + mannitol + acetazolamide to maintain a high urine output Inhalation burns: suspected with carbonaceous sputum, facial burns, singed facial/nasal hairs, hoarseness, etc. due to smoke inhalation Inhalation burn management: confirm w/ fiberoptic bronchoscopy and order serial ABGs; high COHb levels → Tx 100% O2 Circumferential burns: rapidly become thick and contracted, causing restricted ventilation in the chest and ischemia in extremities; Tx escharotomy

Snake bites: don’t always result in envenomation; if signs of venom evident (pain, swelling, discoloration) then draw blood for labs and Tx anti-venin Bee stings: may present as anaphylactic shock (“warm and pink”) secondary to allergic response; Tx stinger removal and epinephrine Spider bites: black widows have neurotoxins, brown recluses have necrotoxins Black widow spiders: present w/ severe muscle cramps, acute abdomen, and nausea/vomiting; give IV calcium gluconate + muscle relaxants Brown recluse spiders: present as an ulcerated lesion; excise ulcer and skin graft Human bites: requires extensive irrigation and debridement due to high amounts of bacteria ––––––––––––––––– NUTRITION –––––––––––––––– TPN: indicated for nutrition when gut is nonfunctional or not availble, requires personalization of formula for nutrition status TPN × fever: examine catheter site for infection, obtain cultures from catheter site and blood; if –bacteria → change catheter site, if +bacteria → change catheter site and start antibiotics TPN × metabolic coma: hyperglycemic, hyperosmolar, nonketotic coma is commonly due to excessive osmolar diuresis in hyperglycemia TPN × elevated LFTs: very common (up to 30%), TPN can cause fatty liver, structural liver damage, and even cirrhosis with prolonged TPN TPN × dry/scaly skin: indicates free fatty acid deficiency, Tx FFA administration Nitrogen in TPN: positive nitrogen balance is the goal, since negative nitrogen balance indicates a catabolic state; severity of injury correlates with a higher amino acid requirement BEE: basal energy expenditure, equal to (body weight × 25 kcal/kg/day) Nondepleted pts: 1.2× BEE calories needed; good nutritional status before surgery Depleted pts: 1.2-1.5× BEE calories needed; malnourished before surgery

Scalding burns in kids: consider child abuse Burns × methemoglobinemia: Sx chocolate-brown blood, central cyanosis of trunk, arrhythmias, seizures, coma; Dx ABGs (pulse ox is unreliable), Tx IV methylene blue ––––––––––––––– BITES & STINGS –––––––––––––– Bite management: all require tetanus PPx Dog bites: rabies PPx only required if bite was unprovoked and dog isn’t available for brain Bx

Hypermetabolic pts: 1.5-2× BEE calories needed; severely stressed catabolic state due to trauma, burns, sepsis, cancer, etc. Macronutrients: carbs (4 kcal/gm), protein (4 kcal/gm), fat (9 kcal/gm), etoh (7 kcal/gm)

Surgery –Subspecialty Surgery

––––––––––––– PEDIATRIC SURGERY –––––––––––– VACTERL syndrome: vertebral, anal atresia, cardiac, TE fistula, esophageal atresia, renal, limbs (radius); presence of any of these requires checking for the others Esophageal atresia: presents as excess salivation, choking spells, coiling NG tube, and often a TE fistula; Tx surgical repair (if delay is necessary, gastrostomy) Anal atresia: high rectal pouch → colostomy then delayed repair, low rectal pouch → repair, if anofistula present → delay repair since further growth may correct condition Congenital diaphragmatic hernia: presents as RDS due to hypoplastic left lung; Dx CXR shows bowel in left chest, Tx intubation w/ low-pressure ventilation Gastroschisis: midline hernia to left of umbilical cord tearing through peritoneum; Tx closure if small, silo if large, and TPN for a month since GI doesn’t work Omphalocele: midline hernia through the cord with peritoneal covering; Tx closure if small, silo if large

Vascular rings: presents as stridor, RDS, crowing respiration, and dysphagia in an infant due to compression of trachea and esophagus; Dx barium swallow and bronchoscopy, Tx surgical correction Cardiac anomalies: all require prophylactic antibiotics for subacute bacterial endocarditis L→R shunts: all present with murmurs and lateonset cyanosis due to Eisenmenger syndrome (pulmonary HTN reversing direction of shunt) ASD: presents as low-grade systolic murmur, fixed S2, and frequent colds; Dx echo, Tx surgery VSD: presents as pansystolic harsh-sounding murmur with failure to thrive; Dx echo, Tx surgery PDA: presents with machinery-like murmur, often seen with congenital rubella syndrome; Dx echo, Tx indomethacin or surgery R→L shunts: all present with murmurs and earlyonset cyanosis

Embolic occlusion of retinal artery: presents as sudden unilateral loss of vision; Tx breathe into paper bag and repeatedly press on eye to shake clot into a more distal branch of retinal artery ––––––––––––– OTOLARYNGOLOGY –––––––––––– Neck masses: three types – congenital, inflammatory, neoplastic; differentiate via onset and resolution Congenital neck masses: thyroglossal duct cyst (midline), branchial cleft cyst (lateral), cystic hygroma (base of neck) Thyroglossal duct cyst: remnant of thyroglossal duct as a mobile midline neck mass, Dx at 1-2 yo due to neck fat, Tx Sistrunk operation (take out cyst, trunk, and medial portion of hyoid bone) Branchial cleft cyst: lateral mass at anterior edge of SCM, may have a small opening and blind tract Cystic hygroma: dilated lymphatic duct at base of neck, common in Turner syndrome, get CT scan to find extent of mass before surgical removal

Tetralogy of Fallot: presents as cyanosis and clubbing in a 5 y/o child who squats for relief; Px determined by degree of pulmonary stenosis, Dx echo shows RVH, Tx surgery

LN DDx: cancers are large (>2 cm), painless, fixed, insidious onset, unusual site; infectious LN are small (<2 cm), painful, rapid onset, mobile, normal site

Malrotation: presents as biliary vomiting and double-bubble on X-ray; Dx contrast enema or upper GI study, Tx emergency surgical correction

Transposition of great vessels: presents as lifethreatening cyanosis in a newborn; Dx echo, Tx surgery

Lymphomas: presents with multiple swollen LN, fever, and night sweats; get excisional biopsy, then Tx chemo

–––––––––––––– OPHTHALMOLOGY –––––––––––––

Supraclavicular metastases: MC primary sites are pancreas and stomach; get excisional biopsy for Dx

Intestinal atresia: presents as biliary vomiting and multiple air-fluid levels on X-ray, aka apple-peel atresia due to vascular accident in utero

Strabismus: misaligned eyes due to uncoordinated extraocular muscles; Tx surgical extraocular muscle manipulation to prevent ambylopia

Biliary vomiting: indicates SBO distal to ampulla of Vater; DDx duodenal atresia, intestinal atresia annular pancreas, or malrotation

Necrotizing enterocolitis: presents as feeding intolerance, abd distention, and ↓platelets in premies; Tx NPO, IVF, TPN, IV abx → surgical repair if signs of intestinal necrosis/perforation present Pyloric stenosis: presents as non-bilious projectile vomiting in first-born boys; Dx palpable epigastric olive, Tx rehydration and pyloromyotomy Biliary atresia: presents as progressive jaundice in a 1-2 month old due to lack of CBD; Dx HIDA scan + phenobarbital (to stimulate GB contraction), Tx liver transplant Hirschsprung’s disease: presents as chronic constipation due to lack of nerves in distal colon, rectal exam can decompress bowel; Dx X-ray shows distended proximal colon, Tx surgical pull-through Intussusception: presents as colicky abd pain that lasts 1 minute then resolves, and currant jelly stools; Dx/Tx barium or air enema (surgery if it doesn’t work) Child abuse: presents as retinal hemorrhages, SDH, multiple healed fx, and scalding burns; call child protective services Meckel’s diverticulum: presents as LGIB in a child, Dx technetium uptake for ectopic gastric mucosa

Amblyopia: vision impairment usually due to strabismus in kids, Tx eyepatch the good eye to develop the impaired one Retinoblastoma: presents as a leukocoria in a baby, Tx surgical enucleation (remove the eye) Narrow-angle glaucoma: presents as severe eye pain, headache, “seeing halos around lights”, eye feels as hard as a rock; Tx iridotomy (give pilocarpine, acetazolamide, or mannitol as first aid) Orbital cellulitis: presents as cellulitis of eyelids w/ fixed/dilated pupil and limited eye ROM; get CT scan then drain the pus Chemical burns of eye: irrigate w/ plain water ASAP, at hospital – irrigate w/ saline, remove corrosive particles, and test pH before sending home; alkaline burns are worse than acid burns Retinal detachment: presents as flashes and floaters, and a dark curtain being pulled down over the eye; Tx emergency laser “spot welding” Amaurosis fugax: emboli from carotid travels to retina causing transient blindness; Dx fundoscopic exam reveals Hollenhorst plaque, a bright shiny spot in a retinal artery

Head/neck SCC: presents as persistent hoarseness, painless ulcer in floor of mouth, or unilateral earache; risk factors are EtOH, smoking, and AIDS SCC management: get triple endoscopy to look for primary tumor → biopsy tumor → CT scan to determine stage; Tx resection, radical neck dissection, cisplatin-based chemo Acoustic neuroma: presents as unilateral deafness due to Schwann cell proliferation on CN VIII, get MRI Facial nerve tumor: presents as gradual-onset unilateral facial paralysis (sudden-onset is Bell’s palsy), get MRI Parotid tumors: present as masses around angle of mandible, two types – pleomorphic adenomas (benign, painless) and mucoepidermoid carcinomas (malignant, painful) Parotid tumor management: get FNA or formal superficial parotidectomy (open biopsy contraindicated due to CN VII) Foreign bodies: any toddler w/ unilateral ENT sx (earache, rhinorrhea, wheezing) has a toy stuck in there; do endoscopy under anesthesia to remove Ludwig angina: abscess in floor of mouth due to tooth infection, Tx I&D and tracheostomy

Surgery –Subspecialty Surgery

Bell’s palsy: sudden CN VII paralysis for no evident reason, Tx antivirals immediately CN VII trauma: sudden CN VII paralysis following facial trauma, will resolve spontaneously Cavernous sinus thrombosis: presents as diplopia in a pt w/ sinusitis due to nerve (CN III/IV/VI) injury, Tx antibiotics, CT scan, and drainage of abscess Epistaxis: nosebleed has different causes and management depending on pt’s age Epistaxis × children: due to nosepicking, Tx local pressure and phenylephrine nasal spray Epistaxis × teens: either cocaine abuse and septal perforation (requires packing) or juvenile nasopharyngeal angiofibroma (surgical resection) Epistaxis × elderly: due to HTN; requires packing, BP control, and often surgical ligation of vessels Vertigo: dizziness can be attributed to diseases of inner ear or brain itself Vertigo × inner ear: “room is spinning”, Tx meclizine, phenergan, or diazepam Vertigo × brain: “room is stable, but patient is spinning”, do a neurologic work-up

then resect (give mannitol, hyperventilate, and highdose steroids while waiting) Frontal lobe tumors: present as disinhibition, anosmia (CN I), ipsilateral blindness (CN II), and contralateral papilledema Craniopharyngioma: presents as GH deficit and bitemporal hemianopsia ◐◑ in a kid, Dx calcified lesion in sella turcica Prolactinoma: presents as amenorrhea and galactorrhea in a young woman, consider possibility of MEN1 syndrome, Tx bromocriptine Acromegaly: presents as huge hands, feet, tongue, and jaws in a tall man due to ↑GH; Dx get somatomedin C levels and MRI, then resection Nelson syndrome: presents as bitemporal hemianopsia ◐◑ and hyperpigmentation in an adult due to pituitary microadenomas that grew to full size; Dx MRI then Tx surgical resection Pituitary apoplexy: presents with typical pituitary adenoma sx, then sudden onset headache and CNS sx due to bleeding into tumor; Dx MRI then emergent steroid replacement Pinealoma: presents as loss of upper gaze and “sunset eyes” due to compression of vertical gaze center in superior colliculi

Vascular CNS diseases: TIA, ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage TIA: brief neurologic deficit that fully resolves within 24 hours; due to thromboembolus from internal carotid arteries TIA management: carotid duplex, then aspirin and elective CEA (if >70% stenosis) Ischemic stroke: a neurologic deficit that doesn’t resolve within 24 hours due to thromboembolus from internal carotid arteries, Tx t-PA within 3 hours, otherwise observe and rehab Hemorrhagic stroke: severe headache and neurologic deficit that doesn’t resolve within 24 hours in uncontrolled HTN; Dx CT scan, Tx rehab and control of HTN SAH: “worst headache of my life” due to rupture of Charcot-Bouchard aneurysm in lenticulostriate arteries; Dx CT scan to confirm SAH, then arteriogram to locate aneurysm, then surgical clipping

Lower UTI: presents as dysuria and cloudy, stinky urine but no fever, chills, or flank pain; common in young women, give antibiotics Pyelonephritis: UTI that has ascended to the kidneys, presents with fever, chills, flank pain; Dx urologic work-up and Tx antibiotics Prostatitis: presents as fever, chills, dysuria, back pain, and tender prostate on rectal exam; give antibiotics and don’t do any more rectal exams Urologic workup in kids: indicated for traumatic hematuria and UTIs, since it may indicate congenital abnormalities otherwise undiagnosed Congenital malformations: posterior urethral valves, hypospadias, epispadias, vesicoureteral reflex, low implantation of ureter, ureteropelvic obstruction Posterior urethral valves: presents as anuria in a newborn boy; cathereterize to empty bladder, then Dx voiding cystourethrogram, Tx resection Hypospadias: presents as urethral opening on ventral side of penis, never circumcise since prepuce is needed for surgical correction Epispadias: urethral opening on dorsal penis

––––––––––––––– NEUROSURGERY –––––––––––––– CNS diseases: vascular (sudden onset), metabolic (hours), infectious (days-weeks), tumors (months), degenerative disease (years)

surgical emergency that requires immediate decompression (stent or perc nephrostomy) in addition to IV antibiotics

Brain tumors in kids: present as cerebellar sx and headaches relieved by knee-chest position, due to posterior fossa lesions; Dx MRI, Tx resection Spinal cord tumors: present as back pain in someone who’s been treated for other cancers (spine is a common site of mets); Dx MRI, Tx neurosurgical decompression Neurogenic claudication: presents with pain on exertion and relief with rest, but pain is positiondependent and pulses are intact; Dx MRI, Tx neurosurgical decompression Trigeminal neuralgia: severe facial pain lasting 60 seconds; Dx MRI to r/o organic cause, then Tx anticonvulsants (radiofrequency ablation as backup) Reflex sympathetic dystrophy: presents as severe pain months after a crush injury w/ sympathetic overload (cold, cyanotic, moist); Dx sympathetic block, Tx surgical sympathectomy –––––––––––––––––– UROLOGY ––––––––––––––––– Testicular torsion: presents as severe testicular pain and “high riding testicle with horizontal lie” due to twisting of the cord; Tx emergent surgical detorsion, then orchiopexy (do not do any Dx tests)

CNS abscess: presents as space-occupying lesions but short-onset (weeks) and w/ nearby infections (otitis media, mastoiditis); get CT scan then resect

Epididymitis: presents like testicular torsion but w/ fever, pyuria, and cord is also tender; Dx U/S to rule out torsion, then Tx antibiotics

CNS tumors: presents as space-occupying lesions and progressive headache over months; get MRI

Obstructive UTI: presents as sepsis (fever, chills, flank pain) in someone passing a kidney stone;

VUR: presents as dysuria, fever, chills, and flank pain in kids due to ascending UTI; give antibiotics and Dx IV pyelo and voiding cystogram to look for reflux, long-term abx until child “grows out of it” Low implantation of ureter: asymptomatic in boys, “wet with urine all the time” in girls b/c ureter drips into vagina instead of bladder; Dx physical exam or IV pyelo, Tx surgical correction Ureteropelvic obstruction: usually asymptomatic, but presents with colicky pain with large diuresis (e.g. colicky pain following “beer drinking binge”) Hematuria: always get IV pyelo (CT scan if allergic or poor renal function) and cystoscopy to r/o cancers Urologic cancers: renal cell carcinoma, transitional cell carcinoma, prostatic cancer, testicular cancer RCC: presents as hematuria, flank mass/pain, and paraneoplastic syndromes (PAPER – PTHrP, ACTH, prolactin, EPO, renin); get CT scan if suspected, Tx surgical resection Bladder TCC: presents as painless hematuria in smokers; get IV pyelo and cystoscopy, then Tx surgical resection, then lifelong f/u for high-rate of local recurrence Prostatic cancer: asymptomatic, detected as rock-hard nodule on rectal exam; get U/S-guided needle biopsy, then TURP or radiation therapy (Tx flutamide and leuprolide if metastatic)

Surgery –Subspecialty Surgery

Testicular cancer: presents as painless testicular mass that doesn’t transilluminate; get radical orchiectomy w/ biopsy, then f/u αFP or βHCG for recurrence (Tx cisplatin or radiation if metastatic) BPH: presents as dribbing, nocturia, and difficulty voiding in an old man; put in Foley for 3 days, and Tx α-blockers (tamsuosin), 5αR-blockers (finasteride) +/- surgical prostate resection Post-op urine retention: presents as a need to void, but inability to do so; Tx straight cath at 6 hours post-op and Foley after 2nd straight cath Stress incontinence: presents as urine leaking w/ abd pressure due to weakened pelvic floor in a multigravid woman; Tx surgical repair of pelvic floor Kidney stones: presents as colicky flank pain and hematuria +/- radiation to inner thigh, Dx plain X-rays; Tx analgesics, fluids, and observation (<3 mm) or shockwave lithotripsy (>3 mm) Impotence: two types – organic and psychogenic, management depends based on etiology Psychogenic impotence: sudden onset w/o traumatic cause, specific to partner or situation; Tx psychotherapy Organic impotence: sudden onset (trauma) or gradual onset (atherosclerosis, diabetes); firstline Tx is PDE5-blockers (sildenafil, Viagra) –––––––––––– TRANSPLANT SURGERY ––––––––––– Transplant donors: almost everyone including braindead pts, Hep and HIV pts to each other, metastatic cancer pts for corneas Transplant rejection: hyperacute (minutes), acute (days/months), chronic (years) Hyperacute rejection: preformed ab’s against donor organ causes vascular thrombosis within minutes; never seen since type-and-cross prevents this from happening Acute rejection: HLA mismatch causes macrophage attack on donor tissue with lymphocytic infiltrate, confirmed by biopsy Liver rejection: indicated by elevated LFTs, first step is to get U/S and Doppler to rule out biliary obstruction and vascular thrombosis Heart rejection: indicated by progressive heart failure; management is getting routine ventricular biopsies and Tx steroid bolus + OKT3 Chronic rejection: gradual deterioration of organ function due to polymorphisms, irreversible and no Tx available

Surgery – Orthopedic Surgery

–––––––––––– PEDIATRIC DISEASES –––––––––––– Congenital hip dysplasia: presents as uneven gluteal folds, posterior dislocating hips (with “snapping”) in a newborn; Dx U/S since hip isn’t calcified for X-ray, Tx splinting Avascular necrosis of femoral head: presents in a kid w/ limping, hip pain, and limited hip ROM; Dx X-ray, Tx cast + crutches

Anterior shoulder dislocation: presents w/ outward rotated arm + deltoid numbness due to axillary palsy

Open fx: require cleaning and reduction within 6 hours to prevent ischemia of distal limb

Posterior shoulder dislocation: rare, presents w/ internally rotated arm held close to body

Gas gangrene: presents as tender, swollen, discolored wound site w/ crepitus following a penetrating injury; Tx high-dose penicillin G, hyperbaric oxygen, and debridement

Colles fx: distal radial fx in osteoporotic women falling on outstretched hand; Tx reduction + cast Monteggia fx: diaphyseal fx of proximal ulna + radial dislocation, following direct trauma to ulna

Hip dislocation: presents as a chubby kid limping due to groin pain, hip has limited internal rotation; Dx X-ray, Tx pin femoral head back in place

Galeazzi fx: diaphyseal fx of distal radius + ulnar dislocation, following direct trauma to radius

Septic hip: presents in toddlers who refuse to move hip following a septic illness; Dx hip aspiration unter anesthesia, Tx perc drain

Scaphoid fx: presents as wrist pain and tender anatomic snuffbox in a young person falling on outstretched hand; Tx thumb spica cast

Osteomyelitis: presents in kids w/ severe localized bone pain following a septic illness; Dx bone scan since X-ray will be false negative, Tx antibiotics

Metacarpal neck fx: presents as swollen and tender hand after punching a wall; Tx splint or plate

Genu varum: aka bowlegs, <3 y/o observe since it’s normal, >3 y/o surgical correction Genu valgus: aka knock-knee, observation okay Osgood-Schlatter disease: presents in teens w/ persistent pain over tibial tubercle, aggravated by quad contraction; Tx immobilization in cast Club foot: presents as bilateral inverted feet in a newborn; Tx serial plaster casts on adducted forefoot → hindfoot varus → equinus Scoliosis: laterally curved spine, common in teenage girls; Tx spine brace until mature, surgery if severe ––––––––––––––– BONE TUMORS ––––––––––––––– Osteosarcoma: presents as low-grade knee pain in a 10-25 y/o, X-ray shows Codman’s triangle and sunburst appearance; consult a specialist Ewing sarcoma: presents as low-grade epiphyseal pain in a child, X-ray shows onion skinning, due to t(11;22); consult a specialist Metastatic bone cancers: usually from breast (lytic) and prostate (blastic), causing bone pain and pathologic fx; Dx bone scan, Tx chemoradiation Multiple myeloma: plasma B-cell tumor results in CRAB – hyperCalcemia, Renal failure, Anemia, and Bone pain (X-ray shows punched-out lesions); Dx urinary Bence-Jones protein, Tx chemotherapy –––––––––––– ORTHOPEDIC TRAUMA –––––––––––– Fractures: all require 2 X-rays (90° from each other) including joints above and below fractured bone; anticoagulation of choice is fondaparinux + leg compression devices Clavicular fx: typically between mid-to-distal third of clavicle; Tx figure-of-eight device for 4-6 weeks

Hip fx: presents as shortened and externally rotated hip in an osteoporotic woman; Tx depends on location of fx Femoral neck fx: may lead to avascular necrosis of femoral head; Tx prosthetic replacement of head Intertrochanteric fx: less likely to cause avascular necrosis; Tx ORIF Femoral shaft fx: Tx intramedullary rod fixation, high risk of hypovolemic shock and fat embolisms Knee injury: all severe knee injuries present w/ swelling, and first step in management is an MRI Unhappy triad: injury to ACL, MCL, and medial meniscus following blow to lateral leg; Tx surgical repair ACL tear: presents as swelling, pain, and positive anterior drawer sign; Dx MRI, Tx immobilization and rehab Meniscal tear: presents as pain, swelling, and “clicking” of knee w/ forceful extension; Tx arthroscopic repair to salvage meniscus Tibial stress fx: presents as localized tibial pain in a soldier following a long march; Tx cast and f/u X-ray in 2 weeks Leg fx: common in pedestrian vs. car accidents; Tx cast for easily reduced fx, intramedullary nailing otherwise, high risk of compartment syndrome Achilles tendon rupture: presents as “popping noise” in ankle following exertion w/ pain and swelling; Tx cast or surgery Ankle fx: common after falling on inverted or everted foot; Tx ORIF ––––––––– ORTHOPEDIC EMERGENCIES ––––––––– Pain under cast: remove cast to examine

PSYCHIATRY

Ψ – Examination and Diagnosis

––––––– MENTAL STATUS EXAMINATION ––––––– Appearance: objective description of pt Appearance buzzwords: pupil size = drug abuse or withdrawal, bruises = abuse, needle marks/tracks = drug abuse, eroding enamel = bulimia, superficial cuts on arms = self-harm Activity: amount/type of motor movement

Word salad: incoherent collection of words Clang associations: rhyming and punning (think hip-hop) Thought blocking: abrupt cessation of speech before idea is finished Tangentiality: never gets to goal, keeps breaking off on a tangent

Psychomotor agitation: excess, non-productive motor activity in response to inner tension

Circumstantiality: overinclusion of trivial or irrelevant details

Psychomotor retardation: visible slowing of thoughts, speech, movement

Perseveration: inability to change the topic, or giving the same response to different questions

Tics: involuntary, spasmodic motor movement Akathisia: subjective feeling of muscular tension resulting in restlessness, pacing, repeated sitting and standing

Thought content: what the pt thinks Poverty of thought vs. overabundance: too few or too many ideas expressed Delusions: fixed, false beliefs

Stereotypic movements: repetitive, fixed pattern of physical action or speech (e.g. head banging) Tardive dyskinesia: involuntary choreoathetoid movements of head/limbs/trunk, due to prolonged use of antipsychotics

Suicidal/homicidal ideation: thoughts about wanting to kill self or others; assess by directly asking about suicide, not just “do you want to hurt yourself?” Phobias: persistent, irrational fears

Echopraxia: imitating movements

Memory: controlled by temporal lobes; three main types – immediate, short-term (recent), long-term (remote) Fund of knowledge: ask pt about simple facts (e.g. “who is the current president?”) Concentration: ask pt to “spell WORLD forwards and backwards” or do serial 7 test Abstraction: ask pt to interpret a proverb, and explain similarities between objects; lack of abstraction → concrete thinking Insight: pt’s awareness and understanding of his/her own problem Judgment: pt’s ability to understand the outcome of his/her actions –––––––––––––––– DIAGNOSIS –––––––––––––––– DSM-IV: axis I – mental illnesses, axis II –personality d/o and mental retardation, axis III – medical conditions, axis IV – psychosocial stressors, axis V – global assessment of function (scale 0-100) GAF ≤30: criteria for hospitalization Intelligence quotient: [IQ = 100 × (mental age / chronological age)], mean IQ is 100 w/ standard deviation of 15

Echolalia: imitating speech

Obsessions: persistent, intrusive thoughts that can’t be repressed, associated w/ anxiety

Dystonia: slow, sustained contraction of trunk or limbs, usually a side-effect of drugs

Compulsions: repetitive behaviors (often acting upon obsessions)

IQ tests: Stanford-Binet test for kids age 2-18, Wechsler Aduit Intelligence Scale (WAIS) for adults age 16-75

Ideas of reference: false belief that others are talking about him/her

Mental retardation: IQ < 70 and deficits in adaptive skills

Speech: pt’s ability to articulate thoughts; measured in terms of rate, amount, volume, articulation, tone Pressured speech: pt is uninterruptible and feels compelled to continue speaking Mood: what the pt feels in his own words; to assess mood, ask “how are you feeling today?” or “rate your mood on a scale of 1 to 10” Affect: how pt’s mood appears to the examiner

Ruminations: mood-congruent concerns that accompany state of depression/anxiety Perception: mental process by which sensory stimuli are brought to awareness Hallucinations: perceptions w/o external stimuli; five types – auditory (risk factor for SI/HI), visual, taste, olfactory, tactile

Labile affect: laughing one moment, then crying the next

Illusions: misperception of external stimuli

Flat affect: pt remains expressionless and monotone despite gravity of situation

Agnosia: inability to recognize people or objects even w/ intact sensory function

Inappropriate affect: pt laughs when told he has a serious illness, or told he faces criminal charges

Depersonalization: feeling that one is falling apart, fragmenting, detached, not oneself, etc.

Personality tests: Minnesota Multiphasic Personality Inventory (MMPI), Thematic Apperception Test (TAT), Rorschach test MMPI: objective personality test used to identify both personality d/o and other psychopathology TAT: pt creates stories based on pictures of people in various situations, used to evaluate motivation behind behaviors Rorschach test: interpretation of inkblots

Thought process: how the pt thinks Goal-directed: normal thought process Loosening of associations: no logical connection from one thought to another Flight of ideas: thoughts change rapidly from one to another, characteristic of mania Neologisms: made-up words

Derealization: feeling that the world is not real Synesthesia: sensation of one modality perceived by another (e.g. seeing sounds) Cognition: pt’s ability to perform mental tasks Alert + oriented x3: alertness controlled by reticular activating system; orientation refers to person, place, time

NSAID use: can ↓lithium excretion → ↑lithium concentrations (except sulindac and aspirin)

Ψ – Psychotic Disorders

–––––––––––––––– PSYCHOSIS –––––––––––––––– Psychosis: distorted perception of reality presenting as delusions, hallucinations, or severely disorganized thought/behavior

SCZ phases: prodromal phase (prepsychotic decline in functioning), psychotic phase, residual phase (negative sx b/t episodes of psychosis) Schizophrenia subtypes: paranoid, disorganized, catatonic, residual, undifferentiated

Psychosis in elderly: evaluate for delirium w/ EEG Psychosis-exacerbating drugs: β-blockers, digoxin, steroids, anticholinergics Delusion: fixed, false belief; two types – bizarre (impossible) and nonbizarre (could be true)

PSCZ: characterized by delusions and AH/CH, deafness is a risk factor DSCZ: characterized by disorganized speech, behavior, and flat or inappropriate affect

Paranoid/persecution delusion: irrational belief that one is being persecuted (e.g. CIA phone-tap)

CSCZ: characterized by rigid posture, inappropriate or repetitive movements, echolalia/echopraxia, and waxy flexibility

Delusion of reference: belief that cues in external environment are directed at individual

RSCZ: prominent negative sx (5 As – Anhedonia, flat Affect, Alogia, Avolition, poor Attention)

Delusion of control: thought insertion, thought withdrawal, and thought broadcasting are unique to SCZ

USCZ: doesn’t fulfill criteria for any other subtype

Schizoaffective disorder: SCZ + mood sx (either manic, depressive, or mixed episode), delusions or hallucinations w/o mood sx for 2 weeks; Tx antipsychotics + mood stabilizers + supportive psychotherapy SAD vs. mood disorders: SAD has 2 week period of psychotic sx w/o mood sx; worse Px than mood d/o Delusional disorder: nonbizarre, fixed delusions for 1+ month w/o functional impairment; 4 subtypes – paranoid, erotomaniac, jealous, somatic Paranoid/persecution delusions: irrational belief that one is being persecuted (e.g. CIA phone-tap) Erotomaniac delusions: delusions regarding love

Delusion of grandeur: belief that one has superpowers, or inflated self-esteem Delusion of guilt: false belief that one is responsible or guilty for something Somatic delusion: false belief that one is infected or has a certain illness Illusion: misinterpretation of sensory stimulus Hallucination: sensory perception w/o stimulus Auditory hallucination: most common in schizophrenia, command hallucinations are specific AH that tell pt to do things Visual hallucination: drug intoxication, drug/alcohol withdrawal, delirium, Lewy body dementia Tactile hallucination: cocaine or amphetamine intoxication, alcohol withdrawal Olfactory hallucination: seizure disorder, must r/o medical conditions Gustatory hallucination: r/o medical conditions

SCZ gender: men = women but men have earlier onset (20 y/o) than women (30 y/o), winter/early spring birthdays have ↑incidence (due to ↓sunlight → ↓vit D) SCZ prevalence: 1% overall, 10% siblings, 50% twins Postpsychotic depression: major depressive episode after resolution of psychotic symptoms Downward drift: ↑SCZ prevalence in lower socioeconomic groups (can’t hold onto good jobs) SCZ pathophysiology: ↑dopamine in mesolimbic pathway (positive sx), ↓dopamine in prefrontal ctx (negative sx); also ↑5-HT, ↑NE, ↓GABA, ↓glutamate SCZ brain: diffuse cortical atrophy w/ enlarged ventricles SCZ Px: good prognosis w/ later onset, good social support, positive sx, mood sx, acute onset, females, ↓relapses, and good premorbid function; 10% suicide SCZ Tx: atypicals first-line, typicals second-line, clozapine if other antipsychotics don’t work Antipsychotic side-effects: EPS (parkinsonism, akathisia, dystonia), NMS, tardive dyskinesia, antiHAM, metabolic syndrome, ↑prolactin, etc.

Psychosis 2/2 GMC: CNS diseases, endocrinopathy, B3/B9/B12 deficiency, lupus, or porphyrias; an axis I disorder but the GMC goes on axis III

SCZ × bad family: increased relapse rate

Substance-induced psychotic disorder: prescription meds, alcohol, cocaine, hallucinogens, marijuana, sedative-hypnotics, or PCP

Brief psychotic disorder: SCZ-like for <1 month; Tx antipsychotics + supportive psychotherapy

–––––––––––––– SCHIZOPHRENIA –––––––––––––– Schizophrenia: >6 months with 2/5 for at least 1 month – delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms

–––––––– OTHER PSYCHOTIC DISORDERS ––––––––

Brief psychotic vs. BPD: BPD can have brief, stressrelated psychoses that are part of the personality d/o and not brief psychotic d/o Schizophreniform disorder: SCZ-like for 1-6 months; Tx antipsychotics + supportive psychotherapy

Jealous delusions: aka Othello syndrome, delusions of unfaithfulness Somatic delusion: false belief that one is infected or has a certain illness (e.g. parasitosis) Delusional disorder Tx: psychotherapy (drugs ineffective) Shared psychotic disorder (folie á deux): pt picks up identical delusions as a significant other; Tx separation + psychotherapy, antipsychotics if not improved in 1-2 weeks following separation

Ψ – Mood Disorders

–––––––––––––––––– MOOD –––––––––––––––––– Mood: inner emotional state

Antidepressants: all equally effective and take 4-8 weeks for effect, SSRI/SNRI are first-line, maintain for 6-9 months

Bipolar II disorder: 1 hypomanic episode + 1 major depressive episode, no full manic episodes BII Tx: mood stabilizers (see BI)

Mood episode: distinct period of abnormal mood; includes major depressive, manic, hypomanic, and mixed episodes Mood disorder: loss of control over mood and subsequent functional impairment; includes MDD, bipolar I/II, dysthymic, and cyclothymic disorders –––––––––––––– MOOD EPISODES ––––––––––––––

MDD in kids: presents as irritability and short temper, rather than sadness or depression MDD in elderly: MC psychiatric disorder in elderly, ↑incidence s/p MI, stroke, and new admits to nursing homes MDD subtypes: melancholic, atypical, catatonic, psychotic, postpartum, seasonal affective disorder

Rapid cycling disorder: 4+ mood episodes in 1 year Rapid cycling Tx: carbamazepine Cyclothymic disorder: alternating hypomania and dysthymia for 2 years, no asx interval of >2 months, and no major depressive or manic episodes CtD Tx: mood stabilizers (see BI)

Major depressive episode: 5/9 SIGECAPS (including depressed mood or anhedonia) for 2 weeks – depressed mood, Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor activity, Suicidal ideation Manic episode: 3/7 DIGFAST (4/7 if irritable mood) for 1 week – Distractibility, Insomnia, Grandiosity, FOI, ↑Activity, Speech pressured, Thoughtlessness Hypomanic episode: 3/7 DIGFAST (4/7 if irritable mood) for 4+ days, no functional impairment or psychotic features (vs. manic episodes) Mixed episode: 5/9 SIGECAPS + 3/7 DIGFAST for every day of 1 week

Melancholic depression: characterized by anhedonia, excess guilt, anorexia, early morning awakenings, and psychomotor disturbance Atypical depression: characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, hypersensitivity to rejection; Tx MAOIs Catatonic depression: rare, characterized by catalepsy, purposeless movements, bizarre postures, and echolalia; Tx ECT Psychotic depression: MDD + delusions or hallucinations; Tx SSRI + antipsychotic Postpartum major depression: onset within 4 weeks of delivery, resolves w/o meds

––––––––––––– MOOD DISORDERS ––––––––––––– Mood disorder 2/2 GMC: must have direct causal, physiologic relationship to mood sx Substance-induced mood disorder: β-blockers (depression), steroids, levodopa, cocaine (mania), OCP (depression) Major depressive disorder: 1 major depressive episode, no manic or hypomanic episodes MDD prevalence: 16.2% (25-50% in elderly) MDD risk factors: stroke (30-50%, lasts 2 years), pancreatic cancer, loss of parent before age 11, genetics (70% in twins) MDD × sleep: difficulty falling asleep, multiple awakenings, and early morning awakenings; hypersomnia characteristic of atypical depression MDD etiology: monoamine hypothesis is most popular (↓5-HT/DA/NE), other causes include ↑cortisol, ↓thyroid, psychosocial and genetics MDD brain: reduced frontal lobe blood flow and metabolism MDD Px: 15% suicide, 30-40% alcoholism, only 50% receive Tx, 50-85% have another episode MDD Dx: Beck depression inventory MDD Tx: antidepressants ± psychotherapy; acute risk → hospitalization, elderly → use lower dose, unresponsive to drugs → add lithium or try ECT

Seasonal affective disorder: 2 consecutive years of 2 major depressive episodes during the same season, Sx triad – irritability, carb cravings, hypersomnia; Tx light therapy Dysthymic disorder: depressive sx for 2 years (1 year in kids) without overt major depressive episodes DtD Tx: antidepressants ± CBT DtD × psychosis: dysthymia can never have psychotic features, consider another diagnosis Double depression: major depressive disorder + dysthymic disorder during residual periods Grief: aka bereavement, normal reaction to a major loss, does not present w/ SI or disorganization Kübler-Ross stages of grief: denial, anger, bargaining, depression, acceptance Grief vs. depression: grief lasts <2 months and has illusions but no delusions, hallucinations, or SI Bipolar I disorder: aka manic depression, 1 manic or mixed episode; 1% lifetime prevalence, 5-10% with first-degree relatives BI Tx: mood stabilizers (lithium ↓ suicidality, carbamazepine for rapid cyclers, valproate for kids <12); pregnant mania → atypicals, h/o postpartum mania → lithium PPx but c/i to breastfeeding BI × antidepressants: will flip into manic mode

Minor depressive disorder: 2-4/9 SIGECAPS w/ functional impairment, euthymic periods also seen (vs. dysthymic disorder), 20% progress to MDD Suicide risk factors: SAD PERSONS – Sex (male), Age (<19 or >45), Depression, Previous attempt, EtOH or drugs, Rational thinking loss, Sickness, Organized plan, No spouse, Social support loss #1 suicide risk factor: previous attempt

Ψ – Anxiety and Adjustment Disorders

–––––––––––––––––– ANXIETY –––––––––––––––––– Anxiety: subjective experience of fear and its sympathetic response (e.g. ↑HR, ↑BP, SOB, etc.) Pathological anxiety: inappropriate to situation and interferes w/ daily functioning

Specific phobia Tx: CBT + desensitization is firstline, BDZs and β-blockers help w/ autonomic sx Social phobia: aka social anxiety disorder, same as specific phobia but related to social settings

Generalized anxiety disorder: excess anxiety + 3/6 DRIFTS for 6 months – Difficulty concentrating, Restlessness, Irritability, Fatigue, Tense muscles, Sleep disturbance

Common social phobias: public speaking, eating out, using public restrooms

GAD epidemiology: 45% prevalence, women > men; frequently comorbid w/ MDD, dysthymia, or other anxiety disorders

Social phobia vs. shyness: shyness + impairment of daily function = social phobia

GAD Tx: CBT + drugs (SSRIs, buspirone, venlafaxine)

Anxiety NTs: ↑NE, ↓GABA/5-HT Anxiety 2/2 GMC: hyperthyroidism, Graves disease, Sjogren syndrome, PE, pheochromocytoma, seizure disorders Substance-induced anxiety disorder: caffeine, theophylline, alcohol/sedative withdrawal, mercury, arsenic, benzene, organophosphates, penicillin, sulfonamides, sympathomimetics, antidepressants

Social phobia Tx: SSRI (paroxetine) + CBT is firstline, BDZs and β-blockers help w/ performance anxiety

–––––––––– ADJUSTMENT DISORDERS –––––––––– Obsession: intrusive, repetitive thought Compulsion: ritualistic behavior

–––––––––––– ANXIETY DISORDERS –––––––––––– Anxiety disorders: panic disorder, agoraphobia, specific and social phobias, OCD, PTSD, ASD, GAD, anxiety 2/2 GMC or substance use Anxiety d/o prevalence: 30% women > 19% men, more frequent in higher socioeconomic groups

GAD vs. phobias: anxiety is free-floating in GAD, rather than being fixed to specific situation

Obsessions of contamination: followed by excessive hand-washing or avoidance of feared contaminant Obsessions of doubt: followed by repeated checking to avoid potential danger (e.g. turning off stove, locking the door)

Adjustment disorder: behavioral or emotional sx following stressful life event, begins within 3 months after the event and ends within 6 months AD etiology: triggered by a non-life threatening psychosocial stressor AD Tx: psychotherapy, should resolve in 6 months by definition Adjustment vs. GAD: no stressor in GAD

Panic attack: peak in 10 min and last <25 min; 4 of the following PANICS – Palpitations, Abdominal distress, Numbness/nausea, Intense fear of death, Choking/chills/chest pain, Sweating/shaking/SOB PA risk factors: mitral valve Prolapse, Pulmonary embolus, Asthma, Angina, Anaphylaxis PA management: order labs (TSH, metanephrine, B12, etc.) to r/o medical and substance causes Panic disorder: PA + 1 of the following for 1 month – persistent concern of another PA, worry about implications of PA, change in behavior due to PA; may present as chest pain + normal EKG PD etiology: dysregulation of autonomic nervous system w/ NT imbalance (↑NE, ↓GABA/5-HT) PD Tx: high-dose SSRI for 8-12 months + CBT, short-term BDZs for immediate relief of attacks Agoraphobia: anxiety in places where escape is difficult or help is not readily available → avoidance of situation Common agoraphobias: bridges, crowds, buses, trains, open areas outside the home

Obsessions of symmetry/order: compulsively slow performance of task

Adjustment vs. PTSD: life-threatening event in PTSD

Intrusive thoughts: often sexual or violent thoughts → distress but no compulsion

Adjustment vs. MDD: consider MDD if sx last over 6 months

Somatic obsessions: cause pts to view parts of their body, waste, or secretions as abnormal

Adjustment vs. normal experience: adjustment has impaired level of social or occupational functioning

Obsessive-compulsive disorder: ego-dystonic obsessions → compulsions OCD etiology: abnormal 5-HT regulation, associated w/ head injury, epilepsy, basal ganglia d/o, and postpartum conditions; onset triggered by stressful life event in 60% of pts OCD epidemiology: 2.5% prevalence, frequently comorbid w/ ADHD and Tourette syndrome OCD vs. OCPD: OCD is ego-dystonic (marked distress over sx), OCPD is ego-syntonic OCD Tx: SSRI (fluvoxamine) is DOC, clomipramine is second line, last-resort is ECT or cingulotomy Acute stress disorder: PTSD for 2 days – 1 month ASD Tx: mobilize social supports

Specific phobia: persistent fear of object/situation → avoidance or tolerated w/ intense anxiety, must be >6 months if <18 y/o, common comorbidities include MDD and substance abuse Common specific phobias: animals, blood or needles, death, flying, heights, illness or injury Specific phobia epidemiology: most common mental disorder in the US, women > men

Post-traumatic stress disorder: traumatic event → intense fear for >1 month; characterized by RAIN – Re-experiencing the event, Avoidance of stimuli, Increased arousal, Numbing of responsiveness PTSD epidemiology: high MDD and substance abuse PTSD Tx: SSRIs are DOC, β-blockers good for hyperarousal sx

Ψ – Personality Disorders

–––––––––– PERSONALITY DISORDERS ––––––––––

––––––––––––––––– CLUSTER B –––––––––––––––––

Personality: stable, predictable emotional and behavioral traits

Antisocial personality disorder: selfish disregard for others → CONDUCT – Capriciousness, Oppressive, Nonconfrontational, Deceitful, Unlawful, Carefree, Temper issues

Personality disorder: maladaptive, ego-syntonic personality traits → functional impairment; 10-20% prevalence Cluster A: schizoid, schizotypal, paranoid; ↑association w/ psychotic disorders Cluster B: antisocial, borderline, histrionic, narcissistic; ↑association w/ mood disorders Cluster C: avoidant, dependent, obsessivecompulsive; ↑association w/ anxiety disorders PD-NOS: passive-aggressive, depressive, sadistic, self-defeating/masochistic

ASPD epidemiology: ↑incidence in prisoners and poor urban areas, high genetic component ASPD vs. conduct disorder: conduct disorder if <18 y/o, ASPD if ≥18 y/o ASPD vs. drug abuse: antisocial behavior may be 2/2 drug use, need to find out which came first ASPD Tx: psychotherapy is useless; SSRIs and mood stabilizers help w/ reducing aggression

AVPD vs. SPD: SPD want to be alone, AVPD want friends but are too shy to make any AVPD vs. social phobia: social phobia is a fear of embarrassment, AVPD is more a fear of rejection AVPD vs. DPD: both cling to relationships, but AVPD are slow to get involved while DPD actively and aggressively seek relationships AVPD Tx: psychotherapy + assertiveness training Dependent personality disorder: excessive need to be taken care of → OBEDIENT – Obsessive about approval, Bound by others’ decisions, Enterprises rarely initiated, Difficulty decision-making, Invalid feelings while alone, Engrossed w/ fears, Needs to be in a relationship, Tentative about decisions DPD defense mechanism: regression (reverting back to childlike behavior)

PD Tx: psychotherapy for all PDs except borderline (use DBT) and antisocial

Borderline personality disorder: IMPULSIVE – Impulsive, Moody, Paranoid, Unstable self-image, Labile relationships, Suicidal, Inappropriate anger, Vulnerable to abandonment, Emptiness

Personality traits vs. PD: PDs show impairment of social or occupational functioning, traits don’t

BPD buzzwords: “best doctor ever”, multiple meds don’t work, >5 allergies, h/o cutting

––––––––––––––––– CLUSTER A –––––––––––––––––

BPD epidemiology: women > men, high rate of childhood sexual abuse, 10% suicide rate

DPD vs. BPD/HPD: DPD have long-lasting relationships w/ one person, BPD/HPD are unable to maintain a long-lasting relationship

BPD defense mechanism: splitting (people are all good or bad, no in-betweens)

DPD Tx: psychotherapy (especially groups and social skills training)

Paranoid personality disorder: general distrust of others → suspicious of spouse and others, grudges, preoccupied w/ doubts, non-trusting, quick to counterattack, etc. PPD defense mechanism: projection (attributing inappropriate thoughts/emotions onto another) PPD vs. social isolation: pts w/o social support system can react w/ suspicion to others, DDx by getting collateral regarding baseline PPD Tx: psychotherapy Schizoid personality disorder: voluntary social withdrawal → ↓friends, ↓sexual interest, emotional detachment, indifferent to others, anhedonia, etc. SPD defense mechanism: fantasy (imagination used as an escape where others aren’t needed for emotional fulfillment) SPD vs. AVPD: SPD want to be alone, AVPD want friends but are too shy to make any

BPD Tx: dialectical behavior therapy (DBT) + setting clear boundaries Histrionic personality disorder: excessive attentionseeking and emotionality, inappropriately seductive, flirtatious, exaggeration-prone HPD defense mechanism: regression (reverting back to childlike behavior) and repression (unconsciously avoiding bad thoughts) HPD vs. BPD: HPD pts generally more functional; BPD pts more likely to have MDD, brief psychotic episodes, and attempt suicide

Obsessive-compulsive personality disorder: preoccupation w/ orderliness, control, and perfection at the expense of efficacy OCPD epidemiology: men > women, oldest child OCPD vs. OCD: OCD is ego-dystonic (marked distress over sx), OCPD is ego-syntonic OCPD vs. NPD: both involve achievement, but OCPD loves the work and NPD loves the status OCPD Tx: psychotherapy –––––––––––––––––– PD-NOS ––––––––––––––––––

HPD Tx: psychotherapy + setting clear boundaries Narcissistic personality disorder: poor self-esteem → need for admiration, lack of empathy, sense of entitlement, arrogance, “fishing for compliments”, takes advantage of others, etc.

Passive-aggressive personality disorder: stubborn, inefficient procrastinors that alternate between compliance and defiance, make excuses and manipulate others into doing their chores/errands PAPD Tx: psychotherapy

SPD Tx: psychotherapy Schizotypal personality disorder: eccentric thoughts or behavior + discomfort w/ close relationships → ↓friends, ideas of reference, suspiciousness, inappropriate/restricted affect, excessive social anxiety, magical thinking, etc.

DPD vs. AVPD: both cling to relationships, but AVPD are slow to get involved while DPD actively and aggressively seek relationships

NPD vs. ASPD: both characterized by exploiting others, but NPD is for self-elevation and ASPD is for material gain or subjugation of others NPD Tx: psychotherapy ± group therapy to learn empathy

STPD vs. SPD: SPD + eccentric behavior = STPD

––––––––––––––––– CLUSTER C –––––––––––––––––

STPD Tx: psychotherapy

Avoidant personality disorder: intense fear of rejection → AFRAID – Avoids occupation w/ others, Fear of criticism, Reserved unless sure of being liked, Always thinking rejection, Isolated from relationships, Distant from others

Depressive personality disorder: chronically unhappy, pessimistic, self-doubting, distressed, etc.

Ψ – Substance-Related Disorders

–––––– SUBSTANCE ABUSE & DEPENDENCE ––––––

EtOH × metronidazole/sulfa drugs: N/V

Abuse: 1/4 WILD for 1 year – Work/school/home obligation failure, Interpersonal consequences, Legal problems, Dangerous use

EtOH × pregnancy: fetal alcohol syndrome, leading cause of MR/DD in US Banana bag: thiamine + folate + MVI + MgSO4 + IVF

Dependence: 3/7 for 1 year – tolerance, withdrawal, time-consuming, can’t cut down, ↓activities, use > intended amount, use despite problems

Alcohol withdrawal: starts in 6-24 hrs and lasts 1 wk; mild sx = irritability, hand tremors, insomnia; moderate sx = ↑sympathetic activity; severe = DTs

Tolerance: need ↑amount to achieve same effect Withdrawal: substance-specific syndrome due to cesssation following heavy and prolonged use Substance-use epidemiology: 17% prevalence, MC substances are alcohol and nicotine, men > women (think VA population) Substance types: sedatives, stimulants, opioids, hallucinogens Sedatives: alcohol, sedative-hypnotics (e.g. BDZs and barbiturates), inhalants Stimulants: strong – cocaine, amphetamines, MDMA/MDEA; weak – caffeine, nicotine Opioids: heroin, oxycodone, codeine, dextromethorphan (cough syrup), morphine, methadone, meperidine (Demerol) Hallucinogens: phencyclidine (PCP), ketamine, psilocybin, mescaline, LSD, marijuana

EtOH withdrawal Tx: BDZ taper, banana bag, monitor sx w/ CIWA scale Alcohol dependence: 2/4 CAGE – Cut down, Annoyed by criticism, Guilty about drinking, Eye opener EtOH dependence Tx: disulfiram (Antabuse) blocks aldehyde DH → aversive reaction; naltrexone blocks opioid-R → ↓cravings; acamprosate → ↑GABA/↓glu → ↓cravings Wernicke-Korsakoff syndrome: COAT RACK Wernicke encephalopathy: acute thiamine deficiency → reversible Confusion, Ophthalmoplegia (CN6 palsy), Ataxia, Thought disturbances; Tx IV thiamine Korsakoff psychosis: chronic thiamine deficiency → irreversible Retrograde /Anterograde amnesia, Confabulations Sedative-hypnotics: BDZs, barbiturates, zolpidem, zaleplon, GHB, meprobamate, etc. BDZs: ↑GABA frequency, used for anxiety

Alcohol: potent CNS depressant (↑GABA, ↑5-HT, ↓VGCC, ↓glu), MC abused substance in the US Alcohol metabolism: alcohol + dehydrogenase → acetaldehyde + dehydrogenase → acetic acid; common cause of ↑anion gap metabolic acidosis Alcohol intoxication: ↓fine motor control (BAL 2050), ↓judgment and coordination (50-100), ataxic gait and balance (100-150), lethargy and amnesia (150-250), possible coma and death (>300) EtOH intoxication Dx: breathalyzer test, blood/urine testing (more accurate); labs show ↑LFTs (AST:ALT >2, ↑GGT, ↑CDT) + ↑MCV EtOH intoxication Tx: ABCs and banana bag; possible injury → head CT, massive EtOH within past hour → GI evacuation

Inhalant OD: death 2/2 ↓RR or arrhythmias Inhalant intoxication Tx: ABCs, identify solvent b/c some (e.g. leaded gas) may require chelation Inhalant withdrawal: rare –––––––––––––––– STIMULANTS ––––––––––––––––

Delirium tremens: delirium, VH/TH, gross tremor, autonomic instability, seizures → 15-25% mortality

––––––––––––––––– SEDATIVES ––––––––––––––––– Sedatives: alcohol, sedative-hypnotics (e.g. BDZs and barbiturates), inhalants

Inhalant intoxication: perceptual disturbances, psychosis, N/V, euphoria, lethargy → stupor → coma

Barbiturates: ↑GABA duration, used as anesthetics and antiepileptics, lower margin of safety vs. BDZs Sedative-hypnotic intoxication: drowsiness, confusion, slurred speech, incoordination, ataxia, etc. SH intoxication Dx: +UDS for variable amount of time

Stimulants: strong – cocaine, amphetamines, MDMA/MDEA; weak – caffeine, nicotine Cocaine: blocks DA reuptake → stimulant effect + activates reward system; blocks NE reuptake → vasoconstriction Cocaine intoxication: euphoria, ↑self-esteem, ↑sympathetic activity, TH, paranoia; possible death by MI, stroke, seizure, arrhythmia, or ↓RR Cocaine intoxication Dx: +UDS for 2-4 days Cocaine intoxication Tx: mild agitation/anxiety → BDZs, severe agitation/psychosis → haloperidol, T>102 → ice bath or cooling blanket Cocaine × alcohol: cocaethylene metabolite has 24× mortality vs. cocaine alone Cocaine dependence: purely psychological Cocaine dependence Tx: psychotherapy, no FDAapproved pharmacotherapy exists Cocaine withdrawal: aka crash, non-life threatening, extreme exhaustion following coke binge, severe depression → risk of suicide Cocaine withdrawal Tx: refer to Narcotics Anonmyous, resolves w/o meds Amphetamines: D-amphetamine, methylphenidate, methamphetamine; blocks DA/NE reuptake and causes DA/NE release → stimulant effect Amphetamine intoxication: dilated pupils, ↑libido, sweating, ↓RR, chest pain; heavy use → amphetamine psychosis (mimics SCZ)

SH OD: respiratory depression → death, especially when combined w/ EtOH

Amphetamine intoxication Dx: +UDS for 1-3 days

SH intoxication Tx: BDZs → flumazenil, barbiturates → IV NaHCO3

Amphetamine OD: hyperthermia, dehydration, rhabdomyolysis → renal failure

Sedative-hypnotic withdrawal: life-threatening, presents similar to alcohol withdrawal; barbiturate withdrawal has highest mortality rate of all drugs

EtOH × H2-blockers: ↑EtOH levels

Amphetamine intoxication Tx: IVF + electrolytes, treat hyperthermia Chronic amphetamine use: acne + meth mouth

SH withdrawal Tx: BDZ taper EtOH × sedative-hypnotics: respiratory depression → death EtOH × NSAIDs: GI bleeding EtOH × acetaminophen/INH: hepatotoxicity

Amphetamine withdrawal: prolonged depression GHB: aka sodium oxybate, CNS depressant that causes memory loss, respiratory distress, coma; common date rape drug, used to Tx cataplexy Inhalants: CNS depressants; includes solvents, glue, paint thinners, fuels, isobutyl nitrates

MDMA/MDEA: aka ecstasy and eve, both stimulants and hallucinogens that induce sense of closeness w/ others, associated w/ clubs and raves MDMA/MDEA × SSRI: serotonin syndrome

Ψ – Substance-Related Disorders

Caffeine: adenosine antagonist + PDE blocker → ↑cAMP, stimulant effect via dopaminergic system Caffeine intoxication: ↑sympathetic activity, anxiety, diuresis, insomnia, GI distress Caffeine OD: tinnitus, severe agitation, and arrhythmias (>1 g); seizures → death (>10 g)

Hallucinogen intoxication: perceptual changes, labile affect, dilated pupils, ↑RR/↑BP/↑HR usually lasting 6-12 hrs Hallucinogen intoxication Tx: monitor closely, agitated psychosis → BDZ or antipsychotics Hallucinogen withdrawal: no withdrawal syndrome, but LSD flashbacks can occur due to storage in fat

Caffeine intoxication Tx: supportive care PCP: aka angel dust, NMDA antagonist Caffeine withdrawal: headache, fatigue, irritability, drowsiness, mild depression Caffeine withdrawal Tx: self-resolves in 1 week Nicotine: nicotinic agonist, addictive effect through the dopaminergic system Nicotine prevalence: 21%, MCC of preventable morbidity and mortality in US Nicotine withdrawal: intense craving and dysphoria, anxiety, irritability, restlessness Nicotine withdrawal Tx: varenciline (Chantix) and buproprion (Zyban) are partial nicotinic agonists; nicotine patch or gum

PCP intoxication: RED DANES – Rage, Erythema, Dilated pupils, Delusions, Amnesia, Nystagmus (vertical or rotary is pathognomonic), Excitation, Skin dryness PCP intoxication Dx: +UDS for 3-8 days, labs show ↑CPK and ↑AST PCP OD: seizures, coma, possible death PCP intoxication Tx: monitor closely; mild agitation/anxiety → lorazepam, severe agitation or psychosis → haloperidol PCP withdrawal: no withdrawal syndrome, but flashbacks can occur due to storage in body fat

Nicotine × pregnancy: low birth weight and chronic pulmonary hypertension

Ketamine: aka special K, NMDA antagonist but less potent than PCP, often used as a date rape drug

–––––––––––––––––– OPIOIDS ––––––––––––––––––

Ketamine intoxication: tachycardia, tachypnea, hallucinations, and amnesia

Opioids: opiate receptor (μ/κ/δ) agonists; heroin, oxycodone, codeine, dextromethorphan (cough syrup), morphine, methadone, meperidine (Demerol) Opioid intoxication: respiratory depression, pupillary constriction (except Demerol → Dilation), sedation, ↓pain, ↓GI motility Opioid intoxication Dx: +UDS for 2-4 days; methadone and oxycodone are false negatives, poppy seed bagels are false positive

Marijuana: aka weed, main ingredient is THC → cannabinoid receptor agonist → inhibit adenylate cyclase → ↓cAMP Marijuana intoxication: euphoria, red eyes, dry mouth, munchies, anxiety, perceptual disturbances MJ intoxication Dx: +UDS for 3 days (single use) to 4 weeks (heavy users) MJ intoxication Tx: psychosocial interventions

Opioid OD: classic triad RAM – Respiratory depression, Altered mental status, Miosis Opioid intoxication Tx: ABCs, naloxone or naltrexone will help respiratory depression but can precipitate withdrawal syndrome

Chronic MJ use: respiratory sx + gynecomastia Marijuana withdrawal: irritability, anxiety, restlessness, depression, headaches, etc. MJ withdrawal Tx: supportive care

Meperidine × MAOI: serotonin syndrome Opioid withdrawal: violent yawning, dilated pupils, abdominal cramps, ↑secretions (lacrimation, rhinorrhea, sweating, nausea/vomiting, diarrhea); not life-threatening Opioid withdrawal Tx: moderate → CLIP – Clonidine, Loperamide, Ibuprofen, Promethazine; severe → methadone or buprenorphine detox, monitor sx w/ COWS scale –––––––––––––– HALLUCINOGENS –––––––––––––– Hallucinogens: psilocybin (shrooms), mescaline (peyote cactus), LSD (acid); LSD acts on 5-HT system

Dronabinol (Marinol): pill-form of THC used to Tx anorexia in AIDS pts and N/V in chemotherapy pts

Ψ – Cognitive Disorders

Cognitive disorder: significant change in cognition from previous level of functioning; two types – delirium and dementia

Definition

Onset Duration Px Amnesia Alert Oriented Dx

Delirium waxing-andwaning change in pt’s level of consciousness acute 3 days – 2 wks reversible immediate and recent memory no no abnormal EEG

Dementia impairment in memory and other cognitive functions chronic months – yrs irreversible recent and remote memory yes sometimes abnormal MRI

Dementia × hypothyroidism: reversible, presents as obesity, coarse hair, constipation, and cold intolerance; Dx TSH and T4 levels Dementia × ↓B12: presents as diminshed position and vibration sensation; Dx B12 levels Dementia × neurosyphilis: presents as diminshed position and vibration sensation, and ArgyllRobertson pupils (accomodates but doesn’t respond to light); Dx CSF FTA-ABS or VDRL levels Dementia × Wilson disease: presents as tremor, ↑LFTs, and Kayser-Fleischer corneal rings; Dx ↓serum ceruloplasmin levels

––––––––––––––––– DELIRIUM –––––––––––––––––

Mini Mental State Exam (MMSE): screening test to Dx dementia; 30 is perfect score, <25 is dementia

Delirium: aka encephalopathy, waxing-and-waning change in pt’s level of consciousness; commonly presents w/ VH, short attention span, and impaired recent memory

Alzheimer disease: MCC dementia → gradual progressive decline in memory and other cognitive functions, average 10 yrs from onset to death

Delirium risk factors: common in elderly, ICU pts, s/p surgery pts, and cancer pts Delirium management: r/o life-threatening causes, then ID and Tx the underlying cause Delirium causes: AEIOU TIPS – Alcohol/drug toxicity or withdrawal, Electrolyte imbalance, Iatrogenic, Oxygen hypoxia, Uremia/hepatic encephalopathy, Trauma, Infection, Poison, Seizures, Stroke Delirium × CVA/mass lesion: presents as focal neuro sx (e.g. hemiparesis); Dx brain CT/MRI Delirium × HTN encephalopathy: presents as ↑BP and papilledema; Dx brain CT/MRI Delirium × drug intoxication: presents as ↑HR and dilated pupils; Dx urine toxicology screen Delirium × meningitis: presents as fever, nuchal rigidity, and photophobia; Dx lumbar puncture Delirium × thyrotoxicosis: presents as ↑HR, tremor, and thyromegaly; Dx TSH and T4 levels Delirium × hepatic encephalopathy: due to ↑ammonia, Tx lactulose + neomycin

Dementia: progressive and irreversible impairment in memory and other cognitive functions w/o change in level of consciousness Dementia epidemiology: prevalence doubles every 5 years (1.5% at 60, 40% at 90) Dementia management: r/o reversible causes Dementia types: Alzheimer (#1), vascular (#2), Lewy body (#3), Pick/FTD, HIV-associated, Huntington, Cruetzfeldt-Jakob, normal pressure hydrocephalus

Pick disease/frontotemporal dementia: diverse group of dementias, average 5 yrs from onset to death (more rapid than Alzhimer) Pick/FTD Sx: profound changes in personality and social conduct, disinhibition, hyperorality, hypersexuality; good memory and language though Pick/FTD brain: gross – marked atrophy of frontal and temporal lobes; microscopic – neuronal loss and astrocytosis of cortical layer II Pick/FTD Tx: anticholinergics and antidepressants help w/ behavior but not cognition HIV-associated dementia: MCC dementia due to infectious disease, neutropenia → infection → dementia

AD NTs: ↓ChAT → ↓ACh synthesis

HAD Sx: rapid decline in memory, cognition, behavior, and motor skills; depression and social withdrawal also common

AD etiology: amyloid cascade hypothesis – high risk genes (presenilin I, presenilin II, APP, and apoE4) predispose to excess Aβ-amyloidosis

HAD Tx: HAART

AD Dx: diagnosis of exclusion, definitive diagnosis requires brain biopsy AD brain: gross – diffuse atrophy with enlarged ventricles and flattened sulci; microscopic – senile plaques, neural plaques, and neurofibrillary tangles (not specific to Alzheimer)

Huntington disease: AD disorder due to CAG trinucleotide repeats on chromosome 4, shows anticipation (longer CAG repeats correlates with earlier age of onset) HD Sx: chorea, apathy, depression, and dementia with onset at 35-50 y/o, ↑rate of suicide HD brain: atrophy of caudate nucleus

AD Tx: AChE-inhibitors for mild-to-moderate AD (tacrine, donepezil, rivastigmine, galantamine), NMDA antagonist for moderate-to-severe AD (memantine) Alzheimer × Down syndrome: trisomy 21 → triple apoE4 expression → inevitable Alzheimer by 40 y/o Vascular dementia: 2nd MCC dementia, due to accumulation of multiple small infarcts → stepwise loss of function + focal neurological sx VD Dx: multiple small lacunar infarcts on CT scan, sensitive but not specific for vascular dementia

Parkinson disease: loss of dopaminergic neurons → both physical and cognitive impairment

VD risk factors: previous stroke, diabetes, HTN

PD Sx: early PD presents as TRAP – Tremor, Rigidity, Akinesia, Postural instability; late PD presents as Alzheimer-like dementia

VD Tx: no effective cure; AChE-inhibitors and antihypertensives can help

PD brain: neuronal death in substantia nigra, senile plaques, and neurofibrillary tangles

Sundowning: worsening of delirium at night ––––––––––––––––– DEMENTIA –––––––––––––––––

LBD Tx: AChE-inhibitors for VH, antiparkinsonians and psychostimulants for motor sx

VD × frontal lobe infarct: sx of schizophrenia, depression, and bipolar I disorder Lewy body dementia: 3rd MCC dementia, due to Lewy body and neurite accumulations in the basal ganglia LBD Sx: presents as waxing-and-waning parkinsonism, VH, and antipsychotic sensitivity LBD Dx: onset of dementia within 12 mo of parkinsonism (after 12 mo of onset is Parkinson’s)

PD Tx: early PD → carbidopa + levodopa (Sinemet), late PD → subthalamic nucleus deep brain stimulation; antipsychotics will exacerbate dementia due to PD Prion diseases: Creutzfeldt-Jakob disease, kuru, Gerstmann-Straussler syndrome, fatal familial insomnia, bovine spongiform encephalopathy Creutzfeldt-Jakob disease: rapidly progressive CNS degeneration due to abnormal prion accumulation; either inherited, sporadic, or acquired

Ψ – Cognitive Disorders

CJD Sx: rapidly progressive dementia, myoclonus (muscle spasms), and personality changes CJD Dx: probable – clinical picture + periodic generalized sharp waves on EEG; definitive – spongiform change on brain biopsy Normal pressure hydrocephalus: potentially reversible dementia due to ↑CSF pressure → enlarged ventricles NPH Sx: 3 Ws – Wet (urinary incontinence), Wobbly (gait apraxia), Wacky (dementia) NPH Tx: CSF shunt to relieve pressure Pellagra: vitamin B3 (niacin) deficiency → 3 Ds – Diarrhea, Dermatitis, Dementia Herpes encephalopathy: involves temporal lobes

Ψ – Geriatric Psychiatry

––––––––––––– GEROPSYCHIATRY ––––––––––––– Normal aging: ↓brain volume w/ enlarged ventricles, ↓muscle, ↑fat, ↓vision/hearing, minor forgetfulness Elderly × MDD: MC psychiatric disorder in elderly, ↑incidence s/p MI, stroke, and new admits to nursing homes Elderly × suicide: white elderly males have highest rate of successful suicides

Definition

Onset Features

Tx

Pseudodementia MDD + cognitive defects due to underlying depression acute often answers “I don’t know”, aware of problems cognitive defects respond to antidepressants

Dementia impairment in memory and other cognitive functions chronic confabulates answers, unaware of problems cognitive defects persist despite antidepressants

Pseudodementia: MDD + cognitive defects due to underlying depression, often mistaken for dementia Pseudodementia Tx: supportive psychotherapy + low-dose antidepressants (SSRIs > TCAs/MAOIs, use nortriptyline if TCA is preferred); depression + low appetite + insomnia → mirtazapine Dementia: progressive and irreversible impairment in memory and other cognitive functions w/o change in level of consciousness Dementia epidemiology: prevalence doubles every 5 years (1.5% at 60, 40% at 90) Dementia types: Alzheimer (#1), vascular (#2), Lewy body (#3), Pick/FTD, HIV-associated, Huntington, Cruetzfeldt-Jakob, normal pressure hydrocephalus Dementia Tx: behavioral and environmental Tx preferred over pharmacotherapy (see cognitive disorders for specifics) Grief: aka bereavement, normal reaction to a major loss, does not present w/ SI or disorganization Kübler-Ross stages of grief: denial, anger, bargaining, depression, acceptance Normal grief: normal response to loss, lasts <2 months and has illusions but no delusions, hallucinations, or SI Complicated grief: lasts ≥6 months and 4/8 Tired And NUMBED – Trouble accepting loss, Agitation, Numbness, Untrusting, Meaninglessness, Bitterness, Emptiness, Difficulty moving on Bereavement-associated depression: essentially MDD following death or loss, similar to complicated grief but may have delusions, hallucinations, or SI

BAD Tx: antidepressants ± psychotherapy; acute risk → hospitalization, unresponsive to drugs → ECT (safe and effective in elderly) Elderly × alcohol abuse: elderly have ↓alcohol dehydrogenase → ↑BAL w/ fewer drinks; ↑CNS sensitivity to alcohol Medical conditions worsened by alcohol: liver diseases, GI diseases, CV diseases, gout, diabetes, depression, anxiety Elderly × sleep: ↓sleep efficiency and ↓total sleep (↑stage 1-2, ↓stage 3-4, ↓REM latency, ↓total REM); ↑incidence of sleep disorders Periodic leg movements: restless leg movements during sleep, due to dopamine imbalance Sleep disturbance Tx: fix sleep hygiene, stop drinking, stop napping, fix underlying causes; hydroxyzine or trazodone are second-line Elderly × antidepressants: elderly are very sensitive to anticholinergic side-effects, including dry mouth, constipation, blurry vision, etc. –––––––––– OTHER GERIATRIC ISSUES –––––––––– Restraints: should be used as a last resort in nonemergency situations, consider pt health and safety Medications: polypharmacy is common in elderly, ↑side-effects due to ↓liver/kidney function and ↓lean body mass Elderly abuse: 10% incidence, perpetrator is usually the caregiver of the victim; can be physical, psychological, neglect, or exploitation (rarely sexual) Nursing homes: provide care and rehab for both chronically ill and short-term care pts; 50% stay on permanently, 50% are d/c after a few months

Ψ – Child Psychiatry

––––––––––– MENTAL RETARDATION ––––––––––– Mental retardation: IQ ≤ 70 and deficits in adaptive skills, with onset before 18 y/o MR/DD types: profound <25, severe 25-40, moderate 40-55, mild 55-70 (intervals of 15) MR/DD causes: 50% idiopathic, Down syndrome (MC genetic), Fragile X (MC inherited), fetal alcohol syndrome (overall MCC); prenatal, perinatal, or postnatal pathology TORCHES complex: perinatal infections than can lead to MR/DD, includes Toxoplasmosis, Rubella, CMV, Herpes simplex, Syphilis Prader-Willi syndrome: partial deletion of 15q → MR/DD, obesity, hypogonadism, almond eyes Fragile X syndrome: MC inherited form of MR/DD; X-linked CGG trinucleotide expansion in FMR1 gene causes DSM-IV – Discontinued chromosomal staining, Shows anticipation, Males, Mental retardation, Macrognathia, Macroorchidism Learning disorders: achievement in reading, writing, or math that is significantly lower than expected; must r/o sensory deficits first Learning disorder types: reading disorder (MC), mathematics disorder, writing disorder Learning disorder Tx: remedial education –––––– DISRUPTIVE BEHAVIOR DISORDERS –––––– Disruptive behavior disorders: includes oppositional defiant disorder and conduct disorder Oppositional defiant disorder: >6 months of hostile and defiant behavior towards parents/teachers, but perfectly fine w/ peers ODD Tx: individual psychotherapy + family involvement Conduct disorder: hostile and defiant behavior towards everyone CD in boys: cruelty to animals, fighting, stealing, fire-setting, vandalism CD in girls: lying, running away, promiscuity CD Px: 40% of conduct d/o → ASPD CD Tx: multimodal approach w/ family and teacher involvement CD vs. ASPD: conduct disorder <18 y/o, ASPD ≥18 y/o CD vs. ODD: unlike conduct disorder, ODD doesn’t involve physical aggression or violation of basic rights of others CD vs. pyromania: pyromaniacs light things on fire due to inner tension, not out of anger issues

Attention deficit disorder: >6 months of hyperactivity, inattentiveness, or both; onset before 7 y/o ADHD types: inattentive type, hyperactiveimpulsive type, combined type ADHD prevalence: boys > girls, >50% have comorbid psychiatric diagnosis

CDD vs. Rett: similar loss of previously acquired skills, but CDD has no ↓head growth or hand wringing –––––––– OTHER PEDIATRIC DISORDERS –––––––– Tic disorders: characterized by sudden, repetitive, involuntary movements (motor tics) or vocalizations (vocal tics); one of few DSM-IV Dx that don’t require significant distress as a qualifier

ADHD Px: 50% go onto adulthood untreated Coprolalia: repetitive speaking of obscene words ADHD Tx: CNS stimulants are DOC w/ 75% success rate, second-line is atomoxetine and α2-agonists (clonidine, guanfacine) ADHD vs. MR/DD: both struggle w/ academic performance, so differentiate via IQ tests

Echolalia: exact repetition of words Tourette disorder: most severe tic disorder w/ multiple daily motor/vocal tics, onset before 18 y/o

––– PERVASIVE DEVELOPMENTAL DISORDERS –––

Tourette prevalence: very rare; ↑rate of comorbid OCD (40%) and ADHD (50%)

Pervasive developmental disorders: includes autism, Asperger, Rett, and childhood disintegrative d/o

Tourette etiology: multifactorial, involves impaired dopamine regulation in caudate nucleus

Autistic disorder: characterized by problems w/ social interaction, impaired communication, and repetitive/stereotyped patterns of behavior and activity; must be present by 3 y/o

Tourette Tx: risperidone and α2-agonists (clonidine, guanfacine) are DOC; severe cases → typical antipsychotics, tics+OCD → SSRIs

Autism prevalence: 70% meet criteria for MR/DD; associated w/ fragile X syndrome, tuberous sclerosis, and seizures Autism Px: most important predictors of adult outcome are intelligence and communication Autism Tx: no cure, but remedial education and behavioral therapy can help w/ developing skills Autism vs. deafness: toddler w/ ↓communication skills needs hearing test to r/o deafness Asperger disorder: mild autism w/ normal language skills and cognitive development, often rigid and overly formal in social interaction

Enuresis: involuntary urination (bed-wetting) after 5 y/o, ≥2/week for 3 months Enuresis etiology: genetics, stress (MC), small bladder, or ↓nocturnal ADH Enuresis Tx: DDAVP is DOC, imipramine is secondline Encopresis: involuntary defecation after 5 y/o, ≥1/month for 3 months Encopresis etiology: genetics, stress, lack of sphincter control, or constipation w/ overflow incontinence (MC) Encopresis Tx: usually remits spontaneously, bowel catharsis + stool softeners if it doesn’t

Aspie Tx: supportive Tx similar to autism Rett disorder: normal development for 5 months, followed by ↓rate of head growth and loss of purposeful hand movements; then ataxia, ↓language skills, and “hand wringing” Rett etiology: ΔMECP2 on X chromosome (only girls get the disease, guys all die in utero) Rett Px: cognitive development never progresses beyond first year of life, ↑risk of sudden death

Selective mutism: refusal to speak in certain situations for ≥1 month despite normal language and comprehension skills Mutism Tx: psychotherapy, behavioral therapy, management of anxiety Separation anxiety disorder: excessive fear of leaving parents or other figures for ≥4 weeks SAD Px: risk factor for development of panic d/o or agoraphobia as an adult

Rett Tx: supportive care Childhood disintegrative disorder: normal development for >2 years, then loss of previously acquired skills before 10 y/o CDD prevalence: boys > girls, ↑rate of abnormal EEG and seizures CDD Tx: supportive care

SAD Tx: family therapy, CBT, low-dose antidepressants Child abuse: either physical abuse, emotional abuse, sexual abuse, or neglect (MC); doctors must report to child protective services Sexual abuse prevalence: 15-25%, perpetrator is usually the child’s parent

Ψ – Dissociative Disorders

–––––––––– DISSOCIATIVE DISORDERS –––––––––– Dissociation: loss of memory, identity, or sense of self; often following trauma, may involve NE + glu Abreaction: strong reaction pts get when retrieving traumatic memories Dissociative disorders: dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization disorder, dissociative disorder NOS Dissociative amnesia: 1+ episode of inability to recall personal information; not due to TBI, medical condition, substance abuse, or ordinary amnesia DA epidemiology: MC dissociative disorder, ↑incidence of MDD and anxiety disorders DA Tx: psychotherapy; most acute cases return to normal after min-days, lorazepam or amobarbital often used to help pt talk freely during interview DA vs. dementia: DA can’t recall common personal info but can remember obscure details, dementia can remember personal info but not obscure details Dissociative fugue: sudden, unexpected travel away from home + inability to recall one’s past DF epidemiology: rare, usually follows stressful life event or personal conflict DF Tx: same as DA DF vs. DA: DA pts are aware of what they can’t seem to remember, DF don’t acknowledge the amnesia DF vs. transient global amnesia: DA pts show loss of identity, global amnesia have difficulty with more recent events but identity remains intact Dissociative identity disorder: 2+ distinct identities + inability to recall information about non-dominant personalities; not due to substance abuse or medical condition, existence is controversial DID epidemiology: usually women w/ prior trauma (e.g. childhood sexual abuse); ↑incidence of MDD, anxiety, BPD, substance abuse, suicide DID Tx: psychotherapy; worst Px of all dissociative disorders DID DDx: DID-like sx may be seen in BPD, psychosis, or malingering (factitious disorder) Depersonalization: feeling that one is falling apart, fragmenting, detached, not oneself, etc. Derealization: feeling that the world is not real Depersonalization disorder: persistent or recurrent episodes of being detached from one’s body or mental processes; not due to substance use or medical condition

DPD epidemiology: women > men, severe stress is a risk factor, ↑incidence of MDD and anxiety disorders DPD Tx: usually chronic, anxiety or MDD → anxiolytics or SSRIs DPD vs. normal stress: transient depersonalization is common during times of stress Dissociative disorder NOS: loss of memory, identity, or sense of self; but doesn’t meet criteria for other dissociative disorders Ataque de nervios: Puerto Rican culturally-bound trance disorder that consists of convulsive movements, fainting, crying, and visual problems Ganser syndrome: giving of approximate answers to simple questions (e.g. “how many legs do you have?”)

Ψ – Somatoform and Factitious Disorders

––––––––––––––––––– GAIN ––––––––––––––––––– Primary gain: internal motives (e.g. stress, anxiety) as the cause of symptoms Secondary gain: external motives (e.g. attention, money, avoiding law) as the cause of symptoms Münchhausen syndrome: aka factitious disorder, consciously feigning symptoms to play the sick role (primary gain) Münchhausen Sx: triad of 3 Ps – Peregrination, Pseudologia phantastica, Polysurgery Münchhausen Tx: establish therapeutic alliance, avoid confrontation and unnecessary procedures Münchhausen by proxy: intentionally producing symptoms in someone else, usually one’s children → must report child abuse Malingering: consciously feigning symptoms for external motives (secondary gain), presents w/ multiple vague complaints and a long medical hx –––––––––– SOMATOFORM DISORDERS –––––––––– Somatoform disorders: not consciously feigning symptoms, though no direct link to medical cause; 50% have comorbid anxiety d/o or MDD Somatoform disorders × gender: women > men, except hypochondriasis where women = men Somatization disorder: onset before 30 y/o with multiple sx (4 pain + 2 GI + 1 sexual/GU + 1 neuro) that are not intentionally produced Somatization Px: chronic and debilitating, worse under stress Somatization Tx: r/o potential medical causes, regularly scheduled visits w/ a single PCP who limits extensive medical work-ups Somatization vs. conversion: somatization pts are concerned over condition, conversion don’t care Conversion disorder: conversion of a psych issue into a neurological one, not limited to pain or sexual dysfunction, preceeded by conflict or stressors Conversion Sx: commonly paralysis, blindness, mutism, parasthesias, seizures, globus hystericus La belle indifference: apathy despite severity of condition Conversion Tx: most spontaneously recover; if it persists → insight-oriented psychotherapy, hypnosis, or relaxation therapy Conversion in elderly: high chance of real neuro deficit, get a neuro consult Conversion × seizures: use EEG to differentiate between epileptic vs. nonepileptic seizures

Conversion × neuropathy: consider multiple sclerosis Hypochondriasis: preoccupation w/ fear of having or contracting a disease, based on misinterpretation of bodily sx, for >6 months Hypochondriasis epidemiology: 80% have comorbid GAD or MDD (vs. 50% in other somatoform d/o), men = women (vs. women > men in other somatoform d/o) Hypochondriasis Tx: regularly scheduled visits w/ a single PCP Hypochondriasis vs. somatization: somatization pts have a long list of sx, hypochondriacs are worried about a specific disease Hypochondriasis vs. BDD: hypochondriasis + about a specific body part = body dysmorphic disorder Body dysmorphic disorder: self-consciousness + preoccupation w/ imagined defect in appearance BDD Tx: optional CBT ± SSRIs, avoid cosmetic procedures Pain disorder: significant pain as the CC, not fully accounted for by a medical condition, not feigned, and not regarding sex only (dyspareunia); acute if <6 months, chronic if >6 months Pain Tx: validate pt’s pain, moderate → biofeedback and relaxation techniques, severe → antidepressants (not analgesics)

Ψ – Impulse Control Disorders

–––––––– IMPULSE CONTROL DISORDERS –––––––– Impulse control disorders: IED, kleptomania, pathological gambling, trichotillomania, pyromania Core qualities: anxiety before act, repetitive or compulsive act in spite of consequences, lack of control during act, relief or satisfaction after act Intermittent explosive disorder: recurrent episodes outbursts of aggression against people or property that remit quickly and spontaneously IED Dx: ↓5-HIAA in CSF IED Tx: SSRIs + lithium + propanolol; individual psychotherapy is difficult and ineffective IED vs. amok: amok has amnesia and only in Asians Kleptomania: inability to resist urges to steal objects not needed for personal use or monetary reasons Klepto etiology: multifactorial but ↑ with stress; ↑incidence of OCD, mood disorders, and eating disorders (25% of bulimics are klepto) Klepto Tx: insight-oriented psychotherapy + behavioral therapy + SSRIs; anecdotal evidence exists for naltrexone Pathological gambling: persistent and recurrent maladaptive gambling behavior Gambling etiology: multifactorial; ↑incidence of OCD, mood disorders, and anxiety disorders Gambling Tx: Gamblers Anonymous is first-line, after 3 months of abstinence → insight-oriented psychotherapy, treat comorbid problems Trichotillomania: recurrent, repetitive, intentional pulling out of one’s hair causing visible hair loss Tricho etiology: multifactorial; ↑incidence of OCD/OCPD, borderline PD, and mood disorders Tricho Tx: behavioral therapy + SSRIs, lithium, or antipsychotics Pyromania: 1+ episode of deliberate fire setting + fascination or attraction to fire; not for monetary gain, expression of anger, or political statement Pyro Tx: supervision + behavioral therapy + SSRIs

Ψ – Eating Disorders

––––––––––––– EATING DISORDERS ––––––––––––– Eating disorders: anorexia nervosa, bulimia nervosa, binge-eating disorder (eating disorder NOS) Anorexia nervosa: fear of being fat → <85% ideal body weight, amenorrhea in postmenarchal females

Bulimia complications: SPARKED – Sialadenosis, Petechiae, Aspirations, Arrhythmias due to ↓K+, Russell’s sign, Kleptomania (25%), Esophagitis, Edema, Dental erosions or caries Russell’s sign: calloused knuckles due to hitting incisor teeth when inducing the gag reflex

Anorexia subtypes: restrictive type doesn’t eat and has OCPD traits; binge/purge type binge eats followed by vomiting or exercising

Bulimia lab values: vomiting → contraction alkalosis, laxatives → metabolic acidosis; ↑BUN, ↑HCO3-, ↑amylase, ΔT4/T3, Δcortisol

Anorexia prevalence: 1%, most commonly in women in industrialized countries

Bulimia vs. binge-eating disorder: both like to binge, but bulimics try to control their weight afterwards

Anorexia Px: 10% mortality due to starvation, suicide (57× normal rate), or cardiac failure

Binge-eating: excessive food intake within 2 hr period + sense of lack of control

Anorexia Tx: food (behavioral therapy + family therapy + supervised weight-gain programs); excessive weight preoccupation → low-dose 2G antipsychotics, preprandial anxiety → BDZs

Binge-eating disorder: recurrent binge-eating w/o compensatory behavior, 2/wk for 6 months

Anorexia complications: BATCH – Bone loss (osteopenia/osteoporosis), Amenorrhea, ↓Thyroid, Constipation, Heart problems (cardiomyopathy, ACS, MVP, arrhythmias due to ↓K+) Anorexia lab values: ↑cortisol, QTc, chol, BUN, GH; ↓RBC/WBC, LH/FSH, E/T, T4/T3, glucose Anorexia × purging: contraction (hypokalemic, hypochloremic metabolic) alkalosis Anorexia DDx: endocrine disorders, GI diseases, genetic disorders, cachexia (due to cancer/AIDS), MDD, bulimia Anorexia vs. bulimia: both may binge and purge, but bulimics are normal weight and anorexics are <85% Anorexia vs. MDD: both may refuse to eat, but anorexics starve in spite of a good appetite and MDD have poor appetite Refeeding syndrome: occurs when severely malnourished pts are refed too quickly → fluid retention and ↓Ca/Mg/Ph → RADS – Respiratory failure, Arrhythmias, Delirium, Seizures Refeeding syndrome Tx: slow feedings and replace electrolytes Bulimia nervosa: binge eating + behaviors intended to counteract weight gain, 2/wk for 3 months Bulimia subtypes: purging type involves vomiting, laxatives, enemas, or diuretics; nonpurging type involves excessive exercise or fasting Bulimia prevalence: 1-4%, most commonly in women in industrialized countries Bulimia Px: chronic and relapsing, but better Px than anorexia nervosa Bulimia Tx: SSRIs (fluoxetine) + therapy (CBT); avoid buproprion which can ↓seizure threshold

BED Tx: psychotherapy + behavioral therapy + diet/exercise program; drugs can be used as an adjunct (stimulants, orlistat, sibutramine)

Ψ – Sleep Disorders

––––––––––––––––––– SLEEP ––––––––––––––––––– Normal sleep cycle: non-rapid eye movement sleep (stages 1-4) alternating w/ REM sleep every 90 min NREM: deeper sleep progression through stages; stage 2 is tooth grinding, stage ¾ (delta sleep) is sleepwalking, bedwetting, and sleep terrors REM: dreaming, loss of motor tone, erections, sympathetic activity (↑HR, ↑RR, ↑BP) Sleep EEG waveforms: BATS Drink Blood – Beta (awake), Alpha (resting), Theta (1), Sleep spindles and K complexes (2), Delta (¾), Beta (REM) Sleep disorders: dyssomnias and parasomnias ––––––––––––––– DYSSOMNIAS ––––––––––––––– Dyssomnias: ↑/↓ or altered timing of sleep Primary insomnia: ↓sleep duration and/or quality; acute insomnia 1-4 wks, chronic insomnia >1 month PI subtypes: sleep-onset insomnia (can’t go to sleep), sleep-maintenance insomnia (can’t stay asleep), sleep-offset insomnia (early morning awakenings), nonrestorative sleep (wake up still tired) PI etiology: usually poor sleep hygiene PI Tx: fix sleep hygiene, Chronic insomnia → CBT, acute insomnia → long-term BDZs or non-BDZ hypnotics, insomnia + depression → trazodone Obstructive sleep apnea: difficulty breathing during sleep → snoring and apneic episodes → sleep fragmentation → excessive daytime sleepiness OSA etiology: repetitive upper airway collapse due to obesity and/or airway narrowing OSA Tx: first-line is weight loss and exercise, second-line is CPAP or BiPAP, third-line is surgery Narcolepsy: excess daytime sleepiness, cataplexy (suddenly fainting w/ intense emotion), hypnogogic and hypnopompic hallucinations Narcolepsy etiology: loss of hypothalamic neurons that contain hypocretin, may have autoimmune component

Circadian rhythm sleep disorders: caused by defect in circadian pacemaker or impaired entrainment; includes DPSD, APSD, SWD, and jet lag disorders Delayed sleep phase disorder: sleep onset and awakening are delayed, but normal duration/quality DPSD Tx: bright light phototherapy in the morning, melatonin in the evening Advanced sleep phase disorder: sleep onset and awakening are early, but normal duration/quality APSD Tx: bright light phototherapy in the evening Shift-work disorder: sleep schedule is messed up due to nontraditional work hours SWD Tx: avoid risk factors, severe → modafinil Jet lag disorder: sleep schedule is messed up due to travel across multiple time zones Jet lag Tx: resolves by itself 2-3 days after travel ––––––––––––––– PARASOMNIAS ––––––––––––––– Parasomnias: unusual sleep-related behaviors (e.g. movements, emotions, dreams, autonomic activity) Sleepwalking: walking around during stage ¾ sleep with “glassy look” on eyes, confusion or violence on forced awakening, amnesia for episode Sleepwalking etiology: unknown, usually not associated w/ any psychiatric problems Sleepwalking Tx: ensure child safety and wait; refractory cases → BDZs (clonazepam) or TCAs Sleep terrors: sudden arousal w/ screaming during stage ¾ sleep, sympathetic activity, confusion or violence on forced awakening, amnesia for episode Sleep terror etiology: ↑comorbidity w/ restless leg syndrome and sleep-disordered breathing Sleep terror Tx: ensure child safety and wait; refractory cases → BDZs (clonazepam) Nightmare disorder: recurrent nightmares w/ vivid recall, no confusion or disorientation on awakening Nightmare etiology: seen in >50% PTSD pts

Narcolepsy Tx: fix sleep hygiene, excess daytime sleepiness → stimulants (e.g. amphetamines, modafinil), cataplexy → sodium oxybate (GHB) Idiopathic hypersomnia: excess daytime sleepiness, prolonged nocturnal sleep, frequent urges to nap Kleine-Levin syndrome: excess daytime sleepiness, aggression, hyperphagia, hypersexuality Circadian rhythm: sleep-wake cycle controlled by suprachiasmic nucleus (SCN) in the hypothalamus

Nightmare Tx: image rehearsal therapy (IRT), severe → antidepressants REM sleep behavior disorder: dream enactment (talking, yelling, walking, punching, etc.) that often presents as injury to the pt or bed partner RBD etiology: unknown, usually in senior males RBD Tx: clonazepam, ensure safety Restless leg syndrome: irresistable urge to move one’s legs while going to sleep; caused by pregnancy, anemia, renal failure, or other metabolic d/o

Periodic limb movement disorder: aka nocturnal myoclonus, frequent limb movement during sleep

Ψ – Sexual Disorders

–––––––––––– NORMAL SEXUALITY –––––––––––– Sexual response cycle: desire to EXPLORE – desire, EXcitement, PLateau, Orgasm, REsolution Refractory period: post-resolution period in which men can’t reexperience orgasm Sex × male aging: desire unchanged but requires ↑stimulation and time to orgasm, ↓intensity of ejaculation, ↑refractory period Sex × female aging: desire unchanged but ↓estrogen levels → vaginal dryness and thinning Sex × drugs: ↑libido – cocaine, amphetamines, marijuana, and acute alcohol use; ↓libido – narcotics and chronic alcohol use Sex × NTs: DA ↑libido, 5-HT inhibits sexual function Sex × hormones: testosterone ↑libido, progesterone ↓libido, postmenopausal ↓estrogen levels → vaginal dryness and thinning Substance-induced sexual dysfunction: anti-HTN, anticholinergics, antipsychotics, antidepressants (esp. SSRIs), or substance abuse Sexual dysfunction 2/2 GMC: atherosclerosis (ED), diabetes (ED + neuropathy), pelvic adhesions (dyspareunia), depression or anxiety

Orgasmic disorder: can’t orgasm or achieves orgasm w/ great difficulty Male OD Tx: gradually progress from extravaginal ejaculation (via masturbation) to intravaginal

Fetishism: sexual preference for inanimate objects (e.g. women’s shoes)

Female OD Tx: masturbation ± vibrator

Transvestic fetishism: sexual gratification in men from wearing women’s clothing

Dyspareunia: genital pain before, during, or after sexual intercourse; women > men, often associated w/ vaginismus Dyspareunia Tx: gradual desensitization to achieve intercourse (muscle relaxation → erotic massage → sexual intercourse) Vaginismus: involuntary muscle contraction of outer 1/3 of vagina during insertion; ↑incidence in higher socioeconomic groups and strict religious upbringing Vaginismus Tx: manual dilation Homosexuality: sexual/romantic desire for same sex, not a sexual disorder, etiology unknown Homosexual × depression: consider MDD or adjustment d/o due to conflict w/ societal values; homosexuality is not a disorder Homosexual × prepuberty: same-sex exploratory activities are common in prepubescent kids and don’t signify latent homosexuality

––––––––––––– SEXUAL DISORDERS ––––––––––––– Sexual disorders: problems involving any stage of sexual response cycle or pain during intercourse, not due to substance use or GMC MC sexual disorders: premature ejaculation and 2° ED in men, HSDD and orgasmic disorder in women Hypoactive sexual desire disorder: deficient or absent libido HSDD Tx: hormone replacement therapy Sexual aversion disorder: avoidance of genital contact w/ sexual partner Erectile dysfunction: aka impotence, can’t get it up, either 1° (never had one) or 2° (had it but lost it) ED Tx: PDE5-inhibitors (sildenafil) or alprostadil injection are first-line; vacuum pumps, surgical tube insertion, or constrictive rings ED vs. psychological condition: men w/ psych condition can get it up at other times (e.g. other partners, masturbating, morning wood) Sexual arousal disorder: can’t get it wet Premature ejaculation: ejaculation earlier than expected Premature ejaculation Tx: SSRIs or TCAs can prolong time to ejaculation

Masochism: sexual excitement from being hurt or humiliated

Transsexuality: aka gender identity disorder, strong cross-gender identification + persistent discomfort w/ own sex Transsexuality Tx: therapy, family involvement for younger pts, possibly sex reassignment Transsexual vs. transvestite: transsexuals identify with the other sex, transvestites like to wear other gender’s vestments (clothing) –––––––––––––––– PARAPHILIAS –––––––––––––––– Paraphilias: engagement or preoccupation w/ unusual sexual urges or fantasies, must last >6 months and interfere w/ daily life MC paraphilias: pedophilia, voyeurism, exhibitionism Pedophilia: getting turned on by kids <13 y/o, pedophile must be >16 y/o and at least 5 years older than the child Frotteurism: sexual pleasure from touching or rubbing up against a nonconsenting person Voyeurism: watching unsuspecting nude people for sexual pleasure Exhibitionism: exposing self to others Sadism: sexual excitement from hurting or humiliating others

Necrophilia: sexual pleasure from f-ing a corpse Telephone scatologia: sexual excitement from calling unsuspecting women and having phone sex with them Paraphilia Px: good prognosis w/ self-referral (vs. police arrest), sense of guilt, and low frequency of behavior Paraphilia Tx: insight-oriented psychotherapy + aversion therapy; antiandrogens for refractory hypersexual paraphilias in men Paraphilia vs. normal fantasy: occasional fantasies are normal if <6 months and don’t interfere w/ daily functioning Transvestic fetishism vs. homosexuality: dressing up as a woman doesn’t mean you’re turned on by men –––––– TREATMENT OF SEXUAL DISORDERS –––––– Sexual disorder Tx: psychotherapy, medications, and mechanical therapy all play a role Psychotherapy: dual sex therapy for marriage or couple issues, behavioral therapy for maladaptive behaviors, hypnosis for anxiety Pharmacotherapy: (see specific disorders) Mechanical therapy: (see specific disorders)

Ψ – Psychotherapy

––––––––––––– FREUD’S THEORIES ––––––––––––– Topographic theory: mind is composed of three types of thoughts – conscious, preconscious, and unconscious Conscious thoughts: current thoughts and 2° process thinking (logical, mature, organized, etc.) Preconscious thoughts: memories that are not immediately aware but easy to recall Unconscious thoughts: repressed thoughts that are out of one’s awareness, involves 1° process thinking (primitive and pleasure-seeking) Structural theory: mind is composed of three identities – id, ego, and super-ego

Displacement: redirecting thoughts or feelings about one thing onto something more tolerable Isolation of affect: separation of an unpleasant idea from the feelings it evokes Controlling: regulating aspects of external environment to relieve anxiety Immature defenses: acting out, denial, distortion, fantasy, regression, passive aggression, projection, projective identification, splitting, undoing Acting out: giving into an impulse, even if it’s socially inappropriate Denial: not accepting reality that is too painful, first stage of Kubler-Ross grief model

Id: primitive; involves sexual/aggressive urges and 1° process thinking

Distortion: grossly reshaping external reality to suit inner needs

Ego: realistic; mediates id, super-ego, and external environment using defense mechanisms

Fantasy: substituting fantasy for reality to resolve inner conflicts; characteristic of schizoid PD

Super-ego: idealistic; represents morals, society, and parental teaching

Regression: reverting back to childlike behavior; characteristic of histrionic PD and dependent PD

Normal development: id is present at birth, ego develops after birth, superego begins at age 6 ––––––––––– DEFENSE MECHANISMS ––––––––––– Defense mechanisms: used by ego to mediate id, super-ego, and external environment; three types – mature, neurotic, and immature Mature defenses: mature women wear a SASH – Sublimation, Altruism, Suppression, Humor Sublimation: satisfying socially objectionable impulses in an acceptable manner Altruism: performing acts that benefit others to feel better about oneself

Passive aggression: nonconfrontational expression of aggression towards others Projection: attributing one’s inappropriate thoughts or emotions onto another (e.g. stealing from a friend you suspect is stealing from you) Projective identification: attributing one’s inappropriate thoughts onto another, then identifying with the countertransference Splitting: labelling people as all good or all bad; characteristic of borderline PD Undoing: attempting to reverse a situation by adopting a new behavior

Countertransference: doctor projects unconscious feelings onto pt (e.g. all antisocial pts are malingering for benzos) Psychoanalysis-related therapies: brief dynamic (psychoanalytically-oriented) therapy, interpersonal therapy, supportive therapy Brief dynamic therapy: like psychoanalysis but briefer and face-to-face instead of lying on a couch Interpersonal therapy: focuses on development of social skills Supportive therapy: focuses on helping pt feel safe during a difficult time, builds up healthy defense mechanisms, not insight-oriented –––––––––– OTHER PSYCHOTHERAPIES –––––––––– Behavioral therapy: uses learning theory to get rid of bad behaviors and replace w/ healthy alternatives Learning theory: behaviors can be learned by conditioning, and extinguished by deconditioning Classical conditioning: stimulus can eventually evoke a conditioned response (e.g. Pavlov’s dog) Operant conditioning: uses positive (rewards) or negative reinforcement (removing an aversive stimulus) to encourage behavior Systematic desensitization: pt uses relaxation techniques while being exposed to increasing doses of anxiety-provoking stimuli Flooding and implosion: pt is exposed to real (flooding) or imagined (implosion) anxietyprovoking stimuli and not allowed to withdraw until he/she feels calm and in control Aversion therapy: uses punishment to discourage behavior (e.g. electric shock)

–––––––––––––– PSYCHOANALYSIS –––––––––––––– Suppression: consciously avoiding unacceptable impulse or emotion (vs. repression) Humor: using comedy to express thoughts or feelings w/o discomfort to self or others Neurotic defenses: RIDICulous – Rationalization, Reaction formation, Repression, Intellectualization, Displacement, Isolation of affect, Controlling Rationalization: making reassuring but incorrect explanations for outcome or behavior Reaction formation: doing the exact opposite of an unacceptable impulse Repression: unconsciously avoiding unacceptable impulse or emotion (vs. suppression) Intellectualization: using excessive abstract thinking to avoid experiencing disturbing feelings

Split treatment: one psychiatrist provides medication, another provides the therapy Psychoanalysis: resolving unconscious conflicts by making pt aware of repressed experiences and feelings, then integrating them into consciousness; an insight-oriented approach, 5 times/wk for years Psychoanalysis techniques: free association, dream interpretation, therapeutic alliance, interpretation of transference

Token economy: rewards (tokens) given after specific behaviors for positive reinforcement Biofeedback: vital signs given to pts as they try to mentally control physiological states Negative reinforcement vs. aversion therapy: negative reinforcement removes aversive stimulus to encourage behavior, aversion therapy adds an aversive stimulus to discourage behavior Cognitive therapy: identifying bad thoughts and replacing them w/ positive ones

Free association: pt says whatever comes to mind Dream interpretation: dreams represent conflict between urges and fears, interpret for resolution Therapeutic alliance: bond between pt and therapist Transference: pt projects unconscious feelings onto doctor (e.g. therapist seen as father figure)

Cognitive behavioral therapy: identifying bad thoughts, making the connection w/ bad behaviors, then setting an agenda to change thoughts in order to change behavior Dialectical behavioral therapy: CBT subtype used to ↓self-destructive behavior, ideal Tx for borderline PD

Ψ – Psychotherapy

Group therapy: 3+ pts w/ similar problems meet w/ therapist for behavioral, cognitive, or supportive therapy; useful for substance abuse, adjustment d/o, and personality d/o Peer led group therapy: no therapist (e.g. AA) Family therapy: sessions w/ entire family to reduce conflict, help understand each others’ needs (mutual accomodation), and cope w/ internally destructive forces Boundaries and triangles: boundaries between family members may be too rigid or permeable; triangles are two family members against a third Couples therapy: used to address conflicts, sexual problems, and communication issues within couples Couples therapy types: conjoint therapy (see couple together), concurrent therapy (see both separately), collaborative therapy (one therapist per pt), four-way therapy (all of the above)

Ψ – Psychopharmacology

––––––––––– NEUROTRANSMITTERS ––––––––––– Anti-H2: sedation, weight gain Anti-A1: orthostatic hypotension, sexual dysfunction Anti-M: dry mouth, blurry vision, constipation, urinary retention, exacerbates Alzheimer disease

CYP450: liver enzymes that metabolize drugs; CYP450 inducers ↓drug levels, CYP450 inhibitors ↑drug levels CYP450 inducers: smoking, carbamazepine, barbiturates, St. John’s wort CYP450 inhibitors: fluvoxamine, fluoxetine, paroxetine, duloxetine, sertraline

Anti-D2: anti-psychosis, EPS, ↑prolactin Anti-5-HT1c: weight gain

Teratogenic drugs: TCAs (fetal limb defects), VPA (neural tube defects), lithium (Ebstein’s anomaly), BDZs (cleft palate + FAS facies)

5-HT2: agitation, akathisia

Mirtazapine (Remeron): can cause weight-gain and sedation TCAs: inhibit 5-HT/NE reuptake, rarely first-line since OD can be lethal (Tx NaHCO3); three types – tertiary tricyclics, secondary tricyclics, tetracyclics TCA side-effects: anti-HAM + 3 Cs – Cardiotoxicity (↑QTc), Convulsions, Coma; lots of interactions (highly protein bound) and lethal in OD 2° vs. 3° TCAs: tertiary are more anticholinergic and sedating, and more lethal in OD; secondary are active metabolites of tertiary amines

––––––––––––– ANTIDEPRESSANTS ––––––––––––– Imipramine (Tofranil): Tx enuresis

5-HT3: diarrhea, nausea/vomiting ––––––––––––––– SIDE-EFFECTS ––––––––––––––– Anti-HAM side-effects: TCAs and low-potency antipsychotics can cause anti-H2, anti-α1, anti-M Serotonin syndrome: ↑5-HT → fever, confusion, flushing, sweats, tremor, hypertonicity, rhabdomyolysis → renal failure, death Serotonin syndrome combos: SSRI+MAOI, SSRI+OTC cough medicine, SSRI+linezolid, MAOI+meperidine, MAOI+MDMA/MDEA Serotonin syndrome Tx: cyproheptadine or BDZ, avoid taking within 5 weeks of each other Hypertensive crisis: MAOI+tyramines or sympathomimetics can cause ↑NE/↑epi (severe HTN) Extrapyramidal side-effects: high-potency typical antipsychotics can cause Parkinsonism, akathisia, and dystonia within days EPS Tx: acute dystonia → benztropine or diphenhydramine, akathisia → β-blockers or BDZ, Parkinsonism → levodopa or amantadine Tardive dyskinesia: high-potency typical antipsychotics can cause choreoathetosis of mouth and tongue after years of use TD Tx: irreversible, so monitor sx with AIMS (abnormal involuntary movement scale)

Antidepressants: SSRIs, TCAs, MAOIs, and atypicals; all have similar efficacy but differ in side-effect profile, require 3-4 week trial to take effect, none cause elation or have abuse potential

Amitriptyline (Elavil): strong anticholinergic sideeffects Clomipramine (Anafranil): very sedating, Tx OCD

Withdrawal phenomenon: dizziness, headache, N/V, insomnia, malaise after stopping most antidepressant use; may require tapering SSRIs: first-line for MDD due to low incidence of side-effects and safe in OD; includes fluoxetine, sertraline, paroxetine, fluvoxamine, (es)citalopram SSRI side-effects: sexual dysfunction, GI distress, serotonin syndrome, black box for suicidality

Doxepin (Sinequan): very sedating, useful as a sleep aid in low doses Nortriptyline (Pamelor, Aventyl): fewest antiHAM side-effects Desipramine (Norpramin): more activating, less sedating, least anticholinergic

SSRI × sexual dysfunction: switch to bupropion

Amoxapine (Asendin): metabolite of loxapine, only antidepressant that can cause EPS

Fluoxetine (Prozac): longest T½ (fewest withdrawal sx)

Maprotiline (Ludiomil): ↑rate of seizures, arrhythmias, and fatality w/ OD

Sertraline (Zoloft): highest GI distress Paroxetine (Paxil): shortest T½ (highest withdrawal sx), most anticholinergic side-effects Fluvoxamine (Luvox): Tx OCD Citalopram (Celexa): fewest drug interactions, fewest sexual side-effects Escitalopram (Lexapro): L-enantiomer of citalopram, even fewer side-effects but more $$$

MAOIs: not first-line due to side-effects but useful for atypical depression; includes phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), selegiline (Emsam) MAOI side-effects: serotonin syndrome (MAOI+ SSRI within 5 weeks), HTN crisis (MAOI+tyramine) –––––––––––––– ANTIPSYCHOTICS –––––––––––––– Antipsychotics: typical (1G) and atypical (2G) are both good for positive psychotic sx, but atypicals are better for negative psychotic sx

Venlafaxine (Effexor): SNRI, ↑↑BP Withdrawal dyskinesia: tendency for TD to temporarily increase following d/c antipsychotic Hyperprolactinemia: high-potency antipsychotics and risperidone can ↑prolactin (galactorrhea, amenorrhea, ↓libido, infertility), due to ↓dopamine in tuberoinfundibular pathway Neuroleptic malignant syndrome: all antipsychotics can cause FALTER – Fever, Autonomic instability, Leukocytosis, Tremor, Elevated CPK, “lead pipe” Rigidity; mortality rate is 20%

Desvenlafaxine (Pristiq): SNRI, active metabolite of venlafaxine, more $$$ Duloxetine (Cymbalta): SNRI, good for painful diabetic neuropathy, more $$$ Buproprion (Wellbutrin): no sexual side-effects, contraindicated with seizures and eating disorders (↑risk of seizures) Trazodone (Desyrel): can cause sedation and priapism (Tx epi injection into penis)

NMS Tx: dantrolene or bromocriptine Metabolic syndrome: atypical antipsychotics can ↑BP, ↑insulin, ↑body fat, ↑risk of CAD/stroke/diabetes; switch to typical antipsychotic if pt is at risk

Nefazodone (Serzone): can cause sedation, black box for hepatotoxicity

Depot antipsychotics: long-acting decanoate forms ideal for noncompliant psychotic pts; includes haloperidol, fluphenazine, risperidone, paliperidone Typical vs. atypicals: typicals have more EPS, tardive dyskinesia, anti-HAM, and lethality in OD due to QTc prolongation; atypicals have more weight gain, DKA, and metabolic syndrome Typical antipsychotics: blocks DA only Typical side-effects: EPS (parkinsonism + akathisia + dystonia), ↑prolactin, anti-HAM, tardive dyskinesia (1% annual incidence), NMS Low potency: ↑anti-HAM, ↓EPS and TD; includes chlorpromazine (corneal pigmentation + photo-

Ψ – Psychopharmacology

sensitivity) and thioridazine (retinal pigmentation → night blindness) Mid-potency: midrange properties; includes loxapine (↑seizures), thiothixene (ocular pigmentation), trifluoperazine (↓anxiety), and perphenazine High potency: ↑EPS and TD, ↓anti-HAM; includes haloperidol, fluphenazine, pimozide Atypical antipsychotics: blocks both DA and 5-HT Atypical side-effects: weight gain, DKA, metabolic syndrome (monitor weight and lipids) Clozapine (Clozaril): ↓suicide but ↑weight gain, seizures, agranulocytosis (requires weekly WBC counts), R-sided obstipation Risperidone (Risperdal): #1 for ↑prolactin and dystonic reactions

––––––––––––– ANTICONVULSANTS ––––––––––––– Anticonvulsants: includes carbamazepine, oxcarbazepine, valproic acid, lamotrigine, gabapentin, pregabalin, tiagabine, topiramate

Ramelteon (Rozerem): melatonin MT-2/3 agonist used for sedation, no tolerance/depedence

Carbamazepine (Tegretol): good for rapid-cycling bipolar disorder and trigeminal neuralgia; takes 5-7 days for onset and requires CBC/LFT monitoring

Buspirone (BuSpar): 5-HT1A partial agonist given for anxiety, useful in alcoholics (no EtOH potentiation like BDZ)

CBZ side-effects: BATHS – Blood dyscrasias, P450 Autoinduction, Teratogenic, Hepatotoxic, Stevens-Johnson syndrome Valproic acid (Depakote): requires CBC/LFT/VPA monitoring VPA side-effects: 4 Fs – Fat (weight gain), Farts (GI distress), Fatal hepatotoxicity, Fetal teratogen (neural tube defects) Lamotrigine (Lamictal): can ↓VPA levels, causes Stevens-Johnson syndrome so raise levels slowly

Paliperidone (Invega): metabolite of risperidone Quetiapine (Seroquel): can cause sedation and orthostatic hypotension

Chloral hydrate (Somnote): sedative, rarely used due to tolerance/depedence and liver toxicity

Topiramate (Topamax): causes weight loss, cognitive slowing (aka Dopamax), kidney stones Gabapentin (Neurontin): good for chronic pain

Diphenhydramine (Benadryl): antihistamine given for sedation, ↑anticholinergic side-effects Hydroxyzine (Atarax): antihistamine given for anxiety, ↑anticholinergic side-effects Propanolol: β-blocker used to Tx panic attacks, performance anxiety, and akathisia ––––––––––––––– OTHER DRUGS ––––––––––––––– Psychostimulants: Tx ADHD and refractory depression; includes D-amphetamine, amphetamine salts, methylphenidate, atomoxetine, modafanil Amphetamines (Dexedrine, Adderall): schedule II (↑abuse potential), monitor BP and watch for weight loss, insomnia

Olanzapine (Zyprexa): ↑weight gain Oxcarbazepine (Trileptal): rarely used Ziprasidone (Geodon): ↓weight gain Pregabalin (Lyrica): rarely used Aripiprazole (Abilify): #1 for akathisia (Tx βblockers or BDZ) Ziprasidone doesn’t work: pt wasn’t eating, food is required to activate Geodon in the body ––––––––––––– MOOD STABILIZERS ––––––––––––– Mood stabilizers: Tx acute mania and prevent relapses of manic episodes, includes lithium and anticonvulsants (valproic acid, lamotrigine, carbamazepine)

Tiagabine (Gabatril): rarely used

Li+ side-effects: LMNOP – Lithium causes Movement (tremors → Tx propanolol), Nephrogenic DI, Narrow TI (0.6-1.2), hypOthyroidism (Tx Synthroid), Pregnancy problems (Ebstein’s anomaly) Li+ level factors: NSAIDs (↑ except aspirin), dehydration (↑), salt deprivation (↑), sweating (↑), renal failure (↑), diuretics (↑)

Modafanil (Provigil): used in narcolepsy Anxiolytics: benzodiazepines, barbiturates, and nonbenzodiazepine hypnotics/anxiolytics Benzodiazepines: three types based on T½ (<6 hrs, 6-20 hrs, >20 hrs), choice of BDZ depends on onset, duration, and metabolism

Non-liver metabolized BDZ: LOT – Lorazepam, Oxazepam, Temazepam Long-acting BDZ: T½ >20 hrs; includes diazepam (Valium) and clonazepam (Klonopin)

Lithium × HTN: Tx Ca2+-channel blockers

Cognitive enhancers: used in dementia AChE inhibitors: Tx mild Alzheimer disease; includes donepezil, galantamine, rivastigmine, tacrine Memantine (Namenda): NMDA blocker used for moderate-severe Alzheimer disease –––––––––––– OTHER TREATMENTS –––––––––––– Electroconvulsive therapy: Tx refractory depression; 8-12 sessions given 3/week then monthly ECT to prevent relapse; safe for pregnant and elderly

Intermediate-acting BDZ: T½ 6-20 hrs; includes alprazolam (Xanax), lorazepam (Ativan), oxazepam (Serax), and temazepam (Restoril)

ECT method: pt put under general anesthesia and muscle relaxant, then electrodes induce a seizure; efficacy based on length of postictal suppression

Short-acting BDZ: T½ <6 hrs; includes triazolam (Halcion) and midazolam (Versed), used mainly in medical and surgical settings

ECT side-effects: amnesia (MC), headaches, muscle soreness, confusion

Barbiturates: rarely used b/c lethal in overdose

ECT electrodes: bilateral electrodes ↓number of sessions but ↑amnesia and confusion

Barbiturate overdose: Tx IV NaHCO3

ECT efficacy: 75%

Non-benzo hypnotics: zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta); Tx short-term insomnia, no tolerance/dependence

ECT c/i: recent MI, anything w/ possibility of hemorrhagic stroke (raised ICP, aneurysms, bleeding d/o, BBB distruption)

Lithium overdose: if blood level >4.0, hemodialysis Lithium duration: maintain use for 1 year following single episode, maintain for lifetime if 3+ relapses

Atomoxetine (Stattera): ↓appetite suppression and insomnia, but ↑hepatotoxicity and SI in adolescents

–––––––––––––––– ANXIOLYTICS ––––––––––––––––

BDZ overdose: give flumazenil Lithium: DOC for acute mania and PPx for manic episodes, takes 5-7 days for onset, only mood stabilizer to ↓suicidality

Methylphenidate (Ritalin, Concerta): schedule II (↑abuse potential), monitor BP/CBC/LFTs and watch for weight loss, insomnia

Ψ – Psychopharmacology

Deep brain stimulation: Tx chronic pain, Parkinson’s disease, tremor, and dystonia DBS method: implant device in brain that sends regular electrical impulses to specific regions, high risk of surgical complications Repetitive transcranial magnetic stimulation: noninvasive method to excite neurons via electromagnetic induction, Tx psychiatric conditions but modest effects at best rTMS side-effects: rare seizures, discomfort at the delivery site Light therapy: Tx seasonal affective disorder

Ψ – Forensic Psychiatry

––––––––––––––– LEGAL ISSUES –––––––––––––––

Parens patriae: protecting citizens who can’t care for themselves

Forensic psychiatry: psychiatry + legal issues ––––––––––– DISABILITY & INSANITY ––––––––––– Legal issues: two types – criminal if being charged with a crime, civil if other rights are violated Standard of care: skill level and knowledge base of the average psychiatrist

Mental impairment: loss or derangement of a mental function Mental disability: inability to meet personal, social, or occupational demands due to mental impairment

Negligence: practicing below standard of care Malpractice: act of being negligent as a doctor; must meet the 4 Ds – Deviation (neglect) from Duty that was the Direct cause of Damage Damages: reward for malpractice case, includes compensatory damages (financial reimbursement) and punitive damages (money awarded to punish the doctor) Confidentiality: nondisclosure of information except to another authorized person

Competence: legal term for pt’s ability to make informed treatment decisions; 6th + 14th amendments require competence to stand trial 6th amendment: right to counsel and to confront witnesses 14th amendment: right to due process of law Conviction: judgment of guilty in a criminal case; requires both actus reus (evil deed) and mens rea (evil intent)

Exceptions: COPS – Child abuse, Other staff involved in pt’s care, Potential harm to others, Subpoena, Suicidality

Insanity defense: if someone is declared legally insane, they are not criminally responsible for the act (i.e. not guilty by reason of insanity, NGRI)

Tarasoff duty: legal obligation to breach patient confidentiality and warn potential victims about a pt who may physically harm them

Insanity defense standards: M’Naghten rules, American Law Institute (ALI) model, Durham test

Child abuse: doctors are required to contact child protective services, lawyers are not Informed consent: pt knowingly and voluntarily agrees to a treatment or procedure; includes 4 Rs – Reason for Tx, Risks and benefits, Reasonable alternatives, and Refused Tx consequences Exceptions: medical emergencies, suicide or homicide prevention, unemancipated minors receiving obstetric care, STD Tx, or substance abuse Tx Emancipated minors: do not need parental consent to make medical decisions; minors are emancipated if self-supporting, military, married, or have children Capacity vs. competence: both refer to pt’s ability to make informed treatment decisions, but capacity is a medical term and competence is a legal term Decisional capacity: task specific Guardian: appointed to make treatment decisions for incompetent pts Voluntary admission: pt checks self into psych ward, may not have the right to be discharged immediately upon request Involuntary admission: pt checked in for potential harm or inability to provide for basic needs; supported by legal principles of police power and parens patriae Police power: protecting citizens from each other

M’Naghten Rules: person does not understand what he was doing or its wrongfulness ALI Model: person could not appreciate right from wrong or could not control his/her actions (aka “irresistible impulse” test) Durham Test: person’s criminal act has resulted from mental illness Violence risk assessment: h/o violence (#1 factor), h/o impulsivity, specific threat w/ a plan, psychiatric illness, substance abuse ––––––––––––––– OTHER ISSUES ––––––––––––––– Expert witness standards: evidence must be accepted by appropriate scientific community (Frye 1923), and judge decides if evidence is based on relevant and reliable science (Daubert 1993) Malingering: feigning or exaggerating sx for secondary gain (e.g. money, drugs, avoiding work) Malingering buzzwords: ASPD, h/o substance abuse, “doctor shopping”, textbook description of illness, symptomatic only when observed Child forensic psychiatry: involves child custody, child abuse/neglect, termination of parental rights Correctional psychiatry: involves balancing confidentiality vs. violence

Ψ – Additional Notes

–––––––– EXAMINATION AND DIAGNOSIS –––––––– Prevention: PDR – 1° is Prevention, 2° is Detecting disease, 3° is Reduction of disability

Kluver-Bucy syndrome: presents as docility, hyperphagia, hypersexuality, and disinhibition due to bilateral amygdala lesions

Suicidal pt: admit to inpatient care (against will if necessary) Homicidal pt: admit to inpatient care

––––––––––––– MOOD DISORDERS ––––––––––––– Circumlocution: substitution of a word or description for a word that can’t be recalled (e.g. “that thing you write with”) Tangentiality vs. circumstantiality: tangentiality never comes back to original topic, circumstantiality eventually does Abuse vs. dependence: inability to quit despite knowledge of harm best indicates dependence over abuse

Psychotic pt: acknowledge pt’s distress Postpartum blues: 20-40%, dysthymia that lasts <2 weeks, resolves spontaneously Postpartum depression: 10-15%, resembles MDD Postpartum psychosis: 0.1%, a subtype of bipolar disorder, admit into inpatient care → Tx antipsychotic + antidepressant Bipolar disorder: 25% among relatives, average age of onset is 30 y/o

Verbigeration: repetitive, meaningless talking Glossolalia: ability to speak a new language suddenly ––––––––––– PSYCHOTIC DISORDERS –––––––––––

Porphyria: presents as psychotic or manic sx + abdominal pain → get urinary porphobilinogen Hamilton Depression Scale: used to measure depressive sx

Dementia praecox: another name for SCZ ––––––– SUBSTANCE-RELATED DISORDERS ––––––– Psychogenic polydipsia: SCZ pt drinks too much water causing hyponatremia (Na+ <135)

Angry pt: encourage discussion about what’s bothering the pt Inappropriate pt: respond firmly but politely, remain professional Anorexic pt: admit to inpatient care if <75% ideal body weight and/or medical complications Abused pt: ask about abuse in an empathetic, openended question Suspected child abuse: complete a thorough physical exam, then get X-rays, then call child protective services if necessary Breaking bad news: set the stage and assess pt’s comprehension, then deliver news in empathetic manner

Nasal septum erythema: cocaine abuse Medical error: admit the mistake and apologize

SCZ brain: diffuse atrophy with decreased size of hippocampus, parahippocampal gyrus, amygdala

Rotary or vertical nystagmus: PCP abuse Injected eyes: marijuana (cannabis) abuse

Koro: Asian pt believes that his penis is shrinking and will disappear causing his death

––––––––––– COGNITIVE DISORDERS –––––––––––

Amok: sudden unprovoked outbursts of violence of which the person has no recollection (think “to run amok”)

Delirium Dx: abnormal EEG

Brain fag: headache, fatigue, and visual disturbances in African male students

Multiple sclerosis brain: multiple plaques of frontal white matter

Ataque de nervios: Puerto Rican trance d/o with convulsions, fainting, crying, and visual problems

Pseudoseizure: resembles seizure but normal EEG

Dementia Dx: MRI

Colleague makes medical error: always act in pt’s best interest Pt refuses tx: respect pt wishes, unless it puts others at risk (e.g. infx) → requires involunary admit Parents refuse tx for minor: nonemergent and not fatal → respect parent wishes; nonemergent but potentially fatal → get court order; emergent → proceed w/ tx; one parent agrees → proceed w/ tx Kid w/ imaginary friends: completely normal Teen w/ behavioral changes: get urine tox screen

Mal de ojo: Mediterranean “evil eye”

Localized amnesia: memory loss surrounding a discrete period of time

Pt requests medical records: give it to them

Sangue dormido: Portugese d/o with numbness, tremors, paralysis, convulsions, stroke, heart attack

Selective amnesia: inability to recall certain aspects of an event

Relative requests dx not be revealed to pt: ask relative about reasoning, since pt has right to know

Dhat: anxiety and hypochondriasis regarding semen discharge

–––––––––– PSYCHOPHARMACOLOGY –––––––––– Placebos: 33% efficacy for depression

Windigo: Native American d/o regarding possession by a demon that murders and eats human flesh Autoscopic psychosis: VH of transparent phantom of one’s own body, aka doppleganger

Antidepressants: 70% efficacy for depression ECT: 75% efficacy for depression NE: synthesized in locus ceruleus

Capgras syndrome: delusion that friends/family have been replaced by identical impostors Lycanthropy: delusion that one is a werewolf (or another animal)

5-HT: synthesized in raphe nucleus DA: synthesized in substantia nigra ACh: synthesized in nucleus accumbens

Cotard syndrome: delusion that one has lost everything, including one’s internal organs

–––––––––––––––––– ETHICS –––––––––––––––––– Depressed pt: ask about suicidal ideation

Family disagrees w/ advance directives: discuss situation w/ family, if unresolved after meeting → call ethics committee Pregnant woman vs. fetus: woman has right to refuse tx, even if it puts the fetus at risk

OBSTETRICS/GYNECOLOGY

OB 1 – Pregnancy

Terminology

Embryo: 0-8 wk Fetus: 8 wk – delivery Infant: delivery – 1 yr

GXPTPAL

Gravidity: number of times a woman’s been pregnant Parity: number of times a woman’s delivered T: >37 wk P: 20-36 wk A: <20 wk L: living births Grand multip: parity ≥5

Pregnancy signs

Chadwick sign: bluish discoloration of vagina/cervix Goodell sign: softening of cervix Hegar/Ladin sign: softening of uterus

Fetal dating

Naegele’s rule: EDC = LMP + 1y – 3m + 7d U/S indications: not mandatory, but useful for uncertain gestational age, size/date discrepancies, multiple gestations, etc. Physical landmarks: pubic symphysis at 12 wk, umbilicus at 20 wk

Physiologic changes

CV: hyperdynamic (↑CO), hypotensive (↓SVR → ↓BP) state Pulmonary: ↑TV creates ↑CO2 gradient w/ fetus for gas exchange GI: ↑E/P/hCG results in morning sickness, hyperemesis gravidarum if severe Renal: ↑GFR by 50%, ↑risk of pyelonephritis Blood: hypercoagulable, dilutional anemia (due to ↑↑plasma despite ↑RBC) Endocrine: ↑E/P, ↑hCG, ↑hPL, ↑TBG hCG: doubles every 48 hrs until peaking at 10-12 wks, then declines to steady state at 15 wk hPL: maintains fetal nutrition (lipolysis → ↑FFA), blocks insulin (can cause GDM) MSK: hyperlordosis (due to lower center of gravity) Skin: ↑E causes spider angiomata and palmar erythema, ↑MSH causes linea nigra and melasma/chloasma

Nutrition

↑: kcal, folate (neural tube defects), iron (RBC), vitamin C, Ω3 fatty acids ↓: vitamin A (teratogenic), calcium (need more but chelates iron)

Common pregnancy complaints

Complaint Lower back pain Constipation Braxton-Hicks contractions Dehydration Edema GERD Hemorrhoids PICA Round ligament pain Urinary frequency Varicose veins Hyperemesis gravidarum

Prenatal labs

Management d/t hyperlordosis; Tx mild exercise + stretching, Tylenol Tx fluids, exercise, fiber supplement irregular contractions w/o cervical dilatation, normal Tx PO fluids Tx leg elevation + r/o preeclampsia Tx antacids, PPIs or H2-blockers if severe Tx topical steroids, fiber, stool softeners, sitz baths eating inedible items; Tx encourage immediate cessation + toxicology consult shooting pelvic pain due to ligament stretching; Tx Tylenol + warm compresses normal, but get UA/UCx to r/o UTI Tx leg elevation + pressure stockings Tx NPO ×3 days, IV fluids + antiemetics; if severe → doxylamine + vitamin B6

Prenatal visits: first visit in first trimester, then q4wks until 28th, q2wks until 36th, and qwk until delivery Lab test CBC Blood type Rh status HBsAg HIV ELISA RPR-VDRL UA/UCx Rubella Ab GC/chlamydia

Management check for anemia or hemoglobinopathies for future transfusion if Rh–, give RhoGAM at week 28 and postpartum (if fetus is Rh+) if HBsAg+, get LFTs and hepatitis panel to determine acute vs. chronic infx; Tx infant HBIG and HBV vaccine if ELISA+, confirm w/ Western blot; if WB+ then give anti-HIV meds, elective C/S, or IV ZDV during labor if RPR+, confirm with FTA-ABS; if FTA-ABS+ then determine syphilis stage and Tx benzathine PCN G if positive, Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN during labor if rubella ab–, stay away from sick ppl and vaccinate postpartum if GC/CT+, Tx ceftriaxone + azithromycin

Antenatal assessment NST (non-stress test): continuous fetal monitoring (toco + HR), look for reactivity (2×15×15) BPP (biophysical profile): U/S evaluation on a 10 pt scale BPP >8: normal BPP =6: get CST BPP <4: deliver CST/OCT (ctx stress test/oxytocin challenge test): give oxytocin, look for 3 ctx/10 min w/o late decels

OB 2 – Pregnancy × Early Complications

Ectopic pregnancy

Ectopic pregnancy: Implantation outside uterine cavity, MC site is fallopian tube Heterotopic pregnancy: one normal + one ectopic pregnancy Sx: unilateral abd pain ± vaginal bleeding Risk factors: prior ectopic, tubal scarring (STIs or PID), IUD, assisted fertility, endometriosis Incidence: 1:100 pregnancies Management: Ectopic pregnancy? screen ↑β-HCG confirm TV U/S yes

r/o ectopic

ruptured

not ruptured

stabilize w/ IVF ex lap

if no definitive dx, f/u serial β-HCG Q 48hrs

Tx MTX

if β-HCG doesn’t fall 15% in 4-7 days, repeat MTX

1st trimester SAB

Sx: vaginal bleeding, abdominal pain, cramping, ↓sx of pregnancy Causes: abnormal chromosomes (MCC) Management: 1st trimester abortion? labs: β-HCG, CBC, type/cross pelvic exam to r/o other sources of bleed stabilize w/ IVF complete abortion

incomplete abortion inevitable abortion missed abortion

f/u for recurrent bleed or signs of infx

2nd trimester SAB

Tx D+C, prostaglandins, or allow to finish on its own

threatened abortion

f/u for continued bleeding give RhoGAM if Rh-

Sx: vaginal bleeding, abdominal pain, cramping, ↓sx of pregnancy Causes: anatomic defects (MCC), infx, maternal disease, trauma, fetotoxic agents Management: 2nd trimester abortion? r/o PTL + incompetent cervix Tx D+E, high-dose oxytocin, or prostaglandins

Incompetent cervix

Incompetent cervix: painless dilation and cervical effacement before term, usually 2nd trimester Causes: surgery or trauma (MCC), uterine abnormalities, DES exposure Management: Incompetent cervix? Dx dilated cervix on PE, or hourglass membranes on U/S viable (>24 wks) Tx betamethasone + strict bed rest

previable (<24 wks) emergent cerclage

if cerclage fails, transabdominal cerclage Hx of incompetent cervix: offer elective prophylactic cerclage at 12-14 wks Cerclage: surgical closure of cervix at external os (McDonald) or internal os (Shirokar) Complications: rupture of membranes, PTL, infx

OB 2 – Pregnancy × Early Complications

Recurrent preg loss

Recurrent pregnancy loss: 3+ consecutive SABs Causes: APA syndrome (↑clots) and luteal phase defect (↓P) are MCC Management: look for etiology, then Tx accordingly Etiology Abnormal chromosomes Anatomy (e.g. bicornuate uterus) APA syndrome Luteal phase defect Infection Hypothyroidism

Dx karyotype of both parents screen w/ HSG (hysterosalpingogram), confirm w/ hysteroscopic or ex lap RPR-VDRL, lupus anticoagulant, ANA, coag panel, anticardiolipin antibody ↓progesterone levels cx cervix, vagina, endometrium ↑TSH, ↓T4

Tx IVF or preimplantation dx surgery (may not be correctable) low-dose aspirin progesterone abx Synthroid

OB 3 – Prenatal Diseases

Epidemiology Dx+ Dx–

Disease+ TP FN (type II)

Disease– FP (type I) TN

Sensitivity: TP / (TP+FN) Specificity: TN / (TN+FP) PPV: TP / (TP+FP) NPV: TN / (TN+FN) Cystic fibrosis

Cystic fibrosis: AR ΔCFTR (Cl- channel) → thicker mucus →

Sickle-cell disease

Sickle-cell disease: AR ΔHbE6V (hemoglobin β-chain) → hemolytic anemia, vasoocclusive crises, autosplenic infarction Dx: screen mom w/ Hb electrophoresis, then dad if positive, then confirm w/ fetal dx Epidemiology: heterozygote advantage – allows for resistance to P. vivax malaria in Africans

Tay-Sachs disease

Tay-Sachs disease: AR ΔHexA → ganglioside accumulation → progressive neurodegeneration developmental delay “cherry red spot” on macula onion-skin lysosomes Dx: screen all high-risk carriers, confirm w/ fetal dx Epidemiology: founder effect – high frequency in Ashkenazi Jews due to small ancestral group

β-thalassemia

β-thalassemia: AR deletion of β-chain → ↑α:β ratio Dx: screen w/ CBC, if microcytic anemia then confirm w/ Hb electrophoresis

α-thalassemia

α-thalassemia: cumulative deletions of α-chain → ↓α:β ratio Silent carrier: 1-2 gene deletion; asx HbH disease: 3 gene deletion → ↑HbH (β4) → severe microcytic anemia Barts disease: 4 gene deletion → ↑HbBarts (γ4) → hydrops fetalis (IUFD) Dx: screen w/ CBC, if microcytic anemia then confirm w/ Hb electrophoresis

Chromosomal defects

chronic bronchitis recurrent Pseudomonas pneumonia bronchiectasis pancreatic insufficiency male infertility ADEK deficiency meconium ileus Dx: screen mom and dad for ΔF508/G542X, confirm w/ fetal dx Tx: N-acetylcysteine loosens mucus plugs, pancreatic enzyme replacement

Disease Down syndrome

Δ trisomy 21

Sx flat facies, epicanthal folds, simian crease, Alzheimer by 40 y/o, MR

Edwards syndrome

trisomy 18

Patau syndrome

trisomy 13

Turner syndrome

45/X

Klinefelter syndrome

47/XXY

Cri-du-chat syndrome

5p-

Williams syndrome

7q-

DiGeorge & velocardiofacial syndrome

22q11

micrognathia, clenched hands, rocker-bottom feet, MR; death by 1 y/o cleft lip/Palate, holoProsencephaly, Polydactyly, rocker-bottom feet, MR; death by 1 y/o Coarctation of aorta Lymphedema Ovarian dysgenesis Webbed neck (cystic hygroma) Nipples spread (shield chest) Short stature female traits on a man (long legs, gyno, highpitched voice, female habitus, etc.) microcephaly, cardiac problems, high-pitched meowing, epicanthal folds, MR Elfin facies, Extreme friendliness w/ strangers, well-developed English, MR Cleft palate Abnormal facies Thymic aplasia Cardiac defects Hypocalcemia

Dx quad screen at 15-20 wk (↑β-HCG, ↑inhibin, ↓αFP, ↓estriol) + nuchal translucency on U/S ; MCC abnormal value is error in dating triple screen (↓β-HCG, ↓αFP, ↓estriol) found on routine U/S ---

---------

OB 3 – Prenatal Diseases

Embryogenesis

Week 0 Week 1 Week 2 Week 3 Week 3-8 Week 4 Week 8

fertilization, cell division (blastula → morula → blastocyst) implantation + β-HCG secretion bilaminar disc (epiblast + hypoblast) gastrulation (3 tissues), neurulation organogenesis (most susceptible to teratogens) heart (4 chambers), limbs (4 limbs) fetus

Endoderm: becomes GI and respiratory systems Mesoderm: becomes CV, MSK, GU systems Ectoderm: becomes CNS, skin, etc. Neural tube defects

NTDs: ↓folate → defective neural tube closure at 4 wk Etiology: low dietary folate, Δmethyl-THF reductase Myelomeningocele: Dx screen ↑αFP, confirm U/S shows lemon sign (concave frontal bones) and banana sign (flat caudal cerebellum); Tx surgery in utero Spina bifida occulta: asx lumbar tuft of hair

Cardiac defects

Echogenic intracardiac focus (EIF): calcification of papillary muscle on U/S, usually insignificant L→R shunts: all present with murmurs + late-onset cyanosis due to Eisenmenger syndrome (pulmonary HTN reversing direction of shunt) ASD: presents as low-grade systolic murmur, fixed S2, and frequent colds VSD: presents as pansystolic harsh-sounding murmur with failure to thrive PDA: presents with machinery-like murmur, often seen with Congenital Rubella Syndrome R→L shunts: all present with murmurs + early-onset cyanosis Tetralogy of Fallot: presents as cyanosis and clubbing in a 5 y/o child who squats for relief; Px determined by degree of pulmonary stenosis Transposition of great vessels: presents as life-threatening cyanosis in a newborn Dx: fetal echocardiogram Tx: surgery, indomethacin for PDA

Potter syndrome

Potter syndrome: failure of mesonephros and metanephros to meet at ureteropelvic junction → bilateral renal agenesis → anhydramnios (no amniotic fluid) → pulmonary hypoplasia + limb contractures Dx: U/S shows anhydramnios or oligohydramnios (AFI <5) Tx: none available

Prenatal diagnosis

Prenatal sampling: amniocentesis, chorionic blood sampling (CVS), percutaneous umbilical blood sampling (PUBS) Method Amniocentesis CVS PUBS

Technique insert needle transabdominally into uterus and withdraw amniotic fluid insert catheter into intrauterine cavity and aspirate chorionic villi from placenta insert needle transabdominally into uterus and withdraw umbilical cord blood

Prenatal imaging: level-I U/S at 18-22 wk is standard of care

Advantages/disadvantages + 1:200 risk of PTL, PROM, injury – 2nd trimester + 1st trimester – >1:200 risk of PTL, PROM, injury + rapid karyotype analysis – may take maternal blood

OB 4 – L&D

Labor

Labor: ctx + cervical dilation Timing: preterm <37 wks term 37-42 wks postterm >42 wks Prodromal (false) labor: irregular Braxton-Hicks ctx w/o cervical dilation

3 Ps of labor

3 Ps of labor: Power, Passenger, Passage determine progression of labor Power: ctx frequency + intensity + duration Adequate ctx: 3-5 ctx/10 min + >200 MVU Passenger: fetus Fetal lie: longitudinal, transverse, or oblique Fetal presentation: first part in vagina; cephalic/vertex or breech Fetal position: depends on occiput position… Leopold maneuver: used to determine presentation, position, engagement fetal position Passage: pelvis type Gynecoid: MC type, best px Platypelloid: seen in Asians, can lead to deep transverse arrest

pelvis types Induction of labor

Induction of labor: attempt to begin labor in nonlaboring pt Methods: prostaglandins (Cytotec), oxytocin (Pitocin), or amniotomy (AROM) Indications: postterm (>42 wk), PROM (≥34 wk), preeclampsia, IUGR, nonreassuring fetal testing PGE contraindications: maternal asthma or glaucoma, >1 prior C/S IOL success: vaginal delivery; progress measured by Bishop score Augmentation of labor: increasing ctx in already laboring pt Bishop score: cervical exam w/ 5 components – dilation, effacement, station, position, consistency Dilation: diameter of internal os (range 0-10 cm) Effacement: thinning out of cervix (range 0-100%) Station: 0 station (midpoint) is ischial spines, measure in cm above/below (range -5 to +5 cm) Position: advancement of cervix as labor progresses (range posterior to anterior) Consistency: softening of cervix as labor progresses (Hegar or Ladin sign) Progress of labor:

Bishop score 0-4 5-9 10+

Management cytotec pitocin expectant management

OB 4 – L&D Stages of labor

Stage 1: onset to complete dilation (10 cm) Phases: latent phase is 0-4 cm and slow, active phase is >4 cm and rapid Active phase arrest: no change in dilation or station for 2 hrs, indicated for C/S Stage 2: dilation to delivery Prolonged stage 2: >2 hrs if nulliparous, >1 hr if multiparous (add 1 hr w/ epidural) Ritgen maneuver: pressure on fetal head to help shoulders pass through Stage 3: delivery to placenta delivery (10 min) Retained placenta: stage 3 lasts >30 min; Tx manual extraction + abx Signs of placental separation: gush of blood, lengthening of cord, change in shape of uterine fundus Too much traction: ↑risk of cord avulsion, uterine inversion Stage 4: placenta delivery to 2 hrs postpartum Episiotomy: incision in perineum to facilitate delivery, two types – median and mediolateral Lamaze method: classes to teach natural birthing techniques (relaxation, breathing, etc.)

Cardinal movements

Cardinal movements:

1. Engagement (0 station) 2. Flexion 3. Descent 4. Internal rotation 5. Extension 6. External rotation 7. Expulsion

Operative vaginal delivery

Operative vaginal delivery: usage of forceps or vacuum to deliver fetus Forceps: ↑risk of CN VII palsy Vacuum: ↑risk of cephalohematoma and shoulder dystocia Conditions: experienced operator (most important), full dilation, ruptured membranes, engaged w/ >2 station, knowledge of fetal position, anesthesia, empty bladder, no evidence of cephalopelvic distortion

Perineal lacerations

1st degree: superficial tear 2nd degree: extends into perineal body 3rd degree: extends into anal sphincter 4th degree: extends into rectum

Caesarian section

C/S: delivery by uterine incision Indications: MC primary is failure to progress in labor, MC overall is prior C/S VBAC: vaginal birth after C/S; only true c/i is previous vertical (classical) C/S TOLAC: trial of labor after C/S, MC complication is rupture of uterine scar Rupture sx: sudden onset severe abd pain ± vaginal bleed, subjective “pop” sensation

Anesthesia

Pudendal block: indicated for operative vaginal delivery, direct needle towards jxn of ischial spine and sacrospinous ligament Local anesthesia: indicated for episiotomy and laceration repairs Epidural anesthesia: more commonly used during labor, can lengthen stage 2 Spinal anesthesia: more commonly used during C/S

OB 4 – L&D Fetal HR

Fetal HR: baseline + variability + periodic changes Baseline HR: normal is 110-160 bpm; tachy >160 for 10 min, brady <110 for 10 min Variability: determined by SNS-PSNS interplay; ↑↑ and ↓ variability is bad sign

Periodic changes

Early decel: along w/ ctx, due to head compression → CN X stimulation Variable decel: no relation w/ ctx, due to cord compression (possibly oligohydramnios) Late decel: happens after ctx, due to uteroplacental insufficiency Prolonged decel: >15 bpm for 2-10 min Accelerations: reactive if 2× (15 bpm × 15 sec) / 20 min Sinusoidal pattern: sine-wave shaped, due to fetal anemia (e.g. fetal vx rupture)

Category 1 (best): FHR 110-160, moderate variability, no late/var decels Category 2: everything else Category 3 (worst): absent variability + recurrent late/var decels, bradycardia, sinusoidal pattern FHR tracing management: obtain FHR pattern category 1

category 2

routine mgmt

evaluation and surveillance

category 3 resuscitative measures, prepare for delivery

if no accels or variability, resuscitative measures if not improved, prompt delivery Resuscitative measures: give O2 + change maternal position

OB 5 – Antepartum Hemorrhage Terminology

Placenta previa: placenta develops over internal os Placenta accreta: placenta adheres to uterine wall Placenta increta: placenta invades into myometrium Placenta percreta: placenta penetrates through to uterine serosa Circumvallate placenta: membranes form dense ring around placenta Vasa previa: fetal vessels develop over internal os Velamentous placenta: fetal vessels insert between amnion and chorion Succenturiate placenta: extra lobe of placenta ± blood fetal vessels between two lobes Abruptio placentae: premature separation of placenta from uterine wall

Antepartum hemorrhage

Obstetric causes: placenta previa (20%), abruptio placentae (30%), fetal vessel rupture, uterine rupture Non-obstetric causes: cervical/vaginal lacerations, hemorrhoids, infx, neoplasms DDx: present as spotting (not frank bleeding), no contractions or abdominal pain Px: simple management, good outcomes (vs. obstetric causes)

Placenta previa

Placenta previa: placenta develops over internal os Subtypes: complete, partial, marginal Sx: painless vaginal bleeding + risk of hemorrhagic shock Previa management: Placenta previa? Dx transabdominal or translabial U/S (vaginal exam is c/i due to hemorrhage) if prior to 3rd trimester, repeat U/S to see if it’s resolved labs: H+H, type/cross give RhoGAM if Rhunstable

stable

stabilize w/ IVF emergent C/S

expectant management tocolytics + betamethasone (<34 wk)

Placenta accreta

Placenta accreta: placenta adheres to uterine wall Placenta increta: placenta invades into myometrium Placenta percreta: placenta penetrates through to uterine serosa Sx: usually asx during pregnancy, presents as vaginal bleed + inability to separate placenta after delivery Tx: puerperal hysterectomy

Abruptio placentae

Abruptio placentae: premature separation of placenta from uterine wall Subtypes: revealed/external (80%), concealed (20%) Sx: 3rd trimester vaginal bleeding + severe abd pain, strong ctx Complications: hemorrhagic shock, DIC, premature delivery, uterine tetany, fetal death (35%) Risk factors: HTN (#1), trauma, previous abruption, smoking, cocaine Abruption management: Abruptio placentae? Dx clinical presentation stabilize w/ IVF labs: H+H, type/cross RhoGAM if Rhbetamethasone (<34 wk) delivery (unstable or FHR nonreassuring)

Uterine rupture

Uterine rupture: rupture of uterus associated w/ prior uterine scar (C/S or other surgery) Sx: sudden onset severe abd pain ± vaginal bleeding, subjective “pop” sensation Tx: emergent ex lap and delivery

Fetal vessel rupture

Vessel rupture causes: velamentous placenta, succenturiate placenta, vasa previa Vasa previa: fetal vessels develop over internal os Velamentous placenta: fetal vessels insert between amnion and chorion Succenturiate placenta: extra lobe of placenta ± blood fetal vessels between two lobes Sx: vaginal bleeding + sinusoidal pattern on FHR [tachy → brady → sinusoidal] Dx: Apt test (examine blood for fetal/nucleated RBCs, pink indicates fetal blood) Tx: emergent C/S

OB 6 – L&D × Complications Preterm labor

PTL: labor <37 wks PTL management: tocolytics + betamethasone for lung maturity PTD: delivery <37 wks, occurs in 10% of pregnancies Complications: RDS, intraventricular hemorrhage, necrotizing enterocolitis

Tocolysis

Premature rupture of membranes

Tocolysis: delaying premature labor for 48 hrs, to allow for fetal lung maturity w/ betamethasone Tocolytic Nifedipine MgSO4

MOA Ca-channel blocker (1st line) competes w/ Ca2+ for Ca-channels

Terbutaline Ritodrine Indomethacin

β2-agonist β2-agonist NSAID (blocks PGF2α production)

Side-effects headache, flushing, dizziness headache, flushing, dizziness, pulmonary edema, cardiac arrest (high dose) headache, tachycardia, anxiety headache, tachycardia, anxiety fetal PDA closure, pulmonary hypertension, renal failure → oligohydramnios

ROM: disruption of the amniotic sac ROM Dx: pool test (visualize fluid pooling) nitrazine test (alkaline pH turns nitrazine paper blue) fern test (see ferning under scope) amnio dye/tampon test (inject dilute indigo-carmine dye into amniotic sac and look for leakage into tampon) PROM: rupture >1 hr before labor, ↑risk of infx Risk factors: smoking, chorioamnionitis (Tx IV abx + delivery), ↑latency w/ ↓GA PROM management: depends on GA… ≥34 wk: delivery 24-33 wk: expectant management, tocolytics + betamethasone <24 wk: pt counseling, expectant management or induced labor Prolonged PROM: rupture >18 hrs before labor, ↑↑risk of infx PPROM: rupture >1 hr before labor, preterm

Cephalopelvic disproportion

CPD: fetal head is too big to pass through maternal pelvis; MCC active phase prolongation CPD management: suspected CPD → trial of labor anyways, if CPD confirmed by CT or U/S → C/S

Breech presentation

Breech presentation: fetus presents w/ buttocks first, 2% Complete breech: thighs and legs flexed Frank breech: thighs flexed, legs straight Incomplete (footling) breech: feet first Breech management: Dx Leopold maneuvers, vaginal exam, or U/S → Tx external version to vertex, C/S, or breech delivery (rare) Complications of breech delivery: cord prolapse, head entrapment, neurologic injury

Malpresentation of vertex

Malpresentation: includes face, brow, compound, persistent OP and OT Face presentation: face first Brow presentation: orbital ridge first Compound presentation: vertex/breech + limb, high-risk for cord prolapse Persistent OP: facing anterior, may require external version to OA Persistent OT: facing sideways, high-risk of deep transverse arrest w/ platypelloid pelvis type Malpresentation management: vaginal delivery but needs close monitoring

Fetal bradycardia

Bradycardia: <110 bpm for >10 min (2-10 min is prolonged decel) Preuterine causes: maternal hypotension or hypoxia (seizure, PE, AFE, MI, etc.) Uteroplacental causes: placental abruption, infx, hemorrhage Postplacental causes: cord prolapse, cord compression, fetal vx rupture Bradycardia management: place in LLD/RLD → start 2L O2 NC → look for cause → Tx appropriately

OB 6 – L&D × Complications Shoulder dystocia

Shoulder dystocia: anterior shoulder gets caught behind pubic symphysis Complications: fetal humerus/clavicle fx, brachial plexus injury, phrenic nerve palsy, hypoxia → brain injury → death Risk factors: previous dystocia, ↑fetal size (macrosomia, diabetes, maternal obesity, postterm delivery), prolonged stage 2 Dystocia management: special maneuvers → if failed, cut clavicle or pubic symphysis → if failed, Zavanelli maneuver Suprapubic pressure: add pressure to dislodge anterior shoulder McRoberts maneuver: sharp flexion of maternal hips increases pelvic AP diameter Rubin maneuver: apply pressure behind either shoulder to decrease fetal diameter Wood corkscrew: apply pressure behind posterior shoulder to rotate infant Posterior arm delivery: deliver posterior arm first, then rotate infant to for anterior shoulder Zavanelli maneuver: push head back in + perform C/S

Hypotension

Hypotension: maternal BP <80/40; causes include regional anesthesia, hemorrhage, vasovagal events, AFE, anaphylaxis Hypotension management: start IV fluids + ephedrine, then Tx cause (e.g. Benadryl for anaphylaxis) AFE: high mortality rate, Dx fetal cells in pulmonary vasculature at autopsy

Seizure

Seizure vs. syncope: check for postictal disorientation (found in sz but not syncope) Seizure management: Tx IV or IM MgSO4, get PEII panel, consult neuro if negative for eclampsia

OB 7 – Pregnancy × Complications Fetal growth

SGA: <10th percentile, either symmetric or asymmetric LGA: >90th percentile Macrosomia: >4500 g LBW: <2500 g

SGA & LBW

SGA: <10th percentile, two types – IUGR and ↓growth potential ↓growth potential: congenital abnormalities (chromosomal d/o), infx (CMV, rubella), teratogens (EtOH, cigs) MCC: cigarettes IUGR: intrauterine growth restriction, unable to achieve potential size despite good growth potential Etiology: maternal systemic dz → ↓placental perfusion → IUGR SGA management: confirm accuracy of dating → Dx serial U/S + umbilical artery doppler → check for underlying etiology Serial U/S results: low growth potential stays small, IUGR progressively falls off growth curve Doppler results: low or absent diastolic flow indicates ↓placental resistance, reversed diastolic flow is high-risk for IUFD

LGA & macrosomia

LGA: >90th percentile Risk factors: diabetes, maternal obesity, postterm pregnancy, multiparity, advanced maternal age Complications: birth trauma, hypoglycemia, jaundice, ↓Apgar scores, childhood tumors, shoulder dystocia LGA management: confirm accuracy of dating → Dx U/S → consider IOL prior to macrosomic status

Amniotic fluid

Amniotic fluid physiology: produced by fetal kidneys, resorbed by fetal swallowing Amniotic fluid index: measure of fluid in quadrants via U/S; AFI <5 is oligo, AFI >20 is poly

Oligohydramnios

Oligohydramnios: AFI <5, FHR shows variable decels Causes: ROM (MCC), ↓placental perfusion, ↓fetal fluid production, renal malformations (e.g. Potter syndrome) Complications: pulmonary hypoplasia, limb contractures, cord compression → fetal asphyxiation → death Oligo management: Oligohydramnios? Dx AFI <5 preterm

term/postterm

ROM

congenital anomaly

expectant management

deliver

induce labor

compatible w/ life

incompatible w/ life

genetic counseling

meconium in amniotic fluid amnioinfusion

deliver

Polyhydramnios

Polyhydramnios: AFI >20 Causes: congenital abnormalities, diabetes, TTTS, hydrops fetalis Complications: cord prolapse Poly management: careful verification of presentation, observe for cord prolapse

Erythroblastosis fetalis

Erythroblastosis fetalis: Rh– woman w/ Rh+ fetus → anti-Rh IgG crosses placenta → hemolytic anemia → hydrops fetalis (edema, ascites, heart failure) Rh– prevalence: 15% in caucasians, lower in other races Rh– management: Rh– woman

Intrauterine fetal demise

unsensitized

sensitized

give RhoGAM at week 28 and postpartum (if fetus is Rh+)

follow closely w/ serial U/S and amniocentesis (for bilirubin levels indicating hemolysis)

IUFD: fetal death in utero Causes: usually unknown, often chronic placental insufficiency or “cord accident” Retained IUFD: high-risk of DIC if fetus is left >3 wks IUFD management: Dx U/S → Tx delivery (not emergent) → f/u autopsy to search for cause

OB 7 – Pregnancy × Complications Postterm pregnancy

Postterm pregnancy: gestational age >42 wks Complications: macrosomia, oligohydramnios, meconium aspiration, IUFD, dysmaturity syndrome Dysmaturity syndrome: chronic IUGR from uteroplacental insufficiency MCC: inaccurate dating Management: get accurate dating → induce labor, increased fetal surveillance

Cleavage

Cleavage: chorion separates day 4, amnion separates day 8 Di-Di twins: cleavage b/t day 1-3 Mo-Di twins: cleavage b/t day 4-8, at risk for TTTS Mo-Mo twins: cleavage b/t day 8-13 Siamese twins: cleavage b/t day 13-15

Multiple gestations

Multiple gestations: two types – monozygotic and dizygotic Monozygotic twins: 1 sperm + 1 ova → identical DNA; no predisposing factors Dizygotic twins: 2 sperm + 2 ova → separate DNA; ↑ in Africans, IVF, clomiphene citrate Complications: PTL, placenta previa, postpartum hemorrhage, preeclampsia, cord prolapse, malpresentation, GDM, incompetent cervix Management: Siamese twins → C/S Mo-Mo twins → C/S vertex/vertex twins → vaginal delivery vertex/nonvertex twins → vaginal delivery or C/S nonvertex/nonvertex twins → C/S triplets and above → C/S ± selective reduction

TTTS

TTTS: unequal blood flow in shared placenta of Mo-Di twins → small/anemic twin + large/polycythemic twin TTTS management: serial U/S Q 2 wks in all Mo-Di twins → Tx serial amnioreduction in larger twin

OB 8 – Pregnancy × HTN Gestational HTN

Gestational HTN: HTN (>140/90) without proteinuria (<300 mg/day) GHTN management: labetalol, nifedipine

Preeclampsia

Preeclampsia: HTN (>140/90) + proteinuria (>300 mg/day) + edema Etiology: multiorgan vasospasm → brain (severe HA, seizure, stroke) liver (liver damage, RUQ pain, n/v) kidneys (renal failure, proteinuria, edema) placenta (IUGR, IUFD) small vx (thrombocytopenia, DIC) Risk factors: nulliparity, multiple gestation, chronic HTN, family hx Preeclampsia management: Dx PEII panel (labs + 24hr urine protein) → Tx control HTN (labetalol, nifedipine) + seizure ppx (MgSO4 – 4g load + 2g/hr) + delivery if term or unstable Severe preeclampsia: severe HTN (>160/110), proteinuria (>5 g/day or 3+ dipstick), presence of other complications; must deliver (IOL > C/S) First-trimester preeclampsia: consider hydatidiform moles

HELLP syndrome

HELLP syndrome: Hemolysis (schistocytes, ↑LDH, ↑bilirubin), Elevated LFTs, Low Platelets in preeclamptic pts

Acute Fatty Liver of Pregnancy

AFLP: fatty liver + HTN (>140/90) ± proteinuria AFLP management: supportive care, liver txp if necessary

Eclampsia

Eclampsia: tonic-clonic (grand mal) seizures in preeclamptic pts Seizure timing: ¼ before labor, ½ during, ¼ afterwards Eclampsia management: control HTN (hydralazine) + seizure ppx (MgSO4) + delivery after pt is stabilized MgSO4 side-effects: pulmonary edema MgSO4 overdose: DTR depression (first sign), respiratory depression, coma, cardiac arrest; Tx calcium gluconate

Chronic HTN

Chronic HTN: HTN occuring before conception, before 20 wks GA, or lasting >6 wks postpartum Chronic HTN management: control HTN (labetalol, nifedipine) + baseline EKG + 24hr urine protein Superimposed preeclampsia: 24hr urine protein >300 mg in previously HTN pt

OB 9 – Pregnancy × DM Pregestational DM

Pregestational DM: diabetes diagnosed prior to pregnancy

GDM

GDM pathophysiology: ↑hPL/E/P → insulin antagonism Epidemiology: 5-8% incidence, ↑risk of developing T2DM later in life Risk factors: prior GDM, family hx, obesity, race (non-whites) Maternal complications: polyhydramnios, preeclampsia, miscarriage, etc. Fetal complications: macrosomia → shoulder dystocia, hypOcalcemia, hypOglycemia, polycythemia → hyperviscosity Fetal malformations: CV defects, NTDs, caudal regression syndrome, situs inversus, duplex ureter, IUGR GDM Dx: screen w/ GCT at week 26-28 → if ≥140 mg/dL, confirm w/ OGTT GDM management: tight glucose control w/ diet (1st line), insulin (2nd line), glyburide (3rd line); induce at 39-40 wk, C/S if macrosomic Ideal glucose: between 70-110 mg/dL Ideal HbA1c: less than 6.5%

White classification of diabetes

Class A1 A2 B C D F R RF H T

Definition GDM, diet controlled GDM, insulin controlled onset >20 y/o, duration <10 yrs onset 10-19 y/o, duration 10-19 yrs onset <10 y/o, duration >20 yrs neFropathy Retinopathy Retinopathy + neFropathy ischemic Heart disease prior renal Txp

OB 10 – Pregnancy × Infx UTIs

UTI: presents as dysuria, urinary frequency/urgency, suprapubic tenderness Etiology: E. coli (MCC), S. saprophyticus (#2), Enterococcus (#3), other GNB Complications: septic shock (urosepsis), ARDS Management: Dx UA/UCx → Tx Bactrim or Cipro (not pregnant) Tx nitrofurantoin (pregnant) Tx IV cephalosporins + admit (upper UTI) Asymptomatic bacteriuria: >105 CFU on UA Management: Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN during labor

Chorioamnionitis

Other infections

Chorioamnionitis: presents as maternal fever, uterine tenderness, ↑WBC, ↑fetal HR Etiology: MCC are GBS and E. coli Management: Dx amniocentesis and cx amniotic fluid → Tx IV abx + delivery Infx Bacterial vaginosis (Gardnerella vaginalis)

HBV

Presentation thin homogenous vaginal discharge + fishy odor; complications include preterm delivery, PPROM, and puerperal infx subclinical illness or mono-like syndrome Cytomegalic Inclusion Disease (CID): “blueberry muffin” rash, hepatosplenomegaly, jaundice, thrombocytopenia, periventricular calcifications UTIs, chorioamnionitis, endomyometritis, neonatal sepsis (MCC) Neonatal GC/chlamydia: conjunctivitis, ophthalmia, otitis externa, pneumonia ---

HIV

(usually asx)

HSV

fluid-filled vesicles and irritation Neonatal herpes: skin lesions, viral sepsis, pneumonia, herpes encephalitis Erythema infectiosum: slapped cheek rash in kids hydrops fetalis in pregnant women

CMV

GBS GC/chlamydia

Parvovirus B19

Rubella

rash, arthritis/arthralgia, diffuse LN-opathy Congenital Rubella Syndrome (CRS): cataracts + PDA + deafness

Syphilis

Early congenital syphilis: rash, snuffles, hepatosplenomegaly, jaundice, LN-opathy Late congenital syphilis: CN VIII deafness, saber shins, mulberry molar, Hutchinson’s teeth, saddle nose Congenital toxoplasmosis: fever, seizure, chorioretinitis, microcephaly, jaundice, head CT shows ring-enhancing lesions chickenpox or shingles Congenital varicella syndrome: fulminant disseminated infx → death

Toxoplasmosis

VZV

Management Dx “clue cells” on wet prep → Tx PO metronidazole postpartum GCV no tx exists

routine screening at 35-37 wk → if GBS+, Tx IV PCN during labor screen mom for STDs → Tx ceftriaxone + azithromycin screen mom w/ HBsAg → get LFTs and hepatitis panel to determine acute vs. chronic infx → Tx infant HBIG and HBV vaccine screen mom w/ ELISA → confirm with Western blot → Tx anti-HIV meds, elective C-section, or IV ZDV during labor deliver by C/S or Tx IV ACV Dx viral cx of herpetic lesions → Tx IV ACV --if suspected, Dx parvo IgM → Tx serial U/S + fetal transfusion w/ signs of hydrops --if mom is rubella ab negative, stay away from sick ppl and vaccinate postpartum screen mom w/ RPR-VDRL → confirm with FTA-ABS → determine syphilis stage and Tx benzathine PCN G pregnant women should avoid cats/cat litter; Dx amniocentesis → Tx pyrimethamine + sulfadiazine --Tx VZIG for both mom and fetus

OB 11 – Pregnancy × Complications Hyperemesis gravidarum

Hyperemesis gravidarum: severe n/v + intolerance of PO diet HG management: Tx NPO ×3 days, IV fluids + antiemetics; if severe → doxylamine + vitamin B6; get β-HCG to r/o moles Morning sickness: n/v in pregnancy is common and resolves by week 16, HG is more severe and has PO intolerance Boerhaave syndrome: rupture of esophagus following severe emesis

Seizure d/o

Seizure d/o: both seizures and AEDs can cause fetal malformations, pregnancy is a ↑seizure state Etiology: either ↑AED metabolism, ↓pt compliance, ↓seizure threshold, or hormonal changes AED teratogenicity: folate antagonism → NTDs, epoxide generation (fetal hydantoin syndrome) Sz d/o management:

Heart disease

monotherapy w/ lowest AED dose level II U/S at 19-20 wk (look for congenital anomalies) folate supplement vit K supplement at 27 wk

High-risk heart dz: primary PH, Eisenmenger syndrome, severe MS or AS, Marfan syndrome Marfan syndrome: AD Δfibrillin → elastic tissue dysfxn → MVP, aortic aneurysms (cystic medial necrosis), or aortic dissection Heart dz management: terminate pregnancy (first line) baseline EKG + medical stabilization d/c teratogenic drugs (ACEI/ARBs, diuretics, coumadin) if severe MS/AS → surgical or valvuloplasty repair (1 yr prior) if delivering → early epidural, careful fluid monitoring, assisted vaginal delivery, abx ppx for SBE Peripartum cardiomyopathy: dilated cardiomyopathy 2/2 pregnancy, presents w/ sx of CHF (dyspnea/orthopnea/PND) PPCM management: Dx echo shows dilated heart w/ EF <40% → deliver if ≥34 wk, medical mgmt if <34 wk

Renal disease

CKD stages: stage 1 is GFR 90-100 stage 2 is GFR 60-89 stage 3 is GFR 30-59 stage 4 is GFR 15-29 stage 5 (ESRD) is GFR <15 or dialysis Mild renal dz: ↑risk of preeclampsia and IUGR Moderate/severe renal dz: ↑↑risk of preeclampsia and IUGR, and worsening of renal dz postpartum Renal dz management: careful monitoring of renal fxn and fetal status Renal txp management: requires ↑immunosuppressants (e.g. prednisone) dosage due to ↑risk of acute rejection

Coagulation d/o

Coagulation d/o: pregnancy is a hypercoagulable state; increased risk for SVT, DVT, PE Virchow’s triad: ↑risk of blood clots w/ stasis, hypercoagulability (pregnancy), endothelial damage Coagulation d/o SVT DVT

PE

Presentation painful, palpable, venous cord w/ local erythema and edema acute onset dull leg pain, unilateral swelling, and Homans’ sign (calf pain w/ dorsiflexion) acute onset chest pain, dyspnea, and hyperventilation (↓PCO2); right-sided heart failure → MCC maternal death

Management Tx warm compresses + analgesics Dx duplex U/S → Tx heparin or Lovenox (enoxaparin); warfarin is contraindicated in pregnancy Dx D-dimer to r/in, V/Q scan to r/o → Tx heparin or Lovenox; t-PA if <3 hrs and no contraindications

Hyperthyroidism

Hyperthyroidism: Graves’ disease (MCC), toxic adenoma (#2), toxic multinodular goiter (#3) Graves’ disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing exophthalmos, pretibial myxedema, and hyperthyroidism; more common in women Thyroid storm Tx: β-blockers Hyperthyroidism management: screen for TSIs → if elevated, Tx PTU + monitor fetus for goiter and IUGR Infantile hyperthyroidism: maternal TSI (IgG) crosses placenta and attacks fetal thyroid gland

Hypothyroidism

Hypothyroidism: Hashimoto thyroiditis (MCC), surgical thyroidectomy (#2) Hypothyroidism management: requires ↑Synthroid dosage

OB 11 – Pregnancy × Complications SLE

SLE: I’M DAMN SHARP – Immunoglobulins Serositis (pleuritis, pericarditis) Malar rash Hematologic d/o Discoid rash Arthritis ANA Renal d/o Mucositis (oropharyngeal ulcers) Photosensitivity Neurologic d/o Complications: ↑risk of preeclampsia, IUGR, and spontaneous abortion 1/3 rule: 1/3 of SLE improves, 1/3 stays the same, 1/3 gets worse SLE antibodies: ANA (sensitive), anti-dsDNA or anti-smith (specific), antihistone (drug-induced lupus) SLE management: low-dose aspirin, heparin, or corticosteroids for ppx Lupus flare vs. preeclampsia: can present similarly, DDx w/ complement levels (SLE has ↓C3-C5) Lupus flare management: Tx high-dose corticosteroids, cyclophosphamide if unresponsive

Neonatal lupus

Substance abuse

Neonatal lupus syndrome: maternal ag-ab complexes cross placenta and cause lupus in neonate Congenital heart block: anti-Ro (SSA) can cross placenta and attack fetal heart → 3° heart block Substance Alcohol Caffeine Cocaine Nicotine Opiates (heroin, methadone)

Presentation Fetal Alcohol Syndrome: abnormal facies, IUGR, MR, cardiac teratogenic effects ↑risk of SAB w/ >150 mg/day placental abruption, MR IUGR, placental abruption, preterm delivery, fetal death no teratogenic effects w/ opiate abuse; but withdrawal can cause miscarriage, preterm delivery, fetal death

Management stop use reduce to <150 mg/day stop use stop use enroll in methadone program (opiate withdrawal is worse for fetus than chronic abuse)

OB 12 – Postpartum Postpartum care

Postpartum period: first 6 wks after delivery S/p SVD: issues include pain control + perineal care S/p C/S: issues include pain control + wound care Breastfeeding benefits: ↓childhood infx dz (maternal IgA in milk), maternal weight loss, ↓risk of future T2DM Breastfeeding c/i: only c/i are HIV and active HBV infx

Postpartum contraception

Postpartum intercourse: pelvic rest recommended until after 6 wks Postpartum tubal ligation: very effective, permanent Condom use: can be used by anyone Diaphragms/cervical cap use: requires refitting after 6 wks, due to dilated cervix IUD use: best placed after 6 wks, due to dilated cervix OCP use: use progestin-only pills if breastfeeding, wait til 4-6 wks to use combined pills if not

Postpartum hemorrhage

PPH: >500 mL s/p SVD, >1000 mL s/p C/S PPH causes: consider placenta accreta and 4 Ts – Tone (uterine atony, MCC) Tissue (retained POCs) Trauma (cervical or vaginal lacerations, uterine rupture, uterine inversion) Thrombin (bleeding d/o) Placenta accreta: presents as vaginal bleed + inability to separate placenta after delivery; Tx puerperal hysterectomy Uterine atony: Tx IV oxytocin + bimanual uterine massage (1st line), methylergonovine (c/i with HTN), carboprost (c/i with asthma) Risk factors: tocolytics, increased uterine size (multifetal gestation, polyhydramnios, macrosomia) Retained POCs: Tx manual extraction; if unsuccessful → D+C and abx Vaginal/cervical lac: Tx surgical repair Uterine rupture: sudden onset severe abd pain ± vaginal bleeding, subjective “pop” sensation; Tx emergent ex lap and delivery Uterine inversion: due to pulling too hard on cord; Tx manual replacement of uterus, if unsuccessful → laparotomy Sheehan syndrome: pituitary infarction, usually w/ PP hypovolemia; presents as acute cessation of lactation

Postpartum fever

Postpartum fever: consider endometriitis, acute mastitis, and the 5 Ws – Wind (atelectasis POD #1) Water (UTI POD #3) Walking (DVT POD #5) Wound infx (POD #7+) Wonder drug (drug-induced fever) Disease Endometritis Acute mastitis Atelectasis

UTI Urosepsis DVT Wound cellulitis Wound abscess Wound dehiscence

Postpartum mood changes

Presentation polymicrobial infx → fever, uterine tenderness, foul-smelling lochia breastfeeding women get Staph/Strep infection through cracks in nipple w/ yellowish discharge partial lung collapse

dysuria, urinary frequency + urgency UTI + septic shock acute onset dull leg pain, unilateral swelling, and Homans’ sign (calf pain w/ dorsiflexion) pain, swelling, erythema, heat at incision site pain, swelling, erythema, heat, fluctuance at incision site separation of incision site → salmon-colored fluid soaking dressings

Management Tx clindamycin + gentamicin Tx dicloxacillin, do not stop breastfeeding Dx bilateral inspiratory crackles; prevent with pulmonary toilet and incentive spirometry Dx UA/UCx, Tx Cipro or Bactrim Dx UA/UCx, Tx empiric abx + IVF Dx duplex U/S → Tx IV heparin or Lovenox Tx Bactrim or Keflex Tx I+D and BID dressing change Tx stabilize wound site, surgical closure at a later date

Postpartum mood d/o: three types – blues (30-70%), depression (10-20%), psychosis (0.1%) Postpartum blues: self-resolves by day 10 Postpartum depression: Tx SSRIs (sertraline) Postpartum psychosis: admit and consult psych

GYN 1 – Lower GU

Vulva/vagina congenital anomalies

Labial fusion: due to excess androgen exposure (MC overall) or to 21-hydroxylase deficiency (MC endogenous) Excess androgens: Tx d/c androgens + reconstructive surgery 21-OH deficiency: Dx ↑17-OHP → Tx cortisol + reconstructive surgery Imperforate hymen: presents as primary amenorrhea + cyclic abdominal pain; Dx mucocolpos/hematocolpos → Tx surgery Transverse vaginal septum: presents as primary amenorrhea + cyclic abdominal pain; Dx short vagina that ends in blind pouch → Tx surgery Imperforate hymen vs. septum: presence of hymenal ring indicates transverse vaginal septum Vaginal atresia: failure of lower vagina to develop, presents as primary amenorrhea + cyclic abdominal pain; Dx U/S or MRI → Tx surgery (pull-through) Vaginal agenesis: aka MRKH syndrome, absence of vagina w/ partial uterus and tubes; Tx surgery (create neovagina w/ McIndoe procedure)

Vulvar/vaginal epithelial disorders

Epithelial d/o management: Dx palpation + colpo + bx to r/o cancer; Tx (see below) Disorder Lichen sclerosis Atopic eczema (squamous cell hyperplasia) Lichen simplex chronicus Lichen planus Vulvar psoriasis Vaginal adenosis Atrophic vaginitis

Presentation vaginal thinning and atrophy in postmenopausal women, 10% associated w/ cancer chronic irritation → pruritis w/ hyperkeratotic changes chronic irritation → pruritis w/ reactive changes shiny purple papules ± vaginal adesions silvery scaling plaques, Auspitz sign (bleeding when plaques are removed) red spots/patches in upper 1/3 vagina due to DES exposure in utero; precursor for clear cell adeno vaginal dryness ± bleeding in postmenopausal women

Tx topical steroids topical steroids topical steroids steroid suppository + surgery for adhesions topical steroids or UV light close f/u topical estrogen

Vulvar/vaginal cysts

Epidermal inclusion cysts: MC vulvar cyst, due to blocked hair follicle; Tx I+D or excision if infected Sebaceous cysts: due to blocked sebaceous gland, often multiple and asx; Tx I+D if infected Apocrine cysts: due to blocked apocrine sweat glands; found only on groin and axillary region Hidradenitis suppurativa: superinfx of apocrine cysts → abscess formation; Tx I+D or excision Fox-Fordyce disease: multiple pruritic apocrine cysts Skene cysts: appear at 12-o’clock Bartholin cysts/abscess: appear at 4- and 8-o’clock Bartholin management: usually self-resolves; if >40 y/o → bx to r/o cancer; if large/symptomatic → I+D w/ Word catheter or marsupialization Gartner duct cysts: remnant of mesonephric (Wolffian) ducts; Tx excision

Cervical lesions

DES-associated anomalies: vaginal adenosis, clear cell adenocarcinoma, other cervical or uterine anomalies Nabothian cysts: benign; occurs when ectocervix (strat squamous) overgrows endocervix (simple columnar) Cervical endometriosis: reddish-purple, presents w/ sx of endometriosis (dyspareunia/dyschezia/dysmenorrhea) Cervical polyps: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources Cervical fibroids: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources Cervical stenosis: Tx cervical dilataion

GYN 2 – Upper GU

Uterine anatomic anomalies

Uterine anomalies: septate uterus (#1), bicornuate uterus, uterus didelphys; associated w/ urinary tract anomalies and inguinal hernias Etiology: problems in fusion of paramesonephric (Mullerian) ducts Sx: amenorrhea, dysmenorrhea, infertility, recurrent pregnancy loss (2nd trimester), PTL Management: Dx imaging (pelvic U/S, CT, MRI, HSG, etc.) → leave alone if asx Tx surgery for septate uterus and bicornuate uterus

Leiomyoma (uterine fibroids)

Fibroids: benign, estrogen-sensitive smooth muscle proliferation of myometrium Pseudocapsule: compressed smooth muscle cells surrounding fibroids Degenerative changes: fibroid outgrows blood supply → infarction and degeneration → pelvic pain Incidence: 20-30% of reproductive-age women; 50% of black women Subtypes: submucosal (most likely to bleed), intramural (MC), subserosal, pedunculated Sx: usually asx; can cause menorrhagia (MC), pelvic pain and pressure, infertility (rare) Management: Dx pelvic U/S → leave alone if asx temporary shrinkage w/ ↓E (progesterone, danazol, leuprolide) Tx myomectomy if fertility desired Tx hysterectomy (definitive) Tx uterine artery embolization if bad surgical candidate Leiomyosarcoma: sarcoma of uterine smooth muscle, no relation to fibroids

Endometrial polyps

Endometrial polyps: benign overgrowth of endometrial glands/stroma Sx: vaginal bleeding between periods (metrorrhagia) Management: Dx pelvic U/S → Tx D+C + bx to r/o cancer

Endometrial hyperplasia

Endometrial hyperplasia: presents as vaginal bleeding; precursor to endometrial cancer “Penny, nickel, dime, quarter”: simple hyperplasia w/o atypia = 1% progression to cancer complex hyperplasia w/o atypia = 3-5% simple hyperplasia w/ atypia = 8-10% complex hyperplasia w/ atypia = 25-30% Risk factors: ↑E levels – unopposed E therapy (↑E w/o P) tamoxifen use (weak E) obesity/HTN/DM (↑aromatase in fat cells) PCOS/chronic anovulation (↑E w/o P) nulliparity (↑total cycles) early menarche/late menopause (↑total cycles) granulosa cell tumor (↑E synthesis) Protective factors: COC/POP/combination HRT (↑P) multiparity (↓total cycles) diet and exercise (↓fat cells) Management: Dx endometrial bx or D+C → Tx progestins for 3 mo + repeat endo bx; hysterectomy if complex/atypia

Ovarian cysts

Ovarian mass management: Palpable ovarian/adnexal mass? low-risk

high-risk (premenarchal, postmenopausal, size >8 cm, or persists >60 days)

Dx pelvic U/S

ex lap for cancer

Follicular cysts: MC ovarian cyst, due to unruptured follicle, usually asx Management: observe for 8-12 wks, then repeat pelvic U/S; if unresolved → Tx cystectomy or oophorectomy Corpus luteum cysts: due to hemorrhage into persistent corpus luteum, presents as dull abd pain (unruptured) or acute abdomen (ruptured) Management: resolves spontaneously, if recurrent → suppress w/ OCPs Theca-lutein cysts: multiple/bilateral due to FSH/LH stimulation; associated w/ moles and choriocarcinoma Chocolate cysts: ovarian endometriosis PCOS: enlarged ovaries w/ multiple subcortical cysts

GYN 3 – Endometriosis & Adenomyosis

Endometriosis

Endometriosis: presence of endometrial tissue outside endometrial cavity Etiology: three mechanisms – coelomic metaplasia, reverse menses, lymphatic/hematogenous spread Incidence: 10-15% of reproductive-age women Sx: 3 Ds – dysmenorrhea (hallmark = cyclic pelvic pain, worst 1-2 days before menses) dyspareunia dyschezia (due to endometrial implants in pouch of Douglas) Physical exam: uterosacral nodularity on rectovaginal exam, fixed retroverted uterus Complications: intraabdominal inflammation → scarring + adhesions → chronic pelvic pain, infertility Management: Dx requires direct visualization → temporary relief w/ ↓E (progesterone, danazol, leuprolide) + NSAIDs Tx surgical ablation if fertility desired Tx hysterectomy + LOA + removal of implants (definitive) Endometrioma: endometriosis in the ovary, aka chocolate cyst

Adenomyosis

Adenomyosis: extension of endometrial tissue into myometrium Etiology: ↑E → hyperplasia of stratum basalis of endometrium → myometrial invasion Incidence: 10-15% of reproductive-age women Sx: dysmenorrhea, menorrhagia, or both Physical exam: diffusely enlarged, boggy uterus Management: Dx pelvic U/S → temporary relief w/ ↓E (progesterone, danazol, leuprolide) + NSAIDs Tx hysterectomy (definitive) Adenomyoma: well-circumscribed endometrial tissue collection in myometrium, not encapsulated (vs. intramural fibroids)

GYN 4 – Lower GU × Infx

UTI

STDs and other genital infx

UTI: presents as dysuria, urinary frequency/urgency, suprapubic tenderness Etiology: E. coli (MCC), S. saprophyticus (#2), Enterococcus (#3), other GNB Complications: septic shock (urosepsis), ARDS Management: Dx UA/UCx → Tx Bactrim or Cipro (not pregnant) Tx nitrofurantoin (pregnant) Tx IV cephalosporins + admit (upper UTI) Infx Candidiasis

Bug Candida albicans

Presentation thick, white curd-like discharge, itching, satellite lesions, no odor

Syphilis

Treponema pallidum

1° syphilis: painless chancre + inguinal LN-opathy 2° syphilis: palmar/plantar rash, fever, LN-opathy, condyloma lata 3° syphilis: neurosyphilis (tabes dorsalis), CV syphilis, gummas recurrent, painful oral/genital vesicles that can rupture painful chancre + inguinal LNopathy

HSV

HSV-1/2

Chancroid

Haemophilus ducreyi

LGV

Chlamydia trachomatis, L1-L3 serotypes

Condyloma acuminata Molluscum contagiosum

HPV-6/11 MCV

Scabies vs. pediculosis Bacterial vaginosis

Sarcoptes scabiei vs. Phthirus pubis Gardnerella vaginalis

Trichomoniasis

Trichomonas vaginalis

Gonorrhea

Neisseria gonorrhoeae

Chlamydia

Chlamydia trachomatis

1° LGV: transient, painless ulcer 2° LGV: painful LN-opathy 3° LGV: anogenital syndrome (proctocolitis, rectal stricture, rectovaginal fistula, elephantiasis) genital warts (MC overall STD) domed papule w/ umbilicated center itching, irritation, vesicles, burrows thin homogenous discharge, fishy odor green-gray frothy discharge, odor, strawberry cervix (petechiae) cervicitis, PID, TOA, Bartholin abscess cervicitis, PID, TOA, usually asx (MC bacterial STD)

Management Dx budding yeast + pseudohyphae on KOH prep → Tx fluconazole (Diflucan) Dx screen w/ RPR-VDRL → confirm w/ FTA-ABS → Tx benzathine penicillin G Tx IV penicillin G Dx Tzanck smear or viral cx → Tx ACV/VACV + palliative care Dx “school of fish” on Gram stain → Tx azithromycin or ceftriaxone Dx PE or complement fixation → Tx doxycycline

Dx PE → Tx removal Dx PE → Tx removal Dx PE → Tx permethrin cream Dx “clue cells” on wet prep → Tx metronidazole Dx mobile trichomonads on wet prep → Tx metronidazole Tx ceftriazone (± azithromycin) Tx azithromycin (± ceftriaxone)

Jarisch-Herxheimer rxn: acute febrile rxn s/p syphilis tx (MC w/ 2° syphilis), due to dead spirochetes → endotoxin release

GYN 5 – Upper GU × Infx

Endometritis

Endometritis: polymicrobial infx → fever, uterine tenderness, ↑WBC, foul-smelling lochia Risk factors: postpartum period, instrumentation of endometrial cavity Management: Dx clinical judgment → if sure, Tx clindamycin + gentamicin if unsure, get endometrial bx showing plasma cells

PID

PID: Chlamydia or GC infx → inflammation of uterus, fallopian tubes, ovaries Risk factors: MC in sexually active women <25 y/o Complications: infertility, chronic pelvic pain, adhesions, ectopic pregnancy, TOA/TOC, Fitz-Hugh-Curtis syndrome Management: Dx pelvic/abd pain + cervical, adnexal, or uterine motion tenderness → Tx clindamycin + gentamicin (pregnant) Tx ceftriaxone + doxycycline (not pregnant) Chronic cervicitis: cervicitis has cervical motion tenderness but rest of exam is benign (vs. PID); Tx azithro + ceftriaxone

Tubo-ovarian abscess

TOA: abscess in tubes/ovary in the setting of PID Management: Dx adnexal mass w/ PID sx → confirm w/ pelvic U/S → Tx admit + IV abx → drainage if unresponsive

Toxic shock syndrome

TSS: S. aureus → TSST-1 exotoxin → fever, rash, desquamation of palms/soles Risk factors: tampons Management: Dx clinical judgment → Tx admit + stabilize + IV nafcillin (prevents recurrence, not current toxin-mediated illness)

HIV

HIV: retroviral virus infects CD4+ TH cells → ↓cellular immunity → AIDS-related opportunistic infx → death Primary HIV infx: presents as mono-like syndrome ± maculopapular rash Latent stage: CD4+ >500, asymptomatic Symptomatic stage: CD4+ 200-500, mild HIV sx AIDS: CD4 + <200 or presence of AIDS OI Transmission: sexual, parenteral, vertical or via breast milk Management: Dx ELISA screen → confirm w/ WB → Tx HAART (2 NRTIs + 1 NNRTI or PI) + OI tx/ppx HIV+ during pregnancy: give anti-HIV meds, elective C/S, or IV ZDV during labor HIV+ postpartum: avoid breastfeeding

GYN 6 – Prolapse

Pelvic organ prolapse

Pelvic floor: levator muscles + fascia + ligaments + nerves Pelvic organ prolapse: weakened pelvic floor → bladder prolapse (cystocele) urethra prolapse (urethrocele) rectum prolapse (rectocele) bowel prolapse (enterocele) uterine prolapse (procidentia) Vaginal vault prolapse: inversion of vagina into vaginal canal; MC s/p hysterectomy 1° prolapse: in upper 2/3 of vagina 2° prolapse: down to introitus 3° prolapse: protrudes outside vagina (partial) 4° prolapse: entire structure outside vagina (complete) chronic ↑ abdominal pressure (cough, constipation, heavy lifting, tumors) pelvic floor weakness (intrinsic weakness, birth trauma, atrophy w/ aging) Sx: pelvic pressure/pain, dyspareunia, bowel or bladder dysfxn, urinary incontinence Management: Dx H+P → imaging as needed → nonsurgical tx (Kegel exercises, pessaries, E replacement) cystocele → anterior colporrhaphy rectocele → posterior colporrhaphy procidentia → hysterectomy vaginal vault prolapse → vaginal suspension Etiology:

GYN 7 – Incontinence

Continence

Continence: voluntary control of urination Sympathetic: hypogastric n → α1R → detrusor relaxation, int sphincter constriction Parasympathetic: pelvic splanchnic n → MAChR → detrusor constriction, int sphincter relaxation Somatic: pudendal n → ext sphincter constriction

Incontinence

Incontinence: involuntary urine leakage Management: first step is always to get UA/UCx to r/o UTI Type Stress incontinence

Definition urine leakage w/ exertion or straining

Urge incontinence

urine leakage d/t involuntary bladder contractions (detrusor overactivity)

Mixed incontinence Overflow incontinence

stress + urge incontinence urine leakage d/t urinary retention and overdistention

Bypass incontinence

urine leakage d/t fistula following pelvic surgery or pelvic radiation urine leakage d/t physical or psychological issues; common in nursing home or gero pts

Functional incontinence

Etiology chronic ↑ abdominal pressure, pelvic relaxation, old age (↓estrogen → loss of mucosal coaptation) idiopathic (MCC), UTIs, bladder stones or cancer, urethral diverticula, foreign bodies --medications, neurologic disease

vesicovaginal, urethrovaginal, or ureterovaginal fistulas physical impairment, dementia or delirium, medications

Management surgery to stabilize hypermobile urethra (best), Kegel exercises, pessaries anticholinergics (oxybutinin), TCAs (imipramine)

--intermittent self-cath, cholinergics (↑bladder contactility) + α1-blockers (↑urethral resistance) Dx methylene blue or indigo carmine dye → Tx surgery to repair fistula Tx underlying cause

GYN 8 – Menstrual Cycle

Puberty

Adrenarche: regeneration of adrenal gland zona reticularis Gonadarche: pulsatile GnRH starts → gonadal development Thelarche: breast development, measured by Tanner stages Pubarche: growth of pubic hair ± axillary hair Menarche: onset of menstruation, 2½ yrs after thelarche Puberty timing:

Tanner stages

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

HPO axis

“Always go (to) adrenarche gonadarche

the thelarche

at 7 y/o

at 10 y/o

at 8 y/o

---

pub, men.” pubarche/ menarche peak growth at 11 y/o at 12 y/o

kid breast buds breast elevation areolar mound (look 4 big nipples) adult GnRH

DA

TRH

FSH/LH

PRL

TSH

E2/P4

stimulates inhibits

T3/T4

Hypothyroidism × infertility: ↓T3/T4 → ↑TRH → ↑prolactin → ↓GnRH; Tx replacement T3/T4 (Synthroid) Hyperprolactinemia × infertility: ↑prolactin → ↓GnRH; Tx dopamine analogs (cabergoline, bromocriptine) vs. surgery Kallman syndrome: congenital ↓GnRH Menstrual cycle

Ovarian follicle:

Endometrium:

Hormones:

Theca/granulosa cells

Theca cells: stimulated by LH to make desmolase (cholesterol → androgens) Granulosa cells: stimulated by FSH to make aromatase (androgens → estrogens)

Menopause

Menopause: cessation of menses and estrogen-deficient state for >12 months; avg age is 51 y/o Sx: HAVOC – hot flashes, atrophy of vagina, osteoporosis, coronary artery dz Management: Dx ↑FSH, Tx lowest dose HRT (estrogen + progesterone) for only 6-12 months HRT benefits: prevention of osteoporosis, relief of menopausal sx HRT risks: ↑risk of endometrial hyperplasia/cancer HRT contraindications: h/o clotting dz, liver dz, pregnancy, estrogen-dependent neoplasm, undiagnosed vaginal bleeding

GYN 9 – Amenorrhea

Amenorrhea

1° amenorrhea: absence of menarche by age 16, or 4 yrs after thelarche 2° amenorrhea: absence of menses for 6 months, had periods at one time

1° amenorrhea

1° amenorrhea: absence of menarche by age 16, or 4 yrs after thelarche Etiology: three types – outflow tract obstruction, end-organ d/o, central regulatory d/o Outflow tract obstruction: something getting in the way of blood from leaking out Imperforate hymen: Dx PE shows bulging red/purple membrane (hematocolpos), Tx surgery (hymenotomy) Transverse vaginal septum: Dx PE shows septum and presence of hymenal ring, Tx surgery MRKH syndrome: mullerian agenesis or dysgenesis → lack of uterus and upper vagina Vaginal atresia: distal vagina fibrosed but mullerian system intact, Tx surgery Androgen insensitivity syndrome: ΔT-receptor → 46/XY female w/ blind pouch vagina, Tx surgery Central regulatory d/o: something wrong with either GnRH or FSH/LH release Kallmann syndrome: lack arcuate + olfactory nuclei (no GnRH + anosmia), Dx olfactory challenge, Tx exogenous GnRH (pulsatile) Craniopharyngioma: Rathke’s pouch tumor → pituitary compression; Dx supracellar calficied cysts End-organ d/o: ovaries won’t respond to FSH/LH Savage syndrome: ΔFSH/LH-receptor → primary ovarian failure Turner syndrome: 45/XO → rapid ovarian atresia → streak gonads w/o oocytes left; Tx GH + estrogen 17α-hydroxylase deficiency: can’t produce testosterone but still have MIF → 46/XY female w/ blind pouch vagina Swyer syndrome: male w/o testes → 46/XY female w/ both internal and external female genitalia 1° amenorrhea management:

1° amenorrhea labs: 1° amenorrhea? uterus (lacks MIF) vagina

no uterus (MIF present)

no vagina

Central d/o: ↓FSH/LH, ↓E2 Ovarian d/o: ↑FSH/LH, ↓E2 Outflow d/o: normal FSH/LH, normal E2

Dx karyotype …… …... (46/XY females)

outflow tract breasts no breasts obstruction (E present) (lacks E) P challenge 2° amenorrhea

P challenge negative

2° amenorrhea: absence of menses for 6 months, had periods at one time Etiology: four types – pregnancy (MC), acquired abnormalities, hyperprolactinemia, HPO axis d/o Pregnancy: MCC secondary amenorrhea, always r/o w/ ↑β-HCG Acquired abnormalities: either anatomic or ovarian abnormalities causing 2° amenorrhea Asherman syndrome: D+C, surgery, or endometritis → intrauterine adhesions ; Tx lysis of adhesions + estrogen Cervical stenosis: surgical or obstetric trauma → scarring of cervical os; Tx surgical dilation or laminaria PCOS: ↑LH, ↓FSH, ↑T/E → anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss Hyperprolactinemia: anything that elevates prolactin inhibits GnRH (↑TSH, ↓DA, tumors) Progesterone challenge test: give P for 1-2 wks and check for withdrawal bleeding afterwards (checks to see if endometrium is estrogenized) 2° amenorrhea management: 2° amenorrhea? β-HCG (r/o preg) ↑prolactin

prolactin normal

TSH normal

↑TSH

get cone view and prolactin levels

Tx Synthroid

cone view normal and prolactin <100

cone view abnormal or prolactin >50 or visual sx

repeat prolactin q 6 mo, cone views q 1-2 yrs

head CT or MRI

P challenge test negative r/o Asherman syndrome and cervical stenosis FSH >40

microadenoma (<10 mm) or hyperplasia Tx bromocriptine or cabergoline

positive

FSH <40

hirsute

ovarian failure severe hypothalamic dysfunction macroadenoma (>10 mm) PCOS

Tx surgery

nonhirsute

mild hypothalamic dysfunction

GYN 10 – Menstrual Abnormalities Dysmenorrhea

Dysmenorrhea: pain and cramping during menstruation that interferes w/ normal activity 1° dysmenorrhea: ↑PGF2α → uterine ctx → dysmenorrhea w/o organic cause; Tx NSAIDs and/or COCs 2° dysmenorrhea: dysmenorrhea 2/2 endometriosis, adenomyosis, fibroids, cervical stenosis, pelvic adhesions Cervical stenosis: surgical or obstetric trauma → scarring of cervical os; Tx surgical dilation or laminaria Pelvic adhesions: infx (PID), inflammation, or prior surgery → scarring of endometrium; Dx/Tx laparoscopy

PMS/PMDD

AUB

PMS/PMDD: luteal phase sx (HA, bloating, weight gain, dysphoric mood) for 2+ consecutive cycles Etiology: interaction between 5-HT and E/P Management: Dx menstrual diary → Tx SSRI/SNRI, Xanax (alprazolam), Yaz OCP (E + drospirenone), diet and exercise AUB Normal menses Menorrhagia Hypomenorrhea Metrorrhagia Menometrorrhagia Oligomenorrhea Polymenorrhea DUB

Pattern 3-5 days Q 4 wks, 30-50 mL/cycle heavy flow light flow irregular timing heavy flow + irregular timing slow cycles (>5 wks, <6 months) fast cycles (<3 wks) heavy or irregular bleeding w/o identifiable cause, dx of exclusion

MCC --cervical or endometrial lesions hypogonadotropic hypogonadism in athletes/anorexics cervical or endometrial lesions cervical or endometrial lesions anovulation, PCOS, pregnancy, thyroid dz anovulation anovulation

AUB management: Dx labs (β-HCG, TSH, prolactin, FSH) + endometrial bx (>35 or obese) + pelvic U/S; Tx the underlying cause Fibroids: Tx myomectomy vs. hysterectomy Adenomyosis: Tx NSAID/OCP vs. hysterectomy Cervical polyps: Tx polypectomy Endometrial polyps: Tx hysteroscopy vs. polypectomy ± D+C Endometrial hyperplasia: Tx progestins vs. hysterectomy Endometrial cancer: Tx hysterectomy + BSO + radiation Pregnancy: Tx expectant management vs. delivery Miscarriage: Tx expectant management vs. D+C Ectopic pregnancy: Tx MTX vs. surgery Hypothyroidism: Tx Synthroid Hyperprolactinemia: Tx bromocriptine or cabergoline Anovulation: Tx cyclic OCP or progestins DUB

DUB: heavy or irregular bleeding w/o identifiable cause, dx of exclusion Etiology: anovulatory cycles (endometrium continues to grow w/o progesterone, sloughs off at random intervals) DUB management: DUB? r/o AUB w/ labs (β-HCG, TSH, prolactin, FSH) + endometrial bx (>35 or obese) + pelvic U/S acute hemorrhage

chronic DUB

Tx 25mg IV estrogen

Tx NSAIDs + COC (POP if estrogen c/i)

surgery if not responsive to meds (D+C, endometrial ablation, hysterectomy) Postmenopausal bleeding

Postmenopausal bleeding: any vaginal bleeding 12+ months after LMP Etiology: vaginal/endometrial atrophy and exogenous estrogens are MCC, must r/o endometrial cancer Postmenopausal bleeding management: Dx labs (CBC, TSH, prolactin, FSH) + endometrial bx + pelvic U/S; Tx the underlying cause Lacerations: Tx repair Vaginal atrophy: Tx estrogen cream Cervical polyps: Tx polypectomy Endometrial polyps: Tx hysteroscopy vs. polypectomy ± D+C Endometrial hyperplasia: Tx progestins vs. hysterectomy Endometrial cancer: TAHBSO ± pelvic/paraaortic LN-ectomy and radiation (if high-risk)

GYN 11 – Hirsutism/Virilization Hirsutism vs. virilization

Hirsutism: excess male-pattern hair growth Virilization: hirsutism + secondary male sex characteristics (clitoromegaly, deep voice, etc.) Initial management: Hirsutism or virilization? Labs: free T, DHEAS, 17-OHP, ±cortisol If adrenal, CT scan for adrenal tumor If ovarian, pelvic U/S or CT for ovarian tumor Tx underlying cause Cosmetic tx of hirsutism

Hirsutism labs

Hirsutism diseases

↑free T: either adrenal or ovarian source ↑DHEAS: adrenal source ↑17-OHP: indicates congenital adrenal hyperplasia ↑cortisol: indicates Cushing syndrome Disease Cushing syndrome CAH PCOS

Theca-lutein cysts Stromal hyperthecosis Sertoli-Leydig cell tumors Exogenous hirsutism Idiopathic hirsutism

Mechanism/presentation excess production of cortisol from pituitary adenomas, adrenal tumors, or paraneoplastic syndromes congenital deficiency of 21α-hydroxylase (MC), 11βhydroxylase, or 3β-HSD Rotterdam criteria: 2/3 of the following – polycystic ovaries on U/S, anovulation, signs of hyperandrogenism ↑LH or βHCG (pregnancy, moles) → bilateral ovarian cysts → possible androgen production ovarian hyperplasia in postmenopausal women → possible androgen production androblastoma, secretes testosterone due to drug use absence of adrenal or ovarian causes, not drug-induced

Management Dx ↑cortisol → dexamethasone suppression test to confirm → Tx surgery Dx ↑DHEAS + ↑17-OHP → Tx cortisol replacement, consult endocrinology Dx LH:FSH ratio >3:1 + ↑estrone → Tx OCPs, clomiphene, metformin, weightloss; and screen for fasting blood sugars Dx ovarian bx → should resolve postpartum or s/p mole removal Dx ovarian bx Dx pelvic U/S → Tx unilateral salpingooophrectomy Tx d/c meds Dx normal T and DHEAS → look for increased peripheral 5-αR activity → Tx finasteride (5αR blocker) if elevated

GYN 12 – Contraception Contraception and sterilization

Method COC

Mechanism blocks LH surge, thickens cervical mucus, slows tubal peristalsis, creates hostile environment

Failure rate ~1%

Benefits  normalizes cycles  ↓cervical and ovarian cancer  ↓benign breast dz  ↓dysmenorrhea  ↓PID  ↓acne

Risks  $30/month  hypercoagulability  hepatic adenoma

Contraindications smokers >35, clotting dz (PE, DVT, stroke, CAD), uncontrolled HTN, migraines w/ aura, CHF, estrogendependent cancers, pregnancy, liver dz

Ortho Evra

COC as a transdermal patch; 3 weeks on, 1 week off COC as a vaginal ring; 3 weeks in, 1 week out thickens cervical mucus

“

“

“

women >198 lbs

“

“

“

---

0.3%

 indicated for lactating women  indicated for women >40 y/o

---

Depo-Provera

thickens cervical mucus, injection Q 12-14 wks

0.3%

 effective

Implanon

thickens cervical mucus, implantable rod in arm

---

Condoms

prevent sperm and ova from mating prevent sperm and ova from mating

~5%

 good for 3 yrs  no weight gain, depression, or bone demineralization  low cost  STI prophylaxis  low cost

 must take at same time everyday  irregular vaginal bleeding  reversible bone demineralization  prolonged amenorrhea  weight gain  depression  irregular vaginal bleeding  reversible bone demineralization  prolonged amenorrhea  weight gain  depression ---

---

-----

Cervical caps

prevent sperm and ova from mating

~10% nullip ~25% multip

 low cost

Nonoxynol-9, octoxynol-9 Mirena IUD (levonorgestrel)

spermicide

20-30%

inhibits sperm motility, creates hostile environment

<1%

 used in combo w/ other methods  indicated for monogamous pts  good for 5 yrs  low maintenance  ↓menstrual flow

 toxic shock syndrome  ↑UTIs  must leave inside 6-8 hrs after sex  needs to be fitted by MD  ↑↑failure rate  needs to be fitted by MD  must have nl Pap  ↑STI susceptibility

pregnancy, uterine anomalies, infx, unresolved vaginal bleeding, breast cancer

ParaGard IUD (copper-T)

inhibits sperm motility, creates hostile environment

<1%

 indicated for monogamous pts  good for 10 yrs  low mainenance

Natural family planning

periodic abstinence measured by basal body temperature or cervical mucus methods prolactin-induced GnRH suppression

~20%

 free  self-managed

---

 free

plan B (levonorgestrel) given within 72 hrs, or copper IUD inserted within 5 days blocks ova passage

---

 90% effective  not abortifacient

~1%

 99% effective

blocks sperm passage, must use alternative methods for 90 days while sperm die off

~1%

 99% effective  more reversible than tubal ligation  safer and more effective than tubals

 ↑ratio of ectopics  ↑cramping  needs to be placed by MD  risk of PID, uterine perforation, SAB  ↑menstrual flow  ↑ratio of ectopics  ↑cramping  needs to be placed by MD  risk of PID, uterine perforation, SAB  ↑↑failure rate  variability between cycles  ↑↑failure rate  only use for max of 6 months  nausea/vomiting  headache  breast tenderness  permanent  surgical risks  risk of regret (1015%)  no STD protection  permanent  surgical risks  no STD protection  must wait 3 months before sex

NuvaRing POP

Diaphragms

Lactational amenorrhea Emergency contraception Tubal ligation

Vasectomy

~5%

---

---

---

---

pregnancy, uterine anomalies, infx, unresolved vaginal bleeding, copper allergy or Wilson dz

---

>5 days

women <25 y/o, uninformed about other methods, making decision under pressure men <25 y/o, uninformed about other methods, making decision under pressure

GYN 13 – Abortion

1st trimester abortion

1st trimester abortion: suction D+C (MC), manual vacuum extraction, medical abortion (≤7 wk) MCC death during abortion: general anesthesia Suction D+C: 90% of all abortions, safest method, most effective 7-13 wk Medical abortion: indicated ≤7 wk only, requires f/u in 2 wks for β-HCG levels Mifepristone (RU-486): blocks progesterone stimulation → embryo detachment Methotrexate: blocks DHF reductase → ↓cell division → blocks placental proliferation Misoprostol: ripens cervix; use w/ MTX or RU-486 to ↑efficacy rates Side-effects: abd pain/cramps, uterine bleeding, nausea/vomiting

2nd trimester abortion 2nd trimester abortion: D+E or induction of labor (IOL is better, since intact fetus can be used for autopsy) D+E: like D+C, but requires wider cervical dilation + use of special forceps to extract fetal parts Complications: trauma, infx, retained tissue, uterine perforation Induction: cervical ripening w/ misoprostol (Cytotec) → amniotomy → induction w/ high-dose oxytocin (Pitocin) Complications: trauma, infx, retained tissue 3rd trimester abortion

3nd trimester abortion: illegal ≥24 wk, unless necessary for preservation of maternal life

GYN 14 – Infertility

Infertility

Infertility: failure to conceive after 12 mo of unprotected sex (6 mo if woman >35 y/o) Fecundability: ability to get pregnant in one cycle Categories: male factor (35%) female factor (45-55%) combined (10-20%) unexplained (10%) Infertility management:

Female factor infertility

Category Ovarian factors

Disease PCOS

Tubal factors

Advanced maternal age PMOF Hyperprolactinemia Hypothyroidism Endometriosis Pelvic adhesions PID

Uterine factors

Cervical factors

Tubal ligation Asherman syndrome Polyps Submucosal fibroids Congenital malformations Endometritis Cervical stenosis Chronic cervicitis DES exposure Congenital malformations

Tx OCPs, clomiphene, metformin, weight-loss, and screen for fasting blood sugars ART ART cabergoline or bromocriptine Synthroid surgical ablation (if fertility desired) hysterectomy + LOA + removal of implants (definitive) surgery (lysis of adhesions) IV clindamycin + gentamicin (pregnant) IV ceftriaxone + doxycycline (not pregnant) IVF/ICSI hysteroscopic lysis of adhesions + estrogen hysteroscopic polypectomy hysteroscopic myomectomy surgery, may not be treatable IV clindamycin + gentamicin cervical dilation or IUI IVF/ICSI none surgery, may not be treatable

Male factor infertility

Male factor infertility: 3 categories – sexual problems, endocrine d/o, sperm abnormalities Management: stay away from risk factors (drugs, radiation, heat) + Tx underlying cause

Unexplained infertility

Unexplained infertility: no underlying cause found during initial assessment Management: refer to REI clinic → Tx IVF/ICSI or use donor sperm

Assisted reproductive ART: any therapy where sperm/egg are handled for increasing rate of conception technologies Clomiphene: blocks E-receptors in hypothalamus → ↑FSH/LH → promotes ovulation Indications: chronic anovulation, hypothalamic insufficiency Letrozole: aromatase inhibitor → ↓E → ↑FSH/LH → promotes ovulation HMGs: FSH/LH analogs → promotes ovulation Indications: second line to Clomid Complications: antiestrogen effects, ovarian hyperstimulation syndrome (OHSS), multiple gestation OHSS: overstimulation of ovaries → ↑risk of torsion or rupture IVF: insert fertilized gamete into uterus ICSI: inject sperm into oocyte before IVF

ONC 1 – Vulvar/Vaginal Cancer

Squamous neoplasia

Squamous neoplasia: defined by depth of epithelial involvement (xIN if not invasive, SCC if invasive) Risk factors: multiple sexual partners (#1), sex at young age, high-risk HPV strains, smoking, immunosuppression, other xINs

VIN

VIN: premalignant dz of vulvar epithelium, three grades (VIN I-III) Sx: usually asx but can have vulvar itching and irritation; classic presentation is “fungal infx” that doesn’t resolve w/ antifungal cream Management: Dx vulvar bx → Tx wide local excision if unifocal, vulvectomy or laser ablation if multifocal

Vulvar SCC

Vulvar SCC: malignant dz of vulvar epithelium, 90% are unifocal Sx: vulvar itching, pain, bleeding, ulceration Management: Dx vulvar bx → Tx (see below) Px: depends on LN+ status – good if 0-2, <15% if 3+ Stage Ia Ib II III

TNM criteria <2 cm, <1 mm depth <2 cm, >1 mm depth >2 cm LN+ or local spread (lower urethra, distal vagina, anus)

IVa IVb

local met+ (bladder or rectum) distal met+

Tx wide local excision + ipsi LN-ectomy " radical vulvectomy + bilat LN-ectomy radical vulvectomy + bilat LN-ectomy + pelvic exenteration " "

Verrucous carcinoma: well-differentiated subtype of vulvar SCC, good px VAIN

VAIN: premalignant dz of vaginal epithelium, 50-90% associated w/ VIN or CIN Sx: usually asx but can have vaginal discharge or postcoital spotting; classic presentation is persistent abnl Pap but nl cervical bx Management: Dx colpo-directed bx → Tx local excision, laser ablation, or topical 5-FU

Vaginal SCC

Vaginal SCC: malignant dz of vaginal epithelium, usually in upper 1/3 and posterior wall Sx: usually asx but can have vaginal discharge, itching, or bleeding Management: Dx colpo-directed bx + check for spread (CXR/cystoscopy/proctosigmoidoscopy/IVP) → Tx (see below) Stage 0 I II III IVa IVb

TNM criteria carcinoma in situ within vaginal wall spread into subvaginal tissue spread into pelvic wall local met+ (bladder or rectum) distal met+

Tx surgical resection " radiation tx " " "

Vaginal clear cell adenocarcinoma

Vaginal adenosis: red/superficial ulcer, precursor to clear cell adenocarcinoma Clear cell adenocarcinoma: vaginal cancer in women <20 y/o w/ in utero DES exposure

Extramammary Paget disease

Paget disease: red, velvety lesions + scarred white plaques; 20% associated w/ underlying adenocarcinoma Paget vs. melanoma: Paget “halo” cells are PAS+, mucicarmine+, Alcian blue+; melanoma cells are PASSx: classic presentation is vulvar itching and pain in women >60 y/o Management: Dx vulvar bx → Tx wide local excision + r/o underlying adeno Px: high local recurrence rate, fatal if LN+

Sarcoma botryoides

Sarcoma botryoides: embryonal rhabdomyosarcoma, resembles grape-like mass protruding from vagina in girls <5 y/o Management: Dx bx shows desmin+ spindle-shaped rhabdomyoblasts, Tx excision

ONC 2 – Cervical Cancer

HPV

HPV-1-4: verruca vulgaris (common warts) HPV-6/11: low-risk strains cause condyloma acuminata (genital warts) HPV-16-18/31/33/45: high-risk strains cause cervical dysplasia/cancer Gardasil: quadrivalent 3-series HPV vaccine for strains 6/11/16/18; indicated for women 11-26 y/o

Pap smears

Pap smear: scrape transformation zone w/ spatula, then sample endocervical canal w/ brush Screening protocol: start age 21, Q2 yrs 21-29 y/o, Q3 yrs >30 y/o after 3 negative Paps Exceptions: annual if HIV, immunosuppressed, DES, previous CIN II+; don’t need s/p total hysterectomy

Bethesda system

Pap result ASC-US

Definition atypical squamous cells, undetermined significance

ASC-H LSIL HSIL SCC AGC

atypical squamous cells, can’t r/o high grade low-grade squamous intraepithelial lesion = CIN I high-grade squamous intraepithelial lesion = CIN II-III squamous cell carcinoma atypical glandular cells

Management HPV DNA testing → repeat Pap in 1 yr if HPV–, colpo + cervical bx if HPV+ colpo + cervical bx " " " "

Diagnostic cone bx

Cone indications:

Microinvasion <3mm ECC positive Discrepancy of 2 steps (high-grade Pap, not confirmed on bx) Inadequate colpo (can’t see all borders of TZ or lesion) Adenocarcinoma in situ Cone complications: bleeding or infx (common), cervical stenosis, incompetent cervix, PROM/PTL

CIN

CIN: premalignant dz of cervical epithelium due to high-risk HPV strains, three grades (CIN I-III) MC timing: during menarche and after pregnancy MC location: anterior lip of transformation zone, multifocal Stage CIN I

Definition dysplasia in basal 1/3 of epithelium, mild

Management repeat Pap Q 6 mo ×2 or HPV testing in 12 mo (65% regression rate) → LEEP if persistent for 2 yrs LEEP LEEP diagnostic cone bx

CIN II dysplasia in basal 2/3 of epithelium, moderate CIN III dysplasia >2/3 to full epithelium, severe 2-step discrepancy (e.g. HGSIL on pap but normal bx) Cervical SCC

Cervical SCC: malignant dz of cervical epithelium defined by basement membrane invasion Epidemiology: US incidence ↓↓ after Pap smear; #1 cancer killer of women in 3rd world countries Sx: usually asx, can present as postcoital bleeding Stage 0 Ia Ib IIa IIb

TNM criteria carcinoma in situ cervix only,<7 mm cervix only, >7 mm or visible lesion involves upper 2/3 vagina, no parametrium involves upper 2/3 vagina, parametrium

IIIa IIIb

involves lower 1/3 vagina, no pelvic wall involves lower 1/3 vagina, pelvic wall and/or hydronephrosis or nonfunctional kidney local met+ (bladder or rectum) distal met+

IVa IVb

Tx simple hysterectomy or cold knife cone " radical hysterectomy or radiation tx " chemoradiation (external and internal radiation + cisplatin chemotherapy) " "

Px (5 yr) -->80% " 60% "

" "

20% "

40% "

Simple hysterectomy: removes uterus only Radical hysterectomy: removes uterus + parametria, upper vaginal cuff, uterosacral/cardinal ligaments, local vascular and lymphatic supply

ONC 3 – Endometrial Cancer

Endometrial hyperplasia

Endometrial hyperplasia: precursor to type I endometrial cancer “Penny, nickel, dime, quarter”: simple hyperplasia w/o atypia = 1% progression to cancer complex hyperplasia w/o atypia = 3-5% simple hyperplasia w/ atypia = 8-10% complex hyperplasia w/ atypia = 25-30% Risk factors: ↑E levels – unopposed E therapy (↑E w/o P) tamoxifen use (weak E) obesity/HTN/DM (↑aromatase in fat cells) PCOS/chronic anovulation (↑E w/o P) nulliparity (↑total cycles) early menarche/late menopause (↑total cycles) granulosa cell tumor (↑E synthesis) Protective factors: COC/POP/combination HRT (↑P) multiparity (↓total cycles) diet and exercise (↓fat cells) HNPCC/Lynch II syndrome: high-risk for colon, endometrial, ovarian cancer; get annual endo bx ≥35 y/o

Endometrial cancer

Endometrial cancer types: Type Type I Type II

Etiology E-dependent neoplasm preceded by hyperplasia E-independent neoplasm, not preceded by hyperplasia (papillary serous or clear-cell)

% 80% 20%

Race white black, asian

Age perimenopausal postmenopausal

Px good bad

Sx: presents as postmenopausal bleeding or other abnormal vaginal bleeding Management: (premenopausal) Dx endometrial bx → Tx (see below) (postmenopausal) Dx U/S → if endometrial stripe >5 mm then endometrial bx → Tx (see below) Stage Ia

TNM criteria uterus, endometrium only

Ib uterus, <50% myometrial invasion Ic uterus, >50% myometrial invasion IIa endocervix, glands only IIb endocervix, stroma IIIa in serosa IIIb in vagina IIIc pelvic/paraaortic LN+ IVa spread beyond true pelvis, or in bladder or rectum IVb distal met+ Pelvic recurrence Vaginal recurrence

Tx TAHBSO ± pelvic/paraaortic LN-ectomy and radiation (if high-risk) " " " " " " " " " High-dose progestins ± chemotherapy Vaginal radiation

Px: grade is #1 factor; three grades – G1 shows <5% solid growth pattern, G2 6-50%, G3 >50% High-risk endo cancers: >50% myometrial invasion type 2 (papillary serous or clear-cell) grade 3 (>50% solid growth) stage 3+ size >2 cm LN+

ONC 4 – Ovarian/FT Cancer

Ovarian cancer

Ovarian cancer: four types – epithelial (90%), germ cell, sex-cord stromal, metastatic Sx: asx in early stages; present w/ vague abd pain, bloating, distention, early satiety in later stages Etiology: chronic uninterrupted ovulation → ↑cellular repair → ↑opportunities for gene deletion/mutation CA-125: ovarian tumor marker useful for testing tx response and recurrence, but not screening or dx Risk factors: family hx (#1), familial ovarian cancer syndrome, uninterruped ovulation, old age Familial ovarian cancer syndrome: BRCA1/2, HNPCC (Lynch II) Uninterrupted ovulation: nulliparity, infertility, early menarche, late menopause Protective factors: OCPs, multiparity, breastfeeding, chronic anovulation (all ↓ ovulation) Management: Dx pelvic U/S → stage → Tx (see below) Stage Ia Ib Ic IIa IIb IIc IIIa IIIb IIIc IV

TNM criteria one ovary two ovaries Ia/Ib + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+ invades FT or uterus invades other pelvic tissue IIa/IIb + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+ abd peritoneal met+, <2 cm abd peritoneal met+, >2 cm pelvic/paraaortic/inguinal LN+ distal met+

Class Epithelial Germ cell Sex-cord stromal

Tx surgery (TAHBSO, omentectomy, pelvic/paraaortic LN-ectomy) + carboplatin/paclitaxel USO + BEP (bleomycin/etoposide/cisplatin) USO only

Ovarian cancer complications

Carcinomatous ileus: intraperitoneal tumor spread → ascites and bowel encasement → intermittent bowel obstruction Sister-Mary-Joseph nodule: ovarian cancer metastasis to umbilicus Pseudomyxoma peritonei: “jelly belly” associated w/ appendiceal carcinoma and mucinous cystadenocarcinoma Meigs syndrome: fibroma + ascites + right-sided hydrothorax Latzko triad: pain, profuse watery d/c, pelvic mass; associated w/ FT adenocarcinoma Precocious puberty: granulosa cell tumor

Epithelial tumors

Epithelial tumors: slow growing and usually asx, thus found at stage III+ MC type: serous cystadenocarcinoma Serous cystadenoma: bilateral, lined w/ FT-like epithelium Serous (papillary) cystadenocarcinoma: bilateral, Dx Psamomma bodies Mucinous cystadenoma: multilocular cyst lined w/ mucus-secreting epithelium Mucinous cystadenocarcinoma: pseudomyxoma peritonei Endometrioid carcinoma: resembles endometrial cancer, good px Clear cell carcinoma: masses of glycogen-filled clear cells, poor px Brenner tumor: benign, resembles bladder (transitional epithelium)

Psammoma body

Germ cell tumors: rapidly growing in women <20 y/o, thus found at early stages MC type: mature teratoma aka dermoid cyst (MC overall), dysgerminomas (MC malignant) Teratoma: tumor of totipotent fetal tissue Mature teratoma: benign, contains hair/teeth/calcifications Immature teratoma: aggressively malignant, contains neural tissue Struma ovarii: monodermal, contains thyroid tissue Dysgerminoma: ↑LDH, associated w/ Turner syndrome (45/XO), good px due to radiosensitivity Endodermal sinus (yolk sac) tumor: ↑AFP, Dx Schiller-Duval bodies resembling primitive glomeruli Choriocarcinoma: ↑β-hCG, also a malignant type of GTD

Schiller-Duval body

Germ cell tumors

Sex-cord stromal tumors

Sex-cord stromal tumors: slow growing, steroid hormone secreting tumors MC type: granulosa cell tumor Granulosa cell tumor: secretes estrogen → ↑risk of endometrial hyperplasia, Dx Call-Exner bodies Fibroma: pulling sensation in groin, Dx bundles of spindle-shaped fibroblasts Sertoli-Leydig cell tumor: androblastoma, secretes testosterone → virilization

Metastatic tumors

Krukenberg tumor: metastatic stomach cancer, Dx mucin-containing signet ring cells

FT cancer

FT adenocarcinoma: very rare (0.5%), mets to FT are more common than primary FT cancer Sx: 15% present as Latzko’s triad – Pain, Profuse watery discharge (hydrops tubae profluens), Pelvic mass Management: Dx pelvic U/S → Tx same as epithelial ovarian cancers

Call-Exner body

ONC 5 – Gestational Trophoblastic Disease

GTD

GTD: group of diseases 2/2 abnl proliferation of trophoblastic (placental) tissue Benign GTD: complete and partial hydatidiform moles (80%) Malignant GTD: persistent/invasive moles (15%), choriocarcinoma (<5%), PSTTs (rare)

Benign GTD

Hydatidiform moles: two types – complete (90%) and partial (10%) Epidemiology: highest incidence in Asian women Risk factors: extremes in age, prior GTD, nulliparity, low β-carotene/folate/fat diet Etiology Karyotype β-hCG Pathology Presentation Other sx

Malignant potential Management

Malignant GTD

Complete moles (90%) empty egg + sperm 46/xx (both paternal) ↑↑↑ (>100,000), 14 wks to return to normal enlarged uterus + “grape cluster” villi ± bilateral theca-lutein cysts presents as abnormal vaginal bleeding severe hyperemesis gravidarum, 1st trimester preeclampsia, hyperthyroidism, anemia (all related to ↑β-hCG) 15-20% overall, 2% choriocarcinoma Dx ↑↑↑β-hCG and pelvic U/S showing “snowstorm” pattern → Tx D+C ± oxytocin → f/u serial β-hCG and reliable contraception for 6 months

Partial moles (10%) egg + 2 sperm 69/XXY normal or slightly ↑, 8 wks to return to normal normal-sized uterus, fetal parts found on autopsy of abortion prodcuts presents as a missed abortion rare

<5% overall, no choriocarcinoma Dx pelvic U/S shows “swiss cheese” uterus → Tx D+C ± oxytocin → f/u serial β-hCG and reliable contraception for 6 months

Nonmetastatic: confined to uterus Metastatic: spread beyond uterus Low-risk: duration <4 mo, β-hCG <40k, liver/brain met–, no prior chemo High-risk: duration >4 mo, β-hCG >40k, liver/brain met+, failed chemo, GTD following pregnancy Persistent/invasive moles remnant of benign hydatidiform moles

Choriocarcinoma malignant, necrotizing tumor

Presentation

presents as plateauing or ↑βhCG s/p molar evacuation

Management

Dx ↑β-hCG and pelvic U/S → Tx single-agent chemo (nonmet or low-risk), multi-agent chemo (high-risk) → f/u serial β-hCG and reliable contraception for 6 months

presents w/ sx of metastasis (lungs, vagina, liver, brain, kidneys) Dx ↑β-hCG and pelvic U/S → check for mets → Tx singleagent chemo (non-met or low-risk), multi-agent chemo (high-risk) → f/u serial β-hCG and reliable contraception for 6 months

Etiology

PSTTs rare tumors that arise from placental invasion site, have no villi presents as abnormal vaginal bleeding Dx ↓β-hCG (persistently <100) and pelvic U/S → Tx hysterectomy + multiagent chemo

ONC 6 – Breast Disease/Cancer

Breast anatomy and physiology

Blood supply: internal mammary (off subclavian) + lateral thoracic (off axillary) arteries Lymph drainage: axillary LN (97%) + internal mammary LN (3%) Estrogen: promotes ductal development + fat deposition Progesterone: promotes lobular-alveolar (stromal) development Prolactin: promotes milk production Oxytocin: promotes milk letdown, uterine ctx

Breast pain

Breast pain management: Breast pain? H+P likely benign

h/o trauma

reassurance, NSAIDs, sports bra, compresses

high-risk

U/S

mammogram

Nipple discharge

Bloody discharge: intraductal papilloma Milky discharge: pregnancy, hyperprolactinemia, hypothyroidism, drug-induced (e.g. antipsychotics) Yellowish discharge: fibrocystic change, galactocele, acute mastitis Green/sticky discharge: mammary duct ectasia Purulent discharge: breast abscess

Breast cancer

Incidence: 1 in 8 women Screening: annual mammogram (>50, >40 if strong family hx); monthly self-exam + annual physician exam (>20) Risk factors: family hx (#1), previous breast cancer, old age, BRCA1 and BRCA2 genes (only 5-10% are genetic) MC location: upper outer quadrant (has most breast tissue) Mets sx: bone → pathologic fx, back pain, coma (hypercalcemia) liver → jaundice, elevated LFTs lung → dyspnea, cough, hemoptysis brain → severe HA, seizures pleura → pleuritic chest pain

Breast masses

MC breast masses:

<25 y/o fibroadenoma 25-50 y/o fibrocystic change >50 y/o infiltrating ductal carcinoma Benign masses: soft/rubbery, smooth surface, mobile, painful, <50 y/o Malignant masses: firm/hard, irregular surface, fixed, painless, >50 y/o Breast mass management: Breast mass? <30 y/o

≥30 y/o Nonpalpable abnormal mammogram finding?

U/S cystic

solid wire-guided excision

needle drainage resolves f/u in 4 wks

BI-RADS

Cat 0 1 2 3 4 5 6

Definition incomplete negative benign probably benign suspicious of malignancy probably malignant malignant

FNA bloody/recurrent core needle bx

mammogram + core needle bx

excisional bx if nondiagnostic

Management additional imaging needed routine f/u routine f/u short-term f/u (6 mo) core needle bx core needle bx tx

Risk of malignancy --0% 0% ≤2% 2-95% ≥95% 100%

ONC 6 – Breast Disease/Cancer

Benign tumors

Fibroadenoma: firm, mobile, rubbery mass <5 cm in young women; Tx elective removal Giant juvenile fibroadenoma: ≥5 cm, seen in teens with rapid breast growth; Tx excision to avoid breast deformity Intraductal papilloma: presents as bloody nipple discharge; Tx galactogram/ductogram-guided excision (due to small risk of carcinoma) Phyllodes tumor: huge, benign tumors that distort the breast; Dx core or incisional biopsy since FNA is insufficient, Tx excision w/ negative margins

Malignant tumors

DCIS: mammogram shows clustered microcalcifications, Tx simple mastectomy LCIS: multiple/bilateral; Tx close observation ± tamoxifen Infiltrating ductal carcinoma: MC breast cancer, Tx (see below) Infiltrating lobular carcinoma: multiple/bilateral, Tx (see below) Paget disease: “crusty” nipple eczema, indicates underlying infiltrating ductal carcinoma, Tx (see below) Inflammatory carcinoma: resembles cellulitis w/ peau d’orange, “tumor cells in dermal lymphatics”, Tx pre-op chemo + (see below)

Breast cancer Tx

Stage I

TNM criteria T1 (<2 cm)

II III IV

T2+ (>2 cm) or N1 (mobile ipsi ALN+) N2+ (fixed ipsi ALN+) M1 (distal met+)

Tx lumpectomy + ALND/SLN + post-op radiation; or modified radical mastectomy " chemotherapy "

ALND/SLN+: indicates LN involvement; Tx chemotherapy ER/PR–: indicates poor px; Tx chemotherapy ER/PR+: indicates good px; Tx tamoxifen or aromatase inhibitors (letrozole, anastrazole, exemstane) HER2/neu+: indicates poor px; Tx trastuzumab (Herceptin), most associated w/ comedocarcinomas Modified radical mastectomy: removes breast + pectoralis major/minor + axillary LN Complications: winged scapula (cut long thoracic nerve), arm lymphedema (lymphatic blockage) Breast reconstruction: add implants or autogenous tissue, good for psychosocial benefits Breast diseases

Fibrocystic change: painful, multiple/bilateral lumps that vary with menstrual cycle; Tx reduction in tea/caffeine/chocolate Dominant lump: Tx aspiration → excision if mass recurs or persists Atypical ductal hyperplasia: Tx excision; not precancerous, but high risk of becoming a cancer Acute mastitis: breastfeeding women get Staph/Strep infection through cracks in nipple w/ yellowish discharge, Tx dicloxacillin + continue breastfeeding Periductal mastitis: subareolar infection in smokers, both males and females affected Breast abscess: pus pocket in lactating women; Tx I&D + biopsy to r/o possible cancer Mammary duct ectasia: bilateral breast pain and green/sticky discharge in perimenopausal women; Tx excision + biopsy to r/o possible cancer Dystrophic calcification: presents as breast lump following trauma, but work up as a cancer until proven otherwise (trick question!)

INTERNAL MEDICINE

MEDICINE × CV ISCHEMIC HEART DZ

Coronary artery dz: atherosclerotic occlusion of coronary vx → asx stable angina increasing unstable angina severity acute MI sudden cardiac death Acute coronary syndrome: ruptured atherosclerotic plaque → unstable angina or acute MI Dz Stable angina

Acute coronary syndrome

Presentation substernal “gripping” chest pain or pressure on exertion, relieved w/ rest or NTG

unstable angina ↓ +biomarkers NSTEMI ↓ +EKG change STEMI Unstable angina: ruptured atherosclerotic plaque → increasing pain or pain at rest NSTEMI/STEMI: ruptured atherosclerotic plaque → typical MI-pattern chest pain; can be asx in elderly, diabetics, women, s/p heart txp

Prinzmetal (variant) angina CHF

transient coronary vasospasm → episodic angina at rest Left-sided CHF: dyspnea, orthopnea, PND Right-sided CHF: pitting edema, hepatic congestion, JVD, ascites NYHA class I: sx only w/ vigorous activity (e.g. sports) NYHA class II: sx w/ moderate activity (e.g. stairs) NYHA class III: sx w/ ADLs NYHA class IV: sx at rest

CARDIAC DRUGS

Adenosine toxicity: HA, flushing, nausea, SOB, chest pressure Nitrate toxicity: headache, orthostatic hypotension, tolerance, syncope Digoxin toxicity: atrial tachycardia w/ AV block

Management EKG normal

abnl ST or T-wave

exercise stress test (pharmacological if unable to exercise)

Tx for unstable angina

positive

negative

catheterization

close f/u

• mild (1 vx) → Tx β-blocker + aspirin + nitrates • moderate (2 vx) → Tx (above) vs. PTCA/CABG • severe (3 vx) → Tx CABG • Dx EKG + cardiac enzymes • Tx MONABASH – Morphine (analgesia) O2 Nitrates (analgesia) Aspirin ± clopidogrel β-blockers ACE inhibitor (remodeling) Statins Heparin vs. enoxaparin • (only ASA, β-blockers, ACEI reduce mortality) • angina/NSTEMI → medical management • STEMI → call cath lab for PTCA or CABG

Other Positive stress test: chest pain, ST depression, hypotension, or significant arrhythmias Pharmacological stress test: IV adenosine, dipyridamole, or dobutamine can stress the heart in place of exercise Coronary steal: dipyridamole causes blood flow redistribution to nondiseased vx in stress test

CK-MB: peaks in 24 hrs and lasts 2-3 days, good for recurrence Troponin I: peaks in 24 hrs and lasts 1-2 weeks, most specific EKG changes: peaked T waves, ST-elevation, ST-depression, Q waves, T wave inversion Lateral: I, aVL Inferior: II, III, aVF Anterior: V1-V4 Posterior: V1-V2 Complications: CHF, arrhythmias, recurrent infarction, free wall rupture, papillary muscle rupture, acute pericarditis, tamponade, Dressler syndrome

• Dx EKG (ST-elevation during episode), • inducible by IV ergonovine • Dx EKG + cardiac enzymes (r/o MI) + ↑BNP + • echo (best test, estimates EF) • class I → Tx loop diuretic + ACE inhibitor • class II-III → add β-blocker • class IV → add digoxin

Frank-Starling curve: normal heart has ↑contractility with ↑preload, but impaired in CHF Systolic etiology: post-MI (MCC) Diastolic etiology: LVH due to chronic HTN (MCC)

MEDICINE × CV ARRHYTHMIAS

Arrhythmia PAC PVC

EKG tracing early P wave that looks differently than other P waves wide QRS without preceding P wave

AFib

“irregularly irregular” rhythm

AFlutter

MAT

saw-tooth baseline w/ HR = 150 looks like AFib but the P waves are variable, need 3 different P waves for dx

Management/Other • reassurance • no risk factors → reassurance • recurrrent PVCs w/ underlying • heart dz → implantable defib Couplet: 2 PVCs Bigeminy: sinus beat + PVC Trigeminy: sinus beat + 2 PVCs • acute, stable → anticoagulate + • rate control w/ Ca-blockers • then cardioversion • acute, unstable → immediate • cardioversion • chronic → anticoagulate + • rate control w/ Ca-blockers • (same as AFib)

• Tx improve oxygenation Etiology: end-stage COPD (MCC) • Tx IV adenosine if stable, • • cardioversion if unstable

PSVT

HR > 200 • Tx ablation

WPW syndrome

“delta wave” reflects accessory conduction pathway from atria to ventricles • sustained → Tx IV amiodarone • nonsustained → reassurance • torsades → Tx IV mag sulfate

VTach

Sustained VTach: lasts >30 sec, always symptomatic Nonsustained VTach: lasts <30 sec, usually asx Torsades de pointes: rapid, polymorphic VTach due to QT prolongation • Tx immediate defib + CPR, then • continue IV amiodarone

VFib

Sinus bradycardia

sinus rate <60 bpm

Sick sinus syndrome 1° AV block

persistent sinus bradycardia; presents as dizziness, syncope, fatigue

Pulseless electrical activity: EKG shows activity but no pulses felt • usually insignificant; if sx → Tx • atropine (blocks vagus nerve) • Tx pacemaker • reassurance

PR interval >0.2 sec (1 block) • reassurance

2° AV block (Mobitz type 1) progressive PR prolongation until QRS drops, dz in AV node

• Tx pacemaker (can convert to • 3° w/o Tx)

2° AV block (Mobitz type 2)

random QRS drop, dz in bundle of His • Tx pacemaker

3° AV block (complete)

P waves and QRS complexes function independently

MEDICINE × CV MYOCARDIAL DZ

Dz DCM

Presentation ↓contractility → CHF sx

HCM

exertional dyspnea, angina, syncope, “sudden death in a young athlete”, murmur enhanced by ↓preload (e.g. handgrip, Valsalva) infiltration of myocardium → ↓compliance → CHF sx

RCM

PERICARDIAL DZ

Other Etiology: MI (MCC), infx, alcohol, doxorubicin (Adriamycin), etc. Etiology: most are autosomal dominant, few are sporadic

• Dx echo + endomyocardial bx to find cause • Tx underlying cause

Etiology: CASHES – carcinoid syndrome, amyloid, sarcoid, hemochromatosis, endocardial fibroelastosis (kids), scleroderma Etiology: coxsackie B virus (MCC)

Myocarditis

usually asx, can present w/ fever, chest pain, pericarditis

• Dx ↑cardiac enzymes, ↑ESR • Tx underlying cause

Dz Acute pericarditis

Presentation pleuritic positional chest pain (relieved by leaning forward), pericardial friction rub; can lead to pericardial effusion and cardiac tamponade fibrous pericardial scarring → ↑systemic venous pressure → edema, ascites, hepatic congestion, JVD, pericardial knock, Kussmaul sign muffled heart sounds, soft PMI, ±pericardial friction rub

Management • Dx EKG (diffuse ST elevation + PR dePRession) • Tx NSAIDs

Constrictive pericarditis

Pericardial effusion

Cardiac tamponade

VALVULAR DZ

Management • Dx echo + CXR • Tx for CHF + heart txp (MC indication) • Dx echo + family hx • asx → avoid exercise • sx → β-blockers vs. myomectomy vs. • pacemaker implantation

pulsus paradoxus + Beck’s triad (hypotension, JVD, muffled heart sounds)

• pericarditis + uremia → Tx hemodialysis • Dx EKG shows AFib, cardiac cath shows • “square root sign” • Tx pericardiectomy

• Dx echo (gold standard), CXR shows “water • bottle” silhouette • small/asx → repeat echo in 1-2 wks • rapidly developing → pericardiocentesis • Dx echo (gold standard), EKG shows electrical • alternans • nonhemorrhagic, stable → close monitoring • nonhemorrhagic, unstable → • pericardiocentesis • hemorrhagic → ER thoracotomy

Other Etiology: coxsackie B virus (MCC) Dressler syndrome: post-MI pericarditis, “feels like a second heart attack”; Tx NSAIDs Constrictive pericarditis vs. tamponade: pericarditis fills rapidly then stops suddenly, tamponade fills slowly throughout diastole Etiology: acute pericarditis (MCC)

Etiology: trauma, pericarditis, post-MI w/ free wall rupture Rate vs. amount: rate is more important than amount b/c pericardium has ability to stretch

Valvular dz: all require warfarin (anticoagulate) + amoxicillin (SBE ppx) Dz Mitral stenosis

Presentation loud S1, opening snap w/ late diastolic rumble

Management • asx → nothing • sx → Tx balloon valvuloplasty

Other Etiology: rheumatic heart disease (MCC)

Mitral regurgitation

holosystolic blowing murmur

• asx → medical management • sx → Tx valve replacement

Etiology: ischemic heart dz, MVP, LV dilation

Aortic stenosis

systolic crescendo-decrescendo murmur following opening snap, “parvus et tardus”; triad of angina, syncope, dyspnea

• asx → nothing • sx → Tx valve replacement

Etiology: calcified tricuspid valve (old), calcified bicuspid aortic valve (young) Px: usually asx until old age, then 1-3 yrs after development of sx

Aortic regurgitation

high-pitched blowing diastolic murmur, wide pulse pressures, head bobbing, pulsating uvula, pistol-shot over femoral arteries

• asx → medical management • sx → Tx valve replacement • acute-onset → emergent valve replacement

Etiology: bicuspid aortic valve, syphilitic aortitis, rheumatic fever

Tricuspid regurgitation

holosystolic blowing murmur, pulsatile liver

• asx → medical management • sx → Tx valve replacement

Etiology: tricuspid endocarditis (IVDA), RV dilation

Mitral valve prolapse

midsystolic click, late systolic crescendo murmur; enhanced by ↑TPR (Valsalva, hand grip)

• reassurance

Etiology: connective tissue d/o, MCC Marfan’s

MEDICINE × CV ENDOCARDITIS

Endocarditis: diseases of endocardial lining of heart, most commonly in valves Dz Rheumatic fever

Rheumatic heart disease Infx endocarditis

Marantic (thrombotic) endocarditis Libman-Sacks endocarditis

CONGENITAL HEART DZ

Presentation strep throat (GAS) → anti-M ab → type 2 hypersensitivity → FEVERSS – fever, erythema marginatum, valvular damage, ↑ESR, red-hot joints (migratory polyarthritis), subcutaneous nodules, Sydenham chorea repeated episodes of rheumatic fever → scarring of mitral valve Acute: S. aureus on normal valves → rapid onset Subacute: dental procedures → S. viridans (or GU/GI procedures → enterococcus) on damaged valves → insidious onset

Management • Dx ASO titers • strep throat → Tx PCN or erythromycin • rheumatic fever → Tx steroids

Other MC murmur: mitral regurgitation

• Tx valve repair

MC murmur: mitral stenosis

• Dx Duke’s criteria (sustained bacteremia, • endocardial involvement, fever, immune or • vascular phenomena, +blood cx, +echo) • Tx IV abx

Rapid onset: S. aureus Dental procedures: S. viridans GI/GU procedures: enterococcus Colon cancer: Strep bovis, Clostridium septicum IVDA: S. aureus on tricuspid valve >> Pseudomonas, Candida Prosthetic valves: S. epidermidis Cx-negative: HACEK group

metastatic cancer → hypercoagulable state → clots form on valves → can embolize SLE → wart-like vegetations on both sides of mitral valve → mitral regurg > mitral stenosis

• Tx heparin (controversial)

• Dx ANA • Tx underlying SLE + anticoagulate

CHD × endocarditis: all CHD require amoxicillin (SBE ppx) before dental procedures Eisenmenger syndrome: L-to-R shunts → pulmonary HTN → reversal of shunting → late-onset cyanosis Dz ASD

Presentation low-grade diastolic rumble murmur w/ fixed split S2

VSD

holosystolic murmur at mid-LSB

PDA

continuous, machinery-like murmur

Aortic coarctation

HTN in upper extremities, hypotension in lower extremities; midsystolic murmur heard over back

Management • Dx echo • asx → reassurance • sx → Tx surgical repair • Dx echo • asx → reassurance • sx → Tx surgical repair • Dx echo • infants → Tx indomethacin • adults w/o Eisenmenger → surgical ligation • adults w/ Eisenmenger → surgery is • • contraindicated • Dx CXR (rib notching + “figure 3” aorta) • Tx surgical decompression

Other Paradoxical emboli: venous clots can travel through ASD and cause stroke instead of PE

Congenital rubella syndrome: PDA + deafness + cataracts MCC death: heart failure, infectious endocarditis Aortic coarctation in short women: Turner syndrome

MEDICINE × CV ARTERIAL DZ

(vasculitides in MSK section) Dz HTN urgency HTN emergency

Aortic dissection

AAA

Management • lower BP gradually over 24 hrs w/ PO meds • lower BP by 25% in 1-2 hrs w/ IV nitroprusside • severe HA → get head CT to r/o intracranial • bleeding → lumbar puncture if CT is negative • Dx screen w/ CXR (widened mediastinum), • confirm w/ TEE or CT scan • type A → Tx β-blockers + surgery • type B → Tx β-blockers

usually asx, can present as pulsatile mass on abd exam

• Dx abdominal U/S • <5 cm → close f/u vs. elective repair • >5 cm or sx → Tx synthetic graft

Ruptured AAA

triad of tearing abdominal pain, hypotension, pulsatile mass

• Tx emergency laparotomy (don’t waste time • on dx tests)

Peripheral vascular dz

peripheral atherosclerosis → intermittent claducation (mild), rest pain and ischemic ulcers (severe)

• Dx arteriogram (gold standard) • Dx ABI (normal ≥1.0, mild <0.7, severe <0.4; • calcified arteries give false readings) • mild → conservative management • severe → bypass graft vs. angioplasty

Acute arterial occlusion

Cholesterol embolization syndrome

Mycotic aneurysm Luetic heart

VENOUS DZ

Presentation BP >220/120 BP >220/120 + end-organ damage (e.g. headache, renal failure, pulmonary edema) acute-onset tearing chest pain (type A) or interscapular back pain (type B), asymmetric BP, pt usually in severe distress

emboli → arterial occlusion → 6 Ps – pain, pallor, paralysis, parasthesias, poikilothermia, pulselessness surgical or radiographic procedure → disruption of atherosclerotic plaque → cholesterol emboli → small areas of tissue ischemia (e.g. black/blue spots on toes) bacterial (not fungal) infx → aortic aneurysm tertiary syphilis → aortic aneurysm + aortic regurg + coronary artery stenosis

• Dx arteriogram • Tx IV heparin + surgical embolectomy (<6 hrs) • vs. amputation (>6 hrs) • Tx fasciotomy for compartment syndrome ppx • Tx supportive care • severe → amputation

Other

Etiology: HTN, connective tissue diseases Stanford classification: type A involves Ascending aorta, type B involves descending aorta MC site: below the renal arteries MC pts: old smoking men Aortoenteric fistula: small herald bleed followed by massive UGIB s/p aortic graft placement Signs of impending rupture: Cullen sign (umbilical ecchymoses), Grey-Turner sign (flank ecchymoses) MC site: superficial femoral artery Risk factors: diabetes, smoking Leriche syndrome: PVD of distal aorta above bifurcation → bilateral claudication, impotence, ↓femoral pulses Etiology: AFib (MCC) MC site: common femoral artery

• Tx IV abx + surgical excision • Tx IV PCN G + surgical repair

Virchow’s triad: ↑risk of blood clots w/ stasis, hypercoagulability, endothelial damage Heparin vs. enoxaparin: enoxaparin (Lovenox) and dalteparin (Fragmin) have longer T½ for qday dosing, more $$$ Dz SVT

Presentation painful, palpable venous cord w/ local erythema and edema

DVT

acute-onset dull leg pain, unilateral swelling, and Homans’ sign (calf pain w/ dorsiflexion) acute-onset chest pain, dyspnea, hyperventilation, hemoptysis, right-sided heart failure → death

PE

Phlegmasia cerulea dolens

Post-thrombotic syndrome (chronic venous insufficiency)

venous outflow obstruction → acute onset leg edema with pain and cyanosis DVT damages valves → chronic venous HTN → severe leg edema and ulceration around ankle area

Management • mild → Tx aspirin • severe → Tx aspirin + warm compresses • septic → remove IV cath + give IV abx • Dx duplex U/S • Tx heparin + warfarin • PPx compression boots + early ambulation ± • heparin/LMWH • Dx D-dimer to r/o, spiral CT or V/Q to confirm • Tx heparin + warfarin • Tx tPA to speed up clot resolution (massive • PE, unstable, right heart failure, no c/i) • recurrent PE → Tx IVC filter • Dx duplex U/S or pelvic CT scan • Tx heparin + venous thrombectomy • Tx compression stockings + leg elevation; • wet-to-dry TID for ulcers

Other Migratory SVT: consider pancreatic cancer (Trousseau phenomenon)

PE on EKG: sinus tachycardia is more common than S1Q3T3

MEDICINE × CV SHOCK

Shock: inadequate tissue perfusion Types of shock: cardiogenic (JVD) hypovolemic septic (warm skin) neurogenic (↑CO, warm skin) Initial shock management: ABCs → 2 large-bore IVs + 2L IV fluids (except cardiogenic) → EKG, CXR, labs (CBC/renal/coags) Dz Cardiogenic shock

Presentation typical shock sx (∆MS, ↓BP/↑HR, pale cool skin) + JVD

Hypovolemic shock

Class I: <15% + asx Class II: 15-30% + ↑HR Class III: 30-40% + ↓BP Class IV: >40% + ∆MS, anuria SIRS: 2+ of the following – ↑/↓T, ↑RR, ↑HR, ↑/↓WBC Sepsis: SIRS + positive blood cx Septic shock: sepsis + ↓BP MODS: multiple organ dysfxn syndrome 2/2 septic shock sympathetic denervation → loss of vascular tone → typical shock sx (∆MS, ↓BP/↑HR, warm skin)

Septic shock

Neurogenic shock

CARDIAC NEOPLASMS

Dz Cardiac metastases

Presentation ---

Atrial myxoma

pedunculated, benign mass that presents like intermittent mitral stenosis MC heart tumor in kids

Cardiac rhabdomyoma

EKG READING

Management • (initial shock management) but use dopamine • or IABP instead of IV fluids • Dx EKG + echo to find underlying cause • Tx underlying cause • (initial shock management) • hemorrhagic → find and stop source of bleed • nonhemorrhagic → stabilize w/ IVF + close • monitoring for improvement • (initial shock management) • Tx IV abx + IV fluids, dopamine (2nd line)

Other Etiology: acute MI (MCC), cardiac tamponade, tension PTX, massive PE, etc.

Complications: septic shock is MCC of ARDS + ICU death

• (initial shock management) • Tx IV fluids + supine or T-berg position

Management • Dx CT scan • Tx surgical excision

Other more common than primary tumors (75%) Etiology: most are sporadic, few are autosomal dominant Etiology: associated w/ tuberous sclerosis

EKG reading: 0. find old EKG for comparison 1. Rate: use 300-150-100-75-60-50 rule, or count long strip x12 2. Rhythm: look at long strip • Irregularly irregular: AFib or MAT 3. Axis: look at leads I and II • I+/II+: normal • I+/II–: left-axis deviation • I–/II+: right-axis deviation 4. Intervals: look at PR interval, QRS complex, QT interval • PR interval: normal <0.2 sec, heart block >0.2 sec • QRS complex: normal <0.12 sec • LBBB: WiLLiaM – W in V1-V2, M in V3-V6 • RBBB: MaRRoW – M in V1-V2, W in V3-V6 • QT interval: normal if T-wave doesn’t go past mid QRS-QRS, prolonged QT is risk of torsades de pointes 5. Waves: look for chamber enlargement and signs of ischemia/infarct • LAE: lead II wide P-wave (>0.12 sec) • RAE: lead II tall P-wave (>2.5 mm) • LVH: left-axis deviation + V1/V2 and V5/V6 overlapping • RVH: right-axis deviation + lead V1 R-wave >7 mm • Ischemia: T-wave inversion, ST elevation or depression • Infarct: T-wave inversion, ST elevation, significant Q waves

MEDICINE × PULMONARY OBSTRUCTIVE LUNG DZ

Lung volumes:

Obstructive lung dz: ↑TLC, ↓FEV1/FVC (<70%), ↑compliance, ↓elasticity Restrictive lung dz: ↓TLC, ↑FEV1/FVC, ↓compliance, ↑elasticity COPD: emphysema + chronic bronchitis, commonly coexist, MCC of both is smoking Dz Emphysema

Presentation destruction of alveolar walls → permanent alveolar dilation → “pink puffers”, thin w/ barrel chest, expiration w/ pursed lips

Management • Dx spirometry shows FEV1/FVC <70% • Dx CXR shows hyperinflated lungs and • increased AP diameter (emphysema only) • <50 y/o → Dx A1AT levels

Chronic bronchitis

chronic productive cough of 3 months/year for 2 years → “blue bloaters”, overweight and cyanotic, may have signs of cor pulmonale

• stage I (FEV1 ≥80%) → Tx short-acting • bronchodilators (albuterol, ipratropium) • stage II (FEV1 50-80%) → add long-acting • bronchodilators (salmeterol, tiotropium) • stage III (FEV1 30-50%) → add inhaled steroids • (fluticasone, triamcinolone) • stage IV (FEV1 <30% or <5o% w/ hypoxia) → • add O2 therapy for 18 hrs/day

Asthma

Asthma attack: airway inflammation → reversible airflow obstruction → wheezing, shortness of breath, cough, chest tightness

• COPD exacerbation → Tx bronchodilators + • abx + systemic steroids + O2 therapy • Dx spirometry shows reversible FEV1/FVC <70% • 1-2 atk/wk → prn SABA (albuterol) • 2+ atk/wk → add low-dose inhaled steroids • daily atk → add LABA (salmeterol) • continuous → add high-dose inhaled steroids

Status asthmaticus: sustained asthmatic state, not responsive to meds

Bronchiectasis

destruction of bronchial walls → permanent bronchiolar dilation → chronic cough w/ “cupfuls” of sputum, dyspnea, hemoptysis, recurrent Pseudomonas pneumonia

• Dx high-res CT scan shows “signet rings” • Tx bronchodilators + abx for acute • exacerbations

Other Etiology: smoking causes centriacinar emphysema in upper lungs; A1AT deficiency causes panacinar emphysema in lower lungs in pts <50 y/o Etiology: smoking (MCC)

Extrinsic asthma: IgE-mediated rxn to environmental triggers Intrinsic asthma: not related to triggers or atopy Atopy: asthma + allergic rhinitis + atopic dermatitis (eczema) Triad asthma: asthma + aspirin sensitivity (↑LT) + nasal polyps ABPA: asthma + pulmonary infiltrates + Aspergillus allergy Churg-Strauss syndrome: asthma + eosinophilia + granulomatous vasculitis Etiology: cystic fibrosis (MCC), Kartagener syndrome (∆dynein)

MEDICINE × PULMONARY LUNG NEOPLASMS

Dz Lung cancer

Solitary pulmonary nodule (“coin lesion”)

Presentation cough, hemoptysis, dyspnea, wheezing, recurrent PNA in same lobe

Management • Dx CXR → if suspicious, sputum cytology and • CT scan → if still suspicious, bronchoscopy and • mediastinoscopy w/ biopsy (“tissue is the • issue”)

Pancoast tumor: superior sulcus tumor at the apex of the lung; presents as Horner syndrome – ipsilateral ptosis, miosis, anhidrosis, flushing due to loss of sympathetic tone (invades superior cervical ganglia)

• NSCLC stage I (local) → pneumonectomy vs. • sleeve lobectomy • NSCLC stage II (hilar LN) → pneumonectomy • vs. sleeve lobectomy • NSCLC stage III (distal LN) → chemo/radiation • NSCLC stage IV (mets) → chemo/radiation

Bronchial adenoma: MC cancer in women and nonsmokers

• SCLC limited (ipsi) → chemo/radiation • SCLC extensive (contra) → chemo/radiation

solitary pulmonary nodule found incidentally on a CXR; DDx primary lung cancer, granuloma (TB or fungal), hamartoma, metastatic cancers

Other Complications: SPHERE – SVC syndrome, Pancoast tumor → Horner syndrome, Endocrine (paraneoplastic), Recurrent laryngeal nerve (hoarseness), Effusions (pleural or pericardial) Lambert-Eaton myasthenic syndrome (LEMS): SCLC → antiVGCC antibodies → myasthenia gravis-like presentation Paraneoplastic syndromes: squamous cell makes PTH-rP, SCLC makes ADH and ACTH

• Bronchial adenoma → lobectomy is curative • Pancoast tumor → irradiation for 6 weeks to • shrink tumor, then surgical resection • Dx get an older CXR for comparison studies → • if suspicious, sputum cytology and CT scan • Benign coin lesions (calcification = granuloma, • bull’s-eye shape, popcorn shape = hamartoma, • air-crescent or halo sign = aspergilloma, • Southwest region = coccidioidomycosis, Ohio • river valley = histoplasmosis) → leave alone • Indeterminate coin lesions → resection • indicated • Malignant coin lesions (spiculations or 20+ • pack-year smoking = primary lung cancer, • multiple lesions = metastatic cancer) → • resection indicated

PLEURAL DZ

Dz Pleural effusion

Presentation fluid build-up in pleural space; two types – transudative (thin) and exudative (thick)

Management • Dx CXR shows blunting of costophrenic angle • Dx thoracentesis + 4 Cs – chemistry (glucose, • protein), cytology, CBC+diff, culture • transudative → Tx diuretics + Na+ restriction • exudative → Tx underlying disease • parapneumonic → abx ± chest tube drainage

Empyema

PTX

Tension PTX

Mesothelioma

collection of pus within pleural cavity → nonproductive cough, fever, chest pain air pocket in pleural space → chest pain, cough, dyspnea

PTX + building pressure → mediastinal shift, hypOtension, JVD, absent breath sounds, hyperresonance to percussion cancer of mesothelial lining → dyspnea, cough, weight loss

• Dx CXR or CT scan • Tx abx + insert chest tube, evacuate pus • collection, then re-expand the lung • Dx CXR shows visceral pleura line or deep • sulcus sign • small/asx → observation • large or sx → Tx chest tube drainage • recurrent → Tx pleurodesis (scraping vs. talc) • always get CXR after transthoracic needle • aspiration, chest tube, or central line to r/o • Dx H+P, do not get a CXR • Tx immediate needle decompression (2nd • • intercostal space) + chest tube • Dx CT scan shows thick pleural walls • Tx extrapleural pneumonectomy (high rate of • morbidity/mortality)

Other Light’s criteria: pleural fluid is exudative if any of the following – p/s protein <0.5, p/s LDH <0.6, p LDH at upper 2/3 of normal Pleural fluid analysis: • amylase = esophageal rupture, • pancreatitis, malignancy • milky fluid = chylothorax • purulent fluid = empyema • bloody fluid = cancer • lymphocytic fluid = TB • pH <7.2 = empyema or • parapneumonic effusion • glucose <60 = r/o RA Etiology: Staph aureus is MCC

1° spontaneous PTX: rupture of apical blebs in healthy young people 2° spontaneous PTX: due to underlying lung dz (MCC COPD) Traumatic PTX: s/p transthoracic needle aspiration, chest tube, or central line

Etiology: asbestos exposure (especially shipyards, rooftops)

MEDICINE × PULMONARY INTERSTITIAL LUNG DZ

ILD presentation: dyspnea, nonproductive cough, fatigue ILD management: Dx spirometry (↓TLC, ↑FEV1/FVC) → get CXR + tissue bx + UA if hematuria Honeycomb lung: end-stage ILD → scarred, shrunken lung w/ dilated air spaces Dz Drug-induced pulmonary fibrosis Sarcoidosis

Presentation (classic ILD sx) s/p amiodarone, busulfan, bleomycin, MTX, or nitrofurantoin young black female w/ respiratory complaints, erythema nodosum, and blurry vision (anterior uveitis)

Histiocytosis X

(classic ILD sx)

Wegener granulomatosis

triad of necrotizing vasculitis, necrotizing granulomas in lungs and upper respiratory tract, and necrotizing glomerulonephritis → hematuria + hemoptysis triad of asthma + eosinophilia + necrotizing vasculitis inhalation of coal dust containing carbon and silica → (classic ILD sx) inhalation of asbestos → fibrosis of lower lungs + pleural plaques

Churg-Strauss syndrome Coal worker pneumoconiosis

Asbestosis

Silicosis

inhalation of silicon → fibrosis of upper lungs

Berylliosis

inhalation of beryllium → sarcoidosis-like presentation Acute form: inhalation of antigenic agent (e.g. bird droppings) → type III and IV hypersensitivity → flu-like sx Chronic form: (classic ILD sx) (classic ILD sx) + fever + eosinophilia

Hypersensitivity pneumonitis (extrinsic allergic alveolitis)

Eosinophilic pneumonia

Goodpasture syndrome

Pulmonary alveolar proteinosis

anti-GBM antibodies attack alveolar and glomerular basement membrane (type II) → hematuria + hemoptysis accumulation of surfactant-like protein and phospholipids in alveoli → (classic ILD sx)

Idiopathic pulmonary fibrosis (IPF)

(classic ILD sx) → death in 3-7 yrs

Cryptogenic organizing pneumonitis (COP)

infectious pneumonia-like presentation (cough, dyspnea, flu-like sx) but unresponsive to abx s/p thoracic radiation for lung or breast cancer → alveolar thickening and pulmonary fibrosis → (classic ILD sx)

Radiation pneumonitis

Management • Tx d/c meds

Other

• Dx CXR shows bilateral hilar LN-opathy • (pulmonary fibrosis is end-stage finding) • Dx tissue bx shows noncaseating granulomas • w/ Schaumann and asteroid bodies • Tx steroids • Dx CXR shows honeycomb lung • Dx tissue bx shows eosinophilic granulomas • Tx steroids vs. lung txp (if not responding) • Dx ↑c-ANCA • Dx tissue bx shows necrotizing granulomas • Tx cyclophosphamide

Complications: GRAINeD – ↑IgG, rheumatoid arthritis, ↑ACE, ILD, noncaseating granulomas, ↑1αhydroxylase → ↑vitamin D

• Dx ↑p-ANCA • Tx steroids ---

• Dx CXR shows lower lung fibrosis + pleural • plaques • Dx tissue bx shows ferruginous bodies • Tx supportive care • Dx CXR shows upper lung fibrosis + “egg shell” • calcifications • Tx supportive care • Dx beryllium lymphocyte proliferation test • Tx steroids • Dx CXR shows pulmonary infiltrates (acute • form), interstitial fibrosis (chronic form) • Tx steroids + avoid birds

• Dx CXR shows peripheral infiltrates, CBC+diff • shows eosinophilia • get p-ANCA to r/o Churg-Strauss • Tx steroids • Dx tissue bx shows linear staining • get c-ANCA to r/o Wegener • Tx steroids + cyclophosphamide + • plasmapheresis • Dx CXR shows ground glass appearance w/ • bat-shaped bilateral alveolar infiltrates • Dx tissue bx (definitive) • Tx lung lavage vs. GM-CSF • Dx CXR shows honeycomb lungs w/ temporal • heterogeneity • Dx tissue bx shows UIP (usual interstitial PNA) • Tx steroids (temporizing), lung txp • Dx CXR shows bilateral patchy infiltrates • Tx steroids

• Dx CT scan shows diffuse infiltrates (CXR is • usually normal) • Tx steroids • PPx not useful

Caplan syndrome: rheumatoid nodules + pneumoconiosis Etiology: shipyards, naval bases, rooftops Complications: bronchogenic carcinoma >> mesothelioma Etiology: mining, stone cutting, glass manufacturing

MEDICINE × PULMONARY RESPIRATORY

FAILURE

Dz Acute respiratory failure

Presentation dyspnea (first sx), cough, respiratory distress, etc. Types: hypoxia (PaO2 <60), hypercapnia (PCO2 >50)

Management • Dx ABG analysis…

↑A-a A-a nl

ARDS

diffuse inflammatory response → neutrophil activation → interstitial damage and alveolar collapse → massive shunting → dyspnea + respiratory distress Neonatal RDS: due to preterm birth <34 wks w/o surfactant

VENTILATION

↑CO2 CO2 nl V/Q mismatch vs. shunting (DDx w/ supplemental O2) hypoventilation ↓inspired PaO2

• Dx CXR, CBC/renal, cardiac enzymes if needed • Tx underlying cause, supplemental O2, • CPAP/BIPAP if conscious, ventilation if not • Dx CXR shows diffuse bilateral pulmonary • infiltrates (white-out of lungs) • Dx ABG shows hypoxia (PaO2 <60) not • responsive to O2 therapy • Dx PCWP shows no evidence of CHF

Other V/Q mismatch: imbalance between lung perfusion and ventilation, presents as ↓O2 but nl CO2 Shunting: lack of ventilation in well-perfused areas (e.g. PNA, atelectasis); not responsive to supplemental O2 Hypoventilation: not breathing ↓inspired PaO2: high altitudes Etiology: septic shock (MCC), aspiration pneumonia, trauma

• Tx ventilation w/ ↓FiO2, ↑PEEP

Ventilation goals: maintain alveolar ventilation, correct hypoxia Ventilator settings: 1. AC (assisted control) – has backup RR, gives preset VT per attempted breath 2. SIMV (synchronous intermittent mandatory ventilation) – has backup RR, does not have preset VT per breath 3. CPAP (continuous positive airway pressure) – no backup RR, continuous PEEP support 4. PSV (pressure support ventilation) – PEEP support only with attempted breath Key parameters:

RR and VT control CO2 FiO2 and PEEP control O2

Tracheomalacia: softening of tracheal cartilage w/ prolonged ventilation; PPx tracheostomy if ventilator-dependent for 2+ wks

PULMONARY VX DZ

Dz Pulmonary HTN

Presentation PA pressure >25 mmHg (rest) or >30 mmHg (exercise) → presents as exertional dyspnea, fatigue, chest pain, ±syncope pulmonary HTN w/o identifiable cause (a dx of exclusion)

Management • Dx loud P2 + subtle sternal lift on auscultation • Dx find the underlying cause via CXR, PFTs, • ABG, EKG, echo, catheterization • Tx underlying cause + bosentan • Dx (see above) • Tx pulmonary vasodilators (CCB) + lung txp

Cor pulmonale

pulmonary HTN + RVH

• Dx (see above) • Tx underlying cause + bosentan

PE

acute onset chest pain, dyspnea, hyperventilation, hemoptysis, right-sided heart failure → death

• Dx D-dimer to r/o, spiral CT or V/Q scan to r/in • Tx heparin + warfarin • Tx tPA to speed up clot resolution (massive • PE, unstable, right heart failure, no c/i) • recurrent PE → Tx IVC filter

Dz Pulmonary aspiration

Presentation either acute onset respiratory distress, or delayed onset of respiratory sx (cough, SOB, fever, tachypnea, dypsnea, etc.)

Management • Dx CXR + H+P • Tx ABCs, O2 mask, supportive care • aspiration pneumonia → Tx abx • obstruction → Tx bronchoscopy

1° pulmonary HTN (PPH)

OTHER LUNG PROBLEMS

Other

Etiology: ∆BMPR2 → uninhibited smooth muscle growth → ↑pulmonary resistance Px: mean survival 2-3 yrs Etiology: COPD (MCC), recurrent PE, ILD, asthma, sleep apnea, CF, pneumoconioses PE on EKG: sinus tachycardia is more common than S1Q3T3 Fat embolism: dyspnea, ∆MS, petechiae in a pt w/ long bone fx Amniotic fluid embolism: intraor postpartum, or amniocentesis

Other Etiology: gastric aspirates (can lead to ARDS), oral flora (can lead to abscess), foreign bodies Risk factors: ∆MS, alcoholics, instrumentation, esophageal d/o

MEDICINE × GI ABDOMINAL PAIN

RUQ pain:

RLQ pain:

COLON DZ

• liver (hepatitis) • common bile duct (cholecystitis, cholangitis) • lungs (PE, pneumonia) • duodenum (ulcer) • bowels (appendicitis, perforated ulcer, IBD, • inguinal hernia) • male GU (testicular torsion) • female GU (ectopic, PID, ovarian cyst) • ureters (ureterolithiasis)

Dz Colorectal cancer

Presentation Proximal colon: bleeding → melena, iron-deficiency anemia, fatigue, dull pain

LUQ pain:

• pancreas (pancreatitis) • spleen (splenic dz) • lungs (PE, pneumonia, subphrenic abscess)

LLQ pain:

• bowels (diverticulitis, IBD, inguinal hernia) • male GU (testicular torsion) • female GU (ectopic, PID, ovarian cyst) • ureters (ureterolithiasis)

Management • >50 y/o → colonoscopy screen q 10 yrs • Dx barium enema (“apple core”) + CEA marker

Distal colon: obstruction → constipation, colicky pain, hematochezia Rectal cancer: hematochezia, rectal mass, tenesmus Metastatic: portal drainage to liver → jaundice, ↑LFTs

•

Polyps

asx

• Dx colonoscopy • Tx polypectomy

Diverticulosis

low-fiber diet → need more strain to poop → outpouching of sigmoid colon → erosion → painless rectal bleeding fecalith impacts in diverticula → necrosis → infx → LLQ pain, fever, ↑WBC (no bleeding) AV malformation in submucosa of colon wall → erosion → LGI bleed (MCC) compromised blood supply to SMA or SMV → ischemia ± infarction → acute onset severe abd pain

• Dx barium enema • Tx stool softeners (high-fiber diet, psyllium)

Diverticulitis

Angiodysplasia (vascular ectasia, AVM) Acute mesenteric ischemia

Chronic mesenteric ischemia

Ogilvie syndrome

Pseudomembranous colitis

Volvulus

Arterial embolism: MCC, most sudden and severe Arterial thrombosis: gradual onset and less severe Nonocclusive ischemia: due to ↓CO, seen in critically ill pts Venous thrombosis: rare, slowest onset and least severe atherosclerosis of celiac artery, SMA, or IMA → postprandial dull abd pain colonic pseudoobstruction w/o mechanical cause → bloating, obstipation, nausea/vomiting abx use → kills off colonic flora and allows C. diff overgrowth → profuse watery diarrhea twisting of redundant bowel → acute-onset colicky pain, obstipation, nausea/vomiting

• Duke stage A (local) → Tx surgery • Duke stage B (invasive) → Tx surgery • Duke stage C (LN) → Tx surgery + chemo • (5-FU, leucovorin) + Radiation if Rectal • Duke stage D (mets) → Tx surgery + chemo • (5-FU, leucovorin) + Radiation if Rectal

Other Risk factors: old age (>50), villous adenomas, IBD, family hx, low-fiber diet, major polyposis syndromes FAP: AD ∆APC → thousands of polyps → 100% progression to CRC; Tx ppx colectomy Gardner syndrome: FAP + osteomas, soft tissue tumors Turcot syndrome: FAP + CNS tumors Peutz-Jeghers syndrome: multiple nonmalignant hamartomas throughout GI tract w/ pigmented spots around mucus surfaces HNPCC/Lynch syndrome: AD ∆DNA repair genes → hundreds of polyps → 80% progression to CRC Hyperplastic polyps: MC type, leave alone, no malig potential Juvenile polyps: polyps in kids, remove due to vascularity Inflammatory (pseudo) polyps: associated w/ UC Adenomatous polyps: high risk of malig potential, worst types are large villous polyps Complications: hypovolemic shock, diverticulitis

• Dx CT scan • first episode → Tx IVF, NPO, IV abx • recurrent episodes →Tx surgery • Dx colonoscopy • Tx observation (90% stop spontaneously), • colonoscopy w/ coagulation (2nd line) • Dx screen w/ ↑LDH, confirm w/ mesenteric • angiography • Tx IVF, NPO, IV abx; intra-arterial papaverine if • arterial, heparin if venous • dead bowel → Tx surgery

Complications: abscess, bowel obstruction, colovesical fistulas, perforation Heyde syndrome: angiodysplasia + aortic stenosis

• Dx mesenteric angiography • Tx surgical revascularization

(equivalent to stable angina of the bowels)

• Dx of exclusion (r/o other causes) • Tx underlying cause, decompressive • colonoscopy (2nd line), neostigmine (3rd line) • colon >10 cm → Tx emergent decompression • Dx C. diff stool toxins • Tx Flagyl (1st line), PO vancomycin (2nd line)

Etiology: surgery or trauma, serious medical illnesses, drugs (e.g. opiates)

• Dx KUB shows Omega loop sign (dilated • sigmoid colon) or coffee bean sign (cecal • volvulus causing RLQ air-fluid level) • sigmoid volvulus → Tx sigmoidoscopy w/ • decompression ± elective surgery • cecal volvulus → Tx emergent surgery

MC site: sigmoid colon

(equivalent to MI or unstable angina of the bowels)

Complications: toxic megacolon, perforation

MEDICINE × GI APPENDICEAL DZ

Dz Acute appendicitis

Carcinoid tumor

STOMACH DZ

Dz Peptic ulcer disease (PUD)

Acute gastritis

Chronic gastritis

Gastric adenocarcinoma

Presentation lymphoid hyperplasia or fecalith in appendix → ischemia → infx and necrosis → perforation → peritonitis Nonruptured sx: umbilical abd pain that migrates to RLQ, anorexia, n/v Ruptured sx: severe abd pain w/ guarding in all 4 quadrants neuroendocrine tumor that secretes 5-HT, most commonly found in appendix (no systemic effects b/c liver metabolism) Carcinoid syndrome: metastasis of carcinoid tumor to liver → systemic 5-HT effects → flush + diarrhea + wheezing + TIPS (tricuspid insufficiency, pulmonary stenosis)

Management • Dx CT scan + CBC (↑WBC) + β-HCG (r/o ectopic • in females) • Tx appendectomy

Other Rovsing sign: LLQ pressure causes referred RLQ pain Psoas sign: right psoas flexion causes RLQ pain Obturator sign: right obturator flexion causes RLQ pain McBurney point: 2/3 distance from umbilicus to right ASIS

• Dx CT scan • Tx appendectomy (<2 cm), right • hemicolectomy (>2 cm) • Dx urinary 5-HIAA • Tx resection

Presentation aching or gnawing epigastric pain, either relieved (DU) or exacerbated (GU) by eating

Management • Dx EGD • H. pylori → Dx stool ag > urease breath test, • Tx triple or quad therapy

Duodenal ulcers: due to ↑acid secretion; most commonly in 1st part of duodenum, DU in 2nd-4th part indicates Z-E syndrome Gastric ulcers: due to ↓mucosal protection; type I – lesser curvature, type II – duodenum and stomach, type III – pylorus, type IV – GE junction Perforated ulcer: severe abd pain, hemodynamic instability Gastric outlet obstruction: early satiety, nausea/vomiting Bleeding ulcer: iron-deficiency anemia (slow) or hypovolemic shock (rapid) inflammation of gastric mucosa → aching or gnawing epigastric pain either H. pylori or pernicious anemia → atrophy of gastric mucosa → aching or gnawing epigastric pain presents as epigastric abd pain, weight loss, early satiety, etc.

• Tx triple therapy → if ulcer persists, surgery • (HSV) + get serum gastrin levels to r/o Z-E

• Tx PPIs → if ulcer persists for 6 wks, EGD w/ bx • to r/o gastric cancer → if ulcer persists for 18 • wks, surgery (wedge resection or distal • gastrectomy)

Other Etiology: NSAIDs and H. pylori (MCC); EtOH, uremia, burns (Curling), smoking, stress, head injury (Cushing) Zollinger-Ellison syndrome: gastrinoma → ↑gastrin → parietal cell stimulation → ↑HCl → ulcer formation

• Dx CXR (pneumoperitoneum) • Tx emergent surgical repair • Dx barium swallow • Tx NPO/IVF/NG tube • Dx EGD • Tx PPIs (slow) or surgical repair (rapid) • Dx EGD w/ bx • Tx d/c NSAIDs, triple therapy for H. pylori • Dx EGD w/ bx • Tx d/c NSAIDs, triple therapy for H. pylori

Complications: PUD, gastric adenocarcinoma or lymphoma

• Dx EGD w/ bx, then CT scan for staging • Tx surgical resection

Krukenberg tumor: ovarian mets (bx shows “signet ring” cells) Blumer shelf: rectal mets SMJ node: periumbilical LN mets Virchow node: left supraclavicular LN mets Irish node: left axillary LN mets

Linitis plastica: “leather bottle” stomach due to full thickness infiltration and fibrosis, poor px

Risk factors: type A blood, Japanese (smoked foods) Gastric lymphoma

presents as epigastric abd pain, weight loss, early satiety, etc.

• Dx EGD w/ bx • Tx radiation (partial thickness) or surgical • resection (full thickness)

MEDICINE × GI GI BLEEDING

Dz UGIB

LGIB

ESOPHAGEAL DZ

Dz Esophageal cancer

Achalasia

Diffuse esophageal spasm

Hiatal hernia

Mallory-Weiss syndrome Boerhaave syndrome

Plummer-Vinson syndrome

Schatzki ring

Esophageal divertula

Presentation GI bleed proximal to Ligament of Treitz → hematemesis, melena, hematochezia (if rapid)

GI bleed distal to Ligament of Treitz → hematochezia, melena (if slow)

Presentation dysphagia of solids > liquids + weight loss ± odynophagia (if severe) SCC: found in upper 2/3, due to smoking and EtOH abuse Adenocarcinoma: found in lower 1/3, due to GERD/Barrett’s hypertonic and nonrelaxing LES w/ poorly relaxing esophagus → dysphagia of liquids > solids uncoordinated esophageal peristalsis → dysphagia + angina-like chest pain Type 1 HH: sliding hernia, can present as GERD or reflux esophagitis Type 2 HH: paraesophageal hernia, high risk of incarceration and strangulation Type 3 HH: both type 1+2 retching → laceration of lower esophagus → UGIB retching → perforation of lower esophagus → epigastric pain, fever, pneumomediastinum iron deficiency → anemia, upper esophageal webs (dysphagia), koilonychia ingestion of acids, alkali, bleach, or detergents → lower esophageal webs → usually asx, dysphagia if severe Zenker diverticulum: lack of cricopharyngeal relaxation → diverticulum at upper esophagus → food gets stuck → halitosis + dysphagia Traction diverticulum: TB or cancer → LN-opathy → traction → diverticulum at middle esophagus Epiphrenic diverticulum: esophageal motility d/o → diverticulum at lower esophagus

Management • Dx NG tube aspirate/lavage… • • +blood/±bile is UGIB • • –blood/+bile is LGIB • • –blood/–bile is indeterminate • UGIB → Dx/Tx EGD • LGIB → Dx colonoscopy • bleeding won’t stop → Dx tagged RBCs or • angiography to localize site of bleeding • “hemodynamic instability despite • transfusion”, loss of 4-6 units in 24 hrs, or 8-10 • units in 48 hrs → Tx ex lap • unstable pt w/ massive BRBPR, no imaging to • help localize site → Tx total colectomy

Management • Dx esophagoscopy w/ bx, then staging via • endoscopic U/S + CT scan

Other Etiology: PUD (#1), NSAID use (#2), esophageal varices (#3) UGIB in ICU pt: stress ulcer UGIB in alcoholics: esophageal varices, Mallory-Weiss tear, Boerhaave syndrome UGIB s/p aortic graft: aortoenteric fistula (small herald bleed followed by massive UGIB) Etiology: diverticulosis (#1), AVM (#1), colon cancer (#3) LGIB in kids: Meckel diverticulum

Other

• upper 1/3 → Tx chemo + radiation • middle 1/3 → Tx chemo + radiation, then • esophagectomy • lower 1/3 → Tx esophagectomy + proximal • gastrectomy • Dx screen w/ barium swallow (bird’s beak), • confirm w/ manometry (↑LES pressure) • Tx botox vs. Heller myotomy • Dx screen w/ barium swallow (corkscrew), • confirm w/ manometry (uncoordinated) • Tx nifedipine, nitrates • Tx PPIs vs. lap Nissen

• Tx surgical repair

• Tx surgical repair • Dx upper GI endoscopy • Tx observation (bleeding stops on its own) • Dx barium swallow • Tx emergent surgical repair

Etiology: alcoholics (MCC), hyperemesis gravidarum, etc. Etiology: alcoholics (MCC), hyperemesis gravidarum, etc.

• Tx esophageal dilatation + PO iron supplement

• dysphagia → Tx esophageal dilatation • full-thickness necrosis → Tx esophagectomy

• Dx barium swallow • Tx cricopharyngeal myotomy

• Dx barium swallow • Tx observation

• Dx barium swallow • Tx esophagomyotomy

Complications: esophageal stricture or cancer

MEDICINE × GI SI DZ

IBD

Dz SBO

Presentation colicky abd pain, n/v, obstipation or constipation

Paralytic ileus

lack of peristalsis

Celiac sprue

gluten hypersensitivity → villi atrophy w/ dietary wheat → malabsorption, diarrhea, weight loss, bloating

Management • Dx KUB (dilated loops w/ air-fluid levels) • Tx NPO/IVF/NG tube, observation • adhesions → Tx LOA + resect dead gut • hernias → Tx herniorrhaphy + resect dead gut • Dx KUB (uniform gas in SI, colon, rectum) • Tx NPO/IVF/NG tube, observation

• Dx anti-gliadin or anti-endomysial ab • Tx avoid wheat/gluten in diet

Other Etiology: adhesions from prior abd surgery (MCC), hernias (#2) Complications: septic shock, gangrene, peritonitis, bowel perforation Etiology: s/p abd surgery, meds (e.g. narcotics, anticholinergics), spinal cord injury, shock, hypokalemia, peritonitis Dermatitis herpetiformis: skin lesions found in celiac sprue

IBD: Crohn’s disease and ulcerative colitis Dz Crohn disease

Ulcerative colitis

Presentation flare-and-remission pattern of crampy abd pain, bloody diarrhea, recent weight loss

flare-and-remission pattern of crampy abd pain, bloody diarrhea, recent weight loss

Pouchitis: fever, bloody diarrhea, and dyschezia s/p ileal pouch formation in a UC pt Toxic megacolon: huge flare → paralyzes the colon → fever, bloody diarrhea, abd distention in a UC pt

Management • Dx KUB (terminal ileum string sign), flex sig, • tissue bx (transmural, noncaseating • granulomas, creeping fat) • Tx steroids + 5-ASA (sulfsalazine) • perianal Crohn → Tx metronidazole • rectal Crohn → Tx subtotal colectomy • Dx KUB (lead pipe sign), flex sig, tissue bx • (mucosa only, crypt abscesses, pseudopolyps) • Tx steroids + 5-ASA (sulfsalazine) • severe dysplasia → Tx total proctocolectomy • Tx metronidazole

• Dx KUB (dilated colon) • Tx NPO/IVF/NG tube, IV steroids, abx

Other Location: “mouth to anus” w/ skip lesions, terminal ileum is MC site Complications: erythema nodosum, SBO, fissures/fistulae

Location: colorectal only, continuous lesions Complications: CRC, pyoderma gangrenosum, sclerosing cholangitis, cholangiocarcinoma, pouchitis, toxic megacolon

MEDICINE × HEPATOBILIARY/PANCREATIC LIVER DZ

Dz Cirrhosis

Wilson disease (hepatolenticular degeneration)

Hemochromatosis (“bronze diabetes”)

Hepatic adenoma

Cavernous hemangioma Focal nodular hyperplasia (FNH)

Presentation fibrosis → disruption of liver architecture → portal HTN + impaired biosynthetic function → multiple complications Varices: portal HTN → dilated veins in butt (hemorrhoids), gut (esophageal varices), and caput (caput medusae)

Ascites: portal HTN + hypoalbuminemia → fluid accumulation in abd cavity Hepatic encephalopathy: ↓NH4 metabolism → ↑NH4 → CNS toxicity → ∆MS, asterixis, rigidity, hyperreflexia, fetor hepaticus Hepatorenal syndrome: endstage liver dz → renal vx vasoconstriction → progressive renal failure (despite normal kidneys) Spontaneous bacterial peritonitis (SBP): infx of ascitic fluid → abd pain, fever, n/v, rebound tenderness Hyperestrinism: ↓estrogen metabolism → ↑estrogen → spider angiomas, palmar erythema, gynecomastia, testicular atrophy Coagulopathy: ↓clotting factor synthesis → ↑risk of bleeding AR ∆ceruloplasmin → copper accumulation in liver (cirrhosis), corneas (Kayser-Fleischer rings), brain (movement d/o), RBCs (schistocytes) ↑iron → accumulation in liver (cirrhosis), heart (restrictive CM), joints (arthritis), skin (bronze suntan), pancreas (DM) usually asx, can present as hypovolemic shock and distended abdomen if ruptured usually asx, MC benign liver tumor usually asx

Hepatocellular carcinoma (HCC)

vague RUQ pain and mass + s/sx of chronic liver dz (portal HTN, ascites, jaundice)

Nonalcoholic steatohepatitis (NASH) Gilbert syndrome

fatty liver in a nonalcoholic pt, usually asx AD ∆UDP-glucuronyltransferase → usually asx, but can present w/ mild jaundice after fasting injury to liver or biliary tract → blood drains into duodenum via CBD → UGIB, jaundice, RUQ pain Polycystic liver: ADPKD → simple cyst in liver and kidneys Hydatid cysts: Echinococcus granulosus (dog tapeworm) → multilocular cyst w/ calcified walls multiple types, all present as fever, RUQ pain, jaundice

Hemobilia

Liver cysts

Liver abscess

Budd-Chiari syndrome

occlusion of hepatic vein outflow → hepatic congestion + portal HTN → hepatomegaly, RUQ pain, ascites, jaundice

Management • Dx liver bx

• PPx β-blockers • bleeding esophageal varices → Tx band the • varices, correct coagulopathy, IV octreotide to • lower portal pressure → if bleeding continues, • repeat banding → if bleeding continues, TIPS • or gastric balloon tamponade • Dx PE (shifting dullness, fluid wave) + • paracentesis (to determine cause) • Tx salt restriction + loop diuretic • Tx lactulose (prevents NH4 absorption) + • neomycin (kills GI flora that make NH4) + low • protein diet

Other Etiology: alcohol (MCC), HBV and HCV (2nd), other causes Child’s classification: stratifies risk of surgery in pts w/ liver failure; measure 3 labs (albumin, bilirubin, PT) and 3 clinical findings (encephalopathy, ascites, nutrition)

• Tx liver txp

• Dx paracentesis (↑WBC) • Tx IV abx + repeat paracentesis in 2-3 days

---

• Dx ↑PT/PTT • Tx FFP transfusion (vit K won’t work) • Dx ↓ceruloplasmin, ↑AST/ALT, liver bx • Tx D-penicillamine (copper chelating agent) + • zinc (copper uptake competition)

• Dx ↑ferritin, ↓TIBC, liver bx • Tx repeated phlebotomies

• Dx CT scan or U/S • Tx d/c OCP, if it persists → Tx resection due to • possibility of rupture • Dx CT scan or U/S • Tx reassurance • Dx CT scan (central stellate scar or sunburst • pattern) • Tx reassurance • Dx CT scan, ↑αFP • Tx resection w/ negative margins (as long as • there’s no mets)

1° hemochromatosis: AR dz that ↑GI iron absorption 2° hemochromatosis: ↑iron 2/2 multiple transfusions or chronic hemolytic anemia Etiology: associated with OCP and anabolic steroid use Etiology: VAT – vinyl chloride, aflatoxin, thorotrast

Etiology: cirrhosis (MCC), A1AT deficiency, hemochromatosis, Wilson dz, smoking, chemical carcinogens

• Dx mild ↑ALT/AST • Tx controversial • Tx reassurance

• Dx arteriogram (gold std); EGD shows • bleeding from ampulla of Vater • Tx supportive care, stop bleeding if severe

Etiology: trauma (MCC), surgery (CBD exploration), tumors, infx

• Tx reassurance • Tx inject hypertonic saline inside cyst and • carefully excise it + post-op mebendazole

• multiple/small bacterial abscesses → Tx IV abx • single/large bacterial abscess → Tx perc drain • amebic abscess (in Mexicans) → Tx Flagyl • Tx TIPS as a “bridge to liver txp”

Etiology: polycythemia vera (MCC), OCPs (#2)

MEDICINE × HEPATOBILIARY/PANCREATIC LFTS

↑AST/ALT (ALT>AST): chronic viral hepatitis (virALT) ↑AST/ALT (AST>ALT): acute alcoholic hepatitis (toAST) ↑↑AST/ALT: acute viral hepatitis ↑↑↑AST/ALT: severe hepatic necrosis AΦ ↑AΦ + GGT nl: pregnancy or bone dz (e.g. Paget’s) ↑AΦ + ↑GGT: biliary obstruction

albumin

AST bilirubin ALT

↑bilirubin (conjugated <20%): hemolytic jaundice ↑bilirubin (conjugated 20-50%): hepatocellular jaundice (viral or alcoholic hepatitis) ↑bilirubin (conjugated >50%): obstructive jaundice (cancer, choledocholithiasis) ↓albumin: chronic liver dz, nephrotic syndrome, malnutrition, inflammatory states

BILIARY DZ

Dz Gallstone dz

Presentation cholelithiasis fatty meal passes biliary colic into CBD lodge/infx acute cholecystitis

Management • Dx RUQ U/S (HIDA scan if inconclusive) + get • ERCP for choledocholithiasis/acute cholangitis

choledocholithiasis lodge/infx acute cholangitis lodge gallstone pancreatitis

Acalculous cholecystitis

GB adenocarcinoma

1° sclerosing cholangitis (PSC)

1° biliary cirrhosis (PBC)

Cholangiocarcinoma

Choledochal cysts Biliary stricture

Biliary dyskinesia

Cholelithiasis: presence of stones in GB, usually asx Biliary colic: cholelithiasis → RUQ pain after fatty meals ± n/v Acute cholecystitis: impacted stone in cystic duct → infx → RUQ pain, n/v, Murphy’s sign Choledocholithiasis: presence of stones in CBD Gallstone pancreatitis: impacted stone in pancreatic duct → reflux of pancreatic enzymes → midepigastric pain Acute cholangitis: impacted stone in CBD → infx → Charcot triad → Reynold pentad acute cholecystitis (RUQ pain, n/v, Murphy’s sign) w/o stones in the cystic duct, usually found in ICU pts presents as a mass in GB fossa

thickening of bile duct walls → narrowed lumens → gradual jaundice and pruritus → liver failure, cirrhosis, portal HTN AMA → destruction of intra-hepatic bile ducts → gradual jaundice and pruritus → liver failure, cirrhosis, portal HTN tumor of bile ducts → s/sx of obstructive jaundice (dark urine, clay stools, pruritus)

cystic dilation of biliary tree → RUQ mass/pain, jaundice, fever iatrogenic injury → s/sx of obstructive jaundice (dark urine, clay stools, pruritus) motor dysfxn of sphincter of Oddi → recurrent biliary colic w/o stones

Other Boas sign: referred right scapular pain of biliary colic Charcot triad: RUQ pain, fever, jaundice Reynold pentad: Charcot triad + ∆MS, hypotension Gallstone ileus: gallstone enters bowel through cholecystenteric fistula → gets stuck in terminal ileum → SBO

• Tx reassurance • Tx elective lap chole • Tx NPO, IVF, abx → lap chole within 24 hrs

• Tx NPO, IVF, ±abx → ERCP to remove stone • if amylase returns to normal → Tx lap chole • if amylase elevated → ERCP to remove stone

• Tx NPO, IVF, abx → ERCP to decompress CBD • → finally lap chole • Tx NPO, IVF, abx → lap chole within 24 hrs; • perc drain w/ cholecystostomy if nonsurgical • candidate • Dx CT scan • Tx radical cholecystectomy (GB + hilar LN + • liver resection w/ negative margins) • Dx ERCP (beading of bile ducts) • Tx cholestyramine (helps w/ pruritus), liver txp • (definitive)

Porcelain GB: dystrophic calcification of GB has 50% risk of adenocarcinoma, take it out Etiology: idiopathic, but highly associated w/ UC

• Dx screen w/ AMA (anti-mitochondrial ab), • confirm w/ liver bx • Tx ursodeoxycholic acid

2° biliary cirrhosis: progressive cirrhosis 2/2 biliary obstruction, sclerosing cholangitis, cystic fibrosis, or biliary atresia Etiology: PSC (MCC US), Chlonorchis sinensis (MCC China) Klatskin tumor: tumor of proximal 1/3 of CBD, poor px since it’s not resectable

• Dx ERCP • Tx Whipple if resectable

• Dx ERCP • Tx resection • Dx ERCP • Tx endoscopic stent (1st line), surgical bypass • Dx HIDA scan (fill up GB w/ contrast and give • CCK to determine ejection fraction) • Tx lap chole

Complications: 2° biliary cirrhosis, acute cholangitis, liver abscess

MEDICINE × HEPATOBILIARY/PANCREATIC PANCREATIC DZ

Dz Acute pancreatitis

Chronic pancreatitis

Pancreatic cancer

Presentation stabbing epigastric pain boring through to the back

Management • Dx screen w/ ↑lipase, confirm w/ CT scan • Tx NPO/IVF/pain meds

Hemorrhagic pancreatitis: presents as MSOF, ARDS, hemodynamic instability, signs of ecchymoses (Grey-Turner, Fox, Cullen signs) Pancreatic abscess: presents as abd pain and early satiety 2 wks s/p acute pancreatitis Pseudocyst: presents as abd pain and early satiety 5 wks s/p acute pancreatitis chronic epigastric pain, steatorrhea, diabetes mellitus

• Dx CT scan • Tx admit to ICU for close monitoring

dull abd pain + s/sx of obstructive jaundice (dark urine, clay stools, pruritus)

• Dx CT scan • Tx perc drain + IV abx • Dx CT scan • Tx observation (<5 cm), perc drain (>5 cm) • Dx stool elastase test • Tx insulin + pancreatic enzyme replacement, • IVF/NPO/pain meds for acute attacks • Dx CT scan • cancer in head → Tx Whipple • cancer in body or tail → Tx distal • pancreatectomy • mets or local invasion → palliative care • f/u tumor markers CA 19-9, CEA

Other Etiology: I GET SMASHED – idiopathic, gallstones (#1), EtOH (#2), trauma, steroids, mumps, autoimmune, scorpion sting, hypertriglyceridemia (#3), hypercalcemia, ERCP, drugs Grey-Turner sign: flank ecchymoses Cullen sign: periumbilical ecchymoses Fox sign: ecchymoses of inguinal ligament Etiology: alcoholism (MCC adults), cystic fibrosis (MCC kids) Trousseau phenomenon: migratory SVT in 10% of pancreatic cancer pts Courvoisier sign: palpable GB w/o pain in 30% of cancer pts

MEDICINE × ENDOCRINE THYROID DZ

Dz Thyroglossal duct cyst Hyperthyroidism

Thyroid storm

Hypothyroidism

Myxedema coma

Thyroid nodules

Presentation remnant of thyroglossal duct → mobile midline neck mass Graves disease (diffuse toxic goiter): autoimmune dz due to TSI (anti-TSH) → hyperthyroid sx, exophthalmos, thyroid bruits, pretibial myxedema Plummer disease (toxic multinodular goiter): multiple hyperfunctioning areas in thyroid → hyperthyroid sx Toxic adenoma: single hyperfunctioning nodule → hyperthyroid sx precipitating factor (stress, infx) → hyperthyroidism exacerbation → marked fever, tachycardia, agitation, GI sx Hashimoto thyroiditis: autoimmune dz w/ lymphocytic infiltration → hypothyroid sx De Quervain thyroiditis: painful granulomatous inflammation following viral URI → hypothyroid sx Acute thyroiditis: painful, swollen, tender thyroid mass due to Staph/Strep infx → hypothyroid sx Riedel thyroiditis: firm, painless thyroid → hypothyroid sx precipitating factor (stress, infx) → hypothyroidism exacerbation → marked hypothermia, ∆MS, respiratory depression thyroid nodule found on physical exam

Management • Tx Sistrunk operation (take out cyst, trunk, and • medial portion of hyoid bone) • Dx ↓TSH, ↑free T4 • Tx PTU (pregnant), methimazole (not • pregnant), oral radioiodine (can become • hypothyroid), subtotal thyroidectomy • (permanent) • Dx ↓TSH, ↑free T4 + patchy uptake on T3 scan • Tx oral radioiodine (<2 cm), subtotal • thyroidectomy (>2 cm)

Other

Hyperthyroidism in elderly: presents as weakness, weight loss, atrial fibrillation

• Dx ↓TSH, ↑free T4 + hot nodule on T3 scan • Tx oral radioiodine (<2 cm), lobectomy (>2 cm) • Tx β-blockers + antithyroid drugs

Px: 20% mortality rate

• Dx ↑TSH, ↓/nl free T4 • Tx Synthroid

Hashimoto abs: anti-TSH, antimicrosomal, anti-thyroglobulin, anti-peroxidase (TPO)

• Dx ↑TSH, ↓/nl free T4 • Tx NSAIDs + observation (will self-resolve)

• Dx ↑TSH, ↓/nl free T4 • Tx I+D

• Dx ↑TSH, ↓/nl free T4 • Tx Synthroid vs. surgery • Tx IV thyroxine + hydrocortisone + supportive • care

Dx TSH (normal)

MC type: benign colloid nodule Malignancy signs: solid nodules, cold nodules (lack of radioiodine uptake), size >1.5 cm

Dx FNA benign

indeterminate

malignant

Dx thyroid scan hot

Thyroid cancer

thyroid nodule or mass found on physical exam; 80% papillary, 15% follicular, 4% medullary, 1% anaplastic Papillary cancer: lymphatic spread, “Psamomma bodies w/ Orphan Annie nuclei”, best px Follicular cancer: hematogenous spread, endemic to iodine-deficient areas Medullary cancer: lymphatic and hematogenous spread, amyloid deposits Anaplastic cancer: rare, worst px Hürthle cell cancer: aggressive , lymphatic-spreading variant of follicular cancer

cold

observation Tx surgery • Dx FNA (for all types except follicular, must • see capsular invasion for adenoma/carcinoma)

• Tx total thyroidectomy w/ central LN excision • → modified radical neck dissection if +LN • f/u thyroglobulin levels • Tx hemilobectomy + frozen bx → total • thyroidectomy if bx shows carcinoma • f/u thyroglobulin levels • Tx total thyroidectomy w/ central LN excision • → modified radical neck dissection if +LN • f/u calcitonin levels + 24-hr urinary VMA • (MEN2 syndrome also has pheos) • Tx palliative care • Tx total thyroidectomy w/ central LN excision • → modified radical neck dissection if +LN • f/u thyroglobulin levels

Risk factors: Post-radiation (Papillary), MEN2 syndrome (Medullary) Px: MACIS system – Metastasis, Age (<45), Completeness of resection, Invasion, Size (>2 cm) Surgery complications: recurrent laryngeal nerve (hoarseness), superior laryngeal nerve (soft, deep voice), parathyroid glands (hypocalcemia)

MEDICINE × ENDOCRINE PARATHYROID DZ

Hypocalcemia sx: neuromuscular irritability (tingling, tetany), prolonged QT, arrhythmias Hypercalcemia sx: stones (kidney) bones (bone pain, osteitis fibrosa cystica) groans (peptic ulcers, pancreatitis) psychic overtones (depression, anxiety, ∆MS) Dz Hypoparathyroidism

Presentation head/neck surgery → accidental PTH-ectomy → hypocalcemia sx

Management • Dx ↓PTH, ↓Ca, ↑P • Tx vit D + calcium replacement

Pseudohypoparathyroidism

end-organ resistance to PTH → hypocalcemia sx

• Dx ↑PTH, ↓Ca, ↑P • Tx vit D + calcium replacement

1° HPTH

90% adenoma, 9% hyperplasia, 1% carcinoma → hypercalcemia sx

2° HPTH

renal failure → ↓1α-hydroxylase → ↓vit D → ↓Ca → compensatory ↑PTH 2° HPTH pts get renal txp but parathyroid glands still hypersecretory despite ↑Ca Ca >15

• Dx ↑PTH, ↑Ca, ↓P + Cl:P ratio >33:1 • Tx surgery (adenoma → take it out, • hyperplasia → 3½ gland removal, carcinoma • → en bloc resection of parathyroid and ipsi • thyroid lobe) • Dx ↑↑PTH, ↓Ca, ↑P • Tx vit D + calcium replacement, low P diet

3° HPTH

Hypercalcemic crisis

PITUITARY DZ

Other Chvostek sign: tapping on Cheek causes muscle contractions Trousseau sign: inflating BP cuff causes carpal muscle spasms DiGeorge syndrome: thyroid + parathyroid hypoplasia Knuckle-knuckle-dimple-dimple sign: hand morphology seen w/ pseudohypoparathyroidism

• Dx ↑PTH, ↑Ca, ↓P • Tx observation for 1 year, then 3½ gland • excision if still problematic • Tx “flush and drain” (NS then Lasix), then • surgery for parathyroid carcinoma

Polyuria/polydipsia DDx: DM, DI, diuretic use, primary polydipsia (Ψ d/o) Dz Pituitary adenoma

Craniopharyngioma

Diabetes insipidus (DI)

SIADH

Presentation tumor of anterior pituitary gland → bitemporal hemianopsia (◐◑) + hyperpituitary or hypopituitary sx Prolactinoma: ↑PRL → galactorrhea, amenorrhea, infertility, ↓libido Acromegaly: ↑GH → overgrowth of brow, jaw, hands, and feet; MCC death is CV disease Pituitary Cushing: ↑ACTH → truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, immunosuppression Hypopituitarism: ↓FSH/LH, ↓ACTH, ↓TSH, ↓PRL, ↓GH embryological remnant of Rathke pouch → bitemporal hemianopsia (◐◑), headache, papilledema, ∆MS polyuria, polydipsia

Central DI: ↓ADH secretion from posterior pituitary Nephrogenic DI: normal ADH but kidneys don’t respond ↑ADH secretion from posterior pituitary → volume expansion, hyponatremia (coma/sz/death if acute, asx if chronic)

Management • Dx MRI

Other

• Dx ↑PRL + β-HCG/TSH (r/o 2° causes) • Tx bromocriptine or cabergoline (<1 cm), • transsphenoid hypophysectomy (≥1 cm) • Dx oral glucose test • Tx transsphenoid hypophysectomy + • octreotide (suppress GH) • Dx ↑ACTH + dexa suppression test (pituitary • Cushing is suppressable) • Tx transsphenoid hypophysectomy

• Dx hormone levels • Tx hormone replacement • Dx MRI (supracellar calcified cysts) • Tx transsphenoid hypophysectomy

• Dx water deprivation test (normal pts increase • urine osm >280, central DI <280 but normalize • w/ ADH, nephrogenic DI <280 and don’t • normalize w/ ADH) • Tx DDAVP • Tx HCTZ • Dx Na <135, plasma osm <270 • Tx water restriction

Central pontine myelinolysis: rapid correction of hyponatremia will cause demyelination and locked-in syndrome, so replace Na at a max of 0.5/hr

MEDICINE × ENDOCRINE ADRENAL DZ

Dz Cushing syndrome

Presentation ↑cortisol → truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, immunosuppression

Management

Other Cushing syndrome

Dx ACTH, cortisol, dexamethasone suppression test ↑ACTH, ↑cortisol

↓ACTH, ↑cortisol adrenal Cushing (Dx abd CT)

>50% suppression

Pheochromocytoma

1° hyperaldosteronism (Conn syndrome) Adrenal insufficiency

Congenital adrenal hyperplasia

Incidentaloma

PANCREATIC DZ

Dz Insulinoma

Gastrinoma (ZE syndrome)

Glucagonoma

Somatostatinoma VIPoma

MEN SYNDROME

Dz MEN 1 (Wermer syndrome)

MEN 2A (Sipple syndrome)

MEN 2B

Pituitary Cushing: ↑ACTH secretion from pituitary gland Adrenal Cushing: ↑cortisol secretion from adrenal gland Ectopic Cushing: ↑ACTH secretion from SCLC (paraneoplastic syndrome) Iatrogenic Cushing: MCC 0verall, d/t exogenous steroids episodic catecholamine excess → 5 Ps – Pressure (BP), Pain (HA), Perspiration, Palpitations, Pallor 67% adenoma, 33% hyperplasia → ↑aldosterone → ↑Na (HTN), ↓K, ↓H (metabolic alkalosis) ↓cortisol/↓aldosterone → hypoglycemia, HTN, fatigue, hyperpigmentation, weight loss, abd pain 1° adrenal insufficiency (Addison disease): autoimmune (MC US), TB (MC 3rd world), Waterhouse-Friderichsen syndrome (N. meningitidis) 2° adrenal insufficiency: due to abrupt cessation of steroid use (MCC overall) congenital deficiency of 21αhydroxylase (MC) or 11βhydroxylase → hirsutism, virilization, ↓Na/↑K/↑H adrenal tumor found incidentally on CT scan

Presentation ↑insulin → Whipple’s triad (hypoglycemia, worse w/ fasting, better w/ glucose) ↑gastrin → ↑gastric acid secretion → ulcers

↑glucagon → new-onset diabetes + necrolytic migratory erythema ↑SST → triad of gallstones, diabetes, steatorrhea ↑VIP → “rice water” diarrhea

Presentation pituitary adenoma, pancreatic endocrinoma (MC gastrinoma), parathyroid hyperplasia parathyroid hyperplasia, pheochromocytoma, thyroid medullary cancer pheochromocytoma, thyroid medullary cancer, mucosal neuromas, Marfanoid habitus

<50% suppression

pituitary Cushing ectopic Cushing (Dx head MRI) (Dx chest/abd CT) • Tx transsphenoid hypophysectomy • Tx adrenalectomy • Tx underlying cause

• Tx taper steroids slowly • Dx 24 hr urinary VMA/metanephrines • Tx α-blockers (phenoxybenzamine) then • β-blockers then adrenalectomy

Rule of 10’s: 10% malignant, 10% bilateral, 10% extraadrenal, 10% calcify, 10% kids, 10% familial (MEN2A/2B)

• Dx abd CT scan • Tx adrenalectomy (adenoma), spironolactone • (hyperplasia) • Dx ↓cortisol + ACTH levels (↑ACTH if primary, • ↓ACTH if secondary)

• Tx glucocorticoid (prednisone) + • mineralocorticoid (fludrocortisone)

• Tx glucocorticoid (prednisone) only

• Dx ↑17-OHP • Tx glucocorticoid (prednisone) + • mineralocorticoid (fludrocortisone) • <5 cm → leave alone • >5 cm → Tx resection + check other organs • since adrenals are common site of metastasis

Management • Dx ↑C-peptide levels or monitored fasting (to • see if they’re “faking it”) • Tx resection • Dx gastrin levels (<200 absent, >500 present); • if 200-500, get secretin stimulation test • (paradoxical ↑gastrin w/ secretin) • Tx resection • Dx glucose challenge test • Tx resection

Other

Gastrinoma triangle: neck of pancreas, cystic duct, junction b/t 2nd and 3rd part of duodenum

• Tx resection • Tx resection

Management • Tx excise parathyroid first (since hyper • calcemia can cause ↑gastrin), then gastrinoma, • then pituitary adenoma (w/ cabergoline) • Tx excise pheo first (life-threatening)

Other

• Tx excise pheo first (life-threatening)

Etiology: AD ret proto-oncogene

Etiology: AD ret proto-oncogene

MEDICINE × ENDOCRINE DIABETES MELLITUS

Dz Impaired glucose tolerance T1DM

T2DM

Presentation asx autoimmune destruction of βcells → lack of insulin → pt usually presents in acute DKA obesity → ↑FFA release → ↑insulin resistance → ↑glucose → classic sx (polyuria, polydipsia, polyphagia) + blurry vision, weight loss, recurrent vaginal yeast infx

Management • Dx fasting glc 110-126 • Tx insulin, 0.5-1 u/kg (2/3 morning, 1/3 evening) • inpatient → Tx SSI

Other

• Dx fasting glc >126, random glc >200 w/ sx, or • HbA1C >6.5%

Ideal levels: HbA1c <7%, fasting glc <130, post-prandial glc <180, BP <130/80, LDL <100

T2DM fasting glc <240 lifestyle changes (still high) Tx metformin or sulfonylurea (still high) add another PO drug

DM complications

DKA

HHNS

Hypoglycemia

Macrovascular complications: nonenzymatic glycosylation (NEG) → atherosclerosis → CAD, MI, PVD, stroke/TIA, etc. Diabetic nephropathy: NEG of basement membrane → loss of negative charge → microalbuminuria → proteinuria → CKD → ESRD Diabetic retinopathy: NEG of retinal vx → either background or proliferative retinopathy Diabetic neuropathy: NEG of peripheral nerves → damage → “stocking/glove” burning pain, numbness, tingling Diabetic foot: peripheral neuropathy + PVD (ischemia) → repetitive injuries → ulcers and nonhealing T1DM exacerbation → ↓insulin → hyperglycemia + ketosis → osmotic diuresis, dehydration, fruity breath, Kussmaul respiration, etc. T2DM exacerbation → ↓insulin → hyperglycemia → hyperosmolarity, osmotic diuresis, severe dehydration ↓glc → ↑epinephrine (sympathetic sx), CNS dysfunction at 40-50 (HA, weakness, drowsiness, coma)

fasting glc >240

Insulin dosage: “basal bolus” – long-acting Lantus + short-acting Novolog w/ meals

Tx insulin (still high)

Outpatient mgmt: q day – glucose q visit – BP, foot chk q 3 mo – HbA1c q 6 mo – neuropathy chk q yr – microalbuminuria, BUN/Cr, lipids, eye chk • PPx reduction of risk factors (BP, lipids, • smoking, diet, exercise)

Microalbuminuria: 20-200 μg/min or 30-300 mg/day

• PPx annual microalbuminuria screening • Tx ACE inhibitors

• PPx annual ophtho referral • Tx photocoagulation • neuropathy → Tx amitriptyline (1st line), • gabapentin or duloxetine (2nd line) • gastroparesis → Tx metoclopramide • PPx regular foot check • Tx wound care, amputation (last resort)

• Dx ↑glc, ↑ketones, metabolic acidosis • Tx insulin + IVF (NS) + potassium (paradoxical)

• Dx ↑glc, ↑osmolarity, no acidosis or ketosis • Tx insulin + IVF (NS)

• Dx ↓glc • Dx C-peptide, insulin levels, anti-insulin ab, and • sulfonylurea levels (look for underlying cause) • Tx underlying cause + sugary foods or IV D50W

Etiology: insulin overdose (MCC), factitious hypoglycemia (low Cpeptide levels), insulinoma, etc.

MEDICINE × NEURO STROKE

Stroke types: ischemic (85%), hemorrhagic (15%) Stroke in young pt: cocaine abuse Carotid bruit: either internal carotid artery stenosis, or referred heart murmur Dz Subclavian steal syndrome

Transient ischemic attack (TIA)

Ischemic stroke

Hemorrhagic stroke

HEAD TRAUMA

Presentation asx at rest, but arm claudication and CNS sx with exercise due to stenotic subclavian artery (can present like a TIA) focal neuro sx <24 hrs (usually <1 hr) Carotid TIA: abrupt contralateral sx Vertebrobasilar TIA: ipsilateral CN palsy, contralateral hemiplegia Drop attacks: brief paralytic spells resulting in pt dropping to knees w/o LOC Transient global amnesia: TIA in temporal lobes or thalamus → rapid retrograde memory loss + confusion but preservation of self-identity Amaurosis fugax: TIA in retinal artery → temporary unilateral loss of vision focal neuro sx >24 hours ACA syndrome: contralateral leg hemiparesis, incontinence MCA syndrome: contralateral face/arm hemiparesis PCA syndrome: homonymous hemianopia Vertebrobasilar syndrome: ipsilateral CN palsy, contralateral hemiplegia Cerebellar infarction: headache, nausea, vomiting, vertigo, nystagmus Lacunar syndromes: pure motor or sensory stroke, clumsy hand-dysarthria syndrome ICH: bleeding into brain parenchyma → focal neuro sx + sudden headache + vomiting SAH: rupture of berry aneurysm → bleeding into subarachnoid space → “worst headache of my life”

Management • Dx arteriogram • Tx bypass surgery

Other

• CV risk factor analysis, since risk of stroke is • much higher in the near future • anterior circle TIAs → Dx carotid duplex; • consult surg for CEA if ≥70% stenosis

• Dx head CT w/o contrast (dark areas) • Tx TPA <3 hrs, aspirin ≥3 hrs or TPA c/i • AFib-related stroke → Tx heparin/warfarin • lacunar strokes → Tx control HTN • anterior circle strokes → Dx carotid duplex; • consult surg for CEA if ≥70% stenosis

• Dx head CT w/o contrast (white areas) • Tx intubate and hyperventilate, slowly lower • BP, control ↑ICP w/ mannitol, admit to ICU • Dx head CT w/o contrast (white areas), • do an LP if not sure (blood, xanthrochromia) • Tx bed rest in dark/quiet room, analgesics for • headache, nifedipine for vasospasm ppx, • consult neurosurg to clip berry aneurysm

Risk factors: HTN (#1), old age (#2), CAD, CHF, acute MI, AFib, diabetes, male sex, Black race, smoking, alcohol, OCPs Etiology: embolic stroke (AFib, endocarditis), thrombotic stroke (atherosclerosis), lacunar stroke (HTN)

Risk factors: HTN (#1)

Basal skull fx: raccoon eyes, hemotympanum, otorrhea, rhinorrhea, ecchymosis behind the ear (Battle sign) Coup-contrecoup injury: injury at site of impact + opposite point of impact Diffuse axonal injury: global damage to entire brain during impact → severe neuro dysfxn, coma Dz EDH

SDH

Concussion

Presentation temporal bone fx → tear in middle meningeal artery → bleeding into epidural space → LOC w/ lucid interval tear in bridging veins → venous bleed into subdural space → ∆MS, headache, cortical dysfxn, possible herniation if acute brief LOC following blunt head trauma w/ confusion, dizziness, impaired concentration, etc.

Management • Dx head CT (convex lens hematoma) • Tx emergent craniotomy

Other

• Dx head CT (crescent moon hematoma) • Tx craniotomy (acute), reassurance (chronic)

Risk factors: shrunken brain states (alcoholics, elderly) SDH in kids: consider child abuse

• no tx available

MEDICINE × NEURO MOVEMENT D/O

Movement d/o in young pt: consider Wilson disease Dz Parkinson disease (PD)

Presentation loss of dopaminergic neurons → early PD presents as TRAP – pill-rolling Tremor, cogwheel Rigidity, Akinesia, Postural instability; late PD presents as Alzheimer-like dementia

Management • early PD → Tx Sinemet (carbidopa + levodopa) • late PD → Tx subthalamic nucleus deep brain • stimulation

Huntington chorea

AD CAG trinucleotide repeats on chromosome 4 → ↓GABA → chorea, apathy, depression, dementia w/ onset at 35-50 y/o

• Dx MRI (caudate atrophy), DNA testing • no tx available

Other PD brain: neuronal death in substantia nigra, senile plaques, Lewy bodies Shy-Drager syndrome: PD + autonomic insufficiency Progressive supranuclear palsy (PSP): PD w/o ophthalmoplegia or tremors

Anticipation: longer CAG repeats correlates with earlier age of onset Essential tremor

Ataxia

Tourette syndrome

AD tremor w/ intentional activity but not at rest, improved w/ EtOH use gait instability, loss of balance, impaired limb coordination Acquired ataxia: ataxia 2/2 EtOH, B12/thiamine deficiency, cerebellar dz, demyelinating dz, or 3° syphilis Friedreich ataxia: ataxia w/ staggering gait, nystagmus, pes cavus and hammer toes Ataxia-telangiectasia: Friedreich ataxia + telangiectasias most severe tic disorder w/ multiple daily motor/vocal tics, onset before 18 y/o; associated w/ OCD and ADHD

• Tx β-blockers

• Tx underlying cause

• Tx clonidine or pimozide (Haldol if severe)

Coprolalia: involuntary swearing, pathognomonic but rare in Tourette syndrome

MEDICINE × NEURO DEMENTIA

Normal aging vs. dementia: no impairment of daily functioning w/ normal aging Delirium vs. dementia: Delirium Dementia Definition

Onset Duration Px Amnesia Alert Oriented Dx

waxing-andwaning change in pt’s level of consciousness acute 3 days – 2 wks reversible immediate and recent memory no no abnormal EEG

impairment in memory and other cognitive functions chronic months – yrs irreversible recent and remote memory yes sometimes abnormal MRI

Dementia: progressive and irreversible impairment in memory and other cognitive functions w/o change in level of consciousness Causes of dementia: Alzheimer (#1), vascular (#2), Lewy body (#3), others Dz Pseudodementia Secondary dementia

Alzheimer disease (AD)

Vascular dementia

Lewy body dementia

Pick disease (frontotemporal dementia)

HIV-associated dementia

Creutzfeldt-Jakob disease

Normal pressure hydrocephalus

Presentation severe depression that can present like dementia in elderly dementia 2/2 hypothyroidism, B12/folate deficiency, thiamine deficiency, neurosyphilis, or medication use ↓ACh → gradual progressive decline in memory and other cognitive functions

Management • Tx SSRIs

accumulation of multiple small infarcts → stepwise loss of function + focal neurological sx Lewy body and neurite accumulations in the basal ganglia → dementia, waxingand-waning parkinsonism, visual hallucinations, sensitivity to antipsychotics profound changes in personality and social conduct, disinhibition, hyperorality, hypersexuality; good memory and language though neutropenia → infection → rapid decline in memory, cognition, behavior, motor skills; depression and social withdrawal also common abnormal prion accumulation → rapidly progressive dementia, myoclonus (muscle spasms), personality changes 3 Ws – Wet (urinary incontinence), Wobbly (gait apraxia), Wacky (dementia)

• Dx MMSE (<25), head CT (multiple small • lacunar infarcts) • no tx available • Dx MMSE (<25), clinical judgment • manage like Alzheimer disease

Other

• Tx underlying cause

• Dx MMSE (<25), head CT (diffuse atrophy w/ • enlarged ventricles, flat sulci) • r/o secondary causes • Tx AChE-inhibitors for mild/moderate AD • (tacrine, donepezil), NMDA antagonist for • severe AD (memantine)

• Dx MMSE (<25), head CT (marked atrophy of • frontal and temporal lobes) • no tx available

• Tx HAART

• Dx EEG (generalized sharp waves), confirm w/ • postmortem brain bx (spongiform change)

• Dx MRI (large ventricles) • Tx CSF shunt

Amyloid cascade hypothesis: high risk genes (presenilin I, presenilin II, APP, apoE4) can predispose to Aβ-amyloidosis Alzheimer × Down syndrome: trisomy 21 → triple apoE4 expression → inevitable by 40 y/o

MEDICINE × NEURO ALTERED MS

ICP: normally 5-15; ICP >20 → bilateral fixed/dilated pupils → herniation → death Cushing triad: triad of vital signs in ICP – ↑BP, ↓HR, irregular RR Glasgow coma scale: GCS score = E+M+V / 15 Abnl pupillary light reflex: mass lesions, pupil drugs, hypoxia, eye drops Bilateral fixed/dilated pupils: severe anoxia Unilateral fixed/dilated pupil: herniation w/ CN III compression Pinpoint pupils: narcotics, ICH (in pons) Dz Delirium

Coma

“Locked in” syndrome

Brain herniation

Presentation waxing-and-waning change in level of consciousness; can also have visual hallucinations, short attention span, and impaired recent memory Sundowning: worsening of delirium at night damage to RAS or bilateral hemispheres → depressed LOC, unresponsive to any stimuli damage to ventral pons → coma-like state but pt is fully conscious and can control blinking, vertical eye movement edema or mass lesion → ↑ICP → brain tissue moves past anatomic barriers

Management • Dx MMSE (<25) • r/o life-threatening causes, then ID and Tx • underlying cause

Other Etiology: AEIOU TIPSS – Alcohol and drug toxicity or withdrawal, Electrolyte imbalance, Iatrogenic, Oxygen hypoxia, Uremia/hepatic encephalopathy, Trauma, Infection, Poison, Seizures, Stroke

• Dx GCS (≤8) • r/o life-threatening causes, then ID and Tx • underlying cause ---

• Dx head CT • Tx intubate, lower ICP, consult neurosurg

CN III: ipsilateral “blown pupil” PCA: contralateral homonymous hemianopia Crus cerebri: ipsilateral paresis Brainstem: Duret hemorrhages, death

DEMYELINATING DZ

CNS NEOPLASMS

Brain death

irreversible absence of brain function despite adequate oxygenation/ventilation, no brainstem reflexes

• Dx EEG (no activity) • d/c life support

Dz Multiple sclerosis

Presentation selective CNS demyelination → optic neuritis, intranuclear ophthalmoplegia (crazy eyes), transient sensory deficits, etc.

Management • Dx MRI (multiple white plaques), LP w/ CSF analysis (oligoclonal bands) • Tx IFN-β (prevent relapses), high-dose steroids (for acute attacks)

Guillain-Barré syndrome

rapid PNS demyelination → ascending weakness/paralysis, possible respiratory arrest

• Dx CSF (↑protein), EMG (↓nerve conduction) • Tx IVIG vs. plasmapheresis

Other

Ring-enhancing lesions: MALT – metastases, abcesses, lymphoma, toxo Brain cancer sx: mass effect → headache, seizures, focal neuro sx MC brain cancers: metastases (overall), astrocytoma (adults), infratentorial tumors (kids) Dz GBM

Astrocytoma Oligodendroglioma Meningioma Acoustic schwannoma CNS metastases Primary CNS lymphoma Meningeal carcinomatosis

Buzzwords can cross corpus callosum (butterfly glioma), pseudopalisading necrosis, GFAP+ Rosenthal fibers, GFAP+ “fried egg” cells, chicken-wire capillary pattern Psamomma bodies, attached to dura S-100+, CN VIII multiple ring-enhancing lesions AIDS/immunosuppression cancer that metastasizes to meninges via bloodstream → focal neuro sx, meningitis, hydrocephalus

Management • Dx MRI • Tx resection (if resectable), radiation • (astrocytomas, oligodendrogliomas, • lymphoma, metastases)

Other

Bilateral schwannoma: NF type 2 Mets source: lung > breast > skin > kidney > colon • Dx LP w/ CSF analysis (malignant cells) • Tx intrathecal chemotherapy

MEDICINE × NEURO NEUROMUSCULAR DZ

Dz Myasthenia gravis

Presentation anti-nAChR → gradually progressive muscle weakness (initial sx is ptosis, diplopia, blurry vision) that get worse w/ repetitive muscle use

Lambert-Eaton myasthenic syndrome (LEMS)

SCLC → anti-VGCC → gradually progressive muscle weakness that get better w/ repetitive muscle use XR ∆dystrophin → muscle cells die off → ascending weakness w/ Gowers maneuver, calf pseudohypertrophy, death by 15 y/o XR ∆dystrophin → same as DMD, but later onset and less severe sx

Duchenne muscular dystrophy

Becker muscular dystrophy

NEUROCUTANEOUS SYNDROMES

Dz Neurofibromatosis type I (von Recklinghausen disease) Neurofibromatosis type II Tuberous sclerosis

Sturge-Weber syndrome Von Hippel-Lindau disease

SPINAL CORD DZ

Presentation AD ∆NF1 → café-au-lait spots, Lisch nodules (iris hamartomas), CNS tumors, pheo AD ∆NF2 → bilateral acoustic neuromas, juvenile cataracts AD ∆TSC1/2 → CNS/retinal hamartomas, sebaceous adenomas, hypopigmented “ash leaf spots”, Shagreen patches, renal angiomyolipoma, cardiac rhabdomyoma facial “port-wine stain” w/ ipsilateral brain AVM AD ∆VHL → hemangioblastomas, bilateral RCC, pheochromocytomas

Management • Dx ↑anti-nAChR (best), edrophonium test, • EMG (decreased response w/ repetitive • stimulation), chest CT to look for thymoma • Tx pyridostigmine, plasmapheresis (if severe), • thymectomy (if thymoma)

Other

• myasthenic crisis → emergent ventilation • Dx ↑anti-VGCC • Tx underlying cause

• Dx ↑CPK, DNA testing • no tx available

• Dx ↑CPK, DNA testing • no tx available

Management • NF pt w/ HTN → Dx urinary metanephrines

Other

-----

-----

CS tract: descending motor signals, crosses at medulla DCML tract: ascending touch and proprioception, crosses at medulla ALS tract: ascending pain and temperature, crosses in spinal cord Dz Syringomyelia

Presentation central cavitation of cervical cord → bilateral “cape-like” loss of ALS, ipsilateral CS

Management • Dx MRI • Tx syringosubarachnoid shunt

Brown-Sequard syndrome

stab wound → spinal cord hemisection → ipsilateral loss of DCML and CS, contralateral loss of ALS

---

Transverse myelitis

viral infx → loss of function of entire spinal cord at a single level → bilateral loss of CS/DCML/ALS below level of lesion + sphincter dysfunction polio infx (fecal-oral) → bilateral lower motor neuron loss of function → asymmetric muscle weakness w/ normal sensation

• Dx MRI • Tx high-dose steroids

Poliomyelitis

• PPx vaccination

Other

MEDICINE × NEURO OTHER CNS DZ

Syncope vs. seizures: prolonged LOC or bowel/bladder incontinence indicates seizures Dz Vertigo

Presentation “spinning of the room”, five types (BLAME) – BPPV, Labyrinthitis, Acoustic neuroma, Meniere disease, EtOH/drug-induced Cardiac syncope: sudden LOC w/o prodromal sx; d/t massive MI, arrhythmias, or obstruction (e.g. aortic stenosis) Vasovagal syncope: paradoxical PSNS activity during intense emotion → LOC w/ premonitory sx (pallor, sweating, nausea) Orthostatic hypotension: delay in peripheral venoconstriction → LOC w/ sudden or prolonged standing Simple partial sz: transient unilateral movements w/o LOC Complex partial sz: transient automatisms w/ LOC → postictal confusion Grand-mal sz: sudden LOC → rigidity (tonic phase) → musculature jerking (clonic phase) → postictal confusion Absence sz: “staring into space” for a few seconds

Management • Tx underlying cause + meclizine for nausea

Amyotrophic lateral sclerosis (Lou Gehrig disease)

upper and lower motor neuron lesions → progressive muscle weakness → death in 5-10 yrs

• Dx EMG (fasciculations, fibrillations), nerve • conduction studies (↓conduction velocity) • Tx supportive care + riluzole (glutamate• antagonist that delays death by 3-5 months)

Aphasia

Wernicke aphasia: superior temporal gyrus lesion → fluent w/ impaired comprehension Broca aphasia: inferior frontal gyrus lesion → nonfluent w/ intact comprehension Conduction aphasia: both gyri lesion → nonfluent w/ impaired comprehension Global aphasia: arcuate fasciculus lesion → can’t repeat “no ifs, ands, or buts” weakness or paralysis of facial muscles innervated by CN VII

• usually resolves on its own

Etiology: stroke (#1), trauma, tumors, Alzheimer dz

• usually resolves on its own • Tx steroids if ≥10 days, ACV if shingles, • doxycycline if Lyme disease

Etiology: trauma, Lyme disease, tumors, Guillan-Barre syndrome, shingles

Syncope

Seizures

Bell palsy

Trigeminal neuralgia (tic douloureux)

Bilateral Bell: Lyme disease or Guillain-Barre syndrome severe, recurrent pain attacks in trigeminal distribution

Other

• first step is to r/o cardiac causes (get EKG, • CV-focused physical) • cardiac syncope → Tx underlying cause • vasovagal syncope → Dx tilt-table study, • Tx β-blockers + disopyramide • orthostatic hypotension → Dx orthostatics, • Tx fluid/sodium intake

• first time → Dx labs (renal panel, glucose) + • EEG + MRI (r/o mass lesions) • epileptic → check anticonvulsant levels • partial sz → Tx phenytoin or CBZ • grand-mal sz → Tx phenytoin or CBZ • absence sz → Tx ethosuximide

• Tx CBZ

Etiology: 4 Is + 4 Ms – Infx, Ischemia (stroke/TIA), ↑ICP, Intoxication, Metabolic and electrolytes, Mass lesions, Missing drugs (anticonvulsants, sedatives/EtOH), Misc Pseudoseizure: looks like sz but no EEG changes Secondary generalization: partial sz → generalized sz Status epilepticus: brain is stuck in a state of persistent seizure

MEDICINE × MSK BUZZWORDS

HLA-B27: PAIR – psoriatic arthritis, ankylosing spondylitis, IBD, Reiter syndrome HLA-DR2: SLE HLA-DR3: SLE, Sjögren syndrome HLA-DR4: Rheumatoid 4rthritis, mixed CT disease C-ANCA: Wegener granulomatosis P-ANCA: Churg-Strauss syndrome, microscopic polyangiitis Anti-basement membrane: Goodpasture syndrome Anti-CCP: rheumatoid arthritis Anti-centromere: CREST syndrome Anti-desmosome: pemphigus vulgaris Anti-dsDNA: SLE Anti-endomysial: celiac sprue Anti-Fc IgG (RF): SLE, RA, many others Anti-gliadin: celiac sprue Anti-hemidesmosome: bullous pemphigoid Anti-histone: drug-induced lupus Anti-Jo-1: polymyositis/dermatomyositis Anti-microsomal: Hashimoto thyroiditis Anti-mitochondrial (AMA): primary biliary cirrhosis Anti-nAChR: myasthenia gravis Anti-nuclear (ANA): SLE, RA, many others Anti-peroxidase: Hashimoto thyroiditis Anti-Scl-70 (anti-topoisomerase): scleroderma (diffuse) Anti-Sm: SLE Anti-smooth muscle: autoimmune hepatitis Anti-SSA/SSB (anti-Ro/La): Sjögren syndrome Anti-thyroglobulin: Hashimoto thyroiditis Anti-TSH (TSI): Graves disease Anti-U1-RNP: mixed CT disease Anti-VGCC: Lambert-Eaton myasthenic syndrome

CONNECTIVE TISSUE DZ

Dz SLE

Drug-induced lupus

Neonatal lupus

APA syndrome

Raynaud disease Scleroderma (diffuse) Scleroderma (CREST syndrome)

Sjögren syndrome

Mixed CT disease

Presentation type 3 HS → flare-and-remission pattern of I’M DAMN SHARP – ↑IgG Malar rash Discoid rash ANA Mucositis (throat ulcers) Neurologic d/o Serositis (pleuritis, pericarditis) Hematologic d/o Arthritis Renal d/o (“wire loops”) Photosensitivity drugs → type 3 HS → SLE-like presentation but no kidney or CNS involvement maternal ag-ab cross placenta → lupus sx; anti-SSA attacks fetal heart → 3° AV block hypercoagulability in SLE or other collagen-vascular dz → high-risk for venous (DVT, PE) and arterial clots (stroke, MI), recurrent abortions digital vasospasm → fingertips go from blue-to-white-to-red severe, widespread fibrosis of skin (sclerodactyly) and viscera Calcinosis of fingers, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly (only face and fingers), and Telangiectasias (over fingers) autoimmune attack of salivary and lacrimal glands → dry eyes, dry mouth, arthritis “overlap syndrome” of SLE, RA, scleroderma, polymyositis

Management • Dx screen w/ ANA, confirm w/ anti-dsDNA, • anti-Sm, or ↓C3-C5 • Tx low-dose aspirin, corticosteroids for flares, • cyclophosphamide for lupus nephritis

Other MC pts: Af-American women

• Dx anti-histone • Tx d/c meds

Etiology: HIPP – Hydralazine, INH, Procainamide, Phenytoin

• Tx close management during prenatal care

• Dx lupus anticoagulant or anticardiolipin ab • Tx anticoagulation (warfarin)

• Tx underlying disorder, keep hands warm, • Ca-blockers if severe • Dx anti-Scl-70 (anti-topoisomerase) • Tx palliative care • Dx anti-Centromere • Tx palliative care

• Dx anti-SSA/SSB (anti-Ro/La) • Tx pilocarpine, artifical tears, oral hygiene • Dx anti-U1-RNP • Tx predominant dz

MEDICINE × MSK ARTHRITIS

Dz Osteoarthritis

Rheumatoid arthritis

Gout

Pseudogout (CPPD)

MYOSITIS

Dermatomyositis

Inclusion body myositis Polymyalgia rheumatica

Fibromyalgia

SPONDYLOARTHROPATHY

Joints: weight-bearing joints (hips, knees, spine), PIP+DIP (Heberden, Bouchard) type 3 HS → symmetric polyarthritis w/ morning stiffness, rheumatoid nodules Joints: wrists (ulnar deviation), MCP+PIP (Boutonniere, swan neck, Z-thumb deformities) cold, stress, EtOH, red meat → hyperuricemia → MSU deposits in joints → sudden-onset monoarthritis (e.g. podagra), chronic tophi

Management • Dx X-ray (joint space narrowing, osteophytes • aka bone spurs, sclerosis, subchondral cysts) • Tx weight loss + physical therapy (1st line), • acetaminophen/NSAIDs (2nd line), steroid • injections (3rd line), joint replacement (4th line)

Other Risk factors: old age, obesity, joint overuse, trauma

• Dx ↑RF, ↑anti-CCP , X-ray (joint space • narrowing, bony erosions) • Tx NSAIDs or low-dose steroids (for pain); • MTX, hydroxychloroquine, TNFα-blockers

Felty syndrome: RA + neutropenia + splenomegaly Juvenile RA: RA before 18 y/o

• Dx arthrocentesis (needle-shaped, negatively • birefringent yellow crystals) • Tx indomethacin > colchicine (acute attacks), • probenecid or allopurinol (chronic ppx)

Etiology: ↓uric acid excretion (90%), ↑uric acid production (10%)

calcium pyrophosphate deposits in joints → suddenonset monoarthritis

• Dx arthrocentesis (rhomboid-shaped, weakly • positively birefringent blue crystals) • Tx indomethacin > colchicine (acute attacks) + • Tx underlying cause

Presentation hip and shoulder muscle weakness ± pain hip and shoulder muscle weakness ± pain, skin rashes (heliotrope rash, Gottron papules, V sign, shawl sign) symmetrical proximal and distal muscle weakness hip and shoulder muscle pain w/o weakness, profound morning stiffness widespread muscle pain and stiffness associated w/ trigger points

Management • Dx ↑CK, anti-Jo-1, muscle bx • Tx steroids • Dx ↑CK, anti-Jo-1, muscle bx • Tx steroids

Lesch-Nyhan syndrome: AR ∆HGPRT → gout, self-mutilation, yellow sand in diapers

-myositis: weakness, may have pain -myalgia: pain, no weakness Dz Polymyositis

SERONEGATIVE

Presentation wear-and-tear of joints → degeneration of cartilage → deep, dull joint pain, worse w/ activity and improved w/ rest

Other

Complications: ovarian cancer

• Dx slightly ↑CK, muscle bx • Tx steroids • Dx ↑ESR (CK is normal) • Tx steroids

Complications: aortic aneurysms, temporal arteritis

• Dx PE (multiple trigger points) • Tx SSRIs, CBT

Complications: depression, anxiety, axis II diagnoses

Seronegative spondyloarthropathies: PAIR – Psoriatic arthritis, Ankylosing spondylitis, IBD, Reiter syndrome Common features: inflammatory oligoarthritis, negative RF, HLA-B27 association Dz Ankylosing spondylitis

Reiter syndrome (reactive arthritis)

Psoriatic arthritis

Presentation bilateral sacroiliitis + gradualonset upward fusion of spine + enthesitis (pain at tendon attachment sites) triad of anterior uveitis, urethritis, arthritis (“can’t see, can’t pee, can’t climb a tree”) following a bacterial GI infx (Salmonella, Shigella, Campy, Chlamydia, Yersinia) asymmetric polyarthritis in 10% of psoriasis pts, usually fingers

Management • Dx X-ray (bamboo spine) • Tx NSAIDs + physical therapy

Other Complications: restrictive lung dz, cauda equina syndrome, spine fx w/ spinal cord damage, osteoporosis, spondylodiscitis

• Dx joint aspiration (r/o infx arthritis) • Tx NSAIDs

• Dx X-ray (pencil-in-cup deformity) • Tx NSAIDs

Complications: dactylitis (sausage fingers)

MEDICINE × MSK VASCULITIS

Small vessel vasculitis: type 3 HS, “palpable purpura” Muscular artery vasculitis: claudication/infarction Elastic artery vasculitis: granulomatous dz, pulselessness Dz Temporal arteritis (giant cell arteritis) Takayasu arteritis Polyarteritis nodosa

Buerger disease (thromboangiitis obliterans) Behçet syndrome Churg-Strauss syndrome Wegener granulomatosis

Hypersensitivity vasculitis

Presentation elderly pt w/ unilateral headache, jaw claudication, visual changes young Asian woman w/ absent pulses and asymmetrical BP vasculitis of renal and visceral vx → abd pain (bowel angina), fatigue, joint pain, renal failure; associated w/ HBV infx smokers w/ gangrene and autoamputation of fingers/toes recurrent oral and genital ulcers, arthritis, uveitis, CNS sx triad of asthma + eosinophilia + granulomatous vasculitis triad of necrotizing vasculitis, necrotizing granulomas in lungs and upper respiratory tract, and necrotizing glomerulonephritis → hematuria + hemoptysis drug-induced type 3 HS → palpable purpura

Management • Dx ↑ESR • Tx emergent high-dose steroids (can become • blind if you wait too long) • Dx arteriogram • Tx steroids, angioplasty for stenosed vx • Dx tissue bx, ↑P-ANCA • Tx steroids

• Tx smoking cessation • Dx tissue bx • Tx steroids • Dx tissue bx, ↑P-ANCA • Tx steroids • Dx tissue bx (necrotizing granulomas), • ↑C-ANCA • Tx cyclophosphamide

• Dx tissue bx • Tx steroids, d/c meds

Other Complications: polymyalgia rheumatica, blindness, aortic aneurysms

MEDICINE × RENAL URINALYSIS

↑protein: proteinuria >150 mg/day, nephrotic syndrome >3.5 g/day ↑albumin: microalbuminuria is earliest sign of diabetic nephropathy ↑glucose: diabetes ↑RBC: microscopic hematuria >3 RBC/HPF, gross hematuria visible to naked eye ↑ketones: DKA or starvation ↑nitrites: indicates bacteria in urine ↑LE: indicates WBC in urine ↑eosinophils: acute interstitial nephritis RBC casts: glomerulonephritis, ischemia, or malignant HTN WBC casts: pyelonephritis, tubulointerstitial dz, or txp rejection Granular casts: acute tubular necrosis (ATN) Broad waxy casts: CRF w/ dilated ducts Fatty casts: nephrotic syndrome Hyaline casts: nonspecific

RENAL FAILURE

BUN: normally reabsorbed, can’t be reabsorbed if kidney is damaged Azotemia: ↑BUN Uremia: ↑BUN w/ sx (usually BUN >60) Cr: freely filtered and not reabsorbed, measure of GFR Acute renal failure: rapid decline in renal fxn → ↑BUN, ↑creatinine Oliguric phase: UOP <500 mL/day, lasts 10-14 days Diuretic phase: UOP >500 mL/day, due to diuresis of retained fluids/electrolytes Recovery phase: recovery of tubular function

Etiology

Urine osm Urine Na+ FENa BUN/Cr

Prerenal ARF ↓renal blood flow → ↓GFR (hypotension, CHF, etc.) >500 <10 <1% >20:1

Intrinsic ARF damage to renal parenchyma (ATN, toxins, glomerulonephritis, etc.) <350 >20 >2% <15:1

Postrenal ARF bilateral urinary tract obstruction (stones, BPH, cancer, etc.) <350 >40 >4% >15:1

Ischemic ATN: ↓renal blood flow → proximal/distal tubules don’t enough O2 for Na/K pump → cell death → ARF Nephrotoxic ATN: toxin-mediated damage to proximal tubules → cell death → ARF (e.g. IV dye, gentamycin, Hb/Mb) Chronic renal failure: irreversible, progressive reduction in GFR Etiology: DM (#1), HTN (#2), chronic glomerulonephritis (#3) Stages: stage 1 GFR 90-100 stage 2 GFR 60-89 stage 3 GFR 30-59 stage 4 GFR 15-29 stage 5 GFR <15 or dialysis (aka ESRD) ARF/CRF complications: ↓GFR → electrolyte retention → ↑Na, ↑K, ↑H → HTN, CHF uremia → n/v, pericarditis, asterixis, encephalopathy, platelet dysfxn ↓EPO → normocytic anemia ↓vit D → renal osteodystrophy, 2° HPTH, calciphylaxis

DIALYSIS

Dialysis: artifical removal of electrolytes/toxins from blood Dialysate: articifial solution that resembles human plasma Indications: AEIOU – Acidosis (severe metabolic acidosis) Electrolytes (severe hyperkalemia) Intoxication (methanol, ethylene glycol, lithium, aspirin) Overload (severe hypervolemia) Uremia (severe uremia, pericarditis, BUN >150) Limitations: doesn’t help w/ kidney synthetic functions (e.g. EPO, vitamin D)

Method

Frequency Advantages Disadvantages

Hemodialysis blood from AV fistula pumped through dialyzer, filtrated, then sent back into pt body MWF or TuThSa  faster/more efficienct  can be initiated quickly  risk of removing too much  fluid or electrolytes  requires vascular access  “first-use syndrome” –  chest and back pain, rare  anaphylaxis w/ new machine

Peritoneal dialysis high-glucose dialysate infused into peritoneal cavity, then drained from abdomen q 4-8 hrs  mimics normal kidney fxn  self-dialysis  risk of hyperglycemia  risk of peritonitis  increased abdominal girth

MEDICINE × RENAL PROTEINURIA AND HEMATURIA

Dz Proteinuria

Hematuria

Presentation >150 mg protein/24 hr

Microscopic hematuria: >3 RBC/HPF Gross hematuria: visible to naked eye

Nephritic vs. nephrOtic syndrome: Etiology Sx

Glomeruli Casts

GLOMERULAR DZ

Management • Dx screen w/ dipstick and UA, then get 24 hr • urine collection • asx/transient → reassurance • asx/persistent → Dx check BP and examine • urine sediment; Tx underlying cause • sx → Tx underlying cause + ACE inhibitors • Dx screen w/ dipstick and UA, then get • imaging of upper/lower urinary tracts • Tx underlying cause

Nephritic syndrome glomerular inflammation - hematuria - oliguria - HTN - azotemia - proteinuria (<3.5 g) hypercellular RBC casts

Other

Etiology: glomerular dz Etiology: postrenal causes (trauma, stones, cancer)

NephrOtic syndrome loss of GBM negative charge - proteinuria (>3.5 g) - edema - hypoalbuminemia - hyperlipidemia - hypercoagulability normo-/hypocellular fatty casts

Nephritic syndrome × chronic pain: analgesic nephropathy Nephritic syndrome × hemoptysis: Goodpasture, Wegener Nephritic syndrome × s/p strep throat: post-strep GN NephrOtic syndrome × deafness/blindness: Alport syndrome NephrOtic syndrome × kids: minimal change dz NephrOtic syndrome × HBV: MGN NephrOtic syndrome × HCV: MPGN NephrOtic syndrome × HIV: FSGS NephrOtic syndrome × Hodgkin lymphoma: minimal change dz Dz Minimal change dz FSGS Membranous glomerulonephritis (MGN) IgA nephropathy (Berger’s dz)

Alport syndrome

Diabetic nephropathy

Presentation nephrOtic syndrome in kids following a viral infx nephrOtic syndrome in adults and HIV+ pts, steroid-resistant nephrOtic syndrome in adults; associated w/ drugs, infx, SLE, and solid tumors nephritic syndrome following URI or gastroenteritis; associated w/ Henoch-Schonlein (palpable) purpura in kids XR ∆type 4 collagen → split GBM (nephritic and nephrOtic syndromes), deafness, ocular and nerve disorders nephrOtic syndrome in DM pts

HTN nephropathy Lupus nephropathy

nephrOtic syndrome in HTN pts ag-ab deposits → nephritic syndrome in SLE pts

Membranoproliferative glomerulonephritis (MPGN) Poststreptococcal GN

nephrOtic syndrome in HCV+ pts coke-colored urine and periorbital edema in a kid w/ strep throat or cellulitis anti-GBM → attacks glomeruli and alveoli → hematuria + hemoptysis

Goodpasture syndrome

Management • Dx EM (foot process effacement) • Tx steroids • Dx LM (segmental sclerosis) • Dx LM (diffuse GBM thickening), EM (“spike • and dome” appearance) • Dx LM (mesangial deposits), IF (IgA stain)

• Dx family hx

• Dx microalbuminuria, LM (mesangial • expansion, Kimmelsteil-Wilson nodules) • Tx ACE inhibitors • Tx underlying HTN • Dx LM (“wire loops”), EM (subendothelial • deposits), IF (“full house”) • Tx underlying SLE • Dx EM (“tram tracks” or “dense deposits”) • Dx ↑ASO, LM (“lumpy-bumpy” appearance) • Tx reassurance • Dx LM (crescent shaped), IF (linear staining)

Other

MEDICINE × RENAL TUBULOINTERSTITIAL DZ

Dz Acute interstitial nephritis (AIN) Chronic interstitial nephritis

Renal papillary necrosis

Renal tubular acidosis (RTA)

Hartnup syndrome

Fanconi syndrome

RENAL CYSTIC DZ

Dz Adult polycystic kidney dz (ADPKD)

Medullary sponge kidney

Simple renal cysts

RENAL VASCULAR DZ

Dz RA stenosis (renovascular HTN)

RV thrombosis

Hypertensive nephrosclerosis

Sickle cell nephropathy

Presentation drug allergy → acute renal railure, rash, fever, eosinophilia slowly progressive nephritis → asx, but can lead to progressive scarring, renal failure, and ESRD damage to renal papillae → necrosis → slough off and cause ureteral obstruction

Management • Dx UA (eosinophuria) • Tx d/c meds ---

Other Etiology: gentamycin, IV dye, Hb/Mb

• Dx excretory urogram • Tx underlying cause

Etiology: analgesic nephropathy (chronic NSAID/Tylenol use), diabetic nephropathy, sickle cell, obstruction, txp rejection

Type 1 (distal) RTA: collecting duct can’t excrete H+ → metabolic acidosis, hypo-K, nephrolithiasis, alkaline urine Type 2 (proximal) RTA: proximal tubule can’t reabsorb HCO3- → metabolic acidosis, hypo-K, hypophosphatemic rickets, alkaline urine Type 3 RTA: type 1 + type 2 Type 4 (hyper-K) RTA: either hypoaldosteronism or lack of response to aldosterone → metabolic acidosis, hyper-K, acidic urine AR ∆neutral amino acid transporter → ↓neutral amino acids → ↓tryptophan for niacin synthesis → pellagra (3 Ds – diarrhea, dermatitis, dementia) proximal tubule dysfxn → defective transport of glucose, amino acids, HCO3-, phosphate → glucosuria, aminoaciduria, type 2 RTA, hypophosphatemic rickets, etc.

• Tx IV HCO3-

Presentation AD ∆APKD1/2 → multiple, large bilateral cysts that can destroy renal parenchyma → renal failure, HTN, berry aneurysms, liver cysts cystic dilation of collecting ducts → resembles sponge in medulla → hematuria, recurrent UTIs, kidney stones benign incidental finding

Management • Dx renal U/S (multiple large cysts) • no tx available

Presentation RA stenosis → ↓renal blood flow → kidney thinks you’re hypotensive → RAA system → HTN, abdominal bruits, ↓renal function intrinsic clot or extrinsic compression → ↓renal blood outflow → flank pain, HTN, hematuria, proteinuria Benign nephrosclerosis: hyaline arteriolosclerosis in chronic HTN Malignant nephrosclerosis: hyperplastic (“onion skin”) arteriolosclerosis in rapidly progressive HTN recurrent sickling → papillary infarction → eventual papillary necrosis, renal failure, UTIs

Management • Dx renal arteriogram (if pt is in renal failure, • use MRA instead since dye is nephrotoxic) • Tx angioplasty

• Tx underlying cause

--• Tx fludrocortisone

• Tx niacin replacement

• Tx electrolyte replacement

Other

• Dx IV pyelo (sponge-like calyx) • no tx available

• leave it alone

• Dx renal venography • Tx underlying cause

• Tx BP control, sodium nitroprusside for • malignant HTN

• Tx ACE inhibitors (w/ hydroxyurea for SCD)

Other Etiology: fibromuscular dysplasia (young women), atherosclerosis (old men)

MEDICINE × RENAL STONES/OBSTRUCTIONS

Dz Nephrolithiasis (kidney stones)

Urinary tract obstruction

GU NEOPLASMS

OTHER GU DZ

Presentation colicky flank pain ± radiation to groin, hematuria, n/v Calcium stones: most common type, 2/2 hypercalciuria or hyperoxaluria Uric acid stones: radiolUcent (rest are all radioopaque), 2/2 gout or tumor lysis syndrome Struvite stones: 2/2 urease+ bugs (P. mirabilis), can form large staghorn caliculi Cystine stones: 2/2 cystinuria colicky flank pain ± radiation to groin (if acute), asx (if chronic)

Dz Prostate cancer

Presentation usually asx, “elderly man w/ low back pain” if invasive

Renal cell carcinoma (RCC)

Bladder cancer

abdominal mass, flank pain, hematuria, and paraneoplastic syndromes (PAPER – PTH-rP, ACTH, prolactin, EPO, renin) painless hematuria

Testicular cancer

firm, painless testicular mass

Penile cancer

exophytic penile mass in a noncircumcised dirty old man

Dz Testicular torsion

Presentation twisting of spermatic cord → severe testicular pain + “high riding testicle w/ horizontal lie” presents like testicular torsion, but w/ fever, pyuria, and cord is also tender

Epididymitis

Management • Dx KUB • Tx analgesics + fluids (<0.5 cm), shockwave • lithotripsy (0.5 – 2 cm), percutaneous • nephrolithotomy (≥2 cm) • recurrent calcium stones → PPx HCTZ • uric acid stones → PPx allopurinol, Tx • potassium citrate • cystine stones → Dx urinary sodium nitro• prusside test, Tx acetazolamide

Other Hematuria + pyuria: stone w/ concomitant UTI Kidney stone diet: high fluids (#1), low sodium, low protein, high calcium (counterintuitive), low oxalate

• Dx renal U/S (shows dilation), then IV pyelo • Tx underlying cause

MC location: ureteropelvic jxn Complications: renal insufficiency, hydronephrosis

Management • Dx screen w/ PSA (≥10) or DRE (firm nodule); • confirm w/ U/S-guided needle bx • Tx radical prostatectomy (local), radiation + • flutamide + leuprolide (invasive) • Dx abdominal CT • Tx radical nephrectomy

Other Cancers that rarely metastasize: prostate, esophageal, skin (nonmelanoma), oropharyngeal

• Dx IV pyelo + cystoscopy w/ bx • Tx resection + close f/u for high recurrence

Risk factors: Pee SAC – pain killer abuse, smoking (#1), aniline dyes, cyclophosphamide Bladder SCC: Schistosoma haematobium

• Dx transillumination (doesn’t light up), • testicular U/S (solid mass) • Tx radical orchiectomy, then CT chest/A/P for • staging, then radiation (if seminoma), • retroperitoneal LN-ectomy (if nonseminoma) • f/u αFP + βHCG levels • Dx skin bx • Tx local excision

Management • Tx emergent surgical detorsion, then • orchipexy (don’t waste time on dx tests) • Dx U/S to r/o torsion • Tx abx

Risk factors: smoking (#1), obesity Bilateral RCC: von Hippel-Lindau

Etiology: HPV-16/18 infx

Other Cremasteric reflex: stroking of inner thigh causes elevation of testicle; absent w/ torsion Etiology: GC or CT in young men, E. coli in kids and elderly

Cystine Uric acid crystal crystal

Cystine crystals

(think gout or TLS)

Uric acid crystals

(think Proteus mirabilis)

Struvite crystal

Oval calcium oxalate crystals

Calcium oxalate crystals

RBCs

Budding yeast

(think CRF w/ dilated ducts)

Broad waxy cast Granular casts

Normal RBC Ghost RBC Crenated RBC Normal RBC

(think nephritic syndrome)

RBC casts (think acute pyelonephritis)

WBC casts

PMNs

Subepi Humps

Granular CapillaryIgG/C3

EM

IF

Light

Nephritic Dz PostInfx

MSG Deposits

Granular MSG IgA

IgA Neprho

MSG HyperCellular -ity

Subepi

Full House:

Class III/IV

SLE Class II

Subendo

“Wire Loops”

Crescents + Fibrin

Normal

Linear Capillary IgG/C3

Anti-GBM

EM

IF

Light

Normal

Normal

Minimal Change

Nephrotic Dz

Foot process effacement

Normal

Segmental Sclerosis

FSGS

Granular Capillary IgG

Pseudolinear Capillary IgG

Art. Hyalinosis

Diabetic Neph

Nodular MSG Expansion

Spikes&Holes in BM

Subepi Deposits

Thick Cap walls

MembranousNeph

Thick GBM

Nodulesl

MEDICINE × FEN FLUIDS

60-40-20 rule: 60% of body weight is water, 40% is ICF, 20% is ECF (5% plasma, 15% ISF) Starling forces: hydrostatic pressure drives fluid into ISF, oncotic pressure sucks it back out Blood osmolarity: 2×Na + BUN/2.8 + gluc/18; normally 285-300 mOsm/L Urine osmolarity: 70-1200 mOsm/L, controlled by ADH Urine output: normally 0.5-1.0 mL/kg/hr IV fluids: NS, LR, D5½NS, D5W NS: good for dehydrated pts LR: good for trauma pts D5½NS: standard maintenance fluid D5W: good for hypernatremic pts 100-50-20 rule: maintenance fluids for 24 hrs (100 mL/kg for first 10 kg, then 50 for next 10 kg, then 20 for each kg over) 4-2-1 rule: maintenance fluids for 1 hr (4 mL/kg for first 10 kg, then 2 for next 10 kg, then 1 for each kg over)

ELECTROLYTES

ADH: causes water reabsorption (V2, aquaporins) and vasoconstriction (V1) Aldosterone: causes ↑Na, ↓K, ↓H PTH: causes ↑Ca, ↓P, ↑vit D Calcitonin: causes ↓Ca, ↓P Vit D: causes ↑Ca, ↑P Imbalance Hypernatremia

Etiology water loss due to 6 Ds – Diuresis, Dehydration, Diabetes insipidus, Docs (iatrogenic), Diarrhea, Diseases SIADH (MCC)

Presentation thirst and signs of volume depletion (slow) or ∆MS (rapid)

Management • Tx PO fluids > IV fluids (correct gradually due • to risk of cerebral edema)

confusion, coma, convulsions

Hyperkalemia

renal failure, K-sparing diuretics, release from dead tissue (crush injury, ischemic bowel, etc.)

nausea/vomiting, intestinal colic, weakness

Hypokalemia

diarrhea, vomiting, diuretics

Hypercalcemia

hyperparathyroidism (MCC outpt), cancer (MCC inpt)

Hypocalcemia

hypoparathyroidism (MCC)

weakness, muscle cramps, ileus, digoxin toxicity (K and dig compete for same Na/K receptors on heart) stones (kidney), bones (bone pain, osteitis fibrosa cystica), groans (PUD, pancreatitis), psychic overtones (depression, anxiety, ∆MS) neuromuscular irritability (tingling, tetany), arrhythmias, Chvostek and Trousseau signs

• Tx water restriction + NS (correct gradually • due to risk of central pontine myelinolysis) • first, confirm w/ repeat blood draw • Dx EKG (peaked T waves, sine waves) • Tx C BIG K DIE – calcium gluconate, bicarb • insulin-glucose, kayexalate, dialysis (if severe) • Dx EKG (scooped T waves) • Tx KCl (<10 mEq/hr)

Hyponatremia

Hypermagnesemia Hypomagnesemia Hyperphosphatemia Hypophosphatemia

ACID-BASE

renal failure (MCC) alcoholism (MCC), DKA renal failure (MCC) alcoholism (MCC), DKA

Acid-base algorithm: CO2 <40 CO2 >40

pH <7.4 met acidosis* resp acidosis

delirium, ↓DTRs, cardiac arrest refractory hypo-K kidney stones, metastatic calcifications rickets, osteomalacia

• Dx EKG (short QT) • Tx “flush and drain” (NS + furosemide), • bisphosphonates if mild • confirm w/ corrected Ca = [measured Ca + • 0.8 x (4 – albumin)] • Dx EKG (prolonged QT) • Tx vit D + calcium replacement • Tx IV calcium gluconate + NS + furosemide • Tx mag replacement • Tx antacids (binds phosphate in GI tract) • Tx phos replacement

pH >7.4 resp alkalosis met alkalosis

*if met acidosis, calculate anion gap (Na+ – (Cl- + HCO3-)), nl 8-12

Respiratory acidosis Respiratory alkalosis Anion-gap metabolic acidosis

Non anion-gap metabolic acidosis Metabolic alkalosis

Causes hypoventilation hyperventilation 2/2 pain, fever, sepsis, or early ARDS MUDPILES – Methanol, Uremia, DKA, Paraldehyde, Iron, INH, Lactic acidosis, Ethylene glycol, Salicylates diarrhea, glue sniffing, RTA, hyperchloremia vomiting, diuretics, antacids, hyperaldosteronism

Management Tx mechanical ventilation Tx underlying cause Tx underlying cause

Tx underlying cause Tx chloride or potassium replacement

pH changes: CO2 ↑10 → pH ↓0.08 HCO3 ↑10 → pH ↑0.15 Post-ictal AGMA: will resolve on its own in 60-90 minutes, recheck labs then Aspirin overdose: tinnitus, fever, hyperventilation → respiratory alkalosis (early), metabolic acidosis (late) Iron overdose: AGMA, shock, abdominal pain, UGIB

MEDICINE × HEM/ONC TRANSFUSION

PRBCs: Hb +1, Hct +3; indicated if Hb ≤7 or acute bleed Platelets: platelets +10,000 FFP: contains clotting factors 1-12; ↓PT, ↓PTT Cryoprecipitate: contains factors 1+8 only; ↓PTT Whole blood: contains everything, rarely used

RBC PANEL

MCV: RBC size, normally 80-100 Ferritin: iron levels in blood TIBC: transferrin levels (protein that binds ferritin); serum ferritin has a negative feedback on TIBC levels RDW: variability in RBC size; characteristic ↓RDW in thalassemias RI: measure of immature RBCs; <2% indicates impaired bone marrow function LDH: enzyme of anaerobyic glycolysis; ↑ w/ intravascular hemolysis or tissue hypoxia Haptoglobin: enzyme in blood that binds free Hb; ↓ w/ intravascular hemolysis Schistocytes + helmet cells: indicates hemolytic anemia Coombs test: detects antibody or complement on RBCs

ANEMIA

Anemia? microcytic (MCV <80)

normocytic (MCV 80-100)

macrocytic (MCV >100)

IDA (↑TIBC) ACD (↓TIBC) thalassemias (↓RDW) sideroblastic anemia

folate deficiency B12 deficiency reticulocytosis

calculate reticulocyte index (retic count × hct/45) impaired erythropoiesis (RI <2%) acute hemorrhage acute IDA or ACD aplastic anemia anemia of CRF (↓EPO)

normal erythropoiesis (RI >2%) intrinsic RBC defects

extrinsic RBC defects

membrane defects (PNH, spherocytosis) abnormal hemoglobin (sickle cell) deficient enzymes (G6PD, PK)

AIHA prosthetic valves MAHA chronic hemorrhage

Anemia sx: conjunctival pallor, headache, fatigue; ↑HR/↓BP if severe Pseudoanemia: ↓Hb/↓Hct/↓WBC/↓plt secondary to dilution (e.g. fluid overload) Dz Iron-deficiency anemia (IDA)

Presentation (typical anemia sx)

Management • Dx RBC panel (MCV <80, ↓Fe, ↑TIBC, ↑RDW) • Tx underlying cause + PO iron supplements

Anemia of chronic disease (ACD) β-thalassemia

(typical anemia sx)

• Dx RBC panel (MCV <80, ↑Fe, ↓TIBC, ↑RDW) • Tx underlying cause • Dx RBC panel (MCV <80, ↓RDW); confirm w/ • Hb electrophoresis • Tx reassurance • Dx RBC panel (MCV <80, ↓RDW); confirm w/ • Hb electrophoresis (↑HbF) • Tx frequent transfusions ---

β-thal minor: heterozygous ∆β-chain → mild anemia sx β-thal major: homozygous ∆β-chain → severe anemia sx

α-thalassemia

Sideroblastic anemia

Aplastic anemia

Folate deficiency

Vit B12 deficiency

Silent carrier: 1-2 α-chain deletion → asx HbH disease: 3 α-chain deletion → severe anemia sx Barts disease: 1-2 α-chain deletion → fetal hydrops biochemical abnormalities → iron gets stuck in mitochondria → can’t make Hb → anemia sx bone marrow failure → pancytopenia (anemia, neutropenia, thrombocytopenia) → anemia sx + ↑infx + petechiae ↓folate → ↓methionine (RBC) → anemia sx, glossitis ↓vit B12 → ↓methionine (RBC) + impaired FA synthesis (myelin) → anemia sx, glossitis, peripheral neuropathy

Other Etiology: Meckel diverticulum (MCC kids), menorrhagia (MCC women), peptic ulcers (MCC men), colon cancer (MCC elderly) Etiology: cancer, chronic infx, systemic inflammation, trauma

• Dx RBC panel (MCV <80, ↓RDW); confirm w/ • Hb electrophoresis (↑HbH) • Tx frequent transfusions • Dx post-mortem autopsy • Dx blood smear (ringed sideroblasts) • Tx underlying cause, vit B6 supplements

Etiology: lead poisoning, vit B6 deficiency, INH or EtOH use

• Dx CBC (↓RBC, ↓WBC, ↓plt); confirm w/ bone • marrow bx • Tx transfusions, bone marrow txp

Fanconi anemia: aplastic anemia + short stature, hypopigmented areas, eye/ear deformities

• Dx RBC panel (MCV >100), hypersegmented • neutrophils, ↓folate • Tx underlying cause, folate supplements • Dx RBC panel (MCV >100), hypersegmented • neutrophils, ↓vit B12; DDx w/ Schilling test • Tx underlying cause, vit B12 injections

Folate source: leafy vegetables Etiology: “tea and toast” diet, alcoholics, phenytoin or MTX use Vit B12 source: meats Etiology: pernicious anemia (lack of IF), s/p gastrectomy, strict vegans, terminal ileal dz (Crohn), D. latum fish tapeworm

MEDICINE × HEM/ONC HEMOLYTIC ANEMIA

Intravascular hemolysis: ABO-mismatched blood → hemolysis within blood stream → immediate fever/chills, nausea, vomiting, chest and flank pain, dyspnea → risk of hypovolemic shock, DIC, renal failure Extravascular hemolysis: minor antigen-mismatched blood (e.g. Kell) → delayed hemolysis within spleen → mild fever, jaundice, anemia Dz Sickle cell disease

Hereditary spherocytosis

G6PD deficiency

Autoimmune hemolytic anemia (AIHA)

Paroxysmal nocturnal hemoglobinuria (PNH)

PLATELET D/O

Platelet range: >750 >450 150-450 <150 <70 <20 <5

Presentation AR ∆HbE6V (β-chain) → sickling of RBCs w/ ↓O2 conditions → small vessel occlusion → extravascular hemolysis, painful vasoocclusive crises, autosplenic infarction AR ∆spectrin → spherical RBCs get stuck in spleen → extravascular hemolysis XR ∆G6PD → ↓glutathione for handling oxidant stressors → intravascular hemolysis, back pain, hemoglobinuria in men Warm AIHA: IgG against RBC → chronic, extravascular hemolysis Cold AIHA: IgM against RBC → acute, intravascular hemolysis triggered by cold acquired ∆DAF → lack of complement inactivation on RBCs → hemolytic anemia + hepatic vein thromboses

Management • Dx blood smear (sickled RBCs), confirm w/ Hb • electrophoresis • Tx avoid crises + hydroxyurea (↑HbF) + early • SHiN vaccination

• Dx osmotic fragility test • Tx splenectomy • Dx blood smear (Heinz bodies, bite cells) • Tx avoid precipitants

• Dx Coombs test (coating w/ IgG is warm, • complement is cold) • Tx steroids (warm), avoid cold exposure (cold)

Other Sickle cell trait: painless hematuria in young black male Splenic sequestration crisis: sudden, rapid pooling of blood into spleen → splenomegaly, hypovolemic shock, death Aplastic crisis: spherocytosis + parvovirus B19 infx, prevent w/ folic acid supplements Etiology: sulfa drugs, antimalarials, infx, fava beans

AIHA × lymphoma: CLL is a trigger for both warm/cold AIHA AIHA × PNA: Mycoplasma pneumoniae is a trigger for cold AIHA

• Dx ↑urine hemosiderin • Tx steroids, bone marrow txp

↑risk of clots thrombocytosis by definition normal thrombocytopenia by definition ↑risk of bleeding during surgery/trauma petechiae major spontaneous bleeding

Thrombocytopenia sx w/ normal plt count: aspirin or NSAID use Dz Thrombocytopenia Heparin-induced thrombocytopenia (HIT)

Idiopathic thrombocytopenic purpura (ITP) Thrombotic thrombocytopenic purpura (TTP)

Bernard-Soulier syndrome Glanzmann thrombasthenia

Presentation plt <150,000; most common sx is petechiae HIT type 1: heparin directly causes platelet aggregation, within 0-2 days HIT type 2: heparin induces auto-antibodies against platelet factor 4, after 3-12 days auto-antibodies against gpIIb/IIIa → platelet clearance → petechiae, ecchymoses, etc. HUS: tons of clots form in small vx (e.g. renal vx) → microangiopathic hemolytic anemia + thrombocytopenia + renal failure TTP: HUS + fever + ∆MS AR ∆gpIb → platelets can’t adhere to subendothelium AR ∆gpIIb/IIIa → platelets can’t aggregate

Management • Tx underlying cause, plt transfusion (severe)

Other Asx thrombocytopenia: consider HIV testing

• Tx reassurance

• Tx d/c heparin

• Dx plt <20, ↑megakaryocytes • Tx steroids, plt transfusion then splenectomy • (severe) • Dx CBC (↓plt, ↓RBC) + blood smear • (schistocytes) • Tx emergent plasmapheresis

-----

HUS × diarrhea: EHEC (O157:H7)

MEDICINE × HEM/ONC COAGULATION

PTT: measures intrinsic pathway (12→→1) PT/INR: measures extrinsic pathway (7→→1) Thrombin time: measures fibrinogen levels (2→1) Bleeding time: measures platelet function Shortest T½: factor 7

ANTICOAGULATION

Heparin: potentiates AT-III to inhibit factors 2/10 → ↑PTT Heparin side-effects: bleeding, HIT, osteoporosis Heparin reversal: protamine sulfate LMWH: longer T½, less side-effects, but more $$$ Warfarin: blocks vitamin K from activating factors 2/7/9/10/C/S → ↑PT/INR Warfarin side-effects: bleeding, skin necroses (d/t protein C/S), teratogen Warfarin reversal: vit K if mild, FFP if severe tPA: activates plasmin to break down existing clots tPA side-effects: severe bleeding (c/i in active bleed, recent surg, prior ICH) tPA reversal: aminocaproid acid Therapeutic INR: 2-3 normally, 2.5-3.5 for prosthetic valves

COAGULATION D/O

Dz von Willebrand disease (vWD)

Management • Dx ↓/∆/no vWF, ↑bleeding time • Tx DDAVP (types 1-2), factor 8 concentrate • (refractory type 2, type 3)

Other

Hemophilia A (classic hemophilia)

Presentation vWD type 1: AD ↓vWF → bleeding diathesis vWD type 2: AD ∆vWF → bleeding diathesis vWD type 3: AD lack of vWF → severe bleeding diathesis XR ∆factor 8 → hemarthroses, hematomas, and ICH in men

• Dx ↑PTT, ↓factor 8 • Tx factor 8 concentrate; analgesia + RICE (for • acute hemarthroses)

Hemophilia A vs. factor 8 inhibitor: mix pt’s plasma w/ normal plasma; if PTT fails to normalize, then factor 8 inhibitor

Hemophilia B (Christmas disease)

XR ∆factor 9 → hemarthroses, hematomas, and ICH in men

Disseminated intravascular coagulation (DIC)

abnl activation of clotting factors → microthrombi all over blood stream → run out of factors → bleed out → die ↓vit K → can’t γ-carboxylate factors 2/7/9/10/C/S → bleeding diathesis

• Dx ↑PTT, ↓factor 9 • Tx factor 9 concentrate; analgesia + RICE (for • acute hemarthroses) • Dx ↑PT/↑PTT, ↑D-dimer, ↓fibrinogen, ↓plt, • blood smear (schistocytes) • Tx underlying cause, supportive measures

Vit K deficiency

Coagulopathy of liver disease AT-III deficiency

Factor V leiden

liver can’t make coagulation factors → bleeding diathesis can’t break down factors 2-12 → hypercoagulability that doesn’t respond to heparin protein C can’t block factor 5 → hypercoagulability

• Dx ↑PT/↑PTT, everything else is nl • Tx vit K supplements, FFP if severe

• Dx ↑PT/↑PTT, ↓fibrinogen, everything else is nl • Tx FFP ---

---

Etiology: G– septic shock (MCC), obstetric complications, cancer, massive burns, rattlesnakes, etc. Vit K source: leafy vegetables, intestinal flora Etiology: critically ill pts that are NPO and on broad-spectrum abx (MCC), fat malabsorption, warfarin overdose, neonates

MEDICINE × HEM/ONC PLASMA CELL D/O

Dz Multiple myeloma

Monocolonal gammopathy of undetermined significance (MGUS) Waldenstrom macroglobulinemia

Presentation monoclonal plasma cell proliferation → makes lots of monoclonal IgG and eats up bone marrow space → CRAB – hyperCalcemia, Renal failure, Anemia, Bone lesions/fx (asx, precursor of myeloma)

monoclonal IgM plasma cell proliferation → ↑IgM → hyperviscosity (IgM is big), anemia, splenomegaly, LNopathy

Management • Dx SPEP (monoclonal spike), urinalysis (Bence • Jones protein), X-ray (punched out lytic bone • lesions), blood smear (rouleaux formation) • Tx chemo/radiation only if symptomatic

Other MCCOD: recurrent lung or urinary tract infx (↓normal IgG)

• Dx SPEP (monoclonal spike), urinalysis (Bence • Jones protein) • Tx close f/u • Dx SPEP (monoclonal spike), urinalysis (Bence • Jones protein), ↑IgM, no bone lesions • no tx exists

Px: <20% convert to myeloma in 10-15 yrs

- painful - small (<2 cm) - rapid onset - mobile - normal site

- Reed-Sternberg cells (CD15+/CD30+) - localized, single group of nodes with contiguous spread - “B” symptoms – fever, night sweats, weight loss - prognosis: stage of disease and HL subtype are most important factors

Hodgkin’s lymphoma

- multiple, peripheral nodes with noncontiguous spread - fewer constitutional “B” symptoms - associated with HIV/immunosuppression

Non-Hodgkin’s lymphoma

- painless - large (>2 cm) - insidious onset - fixed (fibrotic) - unusual site

LYMPHOMA vs. REACTIVE HYPERPLASIA

Is the lymph node swollen due to malignancy or is it an inflammatory process?

T-cell NHL (10-15%)

B-cell NHL (80-85%)

LYMPHOMA

rare RS > lymphocytes

6% RS << lymphocytes

25% RS = lymphocytes

65-75% RS << lymphocytes

high grade

high grade

low grade

low grade

middle grade

high grade

high grade

- older males with disseminated disease - poor prognosis

Lymphocyte-depleted HL

- “popcorn cells” - infrequent classic RS cells - excellent prognosis

Lymphocyte-predominant HL

V - male-dominant - numerous RS cells, EBV association

Mixed cellularity HL

V = viral association

- female-dominant - supraclavicular nodes + anterior mediastinal nodes

Nodular sclerosing HL

- skin lesions with Pautrier’s microabscesses - CD4+ T-cell neoplasm - Sezary syndrome is leukemic phase of mycosis fungoides

Mycosis fungoides

V - adults with aggressive cutaneous lesions - HTLV-1 association

Adult T-cell lymphoma

- H. pylori (stomach), Sjogren’s syndrome (salivary glands)

MALT/extranodal lymphoma

- t(14;18) - overexpression of BCL-2 anti-apoptosis gene

Follicular lymphoma

- t(11;14) - poor prognosis, CD5+

Mantle cell lymphoma

- most common adult NHL - 20% are T-cell origin (counterintuitive)

Diffuse large B-cell lymphoma

V - t(8;14) - EBV association, common childhood NHL - “starry sky” appearanceW - jaw lesion in endemic form in Africa - pelvis/abdomen in sporadic form

Burkitt’s lymphoma

ALL AML/CML CLL

Pre-leukemia

Leukemia

0-14 15-60 60+

(extremely important)

AGE BRACKETS

- <5% blasts - accumulation of mature cells

Chronic leukemias

- >20% blasts - accumulation of immature cells

Acute leukemias

- bone marrow proliferation of myeloid lineages - associated with specific TK abnormalities

Chronic lymphoid neoplasms

myeloid lineage

myeloid lineage

B-cells

B-cells

MKC lineage w/ fibroblasts

MKC lineage

RBC lineage

myeloid lineage

B-cells (90%), T-cells (10%)

Myeloproliferative neoplasms

LEUKEMIA

subtypes

- gum infiltration

Acute monocytic leukemia

- t(15;17), defect in retinoic acid - Tx retinoic acid, possible DIC

Acute promyelocytic leukemia

- severe anemia in elderly - 30% develop AML - ringed sideroblasts

Myelodysplastic syndrome

- positive TRAP stain - splenomegaly - Tx with purine nucleosides

Hairy cell leukemia

- B-cell neoplasm, ↓γ-globulins - MCC generalized lymphadenopathy >60 y/o - smudge cells

CLL

- marrow fibrosis (dry bone marrow aspirate) - extramedullary hematopoiesis → splenomegaly - tear drop RBCs

Primary myelofibrosis

- abnormal appearing platelets

Essential thrombocythemia

- ↑plasma volume, ↑RBC mass, normal SaO2, ↓EPO - 4 H’s: hyperviscosity, hypervolemia, histaminemia, hyperuricema

Polycythemia vera

- age: 30-60 y/o - Philadelphia chromosome t(9;22) or Bcr-Abl gene - ↓LAP score

CML

- age: <15 y/o - pre-B cells (90%); CALLA+/TdT+ - CNS and testicle involvement - t(12;21) offers good prognosis

ALL

- age: median onset ~60 y/o - Auer rods in myeloblasts

AML

MEDICINE × ID RESPIRATORY INFX

Dz Pneumonia

Lung abscess

Tuberculosis

Influenza

Bug(s) Typical CAP: Strep pneumo (#1), H. influenzae (#2), aerobic GNR Atypical CAP: Mycoplasma (#1), Chlamydia, Legionella Nosocomial PNA: Staph aureus (#1), Pseudomonas, aerobic GNR PNA × alcoholics: Klebsiella PNA × immigrants: TB PNA × nursing home: nosocomial pathogens PNA × AIDS: Pneumocystis carinii (PCP), TB oral anaerobes (Prevotella, Peptostreptococcus, Fusobacterium, Bacteroides) M. tuberculosis

influenza virus

Presentation Typical CAP: sudden-onset fever/chills, productive cough, pleuritic chest pain Atypical CAP: insidious-onset sore throat, headache, nonproductive cough, dyspnea Complications: pleural effusions, empyema, acute respiratory failure

Management • Dx CXR (consolidations) • suspect TB → acid-fast stain • suspect Legionella → urinary ag • HIV+ → silver stain (fungi, PCP) • admit if 2/5 of CURB-65 – Confusion, Uremia, • RR ≥30, BP <90/60, age ≥65 • outpatient → Tx azithromycin (<60 y/o), • ceftriaxone (≥60 y/o) • inpatient → Tx azithromycin + either • ceftriaxone or fluoroquinolone • PPx annual flu vaccine, Pneumovax if ≥65 y/o

aspiration → cough w/ foul-smelling sputum, SOB, fever/chills 1° TB: granulomatous inflammation in lower lobes → infx contained → usually asx 2° TB: reactivation in upper lobes → fever/chills, night sweats, weight loss, cough w/ hemoptysis Miliary TB: hematogenous “miliary seed” spread of TB → sx depend on organs Pott disease: TB in vertebral body → bone pain, risk for pathological fx rapid-onset fever/chills, malaise, headache, sore throat, nonproductive cough

• Dx CXR (cavitation w/ air-fluid levels, most • commonly in right lower lobe) • Tx IV abx • Dx screen w/ tuberculin skin test (≥15 mm, • ≥10 mm if high-risk, ≥5 mm if HIV+ or CXR+); • confirm w/ CXR (cavitation in upper lobe) • active TB → Tx SPIRE (streptomycin, • pyrazinamide, INH, rifampin, ethambutol) for • 2 months, then INH + rifampin for 4 months • latent TB → Tx INH only • Tx supportive care + oseltamivir if ≤48 hrs

2° bacterial infx: pt gets better from flu, then sick again d/t bacterial colonization

CNS INFX

Dz Meningitis

Encephalitis

Brain abscess

Bug(s) Meningitis × neonates: GBS > E. coli > Listeria Meningitis × kids: MC > Strep pneumo > H. influenzae Meningitis × adults: Strep pneumo > MC > H. influenzae Meningitis × elderly: Strep pneumo > MC > Listeria

viruses (HSV-1 in temporal lobe, arbovirus, enterovirus), toxoplasmosis, aspergillosis Staph, Strep, anaerobes

Presentation triad of fever, nuchal rigidity, ∆MS Kerning sign: inability to fully extend knees when lying supine w/ hips flexed Brudzinski sign: flexion of head causes flexion of hips/knees when lying supine Disseminated meningococcal infx: meningitis, purpura fulminans, bilateral adrenal hemorrhage (W-F syndrome) ∆MS, focal neuro sx, s/sx of meningitis

mass effect → headache, ∆MS, seizures, nausea/vomiting, focal neuro sx

Management • Dx head CT to check for ↑ICP, then lumbar • puncture + CSF analysis • Tx IV abx

• Dx head CT to check for ↑ICP, then lumbar • puncture + CSF PCR • Tx admit + ACV (for HSV), GCV (for CMV) • Dx head CT or MRI • Tx IV abx, surgical drainage, ±steroids

Abscess × AIDS: toxo, fungi Abscess × DKA: zygomycosis

GU INFX

Dz Asymptomatic bacteruria Lower UTI (cystitis)

Bug(s) E. coli (#1), Staph saprophyticus (#2), Enterococcus (#3), other GNB "

Upper UTI (pyelonephritis)

"

Prostatitis

E. coli (kids/elderly), STDs (young adults)

Presentation (asx)

dysuria, ±hematuria, frequency/urgency, suprapubic tenderness Risk factors: diabetes, females (shorter urethra), sexual intercourse, Foley catheter (same as above) + fever/chills, flank pain, CVA tenderness Risk factors: (same as above) + VUR Acute prostatitis: fever/chills, dysuria, frequency, urgency, low back pain Chronic prostatitis: usually asx

Management • Dx UA/UCx (≥105 CFU w/o squamous cells) • Tx only if pregnant (nitrofurantoin) or before • urologic surgery, otherwise reassurance • Dx UA/UCx (≥105 CFU w/o squamous cells) • Tx Bactrim or Cipro, nitrofurantoin if pregnant, • low-dose Bactrim ppx if recurrent

• Dx UA/UCx (≥105 CFU w/o squamous cells, • WBC casts) • uncomplicated → Tx Bactrim or Cipro • complicated → Tx admit + IV amp/gent • Dx DRE (boggy tender prostate) + UA/UCx • Tx Bactrim or Cipro • Dx prostatic secretion analysis (↑WBC) • Tx long-term Cipro

MEDICINE × ID GI INFX

Dz Viral hepatitis

Bug(s) HAV (fecal-oral)

Presentation jaundice, dark-colored urine, RUQ pain, n/v

HBV (parenteral or sexual)

Buzzwords: Asx (usually), daycare, travel jaundice, dark-colored urine, RUQ pain, n/v Buzzwords: polyarteritis nodosa, MGN

Botulism

Intra-abdominal abscess Diarrhea

SKIN/SOFT TISSUE INFX

Dz Cellulitis

Erysipelas Necrotizing fasciitis (“gas gangrene”) Lymphadenitis

HCV (parenteral)

jaundice, dark-colored urine, RUQ pain, n/v

HDV (parenteral or sexual)

Buzzwords: Cryoglobulinemia, Chronic infx, Cirrhosis, Carcinoma, Carriers, IVDA, MPGN jaundice, dark-colored urine, RUQ pain, n/v

HEV (fecal-oral)

Buzzwords: Deadly, HBV co-infection jaundice, dark-colored urine, RUQ pain, n/v

Clostridium botulinum preformed exotoxin (from canned food or wound infx) polymicrobial

Buzzwords: cruise ships, fatal in pregnancy symmetric, descending flaccid paralysis

fever/chills, abd pain, mass

Management • Dx HAV IgM = acute infx • Dx HAV IgG = previous infx or immunity • Tx supportive care • Dx HBsAg = acute/chronic infx • Dx HBsAb = previous infx or immunity • Dx HBeAg = infectivity • Dx HBcAb IgM = window period • Tx IFN-α • Dx HCV RNA • Tx IFN-α + ribavarin, liver txp if severe

• Dx HDV Ab • Tx IFN-α • Dx HEV Ab • Tx supportive care • Dx toxin assay • Tx admit + antitoxin • Dx CT scan (cavitation w/ air-fluid levels) • Tx I&D + IV abx acute diarrhea

Diarrhea × n/v: viral gastroenteritis or food poisoning Diarrhea × fever/blood: Shigella, Salmonella, Campy, EHEC Diarrhea × mayonnaise: Staph aureus (<6 hrs), Salmonella Diarrhea × raw chicken: Salmonella, Shigella Diarrhea × raw seafood: Vibrio, Salmonella, hep A Diarrhea × abx: C. diff Diarrhea × travel: ETEC Diarrhea × daycare: rotavirus, Shigella, Giardia Diarrhea × AIDS: Cryptosporidium

---

Bug(s) skin flora (Strep pyogenes, Staph aureus)

Presentation infx of skin and subcutaneous tissue → erythema, warmth, pain, swelling

Management • Tx Keflex or Bactrim, consult ophtho if orbital • involvement

“fiery red”, painful skin lesion on face or extremities infx of deeper fascia → extreme fever and pain, evident tissue necrosis, crepitus infx of LN → tender LN w/ local cellulitis

• Tx PCN or erythromycin

blocks GABA and glycine release → trismus (lockjaw), opisthotonos (spastic back), risus sardonicus (spastic smile) fever, rash, desquamation of palms/soles; associated w/ menstruation and tampons

• Tx tetanus antitoxin (TIG) in one site, Td • immunization in a different site

Cellulitis × fight bite: Eikenella Strep pyogenes

Tetanus

Strep pyogenes, Clostridium perfringens skin flora (Strep pyogenes, Staph aureus) Clostridium tetani exotoxin

Toxic shock syndrome

Staph aureus TSST-1 exotoxin

H+P not complicated

complicated (blood, fever, n/v)

Tx symptomatic relief (rehydrate, ±loperamide) Dx fecal leukocytes –WBC

+WBC stool cx, C. diff toxin

• bacteria → Tx ciprofloxacin x5 days • C. diff → Tx Flagyl or PO vancomycin

• Tx rapid surgical exploration + debridement, • broad-spectrum IV abx • Tx Keflex or Bactrim, warm compresses

• Tx admit + stabilize + IV nafcillin (prevents • recurrence, not current toxin-mediated illness)

MEDICINE × ID STDS

BONE/JOINT INFX

Dz Chlamydia

Bug(s) Chlamydia trachomatis

Gonorrhea

Neisseria gonorrhoeae

Vaginal candidiasis

Candida albicans

Syphilis

Treponema pallidum

Chancroid

Haemophilus ducreyi

HSV

HSV-1/2

Presentation Women: cervicitis, PID, TOA, usually asx Men: urethritis Women: cervicitis, PID, TOA, usually asx Men: urethritis Disseminated gonoccocal infx: migratory polyarthritis, endocarditis, skin rash Fitz-Hugh-Curtis syndrome: perihepatitis causing RUQ pain, ↑LFTs, “violin string” adhesions thick, white curd-like discharge, itching, satellite lesions, no odor 1° syphilis: painless chancre + inguinal LNopathy 2° syphilis: palmar/plantar rash, fever, condyloma lata, generalized LN-opathy 3° syphilis: neurosyphilis (tabes dorsalis), CV syphilis (luetic heart), gummas Jarisch-Herxheimer rxn: acute febrile rxn s/p syphilis tx (MC w/ 2° syphilis), due to dead spirochetes → endotoxin release painful chancre + inguinal LN-opathy recurrent, painful oral (HSV-1) or genital (HSV-2) vesicles that can rupture

LGV

Chlamydia trachomatis, L1-L3 serotypes

Condyloma acuminata

HPV-6/11

Herpetic whitlow: painful, paronychia-like lesions in fingers of healthcare workers 1° LGV: transient, painless ulcer 2° LGV: painful LN-opathy 3° LGV: anogenital syndrome (proctocolitis, rectal strictures, rectovaginal fistulae, genital elephantiasis) genital warts

Bacterial vaginosis

Gardnerella vaginalis

thin homogenous discharge, fishy odor

Trichomoniasis

Trichomonas vaginalis

HIV/AIDS

HIV-1/2 (sexual, parenteral, vertical, or breastmilk)

Pediculosis pubis (“crabs”)

Phthirus pubis

green-gray frothy discharge, odor, strawberry cervix (petechiae) Primary infx: presents as mono-like syndrome ± truncal maculopapular rash Asx stage: CD4+ >500, asx Sx stage: CD4+ 200-500, mild sx (generalized LN-opathy, fungal infx, night sweats, weight loss, diarrhea) AIDS: CD4+ <200, or presence of AIDS OI severe itching, irritation, vesicles, burrows

Dz Osteomyelitis

Bug(s) Staph aureus (#1), coag-neg Staph epidermidis (#2), others

Presentation hematogenous or direct spread → infx of bone → bone pain w/ local inflammation

Infx arthritis

OM × IV catheter: Staph aureus OM × prosthetic joint: coagneg Staph epidermidis OM × diabetic foot: polymicrobial OM × nosocomial: Pseudomonas OM × IVDA: Pseudomonas OM × sickle cell: Salmonella OM × vertebra: TB (Pott dz) OM × cat/dog bite: Pasturella multocida Staph aureus (#1), others Arthritis × sexually-active young adults: N. gonorrhoeae Arthritis × IVDA: Pseudomonas Arthritis × sickle cell: Salmonella

Management • Dx Chlamydia NAAT • Tx azithromycin ± ceftriaxone • Dx discharge Gram stain (G– diplococci) • Tx ceftriaxone ± azithromycin

• Dx KOH prep (budding yeast + pseudohyphae) • Tx fluconazole (Diflucan) or miconazole cream • Dx screen w/ RPR-VDRL, confirm w/ FTA-ABS; • or definitive dx w/ Darkfield microscopy • Tx Benzathine PCN G (1°/2°), IV PCN G (3°)

• Dx Gram stain (“school of fish” appearance) • Tx azithromycin or ceftriaxone • Dx Tzanck smear (multinucleated giant cells) • or viral cx • Tx ACV/VACV + palliative care

• Dx complement fixation • Tx doxycycline

• Dx PE • Tx removal • Dx wet prep (clue cells) • Tx metronidazole • Dx wet prep (mobile trichomonads) • Tx metronidazole • Dx screen w/ HIV ELISA, confirm w/ WB • Tx HAART (2 NRTIs + 1 NNRTI or PI)

• Dx hair under microscope • Tx permethrin shampoo

Management • Dx needle aspiration + cx (best), MRI • Tx admit + IV abx + debride dead bone • f/u serial ESR/CRP to monitor response to tx

hematogenous or direct spread → infx of joints → swollen, painful joint w/ ↓↓ROM

• Dx joint aspiration + analysis • Tx admit + IV abx, drain if shoulder or knee

MEDICINE × ID ZOONOSES AND ARTHROPOD-BORNE INFX

FUNGAL INFX

Dz Lyme disease

Bug(s) Borrelia burgdorferi via Ixodes tick vector

Rocky Mountain spotted fever Malaria

Rabies

Rickettsia rickettsii via tick vector Plasmodium falciparum (24h), P. vivax and ovale (48h), P. malariae (72h) via Anopheles mosquito vector rabies virus via animal host

Dz Candidiasis

Bug(s) Candida albicans

Management • Dx screen w/ ELISA, confirm w/ WB • Tx doxycycline

pain at bite location → fever, malaise → agitation, photophobia, hydrophobia (foaming) → paralysis, coma → death

• Dx viral cx, Negri bodies on Purkinje cell bx • Tx emergent passive + active immunization

Presentation Vaginal candidiasis: thick, white curd-like discharge, itching, satellite lesions, no odor Thrush: thick, white plaques in oral mucosa Cutaneous candidiasis: erythematous, eroded patches w/ satellite lesions

Management • Dx KOH prep (budding yeast + pseudohyphae) • Tx fluconazole or miconazole cream (vaginal), • nystatin powder (cutaneous), nystatin “swish • and-swallow” (thrush)

Risk factors: DM, abx use, immunosuppression, HIV/AIDS ABPA: asthma + pulmonary infiltrates + Aspergillus allergy Aspergilloma: prior lung cavitation, filled up w/ Aspergillus ball → chronic cough ± hemoptysis Invasive aspergillosis: acute-onset fever, cough, respiratory distress, hemoptysis meningitis/encephalitis in HIV+ pts

• Tx doxycycline • Dx blood smear w/ Giemsa stain • Tx chloroquine (mefloquine if resistant) ± • primaquine for P. vivax/ovale hypnozoites

• Dx CXR (air-crescent sign for aspergilloma) • Tx avoidance (ABPA), lung lobectomy • (aspergilloma), IV ampho B (invasive • aspergillosis)

Aspergillosis

Aspergillus fumigatus

Cryptococcosis

Blastomycosis

Cryptococcus neoformans via pigeon droppings Histoplasma capsulatum via bat/bird droppings in caves Blastomyces dermatitidis

Coccidioidomycosis

Coccidioides immitis

Sporotrichosis (“rose gardener disease”)

Sporothrix schenkii via rose thorn prick

Dz Giardiasis

Bug(s) Giardia lamblii

Amebiasis

Entamoeba histolytica

Cryptosporidiosis

Cryptosporidium parvum

Presentation bloating, flatulence, foul-smelling fatty diarrhea flask-shaped ulcers in ascending colon → bloody diarrhea; “anchovy paste” abscess in liver → RUQ pain mild diarrhea, severe diarrhea in HIV+ pts

Ascariasis

Ascaris lumbricoides

usually asx, can cause bowel obstruction

Hookworm

Ancylostoma duodenale (old), Necator americanus (new) Enterobius vermicularis

hooks onto bowel walls and sucks blood → iron-deficiency anemia perianal pruritus, worse at night

Tapeworm

Taenia saginata (beef), Taenia solium (pork), Diphyllobothrium latum (fish)

usually asx, D. latum eats vitamin B12 → macrocytic anemia

Schistosomiasis

S. haematobium

S. mansoni/japonicum cause fibrosis of liver and spleen; S. haematobium causes bladder infx → dysuria, bladder SCC

• Dx stool/urine sample • Tx praziquantel

Presentation erythema around an IV cath left in for too long (>3 days) fever/chills, sore throat, malaise, myalgias, severe cervical LN-opathy after making out w/ someone

Management • Dx remove and send tip for cx • Tx IV abx • Dx Monospot (heterophile agglutination) test • Tx supportive care + avoid contact sports to • prevent splenic rupture

Histoplasmosis

PARASITIC INFX

Presentation Stage 1: erythema chronicum migrans (target-shaped lesion) Stage 2: bilateral Bell palsy + AV block Stage 3: chronic arthritis triad of HA + fever + rash (vasculitis that starts on extremities and comes inward) cyclic fever/chills, headache, anemia, splenomegaly

Pinworm

S. mansoni

usually asx, mild respiratory sx inflammatory lung dz, granulomatous nodules in skin and bone usually asx, mild respiratory sx after earthquakes in SW US local ulcer + ascending LN-opathy

• Dx LP + India ink stain (thick capsules) • Tx IV ampho B + flucytosine • Dx bx (macrophage-filled spores) • Tx itraconazole • Dx bx (Broad Based Buds) • Tx itraconazole • Dx bx (huge spherule w/ endospores) • Tx itraconazole • Dx bx (cigar-shaped yeasts) • Tx itraconazole or potassium iodide

Management • Dx stool sample • Tx metronidazole • Dx stool sample • Tx metronidazole (for diarrhea and abscess) • Dx acid-fast stain • (no tx exists) • Dx stool sample • Tx mebendazole • Dx stool sample • Tx mebendazole • Dx Scotch tape test • Tx mebendazole • Dx stool sample • Tx praziquantel

S. japonicum

OTHER INFX

Dz Catheter-related sepsis Mononucleosis

Bug(s) Staph aureus (#1), coag-neg Staph epidermidis (#2) EBV (#1), CMV (#2)

MEDICINE × SKIN COMMON SKIN DZ

Dz Acne vulgaris

Rosacea Seborrheic dermatitis

Contact dermatitis

Pityriasis rosea

Erythema nodosum

Lichen planus Bullous pemphigoid

Pemphigus vulgaris

INFX SKIN DZ

Dz Warts

Molluscum contagiosum

Shingles (zoster)

Dermatophytes

Scabies

Presentation obstruction of sebaceous follicles → proliferation of P. acnes → noninflammatory comedones (pimples) → inflammatory acne red forehead, nose, cheeks w/o underlying comedones usually asx; can present as scaly patches on scalp (dandruff), hairline, behind ears, eyebrows, armpits, groin area skin rash w/ vesicles and oozing (acute) or crusted, thickened skin (chronic) Irritant contact dermatitis: physical or chemical insult to skin → rash shortly after exposure Allergic contact dermatitis: reexposure to allergen → rash hours-to-days after exposure herald patches (ringworm-like), then generalized “Christmas tree” rash painful, red, subcutaneous nodules over shins

4 Ps – pruritic, purple, polygonal papules anti-hemidesmosome ab → tense blisters on skin but not oral mucosa anti-desmosome ab → tense blisters on skin and oral mucosa w/ acantholysis

Presentation HPV infx → epithelial growth → fleshy asx mass, plantar warts can be painful on walking Common wart: verruca vulgaris found on elbows, knees, palms, and fingers Flat wart: verruca plana found on chin/face, dorsum of hands, and legs Plantar wart: verruca plantaris found on sole of foot Anogenital wart: condyloma acuminatum found on genital areas poxvirus infx → highly contagious domed papules w/ umbilicated center reactivation of latent VZV (chicken pox) infx → pain and rash in dermatomal distribution

Tinea capitis: found on scalp of kids w/ itching and hair loss Tinea corporis: ringworm, found on body/trunk Tinea unguium: onychomycosis, found on finger- and toenails Tinea pedis: athlete’s foot, found on webbing of toes Tinea cruris: jock itch, found in groin and inner thighs Sarcoptes scabiei skin mite → tunnel in epidermis → burrows and severe pruritus

Management • Tx clean skin (1st line), topical benzoyl • peroxide, retinoids, or abx (2nd line), systemic • abx (3rd line), isotretinoin (last line/teratogen)

• Tx topical metronidazole (1st line), systemic • abx (2nd line), isotretinoin (last line) • Tx sunlight + dandruff shampoo (1st line), • topical ketoconazole (2nd line), topical steroids • (last line) • Dx patch test if unsure • Tx cold compresses, topical steroids, systemic • steroids (severe) • PPx avoid allergen

Other Risk factors: male sex, puberty, Cushing syndrome, oily skin, androgens, meds Steroid acne: not associated w/ underlying comedones Rhinophyma: large, bulbous, greasy nose in men

Etiology: ACD is delayed (type 4) HS to poison ivy, oak, sumac, iodine, nickel, rubber, cosmetics

• Tx reassurance

• Dx CXR (for TB, sarcoidosis), VDRL, CBC, ESR, • skin cx/bx to look for underlying cause • Tx underlying cause + symptomatic relief (bed • rest, leg elevation, NSAIDs, heat pads) • Tx systemic steroids

Etiology: Strep, sarcoidosis, IBD, fungal infx, syphilis, TB, pregnancy, meds, idiopathic

• Tx systemic steroids

• Tx systemic steroids

Management • Tx removal (cryotherapy, salicylic acid, • podophyllin, surgical or laser excision)

Other

• Tx removal (cryotherapy, podophyllin, surgical • or laser excision) • Tx ACV + analgesics • PPx shingles vaccine for elderly

• Dx scrape lesions + KOH prep • Tx PO griseofulvin for tinea capitis and • onychomycosis, topical antifungals for others

• Dx scrape lesions + microscopy • Tx permethrin cream for pt and close contacts

MC sites: thorax and trigeminal nerve distribution Complications: postherpetic neuralgia, uveitis, dissemination, meningoencephalitis, deafness

MEDICINE × SKIN SKIN CANCERS

Dz Actinic (solar) keratosis

Presentation small, rough, scaly lesions on face of fair-skinned people; precursor to SCC raised waxy lesion or nonhealing ulcer in upper face, doesn’t spread non-healing ulcer in lower face, spreads to LN

Management • Tx removal (cryotherapy, surgical scraping, • or topical 5-FU)

Melanoma

ABCDE – asymmetric, border irregularity, colors, diameter >6 mm, elevated; highly metastatic

• Tx excisional bx w/ 1 cm margins + search for • mets

Dz Decubitis ulcers (pressure sores)

Presentation prolonged pressure → tissue ischemia and necrosis → ulcers

Management • Tx local wound care, surgical debridement, • BID wet-to-dry for deeper ulcers • PPx turn and reposition q 2 hrs

Psoriasis

Stage 1: skin intact Stage 2: partial-thickness skin loss Stage 3: full-thickness skin loss Stage 4: full-thickness skin loss that extends into underlying muscle, bone, joints, tendons abnormal proliferation of skin cells → silvery, scaling plaques w/ Auspitz sign (bleeding upon removal) “pasted on” dark, oily plaques common in older pts irregular depigmentation of skin, most commonly on face

BCC

SCC

OTHER SKIN DZ

Seborrheic keratosis Vitiligo

ALLERGIC REACTIONS

Other

• Tx excisional bx w/ 1 mm margins

• Tx excisional bx w/ 1 cm margins + LN excision

Risk factors: sunlight exposure, draining fistulas, arsenic, HPV Keratoacanthoma: variant of SCC that grows rapidly and dies off spontaneously Marjolin’s ulcer: SCC arising from a chronic wound Growth phases: initially grows radially, then vertically; px related to depth of invasion Dysplastic nevus: atypical mole, precursor to melanoma Spitz nevus: well-circumscribed, raised lesion confused w/ melanoma

Other MC sites: sacrum, greater tuberosity, ischial tuberosity Risk factors: immobilization, dementia, peripheral vascular dz Complications: secondary bacterial infx (cellulitis, osteomyelitis, nec fasc, gangrene)

• mild → Tx topical steroids, calcipotriene • severe → Tx MTX, infliximab, cyclosporine A

• Tx removal (cryotherapy, surgical excision) • only for cosmetic reasons • Tx topical steroids or photochemotherapy

Type 1 HS: allergen exposure → IgE-mediated mast cell degranulation → HA release, atopic/anaphylactic Type 2 HS: IgG or IgM against cell surface, cytotoxic Type 3 HS: ab-ag complex deposition → complement activation → cell damage Type 4 HS: T-cell mediated activation of macrophages, delayed-type Dz Urticaria (hives)

Presentation type 1 HS → edematous wheals (hives) that cause intense pain/pruritus severe urticaria + target lesions (“bulls-eye lesions”) severe erythema multiforme + mucus membrane involvement severe Stevens-Johnson syndrome fluid extravasation into subcutaneous tissue → painful swelling of eyelids, lips, tongue, genitalia, hands, or feet types 1-4 HS → skin eruptions (MC), lung, kidney, hematologic complications, anaphylaxis

Management • Tx remove offending agent, symptomatic • relief (anthistamines)

Other

• Tx remove offending agent, symptomatic • relief (anthistamines) • Tx remove offending agent, admit to ICU

Etiology: sulfa drugs (MCC), other drugs, HSV infx Etiology: sulfa drugs (MCC), other drugs Etiology: sulfa drugs (MCC), other drugs Etiology: ACE inhibitors (MCC) Hereditary angioedema: C1esterase inhibitor deficiency

Food allergy

type 1 HS → skin eruptions (MC), GI sx, anaphylaxis

• Tx remove offending agent, symptomatic • relief (anthistamines) • anaphylaxis → Tx epinephrine

Insect sting allergy

Nonallergic rxn: localized swelling, pain, pruritis, redness Allergic rxn: looks like cellulitis severe type 1 HS → skin eruptions followed by airway obstruction, then shock

• nonallergic → Tx ice pack • allergic → Tx ice pack + antihistamines • anaphylaxis → Tx epinephrine • Tx ABCs, epinephrine, antihistamines, steroids

Erythema multiforme Stevens-Johnson syndrome Toxic epidermal necrolysis Angioedema

Drug allergy

Anaphylaxis

• Tx remove offending agent, admit to ICU • Tx remove offending agent, symptomatic • relief (anthistamines) • laryngeal edema → Tx epinephrine • Tx remove offending agent, symptomatic • relief (anthistamines) • anaphylaxis → Tx epinephrine

Adverse drug reaction: broad category including drug allergy, side-effects, drug interactions, toxicity, etc. Adverse food reaction: broad category including food allergy, food poisoning, metabolic conditions, malabsorption, etc. Etiology: Hymenoptera spp. (wasps, yellow jackets, honeybees, hornets)

MEDICINE × OUTPATIENT CARDIOVASCULAR DZ

Dz/CC HTN

Presentation asx, but can present w/ end-organ complications...

Management Dx BP cuff H+P lifestyle modifications

Heart: LVH, MI, CHF Eyes: retinopathy, papilledema Kidney: CKD Brain: stroke, TIA Arteries: PVD, aortic dissection

not at goal BP stage 1

Tx HCTZ

stage 2

compelling indications

Tx HCTZ + Tx specific drug ACEI/ARB/BB/CB not at goal BP

optimize dose or add drug • if diabetic, stroke → Tx ACE inhibitor • if CAD, CHF → Tx β-blocker • if pregnant → Tx Ca-blocker • if refractory → check for compliance

HLD

• H+P: ask about CP, SOB, HA, side-effects; • labs (renal panel, fasting lipids) • Lifestyle modifications: weight loss, • DASH eating plan, sodium restriction, • aerobic exercise, moderate alcohol use • Goal BP: <140/90, <130/80 if CKD or DM Dx fasting lipid panel

asx, but can present w/ end-organ complications…

initial evaluation + lifestyle modifications

Atherosclerosis: MI, CAD, stroke, PVD, AAA ↑LDL: xanthelasma, xanthoma ↑TG: acute pancreatitis

not at goal lipids LDL >130 (if high risk) LDL >160 (if med risk) LDL >190 (if low risk) Tx statins

TG >500

Tx niacin

not at goal lipids optimize dose or add drug • Initial evaluation: look for 2° causes + labs • (TSH, LFTs, renal, fasting glucose) • Lifestyle modifications: diet + exercise • Goal lipids: <130, <100 if CHD or DM

Hyperlipidemia drugs: Statins

LDL ↓↓↓

HDL ↑

TG ↓

Niacin

↓

↑↑

↓↓

Bile acid resins (colestipol, cholestyramine) Fibrates (gemfibrozil)

↓↓

↑

↑

↓

↑

↓↓↓

Side-effects hepatotoxicity, rhabdomyolysis (check CK, LFTs) flushing, hyperglycemia, hyperuricemia (check CK, LFTs) GI distress, poorly tolerated hepatotoxicity, rhabdomyolysis, cholesterol gallstones (check CK, LFTs)

Other Pre-HTN: 120-139/80-89 Stage 1 HTN: ≥140/90 Stage 2 HTN: ≥160/100 HTN urgency: ≥220/120 HTN emergency: ≥220/120 + endorgan damage 1° (essential) HTN: 95%, no underlying cause 2° HTN: 5%, due to renovascular dz (MCC), OCPs (MCC young women) or other meds, stimulants, endocrine dz, etc.

MEDICINE × OUTPATIENT HEADACHE

1° HA types: tension, cluster, migraines 2° HA causes: VOMIT – Vascular (SAH, SDH, EDH, ICH, temporal arteritis) Other (malignant HTN, psedomotor cerebri, post-LP, pheo) Meds (nitrates, alcohol withdrawal, analgesic withdrawal) Infx (meningitis, encephalitis, abscess, sinusitis, shingles, fever) Tumor Severe HA w/ HTN: get noncontrast head CT to r/o ICH, then get LP Dz/CC Tension HA

Cluster HA

Migraine HA Rebound analgesic HA

UPPER RESPIRATORY DZ

Presentation tight band-like pain encircling entire head + tightness in posterior neck muscles unilateral, episodic “burning, searing, or stabbing pain” behind eye + ipsi tearing, flush, or nasal discharge in men unilateral, throbbing HA ± n/v, phono-/photophobia in women “migraine” after discontinuing long-term analgesic use

Management • Tx NSAIDs or Tylenol if mild/moderate, • sumatriptan (Imitrex) if severe

Other Etiology: unknown

• Tx sumatriptan + O2 for acute attacks, • use verapamil for ppx

Etiology: unknown

• Tx sumatriptan for acute attacks, • use TCA or propranolol for ppx • Tx wean pt from analgesics (do not give pt • more narcotics)

Etiology: stress → ↓5-HT → vasospasm → headache

Viral vs. bacterial URI: common sx – fever, cough viral only – rhinorrhea, myalgia, headache bacterial only – yellow sputum “Double sickening”: cold that gets better for a few days then gets worse, consider 2° bacterial infx Dz/CC Cough

Acute bronchitis “Common cold” (viral rhinosinusitis)

Presentation ---

cough (dry or productive), ±fever, ±shortness of breath dry cough, sore throat, malaise, rhinorrhea, nasal congestion

Sinusitis

nasal stuffiness, purulent discharge, cough, sinus pain or pressure (maxillary sinuses may resemble dental pain)

Laryngitis

hoarseness, sore throat, ±other viral URI sx ---

Sore throat

Management • suspect pulmonary dz → Dx CXR • suspect infx → Dx CBC • suspect asthma → Dx PFT • Tx underlying cause (if known) + symptomatic • relief (codeine syrup, hydration, expectorants) • smoker → Tx cessation • postnasal drip → Tx antihistamine + • decongestant • suspect PNA → Dx CXR • Tx symptomatic relief (codeine syrup) • Tx symptomatic relief (codeine syrup, • hydration, expectorants, analgesics) • PPx hand washing • Dx (think viral if <7-10 days, bacterial if • >7-10 days) • viral → Tx decongestant (pseudoephedrine) • bacterial → Tx decongestant + amoxicillin; if • not improved after 2 wks, Tx penicillinase • resistant abx ± ENT consult • Tx voice rest • Dx rapid strep test, throat cx • suspect mono → Dx Monospot test • Tx symptomatic relief (salt water gargling, • throat lozenges, analgesics) • strep throat → Tx PCN x10 days

Other Acute cough: <3 wks, MCC viruses Chronic cough: >3 wks, due to smoking, postnasal drip, GERD, or asthma

Etiology: MCC viruses Etiology: MCC viruses, through hand-to-hand transmission Complications: 2° bacterial infx Etiology: viruses, Strep pneumo, H. flu, Moraxella catarrhalis Complications: mucocele, polyps, infx spread (cellulitis, osteomyelitis, abscess) Etiology: MCC viruses Etiology: MCC viruses, bacterial tonsillitis, strep throat, mono

MEDICINE × OUTPATIENT GASTROINTESTINAL DZ

Dz/CC Dyspepsia

GERD

Diarrhea

Presentation spectrum of epigastric sx (pain/discomfort, heartburn, bloating, indigestion)

heartburn, regurgitation, waterbrash (sour taste), cough, dysphagia

---

Management • suspect severe GI dz → Dx endoscopy + • urease breath test • suspect MI → Dx EKG + cardiac enzymes • Tx underlying cause, make lifestyle changes, • antacids for acid reflux • H. pylori → Tx triple or quadruple therapy • Tx PPIs → if it persists >6 wks, Dx EGD w/ bx • to see what’s going on • Esophagitis: multiple nonulcerating erosions; • mild Tx → PPIs, severe → lap Nissen • Barrett esophagus: intestinal metaplasia of • esophageal epithelium; no dysplasia → Tx • PPIs, low-grade dysplasia → Tx lap Nissen + • annual surveillance, high-grade dysplasia → • Tx esophagectomy acute diarrhea H+P not complicated

complicated (blood, fever, n/v)

Tx symptomatic relief (rehydrate, ±loperamide) Dx fecal leukocytes –WBC

+WBC stool cx, C. diff toxin

• bacteria → Tx ciprofloxacin x5 days • C. diff → Tx Flagyl or PO vancomycin

Constipation

IBS

Nausea/vomiting

Hemorrhoids

---

altered bowel habits (diarrhea, constipation, or both) that improve w/ defecation + chronic abdominal pain ---

dilated perianal veins; can present as BRBPR or painful thrombosis

• suspect 2° cause → Dx TSH, renal panel • suspect CRC → Dx CBC, FOBT • suspect obstruction → Dx KUB • Tx underlying cause, make lifestyle changes • (exercise, fluids, high-fiber diet) • obstruction → surg consult • Dx CBC and FOBT to r/o organic causes • constipation → Tx fiber, lubiprostone (2nd line) • diarrhea → Tx loperamide • Dx (ask food intake, meds, recent abdominal • surgery, define vomitus) • suspect 2° cause → Dx CBC, renal panel, LFTs • women → Dx β-HCG • suspect obstruction → Dx KUB • Tx underlying cause, symptomatic relief • (promethazine or prochlorperazine) • severe dehydration → Tx admit + IVF (½NS+K) • Tx symptomatic relief (high-fiber diet, stool • softeners, sitz baths, steroid suppository) • severe → Tx hemorroidectomy or rubber • band ligation (internal only)

Other Etiology: 90% due to GI causes (PUD, GERD, gastritis, nonulcer dyspepsia); must r/o acute MI

Etiology: ↓LES tone → retrograde flow of stomach contents into esophagus Complications: erosive esophagitis, peptic strictures, esophageal ulcers, Barrett esophagus, recurrent PNA w/ lipid-laden macrophages

Acute diarrhea: <2 wks, due to viruses (MCC), bacteria, or meds Chronic diarrhea: >4 wks, IBS (MCC), lots of causes Diarrhea × n/v: viral gastroenteritis or food poisoning Diarrhea × fever/blood: Shigella, Salmonella, Campy, EHEC Diarrhea × mayonnaise: Staph aureus (<6 hrs), Salmonella Diarrhea × raw chicken: Salmonella, Shigella Diarrhea × raw seafood: Vibrio, Salmonella, hep A Diarrhea × abx: C. diff Diarrhea × travel: ETEC Diarrhea × daycare: rotavirus, Shigella, Giardia Diarrhea × AIDS: Cryptosporidium Diarrhea × appendicitis-like pain: Yersinina enterocolitica Diarrhea × mycotic aneurysm: Salmonella Diarrhea × PNA × hyponatremia: Legionella Electrolyte imbalance: hypokalemic metabolic acidosis Etiology: diet (lack of fiber), meds, IBS, obstruction, etc. Complications: hemorrhoids, rectal prolapse, anal fissures, fecal impaction

Etiology: unknown, but more common in women and high prevalence of Ψ d/o Etiology: viral gastroenteritis or food poisoning (MCC), lots of causes Complications: dental caries, aspiration pneumonitis, MalloryWeiss or Boerhaave syndrome Electrolyte imbalance: hypokalemic, hypochloremic metabolic alkalosis Internal hemorrhoids: above the dentate line, painless but can prolapse External hemorrhoids: below the dentate line, painful

MEDICINE × OUTPATIENT MUSCULOSKELETAL DZ

Dz/CC Low back pain

Ankle sprain

Tendinitis

Bursitis

Carpal tunnel syndrome

Osteoarthritis (OA)

Osteoporosis

Presentation Lumbar strain: dull LBP after physical activity Herniated disc: sciatic-type LBP radiating to butt/thigh, worse w/ sitting or leaning forward Degenerative disc dz: chronic LBP, worse w/ activity Cauda equina syndrome: bilat sciatica + bowel/bladder sx, neuro sx Vertebral osteomyelitis: LBP + fever, tender to palpation Malignancy: LBP + night pain, h/o cancer, weight loss, failure to improve Spinal stenosis: LBP worse w/ activity, better w/ sitting or leaning forward Compression fx: well-localized LBP, worse w/ activity Spondylolisthesis: LBP worse w/ hyperextension tenderness directly over injured ligament (ATFL or CFL)

Supraspinatus tendinitis: aka impingement syndrome, dull pain over lateral deltoid w/ arm aBduction Lateral epicondylitis: aka tennis elbow, pain at lateral elbow w/ supination or pronation Medial epicondylitis: aka golfer’s elbow, pain at medial elbow w/ wrist flexion De Quervain dz: pain at radial wrist w/ thumb gripping Olecranon bursitis: swelling “bag of fluid” and pain at point of elbow Trochanteric bursitis: greater trochanter painful on palpation carpal tunnel tightness → median nerve compression → pain, numbness, tingling over median nerve distribution; usually worse at night

wear-and-tear of joints → degeneration of cartilage → deep, dull joint pain, worse w/ activity and improved w/ rest

decreased bone mass (≤2.5 std deviations) → asx, but can present w/ complications

Management

Other LBP H+P

no red flags Tx rest + NSAIDs

red flags (night pain, pain at rest, fever, neuro sx, trauma, bowel/bladder sx, IVDA) focused work-up

• suspect radiculopathy → Dx straight leg raise • suspect compression fx, tumor mets, or • osteomyelitis → Dx X-ray • suspect cauda equina → Dx emergent MRI + • consult neurosurg

• Dx ankle X-ray only if Ottawa rules are met • (can’t walk 4 steps, bony tenderness over • either malleolus, navicular bone, or base of 5th • metatarsal) • Tx RICE + physical therapy • Tx steroid injections, surgical acromioplasty

• Tx forearm splint, physical therapy

• Tx forearm splint, physical therapy

• Dx Finkelstein test (clench thumb under other • fingers then ulnar deviate wrist) • Tx thumb spica splint + NSAIDs • Tx reassurance

• Tx NSAIDs, steroid injections • Dx screen w/ Tinel’s sign (tapping median • nerve causes tingling), Phalen’s test (palmar • flexion for 1 min causes tingling) • Dx confirm w/ EMG • Tx wrist splints (1st line), steroid injections (2nd • line), surgical carpal tunnel release (3rd line) • Dx X-ray (look for joint space narrowing, • osteophytes aka bone spurs, sclerosis, and • subchondral cysts) • Tx glucosamine-chondroitin supplements • Tx weight loss + physical therapy (1st line), • acetaminophen or NSAIDs (2nd line), steroid • injections (3rd line), joint replacement (4th line) • screen women ≥65 w/ DEXA scan q 2 yrs • Dx DEXA scan • Tx calcium + vitamin D + weight-bearing • exercise (1st line), bisphosphonates or HRT

MC joints: hips, knees, spine Risk factors: old age, obesity, joint overuse, trauma HeberDen nodes: OA at DIP Bouchard nodes: OA at PIP Risk factors: postmenopause, old age, steroid or heparin use Complications: vertebral body compression fx (→ kyphosis), Colles fx (distal radius), hip fx

MEDICINE × OUTPATIENT EYE DZ

Dz/CC Age-related macular degeneration (ARMD)

Presentation degeneration of macula → loss of central vision, scotoma

Glaucoma

Wet ARMD: sudden onset Dry ARMD: gradual onset ↑intraocular pressure → optic nerve damage → loss of peripheral vision, blindness

Cataracts

Red eye

Conjunctivitis

Amaurosis fugax

SLEEP D/O

Dz/CC Sleep apnea

Narcolepsy

Insomnia

Open-angle: gradual onset, usually asx for years Closed-angle: sudden onset w/ severe eye pain, tearing, n/v opacification of lens → gradual loss of visual acuity

Conjunctivitis: (see below) Subconjunctival hematoma: blood vx rupture → blotchy red spot in eye Keratoconjunctivitis sicca: dry eyes Blepharitis: eyelid inflammation, due to Staph aureus Scleritis:inflammation of sclera → eye pain, blurry vision Uveitis/iritis: inflammation of iris → circumcorneal injection, eye pain, blurry vision HSV keratitis: presents similar to conjunctivitis but fluorescein stain shows dendritic ulcer

Viral conjunctivitis: adenovirus infx → swollen, red eye w/ watery discharge Bacterial conjunctivitis: Strep pneumo infx → rapid-onset red eye w/ mucopurulent discharge Hyperacute conjunctivitis: N. gonorrhoeae infx → rapid-onset red eye w/ copious purulent discharge Allergic conjunctivitis: bilateral red eye w/ itching, tearing, other upper respiratory sx internal carotid artery plaque → embolize to retinal artery → suddent, transient monocular loss of vision

Presentation neck obesity or structural abnormalities → intermittent airflow obstruction → episodic apenic/hypoxic periods → snoring + fragmented sleep → daytime sleepiness, brain damage, HTN/pulmonary HTN REM sleep disregulation → excessive daytime sleepiness, cataplexy, sleep paralysis, hypnogogic/hypnopompic hallucinations ---

Management • Dx ophthalmoscope shows drusen (yellow• white deposits under pigmented epithelium) • no effective tx exists, but ranibizumab → • ↓rate of vision loss due to wet ARMD

Other

• Dx ophthalmoscope to check CN II damage, • visual field testing, tonometry to measure IOP • open angle → Tx topical β-blockers, α • agonists, acetazolamide, or prostaglandins • closed angle → Tx pilocarpine drops + • emergent iridectomy • Dx ophthalmoscope • Tx surgery

Etiology: old age (MCC), smoking, diabetes, etc. “Second sight”: pts w/ cataracts become increasingly nearsighted and no longer need reading glasses

red eye H+P no red flags

red flags (severe eye pain, flashes, Tx cause floaters, trauma, recent eye surgery, orbital cellulitis, corneal ulcer/opacification) consult ophtho

• subconjunctival hematoma → reassurance • keratoconjunctivitis sicca → Tx artificial tears • blepharitis → Tx warm compress • scleritis → consult ophtho (Tx steroids) • uveitis/iritis → consult ophtho • HSV keratitis → Tx topical ACV • viral → Tx cold compress • bacterial → Tx topical Cipro • hyperacute → Tx topical + PO ceftriaxone • allergic → Tx topical antihistamines

• Dx ophthalmoscope shows Hollenhorst plaque • Dx carotid U/S and cardiac work-up (lipid • panel, EKG) • Tx resolves spontaneously

Management • Dx polysomnography • mild-moderate → Tx weight loss • severe → Tx CPAP, surgery (last resort)

• Tx methylphenidate (Ritalin), modafinil

• Tx underlying cause, short-term symptomatic • relief (Ambien, Lunesta, Sonata)

Other

MEDICINE × OUTPATIENT OTHER PROBLEMS

Dz/CC Hearing loss

Presentation Conductive hearing loss: lesion in external or middle ear → decreased perception of lowvolume sounds Sensorineural hearing loss: lesion in CN VIII or CNS → decreased perception of lowand high-volume sounds w/ tinnitus Stress incontinence: urine leakage w/ exertion or straining

Management • Dx whisper test, audiogram, Weber/Rinne test • suspect CNS lesion → Dx MRI

• Tx anticholinergics (oxybutinin), TCAs • (imipramine)

Fatigue

Urge incontinence: urine leakage d/t involuntary bladder contractions (detrusor hyperactivity) Overflow incontinence: urine leakage d/t urinary retention and overdistention Bypass incontinence: urine leakage d/t fistula following pelvic surgery or pelvic radiation Functional incontinence: urine leakage d/t physical or psych issues; common in nursing home or gero pts ---

Erectile dysfunction (ED)

Chronic fatigue syndrome (CFS): profound fatigue for >6 months, not due to medical or psych d/o can’t get it up

Alcoholism

---

Urinary incontinence

• cerumen impaction → Tx Debrox eardrops • conductive → Tx underlying cause • sensorineural → Tx underlying cause, consider • cochlear implants

• Tx surgery to stabilize hypermobile urethra • (best), Kegel exercises, pessaries

• Tx intermittent self-cath

Etiology: vesicovaginal, urethrovaginal, ureterovaginal fistulas

• Tx underlying cause

Etiology: physical impairment, dementia or delirium, medications

• Dx CBC (anemia), TSH, fasting glucose, renal • panel, UA, LFTs to r/o organic causes • Tx underlying cause • CFS → Tx CBT ± SSRIs

Etiology: depression (MCC), lots of other causes

• Tx sildenafil (nitrates c/i)

Etiology: penile vasculature atherosclerosis (MCC), meds (anti-HTN), alcohol abuse, etc. Wernicke encephalopathy: acute thiamine deficiency → reversible Confusion, Ophthalmoplegia (CN VI palsy), Ataxia, Thought disturbances

• Dx CAGE screening (cut down, annoyed by • criticism, guilt, eye opener) • Dx labs show ↑LFTs (AST:ALT >2, ↑GGT, ↑CDT), • ↑MCV (folate deficiency)

Smoking

---

• Tx varenciline (Chantix) and buproprion • (Zyban) are partial nicotinic agonists; nicotine • patch or gum

Dz HTN HLD

Population adults ≥18 adults ≥18

Colorectal cancer

adults ≥50

Prostate cancer Breast cancer

--women ≥20

Cervical cancer

women 21-65

STDs

sexually active women <25, other high-risk women women ≥65 adults ≥18 adults ≥18 adults ≥18

Screening test measure BP fasting lipid panel q 5 yrs (more frequently if increased risk of CAD) annual FOBT + either colonoscopy q 10 yrs or flex sigmoidoscopy q 5 yrs not recommended monthly self-exam + physician exam q 3 yrs until 40, then q yr + mammogram q 1-2 yrs ≥40 Pap smear q 2 yrs 21-29, q 3 yrs >30 after 3 negative Paps (don’t need s/p hysterectomy) cervical sampling + RPR-VDRL ± HIV ELISA

Osteoporosis Smoking Alcohol Depression Diabetic retinopathy Hearing loss Atherosclerosis complications (PVD, stroke, CAD)

diabetic pts adults ≥65 adults ≥65

Etiology: chronic ↑ abdominal pressure, pelvic relaxation, old age (↓estrogen → loss of mucosal coaptation) Etiology: idiopathic (MCC), UTIs, bladder stones or cancer, urethral diverticula, foreign bodies Etiology: medications, neurologic disease

• Dx methylene blue or indigo carmine dye • Tx surgery to repair fistula

• Tx AA referral • Tx disulfiram (Antabuse) blocks aldehyde • dehydrogenase → aversive reaction; • naltrexone blocks opioid-R → ↓cravings; • acamprosate → ↑GABA/↓glu → ↓cravings

HEALTH MAINTENANCE

Other Etiology: cerumen impaction (MCC conductive), presbycusis (MCC sensorineural), lots of other causes

DEXA scan q 2 yrs screen + counsel screen + counsel screen + counsel if clinic has adequate mechanisms for dx, tx, and f/u referral to ophtho for annual fundoscopic exam hearing test assess risk factors

Korsakoff psychosis: chronic thiamine deficiency → irreversible Retrograde and Anterograde amnesia, Confabulations Complications: CV dz (CAD, MI, stroke, PVD), COPD, cancers, osteoporosis, Buerger dz, etc.

PEDIATRICS

Pediatrics – Shelf notes

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GENERAL PEDS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

★ Developmental milestones

Fine motor ---

Speech cooing

Social recognizes parents, social smile

6 mo 1 yr

Gross motor holds head up, rolls front-to-back sits up walks

raking grasp throws object, 3 blocks

babbling 10 words

2 yr

climbs stairs

turns pages, 6 blocks

3 yr

rides tricycle

draws circle, 9 blocks

4 yr

hops on one foot

draws cross

40 words, 2-word sentences, 50% understandable 900 words, 3-word sentences, 75% understandable counts to ten, tells stories, 100% understandable

stranger anxiety comes when called, imitates actions, object permanence parallel play

3 mo





cooperative play, imaginary friends

 Speech delay: deafness, autism, child abuse Vaccinations: only contraindication across all vaccines is a severe allergic response  DTaP contraindications: severe allergic response, encephalopathy within 7 days  Adverse response to DTaP: give DT instead, since rxn is due to pertussis component  Foot drop s/p injection: needle injection in lower/inner gluteal quadrant → iatrogenic damage to sciatic nerve Orthopedic issues  Clavicle fx: presents w/ clavicular crepitus or callus, ↑risk w/ LGA infants and breech deliveries; Tx reassurance > figure-of-8 splint  Supracondylar fx: MC fx in kids, due to trauma to humerus; Tx ortho c/s + check radial pulse since brachial artery can be injured  Toddler fx: nondisplaced spiral fx of distal tibia in infants; Tx splint immobilization  Nursemaid elbow: pulling on hand → subluxation of radial head from annular ligament → kid holds arm in a pronated position; Tx manual reduction via supinating motion  Radial epiphyseal separation: falling out outstretched arm → separation of radius at epiphyseal plate  Genu varum (bowlegs): observe in kids <2 y/o, called Blount disease in kids >2 y/o and requires ortho c/s  Genu valgus (knock-knees): observation okay  Metatarsus adductus: congenital foot deformity, forefoot pointing inwards Presentation Management Type I metatarsus adductus overcorrects into position w/ passive and active movements Tx reassurance Type II metatarsus adductus corrects into position w/ passive and active movements Tx orthosis or corrective shoes Type III metatarsus adductus doesn’t correct into position w/ passive or active movements Tx surgical correction 



group play

Clubfoot: congenital foot deformity, inward and downward-pointing feet, ↑risk of associated spina bifida; Tx stretching + manipulation + serial casts (<3 mo), surgery (>3 mo)  ★ Legg-Calve-Perthes disease: avascular necrosis of femoral head, presents as painless limp in a boy <10 y/o, requires ortho c/s  ★ Slipped capital femoral epiphysis: painful limp in a fat boy; Dx X-ray, requires ortho c/s  ★ Osgood-Schlatter disease: overuse injury of quads and patellar tendon → traction apophysitis of tibial tuberosity → localized pain/swelling; Tx RICE + NSAIDs  Congenital hip dysplasia: presents as uneven gluteal folds and “snapping hips” during physical exam in a newborn; Dx U/S (not calcified enough for X-ray), Tx splinting  Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg for 3 days), Tx admit + IV abx  Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx drainage + IV nafcillin  Osteogenesis imperfecta: AD ∆type 1 collagen → abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss; often mistaken as child abuse  Osteosarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows Codman’s triangle and “sunburst appearance”, Tx ortho c/s for surgery  Ewing sarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows “onion skin” appearance, Tx ortho c/s for surgery  Growing pains: deep aching pain in leg muscles w/o any “red flags” (fever, swelling, systemic sx); Tx reassurance  Patellofemoral syndrome: chronic anterior knee pain, worse w/ exercise or prolonged sitting; Tx strengthening exercises ★ Skin rashes Presentation Management Eczema (atopic dermatitis) chronic pruritic rash on cheeks, behind ears, Tx moisturizers (calamine or eucerin extensor surfaces, flexural areas lotion) + topical steroids Urticaria allergic reaction → pruritic “wheal and flare” Tx antihistamines + PO steroids + avoid rash allergen Chickenpox (varicella) VZV infx → “dew drops on a rose petal” Tx antihistamines, ACV if onset <24 hrs vesicular rash in an ill child Staphylococcal scalded skin syndrome Staph aureus exfoliatoxins A/B → fever + Tx abx + local skin care (SSSS) severe, painful rash that develop into bullae, rupture, and eventually desquamate Pityriasis rosea single oval herald patch (resembles Tx reassurance ringworm), followed by diffuse “Christmas tree” pattern rash on back 5-10 days later Lichen planus Purple Polygonal Pruritic Papules (rare in Tx PO steroids children) Contact dermatitis skin rash w/ vesicles and oozing (acute) or Tx antihistamines + topical steroids +

Pediatrics – Shelf notes

Psoriasis Henoch-Schonlein (anaphylactoid) purpura

Scabies Impetigo Porphyria cutanea tarda







crusted, thickened skin (chronic) in an exposure pattern (e.g. linear for poison ivy, localized for nickel) thick silvery scales that bleed upon removal (Auspitz sign) IgA-mediated small vessel vasculitis → “palpable purpura” on buttocks and legs, renal disease (IgA mesangial expansion), ileocecal edema → colicky abdominal pain + ↑risk for intussusception Sarcoptes scabeii infx under skin → pruritic bullae and pustules (not burrows like adults) Staph aureus infx → vesicles/pustules on face and extremities w/ classic “golden crust” ∆uroporphobilinogen decarboxylase → photosensitivity to UV light, tea-colored urine, recurrent attacks of abdominal pain

avoid exposure

Tx topical steroids + calcipotriene (mild), MTX/infliximab/cyclosporine A (severe) Tx steroids vs. symptomatic relief, will self-resolve

Tx permethrin cream (lindane causes seizures in kids/elderly) Tx topical mupirocin > PO erythromycin ---

Behavioral issues  ★ Enuresis: involuntary urination >5 y/o; Dx UA to r/o UTI, Tx bed-wetting alarm > desmopressin > imipramine  ★ Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows dilated/stoolfilled colon, Tx bowel catharsis + miralax  Breath-holding spells: child holds breath and passes out, due to pain or being upset; Tx avoid reinforcing behavior  Night terrors: child wakes up screaming/agitated, but falls back asleep and remembers nothing in the morning  Nightmares: child wakes up scared and crying, remembers incident  Learned behavior: child wakes up scared and crying, in order to gain sympathy and sleep in mommy’s bed; Tx avoid reinforcing behavior  Somnambulism: sleepwalking, don’t wake up the child  Somniloquy: sleeptalking, benign  Conduct disorder: Capriciousness, Oppressive, Nonconfrontational, Deceitful, Unlawful, Carefree, Temper issues; <18 y/o  Antisocial personality disorder: conduct disorder >18 y/o  ★ ADHD: short attention span, impulsivity, hyperactivity for >6 months in 2+ settings (e.g. home and school); ↑risk of aggression; Dx Vanderbilt scale, Tx dextroamphetamine or methylphenidate  Mental retardation (MR/DD): IQ <70; MCC overall is fetal alcohol syndrome, MC genetic cause is Down syndrome, MC inherited cause is Fragile X syndrome Abnormal physical exam findings  Head lice: due to Pediculosis capitis; Tx permethrin shampoo (lindane causes seizures in kids/elderly)  Traction alopecia: linear hair-loss in kids who tie their hair too tightly  Alopecia areata: hair stops growing suddenly → small patches of complete hair loss w/ “exclamation point” stubs  Asymmetric red reflex: retinoblastoma (AD ∆Rb on chromosome 13), juvenile cataracts (galactosemia, congenital rubella syndrome, neurofibromatosis II, myotonic muscular dystrophy)  Cherry-red macula: Tay-Sachs disease (AR ∆hexosaminidase A) w/o HSM, Niemann-Pick disease (AR ∆sphingomyelinase) w/ HSM  Strabismus: cross-eyes; Tx ophtho c/s to patch the good eye (uncorrected strabismus can lead to ambylopia)  Blue sclerae: osteogenesis imperfecta  Pinpoint pupils: opioids (Tx naloxone), organophosphates (Tx atropine + pralidoxime)  Cholesteatoma: small whitish debris-containing sac on TM, ↑risk w/ recurrent otitis media; Tx ENT c/s for surgical removal  Nasal polyps: cystic fibrosis, triad asthma (aspirin-sensitive)  Strawberry tongue: Kawasaki disease, scarlet fever, toxic shock syndrome  Primary teeth eruption: central incisors (at ~6 mo), lateral incisors, first molars, canines  Permanent teeth eruption: central incisors (at ~6 yr), lateral incisors, canines, first molars, second molars, third molars  Tooth decay: prolonged use of bottles → high sugar concentration → extensive tooth decay of all but mandibular front teeth  Tooth avulsion: facial trauma → knocked out teeth; Tx transport teeth in mouth or milk/saline, then replant permanent teeth within 30 min (earlier is better)  Retained primary teeth: Job syndrome (hyper-IgE)  Single central incisor: GH deficiency  Thyroid nodule: Dx TSH levels, if euthyroid then get FNA  Café-au-lait spots: neurofibromatosis I, McCune-Albright syndrome  Knuckle-knuckle-dimple-knuckle sign: brachydactyly of 4th digit = Turner syndrome  Knuckle-knuckle-dimple-dimple sign: brachydactyly of 4th/5th digits = pseudohypoparathyroidism  Erythema nodosum: painful red nodules on shins; MCC in kids is Strep pyogenes (not sarcoidosis like adults)  Pes cavus: high-arched foot associated w/ Friedreich ataxia, Charcot-Marie-Tooth disease  Micropenis: GH deficiency  ★ Child abuse: suspect w/ retinal hemorrhages, subdural hematoma, multiple healed fx, posterior rib fx, metaphyseal corner (“bucket handle”) fx, long-bone spiral fx (except distal tibia), cigarette burns, stocking-and-glove scalding water injury, or genital trauma/STDs; first r/o medical causes, then do a complete physical exam, then get whole-body X-rays, then call CPS if necessary  Neonatal HIV: suspect w/ thrush, generalized LAD, hepatomegaly, and FTT; Dx HIV PCR (not ELISA since mom’s ab can cause false-positive), requires Bactrim ppx for PCP pneumonia Environmental exposure  Dog/cat bite: Tx copious irrigation, make sure tetanus is up-to-date, allow healing by 2° intention, PPx Augmentin for Pasturella cellulitis  Human bite + cellulitis: due to Eikenella or other oral anaerobes; Tx admit + debridement + IV abx, leave open to heal by secondary intention

Pediatrics – Shelf notes

        

Black widow bite: neurotoxin → severe abdominal cramps, acute abdomen, n/v; Tx IV calcium gluconate + muscle relaxants Brown recluse bite: necrotoxin → local skin ulceration; Tx excise ulcer + skin graft Heat stroke: T>105 after playing in the sun, #1 risk factor is dehydration, ↑risk of rhabdomyolysis → renal ATN; Tx emergent cold water bath + IV fluids Frostnip: cold exposure → small/firm/cold/white blisters on exposed skin; Tx rewarming Frostbite: cold exposure → dead tissue → numb/white extremities followed by erythema and pain on reexposure to heat Chilblain: cold exposure → small, ulcerated lesion on ears and fingertips; Tx reassurance Cold panniculitis: cold exposure → destruction of fat cells; “popsicle panniculitis” found on lips/cheeks of kids during summertime Hypothermia: cold exposure → T<95, lethargic, tired, uncoordinated, bradycardia; Tx gradual rewarming Trench foot: prolonged cold/moisture exposure → foot becomes cold, clammy, numb, pale, swollen

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NEWBORN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 





       



APGAR score: score of 0-10 taken at 1 and 5 minutes; score of 0-3 requires resuscitation 0 1 Appearance all blue/pale mixed blue/pale and pink Pulse 0 <100 Grimace no response to stimulation grimace Activity limp some flexion of limbs Respirations 0 slow/irregular

2 all pink >100 active cough active flexion of limbs regular

Primitive reflexes: originate from brainstem and vestibular (CN VIII) nuclei  Moro reflex: limb flexion when extending head  Grasp reflex: grasps at finger when placed in baby’s palm  Rooting reflex: turns face towards cheek stimulation  Placing reflex: steps up when stimulating dorsum of feet  Tonic neck reflex: turning neck causes arm extension (ipsi) and flexion (contra)  Babinski reflex: fanning of toes when scratching dorsum of feet  Parachute reflex: startled arm extension when dropping baby ★ Neonatal skin rashes  Milia: benign, tiny white bumps on nose  Salmon patch (nevus flammeus): benign, splotchy red rash on forehead, eyelids, or back of neck; more prominent with exercise or emotion  Pustular melanosis: benign, little pustules that leave a hyperpigmented spot when ruptured  Erythema toxicum: benign, yellow-white papules w/ surrounding erythema, fluid exam shows eosinophils  Mongolian spots: benign, bluish macules on back and buttocks  Seborrheic dermatitis: greasy scaly rash, usually on scalp in newborns (“cradle cap”), can result in dandruff; Tx sunlight + mild shampoo  Sebaceous nevus: raised, yellow-orange hairless lesion on scalp; Tx resection before adolescence (can undergo malignant degeneration)  Neonatal acne: pimples on healthy newborn due to maternal hormones; Tx reassurance (mild), topical benzoyl peroxide or tretinoin (severe)  Strawberry hemangioma: small reddish capillary malformations  Incontinentia pigmenti: XR, inflammatory bullae that evolve into hyperpigmented lesions, lethal in males ★ SIDS: sudden-death in infants w/o underlying cause; prevent by putting infant on “back to sleep”, don’t smoke around your kid Breastfeeding contraindications: HIV, HSV on breast, active TB, chemotherapy, galactosemia, PKU, lithium, EtOH, iodine LP contraindications: elevated ICP w/o open fontanelle, severe cardiorespiratory distress, puncture site cellulitis, severe coagulopathy Circumcision contraindications: hypospadias (foreskin used to repair defect) Oligohydramnios: renal problems → ↓amniotic fluid → pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet) Polyhydramnios: GI obstruction or maternal diabetes → ↑amniotic fluid Twin-twin transfusion syndrome (TTTS): abnormal vascular flow between mono-di twins → donor twin oligohydramnios/anemia, recipient twin polyhydramnios/polycythemia; Dx hct difference >15 Coombs test: indicated for neonatal jaundice in type-O or Rh- moms  ★ ABO hemolytic disease: type-O mom w/ type-A/B baby develops anti-A/B IgG → crosses placenta and attacks fetal RBCs → causes fetal hydrops; ↑risk of late-onset high output CHF; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions  ★ Rh hemolytic disease (erythroblastosis fetalis): Rh- mom w/ 2nd Rh+ baby develops anti-D IgG → crosses placenta and attacks fetal RBCs → causes fetal hydrops; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions Neonatal care  Neonatal shots: HBV vaccine, vitamin K  ★ Choanal atresia: non-canalized nasal passages → difficulty breathing while feeding but normal when crying; Dx nasal catheter or checking for fog under nares, Tx nasal tubes  ★ Meconium aspiration: suspect w/ meconium staining, low Apgar scores, respiratory distress, can result in systemic hypoxia and pulmonary hypertension; Tx intubation + tracheal suction + O2 mask  ★ Transient tachypnea of the newborn (TTN): tachypnea, grunting, possible cyanosis in a c/s infant due to retained fetal lung fluid; Dx CXR shows pulmonary vascular markings, Tx 100% O2 (will resolve in 3 days)  TTN vs. RDS: TTN improves w/ O2, RDS persists despite O2  Neonatal bloody stool: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal  Neonatal hypothermia: ↑risk of hypoglycemia; Tx place under a warmer  Neonatal hypoglycemia: increase feedings if glucose <40, start IV if <20  AGA: Appropriate for Gestational Age, 10th–90th percentile  SGA: Small for Gestational Age, <10th percentile; ↑risk of congenital malformations, hypoglycemia (low glycogen/fat stores), future growth retardation

Pediatrics – Shelf notes

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 

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LGA: Large for Gestational Age, >90th percentile; ↑risk of shoulder dystocia, type 2 DM, future obesity Hyperviscosity syndrome: fetal hypoxia → reactive polycythemia (hct >65%) → sludging/clotting of blood in lungs (respiratory distress), brain (seizures, tremors), kidney (renal vein thrombosis), GI (necrotizing enterocolitis); Tx partial exchange transfusion  Narcosis: lethargic/limp neonate in mom that got intrapartum opioids for pain control; Tx NICU admit + naloxone  Diaphragmatic hernia: bowels herniate into chest cavity → respiratory distress in a newborn; first put in a orogastric tube, then Dx CXR shows bowels in chest cavity, Tx surgical repair (high morbidity/mortality)  ★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction  ★ Duodenal atresia: presents as bilious vomiting and polyhydramnios, ↑risk w/ Down syndrome; Dx KUB shows “double bubble” appearance, Tx surgical repair  ★ Intestinal atresia: aka “apple peel” atresia; presents like duodenal atresia, due to vascular accidents in utero; Dx KUB shows “triple bubble” appearance, Tx surgical repair  Cleft lip/cleft palate: complications include recurrent OM, hearing loss → speech defects; Tx surgical repair (CL in 2-3 months, CP in 6 mo)  Pierre-Robin sequence: micrognathia → posteriorly displaced tongue (glossoptosis) → cleft palate + airway obstruction  Neonatal hypothyroidism : thyroid dysgenesis → lack of T4/T3 synthesis → subtle, nonspecific sx (constipation → distended abdomen → umbilical hernia, bradycardia, hypothermia, large fontanelles, etc.); Dx ↑TSH, Tx Synthroid  Neonatal thyrotoxicosis: maternal TSI crosses placenta → hyperthyroidism → tachycardia, tachypnea, irritability, diarrhea, vomiting, CHF, etc.; Dx ↓TSH, Tx propylthiouracil (PTU) for 2-4 months until mom’s ab disappear  ★ Neural tube defects: anencephaly, spina bifida occulta (“tuft of hair”), meningocele, myelomeningocele; Dx ↑AFP, PPx folate supplements before 4th week of gestation  Thumb polydactyly: rare, requires full genetic work-up  Pinky polydactyly: Tx surgical removal, also get echo for white (but not black) kids since white kids have cardiac issues as well  Neonatal tetanus: tetanus toxin (found in dirt) infects umbilical stump → rigidity, trismus, opisthotonus, risus sardonicus  Neonatal thrush: acquired from mom’s vag, does not indicate immunodeficiency; Tx nystatin swish-n-spit  AVM of great vein of Galen: presents w/ cranial bruits + high-output CHF Colic: unexplained crying for >3 hrs in an infant <3 months, Tx swaddle infant to calm him/her Premature infants: increased risk of necrotizing enterocolitis, intraventricular hemorrhage, neonatal RDS  ★ Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated  Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Tx VP shunt  ★ Neonatal RDS: prematurity or infant of diabetic mother → lack of surfactant → respiratory distress in a newborn; Dx L:SM ratio <2, PPx 48 hrs of maternal steroids, Tx surfactant + O2 therapy + CPAP  Retinopathy of prematurity: disorganized growth of retinal blood vx in premies → scarring and retinal detachment; ↑risk w/ both hypoxia and oxygen toxicity  Harlequin syndrome: transient erythema on dependent half of body, more common in premies Cerebral palsy: cerebral anoxia in utero → brain damage → non-progressive impairment of motor function (hypotonia, hyperactive DTRs, learning disabilities, low APGAR at birth) ★ TORCHES Presentation Management Congenital toxoplasmosis chorioretinitis + hydrocephalus + intracranial Tx pyrimethamine + sulfadiazine calcifications Congenital rubella syndrome cataracts + deafness + PDA Tx supportive care Congenital CMV usually asx, MC sequelae is sensorineural --hearing loss CMV inclusion disease “blueberry muffin” rash, HSM/jaundice, Tx IV GCV + supportive care thrombocytopenia, periventricular calcifications Neonatal HSV vesicular rash, HSV pneumonitis, temporal lobe Tx IV ACV + vidarabine if disseminated/systemic encephalitis (focal seizures) Neonatal HIV suspect w/ thrush, generalized LAD, Dx HIV PCR (not ELISA since mom’s ab can cause hepatomegaly, and FTT false-positive), requires Bactrim ppx for PCP pneumonia, give IV ZDV to all neonates of infected mothers Early congenital syphilis maculopapular peeling rash, snuffles (rhinitis w/ Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTAserous, purulent, or bloody discharge), HSM, ABS, Tx PCN + supportive care jaundice, generalized LAD Late congenital syphilis deafness, saber shins, mulberry molars, Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTAHutchinson teeth, saddle nose ABS, Tx PCN + supportive care Congenital varicella syndrome limb hypoplasia, clear vesicles → cutaneous Tx VZIG if mom has chickenpox from 5 days prior scars, chorioretinitis, cortical atrophy to 2 days after delivery, otherwise reassurance Neonatal head trauma  ★ Caput succedaneum: soft-tissue swelling of scalp where baby was delivered, crosses midline  ★ Cephalohematoma: bleeding between periosteum and skull → “squishy” feel to scalp that doesn’t cross midline  Subgaleal hemorrhage: bleeding under galeal aponeurosis → “squishy” feel to rapidly expanding scalp that crosses midline; Tx NICU admit for possible hemorrhagic shock  Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Dx head CT, Tx VP shunt  Epidural hematoma: head trauma to temporal bone → torn middle meningeal artery → LOC w/ “lucid interval” → uncal herniation → death; Dx head CT shows convex lens, Tx emergent craniotomy  Subdural hematoma: “shaken baby syndrome”

Pediatrics – Shelf notes

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– FEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––    



Length: 1× at birth → 1.5× in 1 yr → 2× in 5 yrs Weight: 1× at birth → 0.9× in 1 wk (ECF diuresis) → 1× in 2 wks → 2× in 6 mo → 3× in 1 yr  Adiposity rebound: period of growth where BMI increases faster than height, average 5 yrs Vision: 20/200 at birth → 20/40 at 6 mo → 20/20 at 4 yr ★ Failure to thrive: growth <5th percentile in 2+ of the following – height, weight, head circumference; most commonly due to nonorganic causes; Dx bone age (left wrist X-ray), Tx underlying cause  Constitutional growth delay: bone age < real age, tracks along low percentile on growth chart, good prognosis  Familial short stature: bone age = real age, usually have short parents, poor prognosis  Pathologic short stature: craniopharyngioma, hypothyroidism, GH deficiency, Turner syndrome, renal tubular acidosis ★ Vitamins Deficiency Toxicity Vitamin A: used to treat cystic acne, night blindness, dry skin increased CSF pressure (headache, blurry measles, and AML (M3 type) vision), dry skin, teratogenic; found in animal liver consumption Vitamin B1 (thiamine): given to kids dry beriberi (peripheral neuropathy), wet --before IV D5 to prevent iatrogenic beriberi (CHF), Wernicke-Korsakoff (ataxia, Wernicke-Korsakoff amnesia, confabulations, etc.) Vitamin B2 (riboflavin) cheilosis (dried cracks along corners of lips), --corneal vascularization Vitamin B3 (niacin) pellagra (diarrhea, dermatitis, dementia) flushing, pruritus (Tx NSAIDs) Vitamin B6 (pyridoxine) peripheral neuropathy, seizures, --sideroblastic anemia; found in INH usage Vitamin B7 (biotin) seborrheic dermatitis, enteritis, alopecia; --found in kids who eat raw eggs (avidin binds biotin) and biotinidase deficiency Vitamin B9 (folate): given to sickle cell megaloblastic anemia w/o neuro sx, neural --kids to help hematopoiesis tube defects; found in babies fed goat’s milk Vitamin B12 (cobalamin) megaloblastic anemia w/ neuro sx; found in --strict vegan diets and pernicious anemia Vitamin C scurvy (bleeding gums) uric acid stones Vitamin D: given to breast-fed kids who rickets (bowed legs, rachitic rosary) metastatic calcifications, kidney stones don’t get enough sunlight Vitamin E hemolytic anemia hemorrhagic diathesis Vitamin K: all infants get vitamin K shot hemorrhagic diathesis --at birth 

       

ADEK deficiency: malabsorption syndromes (cystic fibrosis, celiac sprue, tropical sprue, Whipple disease, abetalipoproteinemia, pancreatic insufficiency, lactose intolerance, etc.) ★ Goat milk: ↓folate → megaloblastic anemia ★ Cow milk: ↓iron → microcytic anemia ± pica, fatigue, pallor; Tx PO iron supplements ★ Breast milk: ↓vitamin D → nutritional rickets Zinc deficiency: acrodermatitis enteropathica (erythematous desquamating rash on hands/feet, scalp, buttocks, mouth) Selenium deficiency: CHF Kwashiorkor: protein malnutrition → FTT, anemia, edema, apathy, fatty liver Marasmus: overall lack of calories → FTT, subcutaneous fat loss, muscle atrophy, premature aged look Fluids/electrolytes  Serum osmolarity: 2×Na + BUN/2.8 + glucose/18  Maintenance fluids: D5½NS+20KCl using 100/50/20 rule for daily fluids, 4/2/1 rule for hourly fluids  Resuscitation fluids: 20 mL/kg bolus of NS or LR  ★ Vomiting: hypokalemic, hypochloremic, metabolic alkalosis  ★ Diarrhea: hypokalemic, metabolic acidosis  Dehydration: diarrhea or vomiting → lethargy, ↑HR, ↓BP, delayed capillary refill; Tx PO fluids (mild), 20 mL/kg bolus of NS/LR (severe)  Parkland formula: fluid resuscitation for burn victims; give LR at 4 mL/kg × %BSA, ½ over first 8 hrs then ½ over the next 16 hrs  Hyponatremia + pancytopenia: consider RMSF

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– DRUGS/POISONS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––  ★ Poisons Presentation Management Acetaminophen n/v, malaise, liver damage (↑LFTs) wait 4 hrs then get acet levels, determine need for N-acetylcysteine at that time (no harm in waiting up to 8 hrs before giving antidote) Aspirin, oil of wintergreen triad of fever, tinnitus, tachypnea → causes Tx sodium bicarb vs. hemodialysis mixed respiratory alkalosis + AGMA Caustic agents, drain cleaner, lye esophageal erosion, possible perforation Dx endoscopy to determine extent of damage, Tx controversial (call poison control) Cyanide headache → agitation/confusion → seizures Tx nitrites + hydroxocobalamin + and metabolic acidosis thiosulfate Hydrocarbons usually asx, may have transient gagging and Dx CXR to r/o aspiration pneumonitis,

Pediatrics – Shelf notes

Iron Lead

Methanol, ethylene glycol

Opioids Organophosphates

Phenothiazine, metoclopramide Shellfish TCAs Warfarin 

admit + observe for 24 hrs Dx iron levels, Tx deferoxamine Dx blood lead >10 μg/dL, Tx CaEDTA + dimercaprol + dimercaptosuccinic acid

Tx EtOH vs. fomipezole (4-MP)

Tx naloxone Tx atropine + pralidoxime (2-PAM)

Tx diphenhydramine Tx supportive care, may need mechanical ventilation Tx sodium bicarb or Fab antibody fragments Dx ↑PT/↑PTT, Tx vitamin K + FFP if severe

Teratogens: worst when exposed within first 8 weeks of gestation Effect ACE inhibitors renal dysgenesis Alcohol fetal alcohol syndrome (MR, abnormal facies, smooth philtrum, IUGR, congenital heart defects) Alkylating agents adactyly AmiNOglycosides Nephrotoxicity, Ototoxicity Cocaine fetal addiction, IUGR, placental abruption DES vaginal clear-cell adenocarcinoma Folate antagonists NTDs Iodide Lithium Maternal diabetes Retinoic acid Smoking Tetracyclines Thalidomide Valproic acid Warfarin X-rays, CT scans



coughing upper GI bleed, abd pain, metabolic acidosis, shock LEAD – Lead lines (basophilic stippling), Encephalopathy, Anemia and Abdominal pain, wrist Drop, foot Drop; MC source is paint in old homes (before 1950) AMS and AGMA after drinking “homemade alcohol”, methanol has optic disc hyperemia, EG has renal failure (oxalic acid crystals) miosis, bradypnea, bradycardia, hypotension “kid playing in garden shed found salivating/unconscious”, blocks ACh-esterase → muscarinic sx (LUSHPADS BBB) extrapyramidal sx (e.g. torticollis, opisthotonus, dysphagia) perioral parasthesias/numbness, generalized weakness, paralysis AMS, hypotension, anticholinergic effects (dilated pupils, etc), widened QRS complex hemorrhagic diathesis

goiter, hypothyroidism Ebstein anomaly fetal macrosomia (risk of shoulder dystocia), caudal regression syndrome (anal atresia to sirenomelia), CV defects CNS defects, hydrocephalus, microtia/anotia, micrognathia, athymia preterm labor, IUGR, ADHD tooth discoloration phocomelia (hands attached to shoulders) blocks folate absorption → NTDs; best management for anticonvulsants is monotherapy at lowest effective dose w/ careful monitoring bone deformities, fetal bleeding, abortion multiple anomalies

Common side-effects Corticosteroids Cyclophosphamide Diphenhydramine Doxorubicin (Adriamycin) Erythromycin HCTZ Inhaled corticosteroids Local epinephrine Nitrates NSAIDs Pseudoephedrine Sodium nitroprusside Topical benzocaine (Orajel) Vincristine

Side-effects infection, HTN, hyperglycemia, cataracts, osteoporosis, truncal obesity w/ abdominal striae, etc. hemorrhagic cystitis (Tx mesna) drowsiness dilated cardiomyopathy ↑risk of pyloric stenosis in <1 mo hyperGLUC – hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia thrush vasoconstriction (contraindicated in end-organ supply) methemoglobinemia (Tx IV methylene blue) platelet dysfxn, renal impairment, peptic ulcers sympathetic stimulation (tachycardia, hypertension, etc.) cyanide poisoning methemoglobinemia (Tx IV methylene blue) peripheral neuropathy

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GENETICS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––  

Triplet expansion syndromes: Fragile X, DMD, Huntington chorea, Friedreich ataxia ★ Genetic syndromes Mutation Presentation Patau syndrome trisomy 13 MR, cleft lip/Palate, holoProsencephaly, Polydactyly, rocker-bottom feet, death by 1 y/o Edward syndrome trisomy 18 MR, VSD, micrognathia, clenched hands, rocker-bottom feet, death by 1 y/o Down syndrome trisomy 21 (95%), MR, flat facies, epicanthal folds, simian crease, AVSD (endocardial Robertsonian cushion defect), GI issues (Hirschsprung dz, duodenal atresia), translocation (5%) ↑↑incidence of ALL, Alzheimer by 40 y/o; high-risk in women >35 y/o [note: Down syndrome + UMN sx = atlantoaxial instability]

Pediatrics – Shelf notes

Fragile X syndrome

XR ∆FMR1 (CGG trinucleotide repeats)

Williams syndrome

7q– (includes elastin)

Cri-du-chat syndrome

5p–

DiGeorge/velocardiofacial syndromes

22q11–

Klinefelter syndrome

47, XXY

47, XYY males Turner syndrome

47, XYY 45, XO

Noonan syndrome

---

VACTERL syndrome

---

AngelMan syndrome

Maternal 15q11–

Prader-Willi syndrome

Paternal 15q11–

Cornelia de Lange syndrome Marfan syndrome

--AD ∆fibrillin (15q)

Ehlers-Danlos syndrome

AD ∆type 3 collagen

Beckwith-Wiedemann syndrome

---

Holt-Oram syndrome

AD ∆TBX5

Jeune syndrome (asphyxiating thoracic dysplasia) Crouzon syndrome Neurofibromatosis I (von Recklinghausen disease)

---

Neurofibromatosis II Tuberous sclerosis

AD ∆NF2 AD ∆TSC

Sturge-Weber syndrome

---

PHACES syndrome

---

Von Hippel-Lindau syndrome Alport syndrome Waardenburg syndrome

AD ∆VHL XR ∆type 4 collagen AD or associated w/ advanced paternal age AD ∆FGFR3 or associated w/ advanced paternal age ---

--AD ∆NF1

Achondroplasia

Frohlich syndrome (adiposogenital dystrophy) Laurence-Moon-Biedl syndrome

---

Kartagener syndrome

∆dynein → immotile cilia AR ∆frataxin (GAA triplet repeats)

Friedreich ataxia



DSM-V – Discontinued chromosomal staining, Shows anticipation, Males-only, MR, Macrognathia, Macroorchidism, Mitral valve prolapse MR, elfin facies, extreme friendliness, English skills, hypercalcemia, CV defects (supravalvular aortic stenosis) MR, high-pitched “mewing” cry, microcephaly, epicanthal folds, CV defects CATCH-22 – Cleft palate, Abnormal facies, Thymic aplasia (no T-cells), CV defects, Hypocalcemia (no PTH), 22q11–; Dx intradermal Candida test, requires irradiated transfusions (prevent GVHD) female traits on a male (e.g. long legs, small balls, gyno, high-pitched voice, etc.) aggressive, antisocial behavior CLOWNS – Coarcted aorta, Lymphedema (knuckle-knuckle-dimpleknuckle), Ovarian dysgenesis, Webbed neck (cystic hygroma), Nipples spread (shield chest), Short stature; Tx GH replacement + ppx bilateral gonadectomy phenotypically similar to Turner syndrome but AD (males = females), associated w/ pulmonic stenosis rather than aortic coarctation Verbetral defects, Anal atresia, CV defect, TE fistula, Esophageal atresia, Renal/Radial defects, Limb defects “happy puppet syndrome” – MR, ataxia, flailing arms, outbursts of laughter MR, hypotonia, hyperphagia/obesity, hypogonadism, “almond eyes”; Tx GH replacement + dietary caloric restriction MR, bushy eyebrows + hirsutism, limb defects, self-injurious behavior elongated body habitus, MVP, aortic aneurysms, aortic dissection, lens subluxation [note: Marfan + clotting sx = homocystinuria] thin fragile skin, joint hypermotility/dislocations, MVP, aortic aneurysms, aortic dissection generalized overgrowth, large tongue, neonatal hypoglycemia, certain cancers (Wilms tumor, hepatoblastoma (Dx ↑AFP)) upper limb abnormalities (hypoplastic thumb, hypoplastic radii, missing pectoralis major) + cardiac abnormalities (Heart-Arm syndrome) long/narrow thorax → hypoplastic lungs, fibrotic liver, death due to pulmonary causes craniosynostosis, wide-eyes w/ proptosis, “beak nose” café-au-lait spots, Lisch nodules (iris hamartomas), optic gliomas, CNS tumors, pheos [note: NFI + HTN = Dx 24 hr urinary metanephrines to r/o pheo] bilateral acoustic neuromas, juvenile cataracts CNS/retinal hamartomas, sebaceous adenomas, hypopigmented “ash leaf” spots, Shagreen patches, renal angiomyolipomas, cardiac rhabdomyomas facial “port-wine stain” w/ ipsilateral AVM (Dx head CT shows “gyriform calcifications”) Sturge-Weber syndrome + other commonly-associated defects; Posterior fossa tumors, Hemangiomas on face, Arterial abnormalities, Coarctation of aorta, Eye abnormalities, Sternal defects bilateral RCC, hemangioblastomas, pheos nephritic syndrome (hematuria), deafness, ocular defects wide-eyes, broad nasal bridge, medial hyperplasia of eyebrows, white forelock (think Rogue), heterochromia, deafness short limbs but normal-sized torso (think Mini-me)

hypothalamic tumor → hyperactive feeding center (childhood obesity) + ↓GnRH secretion (secondary hypogonadism); similar to Prader-Willi syndrome obesity + MR, hypogonadism, polydactyly, retinitis pigmentosa → night blindness situs inversus (right-sided heart), recurrent pulmonary infx, infertility staggering gait + frequent falls, kyphoscoliosis, pes cavus, hammer toes; MCC death is hypertrophic cardiomyopathy

★ Inborn errors of metabolism: suspect w/ neonatal vomiting + metabolic acidosis, unusual odor of urine/sweat, HSM, MR, hyperammonemia, FHx of

early infant death, seizures PKU

Mutation AR ∆phenylalanine hydroxylase

Presentation MR, mousy body odor, blue eyes, blond hair

Maple syrup urine disease (MSUD)

AR ∆branched-chain amino acid

inability to digest isoleucine, leucine, valine (“I LoVe maple syrup”) →

Management Dx Guthrie test, Tx dietary ↓phe/↑tyr, can relax dietary restrictions over time but must reinstate during pregnancy to prevent maternal PKU Tx dietary ↓ile/↓leu/↓val

Pediatrics – Shelf notes

Galactosemia

Hereditary fructose intolerance

AR ∆aldolase B

Biotinidase deficiency

AR ∆biotinidase

Tyrosinemia

AR ∆fumarylacetoacetate hydrolase AR ∆glucose-6phosphatase

Von Gierke disease



decarboxylase AR ∆gal-1P uridyltransferase

Pompe disease

AR ∆acid maltase

A1AT deficiency

AR ∆α1-antitrypsin

Mitochondrial diseases

---

Lysosomal storage diseases

---

Hurler syndrome

AR ∆α-L-iduronidase

OTC deficiency

XR ∆ornithine transcarmbamylase

Alkaptonuria

AR ∆homogentisate oxidase

Homocystinuria

AR ∆cystathionine βsynthase

Lesch-Nyhan syndrome

XR ∆HGPRT

Medium-chain acyl-CoA deficiency (MCADD)

AR ∆fatty acid oxidase

PKU-like sx w/ sweet-smelling urine inability to digest galactose → Tx dietary ↓lactose/↓galactose profound illness following first milk/formula feedings, ↑risk of E. coli sepsis inability to digest fructose → Tx dietary ↓sucrose/↓fructose profound illness following first fruit juice feedings inability to synthesize biotin (vitamin Tx biotin supplements B7) → seborrheic dermatitis, enteritis, alopecia inability to digest tyrosine → failure Tx nitisinone (enzyme that helps to thrive, hepatomegaly, liver failure bypass metabolite accumulation) inability to run glycolysis → FTT, --hypoglycemia, hepatomegaly, lactic acidosis, characteristic appearance (short w/ fat cheeks, thin arms, big abdomen) inability to run glycolysis → FTT, --hypoglycemia, cardiomegaly inability to export enzyme → builds --up in liver (cirrhosis) + can’t break down proteolytic enzymes in lungs (early-onset panacinar emphysema) maternal inheritance w/ --heteroplasmy, affects permanent cells (heart, skeletal muscle, brain); diseases include MERFF, MELAS, LHON, and Kearns-Sayre syndrome inability to digest cellular debris → Dx urinary mucopolysaccharides, Tx systemic effects of mucopolybone marrow txp + enzyme saccharide accumulation (coarse replacement therapy facial features, HSM, joint contractures, MR, etc.) Fabry disease: XR ∆β-galactosidase, “bathing trunk” angiokeratomas Gaucher disease: AR ∆β-glucosidase, “Erlenmeyer-flask” appearance of long bones, “wrinkled paper” cells Metachromatic leukodystrophy: AR ∆arylsulfatase A Niemann-pick disease: AR ∆sphingomyelinase, “cherry-red macula” w/ HSM Tay-Sachs disease: AR ∆hexosaminidase A, “cherry-red macula” w/o HSM, exaggerated startle response (hyperacusis) Sandhoff disease: AR ∆hexosaminidase A+B inability to digest glycosaminoDx urinary dermatan sulfate and glycans → coarse facial features heparan sulfate (“gargoyle-like”), HSM, progressive developmental delay, death inability to digest amino acids in Tx arginine, benzoic acid, or urea cycle → profound illness phenylacetate to get rid of following first protein feedings ammonia; dialysis if unresponsive accumulation of homogentisate in --urine and joints → urine that turns brown/black on air exposure, adultonset arthritis HOMOCysteine – Hypercoagulable, Tx vitamin B6 + cysteine Optic lens dislocation, MR, Marfanoid habitus, Osteoporosis, Cysteine becomes essential in diet impaired purine metabolism → MR, --hyperuricemia, gout, self-mutilation can’t break down FA for energy → Tx L-carnitine + avoid prolonged hypoketotic hypoglycemia w/o fasting acidosis

Collagen defects  Osteogenesis imperfecta: AD ∆type 1 collagen → abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss; often mistaken as child abuse  Ehlers-Danlos syndrome: AD ∆type 3 collagen → thin stretchy skin, joint hypermotility/dislocations, MVP, aortic aneurysms, aortic dissection  Alport syndrome: XR ∆type 4 collagen → nephritic syndrome (hematuria), deafness, ocular defects

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CARDIOVASCULAR ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––    

Antibiotic ppx for dental procedures: give amoxicillin only if prior endocarditis, prosthetic valve, heart txp, or severe or repaired congenital heart defects (do not give for innocent childhood murmurs) Cyanosis: normal if peripheral (doesn’t involve mucus membranes), diagnostic for R-to-L shunt if central (involves mucus membranes) Benign murmurs: asymptomatic, grade III, diastolic or continuous

Pediatrics – Shelf notes



★ Congenital heart defects: 1% incidence, 2-6% w/ one sibling, 20-30% w/ two siblings

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L-to-R shunts: late-onset cyanosis due to Eisenmenger syndrome; includes VSD, ASD, PDA  ASD: presents w/ fixed-split S2 + exercise intolerance  Thrombocytopenia-absent radius syndrome (TAR): thrombocytopenia + bilateral absent radii + ASD  VSD: MC CHD overall, presents w/ holosystolic blowing murmur at LLSB, louder is better, most resolve spontaneously  PDA: presents w/ continuous machinery-like murmur + bounding pulses; Tx keep Patent w/ PGE1 and closed w/ indomethacin, surgical closure if >1 mo (won’t close spontaneously)  Eisenmenger syndrome: pulmonary hypertension reverses L-to-R shunts into R-to-L shunts  R-to-L shunts: early-onset cyanosis; includes ToF, TGV, TAPVR, Tricuspid atresia  Tetralogy of Fallot: PROVe – Pulmonic stenosis (determines Prognosis), RVH, Overriding aorta, VSD; presents as cyanotic “tet spells” and clubbing in a kid who squats for relief; Dx CXR shows “boot-shaped heart”, Tx shunt placement  Transposition of the great vessels: presents w/ life-threatening cyanosis in a newborn + single loud S2 without murmur; Dx CXR shows “egg on a string” w/ RVH, Tx emergent PGE1 then cath lab for atrial septostomy  TAPVR: presents w/ cyanosis + dyspnea; Dx CXR shows “diffuse reticular pattern” from pulmonary edema  Tricuspid atresia: lack of tricuspid valve + hypoplastic RV → cyanosis + LVH; Tx emergent PGE1 to keep PDA open and consult surgery  Aortic coarctation: suspect w/ weak femoral pulse or treatment-resistant HTN at young age, consider Turner syndrome in short women; Dx CXR shows rib-notching and “figure 3” aorta, Tx balloon angioplasty  Ebstein anomaly: RA hypertrophy + atrialized RV + tricuspid valve dilatation; associated w/ antenatal lithium use  Mitral valve prolapse: AD; presents w/ mid-systolic click and late-systolic rumble, does not require abx ppx for dental procedures Carotid artery dissection: trauma to head/neck/soft palate → dissection of internal carotid artery → stroke-like presentation, may have delayed onset relative to traumatic incident; Dx MRI, Tx observation vs. anticoagulation vs. surgical repair Cardiac diseases  Myocarditis: coxsackie B virus infx → inflammation of myocardium results in systolic dysfxn → fever + lethargy + CHF sx  Dilated cardiomyopathy (DCM): ventricular dilatation → systolic dysfunction → CHF sx (dyspnea, orthopnea, PND); Tx diuretics + inotropes, heart txp if severe  Hypertrophic cardiomyopathy (HCM): AD ∆β-myosin heavy chain → exertional dyspnea, angina, syncope, “sudden death in a young athlete”, systolic murmur enhanced by ↓preload; Dx echo + family hx, Tx β-blockers vs. myomectomy vs. pacemaker  Restrictive cardiomyopathy (RCM): endocardial fibroelastosis is MCC in kids  ★ Rheumatic fever: strep throat → anti-M ab → type 2 hypersensitivity → carditis, arthritis (MC), erythema marginatum, chorea, subcutaneous nodules; Dx ASO titer, Tx amoxicillin + PO steroids  ★ Kawasaki disease: CRASH and BURN – Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet swelling, fever >5 days; Tx IVIG + high-dose aspirin (watch out for Reye syndrome)  Postpericardiotomy syndrome: pericardial effusion w/ possible tamponade s/p cardiac surgery; presents w/ Beck triad (hypOtension, JVD, muffled heart sounds) Arrhythmias  Premature atrial beats: premature, abnormally-shaped P wave, benign  Premature ventricular beats: premature, wide QRS complex, benign  Supraventricular tachycardia (SVT): MC symptomatic arrhythmia in kids; re-entrant mechanism → HR >200 → sx of low cardiac output (dyspnea, pallor, syncope); Tx vagal maneuvers (carotid massage) or IV adenosine  WPW syndrome: presence of atrioventricular accessory tract → SVT + “delta wave” on EKG; Tx radiofrequency ablation  Congenital heart block: maternal SLE → anti-Ro/SSA attacks fetal heart conduction → complete (3°) heart block  Prolonged QT syndrome: prolonged QT interval → uncoordinated repolarization → torsades de pointes (Tx IV mag) → death  Prolonged QT + deafness: Jervell-Lange-Nielsen syndrome  Widened QRS + ingestion: TCAs (imipramine, amitriptyline, etc.); Tx sodium bicarb ★ Neurocardiogenic syncope: presents as 6 Ps – syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– RESPIRATORY ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––   

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Acute respiratory failure: hypoxemia (PO2 <50) or hypercapnea (PCO2 >60) → cyanosis, tachypnea, grunting, nasal flaring, chest retractions; Tx ABCs, then adequate oxygenation (may require intubation), then address underlying cause Wheezing: asthma (MCC), bronchiolitis, cystic fibrosis, foreign body aspiration, tracheomalacia ★ Asthma: reversible airway obstruction → wheezing, cough, chest tightness, dyspnea; normal PCO2 is a bad sign (retaining CO2 despite hyperventilation); Dx reversible FEV1/FVC <70%  Asthma + thrush: due to inhaled corticosteroids; Tx rinse mouth after inhaler use  Asthma + hypokalemia: β2-agonists can cause potassium to go into cells  Triad asthma: asthma + aspirin sensitivity (↑LT) + nasal polyps  Churg-Strauss syndrome: asthma + eosinophilia + vasculitis Frequency Tx Mild intermittent asthma <2 times/wk prn SABA (albuterol) Mild persistent asthma 2+ times/wk add low-dose inhaled steroids Moderate persistent asthma daily + nighttime sx 1/wk add LABA (salmeterol) Severe persistent asthma continuous + frequent nighttime sx add high-dose inhaled steroids Asthma exacerbation --albuterol nebulizer + PO steroid burst Status asthmaticus unresponsive to meds admit + intubate Foreign body aspiration: sudden-onset respiratory distress + focal wheezing, can have recurrent PNA in same lobe; Dx/Tx rigid bronchoscopy

Pediatrics – Shelf notes

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Respiratory infx  ★ Croup: parainfluenza infx → barking cough, low-grade fever, respiratory distress; Dx AP neck X-ray shows “steeple sign”, Tx PO steroids + O2 therapy > racemic epinephrine > intubation  Bacterial tracheitis: rare complication of croup (superinfection), presents w/ biphasic stridor, spiking fever, respiratory distress; Tx emergency intubation + IV abx  ★ Epiglottitis: H. flu infx of epiglottis → sore throat, fever, inspiratory stridor, drooling, “sitting on a table leaning forward”; Dx lateral neck X-ray shows “thumbprint sign”, Tx emergency intubation + IV abx  ★ Bronchiolitis: RSV infx during wintertime → bronchiolar inflammation → wheezing, URI sx, respiratory distress, ↑risk of developing asthma; Tx supportive care w/ monitoring of O2 and hydration status (ribavarin if severe, pavilizumab ppx for high-risk infants)  Typical PNA: Strep pneumo (MCC) infx → acute-onset fever, chest pain, productive cough; Dx CXR shows lobar consolidation, Tx ceftriaxone or respiratory fluoroquinolones  Atypical PNA: Mycoplasma (MCC), Legionella, or Chlamydia infx → inflammation of lung interstitium → presents w/ fever, malaise, nonproductive cough; Dx CXR shows interstitial infiltrates, Tx azithromycin  Empyema: Strep/Staph infx of pleural space → respiratory distress; Dx CXR shows unilateral “white out” of lung, Tx vancomycin + chest tube drainage  Tuberculosis: Mycobaterium tuberculosis infx → cough/hemoptysis, fever, weight loss; Dx Tb skin test (>15 mm w/o risk factors, >10 mm w/ risk factors, >5 mm w/ immunosppression or known contacts) → if positive, get CXR  Latent TB: negative CXR, Tx INH x 9 months  Active TB: positive CXR, Tx RIPE (Pyrazinamide + INH + Rifampin + Ethambutol) x 6 months  TB meningitis: Dx CSF shows lymphocytosis + low glucose; Tx RIPE + steroids  ★ Retropharyngeal abscess: Staph/Strep or oral anaerobe infx of posterior pharyngeal wall → fever, sore throat, “muffled voice”, drooling; Dx lateral neck X-ray shows bulging mass, Tx emergent I+D  ★ Peritonsillar abscess: Staph/Strep or oral anaerobe infx → fever, sore throat, “hot potato voice”, deviated uvula; Tx emergent I+D  ★ Pertussis: Bordetella pertussis via respiratory droplets → “whooping cough” (short bursts of cough followed by loud inspiratory sound); Dx CBC (lymphocytosis), confirm w/ nasopharyngeal swab if necessary, Tx azithromycin for pt + all close contacts (regardless of immunization status)  Subcutaneous emphysema 2/2 cough: get CXR to r/o PTX Respiratory malformations  Bronchopulmonary dysplasia: inadequate repair of acute lung injury in premies → arrested lung development → chronic respiratory sx, need for O2 beyond 1 month; Dx abnormal CXR (nonspecific), Tx long-term supplemental O2  Congenital cystic adenomatoid malformation (CCAM): improper development of bronchioles → cystic mass in lungs → asx if small, respiratory distress w/ mediastinal shift if large; Dx chest U/S, Tx surgical excision  Laryngomalacia: soft, small, underdeveloped larynx → inspiratory stridor in neonates; Dx fiberoptic bronchoscopy, Tx reassurance (will resolve w/ growth), feed child only while upright and keep him upright for 30 min afterwards  ★ Vascular rings: congenital abnormalities of aortic arch or branches → rings around airway can compromise ventilation → inspiratory stridor relieved w/ opisthotonic position (“crowing” respiration); Tx surgery  ★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction Neonatal apnea: breath-holding spells >20 seconds (<20 seconds is normal) w/ possible cyanosis or bradycardia, due to immature respiratory center (central) or airway obstruction  Apparent life-threatening event (ALTE): apnea + color change (cyanosis, pallor), change in muscle tone (limpness), choking/gagging  Central apnea: Tx underlying cause, theophylline or caffeine can help  Obstructive sleep apnea: Dx polysomnography, Tx underlying cause (tonsillectomy/adenoidectomy, weight loss, CPAP) Idiopathic pulmonary hemosiderosis: unknown etiology → bleeding into lungs → recurrent PNA w/ hemoptysis, rapid clearing of CXR findings, irondeficiency anemia; Dx BAL shows hemosiderin-laden macrophages, Tx steroids Tension PTX: PTX + building pressure → mediastinal shift, hypOtension, JVD, absent unilateral breath sounds, hyperresonant to percussion; Tx emergent needle thoracostomy + chest tube ★ ABG analysis Dx Causes Management Respiratory acidosis pH <7.4, CO2 >40 hypoventilation increase ventilation Respiratory alkalosis pH >7.4, CO2 <40 hyperventilation 2/2 pain, fever, Tx underlying cause ARDS, sepsis NAGMA pH <7.4, CO2 <40, AG 8diarrhea, glue sniffing, RTA, Tx underlying cause 12 hyperchloremia AGMA pH <7.4, CO2 <40, AG >12 MUDPILES Tx underlying cause Metabolic alkalosis pH >7.4, CO2 >40 vomiting, antacids, Tx underlying cause hyperaldosteronism 

Anion gap: [Na – (Cl + HCO3)], normally 8-12

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GI/HEPATOBILIARY ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––  

Cyclical vomiting: idiopathic, recurrent self-limited episodes of n/v in children, no abdominal pain or constipation/diarrhea; Tx antiemetics Upper GI: proximal to Ligament of Treitz  Infant GERD: common complaint, presents w/ regurgitation of recently ingested food; Dx esophageal pH probe (gold standard but rarely necessary), Tx thickened feeds + reassurance (will resolve by 1-2 y/o)  Eosinophilic esophagitis: allergic response to food in esophagus → GERD-like sx unresponsive to PPIs; Dx EGD + bx shows eosinophils in esophagus, Tx PO steroids  ★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction  Bleeding esophageal varices: Tx octreotide, PPx β-blockers

Pediatrics – Shelf notes

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Mallory-Weiss syndrome: forceful emesis → small mucosal tears in esophagus → streaks of blood in vomitus; Tx reassurance Boerhaave syndrome: forceful emesis → esophageal rupture → severe retrosternal pain + acute distress; Tx surgical repair Caustic ingestion: alkali are worse than acids; Dx endoscopy to determine extent of damage, Tx controversial (call poison control) Foreign body ingestion: Tx emergent removal of disc batteries stuck in esophagus, other materials can be watched ★ Pyloric stenosis: presents w/ non-bilious projectile vomiting in first-born boys; Dx palpable epigastric olive + abdominal U/S, Tx pyloromyotomy  PUD: presents w/ gnawing epigastric pain (can persist at night) + occult GI bleed; Dx EGD, Tx PPIs Lower GI: distal to Ligament of Treitz  Milk protein intolerance: neonate w/ bloody diarrhea + eosinophils in stool  ★ Volvulus (malrotation): incomplete rotation of GI tract during development → bilious vomiting, abdominal pain/distention; Dx barium enema shows malposition of the cecum, Tx emergent surgical correction (↑risk of short gut)  ★ Meconium ileus: pathognomonic for CF, presents in newborn w/ bilious vomiting, abdominal pain/distention; Dx KUB shows dilated megacolon but barium enema shows microcolon from disuse, Tx gastrograffin enema  ★ Acute appendicitis: lymphoid hyperplasia or fecalith impaction → obstructed appendix w/ bacterial overgrowth → presents w/ fever, anorexia, n/v, diffuse abdominal pain that localizes to RLQ; Dx ↑WBC + CT scan or U/S, Tx appendectomy  Mesenteric adenitis: Yersinia enterocolitica infx → appendicitis-like presentation, associated w/ chitterlings and daycare centers  ★ Intussusception: presents w/ colicky abdominal pain that lasts 1 min then resolves + “currant jelly” stools, RUQ “sausage-like mass” on abdominal exam; Dx/Tx air contrast enema  ★ Hirschsprung disease: neural crest cells fail to migrate → lack of nerves in distal colon → chronic constipation since birth; Dx screen w/ barium enema, confirm w/ rectal bx, Tx surgical pull-through  ★ Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated  Anal atresia: Tx surgical repair (low pouch), colostomy then delayed repair (high pouch)  Congenital inguinal hernia: patent processus vaginalis → indirect inguinal hernia → incarcerated bowel is common; Tx elective herniorrhaphy prior to d/c  ★ Meckel diverticulum: MCC painless LGIB in a child; Dx technetium uptake for ectopic gastric mucosa, Tx surgery if symptomatic  Neonatal GI bleed: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal  Functional constipation: infrequent large/hard stools + normal physical exam; Dx KUB shows stool-filled megacolon, Tx reassurance + dietary counseling  ★ Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows stool-filled megacolon, Tx bowel catharsis + miralax  Toddler diarrhea: chronic explosive diarrhea in an infant w/ normal physical exam; Tx reassurance Malabsorption syndromes: present w/ steatorrhea + vitamin ADEK deficiency  ★ Cystic fibrosis: AR ∆CFTR (∆F508) → thick mucus → recurrent Pseudomonas pneumonia, bronchiectasis, infertility, chronic pancreatitis → malabsorption/steatorrhea + type 1 diabetes, meconium ileus (uncommon but pathognomonic), focal biliary cirrhosis, nasal polyps; Dx sweat chloride test x2 (>60), Tx pancreatic enzymes + vitamins ADEK + chest physiotherapy + mucolytics (N-acetylcysteine)  Lactose intolerance: lactase (disaccharidase) deficiency at brush border → lactose provides osmotic gradient for water + acts as GI flora nutrient → bloating, flatulence, diarrhea; Dx hydrogen breath test, Tx dietary ↓lactose  Celiac disease: AR ∆MTTP (microsomal TG transfer protein) → gluten hypersensitivity → chronic non-bloody diarrhea ± dermatitis herpetiformis; Dx anti-gliadin or anti-endomysial ab, Tx dietary ↓wheat/↓gluten  Abetalipoproteinemia: celiac disease-like presentation but normal GI bx; Tx ADEK supplements + low-fat diet  ★ Inflammatory bowel disease (IBD): presents w/ flare-and-remission pattern of crampy abdominal pain, bloody diarrhea, and weight loss Crohn disease Ulcerative colitis Location “mouth to anus” w/ skip lesions, rectal sparing colorectal, continuous lesion Morphology transmural inflammation, cobblestoning, mucosal inflammation, crypt abscesses and noncaseating granulomas pseudopolyps Complications strictures, fistulas, SBO toxic megacolon, colorectal cancer Dx +calprotectin, +ASCA, KUB shows terminal ileal +calprotectin, +p-ANCA, KUB shows “lead pipe sign” “string sign” Tx steroids + 5-ASA steroids + 5-ASA + annual colonoscopy Neonatal hyperbilirubinemia  ★ Physiologic hyperbilirubinemia: appears after day 2, direct bilirubin <1, total bilirubin <12  ★ Pathologic hyperbilirubinemia: suspect w/ jaundice on day 1, direct bilirubin >2, total bilirubin >20 (risk of kernicterus), rate of rise >5/day; MCC neonatal hepatitis and biliary atresia  Biliary atresia: lack of CBD → progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan, Tx hepatoportoenterostomy (Kasai procedure)  Choledochal cyst: cyst in CBD → biliary tree obstruction → progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan, Tx surgery  ★ Breast-feeding jaundice: ↓feeding → dehydration → retained meconium → ↑enterohepatic circulation of bilirubin; Tx ↑feeding frequency  Breast-milk jaundice: d/t glucuronidase and indirect bilirubin in breast milk  Dubin-Johnson syndrome: neonatal direct hyperbilirubinemia + ↑LFTs + “black liver”  Rotor syndrome: neonatal direct hyperbilirubinemia + ↑LFTs + no black liver Hepatobiliary/pancreatic  Acute cholecystitis: inflammation of gallbladder → Charcot triad (RUQ pain, n/v, fever); Dx RUQ U/S, Tx NPO/IVF/abx then lap chole within 24 hrs

Pediatrics – Shelf notes

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Acute pancreatitis: I GET SMASHHED (recall acronym) → inflammation of pancreas → stabbing epigastric pain boring through to the back, exacerbated w/ eating; Dx screen w/ ↑amylase/↑lipase, confirm w/ abdominal U/S, Tx NPO/IVF/pain meds Viral hepatitis: presents w/ jaundice, RUQ pain, n/v, dark-colored urine Buzzwords Management HAV (fecal-oral) asymptomatic, daycare, travel Dx HAV IgM (acute), HAV IgG (immune or previous infx); Tx supportive care HBV (parenteral, sexual) polyarteritis nodosa, MGN Dx HBsAg (acute), HBsAb (immune or previous infx), HBcAb IgM (window), HBeAg (infectious); Tx IFN-α HCV (parenteral, sexual) cryoglobulinemia, chronic infx, carriers, Dx HCV RNA (acute or chronic); Tx IFN-α + ribavarin cirrhosis, carcinoma, IVDA, MPGN HDV (parenteral, sexual) deadly, defective, HBV co-infection Dx HDV Ab; Tx IFN-α HEV (fecal-oral) cruise ships, fatal in pregnancy Dx HEV Ab; Tx supportive care A1AT deficiency: AR ∆α1-antitrypsin → inability to export enzyme → builds up in liver (cirrhosis) and can’t break down proteolytic enzymes in lungs (early-onset panacinar emphysema) Wilson disease (hepatolenticular degeneration): AR ∆ATP7B (copper-transporting ATP-ase) → copper overload → cirrhosis + movement disorder + hemolytic anemia + Kayser-Fleischer corneal rings; Dx ↑LFTs/↓ceruloplasmin/↓total copper/↑free copper, Tx D-penicillamine Reye syndrome: viral infx + ASA = fatty liver/liver failure, vomiting, AMS, 40% mortality rate (due to cerebral edema → herniation) Gilbert syndrome: AD ∆UGT-glucuronyltransferase → mild jaundice following stress or starvation; benign

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– RENAL/GU –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

Renal 

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Nephrotic syndrome: loss of negative charge on GBM → proteinuria → edema, hypoalbuminemia, hyperlipidemia; Dx UA shows fatty casts  Asymptomatic proteinuria: repeat dipstick, then quantify w/ 24 hr urine, then refer to nephro if still positive  Nephritic syndrome: inflammation of glomeruli → hematuria, oliguria, HTN, azotemia; Dx UA shows RBC casts  Asymptomatic hematuria: repeat UA, then get renal imaging if still positive  ★ Minimal change disease: nephrotic syndrome in kids following a viral URI, MCCOD is spontaneous bacterial peritonitis; Tx steroids, saltrestriction + diuretics during flares  ★ WAGR syndrome: ∆WT1 on chromosome 11 → Wilms tumor (kidney), Aniridia, GU anomalies, mental Retardation, hemihypertrophy  ★ Neuroblastoma: N-myc amplification → proliferation of neural crest cells in adrenal gland → abdominal mass/pain + opsoclonus-myoclonus syndrome (muscle jerks + eyelid jerks) ± bone mets (pancytopenia); Dx urinary ↑HVA/↑VMA  Goodpasture syndrome: anti-GBM antibodies attack pulmonary and renal basement membranes → hemoptysis + hematuria; Dx renal bx + linear-staining immunofluorescence  Fanconi syndrome: proximal tubule dysfunction → defective resorption of amino acids, bicarb, glucose, phosphate → polydipsia, polyuria, glucosuria, aminoaciduria, type 2 RTA, hypophosphatemic rickets, etc.  Type 1 RTA: “distal RTA”, collecting duct can’t excrete H+ → metabolic acidosis + urinary alkalosis, hypo-K  Type 2 RTA: “proximal RTA”, proximal tubule can’t resorb bicarb → metabolic acidosis + urinary alkalosis, hypo-K  Type 3 RTA: (does not exist)  Type 4 RTA: “hyperkalemic RTA”, ↓aldosterone or ∆aldosterone-R → metabolic acidosis + urinary acidosis, hyper-K  Low implantation of ureter: asx in boys, “wet w/ urine all the time” in girls b/c ureter drips into vagina instead of bladder; Dx IV pyelo, Tx surgical correction  ★ Posterior urethral valve: presents w/ oliguria + lower abdominal mass (distended bladder) in a neonate; first catheterize to empty bladder, then Dx VCUG, Tx resection  Myoglobinuria: rhabdomyolysis (heat, niacin, etc.) → myoglobin in urine → ↑risk of renal failure; Dx ↑CPK, UA shows heme but no RBC  Alport syndrome: XR ∆type 4 collagen → nephritic syndrome (hematuria), deafness, ocular defects  ★ Enuresis: involuntary urination >5 y/o; Tx bed-wetting alarm > desmopressin > imipramine  Idiopathic hypercalciuria: persistent excretion of calcium irritates urinary tract → dysuria, ↑risk of kidney stones, microscopic hematuria w/ recurrent episodes of gross hematuria  Kidney stones: presents w/ flank pain radiating to groin + hematuria; Dx U/S or CT scan, Tx hydration (<½ cm), shockwave lithotripsy (½–2 cm), surgery (>2 cm) Dialysis indications: AEIOU – Acidosis (severe metabolic acidosis), Electrolytes (severe hyperkalemia), Intoxication, Overload (severe hypervolemia), Uremia (BUN >150, pericarditis) Kidney infx  Lower UTI (acute cystitis): presents w/ dysuria, frequency/urgency; ↑risk in uncircumcised males; Dx UA/UCx, Tx Bactrim > Cipro  Upper UTI (acute pyelonephritis): presents w/ dysuria, frequency/urgency, flank pain, fever/chills; Dx UA/UCx, Tx ceftriaxone  VCUG: indicated to r/o VUR in all males w/ UTIs, girls <5 y/o, or girls >5 w/ 2+ UTIs  ★ Vesicoureteral reflux (VUR): ureters implanted into wrong site on bladder → no mechanism for preventing retrograde urine reflux → recurrent UTIs at young age; Dx VCUG, Tx long-term abx until kid grows out of it (low grade), surgical reimplantation of ureter (high grade)  Chronic pyelonephritis: VUR → recurrent upper UTI → kidney scarring w/ “blunted calyces” on IV pyelo  Nephronia: halfway between pyelonephritis (dysuria, frequency/urgency, flank pain, fever/chills) and renal abscess; Dx CT scan shows “distinct tissue” in kidney, Tx long-term IV abx  ★ Poststreptococcal GN: GAS infx (strep throat, impetigo, cellulitis) → ag-ab complexes deposit in GBM → nephritic syndrome sx (hematuria, HTN, oliguria, azotemia, edema); Dx ↑ASO titers, Tx supportive care Male GU  Inconspicuous penis: normal in fat boys, retract foreskin and measure → refer to urology if <2.5 std dev  Micropenis: GH deficiency  Phimosis: inability to retract foreskin, Tx reassurance (normal for <3 y/o), urology consult (>3 y/o)

Pediatrics – Shelf notes

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Paraphimosis: inability to relocate foreskin after retraction; Tx urology consult ★ Hypospadias: urethral opening on ventral penis, ↑risk of UTIs; Tx urology consult, do not circumcise Epispadias: urethral opening on dorsal penis; Tx urology consult Urethritis: GC or CT infx → dysuria, frequency/urgency, urethral discharge; Dx GC/CT tests, Tx azithromycin + ceftriaxone ★ Testicular torsion: twisting of spermatic cord → severe testicular pain and “high riding testicle w/ horizontal lie”, lacks cremasteric reflex; first consult surgery, then Dx U/S to r/o epididymitis (similar presentation), Tx emergent surgical detorsion (<6 hrs) + orchiopexy ★ Epididymitis: presents like testicular torsion but w/ fever and pyuria; Dx U/S, Tx abx (usually for GC/CT) Varicocele: incompetent valves in spermatic vein → dilation of pampiniform plexus → “bag of worms” appearance when standing up but disappears lying down; Tx reassurance (kids), surgical correction (adults w/ infertility issues) Hydrocele: accumulation of fluid in tunica vaginalis → dilated, fluid-filled sac around testicle; Dx transillumination shines through (vs. testicular cancers). Tx reassurance (small), surgical correction (large)  Hydrocele vs. scrotal edema: scrotal edema feels like a big scrotum, hydrocele feels like a big nut Cryptorchidism: undescended testis → high risk for testicular torsion and seminoma; Dx U/S of inguinal canal, Tx orchipexy if undescended by 1 y/o (to avoid sterility and cancer) ★ Potter sequence: bilateral renal agenesis (or other renal abnormalities) → inability to secrete amniotic fluid in utero → oligohydramnios w/ amnion nodosum (granules on amnion) → pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet) ★ Prune belly syndrome: congenital malformation in males that consists of lax abdominal wall → marked distention, dilated urinary tract → Potter sequence, bilateral cryptorchidism

Female GU  Labial adhesions: benign fusion of labia minora; Tx estrogen cream  Labial adhesions + electrolyte imbalances: congenital adrenal hyperplasia  ★ Infant menstruation: maternal estrogen withdrawal → endometrial sloughing → sticky gray discharge (may be blood-tinged) in a 2-week girl; Tx reassurance (normal phenomenon)  ★ “Bubble-bath” vaginitis: vaginal irritation in little girls due to chemicals from bubble baths; Tx d/c bubble baths, wear cotton underwear, wipe front-to-back after potty  Polycystic ovarian syndrome (PCOS): ↑LH, ↓FSH, ↑E/T → anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss ± metformin  Pelvic inflammatory disease (PID): polymicrobial infx of upper female genital tract (endometritis, salpingitis, peritonitis) → nonspecific lower abdominal pain → ↑risk for infertility, ectopic pregnancy, pelvic adhesions, abscesses; Dx STD tests + “cervical motion tenderness”, Tx ceftriaxone + doxycycline  PID + pelvic mass: tubo-ovarian abscess; Dx transvaginal U/S, Tx I+D Umbilical cord  Delayed cord separation: leukocyte adhesion deficiency; Dx flow cytometry (∆CD11b)  Umbilical granuloma: red nodule on separated umbilical cord; Tx topical silver nitrate  ★ Omphalocele: intestines protrude into umbilical cord w/ peritoneal covering, ↑risk of associated cardiac defects; first sterile wrapping, then Dx echo to r/o cardiac defects, then Tx closure if small, silo if large  ★ Gastroschisis: intestines tear through abdominal wall w/o peritoneal covering; first sterile wrapping, then Tx closure if small, silo if large  ★ Umbilical hernia: associated w/ neonatal hypothyroidism, Beckwith-Wiedemann syndrome; Tx reassurance (<2 cm), surgical repair (>2 cm or persistent into kindergarten)  Patent urachus: failure of urachus to obliterate → urination from umbilical cord  Vitelline fistula: failure of vitelline duct to obliterate → meconium from umbilical cord –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NEURO/MSK ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

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Muscular dystrophy  Duchenne muscular dystrophy (DMD): XR ∆dystrophin → muscle cells die off → ascending weakness w/ Gowers maneuver, calf pseudohypertrophy, death by 15 y/o; Dx ↑CPK + muscle bx, no tx available  Becker muscular dystrophy (BMD): XR ∆dystrophin → milder form of DMD  Myotonic muscular dystrophy: AD; delayed muscle relaxation (can’t release handshake) + distal muscle wasting (older kids), neonatal respiratory distress (newborn), cataracts, ptosis, baldness, hypogonadism; Dx ↑CPK + muscle bx, no tx available  Charcot-Marie-Tooth disease: intrinsic foot muscle atrophy (pes cavus), then intrinsic hand muscle atrophy Muscle weakness/paralysis  Myasthenia gravis: anti-nAChR → gradually progressive muscle weakness (initial sx is ptosis, diplopia, blurry vision) that get worse w/ repetitive use; Dx edrophonium test + get chest CT to r/o thymoma, Tx pyridostigmine  Acute disseminated encephalomyelitis (ADEM): autoimmune demyelination after viral infx → multiple sclerosis-like sx but in kids <10 y/o; Dx MRI shows white matter demyelination, Tx high-dose corticosteroids  Acute infantile hemiplegia: trauma, infx, hypercoagulable state, arteritis, or metabolic d/o → MCA stroke in infant → abrupt onset hemiplegia  ★ Guillain-Barre syndrome: rapidly ascending paralysis after viral infx (or other infx), ↑risk of respiratory arrest (Tx mechanical ventilation); Dx CSF shows ↑protein, Tx IVIG or plasmapheresis  Bell palsy: facial nerve palsy 2 weeks after viral infx; Tx eyedrops (to prevent keratitis), will resolve on its own  Bilateral Bell palsy: 2° Lyme disease, Guillain-Barre syndrome  ★ Phrenic nerve palsy: presents w/ respiratory distress and unilateral decreased breath sounds in neonate (phrenic nerve innervates hemidiaphragm); Dx chest U/S or fluoroscopy shows “seesaw diaphragm”  ★ Erb-Duchenne palsy: C5/C6 palsy after difficult delivery → “waiter’s tip” posture  ★ Klumpke palsy: C7-T1 palsy after difficult delivery → total hand paralysis + ipsilateral Horner syndrome  Werdnig-Hoffman disease (SMA type 1): ∆SMN gene (protects neuroblasts from atrophy) → progressive degeneration of CNS motor neurons → respiratory distress + tongue fasciculations in newborn; Tx supportive care

Pediatrics – Shelf notes

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Seizures      

Simple partial seizure: automatisms Complex partial seizure: automatisms + LOC + postictal confusion Absence (petit mal) seizure: “brief staring spells”; Dx EEG shows 3-Hz spike-and-wave pattern, Tx valproic acid > ethosuximide Tonic-clonic (grand mal) seizure: LOC + rigidity (tonic phase) + muscular jerking (clonic phase) + postictal confusion Pseudoseizure: seizure-like activity w/o EEG changes, usually don’t have bowel/bladder incontinence or self-injury; Tx psych consult Febrile seizure: brief seizure in febrile child usually 2/2 bacterial or viral infx, doesn’t require extensive work-up, #1 risk factor is rate of temp change; Tx underlying cause, phenobarbital if necessary  Phenytoin toxicity: gingival hyperplasia; Tx good dental hygiene  Todd paralysis: focal weakness for 1-2 days following grand-mal seizure Malignant hyperthermia: AD ∆ryanodine receptor → T>104 + muscle rigidity + rhabdomyolysis following anesthesia; Dx caffeine contracture test, Tx dantrolene sodium, 100% O2, cooling blankets ★ Craniosynostosis: premature fusion of skull sutures → abnormal head shape + impaired brain development, 80% sporadic, 20% genetic (e.g. Crouzon syndrome); Tx surgical correction  Apert syndrome: AD, craniosynostosis + syndactyly of fingers/toes  Crouzon syndrome: craniosynostosis + wide-eyes w/ proptosis, “beak nose”  Scaphocephaly: isolated craniosynostosis of sagittal suture → long, narrow skull Headaches  Migraine headache: bifrontal headache w/o aura, or diffuse “throbbing” headache, atypical presentation in kids (no nausea/vomiting, photophobia, phonophobia)  Tension headache: bilateral, tight “squeezing” pain + posterior neck muscle stiffness  Cluster headache: unilateral, episodic “burning, stabbing” pain behind eye + ipsilateral tearing, flush, rhinorrhea  Factitious headache: recurrent headache on Mon-Fri mornings  ★ Pseudotumor cerebri: fat girl w/ pulsatile headache/tinnitus, high risk of blindness; first get imaging to r/o mass lesion (can have empty sella), then get LP w/ opening pressure to r/o infx causes, Tx acetazolamide vs. serial LPs Brain abscess: headache + focal neuro sx + fever, ↑risk w/ congenital heart defects; Dx head CT/MRI, Tx surgery + IV abx (unifocal), IV abx (multifocal) Brain tumor: headache + focal neuro sx + subacute onset; infratentorial more common <10 y/o, supratentorial more common >10 y/o  ★ Craniopharyngioma: embryological remnant of Rathke pouch in sella turcica → headache, bitemporal hemianopsia, papilledema; Dx MRI shows suprasellar calcified cysts, Tx transsphenoid hypophysectomy  Pinealoma: brain tumor at rostral midbrain → vertical gaze paralysis (Parinaud syndrome) + eyelid retraction (Collier sign) + ↑ICP sx  Retinoblastoma: AD ∆Rb on chromosome 13 → retinoblastoma (MCC leukocoria in kids) + ↑risk of osteosarcoma later in life Cushing triad: brain mass lesion → ↑ICP → ↓HR, ↑BP, irregular RR Epidural hematoma: head trauma to temporal bone → torn middle meningeal artery → LOC w/ lucid interval → uncal herniation → death; Dx head CT shows convex lens, Tx emergent craniotomy Infantile botulism: ingestion of C. botulinum bacteria (not toxin) in raw honey → bacteria releases toxin in GI tract → constipation (initial sx) then gradual flaccid paralysis; Tx BabyBIG (botulinum immunoglobulin) + ventilator support Dandy-Walker syndrome: enlargement of 4th ventricle (hydrocephalus) + agenesis of cerebellar vermis Acute cerebellar ataxia: autoimmune attack on cerebellum after a viral infx → cerebellar sx (ataxia, nystagmus, dysarthria); Dx of exclusion Rasmussen encephalitis: autoimmune attack on brain → rapid degeneration, initially presents w/ frequent and worsening seizures; Dx MRI, Tx hemispherectomy Pervasive developmental disorders  ★ Autism: characterized by problems w/ social interaction, communication skills, and repetitive/stereotyped patterns of behavior and activity before 3 y/o; must get hearing test to r/o deafness  Asperger syndrome: mild autism w/ normal language skills and cognitive development  Rett syndrome: ∆MECP in girls → normal development for 5 months, then ↓rate of head growth + loss of purposeful hand movements, then ataxia, ↓language skills, “hand wringing”  Childhood disintegrative disorder: normal development for >2 years, then loss of previously acquired skills  ★ Learning disability: significant discrepancy between IQ and ability in one of the following – math, reading, or writing ★ Neurocardiogenic syncope: presents as 6 Ps – syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration Transient tic disorder of childhood: nonrhythmic, spasmodic, involuntary behaviors (e.g. blinking, throat clearing) that last <1 yr; Tx reassurance Tourette syndrome: severe tic disorder w/ multiple daily motor/vocal tics, may have echolalia or coprolalia (rare), ↑association w/ OCD and ADHD; Tx haloperidol > α2-agonists (clonidine, guanfacine)

–––––––––––––––––––––––––––––––––––––––––––––––––––––––– INFECTIOUS DISEASES –––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

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★ Ophthalmia neonatorum

Chemical conjunctivitis

Timing day 0-1

Management Tx reassurance

Gonococcal conjunctivitis Chlamydia conjunctivitis

day 2-5 day 5-14

Tx topical erythromycin + IV ceftriaxone Tx PO erythromycin

Features not seen anymore since silver nitrate drops are rarely used can cause corneal ulceration can cause chlamydial pneumonia (“staccato cough” + eosinophilia)

STDs Chlamydia

Bugs Chlamydia trachomatis

Presentation urethritis in men; cervicitis, PID, TOA, often asx in women

Management Dx Chlamydia NAAT, Tx azithromycin (+ ceftriaxone)

Pediatrics – Shelf notes

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Gonorrhea

Neisseria gonorrhoeae

urethritis in men; cervicitis, PID, TOA, often asx in women thick, white curd-like discharge, severe itching, satellite lesions

Vaginal candidiasis

Candida albicans

Syphilis

Treponema pallidum

Chancroid

Haemophilus ducreyi

Herpes simplex

HSV-1/2

Lymphogranuloma venereum

Chlamydia trachomatis, L1-L3 serotypes

Condyloma acuminata Bacterial vaginosis

HPV-6/11 Gardnerella vaginalis

Trichomoniasis

Trichomonas vaginalis

green-gray frothy discharge, odor, strawberry cervix

HIV/AIDS

HIV-1/2

Crabs (pediculosis pubis)

Phthirus pubis

1° – mono-like syndrome w/ maculopapular rash asx stage – CD4 >500, asx sx stage – CD4 200-500, general LAD, fungal infx, night sweats, weight loss, diarrhea AIDS – CD4 <200 or opportunistic infx severe itching, irritation, burrows, vesicles

1° – painless chancre + LAD 2° – palmar/plantar rash, condyloma lata, general LAD 3° – neurosyphilis + CV syphilis (luetic heart) + gummas painful chancre + LAD recurrent, painful oral or genital vesicles that can rupture 1° – transient, painless ulcer 2° – painful LAD 3° – anogenital syndrome (proctocolitis, rectal strictures, rectovaginal fistulas, genital elephantiasis) genital warts thin homogenous discharge w/ fishy odor

Dx discharge Gram stain, Tx ceftriaxone (+ azithromycin) Dx KOH prep shows pseudohyphae, Tx diflucan vs. miconazole cream Dx screen w/ RPR-VDRL, confirm w/ FTA-ABS, definitive dx w/ Darkfield microscopy; Tx benzathine PCN G Dx discharge Gram stain, Tx azithromycin or ceftriaxone Dx Tzanck smear, Tx ACV/VACV within 48 hrs Dx complement fixation, Tx doxycycline

Tx removal Dx wet prep (clue cells), Tx metronidazole Dx wet prep (motile trichomonads), Tx metronidazole Dx screen w/ ELISA, confirm w/ WB, HIV PCR in infants; Tx HAART (2 NRTIs + 1 NNRTI or PI)

Dx hair under microscope, Tx permethrin shampoo

Rule-out sepsis: T >100.4 in any neonate (<28 days) gets admitted and the full work-up (UA/UCx, CSF, blood cx, CXR, etc.), MCC viral infx; Tx amp+gent until cx negative Bacteria  Neonatal PNA: MCC GBS; presents as respiratory distress, fever/hypothermia, leukocytosis/leukopenia w/ left-shift; Dx CXR, Tx ampicillin + gentamicin  Neonatal meningitis: MCC GBS; presents as fever, irritability, AMS, ±bulging fontanelle, and may not have meningeal signs; Tx ABCs then LP then ceftriaxone + vancomycin (different from adults, where you’d get CT then LP)  Meningitis + subdural effusions: common, benign finding  Listeria meningitis: due to maternal ingestion of lunch meats or unpasteurized dairy products  Meningococcal meningitis: Tx penicillin  Acute bacterial sinusitis: Strep pneumo > H. flu > Moraxella catarrhalis superinfx of viral URI → sinus tenderness, nasal congestion/discharge, headache, low-grade fever; Tx amoxicillin  Otitis media: Strep pneumo > H. flu > Moraxella catarrhalis; Tx amoxicillin  Otitis externa: Tx cipro drops  Diphtheria: due to Corynebacterium diphtheriae; presents as mild sore throat that leads to pseudomembranous pharyngitis, LAD with “bull neck” appearance, possible respiratory compromise  Shigellosis: watery/bloody diarrhea, fever, tonic-clonic seizures can precede GI sx (Ekiri syndrome); Dx stool cx, Tx IV fluids + ceftriaxone  ★ Strep throat: GAS infx of pharynx → sore throat, fever, tonsillar exudates, palatal petechiae; Dx rapid strep test, Tx amoxicillin  ★ Scarlet fever: due to GAS exotoxin; presents w/ sore throat, fever, strawberry tongue, “sandpaper rash” w/ possible desquamation of palms/soles; Dx ASO titers or rapid strep test, Tx amoxicillin  Arcanobacterium haemolyticum: strep throat/scarlet fever-like presentation but throat cx grows out Arcanobacterium instead  ★ Toxic shock syndrome: due to S. aureus TSST, often found in tampons; presents w/ septic shock, diffuse maculopapular rash (desquamation of palms/soles is late finding), strawberry tongue; Tx admit + stabilize + IV nafcillin (prevents recurrence)  Staph food poisoning: ingestion of preformed S. aureus enterotoxin → diarrhea, vomiting, abdominal cramps within 6 hrs  ★ Meningococcemia: meningitis, purpura fulminans (“petechiae becoming purpura in front of your eyes”), death by bilateral adrenal hemorrhage (W-F syndrome); Dx blood cx x3, Tx IV abx, PPx Rifampin for Roommates  Leptospirosis: due to Leptospira interrogans; presents as fever/chills, sore throat, myalgias, headache, cervical LAD, scleral injection, photophobia, and can lead to meningitis (but most infx are subclinical)  Weil disease: leptospirosis + renal failure + liver failure  Infx endocarditis: usually due to Strep/Staph; presents as FROM JANE – Fever, Roth spots, Osler nodes, Murmurs, Janeway lesions, Anemia, Nailbed hemorrhage, Embolic phenomena; Dx blood cx x3, Tx IV abx  Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg), Tx admit + IV abx  Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx admit + drainage + IV abx  Dacryocystitis: infx of medial canthus of eye; Tx warm compresses + abx drops  Orbital cellulitis: cellulitis around eye, requires emergent ophtho c/s

Pediatrics – Shelf notes

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Fungi     Viruses        

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Orbital vs. preseptal cellulitis: consider preseptal w/ eyelid discoloration; consider orbital w/ proptosis, limited eye movement, pain w/ movement, or loss of vision RMSF: due to Rickettsia rickettsii from Dermacentor ticks; causes fever/chills and rash that starts on hands/feet and moves inward, can result in pancytopenia + hyponatremia; Tx doxycycline (regardless of age) Lyme disease: due to Borrelia burgdorferi from Ixodes ticks; 1° Lyme = erythema chronicum migrans, 2° Lyme = bilateral Bell palsy + AV block, 3° Lyme = chronic arthritis; Tx amoxicillin (<9 y/o), doxycycline (>9 y/o)  Lyme disease + hemolytic anemia: due to Babesia microtii also from Ixodes ticks; Dx RBC smear, Tx clindamycin + quinine Tularemia: “rabbit fever” due to Francisella tularensis; MC presentation is ulceroglandular syndrome (nonhealing ulcer + ascending LAD); Tx streptomycin Pseudomonas: G– oxidase+ rod; commonly found in burns, tennis shoe puncture wounds, swimming pools, hot tubs, cystic fibrosis Peptic ulcer disease: presents as dyspepsia and upper GI bleed; Dx EGD+bx or H. pylori breath test, Tx “triple therapy” (2 abx + 1 PPI) ★ HUS: due to EHEC O157:H7; presents w/ bloody diarrhea and possible renal failure (MCCOD) after eating undercooked hamburgers; Dx stool cx on MacConkey (sorbitol) agar, Tx TPN + peritoneal dialysis (do not use abx) Lymphadenitis: Staph aureus infx → swollen, tender, erythematous LN; Tx dicloxacillin Cat scratch disease: Bartonella henselae infx from cats (flea vector) → Parinaud oculoglandular syndrome (nonpainful conjunctivitis + preauricular LAD); Tx azithromycin Typhoid fever: Salmonella typhi infx → fever, diarrhea, HSM, abdominal pain w/ “rose spot” rash; Dx ↑fecal leukocytes + stool cx Campylobacter gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; ↑risk of Guillain-Barre syndrome Yersinia gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; ↑risk of mesenteric adenitis (appendicitis-like presentation); associated w/ chitterlings and daycare centers Pseudomembranous colitis: broad-spectrum abx use → C. difficile proliferates in colon → profuse watery diarrhea; Dx stool toxins, Tx metronidazole > PO vancomycin

      Parasites       

Sporotrichosis: “rose gardner disease” due to Sporothrix schenckii; presents as nonhealing ulcer + ascending LAD; Tx potassium iodide ★ Tinea capitis: due to Trichophyton tonsurans; presents as boggy scalp lesion w/ hair loss; Dx KOH prep, Tx PO griseofulvin Cryptosporidiosis: chronic diarrhea in HIV+ pts PCP pneumonia: opportunistic infx that indicates T-cell deficiency (AIDS, SCID, DiGeorge, etc.); Dx BAL, PPx azithromycin, Tx Bactrim Viral meningitis: due to enterovirus infx (echo, coxsackie); Dx CSF shows ↑lymphocytes + normal glucose, Tx supportive care ★ Bronchiolitis: due to RSV; presents w/ wheezing, URI sx, respiratory distress; Tx supportive care (ribavarin if severe, pavilizumab ppx for high-risk infants) ★ Erythema infectiosum (fifth disease): due to Parvovirus B19; presents w/ fever, URI sx, “slapped cheek” and lacy rash on extremities, can cause aplastic anemia in SCD or spherocytosis, hydrops fetalis in pregnant women (rare) Hand-foot-mouth disease: due to Coxsackie A16; presents w/ sores/blisters on hand, feet, mouth, genitalia; Tx supportive care Mononucleosis: due to EBV; presents w/ fever/chills, sore throat, myalgia, cervical LAD, HSM after making out w/ someone; Dx Monospot (heterophile agglutination) test, Tx avoid contact sports ★ “Amoxicillin rash”: rash s/p amoxicillin in a misdiagnosed “strep throat” is pathognomonic for EBV infx Mumps: parotitis, orchitis, meningitis, pancreatitis Rabies: commonly found in bats, skunks, raccoons, foxes, coyotes; give reassurance if pet is sterile, kill animal for bx if unknown, give postexposure ppx for any bat exposure ★ Rubeola (measles): cough, coryza (head cold), conjunctivitis, Koplik spots, then diffuse maculopapular rash; Tx vitamin A ★ Rubella: diffuse maculopapular rash (starts on face and migrates down) w/ low-grade fever, marked LAD, sore throat, ±arthralgias ★ Roseola: due to HHV-6; high-grade fever for 3 days, then diffuse maculopapular rash Varicella (chickenpox): due to VZV; “dew drops on a rose petal” vesicular rash in an ill child Viral gastroenteritis: rotavirus infx → fever, vomiting, severe watery diarrhea during the wintertime; Tx supportive care Herpes keratoconjunctivitis: HSV infx → vesicular lesions on skin + dendritic corneal ulcers, ↑risk of blindness Cutaneous larva migrans: due to Toxocara canis/cati; presents as itchy lesion on bottom of foot after playing around barefoot; Tx ivermectin Visceral larva migrans: due to Toxocara canis/cati; presents w/ fever + HSM + eosinophilia; Tx ivermectin Malaria: due to Plasmodium spp; presents w/ cyclic fever/chills and hemolytic anemia; Dx Giemsa stain of blood smear, Tx mefloquine (+ primaquine for hypnozoites) Pinworm: due to Enterobius vermicularis; causes perianal pruritus worse at night; Dx scotch tape test, Tx mebendazole Ascariasis: due to Ascaris lumbricoides; presents w/ eosinophilia + intestinal obstruction Trichinellosis: found in undercooked pork; triad of periorbital edema, myositis, eosinophilia; may have nonspecific splinter hemorrhages Giardiasis: due to Giardia lamblii; presents w/ fever, foul-smelling fatty stools, abdominal pain; Tx metronidazole

––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALLERGY/IMMUNOLOGY ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

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Allergy  Urticaria (hives): pruritic “wheal and flare” rash; Tx PO benadryl + avoid exposure  Erythema multiforme: urticaria + target lesions, <10% BSA (body surface area)  Stevens-Johnson syndrome: EM + mucosal involvement, 10-30% BSA  Toxic epidermal necrolysis: severe SJS, >30% BSA  DRESS syndrome (drug rash, eosinophilia, systemic sx): EM w/ eosinophilia + systemic sx, usually due to anticonvulsants Maternal ab: IgG via placenta (lasts 3-6 months), IgA via breast milk ★ Immunology  Chronic granulmatous disease: XR ∆NADPH oxidase → phagocytic defect → recurrent abscesses; Dx nitroblue tetrazolium (NBT) test

Pediatrics – Shelf notes

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Wiskott-Aldrich syndrome: XR, TIE – thrombocytopenia (petechiae), recurrent infx, eczema; Dx CBC (↓plt), ↓IgM, ↑IgA, ↑IgE Bruton agammaglobulinemia: XR B-cell defect → lack of all Ig types → recurrent bacterial infx (OM, PNA, etc.) after 6 months since mom’s Ig confers passive immunity; Dx ↓serum Ig levels, Tx repeated IVIG T-cell defect: likely DiGeorge syndrome (CATCH-22); Dx intradermal Candida test Combined variable immunodeficiency: acquired B-cell defect (>10 y/o) → lack of all Ig types but normal B-cell levels; ↑risk of lymphomas SCID (“bubble boy disease”): XR or AR ∆adenosine deaminase → lymphocytes can’t make DNA to proliferate (both B- and T-cells) → severe infx → death at young age; Tx bone marrow txp Job syndrome: FATED – coarse Facies, Abscesses, retained primary Teeth, ↑↑IgE, Derm issues (eczema) Asplenia: recurrent encapsulated bacterial infx (SHiN – Strep pneumo, H. influenza, Neisseria), common in SCD kids; Dx CBC w/ smear (HowellJolly bodies) Hereditary angioedema: AD ∆C1 esterase inhibitor → random activation of complement pathway → recurrent episodes of edema w/ positive family hx IgA deficiency: recurrent respiratory infx + diarrhea + anaphylatic transfusion rxns (reacts to donor serum IgA); Dx ↓IgA Complement deficiency: C5-C9 deficiency predisposes to recurrent Neisseria infx; Dx CH50 test

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– HEM-ONC –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 

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Juvenile rheumatoid arthritis (Still disease): RF (anti-IgG Fc domain) → type 3 HS; Tx NSAIDs > MTX > PO steroids  Polyarticular JRA: >5 joints  Pauciarticular JRA: 0-4 joints, can present w/ anterior uveitis (iridocyclitis); Dx slit-lamp eye exam, Tx PO/OU steroids  Systemic JRA: systemic sx prior to arthritis, rheumatoid rash, high spiking fevers Juvenile dermatomyositis: presents w/ progressive muscle weakness, skin rash, fatigue; Dx ↑CPK Neonatal lupus: skin lesions (maternal ab-ag complexes cross placenta) + 3° heart block (anti-SSA attacks fetal heart conduction) Systemic lupus erythematosus (SLE): type 3 HS → flare-and-remission pattern of I’M DAMN SHARP – ↑IgG, Malar rash, Discoid rash, ANA, Mucositis (throat ulcers), Neuro sx, Serositis (pleuritis/pericarditis), Hematologic d/o, Arthritis, Renal d/o (wire loops), Photosensitivity; Dx screen w/ ANA, confirm w/ anti-dsDNA or anti-Smith, Tx low-dose aspirin ITP: autoantibodies against gpIIb/IIIa → platelet sequestration in spleen → petechiae, purpura; Dx ↓plt/↑MKC, Tx RhoGAM (if Rh+), IVIG (if Rh-), steroids (2nd line), splenectomy (if severe) ★ Anemia  Fanconi anemia: AR ∆DNA repair genes → aplastic anemia + short stature, hypopigmented areas, eye/ear deformities; Tx androgens + hematopoietic drugs (EPO, neupogen, etc.)  Anemia of prematurity: MCC anemia in premature and SGA infants; Dx CBC shows profound anemia w/ ↓reticulocytes, Tx iron supplements  Transient erythroblastopenia of childhood: RBC aplasia in children following a viral infx; Dx CBC shows profound anemia w/ no reticulocytes, Tx supportive care (lasts 1-2 months, may need pRBCs)  Blackfan-Diamond anemia: macrocytic RBC aplasia + short stature, webbed neck, cleft lip, shield chest, triphalangeal thumbs  Sickle cell anemia: Dx Hb electrophoresis shows ↑HbF, Tx folate supplements (for effective hematopoiesis) + hydroxyurea (↑HbF)  Sickle cell + sepsis: Strep pneumo  Sickle cell + osteomyelitis: Salmonella  Sickle cell + aplastic crisis: Parvo B19  Dactylitis: sickle cell anemia → vaso-occlusion → vascular necrosis of metacarpals/metatarsals → acute onset painful swelling of hands and feet  Acute chest syndrome: PNA-like presentation; Dx CXR shows infiltrate, Tx azithromycin + ceftriaxone  Sickle cell trait: MC sx is painless gross hematuria; Dx Hb electrophoresis shows HbS of 35-40% Thalassemias Mechanism/presentation Management β-thalassemia minor heterozygous ∆β-chain → mild anemia sx Dx screen w/ CBC (microcytic anemia + ↓RDW), confirm w/ ↑HbA2; Tx reassurance β-thalassemia major homozygous ∆β-chain → severe anemia sx Dx screen w/ CBC (microcytic anemia + ↓RDW), confirm w/ ↑HbF; Tx frequent transfusions Silent carrier 1-2 α-chain deletion → asx --HbH disease 3 α-chain deletion → severe anemia sx Dx screen w/ CBC (microcytic anemia + ↓RDW), confirm w/ ↑HbH; Tx frequent transfusions Barts disease 4 α-chain deletion → fetal hydrops Dx post-mortem autopsy Kasabach-Merritt phenomenon: large vascular anomalies (kaposiform hemangioendothelioma, tufted angioma) sequester RBCs, platelets, and clotting factors → anemia, thrombocytopenia, coagulopathy; Tx steroids + IFN-α G6PD deficiency: XR ∆G6PD in African-American boys → RBCs can’t make enough NADPH to deal w/ oxidative stress (fava beans, sulfa drugs, antimalarials, infx) → hemolytic anemia following exposure to oxidative stress ★ ALL: MC cancer in kids <15 y/o; pre-B-cell proliferation (CALLA+/TdT+) → infiltration of reticuloendothelial system (LAD, splenomegaly) and bone marrow (pancytopenia); Dx bone marrow bx shows >25% lymphoblasts, Tx chemotherapy  ALL prognosis: good px w/ age 1-10, hyperdiploidy, WBC <50, and TEL/AML1 on t(12;21); poor px w/ Philadelphia chromosome on t(9;22) Hodgkin lymphoma: B-cell proliferation into Reed-Sternberg cells → B-type sx (fever, weight loss, night sweats); Dx CXR to look for mediastinal mass then LN bx, Tx chemotherapy Langerhans cell histiocytosis: Langerhans cell proliferation → eosinophilic granuloma → painful, solitary lytic bone lesion (MC site is skull) Hereditary spherocytosis: AR ∆spectrin → hemolytic anemia + jaundice in newborn; Dx CBC shows spherocytes + abnormal osmotic fragility test, Tx splenectomy Disseminated intravascular coagulation (DIC): systemic insult (MCC septic shock) → widespread microcoagulation → run out of clotting factors → bleeding out; Dx ↑PT/INR + ↑PTT + ↑D-dimer + ↓platelets, Tx underlying cause Von Willebrand disease: AD ∆vWF → MCC hemorrhagic diathesis; Dx vWF levels + activity (ristocetin cofactor activity), Tx DDAVP

Pediatrics – Shelf notes

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Tumor lysis syndrome: lysis of cancer cells → hyperkalemia + hyperuricemia + renal failure; Dx renal panel + ↑uric acid, Tx allopurinol –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ENDOCRINE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

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Sick euthyroid syndrome: ↑bodily stress (trauma, starvation, etc.) → ↑cortisol blocks TSH → ↓T4/T3, normal TSH, ↑rT3 (deiodinase 3 activated by stress) Adrenal  Pheochromocytoma: episodic ↑catecholamine → 5 Ps – Pressure (BP), Pain (HA), Perspiration, Palpitations, Pallor; Dx 24 hr urinary metanephrines, Tx α-blockers (phenoxybenzamine) then β-blockers then adrenalectomy  Cushing syndrome: ↑cortisol → truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, immunosuppression; Dx ACTH/cortisol levels + dexamethasone suppression test (pituitary Cushing can be suppressed), Tx underlying cause  Hyperaldosteronism: ↑aldosterone → ↑Na, ↓K, ↓H (HTN, metabolic alkalosis)  Addison syndrome: ↓cortisol/↓aldosterone → fatigue, hypoglycemia, HTN, hyperpigmentation, weight loss; Tx prednisone + fludrocortisone replacement  ★ Congenital adrenal hyperplasia: ∆21α-hydroxylase → ↓aldosterone/↓sex hormones → ↓Na, ↑K, ↑H (metabolic acidosis), hirsutism, virilization; Dx ↑17-OHP, Tx hydrocortisone + fludrocortisone replacement  Central DI: ↓ADH → can’t resorb water → polyuria, polydipsia, hemoconcentration (↑Na, ↑K); Tx DDAVP  Nephrogenic DI: end-organ resistance to ADH → polyuria, polydipsia, hemoconcentration (↑Na, ↑K); Tx HCTZ  SIADH: ↑ADH → fluid overload → hemodilution (↓Na, ↓K); Tx water restriction Pancreatic  HbA1C: reflects 2-3 months of glucose control, normal <6.5%  DM type 2: presents as polyuria (bedwetting), polydipsia, polyphagia, acanthosis nigricans; Dx fasting glucose >126 x2, random >200 w/ sx, or HbA1C >6.5%  Factitious hypoglycemia: mom’s giving baby insulin → hypoglycemia + hyperinsulinemia + low C-peptide levels (high C-peptide reflects insulinoma); Munchhausen by proxy is a form of child abuse Parathyroid  Hypercalcemia sx: stones (kidney, GB), bones (pain, osteitis fibrosa cystica), groans (PUD, pancreatitis), psychic overtones  Hypocalcemia sx: neuromuscular irritability (tingling, tetany), prolonged QT, arrhythmias  Hypercalcemia s/p fracture: due to extensive bone resorption; Dx urine calcium:creatinine ratio >0.2, Tx hydration, calcitonin if severe  Nutritional rickets: dietary ↓vitamin D → normal Ca, ↓P → decreased bone mineralization; increased risk in exclusively breast-fed babies, lack of vitamin D supplements, African-Americans, limited sun exposure  X-linked hypophosphatemic rickets: XD ∆PHEX (renal phosphate resorption gene) → ↑urinary P, ↓serum P → decreased bone mineralization resistant to vitamin D supplements  Pseudohypoparathyroidism: renal tubules unresponsive to PTH → ↓Ca, ↑P, ↑PTH → hypOcalcemia sx + 4th/5th finger bradydactyly (knuckleknuckle-dimple-dimple sign)  Hypoparathyroidism: lack of PTH → ↓Ca, ↑P, ↓PTH → hypOcalcemia sx  1° hyperparathyroidism: excessive PTH → ↑Ca, ↓P, ↑PTH → hypercalcemia sx

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HEADSSS assessment: Home, Education, Activities, Drugs, Sex, Suicide, Safety Eating disorders  Anorexia nervosa: fear of being fat → <85% ideal body weight, secondary amenorrhea, lanugo, hypothermia, osteoporosis, arrhythmias; Tx TID sandwiches  Bulimia nervosa: binge-eating + behaviors intended to counteract weight gain (purging, diuretics, exercise, fasting), sialadenosis, dental caries, Russell’s sign (dorsal knuckle callouses); Tx SSRIs + CBT  Anorexia vs. bulimia: both can have purging behavior, but anorexia has <85% ideal body weight  Refeeding syndrome: increased nutrition in starving pt → ↑synthesis of glycogen, fat, proteins uses up electrolytes (especially ↓K and ↓phosphate) Sports contraindications: bleeding d/o (hemophilia), single eye, single kidney, unexplained syncope, infectious mononucleosis (to prevent splenic rupture) Sports concussions Sx Management Grade 1 (mild) no LOC, confusion <15 min can return to play Grade 2 (moderate) no LOC, confusion >15 min must sit out for a week, go to hospital if >1 hr Grade 3 (severe) LOC go to hospital ★ Tanner (SMR) staging

Tanner 1 Tanner 2 Tanner 3 Tanner 4 Tanner 5

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Males kid scrotal darkening, thin long pubic hair dark curly pubic hair adult pubic hair but w/o full coverage, peak growth velocity adult

Females kid breast buds breast elevation, peak growth velocity areolar mound (look 4 big nipples) adult

 Late-onset congenital adrenal hyperplasia: 21-hydroxylase deficiency → excess of sex steroids → precocious puberty in boys  McCune-Albright syndrome: precocious puberty in girls + café-au-lait spots + polyostotic fibrous dysplasia (bone zits that cause multiple fx) Teenage pregnancy: complications include poor maternal weight gain, premature delivery, low birth weight, ↑risk of pre-eclampsia ★ Substance abuse: suspect w/ declining school performance, poor hygiene, exaggerated mood swings, hanging w/ the wrong crowd, frequent hostile reactions

Pediatrics – Shelf notes

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 Cocaine: euphoria, tachycardia, hypertension, nosebleeds, heart attacks, strokes  Marijuana: euphoria, paranoia, injected eyes, munchies  Anabolic steroids: muscles, hirsutism, acne, gynecomastia, testicular atrophy, roid rage; consider in football players  MDMA (Ecstasy): euphoria, stimulant, “sense of closeness with others”, death by hyperthermia or dehydration; consider in clubs/raves  Inhalants: brain damage, arrhythmias, death Suicide: women attempt more but men are more successful; Tx admit + get full psych eval Sleeping late w/ puberty: due to melatonin phase-delay in sleep-wake cycle ★ Acne vulgaris: not associated with food or caffeine intake; Tx topical benzoyl peroxide (1st line), topical retinoids or abx (2nd line), PO abx (3rd line), isotretinoin (last line, teratogenic) Dysfunctional uterine bleeding: abnormal menses w/o identifiable cause; Dx of exclusion, Tx OCPs to normalize cycle

★ = high-yield topics (review these before the shelf)