The USMLE Step 2 CK BIBLE

The Ultimate Step 2 CK Preparation Guide

JeffreyAnderson,M.D. TheUSMLEStep2CKBIBLE 2ndEdition

 TheUSMLEStep2CKBIBLE Copyright2010JeffreyAnderson,M.D.Allrightsreserved.Nopartofthisbook maybeusedorreproducedinanymannerwhatsoeverwithoutwrittenpermission exceptinthecaseofreprintinthecontextofreviewsandpersonaleducation.

CONTENTS

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

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

FOREWORD
The USMLE Step 2 CK BIBLE is the culmination of over four months of my own intense personal Step 2 CK preparation. This document contains and all of the notes I made, all of the charts, graphs, and images I put together to create the ultimate study guide, and I guarantee it is more than enough to help you pass, and if used properly can help you achieve a top score on the Clinical Knowledge exam. I used five different study guides as well as all of the notes I took from working in the wards to put together this in-depth study guide. This preparation guide contains the most up-to-date as well as the most commonly asked clinical information, which will help you score high on the Step 2 CK exam. When I put this preparation guide together, I did so with my own score in mind, and I made it so that I would have to study from one source, and thats exactly what you have here. If you study hard and use the CK BIBLE, you will not only pass, you will do very well. Best of luck on the Step 2 CK exam

Chapter 1 Surgery

TRAUMA
TraumapatientsaremanagedusingtheABCDEsintheprimarysurveyaftera traumaticincident. AAirway Ensurepatientisimmobilizedandmaintainairwaywithjawthrust Ifairwaycannotbeestablished,insert2largeboreneedlesintothe cricothyroidmembrane Neverperformtracheotomyinthefield Ifpatientisunconsciousoryoucannotestablishanairwayotherwise, intubatethepatient.

BBreathing Lookforchestmovement Listenforbreathingsounds Observetherespiratoryrate Lookforlifethreateninginjuries(tensionpneumothorax,flailchest,open pneumothorax)

CCirculation Placementof2largeboreIVsintheupperextremities Ifpatientisinshock,placeacentrallineinthepatient Keepbloodonstandbyincaseofhemorrhage

DDisability AssesstheneurologicalstatuswiththeGlasgowcomascale Checkalllabtests(blood,ETOH,electrolytes) Lossofconsciousness

AlossofconsciousnesscanbeassessedwiththemnemonicAEIOUTIPS Alcohol,Epilepsy,Insulin,Overdose,Uremia,Trauma,Infection,Psychogenic,Stroke EExposure Examinetheskin(mustremoveallclothes)

 Inthesecondarysurvey,performthefollowing: GLASGOWCOMASCALE STATUS/FINDING EyeOpening Spontaneous 4 ToVoice 3 ToStimulation 2 NoResponse 1 VerbalResponse Oriented 5 Confused 4 Incoherent 3 Incomprehensible 2 NoResponse 1 MotorResponse ToCommand 6 Localizes 5 Withdraws 4 AbnormalFlexion 3 Extension 2 NoResponse 1 Acomascalebelow8indicatessevereneurologicinjury POINTS ChecktheGlasgowcomascale Checkallorificesfortraumaand/orinjuries(bleeding) Performchecksusingultrasound,XRAY,CT Checkforcompartmentsyndrome

SHOCK
Thetypeofshockcanbediagnosedbycheckingthecardiacoutput(CO),the pulmonarycapillarywedgepressure(PCWP),andtheperipheralvascularresistance (PVR). DifferentialDiagnosisofShock CO PCWP PVR HYPOVOLEMIC CARDIOGENIC SEPTIC

Howtocorrectthedifferenttypesofshock HypovolemicShock CardiogenicShock SepticShock Problem DecreasedPreload CardiacFailure DecreasedPVR InitialTreatment 2LargeboreIVs, replacefluids 02,dopamineand/orNE 02,NE,IVantibiotics

RecognizingShock
InChesttrauma: Themostcommontypeofshockresultingfromchesttraumaishypovolemic Patientwillbepale,cold,anddiaphoretic Thispatientislikelylosinglargeamountsofblood,thussearchingforsource ofbleedingisimperative Pericardialtamponadecanbearesultofthoracictrauma,lookfordistended neckveins Insuspectedpericardialtamponade,lookforanenlargedheartonCXR, performcardiocentesis,lookforelectricalalternansonEKG

Managementofshock: Controlthesiteofbleeding Givefluids Prepareforanemergencylaparotomy

**Ifalaparotomyisntwarranted,simplyresuscitatewithfluids

HEADTRAUMA
EpiduralHematoma Therewillbeahistoryoftrauma Suddenlossofconsciousnessfollowedbyalucidinterval,thenfollowedby rapiddeterioration Mostcommonlybleedisfromthemiddlemeningealartery

Diagnosis: WithaCT,lookingforalensshapedhematoma

Management: Emergencycraniotomyessentialbecausethisisadeadlycasewithinafew hours

 SubduralHematoma Isalowpressurebleedcomingfromthebridgingveins Thereisusuallyahistoryofheadtraumawithfluctuatingconsciousness

Diagnosis: CTshowingcrescentshapedbleed

Management: DiffuseAxonalInjury Thistypeofinjuryoccursafteranaccelerationdecelerationinjurytothe head Patientisusuallyunconscious Thereisaterribleprognosisassociatedwiththisinjury Ifthereismidlinedisplacementandsignsofmasseffectthendoan emergencycraniotomy Ifsymptomsarelesssevere,conservativemanagementincludessteroids

Management: LowerICPandpreventfurtherinjury

 BasalSkullFracture Diagnosis: CTscanofheadandneck Thispresentswithecchymosisaroundeyes,behindtheears,orwithCSF leakfromthenose

Management: CSFrhinorrheawillstoponitsown Iffacialpalsyispresent,givesteroids

BURNS
1stdegreeandSeconddegreeburns: ThirdandFourthdegreeburns: Treatment: Dependingonseverity,resuscitatewithfluids Removalofeschars DoaCXRtoruleoutlunginjuries Topicalantibioticsafterescharremoval Burnsthatcovermorethan20%ofthebodyrequireadmissiontoaburn center Affectsalllayers+subcutaneoustissues Painless,dry,charred,andcrackedskin Burnsaffectingalllayersoftheskinrequiresurgicalintervention Epidermisandsuperficialdermis Skinispainful,red,andblistered Treatmentwithointmentsand/orpainrelievers

 SURGICALABDOMEN Thefollowingillustratesthedifferentialdiagnosisforabdominalpainintheright upperquadrant,rightlowerquadrant,leftupperquadrant,leftlowerquadrant.

 RightUpperQuadrantConditionsDifferentiating Hepatitis Cholecystitis Choledocholithiasis BiliaryCholic Cholangitis Alifethreateningcondition PresenceofCharcotstriad:Fever+Jaundice+RUQpain Ifthereisalsohypotensionandmentalstatuschanges,thisqualifiesas Reynoldspentad PerformandultrasoundandaCTtodetectbiliaryductdilatationdueto gallstoneobstruction ConfirmdiagnosiswithERCP ConstantepigastricandRUQpain Performanultrasoundtodetectthepresenceofgallstoneswithoutanyother gallbladderrelatedfindings RUQpainthatisworsenedwiththeingestionoffattyfoods Jaundiceisoftenpresent Performanultrasoundtodetectdilatationofthecommonbileduct RUQpainandtenderness (+)Murphyssign(inspiratoryarrestduringpalpation) Performanultrasoundtodetectgallstones,athickenedgallbladderwall,or pericholecysticfluid PresentswithRUQpainand/ortenderness Jaundiceismostlikelypresent Feverispresent Performanultrasoundtoruleoutothercausesofpain

 Pneumonia FitzHughCurtisSyndrome RightLowerQuadrantConditionsDifferentiating Appendicitis EctopicPregnancy Salpingitis Lowerabdominalpain Purulentvaginaldischarge Cervicalmotiontenderness Performanultrasoundtodetecttheabscess,andaCTtoruleoutother conditions Presentswithconstantlowerabdominalpain,crampyinnature Vaginalbleeding Tenderadnexalmass LabswillshowhCG DiffuseabdominalpainthatlocalizestotheRLQatMcBurneyspoint(2/3 distancefromumbilicustoASIS) Feveranddiarrheaoftenpresent AbdominalxrayorCTtosolidifydiagnosis Decisiontoremoveisbasedonclinicalpresentation RUQpain,fever Thereisgoingtobeahistoryofsalpingitis CausedbyascendingChlamydiaorgonorrhearelatedsalpingitis Performanultrasoundwhichwillshowanormalgallbladderandbiliarytree withfluidaroundtheliverandgallbladder Presenceofpleuriticchestpain PerformaCXR,whichwillshowpulmonaryinfiltrates

 MeckelsDiverticulitis YersiniaEnterocolitis OvarianTorsion Pyelonephritis Intussusception Seenmostcommonlyininfantsbetween5and10monthsofage Presenceofcurrantjellystool(mixofbloodandmucus) Vomiting,intensecrying Infantswilloftenpulllegsintotheabdomentorelievesomepain Bariumenemaisusedforbothdiagnosisandtreatment ClassicallypresentswithCVAtenderness,highfever,andshakingchills BestinitialdiagnostictestisaUAandUrineculture Patientdevelopsanacuteonsetofsevere,unilateralpain Painchangeswithmovement Presenceofatenderadnexalmass Ultrasoundisdonefirst Confirmwithalaparoscopy Presentssimilarlytoappendicitis(fever,diarrhea,severeRLQpain) XRAYwillbenegative Treatwithaggressiveantibiotictherapy Followsthe110100rule 1%2%prevalence 110cminlength 50100cmproximaltoileocecalvalve PresentswithGIbleed,smallbowelobstruction(SBO) Technetiumpertechnetatescantodetect

 LeftUpperQuadrantConditionsDifferentiating MyocardialInfarction PepticUlcer RupturedSpleen LeftLowerQuadrantConditionsDifferentiating Diverticulitis SigmoidVolvulus Mostcommonlyseeninanolderpatient Presentswithconstipation,distendedabdomen,andabdominalpain PatienthasLLQpain,fever,andurinaryurgency DiagnosewithaCTscan,whichshowsthickeningofthelargeintestinewall SimilartotheRLQconditionsare:Ovariantorsion,Ectopicpregnancy,and Salpingitis Usuallyahistoryoftrauma PresenceofKehrssign(LUQpainthatradiatestotheleftshoulder) DiagnosewithanabdominalCT Presentsasepigastricpainthatisrelievedbyfoodsand/orantacids Perforationspresentswithacuteandsevereepigastricpain,mayradiateto shoulders(Phrenicnerveinvolvement) DiagnosewithanupperGIendoscopy Crushingchestpainthatradiatestothejaw,neck,leftarm Nausea,diaphoresisispresent DiagnosedbyEKG,cardiacenzymes(CKMB,tropI)

 Pyelonephritis ClassicallypresentswithCVAtenderness,highfever,andshakingchills DifferentialDiagnosesforMidlineConditions GERD AbdominalAorticAneurysm Pancreatitis PancreaticPseudocyst Isaresultofpancreatitis Considerthisifpatienthadpancreatitisthatrecurredand/ordidnotresolve Ultrasoundwillshowapseudocyst Epigastricpainthatradiatestotheback Nauseaandvomitingareusuallypresent Patientoftenhasahistoryofalcoholism Asymptomaticusuallyuntilitruptures Ifruptureoccurs,patientexperiencesabdominalpain+shock Thereisusuallyapalpablepulsatileperiumbilicalmass Ultrasounddonefirst(leastinvasive),butcanvisualizewithanxrayorCTof theabdomen Epigastric/substernalburningpain Degreeofpainchangeswithdifferentpositions(worsewhenpatientis supine) Diagnosismadewitheitherabariumswallow,pHtesting,orupperGI endoscopy Contrastenematodiagnose,willseetheclassicbirdsbeak

 SurgicalConditionsoftheEsophagus Achalasia SignsandSymptoms: DysphagiatoBOTHsolidandliquid Regurgitationoffood Aconditionwheretheloweresophagealsphincterfailstorelax

Diagnosis: BestinitialtestitstheBariumSwallow,whichdemonstratesnarrowingofthe distalesophagus Mostaccuratetestisesophagealmanometry,whichwilldemonstratethelack ofperistalsis

Treatment: EsophagealDiverticula(Zenkersdiverticulum) SignsandSymptoms: Dysphagia Halitosis Mostcommonpresentationisapatientwithdyphagiathatisaccompaniedby terriblebreath Pathologyisrelatedtotheposteriorpharyngealconstrictormuscleswith dilate,causingthediverticulum Thebestinitialtherapyispneumaticdilation Ifpneumaticdilationisnotsuccessful,surgeryshouldbeperformed Ifpatientdoesnotwantsurgery,canattempttorelaxtheLESwithinjection ofbotulinumtoxin

Diagnosis: Thebestinitialtestisthebariumswallow

 Treatment: Surgicalresectionofthediverticulaisthebestinitialtreatmentoption

CanceroftheEsophagus
ThereareSquamousCellCarcinomaandAdenocarcinoma Commonsymptomstoboth: Dysphagiatosolids1st,thentoliquids2nd Weightloss Heme(+)stool Anemia Hoarseness

SquamousCellCarcinoma Isthe2ndMCCofesophagealcancer Relatedtochronicuseofalcoholandtobacco Mostcommonlyseeninthe6thdecadeoflifeandlater

Adenocarcinoma Diagnosing: Thebestinitialdiagnostictestisanendoscopy OccursinpatientswhohavechronicGERD ChronicGERDleadstoBarrettsesophagus,whichthenleadsto Adenocarcinoma

Treatment: Thebestinitialtreatmentissurgicalresectionaslongasthereisno metastasis Surgeryshouldbefollowedwith5FU

 DiffuseEsophagealSpasms Diagnosis: Manometryisthemostaccuratediagnostictest Patientpresentswithseverechestpain Oftentimes,theydontfitthecriteriaforanMI,butshouldgetthecardiac enzymesanddoEKGtoruleoutanMI Oftencomesafterhavingacolddrink

Treatment: MalloryWeissTear Violentretchingand/orvomitingcausessuddenbleeding Mostcasesresolvespontaneously,iftheydontthoughgiveepinephrineto constrictthebloodvesselsandstopthebleeding Calciumchannelblockersandnitratesarethetreatmentoptionofchoice

 CanceroftheStomach SignsandSymptomsforall: Thereisanriskwhenthereis: Therearesomeclassicfindingsinmetastaticgastriccancer,theyinclude: Virchowsnode: KrukenbergTumor: Themetastasisofgastriccancerbilaterallytotheovaries Ovariesarepalpableinthiscase Theyaresignetringcells Leftsupraclavicularnodeishard Lowfiberconsumption Excessnitrosaminesinthediet(duetosmokedmeats) Excesssaltintakeinthediet Chronicgastritis GIdiscomfortand/orpain Weightloss Anemia Anorexia Mostcancersofthestomacharefoundtobemalignant ThereisalinkofstomachcancerstobloodgroupA,whichmayindicatea geneticpredispositiontothecondition Linitisplasticaisadiffusecancerthatisfatalwithinmonths,andisthemost deadlyformofgastriccancer

 SisterMaryJosephsign: Treatments: Surgery+chemotherapy Palliativecareisoftentheonlychoiceiftooadvanced Hardnoduleattheumbilicusduetometastasis Indicativeofaverypoorprognosis

Hernias
InguinalHernias Isthemostcommontypeofhernia Men>women

DirectInguinalHernia: ProtrudesdirectlythroughHasselbachstriangle(inferiorepigastricartery, rectussheath,andinguinalligament),medialtotheinferiorepigastricartery

IndirectInguinalHernia: SignsandSymptoms: Diagnosis: Mustdifferentiatefromafemoralhernia,whichwillherniatedbelowthe inguinalligament Diagnosisisbasedonclinicalexamination Groinmass(intermittent)thatprotrudeswithvalsalvatypemaneuvers Morecommonthanthedirecthernia,passeslaterallytotheinferior epigastricarteryintothespermaticcord

Treatment: Surgicalrepair

 FemoralHernias VisceralHernias Thistypeofherniacausesintestinalobstruction Women>Men Haveagreaterriskofincarcerationduetothewaytheyherniated Diagnoseclinically Surgicalcorrection(donotdelayduetoriskofincarcerationandsubsequent strangulation)

SignsandSymptoms: Abdominalpain Obstipation(noflatulence)

Diagnosis: XRAYwillshowairfluidlevels,nogasinrectum Differentiatefromadhesions

Treatment: Surgicalrepair

SurgicalConditionsoftheGallbladder
Gallstones(Cholelithiasis) Seenmostlyinwomenwiththe4Fs 1. 2. 3. 4. Treatment: Cholecystitis Isaninfectionofthegallbladderthatisaresultofanobstruction Commoncausesare:E.Coli,Enterobacter,Enterococcus,andKlebsiella Asymptomaticgallstonesrequirenointervention Chronicpainmayrequireacholecystectomy Withanincreasedriskofcancer,suchasinthecaseofacalcifiedgallbladder wall,cholecystectomymaybewarranted Itisntthepresenceofgallstonesthatwarrantsintervention,butthepossible complicationsassociatedwiththem Ultrasoundisthetestofchoiceforidentifyinggallstones Female Fat Forty Fertile

Notetheshadowfromtheimpactedstone.

 SignsandSymptoms: Acuteonsetofrightupperquadrantpainthatisnonremitting (+)Murphyssignarrestofinspirationuponpalpation

Diagnosis: Treatment: AscendingCholangitis Diagnosis: Ultrasoundtodetectdilation AnERCPcanbeusedafterthepreliminaryUSdiagnosis Obstructedbileflowfromanobstructedcommonbileductleadstoan infection PresenceofCharcotstriad:RUQ,fever,jaundiceiscommonlyseen KeeppatientNPO,giveIVfluids,andgiveantibioticstocovergram()rods andanaerobes Donotgivemorphineforpainbecauseitcausesaspasmofthesphincterof oddi Ifimprovementsarenotseen,cholecystectomymaybewarranted Ultrasoundtodetectstones,athickenedwall,orfluidsurroundingtheGB ConfirmwithHIDAscan LabsshowWBCs>20,000,Bilirubin,AST/ALT

Treatment: NPO IVfluids Gram()antibiotics ERCPfordecompressionofthebiliarytreeandforremovalofthestones

 Choledocholithiasis Anobstructionofthecommonbileduct

SignsandSymptoms: Jaundice(obstructive) Alkalinephosphatase Conjugatedbilirubin

Diagnosis: Treatment: Cholecystectomy UltrasoundtodetectCBDobstruction

CanceroftheGB
SignsandSymptoms: Sharp,colickypain Isararecancerthatisassociatedwithahistoryofgallstones Occurslaterinlife TheMCprimarytumorofthegallbladderistheadenocarcinoma AssociatedwithClonorchissinensisinfestation Hasagraveprognosis,withmostpatientsdyingwithin1yrofdiagnosis

Diagnosis: USorCTtodetectthetumor

Treatment: Placementofbileductstents Surgeryasapalliativeoption,butisnotcurative

SurgicalConditionsofthePancreas
Pancreatitis Autodigestionofthepancreasbyitsownenzymes MCCisalcoholandgallstones

SignsandSymptoms: Severeepigastricpainthatradiatestotheback Serumamylaseandlipase

Diagnosis: Clinicalsuspicion+abdominalCT Theremaybediscolorationoftheflank(GreyTurnerssign)andCullenssign (bluishdiscolorationoftheperiumbilicus)

Treatment: NPO,IVfluids,andDemerolforpainrelief Beawareofthepotentialforalcoholwithdrawal

Complication: Thereisariskforabscesses,renalfailure,duodenalobstruction,and pancreaticpseudocysts

 PancreaticPseudocyst Isacomplicationofchronicpancreatitis Resultsinafluidcollectionwithinthepancreasthatisencapsulatedbya fibrouscapsule

Diagnosis: Ultrasound AbdominalCT

Treatment: Surgicaldrainage Creationofafistuladrainingthecystintothestomach

Complications: EndocrinePancreas cellhyperplasiacausesaninsulinoma celltumorcauseshyperglucagonemia Infectionfollowedbyrupturecancauseperitonitis

 CancerofthePancreas SignsandSymptoms: Weightloss Painlessjaundice MorecommoninAfricanAmericans/males/smokers Maybemorecommonindiabetics 90%areadenocarcinomas 60%arisefromtheheadofthepancreas

Diagnosis: bilirubin,alkalinephosphatase,CA199 CTscan

Treatment: Althoughusuallyaterminaldiagnosis,candoaresectionofthepancreas,or Whipplesprocedure The5yrsurvivalrateisonly5%

SurgicalConditionsoftheSmallBowel
SmallBowelObstruction SBOcanbecausedbyanumberofconditions

Causes: Peritonealadhesions Hernias Crohnsdisease Meckels Gallstoneileus Abdominalinflammation

SignsandSymptoms: Nausea/vomiting Abdominalpain Abdominalcramps Tenderness/distention Hyperactiveandhighpitchedbowelsounds

Diagnosis: Abdominalxray Airfluidlevelsonuprightfilm

SmallBowelObstruction(SupineView)

SmallBowelObstruction(UprightView) Treatment: NeoplasmoftheSmallBowel Mostcommonlyisaleiomyoma,secondMCisacarcinoidtumor(benign types) Mostcommonmalignanttypesare:adenocarcinoma,carcinoid,lymphoma, andsarcoma Biopsyrequiredfordiagnosis TreatmentinvolvessurgicalresectionalongwithLNsandmetastases NGtubedecompression NPO IVfluids Ifonlypartiallyobstructedmaybeabletotreatwithoutsurgery Ifsurgeryisrequired,mustremovebothobstructionanddeadbowel

 SurgicalConditionsoftheLargeBowel Polyps Areneoplastic,hamartomas,orinflammatory NeoplasticpolypsareMCadenomas

Adenomascanbeclassifiedas: SignsandSymptoms: MCpresentswithintermittentrectalbleeding Tubular(thesehavethesmallestpotentialformalignancy) Tubulovillous Villous(thesehavethehighestriskofmalignancy)

Diagnosis: Colonoscopyorsigmoidoscopy

Treatment: Polypectomy

DiverticularDisease
GeneralInformation: Uptohalfofthepopulationhasdiverticula Theriskincreasesafter50yrofage Only1/10peoplearesymptomaticwhendiverticulaarepresent ATRUEdiverticulaisrare,andincludesfullbowelwallherniation AFALSEdiverticulaismostcommon,andinvolvesonlyaherniationofthe mucosa TheMCCisalowfiberdietwhichcausesanincreasedintramuralpressure (thisishypothesis)

 Diverticulosis SignsandSymptoms: Mostpeopleareasymptomatic,withdiverticulafoundonlyoncolonoscopy orothervisualprocedures MayhaverecurrentboutsofLLQabdominalpain Changesinbowelhabitsiscommon Rarely,patientmaypresentwithlowerGIhemorrhage Thisisthepresenceofmultiplefalsediverticula

Diagnosis: Colonoscopy Bariumenemacanalsobeusedfordiagnosis

Treatment: Diverticulitis SignsandSymptoms: LLQpain ConstipationORdiarrhea Bleeding Fever Anorexia Inflammationofthediverticuladuetoinfection Therearemanypossiblecomplications,suchasabscess,extensionintoother tissues,orperitonitis Ifpatientisasymptomatic,theonlytherapyshouldbetoincreasefiberand decreasefatinthediet IfpatienthasGIhemorrhage,circulatorytherapyiswarranted(IVfluids, maintenanceofhemodynamicstability)

 Diagnosis: CTdemonstratingedemaofthelargeintestine DONOTperformacolonoscopyorbariumenemainanacutecase,thismight aggravatetheproblem

Complications: Perforation Abscesses Fistulaformation Obstructions

Treatment: ObstructionoftheLargeIntestine Mostcommonsiteofcolonobstructionisthesigmoidcolon Ifthereisanabscess,percutaneousdrainageisrequired Mostpatientsaremanagedwellwithfluidsandantibiotics Forperforationorobstruction,surgeryisrequired

Commoncausesinclude: SignsandSymptoms: Nausea/vomiting Abdominalpainwithcramps Abdominaldistention Adhesions Adenocarcinoma Volvulus Fecalimpaction

Diagnosis: XRAYshowingadistendedproximalcolon,airfluidlevels,andanabsence ofgasintherectum

Treatment: Ifthereisseverepain,sepsis,freeair,orsignsofperitonitistheremustbean urgentlaparotomy

 Volvulus SignsandSymptoms: Highpitchedbowelsounds Distention Tympany Twistingandrotationofthelargeintestine Cancauseischemia,gangrene,perforation TheMCsiteisthesigmoidcolon Occursmostcommonlyinolderpatients Laparotomyifcecaldiameteris>12cm

Diagnosis: XRAYkidneybeanappearance(ie.Dilatedloopsofbowelwithlossof haustra) Bariumenemashowingabirdsbeakappearancepointstothesiteof rotationofthebowel

Treatment: CanceroftheColon Coloncanceristhe2ndMCCofcancerdeaths Believedthatalowfiber,highfatdietincreasestherisk Therearemanygeneticfactorsthatcontributetocoloncancer,suchasLynch syndromeandHNPCC Sigmoidoscopyorcolonoscopyactsasdiagnosisandtreatment Ifthisdoesntwork,laparotomyiswarranted

LynchSyndrome: LS1isanautosomaldominantpredispositiontocoloncancerthatisusually rightsided LS2isthesameasLS1withtheadditionofcancersoutsidethecolon,suchas intheendometrium,stomach,pancreas,smallbowel,andovaries

 Screening: Diagnosis: ObtainpreoperativeCEA(allowsyoutofollowtheprogressionorrecession ofthedisease) Endoscopy+bariumenema Screeningshouldstartat40yrinpeoplewithnoriskfactors Ifafamilymemberhashadcancerofthecolon,screeningshouldstart10yr priortowhentheywerediagnosed(assumingthisislessthan40yr) Shouldhaveyearlystoolocculttests Colonoscopyevery10yr Andasigmoidoscopyevery35yrs

Treatment: Surgicalresection+LNdissection Ifdiseaseismetastatic,add5FUtothepostoperativeregimen

Followup: CEAlevelsevery3monthsfor3years Performacolonoscopyat6and12months,thenyearlyfor5years Ifarecurrenceissuspected,aCTshouldbeperformed

 SurgicalConditionsoftheRectumandAnus Hemorrhoids SignsandSymptoms: Brightredbloodperrectum Itching Burning Palpableanalmass InternalhemorrhoidsareNOTpainful,whileexternalhemorrhoidsARE painful Varicositiesofthehemorrhoidalplexus Oftenrelatedtostrenuousbowelmovements

Treatment: ThrombosedHemorrhoids Thesearenotatruehemorrhoid,butareexternalhemorrhoidalveinsofthe analcanal Theyareapainfulbluishelevationthatliebeneaththeskin Usuallyselflimiting Sitzbath Hemorrhoidalcream Stoolsoftenerstorelievepain

Classifications: 1hemorrhoidsinvolvenoprolapse 2hemorrhoidsclassicallyprolapsewithdefecationbutreturnwithout manualreduction 3hemorrhoidsprolapsewitheitherstrainingordefecationandrequire manualreduction 4hemorrhoidsarenotcapableofbeingreduced

Treatment: Conservativetherapies Sclerotherapy,rubberbandligation,andsurgicalhemorrhoidectomy

 AnalFissure SignsandSymptoms: Themostcommonpresentationisthepassageofapainfulbowelmovement thatisaccompaniedbybrightredblood Acrackortearintheanalcanal Usuallyoccursafterthepassageofdiarrheaorconstipation

Diagnosis: Performananoscopytodiagnose

Treatment: AnalandRectalCancer AnalCancer: Themostcommonformissquamouscellcarcinoma Bulkingagentsandstoolsoftenersareusuallyallthatisneeded Iffissurespersistdespiteconservativemeasurements,alateralinternal sphincterotomymayberequired

SignsandSymptoms: Analbleeding,pain,andmucusuponevacuation

Diagnose: Biopsy

Treatment: RectalCancer: Seeninmales>females Chemotherapy+Radiation

SignsandSymptoms: Rectalbleeding,alteredbowelhabits,tenesmus,obstruction

 Diagnosis: Colonoscopy

Treatment: Surgerythatsparesthesphincter Ifmetastasisinvolved,additionof5FUchemotherapy+radiation

NEUROSURGERY
TumorsoftheBrain Oftenpresentsasaheadachethatissevereenoughtoawakenthepatient duringthenight Increasedintracranialpressurecausingnausea,vomiting,andCushings triad(Bradycardia,hypertension,andCheyneStokesrespiration) Presenceoffocaldeficits Oftenpresentswithafixed,dilatedpupil

Diagnosingabrainlesion: Themostaccuratediagnosiscomesfrombiopsy WithclinicalsuspicionaCTand/orMRIcanoftenhelpmakethediagnosis

Treatment: Differentiatingbetweenthedifferenttypesofbraintumors GlioblastomaMultiforme: Themostcommon1CNSneoplasm Islargeandirregularwitharingenhancingappearance Excisionisthebesttreatmentforalltumors(exceptprolactinomaand lymphoma) PROLACTINOMAgivebromocriptinetoshrinkit,thensurgeryifthis doesntwork LYMPHOMAradiationisthetreatmentofchoice Ifthereismetastasisofbraintumors,adjuncttherapyisradiation

Meningioma: The2ndMC1CNSneoplasm Growsslowly Benign

Retinoblastoma: Occursinchildrenandisoftenbilateral 40%ofcasesarefamilialwhiletherestaresporaticcases

 Medulloblastoma: Commoninchildren Foundinthecerebellum/4thventricle

Prolactinoma: IstheMCpituitarytumor Presentswithmanyendocrinedisturbancessuchasamenorrhea,impotence, galactorrhea,andgynecomastia. TheMCpresentingsymptomsisvisualdisturbance(bitemporal hemianopsia)

Lymphoma: MCCNStumorinAIDSpatients AnMRIshowsaringenhancedlesion Oftenconfusedwithtoxoplasmosis

Schwannoma: Hydrocephalus SignsandSymptoms: ICP,cognition Headache Focalneurologicaldeficits AnincreaseinCSFcausesanenlargementoftheventricles Atumorthataffectsthe8thcranialnerve Presentswithtinnitus,lossofhearing,andincreasedintracranialpressure

Diagnosis: ACTorMRIcanshowthedilationofventricles Alumbarpuncturecanhelpdeterminethetypeofhydrocephalus IfICPisnormal,itisacommunicatinghydrocephalus(presentswithurinary incontinence,dementia,andataxia) IfICPis,itmaybeeithercommunicatingornoncommunicating (Pseudotumorcerebri,congenital)

 Treatment: Ifpossible,treattheunderlyingcause Ifnotpossible,ashuntshouldbeplaced(usuallydrainedintoperitoneum)

 SurgicalConditionsoftheVascularSystem Aneurysms Isadilatationofanarterytogreaterthantwotimesitsnormaldiameter Trueaneurysmsinvolveall3layersofthevessel,andarecausedmost commonlybyatherosclerosisandcongenitaldisorders Falseaneurysmsarecoveredonlybytheadventitiaofthevessel,andare mostcommonlycausedbytrauma

SignsandSymptoms: Gastric/epigastricdiscomfort Backpain Commonlyintheabdomen(abdominalaortaaneurysms) Alsocommonlyintheperipheralvessels

Complications: Aruptureofanabdominalaneurysmisanemergency Presentswithabdominalpain,apulsatileabdominalmass,andsevere hypotension

Diagnosis: Ultrasoundcanhelpdetectaneurysms CTisthebesttesttodeterminesize Themostaccuratetestistheaortogram

Treatment: Controlbloodpressure Reduceriskfactors Surgeryrecommendedifaneurysmsare>5cm

 PeripheralVascularDisease(PVD) SignsandSymptoms: Presentswithclaudication Patientmayhavesmoothandshinyskinwithalossofhairintheaffected area Duetoatherosclerosis

Diagnosis: Ankle:BrachialIndex(ABI)isthebestinitialtestnormaltestis0.9 Themostaccuratetestisanangiography

Treatment: Lifestylemodificationssuchascessationofsmokingandincorporationof exercise ControllipidswithanLDL<100 Controlbloodpressure Dailyaspirin Surgeryisrequiredifthereispainatrest,necrosis,intractableclaudication, and/oranonhealinginfection

 AorticDissection Isadissectionofthethoracicaorta Presentswithintensetearingpainthatradiatestotheback Thereisadifferenceinbloodpressuresbetweentherightandleftarm

Diagnosis: ThebestinitialtestisaCXRshowingawideningofthemediastinum ThemostaccuratetestistheCTangiography

Treatment: Urgentbloodpressurecontrolwithblockersfollowedbynitroprussideto maintainadecreasedbloodpressure UrgentEKGandCXR ThengetaTEEorCT Surgicalcorrectionisnecessary,otherwisethisisrapidlyfatal.

 SubclavianStealSyndrome Anocclusionofthesubclavianarteryleadstoadecreasedbloodflowdistalto theobstruction Thevertebralarterystealsthebloodduetoretrogradeflow Patientexperiencesclaudicationofthearm,nausea,syncope,and supraclavicularbruit

Diagnose: Angiography Dopplerultrasound MRI

Treatment: CarotidVascularDisease Isanatheroscleroticplaqueinthecarotidarteries Carotidsubclavianbypass

SignsandSymptoms: PatientmaypresentwithaTIA Amaurosisfugax(blindnessinoneeye) Carotidbruit

Diagnosis: Angiography

Treatment: Decreasethemodifiableriskfactors Aspirin Otheranticoagulationmedications Surgeryiswarrantedifthereisstenosis>70%,ifpatienthasrecurringTIAs, oriftheyhavesufferedfromapreviouscerebrovascularaccident

 SurgicalConditionsoftheUrinarySystem TesticularTorsion Usuallyoccursinayoungerpatient Acuteedemaandseveretesticularpain Patientusuallyexperiencesnauseaandvomitingduetothedegreeofthe pain ABSENCEofthecremastericreflex Presenceofscrotalswelling Testiclemayhaveahorizontallie

Diagnosis: Ultrasoundtoassessarterialpatency Uponelevationoftheteste,thepainisnotalleviated

Treatment: Epididymitis Unilateralpainofthetesticle Dysuria Painfulandswollenepididymus Lesscommoninprepubertalchildrenasopposedtotorsion 1ststepistosecurethecirculation 2ndstepistoevaluatetheneedforexcisionofthetesticleifitisdead

Diagnosis: SwabforChlamydiaandGonorrhea

Treatment: ProstateCancer Obstructivesymptoms Rockhardnoduleintheprostate NSAIDsandantibiotics

Diagnosis: PSA

 Treatment: Theonlysurgicalrequirementisaradicalprostatectomyinveryseverecases riskofincontinenceand/orimpotence Serumphosphatase Azotemia Transrectalultrasound

Orthopedicconditionsrequiringsurgery
KneeInjuries Include: AnteriorCruciateLigamenttears: Injuryhistoryusuallyrevealsapopsoundduringthetrauma TheLachmantest(anteriordrawertest)isusedinthefieldtomakea diagnosis MRIisthetestofchoicetodeterminetheseverityoftheinjury Treatmentiseitherwithconservativemeasures,orifseverewith arthroscopicrepair Anteriorcruciateligamenttears Posteriorcruciateligamenttears Collateralligamenttears Meniscustears

TearoftheACLwithassociatedjointeffusion PosteriorCruciateLigamenttears: Injuryusuallyoccurswhenthekneeisflexed Posteriordresserdrawersign MRIisthetestofchoicetodetermineseverityoftheinjury

 Treatmentiseitherwithconservativemeasures,orifseverewith arthroscopicrepair

TearofthePCL CollateralLigamenttears: TheMCListhemostcommonlyinjuredligament Seenwithadirectblowtothelateralknee IscommonlyinjuredinconjunctionwiththeinjurytotheACLorPCL MRItodetermineseverityoftheinjury Kneebrace

TearoftheMCL Meniscustears: Oftenseeninolderpatientsandisduetodegeneration Injuryismostcommonlyseeninthemedialmeniscusandismuchmore commoninmen

 DiagnosewithMcMurraystest MRItodeterminetheseverityoftheinjury Treatmentisusuallyrestalone,ifseverecantreatwitharthroscopicsurgery

Medialmeniscustear ShoulderInjuries RotatorCuffInjury SignsandSymptoms: Painandtendernessofthedeltoidwithmovement Painovertheanterioraspectofthehumeralhead Neerssign(+)painelicitedwhenthearmisforcefullyelevatedforward Canrangefrommildtendonitistoseveretears InvolvetheSupraspinatus,Infraspinatus,TeresMinor,Subscapularis

Diagnosis: Clinicalsuspicion MRIisusedforconfirmation

Treatment: NSAIDs Steroidsinjections

 DislocationoftheShoulder Ismostcommonlyananteriordislocation Posteriordislocationseenwhenpatientiselectrocutedand/orexperiencesa statusepilepticusseizure Forseverediseasesthatarenotsuccessfullytreatedwithsteroids, arthroscopicsurgeryishelpful

Anteriordislocationofthehumerus SignsandSymptoms: Immobility Extremepain

Treatment: Tractioncountertractiontechniquestoputthebonebackinthesocket Immobilizationperiod(26weeks)

 HipandThighInjuries Dislocations FemoralNeckFracture Requiressignificantforceforinjury Producesseverepainofthehip/grointhatisexacerbatedwithmovement Legisclassicallyexternallyrotated Diagnosewithxray Requiressurgicalreductionandinternalfixation Dislocationsrequireemergencyreductionundersedation Riskofinjurytosciaticnerve Avascularnecrosisisaseverecomplication

Fractureoftheleftfemoralneck WristInjuries CollesFracture: Thisisafracturetothedistalradius Occursafterfallingonanoutstretchedhand DiagnosewithH&Pandxray Treatwithcastimmobilizationfor24wk

Collesfracture ScaphoidFracture: Almostalwayssecondarytoafall Mostcommonlymisdiagnosedasasprainedwrist Diagnosisisclassicallymadewhenthereispainintheanatomicsnuffbox Managewithathumbsplintfor10weeks Complicationisavascularnecrosis

ScaphoidFracture

 CarpalTunnelSyndrome Diagnosis: PathognomonicsignisTinelsSign,wheretappingoverthepalmaraspect ofthewristelicitsshootingpains Phalenstestisalsodiagnostic WristSplints: Treatment: Holdsthewrist inapositionof Treatbyavoidanceofaggravatingactivity,use slight wristsplintswhichholdthewristinslight extension extension Severecasesshouldfirstbemanagedwithsteroid injectioninthecarpaltunnel,ifnotreatmentsurgeryisperformed Presentswithpain,numbness,tinglingofthehandsalongthedistributionof themediannerve

TheBreast
WorkupofaBreastMassAlgorithm(AAFP)

 CancerRisks FamilyHistoryandBreastCancer: Only5%ofbreastcancersarefamilial Witha1stdegreerelativebeingaffected,theriskofcancerincreases Autosomaldominantconditionswithincreasedrisk:BRCA1,BRCA2,Li Fraumenisyndrome,Cowdensdisease,PeutzJeghers The#1riskfactorforbreastcancerisgender (Female>>>Male) Inwomen,ageisthe#1factorforbreastcancer risk Latemenopauseincreasestheriskofbreastcancer (after50yr) Iflessthan11yratmenarche,theriskofbreast cancerisincreased If>30yratfirstpregnancy,theriskforbreast cancerincreases Historyof Fibroadenoma and/or Fibrocystic diseasedoesnot increasetherisk ofgettingbreast cancer

 TumorsoftheBreast Mammogram Allwomen>40yr(controversialastoageto start)shouldhaveyearlymammograms Noteffectiveinyoungpatientsbecausethe breasttissueistoodense Whentoperform certaintests pertainingtobreast masses: Apalpablemassthat feelscysticalways requiresanultrasound first. Apalpablemassthat doesntfeelcystic requiresaFNA(afteran USorinsteadofanUS). AnyFNAthatreveals bloodyfluidrequires cytology. Alwaysdoa mammograminpatients >40yrwhopresentwith almostallpathologiesof thebreast. Abiopsyisrequired whenacystrecursmore than2timeswithin4 weeks,whenthereis bloodyfluid,whenthere aresignsof inflammatorybreast disease,andwhena massdoesnotdisappear withFNA.

Fibroadenoma Theclassicpresentationisafirm,nontender, mobilebreastnodule Mostcommonlyseeninteensandyounger women

Diagnosis: Breastexam FNA Followupclinicalbreastexamin6weeks

Treatment: Notrequiredasthisconditionisnotacancer precursorandoftendisappearsonitsown

 FibrocysticDisease Thispresentswithmultiple/bilateralpainfullumpsinthebreastthatvaryin painwiththemenstrualcycle Isthemostcommonlyseenbreasttumorinwomenbetween3550yrofage

Diagnosis: Fineneedleaspirationtodrainfluid,anditwillcollapseaftertheFNA

Treatment: PreInvasiveBreastCancers IncludeDuctalCarcinomaInSituandLobularCarcinomaInSitu DuctalCarcinomaInSitu(DCIS) Itspresenceincreasestheriskofinvasivebreastcancers Usuallynonpalpableandseenonmammogramasirregularlyshapedductal calcifications Willleadtoinvasiveductalcarcinoma OCPscanhelppreventthisfromoccurring

 Diagnosis: Histologyshowspuchedoutareasinductsandhaphazardcellsalongthe papillae

Treatment: LobularCarcinomaInSitu(LCIS) IncontrasttoDCIS,thisisnotprecancerous,itdoeshoweverincreasethe riskoffutureinvasiveductalcarcinoma Surgicalexcisionensuringcleanmargins Postoperativeradiationisrecommendedtodecreasetheriskofrecurrence (CangiveTamoxifeninadditiontoradiationorinsteadofradiation)

Diagnosis: Hardtodiagnosewithmammogram Cannotbedetectedclinically Thehistologyshowsmucinouscellsintheclassicsawtoothpattern

Treatment: Tamoxifenaloneisusedfortreatment

 InvasiveBreastCancers Treatmentforallinvasivecancers: 1. Iflumpis<5cm,Lumpectomy+radiation,mayaddchemoandadjuvant therapy. 2. Performsentinelnodebiopsy(preferredoveranaxillarynodebiopsy) 3. Testforestrogen/progesteronereceptorsandtheHER2protein 4. Iftumoris>5cm,thetreatmentinvolvessystemictherapy InvasiveDuctalCarcinoma PagetsDiseaseoftheBreast InflammatoryBreastCancer LobularCarcinoma BRCA1andBRCA2 Testingforthesegenesshouldbeperformedifthereisahistoryofthefollowing: Familyhistoryofearlyonsetbreastcancer Multifocalandwithinthesamebreast(usually) 20%ofcasespresentasbilateralmultifocallesions Lesscommon Rapidgrowth/progression Earlymetastasis Red,swollen,pitted,andwarmbreast(peaudorange) Presentswithanerythematousandscalylesionofthenipplethatispruritic. Nipplemaybeinverted Nippledischargecommon Isthemostcommonformofbreastcancer,seeninalmost85%ofallcases Isunilateral Metastasizestothebrain,liver,andbone Importantprognosisfactorsaresizeofthetumorandthelymphnode involvement

 Familyhistoryofmalebreastcancer Pasthistoryofbreastand/orovariancancerinthatpatient AshkenaziJewishheritage

Chapter 2 Obstetrics

 Terminologies Gravidty=totalnumberofpregnancies Parity=numberofbirthswithagestationalage>24weeks Termdelivery=deliveryafter37weeksofgestation Prematuredelivery=deliveryofinfantbetween20and37weeks

TheUncomplicatedPregnancy
DiagnosingPregnancy Thepresenceofamenorrheaand+urinaryhCGsuggestspregnancy. Confirmpregnancywiththefollowing: Estimatingdateofconfinement(EDC) UseNagelesrule=LastMenstrualPeriod(LMP)+7days3months+1yr. *Calculationaccuracydependsonregular28daycycles. DRUGCATEGORIESDURINGPREGNANCY Category A B C D Description Medicationhasnotshownanincreaseinriskforbirthdefectsin humanstudies. Animalstudieshavenotdemonstratedarisk,andthereareno adequatestudiesinhumans,ORanimalstudieshaveshownarisk, buttheriskhasnotbeenseeninhumans. Animalstudieshaveshownadverseeffects,butnostudiesare availableinhumans,ORstudiesinhumansandanimalsarenot available. Medicationsareassociatedwithbirthdefectsinhumans;however, Presenceofgestationalsac[seenwithtransvaginalUSat45weeks.hCG levelapprox1500mIU/ml.] Fetalheartmotion[seenbyUSbetween56weeks.] Fetalheartsounds[heardwithDopplerUSat810weeks.] Fetalmovement[onexaminationafter20weeks.]

 potentialbenefitsinrarecasesmayoutweightheirknownrisks. Medicationsarecontraindicatedinhumanpregnancybecauseof knownfetalabnormalitiesthathavebeendemonstratedinboth humanandanimalstudies.

COMMONTERATOGENSINPREGNANCY Drug Lithium Carbamazepine, Valproate RetinoidAcid ACEInhibitors Oral hypoglycemics Warfarin NSAIDs BirthDefect Ebsteinsanomaly(singlechamberedrightsideofheart). Neuraltubedefects. CNSdefects,craniofacialdefects,cardiovasculardefects. Decreasedskullossification,renaltubuledysgenesis, renalfailureinneonate. Neonatalhypoglycemia CNS&Skeletaldefects Necrotizingenterocolitis,constrictionofductus arteriosis. Atfirstvisitupondiscoverofpregnancy Performthefollowing: CompletephysicalexamwithpelvicandPapsmear. CultureforgonorrheaandChlamydia

Labsincludethefollowing: CBC BloodtypewithRhstatus UAwithculture RPRforsyphilis Rubellatiter TBskintest OfferHIVtest

Additionaltesting: Genetictestingifhistoryindicatestheneed Ifptnotimmunetorubella,DONOTimmunize(livevirus).

 Recommend: Whattododuringeachtrimester 1sttrimester: Shouldseepatientevery4weeks. Assess: 2ndtrimester: Continuetoseethepatientevery4weeks Assess: At12weeksuseDopplerUStoevaluatefetalheartbeat(eachvisit) Offertriplemarkerscreen(hCG,estriol,fetoprotein(AFP))at1518 weeks,[AFPdecreasedinDownssyndrome],[AFPincreasedinmultiple gestation,neuraltubedefects,andduodenalatresia]. Documentquickening(fetalmovement)at1719weeksandbeyond. Amniocentesisifmotheris>35yrorifhistoryindicates(hxofmiscarriages, previouschildwithdeficits,abnormaltriplemarkerscreen). Glucosescreeningat24wk Repeathematocritat2528wk MSAFP: Neuraltubedefect(NTD),ventral walldefect,twinpregnancy, placentalbleeding,renaldisease, sacrococcygealteratoma. MSAFP: Trisomy21,Trisomy18 *Themost commoncauseof inaccuratelab resultsisdating error. Weightgain/loss Bloodpressure Edema Fundalheight Urineforglucoseandprotein Estimationofgestationalagebyuterinesize Folicacid Iron Multivitamin 2535lbweightgainduringpregnancy

 SECONDTRIMESTERROUTINETESTS Screening Diabetes Anemia Atypical antibodies Test Diagnostic Significance 1hr50gOGTT Abnif (2428wks) >140mg/dL CBCmeasured Hb<10g/dL= between2428 anemia weeks. IndirectCoombs Performedin test Rh()women lookingfor antibodies(anti DAb)before givingRhoGAM Vaginalandrectal (+)GBSisahigh cultureforgroup riskforsepsisin Bstrepat3537 newborns. weeks. [treatwith intrapartumIV antibiotics]. NextStepinMgmt If+,perform3hr 100gOGTT Iron supplementation RhoGAMnot indicatedinRh() womenwhohave developedantiD antibodies IV: PenG Clindamycin Erythromycinin PCNallergic patient.

GBSscreening

3rdtrimester: Seepatientevery4weeksuntilweek32,every2weeksfromweek3236,then everyweekuntildelivery. Assess: Inquireaboutpretermlabor[vaginalbleeds,contractions,ruptureof membranes]. Inquireaboutpregnancyinducedhypertension. ScreenforgroupBstreptococcusat3537weeks. GiveRhoGAMat2830weeksifindicated Theconfirmatorytestfordiabetesinpregnancyisthe3hr100goral glucosetolerancetest(OGTT). Plasmaglucose>125mg/dLatbeginningoftest=DM Abnormalplasmaglucoseis>140mg/dLat1hr,>155mg/dLat2hr,and >180mg/dLat3hr. If1postglucoseloadmeasurementisabnormal,impairedglucose toleranceisthediagnosis. If2ormorepostglucoseloadmeasurementsareabnormal,gestational diabetesisthediagnosis.

 Thefollowingantiemeticsaresafetouseduringpregnancy: Doxylamine Metoclopramide Ondansetron Promethazine Pyridoxine

TheComplicatedPregnancy

Bleedingafter20weeks(latepregnancy) Mostcommoncausesoflatepregnancyvaginalbleedingare: 1. 2. 3. 4. Abruptioplacenta Placentaprevia Vasaprevia Uterinerupture

*Neverperformadigitalorspeculumexaminanypatientwithlatevaginalbleeding untilavaginalultrasoundhasruledoutplacentaprevia ABRUPTIOPLACENTA Suddenonsetofseverelypainfulvaginalbleedinginpatientwithhistoryof hypertensionortrauma. Bleedingmaybeconcealed,inwhichcasetherewillbesevere,constantpain withoutthepresenceofblood. DICisafearedcomplication

Management: PLACENTAPREVIA Suddenonsetofpainlessbleedingthatoccursatrestorduringactivity withoutwarning. Mayincludehistoryoftrauma,sexualactivity,orpelvicexambeforeonset. Occurswhentheplacentaisimplantedinloweruterinesegment BestmanagementisemergencyCsection. EmergentCsectionifpatientorfetusisdeteriorating Admitandobserveifbleedinghasstopped,vitalsandHRarestable,orfetus is<34weeks.

3formsofplacentaprevia: 1. Accretadoesnotpenetrateentirethicknessofendometrium

 2. Incretaextendsfurtherintothemyometrium 3. Percretaplacentapenetratesentiremyometriumtouterineserosa VASAPREVIA Aconditionlifethreateningtothefetus. Occurswhenvilamentouscordinsertionresultsinumbilicalvesselscrossing theplacentalmembranesoverthecervix.Membranerupturecausestearing ofthefetalvessels,andbloodlossisfromthefetalcirculation. Fetalbleedinganddeathoccurrapidly.

Management: ImmediateCsection. Classictriadofvasaprevia: 1. 2. 3. UTERINERUPTURE Occurswhentheresahistoryofuterinescarwithsuddenonsetof abdominalpainandvaginalbleeding. AssociatedwithalossofelectronicfetalHR,uterinecontractions,and recessionofthefetalhead. Ruptureofmembranes Painlessvaginalbleeding Fetalbradycardia EmergencyCsectionisalwaysthefirststepinmanagement

Management: Immediatesurgeryanddelivery

 ComparingPlacentaPreviaandPlacentalAbruption Abnormality Epidemiology PlacentalAbruption Prematureseparationof normallyimplanted placentafromdecidua Riskpreeclampsia, previoushistoryof abruption,ROMinapt withhydramnios,cocaine use,cigarettesmoking, andtrauma. 2030weeks Anytimeafter20weeks Sudden,painlessbleeding Painfulbleeding,canbe heavyandpainful,with frequentuterine contractions USPlacentain Clinical,basedon abnormallocation presentationofpainful vaginalbleeding,frequent contractions,andfetal distress. Hemodynamicsupport, Hemodynamicsupport, expectantmanagement, urgentCsectionor deliverybyCsection vaginalinductionif whenfetusismature patientisstableandfetus enough isnotindistress Associatedwithatwofold Riskoffetalhypoxia increaseincongenital and/ordeath,DICmay malformationsso occurasaresultof evaluationsforfetal intravascularand anomaliesshouldbe retroplacental undertakenatdiagnosis coagulation. PlacentaPrevia Placentaimplantedover internalcervicalos (completelyorpartially) Riskgrandmultiparas andpriorCsection

Timeofonset Signs&Symptoms

Diagnosis

Treatment

Complications

HypertensioninPregnancy
Hypertensioninpregnancypredisposesboththemotherandfetustoserious conditions.ABPof140/90duringpregnancycanbeclassifiedaschronic hypertensionorgestationalhypertension. Hypertensionaccompaniedbysignsandsymptomsofendorgandamageor neurologicalsequelaeisdiagnosedaspreeclampsia,eclampsia,orHELLP syndrome. Sustainedhypertensionmaycausefetalgrowthrestrictionandhypoxia,and increasetheriskofabruptioplacenta.

Diagnosis: WarningSignsofPreeclampsia: Hallmarksymptomsinclude: Signs: Labs: Thrombocytopenia Elevatedliverenzymes Pulmonaryedema Oliguria Headache Epigastricpain Visualchanges/disturbances Elevatedpregnancybeforepregnancyorbefore20weeksgestation=chronic hypertension Developmentofhypertensionafter20weeksgestationthatreturnsto normalbaselineby6weekspostpartum=gestationalhypertension Presenceofproteinuriaand/orpresenceofwarningsigns=preeclampsia

 Disease Preeclampsia Characteristics HTN(>140/90orsystolicBP >30mmHgordiastolicBP>15 mmHgcomparedtopreviousBP). Newonsetproteinuriaand/or edema. Commonlyaroundweek20 SBP>160mmHgorDBP>110 mmHg. Significantproteinuria(>1g/24hr urinecollectionor>1+ondip) CNSdisturbancessuchas headacheorvisualdisturbance Pulmonaryedema RUQpain CONVULSIONS 25%occurbeforelabor,50% duringlabor,25%infirst72hr postpartum

SeverePreeclampsia

Eclampsia

Primiparasareatgreatestriskforeclampsia. Chronichypertensionwithsuperimposedpreeclampsiaisdiagnosedwhenthereis chronichypertensionwithincreasinglyseverehypertension,proteinuria,and/or warningsigns. Eclampsiaisthediagnosiswhenthereisunexplainedgrandmalseizuresina hypertensiveand/orproteinuricinawomaninthelasthalfofpregnancy.Seizures areduetoseverediffusecerebralvasospasm,whichcausecerebralperfusion deficitsandedema HELLPsyndromeisdiagnosiswhenthereisHemolysis,ElevatedLiverenzymes, andLowPlatelets. Treatment: MaintenanceTherapy: FirstlinetherapyMethyldopa Secondlinetherapyblockerssuchaslabetalol BPgoalis140150mmHg(systole)and90100mmHg(diastole). DonttreatunlessBPis>160/100mmHg

 *blockeruseinpregnancycancauseIUGR AcuteelevationinBP: Seizuremanagement: Airwayprotectionfirst IVMagnesiumSulfatebolusforseizureandinfusionforcontinued prophylaxis Inducelaborisfetusis36weekswithmildpreeclampsiaandattempt vaginaldeliverywithIVoxytocinifbothmotherandfetusarestable IVhydralazineorlabetolol

HELLPSyndrome
Management: Immediatedeliveryatanygestationalage IVcorticosteroidsifplateletsare<100,000/mm^3bothantepartumand postpartum,continuinguntilplateletsare>100,000/mm^3andliver functionsnormalize Giveplatelettransfusionifplateletsdropbelow20,000/mm^3orplatelet countlessthan50,000/mm^3ifCsectionwillbeperformed IVMagnesiumSulfateforseizureprophylaxis Steroidsforfetallungmaturity. Occursinupto10%ofpreeclampsiapatients Occursinthirdtrimester,mayoccur2daysafterdelivery Riskfactorsinclude:whites,multigravids,oldermaternalage

ComplicationsofHELLP: DIC Placentalabruption Fetaldeath

 Hepaticrupture Ascites

Normalphysiologicchangesinpregnancy
Therearemanynormalphysiologicalchangesthatoccurinpregnancy,theseinclude thefollowing. Hematologicalpregnancycreatesastateofhypercoagulability clottingfactorlevels Venousstasiscausedbyuterinepressureonlowerextremityveins

AnemiaofPregnancy: Cardiac Pulmonary Mucosalhyperemiacausesnasalstuffinessandnasalhypersecretion Diaphragmelevatesduetouterusexpansion Tidalvolumeandminuteventilation3040% Functionalresidualcapacityandresidualvolume20% CO50%(bothHRandSVincrease) flowcausesS2splitwithinspiration,distendedneckveins,systolic ejectionmurmur,andS3galloparenormalfindings. PVRduetoprogesteronemediatedsmoothmusclerelaxation BPduringfirst6months,thenreturntonormal Betweenweeks630,plasmavolumeincreasesapproximately50% Redcellmassincreasestoasmallerdegree,anemiadueto15%dilution Slightleukocytosis Plateletsdecreaseslightlybutstillremainwnl.

 GI Renal Endocrine Skin Increasedestrogencausesskinchangessimilartothoseinliverdisease Spiderangiomas,palmarerythema Hyperpigmentationduetoestrogenandmelanocytestimulatinghormone fastingglucoseinmotherduetofetalutilization postprandialglucoseinmotherduetoinsulinresistance At911weeksthefetusproducesitsowninsulin maternalthyroidbindingglobulin(TBG)duetoestrogen,totalT3and T4duetoTBG. cortisolandcortisolbindingglobulin bladdertoneduetoprogesteronepredisposestourinarystasisand UTIs/pyelonephritis GFRby50%,thusglucoseexcretionwithoutincreasedproteinloss SerumcreatinineandBUNdecrease GImotility esophagealsphinctertone(leadstoGERD) alkalinephosphatase Hemorrhoidscausedbyconstipationandvenouspressureduetoenlarging uteruscompressiononIVC Hyperventilationthatallowsforapressuregradientsomaternal02can transfertofetus Respiratoryrate,vitalcapacity,inspiratoryreserveallremainunchanged.

MedicalComplicationsinPregnancy
CardiacAbnormalities Heartdisordersaccountforupto10%ofmaternalobstetricdeaths Womenwithveryhighriskdisordersshouldbeadvisedagainstpregnancy duetoincreasedriskofdeath Cardiovascularphysiologicalchangesmayunmaskandworsenunderlying conditions,seenmaximallybetween2834weeksgestation.

PeripartumCardiomyopathy Managingspecificcardiacconditions HeartFailure: Loopdiuretics,nitrates,andblockers Digoxinmayimprovesymptomsbutdoesnotimproveoutcome. NeveruseACEIsinpregnancy Fromthe8thmonthuntil5monthspostpartum,heartfailurewithout identifiablecauseispossible Riskfactorsincludemultiparity,ageover30,historyofmultiplegestations, andpreeclampsia 5yrmortalityrateis50%

Arrhythmias: Ratecontrolaswithnonpregnantpatients Nevergivewarfarinoramiodarone

EndocarditisProphylaxis: Sameasinnonpregnantpatient Dailyprophylaxisinpatientwithrheumaticheartdisease

ValvularDisease: Regurgitantlesionsdonotrequiretherapy Stenoticlesionshaveincreasedriskofmaternalandfetalmortality MitralstenosishasincreasedriskofpulmonaryedemaandAfib.

 HypercoagulableStates PulmonaryEmbolus: TheleadingcauseofmaternaldeathinUS

Whentoanticoagulate: AnticoagulatewhenDVTorPEinpregnancy AnticoagulatewhenAtrialFibrillationispresentwithunderlyingheart disease Whenpatienthasantiphospholipidsyndrome Whenejectionfractionis<30%

Theanticoagulantofchoiceislowmolecularweightheparin(wontcrossplacenta) PatientswithahistoryofDVTorPEinapreviouspregnancyshouldreceive prophylacticLMWHthroughoutthepregnancy,unfractionatedheparin duringlaboranddelivery,andwarfarinfor6weekspostpartum.

ThyroidDisorders GravesDisease: DiabetesinPregnancy Thetargetvaluesforfastingbloodsugararebetween90mg/dLand 120mg/dL1hraftereating. InsulindependentDMrequiresinsulinandissafethroughpregnancy GestationalDMismanagedsolelythroughdiet Propylthiouracil(PTU)isDOCinpregnancy Methimazoleis2ndlinedrug PTUcancrosstheplacentaandcausegoiter+hypothyroidism. MaternalthyroidstimulatingIgsandthyroidblockingIgscancrossthe placentaandcausefetaltachycardia,growthrestriction,andgoiter. Hyperthyroidisminpregnancycausesfetalgrowthrestrictionandstillbirth Hypothyroidisminpregnancycancauseintellectualdeficitsandmiscarriage blockersaretheDOCforsymptomsduetohyperthyroidism Radioactiveiodinenevergiveninpregnancy

 Oralhypoglycemicsarecontraindicatedandshouldalsobeavoidedif breastfeeding,sinceitcancausehypoglycemia.

Routinemonitoringtestsduringpregnancy: Laborinthediabeticpatients: Commonneonatalproblemsindiabeticpregnancy: Hypoglycemia Hypocalcemia Polycythemia Hyperbilirubinemia Respiratorydistresssyndrome Duetodelayedfetalmaturity,aimtodeliverthebabyat40weeks Ifthereispoorglycemiccontrol,inducelaborat3940weeksif<4,500g. CheckL/Sratio,if>2.5andthereispresenceofphosphatidylglycerolthis ensureslungmaturity Ifbabyis>4,500g,scheduleaCsection Ensurematernalglucoseisbetween80100mg/dL,thiscanbeensuredwith D5(5%dextrose) Insulinresistancedecreasesrapidlyafterdelivery,sokeepaneyeoninsulin administrationandmaintainbloodglucoselevelswithaslidingscale Monthlysonograms HbA1c>8.5inthefirst Monthlybiophysicalprofiles trimesterisstrongly HbA1ceachtrimester associatedwithcongenital Triplemarkerscreenat1618weeks malformations,especially assessingNTDs. neuraltubedefects! At32weeksstartweeklynonstresstests andamnioticfluidindex IfgestationalDM,doa2hr75gOGTTat612weekspostpartumtoseeif diabeteshasresolved

 LiverDisease IntrahepaticCholestasisofPregnancy: AgeneticconditionmostcommonlyseeninEuropeanwomen

Si/SxIntractablenighttimepruritisofpalmsandsolesoffeet Diagnosisupto100xincreaseinserumbileacids TreatmentUrsodeoxycholicacidintreatmentofchoice.Antihistaminesalso helpful AcuteFattyLiverofPregnancy: Arareconditioncausedbydisorderedmetabolismoffattyacidsbythefetal mitochondria. CausesHTN,proteinuria,andedemathatcanmimicpreeclampsia.

Diagnosis: liverenzymes(ALT,AST,GGT) Hyperbilirubinemia DIC Hypoglycemia Increasedserumammonia

Treatment: EmergencysituationrequiresICUadmissionandaggressiveIVfluids+ immediatedelivery

 UrinaryTractInfections,Bacteriuria,andPyelonephritis InfectionType Symptoms Asymptomatic Bacteriuria (+)urineculture NOburning NOfrequency NOfever NOurgency Outpatient Nitrofurantoinis theDOC Acute pyelonephritisif untreatedin approximately 30% AcuteCystitis (+)urineculture BURNING FREQUENCY URGENCY NOfever Outpatient Nitrofurantoinis theDOC Acute pyelonephritisif untreatedin approximately 30% Pyelonephritis (+)urineculture BURNING FREQUENCY URGENCY FEVER+CVA TENDERNESS Admission,give: IVhydration IVcephalosporins Givetocolytics Pretermlaborand delivery. Severecasesmay progresstosepsis, anemia,and pulmonary dysfunction

Treatment

Possible Complications

EctopicPregnancy/TubalPregnancy Theearliertheageofgestationthelessthereisariskofcomplications. 1sttrimester: D&Cisthemostcommon1sttrimesterprocedure. Giveprophylacticantibiotics Performundertwilightanesthesia+paravertebralblock CanperformmedicalabortionasanalternativetoD&Cwithuseoforal mifepristone(progesteroneantagonist),andoralmisoprostol(prostaglandin E1).*Mustbeperformedwithin63ofonsetofamenorrhea.

Complications: 2ndtrimester: D&Cisthemostcommon2ndtrimesterprocedure. Formoreadvancedpregnancies,anintactD&Ccanbeused. Endometritis(rarely) Retainedproductsofconception(POCs)

 Complications: Abortion EctopicPregnancy: Implantationoutsideoftheuterinecavity PIDincreasestherisk Terminationofpregnancyusually20weeks,spontaneouslyin15%ofall pregnancies. Riskfactors=paternalage,conceptionwithin3monthsoflivebirth, parity 50%areduetochromosomalabnormalities Vaginalbleedinginfirsthalfofpregnancyispresumedtobeathreatened abortionuntilprovenotherwise Retainedplacentaisthemostcommonimmediatecomplication Cervicaltrauma/cervicalinsufficiencyisthemostcommondelayed complication

Riskfactors: Previousectopicpregnancy Historyofgonorrhea,Chlamydia,PID,salpingitis Advancedmaternalage(>35) >3priorpregnancies

Differentialdxofectopicpregnancy: Ovariantorsion Endometriosis Surgicalabdomen Abortion Salpingitis Rupturedovariancyst

Diagnosing: (+)hCH+UStodetermineintravs.extrauterinepregnancy Lowprogesteronelevelissuggestiveofanonviablepregnancythatmaybe locatedoutsideoftheuterinecavity

 Treatment: Laparoscopicremoval,tubesusuallyhealontheirown Methotrexateearly,especiallyifsizeis<3.5cmindiameter+nocardiac activityonUS RhnegativewomenshouldreceiveRhoGAM SerialhCHmustbedonetoensuresuccessoftermination

TypesofAbortions Threaten Vaginal bleedingin first20wk without passageof tissuesor ROM. Cervixis closed. Occursin 25%of pregnancie s. Diagnose with ultrasound . Ifno cardiac activityby week9 considera D&C. Inevitable Threatene dabortion with dilated cervicalos and/or ruptureof membrane s(ROM). Pregnancy lossis unavoidabl e. Treatwith surgical evacuation +adminof RhoGAMif motheris Rh(). Completed A documented pregnancy that spontaneous lyabortsall productsof conception (POCs). Mustdo pathology reportof POCs. Ptmay require additional curettageif POCsarenot completely evacuated. RhoGAMto Rh() women. Incomplete Cramping, bleeding, dilated cervixwith passageof tissueinto vaginaor endocervical canal. Curettage often required. Rh()pt requires RhoGAM. Hemodynam ic stabilization maybe required. Missed POCsdonot getfully expelled. Nouterine growth,no fetalheart tones, cessationof pregnancy symptoms. Evacuation ofuterus after confirmed fetaldeath. DICisrare complicatio n. RhoGAMis Rh() Recurr. 2 consecutive ortotalof3 spontaneou sabortions. Maybed/t chromosom alanomaly. Treatwith cervical (1316wk) circlage untillabor orROM occurs(36 37wk).

 DisproportionateFetalGrowth IUGR SymmetricIUGR: FetalCauses: growthpotential USshowsainallmeasurements Diagnosedwhenfetalweightis<510percentileforgestationalageor <2,500g(5lb,8oz.) Earlysonogramisrequiredifaccuratedatesarenotknown

Etiology: TORCHinfection Aneuploidy Structuralanomaliessuchas:cardiac,neurological.

Ultrasound: inallmeasurements(symmetric)

Diagnosing: AsymmetricIUGR: 1.MaternalCauses: placentalperfusion Karyotype Screenforfetalinfection Detailedsonogram

Etiology: Hypertension Malnutrition ETOH,tobacco,illicitdrugs

Ultrasound:

 abdomenmeasurementswithnormalheadmeasurements

Diagnosing: 2.PlacentalCauses: placentalperfusion Serialsonograms NST AFI(often,especiallywithsevereuteroplacentalinsufficiency). Biophysicalprofile

Etiology: Infarction Twintwintransfusion Abruption Velamentouscordinsertion

Ultrasound: abdomenmeasurementswithnormalheadmeasurements

Diagnosing: Macrosomia Indicatedbyfetalweight>9095percentileforgestationageorbirthweight of40004500g. Serialsonograms NST AFI(often,especiallywithsevereuteroplacentalinsufficiency). Biophysicalprofile

RiskFactors: GestationalDiabetesMellitus Prolongedgestation Obesity Increasedpregnancyweightgain Multiparity Malefetus

 Complications: Maternalinjuryduringbirth,postpartumhemorrhage,emergencyCsection Fetusshoulderdystocia,birthinjury,asphyxia Neonatehypoglycemia,Erbspalsy Management: ElectiveCsectionindiabeticif>4500g,or>5000ginnondiabeticmother.

FetalAssessmentandIntrapartumSurveillance
Thefollowingmustbeassessedandobservedcloselyduringpregnancy: 1. FetalGrowth USismostreliabletoolforgrowthassessment Measurebyfundalheight,adeviationfromexpectedfundalheightduring weeks1836requirerepeatmeasurementand/orUS Earlypregnancy:Gestationalsac+crownrumplengthcorrelatequitewell withgestationalage Laterpregnancy:4measurementsdoneduetowidedeviationofnormal range:1Biparietaldiameterofskull2Abdominalcircumference3Femur length4Cerebellardiameter 2. Fetalwellbeing 4movementsperhrusuallyindicatesfetalwellbeing Nonstresstest(NST): Biophysicalprofile: Measures: Fetalbreathing Fetalbreathing Fetaltone Measuresresponseoffetalheartratetomovement NormalNSTwhenFHRby15beatsperminutefor15secfollowingfetal movement(2oftheseaccelerationswithin20minconsideredtobenormal) AnonreactiveNSTrequiresfurtherassessment NSThasahighfalsepositiverate,thusarepeatwithin24hrisagoodidea Fetalgrowth Fetalwellbeing Testsoffetalmaturity Intrapartumfetalassessment Isoimmunization Genetictesting

 3. Testsoffetalmaturity Sincetherespiratorysystemislastthingtodevelopinthefetus,decisions regardingdeliveryareusuallybasedonthematurityofthissystem Surfactantisstilllowallthewayupto33weeks Lackofsurfactantcausesneonatalrespiratorydistresssyndrome(RDS) Testingfetallungmaturity: Lecithin:sphingomyelinratio>2.0isthesaferatioandsuggestslung maturity. Phosphatidylglycerolappearslateinpregnancyanditspresenceindicates fetallungmaturity. Qualitativeamnioticfluidvolume Reactivefetalheartrate Allmeasuresfrom02,ascoreof810isnormal,scoreof6requiresfurther evaluation,scoreof4usuallyrequiresimmediateintervention

NOTE:Sphingomyelinremainsconstantthroughoutpregnancy,whilelecithin onlyelevateswhenthefetallungsbecomemature 4. Intrapartumfetalassessment FHRmonitoring: NormalFHRis120160BPM FHR>160for10minconsideredtachycardia(MCCismaternalfever) FHR<120for10minconsideredbradycardia(congenitalheartblock,fetal anoxia,maternaltreatmentwithblockers FHRvariabilityisareliableindicatoroffetalwellbeingandissuggestiveof sufficientoxygenationoffetus. DecreasedFHRvariabilityisassociatedwithfetalhypoxia,fetaltachycardia, depressants,prolongeduterinecontractions

 Accelerations: EarlydecelerationsFHRmirroringcontraction,duetopressureonfetalhead (vagalnervestimulation),isphysiologicandnotharmfultofetus.

Variabledecelerationsdontalwayscoincidewithuterinecontraction, characterizedbyrapiddipinHRfollowedbyrapidreturntobaseline.Reflex mediatedandduetoumbilicalcordcompression

 Latedecelerationsbeginaftercontractionhasstarted,dipsafterpeakof contraction,andreturnstobaselineaftercontractionisover.Viewedasdangerous andisassociatedwithplacentalinsufficiency.

Causes: Placentalabruption Pregnancyinducedhypertension Maternaldiabetes Maternalanemia Maternalsepsis Posttermpregnancy Hyperstimulationofuterus

**Repetitivelatedecelerationsrequireintervention 5. Isoimmunization Followingexposuretofetalredbloodcellantigens,themothercandevelop maternalimmunoglobulinantibodies(IgG).Thiscanoccurduringbirthorduring thepregnancydependingoncertainproblemsthroughoutthepregnancywhere bloodismixed. MostcommonlyoccurswhenmotherisRh()andfetusisRh(+) IgGcrossesplacentaandcanaffectthefetus Asignificanttransferofantibodiescanresultinhydropsfetalis Fetalascitesandedemaoccur(livermakestoomanyRBCsattheexpenseof proteins,causingainoncoticpressure,resultinginfetalascitesand/or edema. AmaternalIgGtiter1.16issufficientlyhightohurtthefetus

 Treatment/Avoidance: GiveRhoGAMwithin72hrofdeliverytopreventanantibodyresponseinthe mother. Givenat28weeksaswell,canfurtherreducerisksby0.2% ImportanttotestfatherforRhstatus,ifheisRh(+),administerRhoGAM bothat28weeksofgestation+at72hrafterdelivery. TheKleihauerBetketesthelpstoidentifyfetalRBCsinmaternalblood.

Othertimesmaternalfetalbloodcanmix: 6. Whentodoprenatalgenetictesting? Advancedmaternalage(mostcommon)Downssyndromeisincreased10 foldwhenmotheris3545yr. AmniocentesisshouldbeofferedtoallmotherswithAMA Whenthereisapriorchildwithchromosomalabnormalities Whenparent(s)haveknownchromosomalabnormalities Whentherehasbeenanabnormalscreeningtest GeneticTesting 50%60%ofspontaneousabortionsduetochromosomalabnormalities 5%ofstillbirthsareduetochromosomalabnormalities 2%3%ofcoupleswithmultiplemiscarriagesarecausedbychromosomal abnormalities 0.6%oflivebirthshavechromosomalabnormalities Duringamniocentesis Afteranabortion Afteranectopicpregnancytreatment

LaborandDelivery
1. InitialPresentation 85%ofpatientsundergospontaneouslaboranddeliverybetween37and42 weeks Regularcontractionsevery5minutesforatleast1hr,ruptureofmembranes, significantbleeding,and/orfetalmovementareallreasonsforvisitingthe hospital InitialExamUponArrival: 2. StagesofLabor Laborisdividedinto3stages: Stage1 Intervalbetweentheonsetoflaborandfullcervicaldilation(10cm) Auscultationoffetalhearttones Determinationoffetallife(Leopoldmaneuver) Vaginalexamination

Thisstagefurthersubdividedintotwophases: Latentphase=cervicaleffacementandearlydilation Activephase=rapidcervicaldilationoccurswhenapproximatelyat34cm Stage2 Istheintervalbetweencompletedilationandthedeliveryoftheinfant

Stage3 Istheintervalbetweendeliveryoftheinfantanddeliveryoftheplacenta

**Thereisa4thstage,whichlasts2hrandistheperiodimmediatelyafterdeliveryof theplacenta,wherebytherearemanyphysiologicalchanges

 3. ManagementofLabor Duringfirststage: ContinuousFHRmonitoring Continuousmonitoringofuterineactivitywithexternaltocodynamometer andintrauterinepressurecatheter Analgesiaand/oranestheticgiven,mostcommonlywhenreachingtheactive stageoflabor.

Duringsecondstage: Atthisstagematernalpushingcanacceleratedelivery Episiotomydoneatthisstage(ifperformedatall) Bulbandsuctionafterdeliveryofthehead Shouldersdeliveredafterhead UmbilicalbloodsentforABOandRhtesting

Duringthirdstage: Deliveryofplacenta

Duringfourthstage: 4. AbnormalLabor Dystocia=DifficultLabor Dystociaisdetectedbyevaluationthreecriteria,theyare: 1. Powerreferringtothestrength,duration,andfrequencyofcontractions. Forcervicaldilationtooccur,theremustbemorethan3contractionin10 minutes 2. Passengerreferringtofetalweight+fetallie+presentation+position 3. Passage Pelvicdiameter Abilityofpelvictoaccommodatepassageofbaby Distendedorgansormassescanhinderpassage Evaluationofcervix,vagina,vulva,perineum,andurethralareafor lacerationsand/ortraumaticinjury

 Laborstage Stage1Latent Phase (Effacement) Definition Beginswithonset ofregularuterine contractions. Endswith accelerationof cervicaldilation. Duration <20hoursin primipara <14hoursin multipara Abnormalities Prolongedlatent phase: Cervixdilated <3cm, Nocervical changein20hr (primi)or14hr (multi) MCCisanalgesia Managewithrest andsedation ActivePhase prolongorarrest: Cervixdilated 3cm Prolongation: cervicaldilation of<1.2cm/hr (primi)or <1.5cm/hr (multi) Cause:passenger abnormality Mgmt: Ifhypotonic contraction:IV oxytocin Ifhypertonic contraction: morphine sedation Ifadequate contractionsdo emergencyC

Stage1Active phase(Dilation)

Cervical preparationfor dilation. Beginswith accelerationof cervicaldilation. Endsat10cm dilation. Rapidcervical dilation

>1.2cm/hr (primipara). >1.5cm/hr (multipara)

 section Beginswhen <2hrifprimi Secondstage 10cmdilated. <1hrifmulti arrest: Additionalhourif Failuretodeliver Endswhenbaby givenepidural within2hr(P)or isdelivered 1hr(M) Cause: abnormalitywith passenger,pelvis, orpower Mgmt: Fetalheadnot engaged(do emergencyC section) Fetalhead engaged(forceps orvacuum extraction) Beginswithbaby <30minutes Prolongedstageif deliveryandends placentatakes withplacental longerthan30 delivery minutesto deliver. Mgmt:IV oxytocin,manual removal. Hysterectomyif thesefail.

Stage2Descent

Stage3 Expulsion

 ProlongationDisorders Dystociacanbedividedintoprolongedlatentphaseandprolongedactivephase 1. Prolongedlatentphase Latentphase>20hrinprimigravidor>14hrinmultigravid Maybeduetoineffectiveuterinecontractions,disproportionbetweenpelvis andfetus,andevenexcessiveanesthesia 2. Prolongedactivephase Consideredprolongedwhenitlasts>12hrand/ortherateofcervicaldilation is<1.2cm/hrinaprimigravidor<1.5cm/hrinmultigravid. Maybeduetoexcessiveanesthesia,ineffectivecontractions,disproportion betweenpelvisandfetus,fetalmalposition,ruptureofmembranesbefore onsetofactivelabor ThiscanincreasetheriskofintrauterineinfectionandincreasedneedforC section ArrestDisorders Anarrestdisorderoccurswhencervicaldilationceasesduringtheactivephasefor 2hr.Mostcommonlyduetoeithercephalopelvicdisproportionorineffective contractionoftheuterus. ManagementofAbnormalLabor Laborinduction=stimulationofuterinecontractionsbeforespontaneousonsetof labor Augmentationoflabor=stimulationofuterinecontractionsthatbegan spontaneouslybuthavesincebecomeinfrequent,weak,orboth Inductiontrialshouldbeattemptedonlyifcervixispreparedorripe.Cervical ripeningviaprostaglandinE2gel. Indicationsforinduction: Suspectedfetalcompromise Fetaldeath Pregnancyinducedhypertension Pastdatepregnancy

 Contraindicationsforinduction: Risksofprolongedlabor: PostpartumHemorrhage UterineAtony: Themostcommoncauseofexcessivepostpartumbleeding Management: Uterinemassageanduterotonicagents(oxytocin,methylergonovine) Laceration:Managementwithsurgicalrepair RetainedPlacenta: Treatmentinvolvesmanualremovaloruterinecurettage Placentaaccreta/increta/percretaisthediagnosisiftheexamshows placentalvilliinfiltration Hysterectomymaybeneededtocontrolintractablebleeding Infection Exhaustion Lacerations Uterineatonywithhemorrhage Placentaprevia Activegenitalherpes Cordpresentation Abnormalfetallie Maternalmedicalcomplication Prematureruptureofmembranes(PROM)

 DIC:Mostcommonlyassociatedwithplacentalabruption,severepreeclampsia, amnioticfluidembolism,orprolongedretentionofadeadfetus. UterineInversion: UrinaryRetention: PrematureRuptureofMembranes(PROM) Ruptureofchorioamnioticmembranebeforetheonsetoflabor Occursin10%15%ofallpregnancies Laborusuallyfollowsin90%ofpatientswithin24hrs PROMat26wksofgestationisassociatedwithpulmonaryhypoplasia Mayoccurwithhypotonicbladder Residualvolume>250mlrequiresbethanecol Ifbethanecolfailsmanagewithurinarycatheterizationfor23days Suspectifabeefyappearingbleedingmassinthevaginaandfailureto palpatetheuterus. ManagewithuterinereplacementfollowedbyIVoxytocin

Diagnosing: Performvaginalexamwithtestingofnonbloodyfluid Nitrazinetest:testspH Ferntest:amnioticfluidplacedonslide,lookingforbranchingfernleaf patternwhenslidedries USconfirmsdiagnosis:findsoligohydramnios

Treatment: Ifanintrauterineinfectionissuspected,givebroadspectrumantibiotics, otherwisetreatasapretermlabor.

 PostpartumContraception Breastfeeding: Breastfeedingprovidescontraceptionfor3monthsbecauseoftemporary anovulation

Combinedestrogenprogestinformulations: OCP,patch,orvaginalring Notstarteduntil3weekspostpartumtopreventhypercaogulablestateand riskDVT Notusedinbreastfeedingwomenbecausetheydiminishlactation

Diaphragmand/orIUDplacement: Deferreduntil6weekspostpartum

Progestincontraception: PostpartumFever PostpartumDay# 0 1 23 45 56 721 Woundinfection Septicthrombophlebitis Infectiousmastitis Mostlikelydiagnosis Atelectasis UTI Endometritis Minipill,DepoProvera Canbesafelyusedwhilebreastfeedingandstartedimmediatelyafter pregnancy

PerinatalInfections

1. GroupBHemolyticStreptococci(GBS) 30%ofwomenhaveasymptomaticvaginalcolonizationwithGBS Verticaltransmissioncancausepneumoniaandsepsisoftheneonate withinhoursofbirth Mortalityrateisashighas50% Treatment: IntrapartumIVpenicillinG InpatientwithPCNallergy,useIVclindamycin,erythromycin,orcefazolin Whenareantibioticsgiven? 1. WhenGBS(+)urine,cervical, orvaginalcultureatanytime inpregnancy. 2. Presenceofhighriskfactors suchas: ProlongedPROM Pretermdelivery Presenceofmaternalfever Anypreviousbabywho experiencedGBSsepsis 2. Toxoplasmosis CausedbyToxoplasmagondiiparasite Ismostcommonlycausedbythehandlingofcatfecesand/orlitterduring pregnancy Maybecausedbydrinkingrawgoatmilkoreatingrawmeat Verticaltransmissionwillonlyoccurwithprimaryinfectionofthemother Mostseriousinfectionresultsfrominfectioninthefirsttrimester Symptoms: Mostcommonpresentationisamononucleosistypesyndrome+the presenceofacatinthehousehold OnUS,theremaybeintrauterinegrowthretardation Whenareantibioticsnotgiven? 1. WithplannedCsection,when thereisnoruptureof membranes. 2. Culture()inthispregnancy butwith(+)cultureinprevious pregnancy

 Prevention: Avoidhandlingcatfeces,rawgoatmilk,and undercookedmeat Ifinfected,mothershouldtakespiramycinto preventverticaltransmission Classiccongenitaltriad: 1. Hydrocephalus 2. Intracranial calcifications 3. Chorioretinitis

Treatment: Afterserologicconfirmation,givepyrimethamine andsulfadiazine.

3. Varicella Primaryvaricellainfectioninmothercausestransplacentalinfection25% 40%ofthetime. Greatestrisktofetusisposedifarashappearsinthemotherfrom5days antepartumand2dayspostpartum. Aneonatalinfectionpresentswithlimbhypoplasia,microcephaly, microphthalmia,chorioretinitis,cataracts,andzigzagskinlesions PreventingVaricellainfection: Nonpregnantwomenshouldreceivevaccination Postexposureprophylaxiswithin96hrsofexposurewithVZV immunoglobulin

Treatment: 4. Rubella Verticaltransmissionoccursupto70%90%ofthetimewithprimary infection Neonatemaypresentwithcongenitaldeafness,PDA,cataracts,mental retardation,hepatosplenomegaly,thrombocytopenia,andablueberrymuffin typerash. Adverseeffectsoccurwithinfirst10weeks Maternalvaricellaantivaricellaantibodiestomotherandneonate Congenitalvaricellaantivaricellaantibodies+IVacyclovirtoneonate

 RUBELLA: Prevention: Performafirsttrimesterscreening Havemotheravoidanyinfectedindividuals Immunizeseronegativewomenafter delivery BlueberryMuffinrash Deafness PDA Cataracts Retardation Hepatosplenomegaly Thrombocytopenia 5. Cytomegalovirus(CMV) IsthemostcommoncongenitalvirusintheUSA. CMVisthemostcommoncauseofsensorineuraldeafnessinchildren CMVisspreadbybodyfluidsecretions Mostinfectionsproduceamononucleosislikesyndrome Approximately10%ofinfantsaresymptomaticatbirth Symptomsinneonate: IUGR Prematurity Microcephaly Jaundice Petechiae Hepatosplenomegaly Periventricularcalcifications Chorioretinitis Pneumonitis CMV IUGR Prematurity Microcephaly Jaundice Hepatosplenomegaly Petechiae Periventricular calcifications Chorioretinitis Pneumonitis

**Thereisnopostexposureprophylaxisavailable

DiagnosingCMV: Viralculturewithin2weeksofbirth PCR

Prevention: Universalprecautionswithavoidanceofbodyfluids AvoidtransfusionwithCMVpositiveblood

Treatment: Ganciclovir(preventshearinglossbutdoesnotcureinfection)

 6. HerpesSimplexVirus(HSV) Contactwithlesionsisthemostcommoncause oftransmission Greatestriskofinfectioninthe3rdtrimester 50%riskoftransplacentalinfectionwith primaryinfection Symptoms: Fever+malaise+diffusegenitallesions Ifinfantsurvives,theymaydevelopmeningoencephalitis,mentalretardation, pneumonia,hepatosplenomegaly,jaundice,andpetechiae.

Aneonatal infectionacquired duringdeliveryhas a50%mortality rate.

Diagnosis: (+)HSVculturefromvesiclefluidorulcerorHSVPCRofmaternalblood

Prevention ACsectionismandatoryifmotherhasactivegenitalHSVlesionsattimeof labor. Itiscontraindicatedtousefetalscalpelectrodesformonitoring;they increaseriskofHSVtransmission. Avoidstandardprecautionssuchassexwithoutbreak

Treatment: 7. HIV Themajorrouteofverticaltransmissioniscontactwithinfectedgenital secretionsattimeofvaginaldelivery. Withouttreatmentverticaltransmissionrateis25%30% ElectiveCsectionismostbeneficialinwomenwithlowCD4+countsand highRNAviralloads(>1000). AllneonatesofHIV+motherswilltestpositiveduetothetransplacental passageofIgG PreventionandTreatment: Tripledrugtherapystartingat14weeksandcontinuingthroughoutthe pregnancy. IVintrapartumzidovudine(AZT) Giveinfantoralzidovudinefor6weekspostdelivery Acyclovirforprimaryinfectionduringpregnancy

 8. Syphilis Transplacentalinfectionismorelikelyinprimaryandsecondaryinfection, andlesslikelyintertiaryinfection Earlyacquired(1sttrimester)congenitalsyphilisincludesthefollowingsymptoms: Hydropsfetalis Maculopapularorvesicularrash Largeandswollenplacenta Anemia,thrombocytopenia,andhepatosplenomegaly Thereisa50%perinatalmortalityrate ProphylaxinfantforPCPwithTMPSMXafterthe6weeksofzidovudine therapy ScheduleaCsectionat38weeksunlesstheviralloadis<1000viral copies/ml MothercannotbreastfeedbecauseHIVpassesthroughbreastmilk AvoidallinvasiveproceduressuchasartificialROMandfetalscalp electrodes

Lateacquiredcongenitalsyphilisisdiagnosedafter2yearsofage,includesthe following: Hutchinsonteeth Sabershins Saddlenose Deafness(CN8palsy) Mulberrymolars ACsectioncannot preventvertical transmissionof syphilis.Itwillbe transmittedthrough theplacentabefore birth.

Diagnosis: VDRLorRPRscreeninfirsttrimester ConfirmapositivetestwithFTAABSorMHATP

Treatment: BenzathinepenicillinIM(1timeforinfectedmothers) IfPCNallergy:DesensitizationfollowedbyfulldosebenzathingPCN

Afterany(+)syphilisscreen,FTAABSorMHATPisdoneasconfirmatorytests.

 9. HepatitisB Neonatalinfectionfromprimaryinfectioninthe3rdtrimesteroringestionof infectedgenitalsecretions 80%ofinfectedneonateswilldevelopchronichepatitis Prevention: HepBinfectionisnotanindicationforCsection Avoidinvasiveprocedures AfterneonatereceivesimmunizationandhepBimmunoglobulin,canbe breastfed

Immunization: HBsAgnegativegiveactiveimmunizationduringpregnancy PostexposureprophylaxisforthemotherHBIG

Treatment: Contraindicationstobreastfeeding HIV ActiveTB HepB(beforeinfantisimmunized) HSV Druguse/medications Drugsofabuse(exceptcigarettes,alcohol) Cytotoxicmedications ConditionsofinfantthatCIbreastmilk HTLV1 Hepatitisimmunization+HBIGinneonate ChronicHBVcanbetreatedwithinterferonorlamivudine

Chapter 3 Gynecology

BenignGynecology
TheMenstrualCycle:
Atbirth,thereareapproximately1millionprimordialfolliclesintheovary, eachwithanoocytethatisarrestedintheprophasestageofmeiosis. Theprocessofovulationsignalstheonsetofpuberty,whichsignalsfollicular maturation. Ovulationoccurs,andthedominantfolliclebecomesthecorpusluteum, whichsecretesprogesteronetopreparetheendometriumforpossible implantation. Iftheovumisnotfertilized,thecorpusluteumundergoesinvolution,which causesmenstruation. Thecycleisregulatedbyhypothalamicgonadotropinreleasinghormone, pituitaryreleaseoffolliclestimulatinghormones(FSH),luteinizing hormones(LH),andtheovariansexsteroidsestradiolandprogesterone. Anorinanyofthesehormonescancausedysfunctionofthenormal menstrualcycle.

Thisgraphdemonstratestheprocessofallthreephasesofthemenstrualcycle, whichhormonesareinplay,thedevelopmentoftheegg,andthedaysthat correspondtoallevents

 Follicular/Proliferative Phase Day113 Estradiolinduced negativefeedbackonFSH andpositivefeedbackon LHinanteriorpituitary leadstoLHsurgeondays 1113. OvulatoryPhase Day1317 Dominantfollicle secretionofestradiol leadstopositivefeedback toanteriorpituitaryFSH andLH,ovulationwill occurwithin3036hrs afterLHsurge,smallFSH surgealsooccursattime ofLHsurge. Luteal/SecretoryPhase Day15Day1ofmenses Markedbychangefrom estradioltoprogesterone predominance,corpus lutealprogesteroneacts onhypothalamus,causing negativefeedbackonFSH andLH,resultingin decreasedbasallevels priortonextcycle,if fertilizationand implantationdonotoccur therewillbearapid decreaseinprogesterone.

Contraception:
Oralcontraceptivesthatcombineprogestinandestrogen EstrogensuppressesFSH,whichpreventsselectionandmaturationofa dominantfollicle. ProgestinworksbysuppressingLH,whichinhibitsovulation.Italsothickens cervicalmucosa,whichfurtherpreventstheabilityofsementopassintothe uterus. Together,theyinhibitpregnancybythinningtheendometrialliningand resultinginlightormissesmenses.

Phasicvs.MonophasicPills: Phasicpillsvarytheratioofestrogenandprogestin.Thisdecreasesthedose ofhormonegivenbutitincreasestheriskofbreakthroughbleeding Monophasicpillsdeliveraconstantdoseofestrogenandprogestin throughoutthemonth

**FollowingcessationofOCPs,fertilizationusuallyresumesimmediately.Asmall percentageofuserswillexperienceaperiodofinfertility,knownaspostpill amenorrhea

 AdvantagesandDisadvantagesofOCPs AlternativestoOCPs Progestinonlypillsminipills DepoProveraIMinjectionlastsfor14weeks Norplantsubcutaneousimplantlastsupto5years Intrauterinedevicedeviceleftinplaceforseveralyears EmergencyContraceptionprogestin/estrogentakenwithin72hr ADVANTAGES Reliablewithfailurerateof<1% Protectiveagainstovarianand endometrialcancer DecreasesincidenceofPIDand ectopicpregnancies Makesmensesmorepredictable andlesspainful/lighter. DISADVANTAGES Mustbetakendailyclosetothe sametime NoSTDprotection Upto30%breakthroughbleeding Maycausedepression,weight gain,hypertension,acne,bloating, andweightgain

PapSmear:
PapSmearClassifications: 1. Intermediatesmear:Atypicalsquamouscellsofundeterminedsignificance (ASCUS) 2. Abnormalsmears: Lowgradesquamousintraepitheliallesions(LSIL):HPV,milddysplasia,or carcinomainsitu1(CIS1) Highgradesquamousintraepitheliallesions(HSIL):moderatedysplasia, severedysplasia,CIS,CIN2orCIN3 Cancer:invasivecancers Beginwithin3yearsofonsetofsexualactivityORage18years(whichever comesfirst). When3annualpapsmearsinarowarenegative,candoevery2yearsuntil age70. Patientswith1sexualpartner,3consecutivenormalpapsmears,andonset ofsexualactivityafterage25canbescreenedlessfrequently.

 WorkupofanabnormalPap StepintheWorkup RepeatedPAP Whenisthisstep warranted AfterfirstASCUSfind NextStepin management Repeatevery46 monthsuntilthereare2 consecutivenegative Papsmears IfHPV16or18 identifiedperform colposcopy Colposcopy, Abnormallesionssent forcytology Nonpregnantpts undergoingcolposcopy forabnormalPap requireECCtoruleout endocervicallesions

HPVDNAtesting Colposcopyand ectocervicalbiopsy Endocervicalcurettage (ECC)

AfterfirstASCUSis found AbnormalPapsmear TwoASCUSPapsmears Allnonpregnant patientsshowingan abnormalPapsmears WhenPapsmearis worsethanbiopsy suggested, WhenECCisabnormal, Withendocervical lesion, Whenbiopsyshows microinvasive carcinomaofcervix

ConeBiopsy

Managementofabnormalhistology StepinManagement Observeandfollowup Ablation Excisionalprocedures Hysterectomy Conditionwarranting thisstep CIN1,CIN2or3after excisionorablation CIN2orCIN3 CIN2orCIN3 RecurrentCIN2/3 Notes/Details Followuptestsq46 monthsfor2years Thisis:cryotherapy, laservaporization, electrofulguration LEEPandColdknife colonization

Vaginitis
Themostcommonpresentingsymptomisdischarge Alwaysruleoutchemicalorallergiccauses 50%ofcasesareduetoGardnerella 25%duetoTrichomonas 25%duetoCandida

Differentiatingbetweenthedifferentcausesofvaginitis VaginalpH Odor Discharge Si/Sx Microscopy Treatment Candida 45 NONE CottageCheese like Itching,burning, swollen Pseudohyphae Fluconazole Trichomonas >6 RANCID Green,frothy Severeitching MotileOrganisms Metronidazole Gardnerella >5 FishyonKOH Variable Variable,none Cluecells Metronidazole

CandidaAlbicansnotethepseudohyphae

 TrichomonasMotileOrganisms

GardnerellaClueCells(largeepithelialcellscoveredwithsmallbacteria)

Endometriosis
Endometrialtissueoutsideoftheuterus,mostcommonlyfoundinthe ovaries. Affectsapproximately1%2%ofwomen Approximately50%ofinfertilewomenhaveendometriosis

Signs&Symptoms: The3DsDyspareunia,Dysmenorrhea,Dyschezia Mayalsohavepelvicpain,infertility,painonrectovaginalexam.

 Diagnosis: Visualizationvialaparoscopyorlaparotomywithhistologicalconfirmation.

Treatments: 1. 2. 3. 4. NSAIDsfirst OCPs Testosterone(DanazolA/E:hirsutism,acne) GnRHanalog(givesbestresultbutcausesmenopausalsymptomswithin36 months)

Recurrenceaftercessationofmedicaltreatmentiscommon,definitivetreatmentis hysterectomy.

ReproductiveEndocrinology
Amenorrhea
Primarywomanhasnevermenstruated Secondarymenstrualagedwomanwhohasnotmenstruatedin6months Mostcommoncauseofamenorrheaispregnancy Everyevaluationmustbyexcludingpregnancy(urinehCG) ThemostcommoncauseofsecondaryamenorrheaisAshermanssyndrome (scarringoftheuterinecavityafterD&C) Hypothalamicdeficiencyisacauseofamenorrhea(excessiveweightloss, excessiveexercise,psychogenic,druguse) Pituitarydysfunction:fromhypothalamicpulsatilereleaseofGnRHor pituitaryreleaseofFSHorLH

Ovariandysfunction: Causes: InheriteddisorderssuchasTurnerssyndrome Prematuremenopause Autoimmuneovarianfailure Chemotherapies FolliclesareexhaustedofFSHand/orLHORareresistanttostimulation

Treatment: HowtodifferentiatebetweenMenopauseandAshermanssyndrome? Anultrasoundwillhelpvisualizethepresenceorabsenceoffollicle.Ashermans syndromewillhavefollicleswhilemenopausewilllackthepresenceoffollicles. Ifhypothalamictreatunderlyingcauseandinduceovulationwith gonadotropins TumorsBromocriptinetoshrinktumorand/orexcision Genitaltractobstructionsurgery OvariandysfunctionExogenousestrogenreplacement

HypothalamicCauses:Stress,Anxiety,Anorexia,AndExcessiveExercise PituitaryCauses:Adenoma OvarianCauses:Earlymenopause,resistantovarysyndrome EndometrialCauses:Ashermanssyndrome

Abnormalbleedinginareproductiveagewoman
Withthepresenceofabnormalbleeding,firstthingistoruleoutPAD: Ppregnancy Aanatomicalabnormalities Ddysfunctionaluterinebleeding DysfunctionalUterineBleeding(DUB): Anatomicmenstruationwithoutanatomiclesionsoftheuterus Ismostcommonlyduetochronicestrogenstimulation Abnormalbleedingisdefinedasbleedingatintervals<21daysor>36days, lasting>7days,orbloodvolumeloss>80ml

Diagnosis: R/Oanatomiccauses(fibroids,cervicalorvaginallesions,infections,cervical and/orendometrialcancer) Evaluatefactorsthatcanaffectthehypothalamuspituitaryaxis(stress, excessiveexercise,weightchanges,systemicdisease,coagulopathies, pregnancies)

Treatment: Giveprogesteronefromday1425ofmenstrualcycle Birthcontrolpillsareanalternative

HirsutismandVirilization
Hirsutismexcessivebodyhairusuallyduetopolycysticovariesoradrenal hyperplasia Virilizationmasculinization,associatedwithmarkedintestosterone,male patternbalding,voicedeepening,clitoromegaly,breastinvolution.

 DifferentiatingcausesofHirsutismandVirilization Disease PolycysticOvarian Disease Characteristics The#1causeof androgenexcessand hirsutism. RelatedtoLH overproduction. Si/Sx:amenorrheaor oligomenorrhea, infertility,hirsutism,acne. Anemia Labsshow:LH/FSH,and testosterone. Isanovariantumorthat secretestestosterone (women2040). Si/Sx:rapidonsetof hirsutism,acne, amenorrhea,virilization. Labs:LH/FSH, Testosterone. MCdueto21 hydroxylasedefect. ARpattern. Severewillcause virilizationofnewborn, whilemilderformscan presentatpubertyor later. LH/FSH,DHEA(DHEA helpsdetermineadrenal source). Treatment OCPstoLHproduction (viafeedbackchanges). Weightloss. Clomiphenemaybe prescribedtoinduce ovulation.

SertoliLeydigCell Tumor

Removeaffectedovary

CongenitalAdrenal Hyperplasia

Glucocorticoidscan suppressadrenal androgenproduction.

Menopause
Thecessationofmensesoccursonaverageat51yrofage. Cyclesnolongerassociatedwithpremenstrualsymptoms,nolongerregular orpredictable.

Signsandsymptoms: Acuteonsetofhotflashes/sweatingthatceaseacutely(within35minutes) Mooddisturbances Sleepdisturbances Vaginaldryness(leadstodyspareunia) Osteoporosis

Diagnosis: Irregularmenstrualcyclesaremostobviousfordiagnosis Presenceofhotflashessuggestmenopause levelsofFSH(>30mIU/ml)

Treatment: 1stlinetreatmentisestrogenreplacementtherapy(continuousestrogenwith cyclicprogestintoallowwithdrawalbleedingordailyadminofbothestrogen andprogestin,whichwontcausew/dbleeding). Raloxifene:a2ndgenerationtamoxifenlikedrug(mixedestrogen agonist/antagonist).Showntopreventosteoporosis,decreasesLDL, decreasesriskofbreastcancer. Calciumsupplementationisnotasubstituteforestrogenreplacement

Infertility
Definedas1yroffrequent,unprotectedintercoursewithoutpregnancy. 60%femalecause,40%malecause

Howtoapproachinfertility: 1stStep:SemenAnalysis(volume,motility,#activesperm) Ifthisisfoundtobeabnormal,attemptIntrauterineInsemination(IUI)or IntracytoplasticSpermInjection(ICSI) Ifsemenanalysisisnormal,considerfemalefactors.

 2ndStep:Testcervicalmucustoseeifitsoftens(donearoundtimeofovulation knownasspinnbarkeit. Howtotest: Howtotreathostilemucus:IntraUterineInsemination(IUI) Performbyinsertingacatheterintothecervixandinjectspermpastthe mucusplug Patientcomesinafterintercourse Withhelpofspeculumgetendocervicalmucus Putmucusonaglassslideandcoverwithanotherslide Attempttopullslidesapart(shouldbeabletoseparateatleast6cmbefore mucusbreakswhichindicatessoftandfavorablemucus) Ifslidebreakstooearly,mucusishostile Alsowanttocheckformucusferningonmicroscopy

Anothersolution:Giveestrogenearlyinthecycle(softensmucus) Next:IfSpermisOKandMucusisOK. 3rdStep:CheckOvulation Checkbasalbodytemperature(1degduetoprogesteronespike) Asignofpregnancyisthelackofbodytemperaturerising Doanendometrialbiopsy Day22isthehighestdayofserumprogesterone LHsurgetherearestripsthatcanmeasureLH,if+patientwillovulate within2448hrs

Ifyoufindaproblemwithovulation,givefertilitydrugs. Treatment: 1stCLOMID(foolsthepituitaryintosecretinglotsofFSHandLH) OR 2ndPERGANOL(concentratedamountsofFSHandLHfromurineofmenopausal women).

 **UseCLOMIDfirst,ithasalowerrateofmultiplegestationandlowerriskof ovarianhyperstimulationsyndrome.WithPERGANOL,thereisa20%multi gestationrisk. Ifsemenisnormal Ifmucusisnormal Ifovulationisnormal NEXTSTEP:Lookfortubalfactors(blockageduetoPID)historyofchronicpain, TOA,ectopicpregnancy,infertility Perform:HysteroSalpingogramtohelpdiagnoseablockage IFthereisatubalproblem,thereare2choices: 1. Tuboplasty(cutsouttheobstruction) 2. InVitroFertilization(doneinalab,thenputzygoteintouterus) InVitroFertilization(IVF): Puts4zygotesintotheuterus Putting<4=lowpregnancyrate Putting>4=riskofmultiplegestation

IVFhasa60%pregnancyrate LastthingtodointheinfertilityworkupisLaparoscopy(checkingfor endometriosis). 20%25%ofthosewithunexplainedinfertilityactuallyhaveendometriosis. **Ifeverythingisnormal,diagnosisisunexplainedinfertility DATAshowsthat50%ofpeoplewithinfertilitywillgetpregnantwithin45years.

AndrogenInsensitivity
Adiagnosismadewhenthereisanabsenceofpubicoraxillaryhair. Karyotyperevealsamalegenotype(XY),andUSrevealstesticles. Testesproducenormallevelsofbothmaleandfemalehormones,ie.Estrogen andtestosterone.

Management: Removaloftestesbefore20yrofageduetoincreasedriskoftesticularcancer.After removalpatientwillrequirelifelongestrogenreplacement.

GonadalDysgenesis(Turnerssyndrome)
Absenceofsecondarysexualcharacteristics KaryotyperevealstheabsenceofoneoftheXchromosomes(45,X). ElevatedFSH LackofasecondXchromosomeleadstolackofovarianfollicledevelopment, leadingtostreakgonads.

Management: Estrogenandprogesteronereplacementtohelpdevelopmentofsecondarysexual characteristics.

Urogynecology
PelvicRelaxation:Mostcommonlycausesthefollowing: 1. UterineProlapse 2. Cystocele(bladderprolapseintovagina) 3. Rectocele(rectalprolapseintovagina) UterineProlapse: Occurswhenligaments(suspensary)ligamentscannolongersupportit Mostcommoncauseischildbirth

Signs&Symptoms: Vaginalpressuresensation Vaginalfullness Lowbackpain

**Cancausecystoceleandrectocele Degreesofprolapse: 1stdegreeprolapseisaboveintroitus 2nddegreegoestotheintroitus 3rddegreegoespastintroitus Cystocele: Bladderprolapseintothevaginaduetoexcessivepelvicrelaxation Severecasescancausestressincontinence

2typesofincontinence: 1. StressIncontinencethemostcommontype(causedbypelvicfloor injuries)

 2. NeurogenicIncontinenceurge/overflowincontinence(causedby innervationandcontrolofbladderfunction,resultingininvoluntarybladder contraction(urges)orbladderatony(overflow). Testingforstressincontinence: 1. Doapelvicexamifyouseeprolapsethissuggestsstressincontinence 2. QtiptestinsertaQtipintourethraandhavetheptcough.Ifitrotates >30degrees,pthasstressincontinence. **Ifpatientdescribesanurgeand/orfrequencyforurination,itissuggestiveof neurogenicincontinence Treatments: StressIncontinence1stattemptkegelexercises,2ndsurgery(colporaphy) NeurogenicAntispasmotics,anticholinergics Othercausesofurinaryincontinence: Neuropathiccausedbyheadinjury,spinalinjury,orperipheralnerveinjury. Treatment:catheter,eitherindwellingorintermittent Anatomicalcausedbyavesicovaginalfistula.Treatment:repairofdefect.

GynecologicOncology
1. 2. 3. 4. 5. 6. EndometrialCancer: Riskfactors: Unopposedpostmenopausalestrogenreplacementtherapy Menopauseafter52yrofage Obesity Nulliparity PCOS Diabetes Chronicanovulation Isthemostcommonreproductivetractcancerwithapproximately30,000 40,000newcaseseachyear. Isanestrogendependentcancer Endometrialcancer Fibroids/Leiomyoma Cervicalcancer Ovarianneoplasms Vulvarandvaginalcancer Gestationaltrophoblasticneoplasia

Signs&Symptoms: Abnormaluterinebleeding,especiallyifwomanispostmenopausal Allwomen>35yrwithabnormalbleedingrequiresanendometrialsampling forhistologicexamination.

Diagnosis: Papsmearnotreliable Bimanualexamformasses,nodules,induration,andimmobility Endometrialbiopsybyendocervicalcurettage,D&C,hysteroscopywithdirect biopsies.

Treatment: Ifsimpleorcomplexhyperplasiagiveprogesteronetoreverse hyperplasticprocesspromotedbyestrogen(Proverafor10days)

 Atypicalhyperplasiahysterectomybecauseoflikelihoodthatinvasive carcinomawillensue EndometrialcarcinomaTotalabdominalhysterectomy+bilateral salpingooophorectomy+lymphnodedissection,adjuvantexternalbeam radiation,treatmentforrecurrenceishighdoseprogestins.

Prognosis: Histologicgradeisthemostimportantfactorinoverallprognosis. Depthofmyometrialinvasionis2ndmostimportantfactorinoverall prognosis

G1highlydifferentiated G2moderatelydifferentiated G3solidorcompletelyundifferentiated G1tumorthatdoesntinvadethemyometriumhasa95%5yrsurvival G3tumorwithdeepmyometrialinvasionhas~20%5yrsurvival UterineLeiomyomasFibroids Signs&Symptoms: Menorrhagia Pelvicpainandpressure(misdiagnosedasdysmenorrheal) Enlarged,firm,asymmetric,nontenderuterus Fibroidsarebenigntumorswhosegrowthisrelatedtotheproductionof estrogen. Growthisoftenrapidperimenopausally 30%ofcaseswarrantahysterectomy

DiagnosingFibroids: USinitially,confirmwithtissuesamplebyeitherD&Corbiopsy(especiallyin postmenopausalwomen).

Treatments: Mildsymptomsonlyrequirereassuranceandobservation EstrogeninhibitorssuchasGnRHagonistscanshrinktheuterus,whichhelp tocreateasimplersurgicalprocedure.

 Surgerymyomectomyrecommendedinyoungpatientswhowantto preservefertility. Hysterectomyisdefinitivetreatmentthatshouldbereservedfor symptomaticwomenwhohavenodesireforchildrenand/oranymore children.

Adenomyosis
Diagnosis Symptoms Leiomyoma Secondarydysmenorrhea andmenorrhagia. (+)or()symptomsof bladder,ureter,and/or rectalcompression Asymmetricallyenlarged, firm,NONTENDERuterus. Adenomyosis Secondarydysmenorrhea andmenorrhagia Abnormallocationofendometrialglandsandstromawithinthemyometrium oftheuterinewall Whensymptomaticiscausesdysmenorrhealandmenorrhagia. Uterusfeelssoft,globular,tender,andsymmetrical. Unlikeleiomyomas,thereisnochangewithhighorlowestrogenstates.

PelvicExam

Sonogram

Hysteroscopy Histology

Largeintramuralor subserosalmyomas (salineinfusioncanhelp visualizethis) Directvisualizationof tumors Isdefinitivediagnosis

Symmetricallyenlarged, soft,TENDERuterus. Maybetender immediatelybeforeand duringmenses Diffuselyenlargeduterus withcysticareaswithin myometrialwall Isdefinitivediagnosis

Leiomyosarcoma
Signs&Symptoms: Sarcomapostmenopausalbleeding,pelvicpain,increasingvaginaldischarge Treatment: HysterectomywithintraopertiveLNbiopsy Surgicalstagingisanimportantaspect Adjunctivetherapieshaveminimaloverallbenefit Ararecancerthataccountsforapproximately3%ofuterinecancers

**Only50%ofpatientssurvive5yr

CervicalCancer ThemostimportantscreeningtoolisthePapsmear Theaverageageofdiagnosisisbetween4550yr. Themostcommondiagnosisissquamouscellcarcinoma(85%),theother 15%areadenocarcinoma

Diagnosis: CervicalBiopsymostcommonlyisSCC Nextstepmetastaticworkup(pelvicexam,CXR,IVpyelogram,cystoscopy,and sigmoidoscopy). **Imagingstudiesnotrequired(invasivecervicalcanceristheonlygynecological cancerthatdoesnotgetstagedclinically). Management: Managementissimplehysterectomyormodifiedradicalhysterectomy+LN dissection.Survival<40%at5yr.

 Adjuvanttherapysuchasradiationandchemoisgivenwhenanyofthe followingconditionsarepresent:MetstoLNs,tumor>4cm,+margins,local recurrence

OvarianNeoplasms
Benigncysts: Functionalgrowthresultingfromfailureofnormalruptureoffollicle Benigntumorsaremorecommonthanmalignanttumors Riskofmalignancyincreaseswithage

Signs&Symptoms: Pelvicpain/pressure Acuteandseverepainwhencystruptures

ConfirmDiagnosisWithUS

 BenignNeoplasms Neoplasm EpithelialCell Characteristics Serouscystadenomaisthe mostcommontype. Usuallybenign (malignancyriskincreases whenbilateral). Others:mucinous, endometrioid,Brenner tumor(allrarely malignant). Diagnose:Clinical/CTor MRI Mostcommontypeis Teratoma(akadermoid cyst). Almostnevermalignant. Containstissuesfromall3 germlayers. Unilateral,cystic,mobile, nontenderadnexalmass, oftenasymptomatic. ConfirmdiagnosiswithUS Arefunctionaltumors secretinghormones. Granulosatumormakes estrogen(gynecomastia, lossofbodyhair). SertoliLeydigmakes androgens(virilizationin females) Treatment Excision

GermCell

Excisiontoprevent torsionorruptureof ovary

StromalCell

Excision

 MalignantTumors: Mostcommonlyseeninwomen>50yr OCPuseisaprotectivefactor Seeninhigherfrequencyinwomenoflowparity,fertility,delayed childbearing Usuallyasymptomaticuntilmetastasishasoccurred Yearlypelvicexamsarethemosteffectivescreeningtools

Signs&Symptoms: Vagueabdominalpains Vaguepelvicpains Constipation,earlysatiety,abdominaldistention,urinaryfrequency

Treatment: Debulkingsurgery+chemo/radiation

MalignantNeoplasms Neoplasms EpithelialCell Characteristics Thecauseof90%ofall ovarianmalignancies. Serous cystadenocarcinomaisthe mostcommontype(often developsfromabenign precursor). Isthemostcommon ovariancancerinwomen <20yr. ProduceshCGorAFP, whichareusefulastumor markers. Subtypesinclude: dysgerminomasand immatureteratomas. Granulosacellsmake estrogen(endometriosis). SertoliLeydidcelltumor makesandrogens Treatment Excision

GermCell

1stRadiation 2ndChemotherapy >80%5yrsurvival

StromalCell

Totalhysterectomy+ oophorectomy.

VulvarandVaginalCancers
VulvarIntraepithelialNeoplasia(VIN): VIN1&2characterizedbymild/moderatedysplasia,riskofprogressingto advancedstagesandthencarcinoma. VIN3=carcinomainsitu Signs&Symptoms: Pruritis Presenceofraisedlesions Irritation

Diagnosis: Biopsyrequiredforadefinitivediagnosis

Differentialdiagnosis: MalignantmelanomaandPagetsdisease

Treatment: VulvarCancer: 90%aresquamouscellcancers Mostoftenthispresentsinpostmenopausalwomen ForVIN1and2localexcision ForVIN3wideexcision

Signs&Symptoms: Pruritis(maypresentwithorwithoutanulcerativelesion)

Treatment: Excision

**5yrsurvivalraterangesfrom70%90%dependingonLNinvolvement. **Withthepresenceofdeeppelvicnodes,survivalratedropsto20%

 Vaginalcarcinomainsituandcarcinoma: 70%ofpatientswithvaginalCIShavepreviousgenitaltractneoplasm

Treatment: Radiation Surgeryreservedforextensivedisease

GestationalTrophoblasticDisease(GTN)
Anabnormalproliferationofplacentaltissuethatinvolvesboththe cytotrophoblastand/orsyncytiotrophoblast. Canbebothbenignandmalignant

Riskfactors: Maternalageonloworhighspectrum(<20yrand>35yr) Folatedeficiencyisariskfactor

Signs&Symptoms: Diagnosing: USrevealshomogenousintrauterineechoeswithoutagestationalsacorfetal parts(lookslikeasnowstorm) Mostcommonsignisafundusthatislargerthandatesshouldshow Bilateralcysticenlargementoftheovary Bleedingat<16weeksgestationandpassageoftissuefromvaginaisthe mostcommonsymptom Hypertension Hyperthyroidism Hyperemesisgravidarum Nofetalhearttonesheard Mostcommonsiteofmetastasisisthelung

Management: GetabaselinequantitativehCG GetaCXRtoruleoutlungMETS D&Ctoevacuatetheuterinecontents PlacethepatientonOCPssothattherewillbenoconfusionbetweenarising hCGtiterfromrecurrentdiseaseandnormalpregnancy

 BENIGNMOLE CompleteMole Emptyegg 46,XX(dizygoticploidy) Fetusisabsent 20%becomemalignant Nochemotherapy. SerialhCGuntilcompletelynegative. Followupfor1yrwhileonOCPs MALIGNANTMOLES Nonmetastatic Uterusonly 100%cure Singleagentchemountil afterhCGisnegativefor 3weeks. Followupfor1yronOCP Metastatic:GoodPx Pelvisorlung >95%cure Singleagentchemountil afterhCGisnegativefor 3weeks. Followupfor1yronOCP Metatstatic:PoorPx Brainorliver 65%cure Multipleagentchemo untilafterhCGis negativefor3weeks. Followupfor5yrson OCP. IncompleteMole Normalegg 69,XXY(triploidy) Fetusisnonviable 10%becomemalignant Nochemotherapy. SerialhCGuntilcompletelynegative. Followupfor1yrwhileonOCPs

TheBreast
BenignBreastDiseases: Fibroadenoma Fibrocysticdisease IntraductalPapilloma FatNecrosis Mastitis

MalignantBreastDiseases: Ductalcarcinomainsitu(DCIS) Lobularcarcinomainsitu(LCIS) Ductalcarcinoma Lobularcarcinoma Inflammatorybreastcancer Pagetsdiseaseofthebreast

Fibroadenoma
Isthemostcommonlyseentumorinyoungwomen(20s) Fibroadenomasgrowrapidlybuthavenoincreasedriskfordeveloping cancer Histologyshowsmyxoidstromaandcurvilinear/slitducts

Treatment:Notrequiredandwilloftenresorbwithinseveralweeks(reevaluateat 1month)

FibrocysticDisease
Isthemostcommontumorinpatientsbetween3550yearsofage. Arisesinterminalductallobularunits Oftenarisesasmultiplebilateralsmalllumpswhicharetenderduringthe menstrualcycle

IntraductalPapilloma
Presentscommonlywithserousbloodynippledischarge Multiplenodulesinyoungerpatientsandsolitarygrowthinperimenopausal patients

 Thereisanincreasedcancerriskwithmultiplepapillomas,butnoincreased cancerriskwithsolitarypipillomas

DuctalCarcinomainSitu(DCIS)
Usuallyseenonmammographybutnotclinicallypalpable Isapremalignancythatwillleadtoinvasiveductalcancer Histologyshowshaphazardcellsalongpapillae,punchedoutareasinducts, withcellsinfiltratingopenspaces.

Treatment: Massexcisionensuringclearmargins. Ifmarginsarenotclearmustexciseagainwithwidermargins. Givepostopradiationtopreventrecurrences.

LobularCarcinomainSitu(LCIS)
LCIScantbedetectedclinicallybutmammographyisalsoaweaktoolfor diagnosis NotprecancerouslikeDCISbutcanbeamarkerforfutureinvasiveductal cancer Mucinouscellsarealmostalwayspresent Thereisasawtoothandcloverleafconfigurationsintheducts

InvasiveDuctalCarcinoma(IDC)
Isthemostcommonbreastcancertype,seenmostcommonlyinthemid30s late50s,andformssolidtumors Mostimportantprognosisfactoristhesizeofthetumor LNinvolvementisalsoanextremelyimportantfactorinprognosis TherearemanysubtypesofIDC,suchasmucinousandmedullary ModeratelydifferentiatedIDCcomesfromcribriformorpapillaryintraductal originators PoorlydifferentiatedIDCcomesfromintraductalcomedooriginator.

InvasiveLobularCarcinoma(ILC)
3%5%ofinvasivecancerislobular Mostcommonlyseenfrom4555yrofage Vagueappearanceonmammogram Growthpatternsinglefilegrowthpatternwithinafibrousstroma

 Treatinginvasivecarcinomas: Iftumoris<5cmperformlumpectomy+radiotherapy+/adjuvanttherapy +/chemotherapy Sentinalnodebiopsyshouldbeperformedoveranaxillarynodebiopsy Alwaystestfor:1.Estrogen&Progesteronereceptors,and2.HER2protein Theprimarytreatmentforinflammatory,tumorsize>5cm,andMETSis systemictherapy

InflammatoryCarcinoma
Classicsymptomsarethatofinflammation(warm,red,painful) Progressesrapidlyandisalmostwidelymetastaticatpresentation Hasaverypoorprognosis

PagetsDiseaseoftheBreast
Moreonthebreast: Withdischarge: Nextstepisamammogramtolookforunderlyingmassesand/or calcifications Themostcommoncauseofnippledischargeisintraductalpapilloma Thepresenceofdischarge+palpablemassincreasesthelikelihoodofcancer isgreater Ifdischargeisunilateral,furtherworkupisrequired Ifdischargeisbloody,furtherworkupisrequired Ifdischargeisassociatedwithamass,furtherworkupisrequired Forbilateral,milkynippledischargedoaworkupforprolactinoma Veryspecificpresentationofdermatitis+macularrashoverthenippleand areola Thereisalmostalwaysanunderlyingductalcarcinoma

 Ifmammographygivesadefinitivediagnosis,excisionofductis recommended Fornippledischarge,neverbasediagnosisoncytology

Mastalgia:
Iscyclicalornoncyclicalbreastpainthatisntcausedbylumps Treatwithdanazol(inducesamenorrhea)

Gynecomastia:
Enlargementofthemalebreast,bothunilateralandbilateral Nolobules Iscausedbyanimbalanceinestrogensandandrogens,mostoftenoccurring duringpuberty Maybeseeninhyperestrogenstates(cirrhosis,drugsinhibitingestrogen breakdownETOH,marijuana,heroin)

CancerRisksofBreastCancers:
Whattodoforcertainbreastmasses? Whentodoanultrasound(US)thisisthefirststepwhenfindingapalpable massthatfeelscysticonphysicalexam. Whentodofineneedleaspiration(FNA)thisisoftenthefirststepwhenfinding apalpablemass,andmaybedoneeitherafteranUSorinsteadofanUS. #1riskfactorisgender(femalesmakeup99%ofbreastcancers) Inwomen,ageisthe#1factor Menarche<11yrisariskfactorforbreastcancer Womenwhoarenulliparousat>30yrhaveanincreasedrisk 95%ofbreastcancerisNOTfamilial Havingafirstdegreerelativewithahxofbreastcancerincreasestheriskof breastcancer Autosomaldominantconditionsthathaveincreasedrisk,suchasBRCA1, BRCA2 Priorcancerintheoppositebreast Cancerofthebreastoccursmostcommonlyintheupperandouterquadrant ofthebreast.

 Whentodoeithermammography(ifpt>40yr)andbiopsy(orbiopsysolelyifpt is<40yr): Ifcystrecursmorethantwicein46months Ifthereisbloodyfluidonaspiration IfmassdoesntappearcompletelywithaFNA Thereisbloodynippledischarge Thereisedemaoftheskinanderythemathatsuggestsinflammatorybreast carcinoma(excisionalbiopsy) Whentoorderforcytologyanyaspiratewithgrossbloodmustbesendfor cytology Whentoobserveandrepeatanexamwithin68weekswheneveracyst disappearswithaspiration,andthefluidisclear,and/orwhentheneedlebiopsy andimagingstudiesarenegative. WhenshouldadjuvanttherapybeincludedinthemanagementUseadjuvant therapyinallhormonereceptor(+)tumorsregardlessofanyotherfactors. WhentotestforBRCA1andBRCA2? Ifthereisahistoryofearlyonsetbreastorovariancancerinthefamily Ifthereisbreastand/orovariancancerinthesamepatient AfamilyhistoryofMALEbreastcancer IfpatientisofAshkenaziJewishheritage

Whenischemotherapyincludedintumormanagement? Whentumoris>1cm Whenthediseaseisnode(+)

Whenistrastuzumabincludedinmanagement? IncludedformetastaticbreastcancerthatoverexpressesHER2/neu Thisisamonoclonalantibodydirectedagainsttheextracellulardomainof theHER2/neureceptor

 Tamoxifen: AromataseInhibitors: LHRHanalogues: AcommonlyuseddrugisGoserelin Analternativeoranadditiontotamoxifeninpremenopausalwomen SideeffectsofTamoxifen Exacerbatesmenopausalsymptoms riskofcanceroftheendometrium **Allwomenwithahistoryoftamoxifen use+vaginalbleedingshouldhavean evaluationoftheendometrium Includedrugssuchas:Anastrazole,Exemestane,andLetrozole Theseblocktheperipheralproductionofestrogen Thesearethestandardofcareinhormonereceptor(+)womenwhoare menopausal(moreeffectivethantamoxifen) Willincreasetheriskofosteoporosis Competitivelybindstoestrogenreceptors Producesa50%decreaseinrecurrenceanda25%decreaseinmortality Excellentforbothpreandpostoppatients

BenefitsofTamoxifen incidenceofcontralateralbreast cancer bonedensityinpostmenopausal women serumcholesterol fractures cardiovascularmortalityrate Treatmentreview:

IfcasedescribesHR(),preorpostmenopausalchemoalone IfcasedescribesHR(+),PREmenopausalchemo+tamoxifen IfcasedescribesHR(+),POSTmenopchemo+aromataseinhibitor

Chapter 4 Pediatrics

TheNewborn
TheAPGARscore: Thisscoremeasuresthenewbornsneedforresuscitationandmeasures5criteriaat 1minuteand5minutes.At1minutewecandeterminehowwellthebabydid duringlaboranddelivery,whileat5minuteswecandeterminetheeffectivenessof resuscitation(ifitwasneeded) APGARSCORINGTABLE

ManagingtheNewborn: Therearesomeimportantthingsthatmustbedoneimmediatelyupondeliveryof thenewborn,upondeliverygivethefollowing: Give1%silvernitrateeyedropsOR0.5%erythromycinophthalmicointment 1mgofintramuscularvitaminK(preventshemorrhagicdiseaseofthe newborn)

Beforedischargingthenewbornfromthehospital,dothefollowing: Abnormalitiesinthenewborn: Therearemanyabnormalitiesofthenewbornthatshouldberecognizable.Itisalso importanttoknowwhicharebenignandwhichrequirefurtherinvestigation. Hearingtesttoruleoutasensorineuralhearingloss Orderneonatalscreeningtests:PKU,galactosemia,hypothyroidism

 Image Description Red,sharply demarcated raisedred lesions Diagnosis Hemangioma Co morbidities Maybe associated withhigh outputcardiac failureifvery large. Consider underlying involvement oforgans whenlarge. Maybe associated withSturge Weber syndrome Management Steroidsor lasertherapy ifitinvolves underlying organs

Unilateralred formationson headandneck (unilateraland permanent)

PortWine Stain

Bluish/gray maculeson lowerback and/or posteriorthigh (most commonly) Firm,yellow white papules/pustul eswith erythematous base,peakson 2nddayoflife Tagsorpitsin frontoftheear

Mongolian Spots

Pulsedlaser therapy. IfSturge Webermust evaluatefor glaucoma andgiveanti convulsives Ruleout childabuse, usuallyfade withinfirst fewyearsof life None,isself limited

Erythema Toxicum

None

Preauricular Tags

Associated USofkidneys withhearing andhearing lossandGU test abnormalities Associated withother CHARGE defects Screenfor CHARGE syndrome

Defectinthe iris

Colobomaof theIris

 Anabsenceof theiris Amasslateral tothemidline Branchial CleftCyst Isaremnant ofembryonic development associated with infections Mayhave ectopic thyroid, associated with infections Associated with chromosomal disordersand other malformation s Associated withintestinal atresia Aniridia Associated withWilms tumor Mustscreen forWilms tumorevery 3months until8yrof age Surgical removal

Amidlinemass Thyroglossal thatriseswhen DuctCyst swallowing Aprotrusionof Omphalocele GIcontents through umbilicus contained withinasac Anabdominal Gastroschisis defectthatis lateraltothe midlinewithno saccovering contents Rectus Hernia abdominus (umbilical) weaknessthat allowsbulging offetaland infantumbilical cord Scrotal swellingthat canbe transilluminate d Hydrocele

Surgical removal

Screenfor trisomies.

Congenital hypothyroidis m

Associated withan inguinal hernia

Thismay close spontaneousl y. Screenfor hypothyroid withTSH screen. Differentiate frominguinal herniaby shining flashlight

 Absenceof teste(s)in scrotum Openingofthe urethraon dorsumofthe penis Cryptorchidis m Epispadias Associated Surgical withcancerof removalby theteste(s) 1yr Urinary incontinence Evaluatefor bladder extrophy

Openingofthe urethraon ventralsurface ofpenis

Hypospadias

Nodefinitive mgmt,but notsupposed tocircumcise theinfant Surgical correction

Reducible Inguinal scrotalswelling Hernia

 DevelopmentalMilestones Developmentalmilestonesshowupoverandoveragainontheboardexams.By memorizingtheimportantmilestonesyouaregoingtoget23easypointsontheCK exam.Milestonesrefertobothinfantandadolescent(puberty)milestones. DevelopmentalMilestones Age Newborn 2months 4months 6months GrossMotor FineMotor Mororeflex, graspreflex Holdsheadup Swipesat objects Rollsfrontto Grasps back Objects Rollsfrom Transfers backtofront, objects sitsupright Crawls,pulls toastand Standson own Pincergrasp, eatswith fingers Mature pincergrasp Language Coos Orientsto voice Babbles Social/Cognition Socialsmile Laughs Develops stranger anxiety,sleeps allnight Wavesgoodbye, respondstoname Recognizes picturesina book/magazine Throwstemper tantrum Beginstoilet training Canfollowa2 stepcommand Knowsfirstand lastnames

9months 12months 15months 18months 24months

Nonspecific words

36months

Specific words mama Walks Usesacup Speaks46 words Throwsaball, Usesspoon Names walksupthe forsolidfoods common stairs objects Starts Usesspoon Speaks2 running,can forsemi word goupand solids sentence downstairs Canridea Caneatneatly Speaks3 tricycle withutensils word sentence

 Puberty: Themilestonesofpubertyareasfollowsandarebasedonpopulationaverages: MALES Testicularenlargement11.5yrs Genitalsincreaseinsize PubicHairGrowthBegins PeakGrowthSpurt13.5yrs ChildAbuse Highriskchildren: Classicfindings: Chipfractures(damagetothecornerofmetaphysisinlongbones) Spiralfractures Ribfractures Burns(immersioninhotwater,cigaretteburns,stockinggloveburnson handsandfeet) HeadinjuryMCCofdeath Sexualabuse Prematureinfants Childrenwithchronicmedicalproblems Infantswithcolic Childrenwithbehavioralproblems Povertystrickenchildren Childrenofteenageparents Singleparents Childrenofsubstanceabusers SuspectedchildabuserequiresyourBYLAWtoreportthesuspectedabuse. Youmustalsoexplaintotheparentswhyyoususpectabuseandthatyouare legallyobligatedtoreportittochildprotectiveservices. Ifaparentrefuseshospitalizationortreatmentoftheirchildagainstthebest interestofthechild,youmustgetanemergencycourtorder. FEMALES Breastbuds10.5yrs PubicHairGrowthBegins LinearGrowthSpurt12yrs Menarche12.5yrs

 Whentohospitalizeachildundersuspectofbeingabused: Workupforsuspectedchildabuse: Treatment: 1stAddressmedicaland/orsurgicalissuesbeforeallelse 2ndReportabusetochildprotectiveservices(CPS) BreastFeeding Therearemanyadvantagestobreastfeeding: Psychologicalandemotionalbondingbetweenmotherandinfant PassivetransferofTcellimmunitydecreasesrisksofallergiesandinfection PT/PTT/BT Fullskeletalsurveyforbreaks Ifinjuriesaresevere,getaCTorMRI+athorougheyeexam Ifinjuryistotheabdomen,getanabdominalCT,checkforbloodinthestool andurine,andcheckliverandpancreaticenzymes Thehospitalisthesafestplaceforthechild Thediagnosisisstillunclear Thechildhasamedicalconditionrequiringhospitalization

Contraindicationstobreastfeeding: HIV CMV HSV(onlyiflesionsareonbreast) HBV(unlessvaccinationisgivenprior) Substanceabuse Breastcancer Acuteillnessinmotherthatisabsentininfant Drugs(listbelowofcontraindicateddrugsduringbreastfeeding) RelativelyContraindicated Steroids Neuroleptics Sedatives

AbsolutelyContraindicated Alcohol Nicotine Antineoplastics

 Lithium Chloramphenicol IodideandMercurialDrugs HighyieldGrowth&DevelopmentFacts InfectiousDiseasesTheToRCHS Ingeneral,allwillhave:jaundice,IUGR,mentalretardation,and hepatosplenomegaly.Lookforthingsthatstandoutwitheachinfection Disease Toxoplasmosis Characteristics Acquiredbymotherthroughpoorlyingestedmeat Acquiredwhenmotherhandlescatfecesthroughlitter box 1/3ofmotherstransmitand1/3ofinfantsareaffected Causes:intracerebralcalcifications,IUGR,severe mentalretardation,hydrocephalus,chorioretinitis, epilepsy,hepatosplenomegaly Ifinfecteddoultrasoundtofindanymajoranomalies Whenacquiredin1sttrimesterthereisan80%chanceof transmission Whenacquiredin2ndtrimesterthereisa50%chanceof transmission Whenacquiredin3rdtrimesterthereisa5%chanceof transmission Theheightofachildat2yearsofagenormallycorrelateswiththefinaladult heightpercentile. By6monthsofagethebirthweightshoulddouble,andby1yearthebirth weightshouldtriple. Theabsolutebestindicatorformalnutritionisachildwhois<5thpercentile forheightandweight. Skeletalandsexualmaturityarerelatedmorethanitisrelatedto chronologicalage. TheMCCoffailuretothrive(FTT)inallagegroupsispsychosocial deprivation. Inpatientswithgeneticshortstatureorconstitutionaldelay,birthweightis normal. Patientswithbothgeneticshortstatureandconstitutionaldelayhavea growthpatternthatisbelowandparalleltothenormalgrowthcurve. Tetracycline Sulfonamides Metronidazole

Rubella

 Signs&Symptomscataracts,IUGR,blueberrymuffin rash,glaucoma,chorioretinitis,PDA,pulmonary stenosis,ASD,VSD,myocarditis,hearingloss,mental retardation,deafness DiagnosisconfirmwithIgMrubellaantibodyin neonatesserum. Treatgoalisuniversalpreventionbyimmunizingall children,theresnotherapyforactiveinfection Affects1%ofallbirthsandisthemostcommon congenitalinfection Infectionisoftenasymptomatic Approx1%riskoftransplacentaltransmission,and approx10%ofinfectedinfantsmanifestdefects Congenitaldefectsmicrochephaly,periventricular intracranialcalcifications,IURG,chorioretinitis,severe mentalretardation,sensorineuralhearingloss Transmissionisthroughbodyfluids DiagnosewithurineCMVculture Vaginaldeliveryduringactiveinfection=approx50% getinfected Csectionisrequiredifactiveinfection 1stweekpneumoniaandshock 2ndweekskinvesicles,keratoconjunctivitis Week34acutemeningoencephalitis Treatacyclovirsignificantlydecreasesmortality Thereisalmosta100%transmissionrate,occursmostly after1sttrimester 40%deathrate(fetalandperinatal) Manifestsearly(first2years),thenlate(withinnext2 decades) Signs/Symptomsofearlyinfectionjaundice,increased LFTs,hemolyticanemia,rashthatisfollowedby desquamationofthehandsandfeet,snuffles(blood tingednasalsecretions),osteochondritis,sattlenose. LatesymptomsHutchinsonteeth(upper2incisorsget notched),mulberrymolars,bonethickening(frontal bossing),sabershins(anteriorbowingoftibia) BestinitialtestVDRLscreening MostspecifictestIgMFTAABS TreatPenicillinGfor1014days

Cytomegalovirus (CMV)

HerpesSimplex Virus

Syphilis

 InfantBotulism AnacuteandflaccidparalysiscausedbyC.Botulinum. IrreversibleblocksreleaseofAch Causedbytheingestionofrawhoney

Signs/Symptoms: Constipation Lethargy Weakcry Poorfeeding Hypotonia Drooling suckreflexes spontaneousmovements

Diagnosis:BasedonPEandtheacuteonsetofflaccidparalysis Treatment:Supportivecare+intubation CommonViralExanthems Disease Measles(Rubeola) Paramyxovirus SignsandSymptoms Beginsathairlinethenmovesdownward,isan erythematousmaculopapularrashthaterupts5 daysafterprodrome. PathognomonicKoplikspotsoftendisappear beforerashstarts(whitespotsonbuccalmucosa) Diagnosiscough,coryza,conjunctivitis(3Cs) Suboccipitallymphadenopathy* Amaculopapularrashstartsonthefacethen generalizes Rashlastsapproximately5days Softpalatemayshowredspotsofvarioussizes Patienthasvesicularrashonthehandsandfeet+ ulcerationsinthemouth Rashlastsapproximately1week Iscontagiousbycontact Acutefeverlasts15days,butchildshowsno physicalsymptomsanddoesnotfeelill Oncefeverdrops,amaculopapularrashappears overthewholebody(lasts24hrs) Slappedcheeksyndrome Anerythematousmaculopapularrashspreads

Rubella(German measles)Togavirus ErythemaInfectiosum (5thdiseaseParvo

Hand,foot,&mouth disease(CoxsackieA) RoseolaInfantum (HHV6)

 B19) Varicella(chickenpox) fromthearmstothetrunk/legs,formsreticular pattern Dangerousifpthassicklecelldiseasedueto tendencytoformaplasticcrisis Highlycontagious,teardropvesiclesthatbreakand crustover. Startsonfaceandtrunkthenspreads Contagiousuntilcrustingover

Vaccinations

Thisdiagramisthetypicalvaccinationrecommendationforchildrenfrom06yrold

RESPIRATORYDISORDERS
UpperRespiratoryInfections Condition Croup (Parainfluenz a1or3, InfluenzaAor B) Presentation 3mnth5yr withURIsx+ deepbarking cough/stridor . Symptoms worsenat night Acuteonsetof muffledvoice, drooling,high fever, dysphagia, and inspiratory stridor. Patientwill leanforward toease breathing Diagnosis Nothing neededfor diagnosisbut aneckxray shouldbe had Management 1. Humidified 02 2. Nebulized epi+ steroids Prognosis Spontaneousl yresolves within1wk. Alwaysbe waryofthe possibilityof epiglottis Without prompt treatment airway obstruction canleadto death

Epiglottitis (Hib,S. pyogenes,s. pneumo,and mycoplasma)

Bacterial Tracheitis(S. Aureus)

Childusually <3yr,aftera viralURIgets coughthat sounds Brassy,has highfever, respiratory distressBUT

Medical 1. Admitto Emergency hospital 2. Anesthesia Mgmtbased andENT onclinical consult dx,stabilize 3. Intubation firstthendo 4. Ceftriaxon workup: e+ steroids Workup: 5. Household Neckxray contacts lookingfor shouldget thumbprint Rifampinif sign. patientis H.Influenza Blood +ve cultures Epiglottic swabculture Dxisclinical AntistaphAbs,if butalsodoa severeintubate laryngoscop yandCXR CXRlooking forsub glottic narrowing

Airway obstructionis alifethreat complication

 nosignsor symptomsof severityof epiglottitis OtitisMedia CommoninchildrenandoftenprecipitatedbyanURI ConditionsthatdisruptproperEustachiantubedrainageleadtochronicOM MCCare:streppneumonia,H.Infl,Moraxella,orviralcauses Bloodcult+ throatcult.

SignsandSymptoms: Erythemaandmotilityoftympanicmembrane hearing Earpressure BulgingtympanicmembranewithvisualizationoffluidbehindTM

Treatment: 1stlineAmoxicillin 2ndlineAmoxicillin+ClavulinicAcid(augmentin) **ForrecurringOM,ENTconsultandtubesmayneedtobeinserted Bronchiolitis Classicallypresentsaschild<2yrwiththefollowing: MildURI Fever Paroxysmalwheezingcough Tachypnea Dyspnea Wheezingandprolongedexpirations

Commoncausesare: RSV(inupto50%) Parainfluenzavirus Adenovirus

 SignsandSymptoms: Diagnosis: Dxisclinicallybased. BestinitialtestCXRlookingforhyperinflation+patchyatelectasis MostspecifictestImmunofluorescenceofnasopharyngealswab Treatment: Mostlysupportive Iftachypneaisseverehospitalizeandgivetrialofnebulizedagonists Inflammation Airtrappingandoverinflation(duetoballvalveobstruction)

Pneumonia
Therearedifferentcausesofpneumonia: ViralMCCinchildren<5yr,MCCisRSV BacterialMCCinchildren>5yr,MCCareS.Pneumo,MycoplasmPneumo ChlamydialCommonininfants13monthwithinsidiousonset Viral: Tachypneaisthemostconsistentfindinginviralpneumonia URIsymptoms Lowgradefever

Bacterial: Acuteonsetwithsuddenshakingchills Highgradefever Cough Chestpain(pleuritispainwithrespiration)

 Chlamydial: Diagnosis: CXR: CBC: Treatment: Mildcasescanbemanagedonanoutpatientbasis,Amoxicillinisthebest choice.Augmentingmayalsobeused SeverecasesrequirehospitalizationandaretreatedwithIVceftriaxone Ifpneumoniaisofviralorigin,witholdAbsunlesspatientdeteriorates. ChlamydiaorMycoplasmatreatedwitherythromycin Viral<20000wbc Bact1500040000 Viralhyperinflationwithbilateralinterstitialinfiltrates Bacterial(pneumo)lobarconsolidation Mycoplasma/Chlamydiaunilaterallowerlobeinterstitialpneumothat looksworsethanthepatientspresentingsymptoms Mostcommonfindingareastaccatocoughandperipheraleosinophilia Nofeverorwheezing Maybeconjunctivitis Diminishedbreathsounds Dullnesstopercussionofthelungfields

MUSCULOSKELETALDISORDERS

Limp Painfullimpingmostoftenoccursacutely,andmaybeassociatedwithfever, irritability. Younginfantsmayrefusetowalk Painlesslimpingusuallyhasaninsidiousonsetandismorecommonlydue toweaknessordeformityofthelimbsecondarytodevelopmentalhip dysplasia,cerebralpalsy,orleglengthdiscrepancy

ThistableshowsthedifferentcausesofPAINFULLIMP Disease Arthritis(Septic) Characteristics The#1causeof painfullimpin1 3yrold Isusually monoarticular(hip, ankle,orknee) MCCS.Aureus Treatment Drainage+antibioticsthat areappropriatetothe cultureobtainedfromthe jointaspirate

ToxicSynovitis

Si/Sx:Acuteonsetofpain, ROM,fever,arthritis, wbc,ESR Xray:showsjointspace widening+softtissue swelling. Diagnose:jointaspirate showsWBC10,000with PMNpredominance MCinmales510yr Rest+analgesiafor35 andmayprocede days URI Si/Sx:insidiousonsetof pain,lowgradefever,wbc andESRarenormal Usuallynotenderness, warmth,orswelling

 Xrayisnormal Diagnose:technetium scanthatshows epiphysealuptake LeggCalvePerthesdx Headoffemur 49yrold Boys5xmorethan girls

AsepticVascular Necrosis

weightbearingon affectedsideoverlong term

SlippedCapitalFemoral Epiphysis(SCFE)

OsgoodSchlatter Tibialtubercle Active child/adolescent Restrelievespain Kohlersbone Navicularbone Si/Sx:afebrilewith insidiousonsetofhip pain,painofinner thigh/knee,painwith movement,withrest, normalwbcandESR Xray:femoralhead sclerosisandwidthof thefemoralneck Dx:technetiumscan showsuptakein epiphysis MCinobesemales Surgicalpinning 817yr 20%30%bilateral 80%occurslowly andprogressively where20%occur acutelyand associatedwith trauma

 Si/Sx:dull,achingpainin hip/knee,painwith activity Xray:icecreamscoop fallingoffconeto describelateral movementofthefemur shaftinrelationtothe femoralhead Dx:strictlyclinical NeonatesS.Aureus50% IVantibioticsfor46 oftime weeks ChildrenStaph,Strep, Salmonella(sicklecell) Si/Sxinyounginfants: onlysymptommaybe fever Si/Sxinolderchildren: fever,malaise,edema,and extremitymovement Dx:neutrophilic leukocytosis,ESR,blood cultures,bonescanis90% sensitive. MRIisgoldstandard

Osteomyelitis

CollagenVascularDisease
JuvenileRheumatoidArthritis Chronicinflammationofjointsinapatient16yr OccursMCin14yrolds,females>males Thereare3categories:Systemic,pauciarticular,andpolyarticular

Diagnosis:Symptomsthatpersistfor3consecutivemonthswiththeexclusionof othercausesofarthritisorcollagenvasculardisease. Treatment:NSAIDs,lowdoseMTX,andprednisoneinacutefebrileonset TypesofJuvenileRA Systemic(Stillsdisease) 10%20% Patienthashighspikingfeverthatreturns tonormaldaily Small,palepinkmaculeswithcentral pallorontrunk&proximalextremities withpossiblepalm&soleinvolvement Jointinvolvementmaynotoccurfor weekstomonths 1/3havedisablingchronicarthritis Involves4joints,primarilyaffecting largejoints(knee,elbow,ankle) Chronicjointdiseaseisabnormal Fever/malaise/anemia/lymphadenopathy common 2Types: Type1MC,females<4yr,90%ANA(+),incr riskofchroniciridocyclitis Type2MCmales>8yr,ANA(),75%areHLA B27(+),incrriskofAnkylosingspondylitisor Reiterssyndromelaterinlife 5jointsareinvolved,bothsmall&large, insidiousonset,fever,lethargy,anemia Thereare2typesthatdependonwhether rheumatoidfactoris(+)or() RF(+)80%females,lateonset,more severe,rheumatoidnodulespresent,75% areANA(+) RF()occursatanytimeduring childhood,mild,rarelyassdwith rheumatoidnodules,25%areANA(+)

Pauciarticular40%60%

Polyarticular

 KawasakisDisease Amucocutaneouslymphnodesyndrome Affectslargeandmediumvesselvasculitisinchildren<5yrofage MorecommonlyseeninchildrenofJapaneseheritage

Diagnosis: DiagnosisrequiresthepresenceofaFEVER>104For40Cformorethan5daysthat isunresponsivetoantibiotics+4/5ofthefollowingcriteria: UsingthemnemonicCRASHtorememberthecriteria 1. 2. 3. 4. 5. Complications: Treatment: Prognosis: WithresponsetoIVIG+aspirinisrapidand2/3becomeafebrilewithin1 day. Alwaysreevaluatein1week,repeatECHOat36wkpostillness IfnofurtherabnonECHOthennofurtherimagingisnecessary IVIGtopreventcoronaryvasculitis+highdoseaspirin Donotgivesteroidsasthiswillexacerbatethecondition 10%40%ofuntreatedcasesshowdilation/aneurysmofthecoronary arteries Conjunctivitis Rash(truncal) Aneurysmsofthecoronaryarteries Strawberrytongue Handandfootinduration(erythemaofthepalmsandsoles)

 HenochSchonleinPurpura AsmallvesselvasculitismediatedbyIgAnephropathy(Bergersdisease)

Signsandsymptoms: Treatment: HistiocytosisX AproliferationofhistiocyticcellsresemblingLangerhansskincells Selflimitedandrarelyprogressestoglomerulonephritis Apalpablepurpuraonthelegsandbuttocksispathognomonicinchildren Mayalsohaveabdominalpainduetointussusception

Thereare3commonvariants: 1. LettererSiwedisease Anacute,aggressive,disseminatedvariantthatisoftenfatalininfants SignsandSymptoms: Hepatosplenomegaly Lymphadenopathy Pancytopenia Lunginvolvement Recurrentinfections

 2. HandSchullerChristian Achronic/progressivevariantthatpresentspriorto5yr Classictriad:Skulllesions+diabetesinsipidus+exophthalmos 3. Eosinophilicgranuloma Extraskeletalinvolvementusuallylimitedtothelungs Hasthebestprognosisofallvariantsandoftenregressesspontaneously

MetabolicDisorders
CongenitalHypothyroidism Newbornscreeningismandatorybylaw T4isessentialduringthefirsttwoyearsoflifefornormalbraindevelopment Usuallyduetosecondarythyroidagenesisorenzymedefects Birthhistoryisusuallynormalwithaprolongedperiodofjaundice

SignsandSymptoms: At612weekstheinfantdevelopspoorfeeding,lethargy,hypotonia,coarse facialfeatures,largeprotrudingtongue,constipation,hoarsecry,and developmentaldelay

Diagnosis: T4,TSH

Treatment: Levothyroxine Delayoftreatmentbeyond6wksresultsinmentalretardation

 NewbornJaundice Timeframe Within24hrofbirth DifferentialDx Sepsis Hemolysis(ABO/Rh isoimmunization,hereditary spherocytosis) Hemolysis Infection Physiologic Infection Hemolysis Breastmilkjaundice Congenitalmalformation hepatitis

Within48hrofbirth After48hr

**50%ofneonateshavejaundiceduringtheirfirstweekoflife Physiologicjaundice: Clinicallybenignconditionthatoccursbetween2448hrafterbirth Characterizedbyunconjugatedhyperbilirubinemia Causeisincreasedbilirubinproduction+arelativedeficiencyinglucuronyl transferaseintheimmatureliver

Treatment: Jaundicepresentatbirthpathologic Workupforpathologicjaundice: Totalanddirectbilirubin DirectCoombstest Bloodtypeofinfantandmother(ABOorRhincompatibility) Isalwayspathologicandappearswithin24hrsofbirth Bilirubinrises>5mg/dL/day Bilirubin>12mg/dLinterminfant Directbilirubin>2mg/dLatanytime Hyperbilirubinemiaispresentafterthe2ndweekoflife Nonerequired

 CBC,retic#,peripheralsmear(assessingforhemolysis) U/Aandurineculture(ifelevatedisdirectbilirubinassessforsepsis)

Ifprolonged>2weeks,dothefollowing: Ifconjugatedbilirubin InitialdiagnostictestsLFTs MostspecifictestUSandliverbiopsy

Ifnoelevationofunconjugatedbilirubin UTIorothertypeofinfection Bilirubinconjugationabnormalities(Gilberts,CriglerNajjar) Hemolysis Intrinsicredcellmembranedefectorenzymedefect(spherocytosis, elliptocytosis,G6PDdef,pyruvatekinasedeficiency)

Treatment: UnconjugatedHyperbilirubinemia Causedbyhemolyticanemiaorcongenitaldeficiencyofglucuronyl transferase(CriglerNajjar,Gilbertssyndrome) Whenbilirubinis>1012mg/dLphototherapy Exchangetransfusionifencephalopathyissuspectedorthereisfailureof improvementwithphototherapy

Hemolyticanemia: ConjugatedHyperbilirubinemia Infectiouscausesaresepsis,ToRCHs,hepatitis,syphilis,listeriainfection Metaboliccausesaregalactosemia,1antitrypsindef Congenitalcausesareextrahepaticbiliaryatresia,DubinJohnson syndrome,Rotorsyndrome Congenitaloracquired Congenitalspherocytosis,G6PD,pyruvatekinasedeficiency AcquiredABO/Rhisoimmunization,infection,drugs,twintwin transfusion,chronicfetalhypoxia,delayedcordclamping,maternaldiabetes

 Treatment: UVlighttobreakdownbilirubinpigments Urgenttreatmentisimperativeinordertopreventkernicterusinduced mentalretardation

Complications: UVlightcancausediarrhea,dermatitis,dehydration,anddamagetothe retina(becautiousoftheseadverseeffects)

ReyeSyndrome
SignsandSymptoms: Alternatesanasymptomaticintervalwithabruptonsetofvomiting,delirium, stupor,abnormalLFTs Rapidprogressiontoseizures,coma,anddeath Theuseofsalicylatesinchildrencausesanacuteencephalopathy+fatty degenerationoftheliver Mostcommonlyoccursinchildrenaged412yr

Diagnosis: Significantlyelevatedliverenzymes

Treatment: UrgentICPmanagementwithmannitolandfluidrestriction Glucoseadministrationduetorapiddepletionofstores

Prognosis: Badifserumammonialevelsareincreased3fold,andifthereisadecreased PTlevelthatWONTrespondtovitaminK Ifdiseaseismildtherecoveryisusuallygoodandrapid Aseverediseasecanresultinpermanentneurodefects

 Seizures Inthenewborn,seizuresmaypresentasjitterswithrepetitivesucking movements,tonguethrusting,andapneicspells. BloodcountsandchemistriesareoftenWNL Neonatalseizurescanbediagnosedbythepresenceofoculardeviationand failureofjitterstosubsidewithstimulus

Diagnosis: EEGoftennormal CBC+chemistrypaneloftenthecauseishypoglycemiaincaseofGDM Aminoacidassaylookingforinbornerrorsofmetabolism TotalcordbloodIgMtolookforToRCHinfections Urinecultures LPifsuspectedmeningitis USofheadifinfantispretermlookingforbleeding

Treatment: FebrileSeizures Usuallybetween3mnt5yr Afeverispresentwithnoothersignsofinfection IstheMCconvulsivedisorderinchildrenandrarelydevelopsintoepilepsy Seizureoccursduringtemperaturerise(102F)butnotatitspeak 1stlineDOCisPhenobarbital PersistentseizurenotresponsivetoPhenobarbitalgivePhenytoin

SignsandSymptoms: MCisatonicclonicseizurethatrarelylastmorethan10min+adrowsy postictalperiodiscommon Seizurelasting>15minisusuallyduetoaninfectiousprocess

Diagnosis: Clinicaldiagnosisisusuallyallthatisneeded Routinelabsonlyrequiredtoidentifyasourceofthefever LPtoruleoutmeningitis(onlyifsuspected)

Treatment: Controlfeverwithantipyretics Reassureparents/counsel

 Alwaysdoacarefulevaluationforthesourceofthefever

**30%50%ofchildrenexperiencerecurrentfebrileseizures

GeneticandCongenitalDisorders
FailuretoThrive Isthefailureofchildrentogrowanddevelopatanappropriaterate Maybeduetoinadequatecaloriesorinabilitytoabsorbthecalories Maybeidiopathicorduetootherdiseases Factorssuchaspoverty,familyproblems,neonatalproblems,andmaternal depressionshouldallbeincludedindiagnosis

Diagnosis: Requires3criteriaforaFTTdiagnosis: 1. Child<2yrwithweight<5thpercentileforageon>1occasion 2. Child<2yrwhoseweightis<80%ofidealforage 3. Child<2yrwhoseweightcrosses2majorpercentilesdownwardona standardizedgrowthchart Exceptions: Geneticallyshortstature Smallforgestationalagechildren Preterminfants Verylean(becarefulhere) heightwithaweightgain(causesanoverweightchildcarefulattention forthisdiagnosis)

Treatment: Organiccausestreatunderlyingcondition+supplementwithsufficientcalories Idiopathiccauseseducateparentonnutritionandobserveparentwhilefeeding Olderinfants/childrenoffersolidsbeforeliquids,mealtimedistractions,have childeatwithothers,neverforcefeed **Monitorcloselyforweightgainwithadequatecalorieconsumption Prognosis: Inthe1styearoflifethepxispoorsincethebraindevelopsearlyinlife 1/3ofchildrenwithnonorganicfailuretothrivearedevelopmentally delayed

 CraniofacialAbnormalities CleftLip: CleftPalate: Macroglossia: Isacongenitallyenlargedtongue SeeninconditionssuchasDownssyndrome,hypothyroidism,andgigantism Canbeacquiredlaterinlifeviaacromegalyand/oramyloidosis IsNOTglossitis,whichisfromaBvitamindeficiency Treatmentisaimedattreatingtheunderlyingcause Maybeanteriororposterior Anteriorcleftpalateisduetofailureofthefusionofthepalatineshelveswith theprimarypalate Posteriorcleftpalateisduetofailureofthefusionofthepalatineshelves withthenasalseptum Theseconditionswillinterferewithfeedingandthusrequireaspecialnipple forthebabytofeedproperly Treatwithsurgicalrepair Mayoccurunilaterallyorbilaterally Causedbyafailureoffusionofmaxillaryprominences MCformisunilateralcleftlip Nointerferencewithfeeding Treatwithsurgicalrepair Themildestformofcraniofacialabnormalityisthebifiduvula,andhasno clinicalsignificance

 ArnoldChiariMalformation Acongenitaldisorderwherethecerebellumiscaudallydisplaced,themedullais elongatedandpassesintotheforamenmagnum.

SignsandSymptoms: Flattenedskullbase Hydrocephalus Aqueductstenosis

Prognosis: NeuralTubeDefects Associatedwithincreasedfetoproteininthematernalserum VERYPREVENTABLEwithFOLATEsupplementation Deathusuallyasneonateoftoddler

SignsandSymptoms: Spinabifida(failureofposteriorvertebralarchestoclose) Meningocele(lackofvertebraecoveringthelumbarspinalcord)

Treatment: Preventioniskey(folicacidsupplementation) Neurodeficitsremain

 FetalAlcoholSyndrome Inchildrenborntoalcoholicmothers,ormotherswhoconsumedexcessive alcoholduringpregnancy

Signsandsymptoms: Characteristicfacialabnormalitiesanddevelopmentaldelays ASD Microcephaly Smoothfiltrumofupperlip

Treatment: CongenitalPyloricStenosis Presentswithprojectilevomitinginfirst2wk2monthoflife Seenmorecommonlyinmalesandin1stbornchildren Thepathognomonicfindingisthepalpableolivemassinthemid epigastrium(hypertrophiedpyloricstenosis) CessationofETOHconsumptionwhenpregnant

Diagnosis: Palpationofolivemassisoftensufficient Ifnomasscanbepalpated,toanultrasound(US)

Treatment: CongenitalHeartDiseases ASD: Oftenasymptomaticandfoundonroutinephysicals CanpredisposetoCHFinthe2ndand3rddecadesoflife Mayalsopredisposetostrokes(duetoanembolusbypasstract) Longitudinalsurgicalincisionofhypertrophiedpylorus

SignsandSymptoms: Midsystolicejectionmurmur LoudS1 WidefixedsplitS2

 Diagnosis: Echocardiography

Treatment: VentricularSeptalDefect(VSD) IstheMCcongenitalheartdefect 30%oftheseVSDsclosespontaneouslyby2yrofage Surgicalpatching Treatmentismoreimportantforfemalesbecausetheyhaveanincreasein cardiovascularstressduringpregnancy

SignsandSymptoms: Smalldefectsmaybeasymptomatic LargedefectscancauseCHF Cancausedelayed/decreaseddevelopmentandgrowth Holosystolicmurmurheardovertheentireprecordiumandmaximallyatthe 4thleftintercostalspace

EisenmengersComplex: Arighttoleftshuntsecondarytopulmonaryhypertension RVhypertrophycausesaflowreversalthroughtheshunt,resultinginaRL shunt Getcyanosissecondarytolackofbloodflowtothelungs

Diagnosis: Echocardiography

Treatment: Simpledefectsrequirecompleteclosure

 TetralogyofFallot Fourdefectsmakeupthistetralogy,theyare: 1. 2. 3. 4. VSD Pulmonaryoutflowobstruction RVhypertrophy Overridingaorta

SignsandSymptoms: Cyanosisdevelopswithinfirst6monthsoflife(notpresentatbirth) TetSpellsareacutecyanosisaccompaniedbypanic,wherechildgoesintoa squattingpositionbecauseithelpsimprovebloodflowtothelungs

Diagnosis: Echo CXRshowsbootshapedcontouroftheheartduetoRVenlargement

Treatment: TranspositionoftheGreatArteries Aortacomesofftherightventricle Pulmonaryarterycomesoffleftventricle WithoutapersistentAVcommunicationthisconditionisincompatiblewith life.ThusrequiresaPDAorpersistentforamenovale. SurgicalrepairofVSDandpulmonaryoutflowtracts

SignsandSymptoms: Markedcyanosisatbirth Earlyclubbingofthedigits CXRshowsanenlargedeggshapedheartandanincreaseinpulmonary vasculature

Diagnosis: Echo

Treatment: Surgicalswitchingofthearterialrootstonormalpositionswithrepairof communicationdefect

 Prognosis: CoarctationoftheAorta SignsandSymptoms: NormalBPinarmswithdecreasedBPinlegs Continuousmurmurovercollateralvesselsintheback TheclassicXRAYshowsribnotching Acongenitalaorticnarrowingthatisoftenasymptomaticinchildren Withouttreatmentisfatalwithinseveralmonthsofbirth

Diagnosis: ConfirmwithCToraortogram

Treatment: PatentDuctusArteriosus(PDA) incidencewithprematurebirths PtpredisposedtoendocarditisandPVDs Surgicalresectionofcoarctationandreanastomosis

SignsandSymptoms: Continuousmachinerymurmurthatsbestheardat2ndleftinterspace Widepulsepressure Hypoxia

Diagnosis: Echoorcardiaccatheterization

Treatment: Indomethacininducesclosure(blocksprostaglandins)forchildren

 GeneticAnomalies Condition
DownsSyndrome(trisomy 21) Increasedriskwhen maternalageis>35yr

Olderchildrenusuallyrequiresurgicalrepair

ClassicFeatures
Epicanthalfolds Slantedpalpebral fissures Specklingofiris Latefontanelclosure Mentalretardation Lowset,malformed ears Microcephaly Micrognathia Clenchedhand Rockerbottomfeet Omphalocele Midfacedefects Eyedefect Defectiveforebrain development Microcephaly Microphthalmia Cleftlipandpalate Wilms Aniridia GUanomalies Retardation(mental) LowIQ Gynecomastia Behavioralproblems Long/slimlimbs Smallstatured female LowIQ Gonadaldysgenesis Webbedneck Broadchest Widespacednipples

Workup/Associations
Hearingexam ECHO:VSD,ASD,PDS GI:TEF,duodenal atresia TSHfor hypothyroidism ALL,decreasedrisk withincreasingage ECHO:VSD,ASD,PDS RenalUS:polycystic kidneys,ectopicor doubleureter Mostptsdont survive1styr ECHO:VSD,PDA, ASD RenalUS:polycystic kidneys Singleumbilical artery Thepresenceof aniridiashouldalert fortheworkupfor WAGR Testosteronelevels: hypogonadismand hypogenitalism Testosterone replacementat11 12yrofage RenalUS:horseshoe kidney,doublerenal pelvis Cardiac:bicuspid aorticvalve, coarctationofthe aorta Thyroidfunction: primary

Edwardssyndrome(trisomy 18)

1. 2. 3. 4.

PatauSyndrome(trisomy 13)

WAGRsyndrome

Klinefelter(XXY) 1/500males

Turnerssyndrome(X0) Asporadicconditionwithno maternalageassociation


hypothyroidism Supplementwith estrogen,GH,and anabolicsteroids AssdwithADHD

FragileXSyndrome BeckwithWiedemann syndrome PraderWilli (deletionat15q11q13 paternallyderived) Angelmansyndrome(aka happypuppetsyndrome). (deletionat15q11q13 maternallyderived) Microcephalyin earlychildhood Largeears Largetestes IstheMCCofmental retardationinboys Multiorgan enlargement Macrosomia Macroglossia Pancreaticbetacell hyperplasia Largekidneys Neonatal polycythemia Obesity Hyperphagia Smallgenitalia Mentalretardation Mentalretardation Inappropriate laughter Absenceofspeech Ataxia/jerkyarm movements Recurrentseizures Mandibular hypoplasia Cleftpalate

Increasedriskofabd tumors USandserumAFPq 6mnthupuntil6yrof agelookingfor Wilmstumor

Morbidobesity decreaseslifespan Epilepsydevelopsin 80%

PierreRobin (assdwithFASand Edwards)

Airwayobstruction possibleoverfirst4 wksoflife,thus monitorairway

TraumaandIntoxication
Poisonings Signs/Symptoms Lethargy&Coma Seizures Hypotension Arrhythmia Hyperthermia PossibleToxins ETOH,sedatives,narcotics,antihistamines, neuroleptics,antidepressants Theophylline,cocaine,amphetamines,anti depressants,antisphychotics,pesticides Organophosphatepesticides,blockers TCAs,cocaine,digitalis,quinidine Salicylates,anticholinergics

Approximately50%ofcasesoccurinchildren<6yr 92%occurathome,60%withnonpharmagents,40%withpharmagents 75%ofcasesareduetoingestion,8%dermal,6%ophthalmic,and6% inhalation Lavageisoftenunnecessaryinchildrenbutmaybeusefulindrugs decreasinggastricmotility Charcoalisoftenmosteffectiveandsafestproceduretopreventabsorption (butisineffectiveinheavymetalorvolatilehydrocarbonpoisoning).

Adolescence
Epidemiology Injuries: 50%ofadolescentdeathsattributedtoinjuries ManyduetoETOH&elicitdrugs OlderadolescentshaveincreasedeathsduetoMVA,whileyounger adolescentshavedeathsduetodrowningandweaponinjuries Homicideratesare5x>forBlacksthanWhitemales

Suicide: Isthe2ndleadingcauseofadolescentdeath Femalesattemptmorebutmalesare5xmorelikelytosucceed SuicideattemptsaregreaterinthosewhoabuseETOHanddrugs

Substanceabuse: Sex: 61%ofallmalesand47%ofallfemalesinhighschoolhavehadsex Biggestrisks:unwantedpregnancy,STDs 86%ofSTDsoccuramongadolescentsandyoungadultsbetween1529yrof age >1millionfemaleadolescentsbecomepregnantyearly,33%are<15yrold Amajorcauseofmorbidityinadolescents Averageageof1stusageis1214yr Highschoolseniorsonaverage:90%triedETOH,40%triedmarijuana

Chapter 5 Biostats

 Successinansweringthebiostatisticsquestionscomesfromnotonlymemorizing thefollowingcharts,butactuallyunderstandingthem.Ifyoucangraspwhatis happeningyouwillnothaveanyissuesinthissection.

TruePositive:isthe#ofpeoplewhohavethediseasewith+veresults FalsePositive:isthe#ofpeoplewhoinfactdonothavethediseasewitha+vetest result TrueNegative:isthe#ofpeoplewhodonothaveadiseasewhotestedve FalseNegative:isthe#ofpeoplewhohavethediseasewhotestedve Sensitivity[A/A+C] Sensitivityisatestsabilitytodetectadisease Specificity[D/B+D] Specificityisatestsabilitytodetecthealth PositivePredictiveValue[A/A+B] Thepositivepredictivevalue(PPV)detectsthelikelihoodthatthepatienthasa diseasewhentheytestpositiveforatest NegativePredictiveValue[D/C+D] Thenegativepredictivevaluemeasureshowlikelyapatientisinfacthealthyaftera testresultcomesbacknegative.

 OddsRatio[(aXd)/(bXc)] ComparestheincidenceofdiseaseinpeopleexposedXincidenceofnondiseasein peoplenotexposed,dividedbytheincidenceofpeopleunexposedandincidenceof nondiseaseinthoseexposed. OR>1=thefactorbeingstudiedisariskfactorfortheoutcome OR<1=thefactorbeingstudiedisaprotectivefactorinrespecttotheoutcome OR=1=nosignificantdifferenceinoutcomeineitherexposedorunexposedgroup RelativeRisk[a/(a+b)/d/(c+d)] Comparesdiseaseriskinpeopleexposedtoacertainfactorwithdiseaseriskin peoplewhohavenotbeenexposed AttributableRisk[a/(a+b)d/(c+d)] Theattributableriskisthe#ofcasesattributabletooneriskfactor

StandardDeviation
1standarddeviation68%fallwithin1SD 2standarddeviations95%fallwithin2SDs 3standarddeviations99.7%fallwithin3SDs

MEANtheaveragevalue MEDIANthemiddlevalue

 MODEthemostcommonvalue

+VESKEW A+veskewedgraphmeansthemean>median>mode

VESKEW Aveskewedgraphmeansthemean<median<mode

Normalbellcurve Mean=median=mode

 NODISEASE DISEASE

Thischartrepresentssensitivity&specificity Ifthecutoffpointforadiseaseismovedfromfalse(+)false(),therewill beaninthe#ofpositiveresults.Thusaninsensitivity(TP,FP,FN, PPV] Ifthecutoffpointisraisedfromthefalse()false(+),thiswillspecificity [TN,FP]

Correlationcoefficient
Measurestowhatdegreethevariablesarerelated(from1to+1) 0=thereisnocorrelation +1=thereisaperfectcorrelation(thusif1variableincreasessodoestheother) 1=thereisaperfectnegativecorrelation(thusif1variableincreasestheother decreases)

Confidenceintervalandpvalue
Twovaluesusedtostrengthenafindingofastudy.Forstatisticalsignificance,the confidenceintervalmustnotcontainthenullvalue(RR=1).Further,statistically significantresultshaveapvalue<0.05(meaningthereis<5%chancethatthe resultsobtainedwereduetochancealone). Apvalue<0.05isgenerallyusedasacutoffforstatisticalsignificanceinmedicine. 0.05meansthereisa5%chancethatresultsobtainedareduetorandomchance. Whenthepvalueis0.05werejectthenullhypothesis(nullhypothesissaysthata resultisduetorandomerrororchance)

 Theconfidenceintervalisgivenin2digits,andtheclosertheyare,themore confidencethereis.*Withincreasedsubjectsthereisatighterconfidenceinterval AttributableRiskPercent(ARP) Measurestheimpactofariskfactorbeingstudied.TheARPrepresentstheexcess riskinapopulationthatcanbeexplainedbyexposuretoaparticularriskfactor. CalculateARP:[(RR1)/RR] IncidencevsPrevalance Incidencethe#ofnewcasesofadiseaseoveraunitoftime Prevalenceisthetotal#ofcasesofadisease(neworold)atacertainpointin time Ifadiseaseistreatedonlytoprolonglifewithoutcuringthedisease(ie.Terminal cancers),thenincidenceremainsthesamebutprevalenceincreases. **Inshorttermdiseases:incidence>prevalence **Inlongtermdiseases:prevalence>incidence Reliabilitygivessimilarorverycloseresultsonrepeatmeasures Validity/Accuracydefinedasatestsabilitytomeasurewhatitissupposedto measure(ascomparedtothegoldstandard) Precisionisincreasedwithatighterconfidenceinterval,andCIismadetighter withahigher#ofsubjects

StudyTypes
CaseControl/ExperimentalIsthegoldstandard,compares2equalgroups whereonehasachangedvariable ProspectiveAlsoknownas:Cohort,Observational,Incidence.Takesasampleand dividesitinto2groupsbasedonpresenceorabsenceofriskfactor,andfollowsover timetoseewhatdevelops.**Thesearetimeconsumingandexpensive. RetrospectiveChoosesapopulation(afterthefact)basedonthepresenceor absenceofariskfactor.**Costsless,lesstimeconsuming,betterforrarediseases. CaseSeriesdescribestheclinicalpresentationofpeoplewithacertaindisease CrossSectional/PrevalenceThisstudylooksattheprevalenceofdiseaseandthe prevalenceofriskfactors.Takessamplefromapopulationatonepointintime. Thiscompares2differentcultures. EpidemicWhentheobservedincidencegreatlyexceedstheexpectedincidence PandemicIsanepidemicseenoverawidegeographicalarea.

TestMethods
TwosampleTtest:isusedtocomparethemeansof2groupsofsubjects ANOVA(analysisofvariance):usedtocompare3variables Chisquared:comparestheproportionsofacategorizedoutcomes(2x2table).If thedifferencebetweentheobservedandexpectedvaluesislarge,anassociated betweentheexposureandtheoutcomeisassumedtobepresent. MetaAnalysis:isamethodofpoolingthedatafromseveralstudiestodoan analysishavingabigstatisticalpower.

TypesofBias
SelectionBias:Biastypeduetomannerinwhichpeopleareselected,orfrom selectivelossesfromfollowup Observer&MeasurementBias:Distortionofmeasurementofassociationby misclassifyingexposed,unexposed,and/ordiseases/nondiseasedsubjects. RecallBias:Resultsfromtheinaccuraterecallofpastexposurebypeopleinthe study HawthorneEffect:Patientschangetheirbehaviorbecausetheyknowtheyarebeing studied Confounding:Isbiasthatresultswhentheexpose/diseaserelationshipismixed withtheeffectofextraneousfactors.(ex.Studyoftheassociationofsmokingand cirrhosis,andfindthatthereisastrongassociation.Thenthedivisionofdrinkers andnondrinkersfindstheresnoassociationofsmokingtocirrhosis.Inthiscase, alcoholistheconfounder).*Matchingisaneffectivewayofcontrollingconfounding LeadTimeBias:Referstothechronologyofthediagnosisandtreatmentbetween differentcases.(ex.Testingofplateletinhibitorsinpilotsvsautoworkers,notfair becausepilotsareundergoingconstanthealthscreening) AdmissionRateBias:Referstodistortioninriskratioduetodifferenthospitals admissionofcases UnacceptabilityBias:Occurswhenparticipantspurposelygivedesirableresponses whichleadto

Chapter 6 Psychiatry

MoodDisorders
MajorDepressiveDisorder Majordepressivedisorderischaracterizedbyadepressedmoodoranhedonia (cannotenjoythingsthattheyonceenjoyed),anddepressivesymptomslastingat least2weeks. Lookforotherpossiblecausessuchashypothyroidism,druguse/substance use.

TheclassicmnemonicfordepressionisSIGECAPS S:sleepdisturbances(toomuchortoolittle) I:interestchanges(lossofinterst) G:guiltyfeelings E:energyloss C:concentrationdisturbances A:appetitechanges(causesweightchangestoo) P:psychomotorchanges S:suicidalthoughs/death Treatment: 1stlinetreatmentisSSRIsuchasfluoxetine,paroxetine,sertraline(possible sideeffectissexualdysfunction) Canincludebenzodiazepineifpatientisagitated TherapyisalsoindicatedalongwithSSRItreatment Ifpatientissuicidalordangeroustoothersalwaysadmit

 DysthymicDisorder Samesymptomsasmajordepressivedisorderexceptis morelowlevelinnature,andispresentonmostdaysfor atleast2years. Treatment: Bereavement Bereavementiscommonlyseenafterdeathofafamilymember(most commonlyseeninolderpeopleafterdeathofaspouse). SSRI(similartreatmentasMajorDepression) Itispossibletogeta majordepressive episodewhile dysthymic.Treatas MDDinthissituation.

Diagnosis: Keytothediagnosisisthetimethathaselapsedsincetheonsetofthe bereavementperiod. Symptoms>2monthsmakesthediagnosismajordepressivedisorderinstead ofnormalbereavement.

Treatment: BipolarDisorder SignsandSymptoms: Acuteonsetofenergy needtosleep Aconditionwithepisodesofmania, depression,aswellasnormalperiods. Seeninapproximately1%ofthepopulation Affectsmales=females Morecommonintheyoungerpopulation Amixofmania,depression,ormixed symptomsforatleast1week RememberingMANIA: Ddistractibility Iinsomnia Ggrandiosity Fflightofideas Aactivityincreased Sspeech(pressured) Ttakesrisks Therapy(griefmanagement)isrecommendedinsuchconditions

 Differentialdiagnosis: Schizophrenia Intoxication(cocaine,amphetamine) Certainpersonalitydisorders Pressuredspeech attentionspan hypersexuality Recklessbehavior(excessivegambling,shopping,spendingmoney)

Diagnosis: Episodeshouldlast1weekandshouldbeabrupt/causesignificant disability Bipolar1amanicepisodewithorwithoutdepressiveepisode Bipolar2depressiveepisodeswithhypomanicepisodes Rapidcycling>4episodesinaoneyearperiod

Treatment: Cyclothymia Treatment: 1stispsychotherapybecausemanypatientscanfunctionwithoutmedication Iffunctioningbecomesimpairedstartpatientonvalproicacid,whichismore effectiveincyclothymiathanlithium Isarecurrenceofdepressiveepisodesandhypomaniaforatleast2years Isamilderformofbipolardisorder Hospitalization(isofteninvoluntarybecausepatientismanic) MoodstabilizersLithiumisDOC,canalsousevalproateorcarbamazepine Antipsychoticscanbeuseduntilacutemaniaiscontrolled Ifrecurrentepisodesofdepressionarepresent,cangiveantidepressants onlyinconjunctionwithmoodstabilizers Lithiumlevelsshouldbecheckedtopreventtoxicity

 DrugInducedMania SignsandSymptoms: Findingssimilartomania Mydriasis Hypertension MIinyoungpeople(highlysuggestiveofcocaineoverdose) Themostcommoncausesarecocaineandamphetamines

Treatment: PostpartumDepression Onset Mothers emotionstoward thebaby Symptoms Postpartum bluesBaby blues Afteranybirth Motherstillcares aboutthebaby MildDepression Postpartum Depression MCafter2ndbirth Thoughtsabout harmingthebaby arecommon SevereDepression Postpartum Psychosis Usuallyafter1st birth Thoughtsabout harmingbabyare common Depressive symptoms+ psychotic symptoms Ifpatientnot breastfeedinggive Moodstabilizers ORantipsychotics +antidepressant Ifpatientis breastfeedingdo ECT ForacutesymptomsgiveCCBs Drugtreatmentprogramsforlongtermmanagement

Treatment

Notreatment necessary

Antidepressants

PSYCHOSIS
Psychosisischaracterizedby: Thistablegivesageneraloverviewofthecausesofpsychosis DISEASE Schizophrenia Schizoaffectivedisorder Delusionaldisorder Mooddisorders Delirium CHARACTERISTICS Thereisastronggeneticpredisposition,onset usuallylateteensthroughthe20s +vesymptoms=hallucinationsand/or delusions vesymptoms=flattenedaffect Othersymptomsincludedisorganizedbehavior and/orspeech Mustlast6monthstobecalledschizophrenia Iflasting16monthscalledschizophreniform Iflasting<1monthitisabriefpsychotic disorder(thesepatientsoftenreturntonormal baselinefunctioning) Combinationofamooddisorder+ schizophrenia Patientgetsnonbizarredelusions Bipolarand/ordepressioncancausedelusions andinextremecasesmaycausehallucinations Oftenseeninpatientswhohaveunderlying conditions Noorientationtoperson,place,ortime Waxingandwaningofcondition Treatmentinvolvestreatingtheunderlying condition Cocaine/amphetaminescauseparanoid delusionsandformication(sensationofbugs crawlingontheskin) LSD/PCPcausehallucinationsofvision,taste, touch,andscent Endocrinedisorders,metabolicdisorders, neoplasticdisorders,andseizuredisorderscan HallucinationsfalsesensoryperceptionthatisNOTbasedonrealstimuli Delusionsfalseinterpretationsofexternalreality Canbeoftheparanoidnature,grandiosity,religious,orideasofreference

Drugs

Medicalcauses

 causepsychosis Treatment: Ifconditionisdisablingorpotentiallydangeroustopatientorothers, hospitalizationisrequired. Pharmacologictherapyiswithdopamineantagonists,andthedifferences amongstthedrugsisbasedonthesideeffectstheyproduce Improvedrugcompliancebygivingdepotformofhaldol Psychotherapytoimprovesocialfunctioning(behavioraltreatmentto improvesocialskills,familyorientedtreatmentforimprovedfamilial functioning) Prognosisisdependentoffrequencyofepisodesaswellasaccompanying symptoms(presenceofnegativesymptomsusuallyindicatesapoor prognosis) Patientswhowereveryhighfunctioningpriortothepsychosisonsethavea betterprognosis DRUG Chlorpromazine Haloperidol Clozapine Risperidone Olanzapine ADVERSEEFFECTS TypicalAntipsychotics Lowpotency,anticholinergiceffects,movementdisorders Highpotency,anticholinergiceffect,movementd/o AtypicalAntipsychotics Forrefractorydisease,giveweeklyCBC(agranulocytosis risk) 1stline,minimalaverseeffects 1stline,minimaladverseeffects

Therearemanypossiblemovementdisordersassociatedwiththeuseof antipsychoticmedications.YouwilllikelyencounteroneontheCKexam.Thistable willdemonstratethetimelineforcertainadversemovementreactions. DISORDER AcuteDystonia TIMEFRAME From4hr4days(4&4) CHARACTERISTICS Patientexperiences sustainedspasms, maybeanywherebut MCseenintheneck, jaw,orback. TreatmentIV diphenhydramine (immediately) Patienthascogwheel rigidity,resting tremor,andshuffling

Parkinsonism

From4days4months

 gait Treatment benztrophine (anticholinergicused inParkinsons disease) Involuntary/irregular movementsofthe head,tongue,lips, limbs,andtrunk Treatmentchange medications immediately(isa permanent condition) Patienthasasenseof discomfort/restlessn ess Treatbylowerthe doseofmedication Isalifethreatening musclerigiditywith fever,increasedBP andHR,and rhabdomyolysisthat appearsover13 days Treatmentis supportive,stopall offendingdrugs immediately,give patientdantrolene (Calciumisinhibited fromreleaseinto cells),andcoolthe patient

TardiveDyskinesia

4months4years

Akithisia

Mayoccuratanytime duringtreatment

NeurolepticMalignant Syndrome Mayoccuratanytime duringtreatment

AnxietyDisorders
PanicDisorder AconditionseenMCinwomenintheirmid20s SymptomsmimicthoseofanMI(chestpain,palpitations,diaphoresis, nausea,anxiety,senseofimpendingdoom) Symptomsusuallyescalateforapproximately10minutesandlastatleast30 minutes Thisdisorderisveryunpredictable,ifitoccursinthesametypeofsetting thensuspectaspecificphobia

Diagnosis: Mustdifferentiatefromdruguse,MI,andothersourcesofphobias Diagnosisofexclusion

Treatment: Agoraphobia Patientfearsbeinginsituationswheretheycannotescape,bringingabouta panicattack Patientsdevelopagoraphobiabecauseofrecurrentandunexpectedpanic attacksincertainsituations Cognitivebehavioraltherapyand/orrelaxationtraining. Relaxationismoreusefulifpatienthasanagoraphobictendency SSRIsandbenzodiazepinescanbeprescribed

Diagnosis: Isclinical,lookingforevidenceofsocialand/oroccupationaldysfunction

Treatment: Exposuredesensitization blockersasprophylaxisfromsympatheticactivationwheninpossibly triggeringsituations

 ObsessiveCompulsiveDisorder(OCD) Patientexperiencesrecurrentthoughtsandperforms recurrentactions/ritualsasacopingmechanism Obsessivethoughtsprovokeanxiety,compulsionsare awayofdealingwiththisanxiety,thisanxietyreliefis onlytemporaryandthusritualsgetperformedover andoveragain. Commonlyinvolvecleanliness(fearofcontamination) thusexcessivehandwashingiscommon DonotconfuseOCD withobsessive compulsive personality disorder,where thepatientseesno wrongintheir behaviors.

Diagnosis: Patientmustbeawareoftheabnormalityoftheirbehavior,andmustbe disturbedbythis.

Treatment: PostTraumaticStressDisorder ThisistheclassicVietnamvetpatient,whohasundergoneatraumatic incidentthatleavesthememotionallyscarred 1stlinetreatmentisSSRI 2ndlineisclomipramine Patientmustundergopsychotherapyaswell,wheretheyareforcedto overcometheirbehavior

Thereare3keygroupsofsymptoms: 1. Avoidanceofstimuliassociatedwiththeirtraumaornumbingof responsivenessbecauseitemitsemotionalpain 2. Reexperiencingthetraumaticeventviadreams,thoughts,recollections. 3. Increasedarousalseenassleepdisturbances,emotionallability, impulsiveness,anxiety. Diagnosis: Alwaysdifferentiatefromanacutestressdisorder, wheresymptomslastlessthan1monthandoccur within1monthofexperiencingthestressor Diagnosisrequiresatraumaticincidentandmustlast longerthan1month Apatientwho functionedvery wellbeforethe onsetofPTSD hasagreater prognosisthan someonewho wasless functional.

 Treatment: GeneralizedAnxietyDisorder Diagnosis: Mustbeevidenceofsocialdysfunction(whichrulesoutnormalanxiety) Patientworriesexcessivelyand/orhaspoorlycontrolledanxietyonmost daysforatleast6months. Thereisnospecificeventorreasonforthisanxiety Patienthastroublesleeping,theinabilitytoconcentrate,excessivefatigue andrestlessness Besuretodistinguishfromspecificphobia/anxietiesorothercausesof anxiety. Whenpatientisinacutedistress,givebenzodiazepinestocalmthemdown Forlongtermtherapy,giveSSRIs+psychotherapy

Treatment: ANXIOLYTICSPRESCRIBEDFORANXIETYDISORDERS: PANICDISORDER:SSRI,Alpralozam,Clonazepam GAD:SSRIs OCD:SSRIsandclomipramine ADJUSTMENTDISORDER:Benzodiazepines SOCIALPHOBIA:SSRI+buspirone Psychotherapyteachingpatienttorecognizetheirworryingandfindinga waytomanagethroughthoughtpatternsandbehavior CangiveSSRIs,buspirone,andbenzodiazepines blockerstoblockexcessivesympatheticactivation

PersonalityDisorders
SomegeneralcharacteristicsofPersonalityDisorders: CLUSTERADISORDERSParanoid,Schizoid,Schizotypal(Eccentric/Weird) CLUSTERBDISORDERSBorderline,Antisocial,Histrionic,Narcissistic (Dramatic/Aggressive) CLUSTERCDISORDERSNarcissistic,Avoidant,Dependent,Obsessive Compulsive(Shy/Nervous) CLUSTERADISORDERS Paranoid: Thesepeoplenegativelyinterprettheintentionsofothers Oftenuseprojectionastheirmainegodefense Theycausefunctionalimpairments Behavioroftencausessignificantdisruptiontoothers(coworkers, classmates,familymembers,etc) Patientsusuallyseenoproblemwiththeirbehaviors

Schizoid: Thesepeoplearesociallywithdrawnandintroverted Avoidformingcloseemotionalconnectionswithothers

Schizotypal: Thesepeoplebelieveinthingsnotnormallyacceptedbysociety,suchas magic Mayhavebriefpsychoticepisodesbutarenotpsychotic Sociallyisolated Manyschizotypalpatientshaveschizophrenicrelatives

 CLUSTERBDISORDERS Antisocial: Breakthelaw,violateothersrights Oftenseductiveinnature Mustbe18yrofagefordiagnosis+musthavebeenthiswaysinceatleast15 yrold(conductdisorder)

Borderline: Exhibitselfdestructivebehaviorsuchascutting Emotionallyvolatile Splittingegodefensecommonlyused(peopleseenaseithergreator terrible) Havetheabilitytodissociatefrompastnegativeexperiences

Histrionic: CLUSTERCDISORDERS Narcissistic: Believetheyaresuperiorandareentitledtothebest Donothandlecriticismwell Attentionseekers Sexuallypromiscuousandusesphysicalappearanceforattention Verydramaticandexaggeratetheirbehaviors Useegodefensessuchasdissociationandrepression

Avoidant: Patientfeelssensitiveanddoesnothandlenegativecommentswell Scaredtotrynewthingsormakenewfriendsforfearofembarrassment

Dependent: Scaredtobeontheirownandcannotdomuchontheirown Requirehelpwithdecisionsfromsomeoneelse

ObsessiveCompulsive: Thispersonisoverlypreoccupiedwithrules,regulations,neatness,etc Theycommonlyisolatethemselves(egodefense)inordertoavoid demonstratingemotions

EgoDefenses
ActingOut:transformationofunacceptablefeelingsintoactions(ex.Tantrums) Identification:copiesthebehaviorofsomeoneelse Rationalization:awayofmakingsomethingunacceptableseemacceptable(ex. Boyfriendbreaksupwithgirlfriendandshesaysshewantedtoenditanyway) ReactionFormation:expressingoutwardlytheexactoppositeofhowyoufeel(ex. Someoneaddictedtosomethingstartsacharitytofightthatcause) Intellectualization:tryingtologicallyexplainsomethinginordertomakesenseof it Regression:resortingtoimmature/childlikebehavior Sublimation:funnelingunacceptablefeelingsintopositiveactions(ex.Funneling sexualfeelingsintoaworkoutregimen)

Somatoform&FactitiousDisorder
SomatoformDisorders
Somatizationdisorder: Mostcommonlyfemalepatientsandstartsbefore30yearsofage Frequentlyvisitsthedoctorformanyproceduresandoperations Oftenhaveahistoryofabusiveand/orfailedrelationships Somatizationand conversiondisorder areneverintentional. Ifaquestionsays patientislookingfor gainordidsomething purposely,thesetwo arenottheright answer.

Symptoms: Somaticcomplaintsinvolvingmanydifferent systems,suchas:

GInausea,vomiting,diarrhea Neurologicweakness,lossofsensationthatisnot explainedbynormalanatomy Sexualirregularmenses,etc Labfindingsdonotexplainanyofthecomplaints

Diagnosis: Mustalwaysruleoutmedicalconditions Ruleoutmaterialgains

Treatment: Importanttoformastrongbondwiththepatient Trytobringtolightthefactthattherearepsychologicalcausesforthe condition Scheduleregularappointments Performaphysicalexambutdonotorderlabtests

 Conversiondisorder: Patientexperiencesneurologicsymptomsthatcannotbeexplainedby medicalorneurologicaldisorder Patientsareoftennotoverlyconcernedabouttheimpairmentknowasla belleindifference Thereareoftenpsychologicalfactorsassociatedwithsymptoms,suchas goinglimpwhensomeoneyellsatthem

Treatment: Hypochondriasis: Thepatientfalselybelievestheyhaveaspecificdiseaseevenwhentheyare ruledoutwithnegativeworkupsand/orlabtests Formationofastrongrelationshipwiththepatient Psychotherapy

Treatment: RegularvisitstoONEprimarydoctor Avoidtests/procedures Providepsychotherapy SSRIsmaybeusefulinsomecases

FactitiousDisorders
Thesepatientshaveintentionallyfeignedtheirsymptoms Thesepatientsoftenseemanydoctorsandvisitmanydifferenthospitals Theyoftenhavemoremedicalknowledgethantheaverageperson(often healthcareworkers)

Factitiousdisorder:purposelyfakedbutnotforobviousgain Malingeringdisorder:purposelyfakedforanobviousgain,suchasmedication, insurance,etc. Verydemandingoftreatment

 Afactitiousorderbyproxy,ismadewhensignsandsymptomsarefakedby anotherperson(ex.Mothermakesupsymptomsinherchildknownas Munchhausensbyproxy)

Munchhausenssyndrome: Afactitiousdisordermainlywithphysicalsymptoms

Munchhausensbyproxy: Diagnosis: Byexclusionofarealmedicalcondition Differentiatebetweenmalingeringandfactitiousdisorders Someoneclaimsnonexistentsymptoms(MCintheirchild) Motivationisusuallytoassumetheroleofcaretaker

Treatment: Verydifficult,patientsoftenverydefensivewhenitissuggestedthattheyare faking

ChildhoodandAdolescentPsychiatry
Autism Seenin0.02%0.05%ofchildren Onsetbefore3yrofage Is35xmorecommoninboys Developsevereproblemsincommunication Havenormalhearing Significantproblemsinformingsocialrelationships Arecomfortableperformingrepetitivebehaviors Oftenperformselfdestructivebehaviors Havesubnormalintelligence(<70IQ)inapproximately2/3ofallpatients Somehaveunusualspecificabilities Prognosisisnotgood,only2%areabletoworkandliveindependently,but mostremainseverelyimpairedinadulthood

Treatment/Management: Aspergerdisorder Thisdisorderisfirstseenat35yearsofage Morecommoninboys Theyhavesignificantproblemsformingsocialrelationships Littleornodelayincognitiveorlanguagedevelopment PrognosisismuchbetterherethanitisinAsperger Behavioraltherapytoincreasesocial/communicativeskills,decrease behavioralproblems,andimprovetheirselfcare Itisoftenmorebeneficialfortheparents,becausetheyhavemuchdifficulty raisingachildwithautism.

 ChildhoodDepression Presentsdifferentlydependingontheagegroup Preschoolersmaybeaggressiveand/orhyperactive,whileadolescentsare irritableorshowantisocialbehavior Importanttonotethattheymayalsoshowthesamesymptomsthatadultsdo whenexperiencingamajordepressivedisorder

Treatment: SeparationAnxiety Childistooattachedtoparentsorotherfiguresintheirlife Childhasexcessiveworrythatthesefigureswillbeseparatedfromthem Familytherapymayberequiredbecausethisisoftenacauseofchildhood depression Useofantidepressantsisverycontroversialinchildrenandteensdueto theirriskofsuicideinthisagegroup

SignsandSymptoms: Somaticsymptomsduringtimesofseperation Troublesleeping

Treatment: OppositionalDefiantDisorder/ConductDisorder OppositionalDefiant: Patientsareargumentativeandtemperamental(moresowithpeoplecloseto them) Oftenhavenofriendsandperformpoorlyinschool Desensitization Imipraminemaybeusedinsomecases

ConductDisorder: Patientisabullytoothers Showsphysicalcrueltytoanimals Violatesanddestroysotherpeoplesproperty,steals.

 Hasnoremorsefortheiractions Familyhistoryoftenshowsnegligence,andabuseofdrugsand/oralcholol Thismayleadtoconductdisorder(butnotalways)

Treatment: Forbothoppositionaldefiantdisorderandconductdisorder,createan atmosphere/settingwithstrictrulesandconsequencesfornotobeyingthese rules

AttentionDeficitHyperactivityDisorder Characterizedbyoveractivity,alimitedattentionspan,poorselfcontrol, impulsiveness,emotionallability,highsensitivitytostimuli,sleepproblems

Diagnosis: Onsetmustbebefore7yrofage 6symptomsfrombothhyperactivityand/orinattentionsubcategories

Treatment: TourettesDisorder Characterizedbyinvoluntarytics,repetitivemovements,andvocalizations DiagnosisMUSTincludebothamotorticandavocaltickthatispresentfor 1yr ThecommonstereotypeofTourettesinvolvesuncontrollableswearing, whichisknownascoprolalia CNSstimulantsareDOC Methylphenidateinchildren>6yrofage OthertypesofCNSstimulantsalsogiven NotetheadverseeffectsofCNSstimulantscanbetheinabilitytogainweight andtheinhibitionofgrowth

Treatment: Haldolisveryeffective,butisnotusedinmildercases Psychotherapyiseffectiveindealingwiththesocialaspectsofthisdisorder, butitdoesnotimprovethetics

 AnorexiaNervosa SignsandSymptoms: Patientsarebelowtheidealweightfortheirageandheight Theyoftenhavemealtimeritualssuchascuttingtheirfoodintotinypieces and/orrearrangingitontheplate Amenorrheaoccurssecondarytotheweightloss,andisrequiredforthe diagnosisofanorexia Oftenstartduringadolescence Thereisaprofounddisturbanceinbodyimageandinapersonsselfworth

Treatment: Hospitalizationmayberequiredtorestorethepatientsweighttoasafe level,aswellascorrectanyelectrolyteimbalances Themostsevereadversereactioniscardiacdysfunction Themainstayoftreatmentispsychotherapy

Prognosisispoorifpreoccupationswithfoodandweightdonotimprove BulimiaNervosa Morecommonthananorexia Characterizedbybingeeating(withaperceivedlackofcontrol) Oftenaccompaniedbypurging(laxativeuseand/orvomiting) Oftenhaveanormalappearanceandnormalweight Oftenhavecutsonthehandsfromshovingthemdownthethroattoinduce vomiting Dentalerosionsseenduetoacidicdestructionfromconstantvomiting

Treatmentissameasthatforanorexia

 DissociativeDisorder(multiplepersonalitydisorder) Apatientpossessesdifferentpersonalitiesthatcaneachtakecontrolatany giventime Childhoodtraumaisverycommonwhenthisconditionispresent Treatmentisfocusedonthegradualintegrationofthesepersonalities

Twodifferentdisordersthatshouldbetakenintoconsideration: DissociativeAmnesia: Personforgetsplentyofpersonalinformation

DissociativeFugue: AdjustmentDisorder Astressfullifeeventleadstotheinabilitytodealemotionallyand/or behaviorally Asyndromewheresomeonetravelstoanotherplacewiththeinabilityto rememberthepastandconfusionabouttheirpresentidentity

Diagnosis: Symptomspresentwithin3monthsofthestressfuleventandmust disappearwithin6monthsofthedisappearanceofthestressor Differentiatefromabereavementdisorder Alwaysaggressivelylookatwhetherthereisadepressivedisorderand/or anxietydisorder,whichmustbetreated

ImpulseControlDisorders
IntermittentExplosiveDisorder Kleptomania Pyromania Trichotillomania Patientimpulsivelypullsouttheirhair Thisresultsinobservablehairloss Individualpurposelysetsfires Thereisnopersonalgaininpyromania,noristhereanyangerinrelationto doingthis(ifthereis,thisshiftsthediagnosistoconduct/antisocialdisorder) Anindividualwhorepeatedlystealstorelieveanxiety Persondoesnotstealbecausetheyneedtheobject Often,thepersonreturnstheobjectafterstealingit Patientshowsaggressivebehaviorthatiswayoutofproportiontothe stressor Mustnotbeassociatedwithdruguse TreatwithSSRIsANDamoodstabilizersuchasLithium Patientsareunabletoresistthedrivetoperformactionsthatmaybeharmful toothersandthemselves Thereisafeelingofanxietybeforeperformingtheimpulsiveactionanda senseofgratificationafterwards

DrugsofAbuse
Alcohol Alcoholisacommonlyabuseddrug Patientsdevelopdifferentlevelsofdependence Alcoholdependenceisthefrequentuseofalcoholthatresultsintolerance, leadingtopsychologicalandphysicaldependence. Alcoholabuseisdiagnosedwhenitsuseresultsinfailuretoperform normallyinsociety(lossofjob,socialimpairment,legalproblems)

Diagnosis: Labtestsarenotrequiredfordiagnosis TheCAGEquestionnaireisthemostaccuratediagnosis

Treatment: Themosteffectivemanagementofanalcoholicisalwaysalcoholics anonymous

Management: Foroutpatientmanagement,thefirstthingistopreventfurtherintakeof alcohol Ifpatientisintoxicatedpreventthemfromoperatingmachinery(driving) Ifpatientisagitatedsedate Admittohospitalifpatientrequiresfurtherhelp

 Thefollowingtablepresentsthemostcommonlyabuseddrugs Si/Sxof intoxication Alcohol Lackof inhibition Talkative Amphetamines/ Agitation Cocaine Mydriasis, Euphoria, Hyperactivity, Stroke/MI Marijuana Impaired motorco ordination, Hyperphagia, Drymouth, Conjunctival redness Hallucinogens Ideasof reference, Hallucination, Dissociative symptoms Inhalants Belligerence, Violent, Impaired judgement, Blurred vision, Stupor,coma. Heroine Dysphoria, (opiates) Miosis, Drowsiness, Slurred speech Phencyclidine Violent, (PCP) Panic, Agitation, Nystagmus. Barbiturates Impaired SUBSTANCE Treatmentof intoxication Ifseveregive mechanical ventilation ST antipsychotics Si/Sxof withdrawal Tremor Seizures Delirium Anxiety Tremor Hyperphagia Depression Suiciderisk None Treatmentof withdrawal Longacting benzodiazepines . Antidepressants

None

None

Talkingdown, None Antipsychotic, Benzos Ifdeliriousor None agitatedgive antipsychotics

None

None

Naloxone

Fever,chills, Abdcramps, Insomnia, Lacrimation None

Clonidine, Methadone

Talkdown, Benzos, Antipsychotic s Respiratory support Flumazenil

None

Autonomic

Longacting

 and/or Benzodiazepine s memoryor concentration , Lackof inhibition hyperactivity , Tremor, Insomnia, Seizure, Anxiety. barbituratesas substitution

Paraphilias
Involverecurrent,sexuallyarousingpreoccupationsthatarefocusedon humiliationand/orsufferingandtheuseofnonlivingobjectsand nonconsentingpartners. Occursfor>6months Causessocialimpairment Treatmentforallispsychotherapyandaversiveconditioning SeverecasesmayrequireantiandrogensorSSRIstoreducepatientssex drive

Types:

Frotteurism:Touchingorrubbingagainstanonconsentingpartner Exhibitionism:Recurrenturgetoexposethemselvestostrangers Pedophilia:Urgesorarousaltowardprepubescentchildren(isthemostcommon paraphilia) Voyeurism:Urgestoobserveanunsuspectingpersonwhoishavingsexortaking offtheirclothes Fetishism:Theuseofnonlivingobjectsassociatedwiththehumanbody(shoesare common) Masochism:Recurrenturgeorbehaviorinvolvingbeinghumiliated Sadism:Causingsufferingtoavictimisexcitingtothepatient

Sleep
NormalSleep Therearetwotypesofsleep: 1. NonREM(NREM),whichhasfourstages 2. REMrapideyemovement Thestagesofnormalsleep Stages NONREM Stage1 Stage2 Stage3,4 REM Characteristics Thisstageconsistsofearly,slowwavesleep Consistsofwavesandwaves Sleepspindlesarepresent wavesarepresentduringthesestages Dreamingoccurshere(thisstageisaffectedbyelicitdrugsand ETOH)

SleepDisorders
Insomnia Patientisunabletofallasleeporstayasleep Recurrentovermorethana1monthperiod Maybeassociatedwithperiodsofstress,anxiety,ordruguse

Treatment: Asleepscheduleisimportanttoregularinternalsleeppatterns Exercise Antihistamines 2weekperiodofbenzodiazepines(carefultoavoiddependence)

 Hypersomnia Narcolepsy: PatientexperiencesacuteattacksofREMsleep Theysuddenlycollapsewithacompletelossofmuscletone(cataplexy)

Treatment: SleepApnea: Apneicperiodsthatoccurduringsleep Mostcommonlyisobstructive(commonlyduetoexcessweight) CNSstimulants

Treatment: PickwickianSyndrome(CentralAlveolarHypoventilation) Asyndromewithsomnolence,obesity,anderythrocytosis Patientgraduallydevelopshypercapnea,hypoxemia,anderythrocytosis Thisiscausedbytheweightofexcessadiposetissuepressingonthelungs Weightloss Continuouspositiveairwaypressure(CPAP) Ifpatientdoesntgetrelieffromthesethenshouldundergosurgerysince sleepapneaisalifethreateningcondition

Treatment: Weightloss

Parasomnias
NightTerrors: ChildarisesduringNREMsleep,isnotawaretheyareawake,screamsin terror,thenfallsbackasleep. Theydonotremembertheoccurrencewhentheyawaken

 Nightmares: SleepWalking: OccursduringNREMsleep Patientgetsoutofbedandwandersabout Patienthasnorecollectionoftheevent OccurduringREMsleep Relatedtoemotionaleventssuchastragedy,scarymovie,etc Patientremembersthedream

Chapter 7
Cardiovascular

 PleuriticChestPain PE Pneumonia Pleuritis Pericarditis Pneumothorax PositionalChestPain Pericarditis TenderChestPain Costochondritis

IschemicHeartDisease(CAD)
MajorRiskFactors: Diabetes Smoking Hypertension(HTN) Hypercholesterolemia Familyhistory Age

MinorRiskFactors: Obesity Lackofestrogen(thisiswhyitoccursinmenmorethanwomen)

The#1preventableRFissmoking StableAngina Chestpainthatoccurswithactivity Causedbyatherosclerosis,wherebythesupplyof02requiredbytheheartis notmet

SignsandSymptoms: Chestpainthatmayradiatetotheleftarm,jaw,andback. Relievedbyrestandnitroglycerin EKGwillshowSTsegmentdepressionandTwaveinversion

Diagnosis: Madebyclinicalpresentationandbasedonsymptoms

 TreatmentofAngina Acute ChronicPrevention Sublingualnitroglycerin(actsin 12min) Maytakenitroupto3times every35minutes Lackofreliefmayindicate infarctioninprogress Longactingnitratesfor prophylaxis blockersmyocardial02 consumptionwhenstressed AspirintopreventPLT aggregationinatherosclerotic plaque Smokingcessation LDLHDLthroughdiet Percutaneoustransluminal coronaryangioplasty Indicatedwhentheresafailurein medicalmanagement Stentplacementcanreducere stenosisby20%30% GPIIbIIIaantagonistsfurther reducestenosisrate Coronaryarterybypassgraft Indicatedwhenmedical treatmentfails

EndovascularIntervention Surgery UnstableAngina

Symptomsaresimilartoanginabutoccurmorefrequentlyandwithoutany relationtoexertion/activity,occurringatrest Unstableangina=ischemia UnstableanginaandnonSTelevationMIareacloselyrelated EKGduringischemiausuallyshowsSTsegmentdepressionorTwave inversion LABSare(+)forcardiacenzymes

 Treatment: Basedonthelikelihoodthatitwillprogresstoapotentiallyfataloutcome(ie. Riskofrecurrentunstableangina,infarction,ordeath30daysafter presentation).

PrinzmetalsAngina STElevationMyocardialInfarction(STEMI) SignsandSymptoms: Diagnosis: EKGwillshowSTelevationandQwaves Crushingsubsternalpainthatisnotrelievedbyrest Diaphoresis Nausea/vomiting Tachycardiaorbradycardia Dyspnea Infarctionusuallysecondarytoacutethrombosisinanatheroscleroticvessel Iscausedbyacoronaryarteryvasospasm EKGshowsSTsegmentelevation STelevationistransientandcardiacenzymesareusuallynegative,which helpsdifferentiatefromanMI Treatmentisvasodilators(nitroglycerinorCCBs) Patientshouldundergocatheterizationbecausevasospasmoftenoccursat thesiteofanatheroscleroticlesioninthecoronaryarteries.

Cardiacenzymeselevated(CKMB,troponinI)CKMBnormalizeswithin 72hr

 Treatment: PostMIDischargeInstructions: ASA blocker Statin ACEI Reestablishvesselpatency #1priorityaspirin(proventomortality) #2priorityblocker(proventomortality) Statinstolowercholesterol(goalistogetLDL<100postinfarct) 02+morphine(paincontrol) Nitrotoreducepreloadandafterload ACEIsareexcellentlateandlongtermtherapy(afterloadandprevent remodeling) Consultaboutsmokingcessation

EKGfindingsandArrhythmias
HeartBlocks: FirstdegreeAVblocknormalsinusrhythmwithPRinterval0.2ms Seconddegree,type1(Weckenbach)blockPRintervalelongatesfrombeatto beatuntilaPRisdropped Seconddegree,type2(Mobitz)blockPRintervalfixedbutthereareregular nonconductedPwavesleadingtodroppedbeats ThirddegreeblocknorelationshipbetweenPwavesandQRScomplexes. Presentswithjunctionalescaperhythmsorventricularescaperhythm

AtrialFibrillation Themostcommonchronicarrhythmia Fromischemia,atrialdilatation,surgicalhistory,pulmonarydiseases,toxic syndromes Classically,thepulseisirregularlyirregular

SignsandSymptoms: Chestdiscomfort

 Palpitations Tachycardia, Hypotension+syncope

Treatment: Controlratewithblockers,CCBs,anddigoxin(notacutely) Iffibrillationslast>24hrthenshouldanticoagulatewithwarfarinforatleast 3weeksbeforecardioversion(preventsembolisms) Ifyoucannotconverttonormalsinusrhythm,thepatientwillrequirelong termanticoagulation.1stlineiswarfarin,2ndlineisaspirin

Cardioversiontoconverttonormalrhythm: 1stlineIVprocainamide,sotalol,amiodarone Electricalshockof100200Jfollowedby360J AtrialFlutter LessstablethanAfib Therateisslowerthanthatofatrialfibrillation(approximately250 350bpm) Ventricularrateinatrialflutterisatriskofgoingtoofast,thusatrialflutteris consideredtobemoredangerous(medicallyslowingthisratecancausea paradoxicalincreaseinventricularrates) Classicrhythmisanatrialflutterrateof300bpmwitha2:1blockresultingin aventricularrateof150bpm Signsandsymptomssimilartothoseofatrialfibrillation Complicationsincludesyncope,embolization,ischemia,heartfailure

ClassicEKGfindingisasawtoothpattern:

Treatment: Ifpatientisstable,slowtheventricularratewithCCBsorblockers(avoid procainamidebecauseitcanresultinincreasedventricularrateastheatrial rateslowsdown) Ifcardioversionisgoingtotakeplacebesuretoanticoagulatefor3weeks Ifpatientisunstablemustcardiovertstartatonly50Jbecauseiseasierto converttonormalsinusrhythmthanatrialfibrillation

 MultifocalAtrialTachycardia(MFAT) Anirregularlyirregularrhythmwheretherearemultipleconcurrent pacemakersintheatria. CommonlyfoundinptswithCOPD

EKGshowstachycardiawith3distinctPwaves

Treatment: SupraventricularTachycardia Manytachyarrhythmiasoriginatingabovetheventricle PacemakermaybeinatriumorAVjunction,havingmultiplepacemakers activeatanyonetime Differentiatingfromventriculararrhythmiamaybedifficultifthereisalso thepresenceofabundlebranchblock Verapamil Treatanyunderlyingcondition

Treatment: Verydependentonetiology Mayneedtocorrectelectrolyteimbalance Mayneedtocorrectventricularrate[digoxin,CCB,blockers,adenosine (breaks90%ofSVT)] Ifunstablerequirescardioversion CarotidmassageifpatienthasparoxysmalSVT

 VentricularTachycardia VTachisdefinedas3consecutiveprematureventricularcontractions Ifsustained,thetachycardicperiodslastaminimumof30s. Sustainedtachycardiarequiresimmediatecardioversionduetoriskofgoing intoventricularfibrillation

Treatment: VentricularFibrillation Erraticventricularrhythmisafatalcondition. Hasnorhymeorrhythm Ifhypotensiveornopulseexistentdoemergencydefibrillation(200,then 300,then360J) Ifpatientisasymptomaticandnothypotensive,thefirstlinetreatmentis amiodaroneorlidocainebecauseitcanconvertrhythmbacktonormal

SignsandSymptoms: Syncope Severehypotension Suddendeath

 Treatment: 1stlineEmergentcardioversionistheprimarytherapy(200300360J), whichconvertstonormalrhythmalmost95%ofthetime Chestcompressionsrarelywork 2ndlineAmiodaroneorlidocaine Iftreatmentisntgiveninatimelymatter,patientexperiencesfailureof cardiacoutputandthisprogressestodeath.

CongestiveHeartFailure
Definition: CHFoccurswhenthecardiacoutputisinsufficienttometsystemicdemands Mayberightsided,leftsided,orboth Causes: Valvulardiseases MI Hypertension PE Anemia Cardiomyopathy Edocarditis Thyrotoxicosis SignsandSymptoms: Leftsided:signsandsymptomsareduetoCOandcardiacpressures Paroxysmalnocturnaldyspnea Exertionaldyspnea Orthopnea Cardiomegaly S3gallop Renalhypoperfusion(leadstosodiumretentionandworsenedCHF) Rightsided:signsandsymptomsareduetopoolingupstreamoftherightheart JVP Edema Hepaticcongestion Atrialfibrillation(increasesriskofembolization) Fatigue Cyanosis Weightloss Diagnosewithechocardiogram Treatment: 1stlineregimenACEI,blockers,furosemideandspironolactone,anddigoxin IfpatientcannottolerateACEI,tryhydralazine+isosorbidedinitrate

 ACEIshavebeenproventodecreasemortalityinCHF

blockershavebeentodecreasemortality
Dontstartblockersduringactivefailurebecausetheycanexacerbatethe condition Startblockersoncepatientisfullydiuresedandisonstabledosesofother medications SpironolactoneproventodecreasemortalityinclassIVCHF LoopsalmostalwaysusedtomaintaindryweightinCHFpatients DigoxinimprovessymptomsbutDOESNTdecreasemortality BewaryofgivingLoopdiureticwithoutspironolactonebecausethiscancause anunsafehypokalemiathatpotentiatestheeffectofdigoxin(1stsignofdigoxin toxicityisaSVTwithAVblockandblurryyellowvision)

Cardiomyopathies
Cause Dilated Hypertrophic Ischmia,infections, Geneticmyosin metabolic disorder conditions,drugs Restrictive Amyloidosis, scleroderma, hemochromotosis, glycogenstorage disease, sarcoidosis PulmonaryHTN, S4gallop,QRS dysfunction 30%5yrsurvival Diureticsand correctionof underlyingcause

Signs& Symptoms

Rightandleftsided heartfailure,S3 gallop,systolic dysfunction Prognosis 30%5yrsurvival rate Treatment Stopoffending agents,txissimilar toCHFtreatment Diagnosisforeachisechocardiography

Exertional syncope,angina, LVH,diastolic dysfunction 5%annual mortalityrate blockersand diuretics

ValvularDiseases
Presentation: Valvularheartdiseasesallpresentwithshortnessofbreathasthechief complaint Oftenworsenswithexertion/exercise CluetoDiagnosis Youngfemaleand/orgeneral population Healthyyoungathlete Immigrant,pregnant Turnerssyndrome Palpitations,atypicalchestpainnot associatedwithexertion PhysicalFindings: Murmurandrales(seeninallcases) Peripheraledema,gallops,carotidpulsefindings(possiblyseen) Murmurs: Systolic: Mostcommonlyseeninaorticstenosis,mitralregurgitation,MVP,andHOCM Diastolic: Mostcommonlyseenwithaorticregurgitationandmitralstenosis. AllrightsidedmurmursINCREASEinintensitywithinhalation AllleftsidedmurmursDECREASEinintensitywithexhalation Diagnosis MiltralValveProlapse(MVP) IdiopathicHypertrophicSubaortic Stenosis(nowcalled:Hypertrophic obstructivecardiomyopathyHOMC) MitralStenosis Bicuspidaorticvalve MitralValveProlapse

 LocationandRadiationofmurmurs: ValvularLesion AorticStenosis Pulmonicvalve Aorticregurgitation/tricuspid/VSD Mitralregurgitation Murmurintensity: I/VIonlyheardwithspecialmaneuvers(valsalva) II/VIandIII/VImajorityofmurmurs IV/VIthrillpresent V/VIcanbeheardwithstethoscopepartiallyoffofthechest VI/VIcanbeheardwithoutastethoscope Diagnosis: Bestinitialdiagnostictestforvalvularlesionsis echocardiogram Themostaccuratetestisleftheartcatheterization Treatment: Regurgitantlesionsbesttreatedwithvasodilatortherapy (ACEI,ARB) Stenoticlesionsbesttreatedwithanatomicrepair(mitral stenosisrequiresballoonvalvuloplasty,severeaorticstenosis requiressurgicalreplacement) AorticStenosis Mostcommonlypresentswithchestpain SyncopeandCHFarelesscommonlypresentwithaorticstenosis Patientisoftenolderandhasahistoryofhypertension Prognosis: Ifcoronarydiseaseispresentthen35yrisavgsurvival Ifsyncopeispresentthen23yravgsurvival IfCHFpresentthen1.52yravgsurvival
Atricktoknow whattypeof therapyyoushould use: Ifthevalsalva maneuver improvesthe murmur,use diuretics. Ifamylnitrate improvesthe murmur,ACEIis indicated.

Bestheardat 2ndrightintercostalspaceandradiates tothecarotids 2ndleftintercostalspace Leftlowersternalborder Apex(left5thintercostalspace)

 Diagnosis: TTEisthebestinitialdiagnosis TEEismoreaccurate Leftheartcatheterizationisthemostaccurate EKGandCXRwillshowLVH Treatment: Diureticsarethebestinitialtherapybutdonotalterthelongterm prognosis,andspecialattentionmustbepaidsinceoverdiuresisisapossibility Treatmentofchoiceisvalvereplacement AorticRegurgitation HTN Rheumaticheartdisease Endocarditis SignsandSymptoms: Diastolicdecrescendomurmurheartbestattheleftsternalborder Diagnosis: TTEisbestinitialdiagnostictest TEEismoreaccurate Leftheartcatheterizationismostaccurate Treatment: ACEIs ARBs Nifedipine Ifejectionfractiondropsbelow55%ortheLVenddiastolicdiametergoes above55mm,surgeryshouldbedoneevenifthepatientisasymptomatic.

 MitralStenosis: MCCofmitralstenosisisrheumaticfever Seeninimmigrantsandpregnantpatients(increasedplasmavolin pregnancy) SignsandSymptoms: Dysphagia(largeleftatriumcompressesesophagus) Hoarseness(pressureonrecurrentlaryngealnerve) Atrialfibrillation PhysicalExam: Diastolicrumbleafteranopeningsnap Diagnosis: TTEisbestinitialdiagnostictest TEEismoreaccurate Leftheartcathismostaccurate EKGand/orCXRshowingleftatrialhypertrophy Treatment: Bestinitialtherapyisdiuretics,howevertheydonotalterprogressionof thedisease Balloonvalvuloplastyisthemosteffectivetherapy(allpregnantwomen musthavethisproceduredone) MitralRegurgitation CausedbyHTN,ischemicheartdisease,andanyconditionthatmayleadto dilationoftheheart Themostcommoncomplainisdyspneaonexertion Physicalexamfindings: HolosystolicmurmurthatobscuresbothS1andS2 Bestheardattheapex,radiatestotheaxilla Diagnosis: TTEisbestinitialtest TEEismoreaccurate

 Treatment: ACEI ARBs Nifedipine IfLVejectionfractiondropsbelow60%orLVendsystolicdiameteris above45mm,thensurgeryshouldbedone

PericardialDisease
Pericarditis Pleuriticchestpain Relievedbyleaningforward Painoftendescribedassharpandbrief SignsandSymptoms: Frictionrubiscommonlyfound Nootherpertinentphysicalfindings Diagnosis: BestinitialtestistheEKG DiffuseSTsegmentelevation PRsegmentdepressionispathognomonicbutisnotalwayspresent Treatment: BestinitialtherapyisNSAIDs Patientshouldreturnin12days,ifthepainisgonetheyarecured Ifpainpersistsafter2daysofNSAIDtreatment,prednisoneorallyis treatment

 PericardialTamponade PresentswithSOB,hypotension,JVD+clearlungs Pulsusparadoxusispresent(decreasedBP>10mmHgoninspiration) Electricalalternansispresent(alterationofQRScomplexonEKG Diagnosis: Echoisthemostaccuratediagnostictest Earliestfindingisusuallycollapseoftherightatriumandventricle EKGshowslowvoltageandelectricalalternans Rightheartcatheterizationwillshowequalizationofallpressuresinthe heartduringdiastole Treatment: Bestinitialtherapyisapericardiocentesis Mosteffectivelongtermtherapyispericardialwindowplacement ConstrictivePericarditis PresentswithSOB Edema JVD Ascites Hepatosplenomegaly Uniquefeaturesofconstrictivepericarditis: Apericardialknock,whichisanextradiastolicsoundfromthehearthitting thecalcifiedpericardium Diagnosis: CXRshowingcalcification LowvoltageEKG ThickenedpericardiumonCT Treatment: Diureticsarethebestinitialtherapy Pericardialstrippingisthemosteffectivetherapy

Chapter 8 Endocrine

PituitaryDisorders
Prolactinoma SignsandSymptoms: Men: Impotence Decreasedlibido Gynecomastia Mostoftenmenalsopresentwithheadacheandvisualdisturbacnes Prolactinsecretingtumor Alwaysthinkofthiswhenthereisvisualdisturbances

Women: Amenorrhea Galactorrhea Bothintheabsenceofpregnancy

Diagnosis: Ruleoutpregnancy Ruleoutdrugssuchas:Metoclopromide,Phenothiazines,and/orTCA MRItoconfirmpresenceoftumor

Treatment: 1stlinetreatmentisadopamineagonistsuchasbromocriptine(most prolactinomasrespondtoDAagonists) Ifmedicaltherapydoesntwork,surgicalremovalisdone

 Acromegaly SignsandSymptoms: Enlargementofthehead,hands,feet,nose,andjaw Maybeenlargementofthesweatthatcancauseintensesweating Jointabnormalities(excessgrowthofarticularcartilage) Amenorrhea Cardiomegalyandhypertension Colonicpolyps DiabetesalsocommonbecauseinsulinisantagonizedbyGH ExcessproductionofGHduetoaGHproducingadenomainthepituitary

Diagnosis: BestinitialtestisIGF(confirmsdiagnosisofacromegaly) Mostaccuratetestisadministrationofglucose(normallyshouldsuppress GH,ifitsuppressesGHthenthisexcludesacromegaly) MRIdoneafterthereisareasonfordoingso

Treatment: Transphenoidalremoval DAagonisttoinhibitGHrelease OctreotidehassomemeritinpreventingGHrelease PegvisomantaGHreceptorantagonist

Diabetes
Type1DM SignsandSymptoms: Polyuria,polyphagia,polydipsia Weightloss DKAemergency Autoimmunedestructionofpancreaticcells,leadstoinsulindeficiency

Diagnosis: Randomplasmaglucose>200withsymptomsOR Twomeasurementoffastingglucose>125 2hroralglucosetoleranttest>200withorwithoutsymptoms

Treatment: Insulinreplacement

Complications: DKA

SignsandSymptomsofDKA: Hyperglycemia>250 Hyperkalemia(duetotranscellularshiftoutofthecellinexchangeforH+) LowpH Elevatedlevelsofacetone,acetoacetate,andhydroxybutyricacid Increasedaniongap

DKAtreatment: 1stIVfluids 2ndpotassiumreplacement(hyperbecomeshypoasDKAistreated),insulin replacement 3rdadditionofglucosetoinsulindripwhenptbecomesnormoglycemic(keep givinginsulinuntilketonesaregone) **insulinisgivenoriginallytoshutdownketogenesis,notdecreaseglucose,thus keepgivinginsulinuntilketonesaregonedespitenormalglucose.

 Type2DM SignsandSymptoms: Acute3Ps(polydypsia,polyphagia,polyuria),fatigue,weightloss Subactueinfections(yeastinfections,Mucor,S.Aureus) Aperipheralinsulinresistance Usuallyadultonset(changingwiththeobesityepidemic) Familyhistoryoftenplaysastrongrole KetosisisNOTassociatedwithDM2

Chronicsignsandsymptoms: Diagnosis:sameastype1 Treatment: MonitoringDMwithHbA1c: HbA1callowsustogetameasureoftheaverageglucoseleveloverthepast3 months Tightglucosecontrolisdirectlyresponsiblefordecreasingcomplicationsand mortalityinbothtypesofinsulin AnHbA1c<7or8isrecommended(this#isalwaysdecreasing) FIRSTtreatmentisalwaysdietandlifestylemodifications Oralhypoglycemicsformild/moderatedisease 1stlinemetformin(biguanide),itsMOAisblockinggluconeogenesis 2ndlinesulfonylurea(glyburide),MOAiscellinsulinsecretion 3rdlineThiazolidinediones(pioglitazone),MOAisincreasingtissue sensitivitytoinsulin Iforaldrugsdontwork,patientmayrequireinsulin Lifelongcasesmostusuallywillrequireinsulintreatment ACEIsimportantbecausetheyslowdowntheprogressionofdiabetic nephropathy Macrovascularstroke,CAD Microvascularretinitis,nephritis Neuropathyparasthesia,stockingandgloveburningsensation,autonomic insufficiency,sensation

 ComplicationsofDM2: HyperosmolarHyperglyicemicNonketoticComa(HHNK): TreatingHHNK: ComplicationsofDiabetes HypertensionControlisessentialinDMpatientsbecauseitcauseslongterm complicationsoftheheart,eye,kidney,andbrain.Goalistokeepit<130/90 LipidManagementGoalsare:LDL<100,ifpatienthasCAD+DM,thegoalis<70. RetinopathyDiabeticsrequireayearlyeyeexamtodetectproliferative retinopathies.Ifpresent,lasercoagulationshouldbeperformed. NephropathyIfanyformofproteinispresentintheurinegivetheDMptACEIs. ThesepreventnephropathiesandACEIsare1stlinedrugsinDMwithHTN NeuropathyYearlyfootexamsareimportant.Ifneuropathyispresentthereis noneedtodelaytreatmentwithgabapentinorpregabalin. ErectileDysfunctionAskpatientaboutthis,sildenafilortadalafilworkwellbut donotgiveiftheyarealsoonnitrates GastroparesisMorecommoninlongtermdiabetics,thereisimpairedstretch receptorsandthusimpairedmotility.Patientwillhavebloating,constipation, fullness,anddiarrhea.Givemetoclopramideorerythromycin(increasegastric motility) Diabetes Onset Type1 Juvenile/childhood Type2 Adult(increasingly commoninyouthtoday) IVfluidsaremostimportant,rehydrationisoftenallthatisneeded. Mayrequireupwardsof10Loffluids Withouttreatment,mortalityrateclimbsover50% Oftenprecipitatedbystress,secondarytohypovolemia Glucosecanbecome>1000mg/dL Thereisnoacidosis(asintype1DM)

 BodyType DKA? Treatment Thin Frequent Insulin Obese Rare 1stlifestyle2ndoral hypoglyclemicagents

AdrenalDisorders
CushingsSyndrome Thereare3sourcesofCushingsdisease,theyarelistedinthistablealongwith pertinentinformation ACTH Highdose dexamethasone Specifictest Treatment PituitaryTumor High Suppression MRI,petrosalvein sampling Removal EctopicACTH Production High Nosuppression Scanthechestand abdomen Removal AdrenalAdenoma Low Nosuppression Scantheadrenals Removal

Thereisacommonpresentationofallpatientswith

hypercortisolism: Diagnosis:

Fatredistribution:Truncalobesity,buffalohump,thinarms/legs,moon facies Striaeandeasybruising:Duetoalossofcollagen(cortisolthinstheskin) HTN:Duetofluidandsodiumretention Hirsuitism:fromincreasedadrenalandrogenlevels Musclewasting

1. 1mgovernightdexamethasonesuppressiontest:normallyapersonwill suppressthe8amlevelofcortisolifgivendexaat11pmthepreviousnight.A normaltest(suppression)willruleouthypercortisolismofallkinds.**atest maybeelevatedduetootherfactorssuchasdepression,alcoholism,or excessivestress

 2. 24hrurinecortisol:thistestaddsspecificitytotheovernight dexamethasonetest,iftheovernighttestwasabnormal(failingtosuppress ACTH),thenthistestconfirmshypercortisolism. **thesetestsaretodiagnosethepresenceofCushingssyndrome,thelocationis stillunknownatthispoint. Diagnosingthelocation: Treatment: AddisonsDisease(adrenalinsufficiency) Canbeprimary(Addisons)orsecondary(ACTHproductionfrompituitary) Addisonsdisease: MCisautoimmunedisorder WaterhouseFriderichsenmaybecause,whichishemorrhagicnecrosisofthe adrenalmedulladuringthecourseofmeningococcemia Removalofwhateveriscausingtheproblem,identifiedbyMRIorabdominal scan(dependingonthelocationoftheproblem) LookingattheACTHcanhelpidentifythelocation IfACTHishighsourceofproblemisthepituitaryorectopicACTH production IfACTHislowsourceistheadrenal

SignsandSymptoms: Fatigue Anorexia Hyponatremia+hyperkalemia Hypotension Nausea/vomiting Constipation Hyperpigmentation(onlyinprimarycase)

 Diagnosis: ACTHandcortisol(inresponsetoACTH) Hyperpigmentation Ifcauseissecondary,thencortisolwillinresponsetoACTH

Treatment: AdrenalCorticalHyperfunction 1 Hyperaldosteronism(ConnsSyndrome): Mostcommonlyduetoanadenomaorhyperplasiaofthezonaglomerulosa oftheadrenalgland ForacuteAddisonsgivefluids+hydrocortisone Forstablepatientgiveprednisone Ifpatientsdonotrespondtoabovetreatments,givefludrocortisone(highest #ofmineralocorticoids)

SignsandSymptoms: Hypertension Na+ Cl K+ renin

Diagnosis: aldosterone renin CTshowingadrenallesion

Treatment: Ifadenomasurgicalresection Ifhyperplasiaspironolactone

 2 Hyperaldosteronism: Increasedreninproduction2todecreasedrenalbloodflow(CHF,shock, renalarterystenosis) Diagnosis: renin(thisisusedtodifferentiatebetween1 and2 causes Treatment: Treatunderlyingcause TreatHTN Pheocromocytoma Patientpresentswith: EpisodicHTN Headache Palpitations Tachycardia Diaphoresis

Diagnosis: Bestinitialtestshighplasmaandurinarycatecholamine/plasmafree metanephrineandVMAlevels MostaccuratetestsCTorMRIofadrenalglands

Treatment: 1stphenoxybenzaminetocontrolBP 2ndpropranolol(onlyafterblockadewithphenoxybenzamine) 3rdsurgicalresection

 MaleGonadalDisorders Disease
Klinfelters Syndrome 5reductase deficiency PraderWilli syndrome

Characteristics
XXYinheritancewithvariableexpressivity Diagnosisusuallyatpubertywhennovirilization Tallwithsmalltestesandgynocomastia Decreasedtestosterone LH/FSH(nofeedback) Dxwithbuccalsmearshowingbarrbody Mildmentalretardation,acne,violent,antisocial behavior Diagnosewithkaryotypeanalysis DefectinDHTreceptor Femaleexternalgenitaliawithsterile,undescended testes Patientappearsfemalebutissterilewithblind vagina Testosterone/estrogen/LHareallelevated Ambiguousgenitaliauntilpuberty Atpubertyaburstoftestosteroneovercomesthelack ofDHT(masculinizingexternalgenitalia) Testosteroneandestrogenarenormal Diagnosisisbygenetictesting Adefectinthesteroidsynthesispathwaycauses virilizationoffemalesorfailuretovirilizeinmales 21hydroxylasedeficiencycauses95%ofallCAH cases severediseasepresentsininfancywithambiguous genitaliaandexcesssaltloss lesssevereminimalvirilizationandsaltloss paternalimprinting shortlimbs,floppybaby hyperphagia(obesityincreasesearlydeath likelihood) mentalretardation classicallyhavealmondshapedeyeswithstrabismus diagnosisisgeneticanalysis ADhypogonadismwithanosmia DecreasedproductionandsecretionofGnRHby hypothalamus DiagnosismadebyfindingdecreasedcirculatingLH andFSH

Treatment Testosterone Supplements

XXYsyndrome Testicular feminization syndrome

None Notx Remove testes Testosterone

Congenital adrenal hyperplasia

Hormone replacement

None

Kallmanns syndrome

Pulsatile GnRH

ThyroidDisorders
Theclinicaldifferencesbetweenhyperthyroidismandhypothyroidism Weight Intolerance Hair Skin Mental Heart Muscle Reflexes Fatigue MenstrualChanges Hypothyroidism Diagnosis: TSH T4 MostcommonlyfromburnoutHashimotosthryoiditis. Patientisfatigued Povertyofmovement Gainingweight HYPOTHYROIDISM Gain Cold Course Dry Depressed Bradycardia Weak Diminished Yes Yes HYPERTHYROIDISM Loss Heat Fine Moist Anxious Tachycardia Weak Yes Yes

Treatment: Hyperthyroidism T4levels TSH 4formsofhyperthyroidism:Graves(MC),Silent,Subacute,Pituitaryadenoma Thyroxine T4(convertedinthetissuetoT3asneeded)

 GravesDisease: Hasmanyfindingsthatareuniquetothistypeofhyperthyroidism: Exophthalmosandproptosis Dermopathy(rednessandthickenedskinbelowtheknee) Onycolysis(seperationofthenailfromthenailbed) RAIUiselevated

Treatment: SilentThyroiditis: Anautoimmuneprocesswithanontenderglandandhyperthyroidism Noeye,nail,orskinfinding RAIUtestisnormal Glandisnotinastateofhyperfunctioning,ratheritisleaking Antibodiestothyroidperoxidaseandantithyroglobulinantibodiesmaybe present PTUormethimazoleisgivenacutelytobringtheglandundercontrol Afterglandiscontrolled,useradioactiveiodineablation Propranololusedtotreatsympatheticsymptoms

Treatment:Thereisnotreatment SubacuteThyroiditis: Aconditionofviraletiology Glandistender

Diagnosis: TSHlow T4increased RAIUlow

Treatment: Aspirintorelievethepain

 PituitaryAdenoma: Rarecondition IstheonlyhyperthyroiddisorderwithanelevatedTSH

Diagnosis: MRIofbrain

Treatment: ExogenousThyroidHormonesAbuse: ThyroidStorm: Thisisanemergencysituationwherethereisseverereleaseofthyroid hormonesfromthethyroidgland Causessymptomsofextremesympatheticstimulation(tremor,tachycardia, diaphoresis,etc) WillbeanelevationinT4(duetotakingthyroidhormone) TheTSHwillbesuppressedduetonegativefeedback Thyroidglandwillatrophy Removalofadenoma

Treatment: 1stgiveiodinetoblocktheuptakeofiodineintothegland 2ndgivePTUormethimazoletoblockthyroxineproduction 3rddexamethasonetoblocktheperipheralconverionofT4T3 4thblocksympatheticeffectswithpropranolol MyxedemaComa: Anemergencyhypothyroidcondition Maybespontaneousorpptebycoldconditions,infections,sedativedrugs, respiratoryfailure

SignsandSymptoms: Hypoventilation Hypotension

 Stupor Coma Seizures

Treatment: ThyroidMalignancies AllsolitarydominantnodulesshouldbediagnosedbyFNA Excisionifmalignancyissuspected Hotnodules(anodulethattakesupmoreradioactiveiodine)arelesslikely tobemalignant Coldnodules(nodulesthattakeuplessradioactiveiodine)aremorelikelyto bemalignant Levothyroxine Cortisone Intubate

Papillarycancer: Mostcommontypeofthyroid Bestprognosis(85%5yrsurvivalrate) Psammomabodies&orphananniebodies/groundglassnuclei

Follicularcancer: Goodprognosis Commonmetastasistoboneandlungs

Medullarycancer: Prognosisisintermediate IsacanceroftheparafollicularCcellsthatarederivedfromcellsofthe5th branchialpouch Secretescalcitonin

Anaplasticcancer: Terribleprognosis Hasa0%5yrsurvivalrate

 MultipleEndocrineNeoplasia: Type1(Wermers) Type2(Sipples) Type2b(Type3) 3Ps:Pituitary,Pancreas,Parathyroid Pheocromocytoma,MedullaryThyroid CA,Parathyroid Pheocromocytoma,MedullaryThyroid CA,Mucocutaneousneuromas(espinGI)

Chapter 9 Infectious Disease

 Answeringquestionsintheinfectiousdiseasesectionareusuallyprettystraight forward.Beingabletocorrectlyanswerthesequestionscomesdownto understandingthefollowing: 1. 2. 3. 4. Forgreatestchancesofsuccesswiththesequestions,thefollowingtablesshouldbe memorized. GramStainCharacteristics ORGANISMCHARACTERISTICS Gram(+)organisms Gram()organisms Gram(+)cocci(pairs) Gram(+)cocci(chains) Gram(+)cocci(clusters) Gram()diplococci Gram()rods Gram()rodswithmucoidcapsule Pseudohyphaeonstain AcidFastOrganisms SilverStaining Spirochete STAININGCHARACTERISTICS Blueincolor Redincolor S.Pneumonia Streptococcus Staphylococcus Neisseria Hemophilus Klebsiella Candida Mycobacterium,Nocardia PneumocystisCarinii Borrelia, Treponema/Leptospira(darkfield) Commonconditionsandtheirassociatedorganisms Commonconditionsandthebestantibioticstouse Organismsandtheirgramstaincharacteristics Commonscenariosandtheircommonlyassociatedorganisms

 Commonsituationsandtheirassociatedorganisms SITUATION Cellulitisfromadogorcatbite Burnwoundinfectionwithablue/green color BabyParalyzedaftereatinghoney Diarrheaaftertakingantibiotics Prickedbythornwhilegardening Gastroenteritisinyoungchild DiarrheaaftertravelingtoMexico AplasticcrisisinSickleCellpatient Foodpoisoningaftereatingreheatrice Foodpoisoningaftereatingrawseafood PneumoniainSouthwestUSA Pneumoniaafterexploringcaves Pneumoniaafterexposuretobird droppingsinOhio Pneumoniaafterexposuretoexotic birds Pneumoniainapatientwithsilicosis Diarrheaafterhikingordrinkingfroma stream B12deficiency Feverandmusclepainsaftereatingraw meat Pneumoniaafterbeingnearanair conditionerorwatertower Slaughterhouseworkerwithafever Fungalball/hemoptysisafterTBor cavitarylungdisease ASSOCIATEDORGANISMS PasteurellaMultocida Pseudomonas ClostridiumBotulinum ClostridiumDifficile SporothrixSchenckii Rotavirus E.Coli ParvovirusB19 B.Cereus VibrioParahemolyticus CoccidioidesImmitis HistoplasmaCapsulatum HistoplasmaCapsulatum ChlamydiaPsittaci Tuberculosis GiardiaLamblia DiphyllobothriumLatum TrichinellaSpiralis LegionellaPneumophilia Brucellosis Aspergillus

 Highyieldconditions/illnessesandtheirmostlikelyorganismandtreatments CONDITION/ILLNESS Cellulitis UTI Endocarditis Sepsis SepticArthritis Meningitis(neonatal) Meningitis(childadult) Osteomyelitis Pneumonia Pneumonia(atypical) Bronchitis ORGANISM Staph,Strep E.Coli Staph,Strep Gram()organisms StaphAureus GroupBStrep,E.Coli,or Listeria NeisseriaMeningitidis StaphAureus,Salmonella (Sicklecellpatient) StrepPneumonia,H. Influenza Mycoplasma,Chlamydia H.Influenza BESTTREATMENT Antistaphylococcus penicillin TMPSMX,Nitrofurantoin (inpregnancy) Antistaphylococcus, Aminoglycoside 3rdgeneration cephalosporins AntistaphylococcusPCN, Vancomycin(severe) Ampicillin+ Aminoglycoside 3rdgeneration cephalosporin AntistaphylococcusPCN, Vancomycin 3rdgeneration cephalosporin Doxycycline,Macrolide Amoxicillin,Erythromycin

 ImportantinformationregardingHIV HowoftenshouldtheCD4countbechecked?Q6months AtwhatpointisPCPaworryinHIV/Aidspatient?WhenCD4is<200 WhatisthemostcommonopportunisticpneumoniainAIDS?PCP HowtopreventPCPinfection?ProphylaxwithTMPSMXwhenCD4200 AtwhatCD4levelshouldprophylaxisagainstMycobacteriumAviumComplexbe started?WhenCD4is<50 WhichtypeofcancerareHIV/Aidspatientsatincreasedriskfor?Kaposis sarcoma Shouldlivevaccinesbegivendothesepatients?NO Whichistheonlylivevaccinetobegiven?MMR Whichtypeofblooddiseaseisincreasedinthispatientpopulation?NHL WhatisthemostlikelycauseofpneumoniainHIVpatient?StrepPneumo WhatisthemostlikelycauseofOpportunisticpneumoniainHIV?PCP(beableto recognizeifthequestionisaskingmostcommoncauseormostcommon opportunisticcause) WhichorganismcancausechronicdiarrheainAIDSpatients?Cryptosporidium

Chapter 10 Allergies

HypersensitivityReactions
Type1Anaphylactic(PreformedIgEantibodies) Type2Cytotoxic(preformedIgGandIgMantibodies) Type3Immunecomplexmediated(antigenantibodycomplexesdepositedin vesselsandcauseaninflammatoryresponse) Type4Delayed/Cellmediated(sensitizedTlymphocytesreleaseinflammatory mediators)

Anaphylaxis
Isatyp1hypersensitivityreaction DuetopreformedIgEantibodiesthatcausetheimmediatereleaseof vasoactiveaminessuchashistaminesandleukotrienes. Commonlyseenafterbeestingsandingestionofmedicationssuchas penicillinandsulfadrugs

Presentation: Symptomsdevelopacutelyandareoftenverydramatic Treatment/Management: Secureairway Givesubcutaneousepinephrine Ifthesearentavailablegivecorticosteroids Giveantihistaminesforcutaneousreactions Difficultybreathing Hypotension+tachycardia Urticaria Angioedema

Angioedema
IsmostcommonlycausedbyadeficiencyofC1esteraseinhibitor

Presentation: Diffuseswellingoftheeyelids,lips,andairway Usuallyoccursaftermildfacialtraumaoringestionofcertainmedications (oftenaceinhibitors) Thereisusuallyafamilyhistory C4levelsarelow

Treatment/Management: Secureairway Givesubcutaneousepinephrine Manageexactlylikeanaphylaxis

AllergicRhinitis
Anallergicreactionthatisverycommon Recurringnasalstuffiness,itching,rhinorrhea,andsneezing

Treatment/Management: Themaintreatmentshouldbeavoidanceoftheallergen Keepairclean Closewindowsandkeepairconditioningrunningduringsummermonths Nonsedatingantihistaminessuchasloratadineareveryeffectiveandcanbe usedcontinually Nasalsalinesprays/nettipotareeffectiveatwashingoutthenasalcavity

PrimaryImmunodeficiencies
IgADeficiency Isthemostcommonprimaryimmunodeficiency,anditisoftenasymptomatic CausesrecurrentrespiratoryandGIinfections Someonereceivingbloodproductsmaydevelopanaphylaxis,whichshould makeyouthinkofanIgAdeficiency Nevergivethesepatientsimmunoglobulins

Treatment: BrutonsAgammaglobulinemia Isanxlinkeddisorderaffectingmales Patientspresentwithinfectionsstartingaround6monthsofage RecurrentsinopulmonaryinfectionsduetoStreporHemophilusorganisms areclassic Manageandtreatinfectionsastheyarise

Treatment/Management: CommonVariableImmunodeficiency Isaconditionthatpresentsinbothmenandwomen Usuallyonlypresentswhentheyareadults Patientpresentswithrecurrentsinopulmonaryinfections Maygetspruelikeabdominaldisorders(malabsorbtion,diarrhea, steatorrhea) InfusionofIVIgs

Diagnosis: IgGlevelsarelow

Treatment: InfusionsofIVIGisrequiredsinceIgGlevelsarelow

 SevereCombinedImmunodeficiency WiskottAldrichSyndrome ChediakHigashiSyndrome ChronicGranulomatousDisease Usuallyanxlinkedrecessivedisorderaffectingmales ThereisadefectinNADPHoxidase,causingrecurringinfectionsdueto catalase(+)organisms(Staph,Pseudomonas,etc) Diagnostictestinvolvesnitrobluetetrazoliumdye(normallygetsreducedby granulocytes)measuresrespiratoryburst,whichislackinginthese patients Duetoadefectinmicrotubulepolymerization Giantgranulesinneutrophils Oculocutaneousalbinism Recurringinfections Anxlinkedrecessivedisorderaffectingonlymales Thereisaclassictriadofeczema,recurringinfections,andthrombocytopenia AnARorxlinkeddisorder Commonlycausedbyadenosinedeaminasedeficiency ThereisaBandTcelldefect,thuspatienthassevereinfectionsearlyinlife Thesearethesocalledbubblebabies,andrequireisolationtopreventlife threateninginfections

Chapter 11 Pulmonary

Hypoxemia
Thereare5causesofhypoxemia: 1. 2. 3. 4. 5. Hereisanalgorithmfiguringoutthecauseofhypoxemia Hypoventilation DiffusionImpairment V/Qmismatch Fi02 Shunt

SignsandSymptoms: Tachycardia,dyspnea Clubbingandcyanosis Cracklesandrales

 Treatment: Treatmentrequirestreatingthecurrenthypoxemiaandthetreatmentof underlyingdisorders Pa02 02bynasalcannula,orCPAP,orintubationifnecessary Ifthereisashunt,thehypoxemiawillnotimprovebyincreasingtheFIO2

COPDs
1. 2. 3. 4. Emphysema Isairspacedilationwithalveolarwalldestruction Themostcommoncauseofemphysemaissmoking Ifayoungpatientgetsthis,consideranalpha1antitrypsindeficiency Emphysema ChronicBronchitis Asthma Bronchiectasis

EmphysemaNoticeLungHyperinflation SignsandSymptoms: Barrelchest Hyperventilation Pursedlipbreathing Knownasthepinkpuffers

Diagnosis: Clinicaldiagnosis+CXRshowinghyperinflationofthelungs

Treatment: Acuteepisodesrequire:

 02andanABG CXR Albuterol(inhaled) Steroidsforacutedesaturations ADVISEPATIENTTOSTOPSMOKING

ChronicmanagementofCOPD: ChronicBronchitis Presentsasaproductivecoughonmostdaysfor3monthsinarowfor 2yrs Knownasthebluebloater Ipratropiuminhaler Albuterolinhaler Yearlyinfluenzavaccination Pneumococcalvaccine FUTHERSMOKINGCESSATIONADVISING Longterm02therapyifP02is<55%orthe02saturationis<88%

SignsandSymptoms: Similartoemphysemahoweverhypoxiaismoresevere RVH+pulmonaryHTN Neckveindistention Hepatomegaly

Diagnosis: Diagnosisislargelyclinical CanconfirmwithalungbiopsythatshowsanincreasedReidindex,whichis aglandularlayerthatis>50%ofthetotalthicknessofthebronchialwall.

Treatment: 02 Bronchodilators

 Asthma PresentswithSOBandexpiratorywheezing Severecasesmaypresentwiththeuseofaccessorymuscles Causedbybronchialhyperresponsivenessthatisreversible

SignsandSymptoms: Expiratorywheezinganddyspnea Onsetisoftenphysicalactivity Conditionisreversiblewithbronchodilatorssuchasalbuterol

Diagnosis: Highlyclinical CheckforaFEVincreaseofmorethan10% Complicationincludesstatusasthmaticus,whichisrefractoryattacksthat lastfordaysandarefatal

Treatment: Treatmentwith2agonistssuchasalbuterol Longtermcontrolinvolvesadditionofinhaledsteroid(ifpatientisnt experiencingenoughcontrolwithalbuterol) Ifalbuterol+steroidsarenotenough,additionofalongactingagonist suchassalmuterolmayhelp Lastresortinlongtermmanagement(refractorytotheseprevious treatments)isoralsteroids

 Bronchiectasis Duetoananatomicdefectthatcausespermanentdilationofthebronchioles Patientexperiencesrecurringlunginfectionsthatproducemassiveamounts ofsputum Patientoftenhasdigitalclubbingaswell

Diagnosis: ThemostaccuratediagnostictestisthehighresolutionCTscan,whichwill showthickenedbronchialwallsanddilatedairways CXRwillshowtheclassictramtrackmarkings

Treatment: Musttreatinfectionsastheyarisebecausethereisnocurativetherapy Antibiotictherapyforrecurringinfections Chestphysiotherapycanbehelpfulinreleasingandeliminatingsputum Longtermcureisalungtransplant

 RestrictiveLungDiseases 1. 2. 3. 4. InterstitialFibrosis Duetochronicinsulttothelungtissuebythingssuchasasbestos,chronic infections,organicdusts DiagnosismadebyaCXR,whichshowsahoneycombpatternofthelung InterstitialFibrosis Parenchymaldisease Extrapulmonarydisease Pleuraleffusion

Treatment: ParenchymalDisease Parenchymaldiseasesarecausedbythingssuchasinfections(TB), inflammation(sarcoidosis),drugs,toxic/chronicinhalationofoffending agents(asbestos),anditmaybeidiopathic Patientpresentswithadrycough,SOB,andchronichypoxia 02,PEEP,steroidsifthereiscollagenvasculardisease

SignsandSymptoms: Velcrorales Clubbing

Diagnosis: CXRorhighresolutionCT Lungbiopsy PFT(allmeasurementsaredecreasedproportionately)

Treatment: Ifinflammatory,steroidscanhelp Therearenodefinitivecuresforotherformsofparenchymaldisease

 ExtrapulmonaryDisease PleuralEffusion Fluidinthepleuralspace Anythingthataffectsthemusculatureresponsibleforaidinginbreathingcan causeproblems Multiplesclerosis,ALS,GuillainBarre,spinalcordtrauma Anythingthatpressesonthediaphragmcanalsocausetrouble,suchas pregnancyandobesity Management/treatmentissupportiveonly

SignsandSymptoms: Decreasedbreathsounds Dullnesstopercussion Decreasedtactilefremitus

Diagnosis: Treatment: Smalleffusionsusuallyresorbspontaneously Diureticscanbeusedifcausingrespiratoryproblems Ifeffusionislarge,insertachesttubefordraining ThebestinitialdiagnostictestisaCXR(lateraldecubidusshowsfreeflowing fluids) Mostaccuratetestisthoracentesis(canshowwhichtypeoffluiditis)

 PulmonaryEmbolism Patientpresentswithasuddenonsetofshortnessofbreath Lungsareclear

TheriskfactorsforPEareusuallytelltaleinthequestions: 1. 2. 3. 4. 5. Diagnosis: ACXRshouldbedoneandisusuallynormal.Mayshowawedgeshaped infarct(largePE),atelectasisisacommonfinding EKGoftenshowsnonspecificSTTwaveelevations BesttesttoconfirmdiagnosisofPEisthespiralCTandshouldbedoneifthe xrayisabnormal Ifthexrayisnormalbutyouarestillsuspicious,aV/Qscanshouldbe performed(thelessnormalthexraythelessaccuratetheV/Qscanwillbe) Dopplerexamisonly70%sensitive,thusmanyPEsaremissedwiththistest. ThebenefitoftheDoppleristhatifitDOESdetectaPE,itis100%accurate Ddimerisahighlysensitivetestbutithaslowspecificity.Thisisthebest testtouseifthepatienthasalowprobabilityofhavingaPEandyouwanta singletesttoruleoutaPE Immobility(Longairplaneride) Trauma(Brokenbone) Surgery(Especiallyreplacementofjointsintheleg) Malignancies Thrombophilias

 PulmonaryHypertension Pulmonaryhypertensionisdefinedashypertensionthatisthatofthesystemic pressure.Normallyitshouldbeapproximately1/8thatofthesystemicpressure Activepulmonaryhypertensionmeansitisprimarilyadiseaseofthelung Passivepulmonaryhypertensionmeansitissecondarytoaconditionofthe heart

PrimaryDisease: Idiopathic,whichoccurscommonlyinyoungwomen Interstitialrestrictivediseases Obstructivepulmonarydiseases

SecondaryDisease: SignsandSymptoms: Tricuspidregurgitation LoudP2 Rightventricularheave Raynaudsphenomenon Seeninheartdisease CommonlyseeninpatientswithHIV/AIDS

Diagnosis: Treatment: 02 Prostaglandins Endothelininhibitorsthatpreventgrowthofthevasculatureofthe pulmonarysystem BestinitialtestistheTTE,whichwillshowRVHandanenlargedrightatrium Mostaccuratetestisrightheartcatheterizationwithincreasedpulmonary arterypressure EKGwilllikelyshowrightaxisdeviation

 Tuberculosis 1TBaffectsthelowerlobesandisusuallyasymptomatic Itoccursinspecificgroupssuchasimmigrants,HIV+patients,homeless patients,andalcoholics.

SignsandSymptoms: Nightsweats Fever Cough Sputum Weightloss

Diagnosis: CXRisthebestinitialdiagnostictest Doanacidfaststainofthesputumtoconfirmdiagnosis

Treatment: Treatmentwith4antiTBmedicationsshouldbestartedwithsixmonthsof therapybeingthestandardofcare Isoniazid(6months),Rifampin(6months),Pyrizinamide(2months),and Ethambutol(2months) DoLFTsbecausethesemedicationscancauselivertoxicity(stopall medicationsiftransaminaselevelsreach5xtheupperlimitofnormal)

SpecificToxicitiescausedbyTBdrugs: Isoniazidperipheralneuropathy,addB6 Rifampinred/orangecoloredbodysecretions Pyrazinamidehyperuricemia Ethambutolopticneuritis

 ThePPDtest Ascreeningtestforthoseinriskgroups. Testingcriteriaisasfollows: 5mm:closecontacts,HIV+,steroidusers 10mm:forthosewhoareinthehighriskgroupsmentionedabove 15mm:thosewithnoincreasedrisk

IfPPDispositive,dothefollowing: 1. CXR 2. IfCXRisabnormal,doasputumstain 3. Ifsputumstainispositive,start4drugtherapy

 CancersoftheLung Lungcancersaccountforthemostcancerdeathsandarethe2ndmost commonlydiagnosedcancer XRAYisNOTagoodscreeningtoolbecausebythetimetheyareseen metastasishasoccurred Commonsignsandsymptoms:Cough,hemoptysis,hoarseness,weightloss, fatigue,recurrentpneumonia

Thefollowingtabledemonstratesthecommoncharacteristicsofdifferenttypes oflungcancers CANCERTYPE Adenocarcinoma Bronchoalveolarcarcinoma LargeCellcarcinoma Squamouscellcarcinoma CHARACTERISTICS Isthemostcommonlungcancerinnon smokers(peripheryandsubpleura) CEA(+),andisusedtofollowtreatment Asubtypeofadenocarcinomathatisnot relatedtosmoking Presentsintheperipheryofthelung Inperiphery Ishighlyanaplasticandhasapoor prognosis Arisesfrombronchusandisacentral hilarmass Stronglylinkedtosmoking PTHrPreleasecauseshypercalcemia Centralhilarlocation Stronglinktosmoking SecretionofADHandACTHcauses multipleendocrineproblems Treatwithradiation+chemotherapy MaycauseLambertEatonsyndrome Secretesserotonin Causesrecurrentdiarrhea,flushingof theskin,asthmaticwheezing Managewitha5HTantagonist Isasmoothmuscleneoplasm Mostcommonlyseeninmenstruating women Presentsclassicallywithpneumothorax Treatwitheitherprogesteroneoralung transplant

Smallcellcarcinoma

Bronchialcarcinoidtumor

Lymphoangioleiomyomatosis

Treatsmallcellcarcinomawithacombinationofradiationandchemotherapy

 Treatallothertypeswithlocalresection+radiation(nonmetastatic),andradiation +chemoifmetastatic SuperiorSulcusTumor AlsoknownasPancoasttumor,whichcausesthefollowing: 1. HornerssyndromePtosis,Anhydrosis,Myosisbecauseitdamagesthe sympatheticcervicalganglioninthelowerneck,AND 2. SuperiorVenaCavaSyndromeobstructionoftheSVCcausesfacial swelling,cyanosis,anddilationofveinsoftheheadandneck

Chapter 12 GI

EsophagealDisorders
TheonlytwoesophagealdisordersthatrequireanendoscopyareCANCERand Barrettsesophagus,bothwhichrequireabiopsytoknowthediagnosis. DYSPHAGIA Achalasia Diagnosis: Treatment: BestInitialtreatmentispneumaticdilation,ifrepeatedlyunsuccessfuldo surgery. Ifpatientrefusessurgery,wecangivethemaninjectionofbotulinumtoxin. Bestinitialtestisthebariumswallow Mostaccuratetestisanesophagealmanometry Dysphagiatobothsolidsandliquidsinayoungnonsmoker. Maybefoodregurgitation,andaspirationofpreviouslyeatenfood. Involvesafailureofthegastroesophagealsphinctertorelax,nomucosal abnormalities

 EsophagealCancer Presentsw/thefollowing: 1. Dysphagia:firsttosolidsthentoliquids 2. Mayhaveheme(+)stooland/oranemia 3. Oftenptsare>50yrandaresmokers/alcoholdrinkers. Diagnosis: Bestinitialtestisanendoscopy Ifendoscopyisnotanoption,doabariumswallow Treatment: Bestinitialtherapyisasurgicalresection(ifnolocalordistantmetastasis) Followsurgeryw/chemobased5FU

Ringsandwebs Alsoknownaspepticstrictures. Canbecausedbyrepetitiveexposureoftheesophagustoacids,resultingin scarringandstrictureformation. Previoususeofsclerosingagentsforvaricealbleedingcanalsocause strictures(thisiswhybandingisthesuperiorprocedure).

 Diagnosis: Followingarethediffkindsofstrictures: 1. PlummerVinsonsyndrome:isaproximalstricturefoundinassociation withirondeficiencyanemia.Ismorecommoninmiddleagedwomenandis associatedwithsquamouscellesophagealcancer Bestinitialtherapyisironreplacement Bestinitialdiagnostictestisabariumstudy

2. Schatzkisrings:isadistalringoftheesophagusthatpresentsw/ intermittentsymptomsofdysphagia ZenkersDiverticulum Look for pt w/ dysphagia w/ horribly bad breath. There is food rotting in the back of the esophagus from dilation of the posterior pharyngeal constrictor muscles. Diagnosis: Bestinitialtestisabariumstudy Bestinitialtherapyissurgicalresection Bestinitialtherapyispneumaticdilation

3. Pepticstricture:resultsfromacidreflux.Treatwithpneumaticdilation

 SpasticDisorders Diffuseesophagealspasmandnutcrackeresophagusareessentiallysame disease. Lookforcaseofseverechestpain,oftenw/oriskfactorsforIschemicheart disease. Mayoccurafterdrinkingacoldbeverage. Painisalwayspresent,butdysphagiaisntalwayspresent. Allcardiactestsarenormal

Diagnosis: Treatment: Esophagitis Esophagitis presents with odynophagia as the food rubs against the esophagus. Diagnosis: CandidaEsophagitis Causes90%ofesophagitisinHIV(+)patients Theothercommoncauseispillesophagitis,wherecertainpillscancause esophagitisinthepatient. IFpatientisHIV(),doanendoscopyfirst IFpatientisHIV(+),hasaCD4count<100givefluconazole..onlydo endoscopyifthepatientdoesntresponsetofluconazle. Calciumchannelblockersandnitratesarethebesttreatmentoptions Mostaccuratediagnostictestismanometry Bariumstudiesmayshowacorkscrewpattern,butonlyduringanepisodeof spasm

 Treatment: . MalloryWeisstear Is an upper GI bleed with violent retching and vomiting of any cause. Theremaybehematemesisorblackstoolonexamorinthehistory Treatment: GERD Patient presents with a history of epigastric pain that is associated with substernal chest pain and possibly a metallic taste in the mouth. Signs and Symptoms (on top of the classic presenting ones) Sorethroat Metallicorbittertaste Hoarseness Chroniccough Wheezing Mostcasesresolvespontaneously,ifbleedingpersists,injectionof epinephrinecanbeusedtostopthebleeding. Haveptsituprightwhentakingthepills Havepatientdrinkmorewaterandremainuprightfor30minutesafter swallowing.

NOTE:Asmanyas20%ofpeoplewhohaveachroniccougharesufferingasaresult ofGERD Diagnosis: PPIadminisbothdiagnosticandtherapeutic. Furthertestingsuchas24hrpHmonitoringshouldonlybedoneifthereisno responsetoPPIsandthediagnosisstillisnotclear

 Treatment:Milddiseaseshouldbecontrolledw/lifestylemodificationssuchas: WeightLoss Sleepinginanuprightposition,oratleastsomewhatangledinbed Smokingcessation Limitingalcohol,caffeine,chocolate,andpeppermintingestion Avoidanceoffoodanddrinkwithin23hoursofgoingtobed

IfthosedontworkthenPPIsarethenextbesttherapyforGERD.Theyshould control9095%ofcases. IfthereisnoimprovementthenatrialofH2blockersshouldbetried(manyadverse effectswiththese) BarrettEsophagus Isametaplasiafromsquamoustocolumnarcells Diagnosis: Performendoscopywhenthereisweightloss,anemia,and/orbloodinthe stool,andinanyonewhohaschronicsymptomsofrefluxdiseaseformore than5yrs. FINDINGONENDOSCOPY Barrettesophagus Lowgradedysplasia Highgradedysplasia MANAGEMENT PPIandrepeatendoscopyevery23 years PPIandrepeatendoscopyin36months Distalesophagectomy

 EpigastricPain Anypt>45yrw/persistentepigastricpainand/ordiscomfortshouldreceivean upperendoscopy.Thisisessentialtoexcludethepossibilityofgastriccancer Non-Ulcer Dyspepsia: Treatment: PepticUlcerDisease Gastritis Not due to hypersecretion of acid, as in PUD. Can be associated with H.Pylori, if this is present treat w/ PPI and 2 antibiotics. Gastritiscanalsobeatrophicfromperniciousanemiaandisoften associatedwithadeficiencyofvitaminB12 Duetohypersecretionofacid Canbeeitherduodenalulcer(DU)orgastriculcer(GU)diseases H.PyloriistheMCCofulcers,2ndMCCisNSAIDs,headtrauma,burns, intubation,Crohnsdisease,andZES. Usually,foodimprovesthepainofaduodenalulcerandmakesthepainofa gastriculcerworse Iftheptisabove45andhasepigastricpain,youmustscopetoexclude gastriccancer. Consistsofsymptomatictherapyw/H2blockers,liquidantacids,orPPIs. IstheMCCofepigastricdiscomfort Canonlybeconcludedafterendoscopyhasexcludedanulcerdisease,gastric cancer,andgastritis

 TestingforH.Pylori: Mostaccuratetest: Endoscopywithbiopsy(ifthisisdonenofurthertestingisrequired) Serologyisverysensitivebutnotspecific,iftheserologyisnegative,this excludesH.Pylori. Apositivetestcantdistinguishbetweennewandpreviousinfection.

Breathtestingandstoolantigentesting: TreatingH.Pylori: TreatthisbacteriawithPPIandclarithromycin+amoxicillin. ONLYtreatifitsassociatedwithgastritisorulcerdisease. Thesearenotstandardorroutinelyused.Theycanhoweverdistinguish betweennewandolddisease.

ThereisnoneedforroutineposttreatmenttestingofHPylori.thereisnobenefitin treatingH.Pylorithatisassociatedwithnonulcerdyspepsia. IfthetreatmentofH.Pyolirdoesntsucceed,trythefollowing: 1. Repeattreatmentwith2newantibioticsandPPI:Usemetronidazole+ tetracyclineinstead 2. Ifrepeattreatmentfails,evaluateforZES(Gastrinoma). StressUlcerProphylaxis: Routine prophylactic use of a PPI or H2 blocker or sucralfate should only be used if one of the following is present: 1. Headtrauma 2. Intubationandmechanicalventilation

 3. Burns 4. Coagulopathyandsteroiduseincombo

**NSAIDorsteroidusealoneisnotanindicationforroutinestressulcerprophylaxis ZollingerEllisonSyndrome(ZES)orGastrinoma ZES is diagnosed by finding an elevated gastrin level and an elevated gastric acid output. **remember that everyone on a H2 blocker or PPI has an elevated gastrin level. Whentotestthegastrinandgastricacidoutput? Whenanyofthefollowingarepresent: 1. 2. 3. 4. largeulcer>1cm multipleulcers distallocationneartheligamentofTreitz recurrentorpersistentdespiteH.Pyloritreatment

*if the gastrin and acid output level are both elevated, then localization of the gastrinoma is next. Diagnosis: Treatment: Localdiseaserequiressurgicalresection MetastaticdiseaserequiresthepatientbeonlifelongPPIs Mostaccurateisanendoscopicultrasound NuclearsomatostatinscanisalsoverysensitivebecauseZESpatientshavea highnumberofsomatostatinreceptors

 InflammatoryBowelDisease(IBD) Both Crohns and ulcerative colitis can present with fever, abdominal pain, diarrhea, blood in stool, and weight loss. UCpresmostoftenwithabdominalpainandbloodydiarrhea

ExtraintestinalmanifestationsofIBDare: Jointpain Eyefindings Skinfindings Sclerosingcholangitis

FeaturesmorecommontoCrohnsdiseaseare: Masses Skiplesions InvolvementofupperGItract Perianaldisease Transmuralgranulomas Fistulae Hypocalcemiafromfatmalabsorbtion Obstruction Calciumoxalatekidneystones Cholesterolgallstones VitaminB12malabsorbtionfromterminalileuminvolvement

Diagnosis: Endoscopyisbestinitialtest Bariumstudiesarealsogooddiagnostictests

CrohnsMarkers: Antisaccharomycescerevesiae(ASCA):positive Antineutrophilcytoplasmicantibody(ANCA):negative

 UCMarkers: ASCA:negative ANCA:positive

Treatment: Bestinitialtreatmentforbothismesalamine Steroidsareusefulinacutecases Surgeryisrequiredifthereisnorelieffromthesetreatmentmodalities

DIARRHEA
Infectious Diarrhea The presence of blood indicates a pathogenic invader, which may include any of the following: Campylobacter - Is the MCC of food poisoning. Salmonella - Transmitted by chicken and eggs Vibrio Parahemolyticus Associated with infected seafood E. Coli There are many different types, which include: E. Coli 0157:H7 MC associated with haemolytic uremic syndrome(via effects of verotoxin). Look for undercooked beef in the history. Vibrio vulnificus: Look for shellfish in a person w/ liver disease Shigella: Secretes Shiga toxin, which is also associated with reactive arthritis Yersinia: Rodents are natural reservoirs, transmission via veggies, milk-derived products, and meat Amebic: Perform three ova & stool parasite exams or serologic testing. Treat with metronidazole

Diagnosis: Best initial test fecal leukocytes Most accurate test stool culture Treatment: Mild disease Keep the patient hydrated, this usually resolves on its own Severe disease Fluoroquinolones are the treatment of choice. Severe disease is defined as presence of any of the following (Blood, fever, abdominal pain, hypotension and tachycardia)

Non-Bloody Diarrhea: Non-bloody diarrhea may still be d/t the above pathogens, which can all present with non-bloody diarrhea. NO BLOOD in diarrhea will exclude all of the following, which never have blood:

1. Viruses Rotavirus, Norwalk virus (Norovirus) 2. Giardia Camping/hiking. Look for bloating/flatus/steatorrhea, stool ELISA is diagnostic test of choice, treatment involves metronidazole. 3. Staph Aureus Presents with vomiting in addition to diarrhea. This resolves spontaneously 4. Bacillus Cereus Is associated with eating refried rice. This resolves spontaneously 5. Cryptosporidiosis HIV (+) patient with a CD4 count <100. Diagnosis with acid-fast stain. There is no proven treatment except to raise the CD4 count w/ antiretroviral therapy. 6. Scombroid Histamine fish poisoning, has fastest onset of poisoning, which is around 10 min after eating infected tuna, mackerel, or mahi-mahi. Patient has vomiting, diarrhea, wheezing, and flushing. Treatment involves giving the patients antihistamines such as diphenhydramine.

Antibiotics Associated Diarrhea (C. Difficile) Develops several days to weeks after use of antibiotics such as Clindamycin, which is the most common cause. There can be both blood and fecal leukocytes with C.Difficilerelated colitis. Diagnosis: Best initial test is a stool toxin assay.

Treatment: The best initial therapy is metronidazole

Chronic Diarrhea The most common cause of chronic diarrhea is lactose intolerance Diagnosis: Removal of milk products will both allow for diagnosis and treatment

MALABSORBTION
Diarrhea caused by malabsorption is always associated with weight loss Fat malabsorption is associated with steatorrhea, which leads to oily/greasy stools that float on the water in the toilet and are foul smelling

The common causes of fat malabsorption are as follows: 1. 2. 3. 4. Celiac Disease Tropical Sprue Chronic Pancreatitis Whipples Disease

All forms of malabsorption are associated with: Hypocalcemia from vitamin D deficiency, which may lead to osteoporosis Oxalate overabsorption and oxalate kidney stones Easy bruising and elevated PT/INR due to vitamin K malabsorbtion Vitamin B12 malabsorption from either destruction of terminal ileum or loss of pancreatic enzymes that are necessary for B12 absorption

Diagnosis: The best initial test is the sudan stain The most sensitive is a 72-hr fecal fat test

Celiac Disease Presents with iron malabsorption and microcytic anemia Diagnosis: Best initial diagnostic test is checking for antigliadin, antiendomyseal, and antitissue transglutaminase antibodies The most accurate test is a small bowel biopsy

*bowel wall biopsy is always necessary even w/ antibody confirmation, in order to exclude bowel wall lymphomas.

Treatment: Elimination of oats, wheat, barley from the diet

Tropical Sprue Patient will have a history of being in a tropical location, and presents the same way as celiac disease. Diagnosis: Small bowel biopsy is the best test to perform

Treatment: Tetracycline or TMP-SMX for 3-6 months

Whipples Disease A GI infection presenting with arthralgias, rash, diarrhea, and anemia Diagnosis: The most accurate test is a small bowel biopsy that shows PAS (+) organisms Can also do a PCR of the stool looking for T. Whippelii

Treatment: Penicillin, Tetracycline, or TMP-SMX for 12 months

Chronic Pancreatitis History of alcoholism is usually present Lipase and amylase levels are likely normal since these wont drop until the pancrease is calcified and fibrosed. Fat soluble vitamins are not absorbed

Diagnosis: The best initial test is an abdominal XRAY or a CT without contrast The most accurate testis secretin stimulation testing (normal person releases large amount of bicarbonate-rich pancreatic fluid).

Treatment: Involves the administration of pancreatic enzymes by mouth.

Irritable Bowel Syndrome Syndrome where the patient experiences an alteration in bowel habits (constipation alternating with diarrhea) Pain is usually relieved after a bowel movement

Diagnosis: Testing may include colonoscopy, xrays, blood tests, but all are negative

Treatment: The best initial treatment is fiber supplementation, which helps by bulking the stool and relieving pain If fiber doesnt work, can add antispasmotic agents to try and relax the bowel If these fail to work, TCAs can be tried

COLON CANCER Hamartomas and hyperplastic polyps are benign Dysplastic polyps are malignant

** The most important thing to know for colon cancer screening is when and what to do for the patient Diagnostic Testing: General Population: 1. 2. 3. 4. 5. Begin screening at 50yr Colonoscopy q10yrs Sigmoidoscopy q 3-5yrs Fecal occult blood testing yearly Barium enema

The best method of screening for colon cancer is performing a colonoscopy every 10yrs One family member with colon cancer requires colonoscopy starting at 40yr or 10yr before age of family member who had cancer. Three family member, two generations, one premature(<50) require a colonoscopy every 1-2yr starting at 25yrs. This is a lynch syndrome or HNPCC

Familial Adenomatous Polyposis(FAP) Start screening sigmoidsocopies at age 12 Perform colectomy if polyps are found

Gardners syndrome This presents with benign bone tumors known as osteomas, as well as other soft tissue tumors. There is no additional screening indicated for Gardners syndrome

Peutz-Jeghers Syndrome This presents with a patient who has melanotic spots on the There are hamartomatous polyps throughout the small bowel and colon There is a lifetime risk of colon cancer is 10%. No extra screening recommended

Juvenile Polyposis There are multiple extra hamartomas in the bowel. No increased risk of colon cancer from hamartomas No extra screening recommended If dysplastic polyps are found, perform repeat colonoscopy in 3-5 years SINGLE FAMILY MEMBER WITH COLON CANCER Start at 40yr or 10yr earlier than when diagnosed THREE FAMILY MEMBERS WITH CANCER Colonoscopy q1-2yr at 25yr FAP GARDNERS, PEUTZJEGHERS, JP No xtra screening recommended

GENERAL POPULATION

Start at 50, then q10yr

Sigmoidoscopy q102 yr starting at 12yr

 DIVERTICULAR DISEASE Includes Diverticulosis and Diverticulitis Diverticulosis Incredibly common in older Americans and it most commonly caused by a low-fiber, high-fat diet Signs and Symptoms: LLQ abdominal pain Lower GI bleed

Diagnosis: The most accurate test is a colonoscopy Best diagnostic test is an abdominal CT scan

Treatment: High-fiber diet low in saturated fats

Diverticulitis Is a complication of diverticulosis and presents with: LLQ abdominal pain Tenderness Fever Elevated white cell count in blood

Treatment: Involves the use of antibiotics. Metronidazole and ciprofloxacin most commonly used.

Gastrointestinal Bleeding
Red blood lower GI bleed, rarely a very acute upper GI bleed can be red blood Black stool upper GI bleed (Proximal to Ligament of Trietz). Black stool usually is 100ml or more blood. Heme (+) brown stool can occur from as little as 5-10ml of blood loss Coffee ground emesis needs very little gastric, esophageal, or duodenal blood loss, as little as 5-10ml. **The most important thing to do in acute GI bleeding is to determine if there is hemodynamic instability

Treatment for GI bleeds: IV fluids if it is a large bleed Correction of anemia or other lab abnormalities

Variceal Bleeding Look for alcoholic with hematemesis and/or liver disease Other clues are the presentation of splenomegaly, low platelets, and spider angiomas or gynecomastia

Diagnosis: Endoscopy

Treatment: First thing to do is add octreotide which decreases portal hypertension 2nd thing to do is an upper GI to band the variceals If banding fails, a shunt between the portal vein and the hepatic vein should be done

Sources of Bleeding Upper GI: Ulcer disease Esophagitis Gastritis Duodenitis Varices Cancer

Lower GI: Angiodysplasia Diverticular disease Polyps Ischemic colitis IBD Cancer

Diagnosing sources of bleeding: Technetium bleeding scan (tagged red cells) detects source of bleed Angiography is an excellent preoperative test because it localizes the site of resection Capsule endoscopy should be done when the other methods fail. This is a small camera that is swallowed and allows for visualization of the small intestine

Acute Mesenteric Ischemia Presents with a sudden onset of severe abdominal pain with a normal appearing exam (ie. The pain is out of proportion to the findings on exam) Diagnosis: The most accurate test is an angiography

Treatment: Surgical resection of ischemic bowel

Other GI Conditions

Constipation Initial management of constipation is hydration and fiber supplements There is usually no clear etiology, for clinical purpose must know possible causes and be able to treat underlying reason. 1. 2. 3. 4. 5. 6. 7. Dehydration: look for signs of dehydration, BUN:Cr of >20:1 CCBs Narcotic medication use/sedatives Hypothyroidism: TSH, T4 Diabetes Ferrous sulphate iron replacement Anticholinergic medications

Dumping syndrome This is a rare disorder related to prior gastric surgery (Often for ulcer disease) This is a disorder where stomach contents are quickly passed through to the intestine, and it then draws fluid into the GI, causing an initial HYPERglycemia follow by a reactive HYPOglycemia

Signs and Symptoms: Shaking chills Diaphoresis Weakness Hypotension Hyperglycemia

Treatment: Small and frequent meals

Diabetic Gastroparesis Longstanding DM impairs neural supply of bowel, there is impairment of normal motility. Patient will present with bloating and constipation as well as diarrhea

Diagnosis: Clinical + history of diabetes

Treatment: Erythromycin (increases motilin in the gut, thus increasing motility) and metoclopramide.

Acute Pancreatitis Presents (classically) as severe midepigastric pain and tenderness that is associated with alcoholism and/or gallstones Diagnosis: Lipase (more specific) and amylase

Treatment: Keep patient NPO Give IV fluids Give pain medications

ACUTE HEPATITIS:
All pts present in a very similar way: 1. 2. 3. 4. Jaundice Fatigue Weight loss Dark urine from bilirubin in the urine

*Hepatitis B and C are more likely to pres with serum-sickness phenomenom like joint pain, urticaria, and fever. No definitive treatment is available for any form of acute hepatitis.

Diagnosis: Conjugated bilirubin levels (will be elevated) Viral Hepatitis gives elevated ALT level Drug-induced hepatitis is associated with increased levels of AST In pregnancy, if a patient gets hepatitis E this can be fatal Most accurate tests for hep A, C, D, and E, the confirmatory test is serology IgM levels acutely rise, and IgG levels rise in the recovery phase. Surface antigens, core antibody, e-antigen, or surface antibodies are only associated w/ hepatitis B.

Hepatitis B testing: The first test to become abnormal in acute hep B infection is the surface antigen. Elevation in ALT, e-antigen, and symptoms all occur after the appearance of hepatitis B surface antigen. Chronic hep B gives the same serologic pattern as acute hep B, but it is based on persistence of the surface antigen beyond six months.

*Tests for active viral replication: hep B DNA polymerase = e-antigen = hep B PCR for DNA, all equal the same thing.

 Hepatitis C testing: Best initial test is hep C antibody, this wont tell the level of activity of the virus Most accurate test Hep C PCR for RNA, also is the most accurate way of testing response to therapy Liver biopsy is the most accurate for finding out the severity of the disease

Treatment of Chronic Hepatitis Chronic hep B: The pt w/ surface antigen, e-antigen, and DNA polymerase or PCR for DNA is the pt most likely to benefit from antiviral therapy. Look for >6mnth of positive serology Treat chronic hep B w/ following single agents: 1. Lamivudine 2. Adefovir 3. Entecavir 4. Telbivudine 5. Interferon (has the most adverse effects) Chronic hep C: Combine interferon with ribavirin (MC adverse effect is anemia)

Vaccination: 1. 2. 3. 4. 5. Hep A and B vaccination is now universally done in children. For adults the strongest indication for both types are the following: Chronic liver disease Household contacts MSM (men who have sex with men) Blood product recipients on a chronic basis Injection drug users

Specific indications: HEP A travelers HEP B health care workers and pts on dialysis. *there is no vaccine or postexposure prophylaxis for hep C

 CIRRHOSIS No matter what the cause may be, it will have a number of features: 1. 2. 3. 4. 5. 6. 7. 8. Edema due to low oncotic pressure (treat with spironolactone + diuretics) Gynecomastia Palmar erythema Splenomegaly Thrombocytopenia due to splenic sequestration Encephalopathy, which should be treated with lactulose Ascites - Treat with spironolactone Esphageal varices - Propranolol will prevent bleeding, perform banding if bleed continues.

Ascites: Perform paracentesis for all pts with ascites if a new ascites, pain, fever, or tenderness are present. Diagnosis: Test the fluid albumin level SAAG > 1.1 is consistent with portal hypertension from cirrhosis

 CHRONIC LIVER DISEASE (Cause of cirrhosis) Alcoholic cirrhosis Is a diagnosis of exlusion. Must exclude all other causes of cirrhosis and look for a history of longstanding alcohol abuse. Treat as described above for cirrhosis

Primary Biliary Cirrhosis Presents most commonly in a middle-aged woman complaining of itching. Xanthalasmas may be found on exam. Also look for a history of other autoimmune disorders Diagnosis: The best initial test is elevated alkaline phosphatase + normal bilirubin level The most accurate test is presence of antimitochondrial antibody

Treatment: Ursodeoxycholic acid

Primary Sclerosing Cholangitis: 80% of those with PSC also have IBD

Signs and Symptoms: Urticaria Elevated bilirubin levels Elevated alkaline phosphatase

Diagnosis: Most accurate test is ERCP

 Anti-smooth muscle antibody, and (+) ANCA Treatment: Ursodeoxycholic acid

Wilsons Disease Involves cirrhosis and liver disease in a person with a choreiform movement disorder and neuropsychiatric abnormalities. Signs and Symptoms: Extrapyrimidal symptoms Mania/depression Kayser-Fleischer rings around the cornea is pathognomonic for Wilsons disease

Diagnosis: Decreased serum ceruloplasmin

Treatment: Penicillamine

Hemochromatosis Most often from a genetic disorder resulting in overabsorbtion of iron Iron deposits throughout the body, most commonly in the liver.

Signs and Symptoms: Darkening of the skin (Bronze diabetes) Arthralgia

 Cardiomyopathies (Restrictive) Infertility Hepatoma

Diagnosis: Best initial test is serum study showing elevated serum iron and ferritin with a low TIBC. Iron saturation will be grossly elevated The most accurate test is a MRI or liver biopsy

Treatment: Phlebotomy

Autoimmune Hepatitis Most often presentation is a young woman who has another autoimmune disease Diagnosis: Best initial test is ANA and anti-smooth muscle antibodies The most accurate test is a biopsy of the liver

Treatment: Prednisone

Nonalcoholic steatohepatitis (NASH) Strong association with obesity, diabetes, and hyperlipidemia Diagnosis: Best initial test is liver studies that show ALT>AST The most accurate test is a liver biopsy that shows fatty infiltration

 Treatment: Management of the underlying condition

Chapter 13 Nephrology

RenalTubularandInterstitialDisorders
DrugInducedInterstitialNephritis ClassicdrugscausinginterstitialnephritisincludePCN,NSAIDs, Sulfonamides,anddiuretics.

SignsandSymptoms: Rash Hematuria Oliguria Fever Eosinophilia EosinophiliuriaisrarebutispathognomonicforhypersensitivityAllergic InterstitialNephritis

Diagnosis: Diagnosisismainlyclinical,removalofoffendingagent+improvementhelps toconfirmdiagnosis

Treatment: AcuteRenalFailure Presentswithazotemia BUN&Creatinine Causedbyeitherprerenal,renal,orpostrenalazotemia Removalofoffendingagent Steroidscanhelp

PrerenalFailure: Hypoperfusionwillleadtorenalfailure Volumedepletion,sepsis,heatstroke,burns,hypotension

IntrinsicRenalFailure: ATNisthemostcommoncause Renalischemiaalsoapossibility

 PostrenalFailure: Test UrineOsmolality UrineSodium FENa BUN/Creatinine Treatment: AcuteTubularNecrosis Fromeitherhypoperfusionthatleadstotissuedeathorfrominsultdueto varioustoxicinjuries Isthemostcommoncauseofacuterenalfailure IVfluidstomaintainurineoutput Diureticstopreventfluidoverload Closemonitoringofelectrolyteabnormalities Dialyzewithsevereelectrolyteabnormalities,unresponsivemetabolic acidosis,uremia,andtoxicingestion Prerenal >500 <20 <1% >20 Postrenal <350 >40 >4% >15 Renal <350 >20 >2% <15 IsduetoobstructionsecondarytoeitherBPH,renalcalculi,and/or bladder/pelvictumors

Treatment: RenalTubuleFunctionalDisorders 1. RenalTubularAcidosis 2. DiabetesInsipidus 3. SyndromeofInappropriateAntidiureticHormone Removecause GiveIVfluidstomaintainurinaryoutput Closelymonitorelectrolytes Givediureticsasneededtopreventfluidoverload

 RenalTubularAcidosis: Type TypeI TypeII TypeIV Characteristic Adefectofthedistal tubule(H+gradient) Proximaltubulefailsto resorbHCO3 Aldosterone(leadingto hyperK+andhyperCl Fromsecretionseenin DM,interstitialnephritis, ACEIs,heparin,and NSAIDuse. Mayalsobedueto aldosteroneresistance fromsicklecellorurinary obstruction UrinarypH >5.5 >5.5earlythen<5.5asthe acidosisworsens <5.5

DiabetesInsipidus: ThereiscentralandnephrogenictypesofDI,both: secretionofADHifitiscentraldiabetesinsipidus,andanADHresistanceif itisnephrogenic

SignsandSymptomsofboth: Polyuria Polydypsia Nocturia Urineosmolality200andserumosmolality300

CentralDI: Iseitheridiopathic(Primary)orcausedbyinsulttobrain(Secondary) TreatthiswithDDAVPnasalspray

NephrogenicDI: Isanxlinkeddiseaseandmaybesecondarytosicklecell,pyelonephritis, nephrosis,amyloidosis,multiplemyelomadrugs Treatbyincreasingwaterintakeandrestrictingsodiumintake

 Diagnosis: SyndromeofInappropriateAntidiureticHormone(SIADH): TherearemanypossiblecausesofSIADH: CNSdisease:trauma,tumors,hydrocephalus Pulmonarydiseases:pneumonia,Smallcellcarcinomaoflung,abscess,COPD Endocrinedisease:hypothyroidism,Connssyndrome Drugs:NSAIDs,chemotherapy,diuretics,phenothiazine,oralhypoglycemics Diagnosis:presenceofhyponatremiawithaurineosmolalityof>300mmol/kg Treatment:thisconditionisusuallyselflimiting,resistantcasesmayrequire demeclocyclinewhichinducesnephrogenicDI ChronicRenalFailure: Alwaysassociatedwithrenalazotemia WithDDAVPadministration,centralDIwillhaveafastdecreaseinurine output,whilenephrogenicDIwillhavenochangeinurinevolume WithDDAVPadministration,centralDIshowsanacuteincreaseinurine osmolality,wherenephrogenicDIshowsnochangeinosmolality TreatcentralDIwithDDAVPorvasopressin TreatnephrogenicDIbycorrectingtheunderlyingcause(electrolyte imbalances).

Characterizedby: Azotemia Acidosis Hyperkalemia HypocalcemiaduetolackofvitaminDproduction Anemia(lackoferythropoietinproduction) HypertensionduetoRAASpathwayactivation

 SignsandSymptoms: Nauseaandvomiting Anorexia Dementia Convulsions Coma PLTdysfunction(leadstobleeding)

Diagnosis: Renalultrasoundshowingsmallkidneysiffailureischronic PresenceofanemiaduetolackofEPOproduction

Treatment: Restrictbothwaterandsalt Preventfluidoverloadwithdiuretics Iftherearesevereelectrolytedisturbancesoracidbaseproblemsgointo dialysis

GlomerularDiseases
NephriticandNephroticSyndromes: Nephrotic:Definedbyhyperproteinuria,hypoproteinemia,hyperlipidemia, edema Proteinuria>3.5g/day Patienthasgeneralizededema Hypercoagulation albumin Hyperlipidemia

Diagnosis: Bestinitialtestisaurinalysisshowingsignificantlyincreasedlevelsof protein Nextbeststepisaspoturinetestforaprotein:creatinine>3.5:1 24hrurineproteincollection>3.5g MostaccuratetestRenalbiopsy COMMONCHARACTERISTICS/TX Thisisseeninyoungchildren. Treatwithprednisone SimilarinpresentationtoMCDbut occursinadults. Mostcommonlyidiopathic. Commonlypresentsinyoung hypertensivemales. Treatwithprednisoneand cyclophosphamide Isthemostcommon1causeof nephriticsyndromeinadults. Aslowlyprogressivedisorder. Manycauses:HBV,HCV,syphilis,certain drugs,malignancies,SLE. Treatwithprednisone+ cyclophosphamide. 50%ofcasesprogresstoendstagerenal failure Type1isslowlyprogressivewhileType 2isaggressive. AutoantibodyagainstC3convertase (C3levels) Treatwithprednisone,plasmapharesis.

TYPEOFNEPHROTICDISEASE MinimalChangeDisease FocalSegmentalGlomerulosclerosis

MembranousGlomerulonephritis

Membranoproliferative Glomerulonephritis

 Treatment: Nephritic: Thishappenswhenthereisdiffuseglomerularinflammation Proteinandsaltrestriction HMGCoAreductaseinhibitorforhyperlipidemia

SignsandSymptoms: Thereisanacuteonsetofhematuria Oliguria Hypertension Edema GFR Bun:Cr COMMONCHARACTERISTICS/TX Anacutecondition. ClassicallyoccursafterStrepPyogenes infection. Immunofluorescenceshowscoarse granularIgGorC3deposits. Labsshowincreasedredcellsandcasts, serumC3,ASOtiter. Anephriticconditionthatprogresses rapidlytorenalfailure. Goodpasturesdiseaseisinthiscategory. Immunofluorescenceshowssmoothand linearIgGdeposits. Treatwithprednisoneand plasmapharesis. Mostcommontypeofnephropathy. IgAdepositsinmesangium. Presentswithrecurrenthematuria+ lowgradeproteinuria. Usuallyharmless,however1in4may progresstorenalfailure. Treatwithprednisone Alwaysinchildren,isanIgA nephropathy. Presentswithabdominalpain,GIbleed, vomiting,andhematuria. Classicallyfindpalpablepurpuraon

TYPEOFNEPHRITICDISEASE PoststreptococcalGlomerulonephritis

RapidlyProgressiveGlomerulonephritis (Crescentic)

BergersDisease(IgAnephropathy)

HenochSchonleinPurpura

 buttocksandlegs Isaselflimitingdiseasethatrequiresno steroids. Thereisanincreasedlightchain production. FindBenceJonesproteininurine. Hypercalcemiaseen. Patientbecomessucceptibleto encapsulatedbacteriabecausethereisa defectinnormalantibodyproduction. Treatmentmustbeontheunderlying myeloma.

MultipleMyeloma

 SystemicGlomerulonephropathies: DISEASE DiabetesMellitus CHARACTERISTICNEPHROPATHY IstheMCCofESRD. Earlymanifestationismicroalbuminuria (giveACEIs,strictglycemiccontrol). MCseenwhenHIVisacquiredbyIV druguse. Presentsasfocalsegmental glomerulonephritis. Earlytreatmentwithantiretroviral Diagnosewithbirefringenceoncongo redstain. Treatwithatransplant LUPUS Norenalinvolvement Isamesangialdiseasewithfocal segmentalglomerularpattern. Treatmentisnttypicallyrequired Isafocalproliferativedisease. Treataggressivelywithprednisoneand cyclophosphamide Diffuseproliferativedisease. Combinationofbothnephriticand nephriticdisease. WireloopabnormalityonLM Treatwithprednisoneand cyclophosphamide Isamembranousdiseasethatis indistinguishablefromotherprimary membranousdiseases. Treatwithprednisone

HIV

RenalAmyloidosis

Type1 Type2 Type3 Type4

Type5

 RenalArteryStenosis Presentswithsuddenonsetofhypertensionalongwithhypokalemia Abdominalbruitheardwithstethoscope Canbecausedbyplaque,fibromusculardysplasia

Diagnosis: BestinitialtestisarenalultrasoundwithDoppler Ifsmallkidneysarethenseen,doanMRA Themostaccuratetestisarenalangiogram

Treatment: Angioplastyandstenting

 ObstructionoftheUrinaryTract BPHandstonesaretheMCCinadults ThereisanincreasedriskofstasisthusincreasingtherisksofUTIs Presentwithurinarycolic,intensepainthatradiatesfromthebackaroundto thepelvisandthegroin

Nephrolithiasis: CalciumPyrophosphate: 85%ofstonesarecalciumpyrophosphate Areradiopaqueandassociatedwithhypercalcemia 50%oftimeitsassociatedwithhypercalciuria Treatcalciumstoneswithhydrationandloopdiuretics(LOOPSeliminate calcium)

AmmoniumMangesiumPhosphate(Struvite): UricAcidStones: Oftensecondarytogoutorconditionsthatcauseincreasedcellturnover, suchasmyeloproliferativedisease Treatbyalkalinizingtheurineand/ortreatinganyunderlyingconditions 2ndMCCofstones Areradiopaque Usuallycausedbyurease(+)ProteusorStaphSaprophyticus Mayformlargestaghorncalculi Treatmentinvolvestakingcareoftheunderlyinginfection

 KidneyTumors Themostcommonrenalmalignancyisrenalcellcarcinoma,whichoccurs MCinmalesfrom5070yrofage Presentswithhematuria,flankpain,fever,palpablemass,andsecondary polycythemia Treatmentinvolvesinterleukinandresection ThemostcommonchildhoodrenalmalignancyisWilmstumor,which occursMCbetween24yrold Presentswithapalpableflankmass PartofWAGRcomplex(Wilms,Aniridia,GUmalformation,Retardation mentalandmotor)

Treatment: Removalofkidneypluschemotherapyand/orradiation

Chapter 14 Hematology

Anemias:
Mildtomoderateanemiapresentswith: Fatigue,pallor,paleconjunctiva,flowmurmur

Severeanemiapresentswith: SOB,lightheadedness,confusion

Diagnosis: LABSforsuspectedanemias: 1. 2. 3. 4. 5. Ironstudies(mostimp) CBCw/peripheralsmear(payingattentiontoMCV,MCHC) B12/folate(B12=neuropathies,folate=noneuropathies) RDW(newersmallerRBCscausechangeinRDW) Reticulocytecount(determineswhethersiteofproblemisbonemarrow synthesisofnewRBCs) 6. LDH,bilirubin,haptoglobin(alldeterminewhetherhemolysisisinplay) 7. TSHwithT4(seewhetherhypothyroidismiscauseoffatigue) 8. CXR/bloodculture/UAforsuspectedsicklecelldisease Themostreliabletestforirondeficiencyanemiaisserumferritin,whichwill bedecreased. Ifapatienthasirondeficiencyanemiaanddoesnotrespondtotreatment,do hemoglobinelectrophoresistolookforanorthalassemia

 IrondeficiencyAnemia SignsandSymptoms: Fatigue Pallor Paleconjunctiva Lowferritin,lowiron,increasedTIBC

Diagnosis: Bestdiagnostictestforirondeficiencyanemiaisironstudies Themostaccuratetestisabonemarrowbiopsy

Treatment: AnemiaofChronicDisease SignsandSymptoms: Samesignsandsymptomswiththeadditionofahistoryofchronic inflammatorydisorderorautoimmunedisorder Oralferroussulfatesupplement

 Diagnosis: Bestdiagnostictestisironstudies(willcomebacknormal)

Treatment: Thalassemia SignsandSymptoms: SmallMCV Presenceoftargetcells Veryothersymptoms Correcttheunderlyingdisease

Diagnosis: Bestinitialtestisanironstudy Themostaccuratetestishemoglobinelectrophoresis BetathalassemiahaselevatedHgA2andHgF Alphathalassemiahasnormallevels

Thereisnotreatmentfortheseconditions

 SideroblasticAnemia

SignsandSymptoms: Diagnosis: Bestinitialtestisironstudies ThemostaccuratetestisthePrussianbluestain Patienthasahistoryofalcoholabuse,exposuretolead,ortheuseof isoniazid(INH)

Treatment: Minorcasesrequireonlypyridoxinereplacement Severecasesrequiretheremovalofexposuretotoxin

MacrocyticAnemia Presentssimilarytomicrocyticanemiawithfatigue,pallor,lightheadedness, butiscausedbyadeficiencyofeithervitaminB12orfolicacid

VitaminB12Deficiency: SignsandSymptoms:

Parasthesias Peripheralneuropathies Dementiaistheleastcommonoccurrence

Diagnosis:

CBCwithperipheralsmear,payingspecialattentiontoneutrophils Neutrophilsarelargeandhypersegmented B12deficiencycanalsocauseglossitisanddiarrhea

Treatment:

ReplaceeitherfolateorvitaminB12

NOTE: Approx30%ofB12deficienciesshownormalB12levelsbecausetranscobalamine isanacutephasereactantwhichelevateswithanyformofstress.Thusisyou suspectB12deficiencyandlevelsarenormal,getamethylmalonicacidlevel.

 AfterfindinglowB12orelevevatedmethylmalonicacid,thebestconfirmatorytest isantiparietalcellantibodiesorantiintrinsicfactorantibodies(bothconfirm perniciousanemiaasthecauseofB12def). Treatment: **Folatedeficiencyismostcommonlycausedbyapoordiet,classicallydescribedas ateaandtoastdiet.Folatestoresdepletewithin3months,thuswithpoordiets thiscanbeseenquickly.Treatthiswithdietmodificationsandimmediatefolate replacement. Sickle Cell Anemia ReplaceB12orfolate

Patientpresentswithextremepaininthechest,back,andthighs Whenapatientpresentswithasicklecellcrisis,giveimmediateoxygen, normalsaline,andanalgesics. Ifpatientpresentswiththesesymptoms+fever,giveIVantibioticsaswell

 Whentodoexchangetransfusioninsicklecellpt? 1. 2. 3. 4. Whatcausessuddendropsinhematocritinsicklecellpt? EitherduetoafolatedeficiencyorparvoB19virus,whichcausesanaplastic crisis AllSicklecellptsshouldbeonfolatesupplements,thusifthatsthecaseitis duetoparvoB19 DoaPCRforDNAofparvoB19 Presenceofvisualdisturbancesduetoretinalinfarct. Pulmonaryinfarctleadingtopleuriticpainandabnormalxray. Priapismduetoinfarctofprostheticplexusofveins. Stroke

Treatment Whatshouldallsicklecellpatientswhoarebeingdischargedbegiven? Folatereplacement Pneumococcalvaccine Hydroxyurea(ThisincreaseshemoglobinF,stopssicklingofcells,and preventsfurthercrises) TransfusionandIVIG

HemolyticAnemia
Allformsofhemolyticanemiapresentwithasuddenonsetofweaknessandfatigue thatisassociatedwithanemia. Areprematuredestructionofredbloodcells Bonemarrowrespondsappropriatelybyincreasingerythropoiesisandthus thereisanincreaseinreticulocytecount Ifbonemarrowdoesntworkproperly,anemiawillensue

Hemolysiswillshowthefollowing: 1. Increasedindirectbilirubin(GetsreleasedwithRBCdestruction) 2. Increasedreticulocytecount(Determinesbonesmarrowsabilitytomake newRBCs) 3. IncreasedLDH 4. Decreasedhaptoglobin(orderedtodistinguishbetweenanemiaand hemolyticanemia) Intravascularhemolysiswillalsoshowthefollowing: 1. Abnormalperipheralsmear(Schistocytes,helmetcells,fragmentedcells) 2. Hemoglobinuria 3. Hemosiderinuria(Metabolic,oxidizedproductorhemoglobininurine). Causes:FactorsexternaltoRBCdefectsORintrinsicRBCdefects 1. FactorsexternaltoRBCdefects(Mostcasesacquired) Immunehemolysis Mechanicalhemolysis(causedbyprostheticheartvalves) Medications,burns,andtoxins

 2. HemolysisduetointrinsicRBCdefects(Mostcasesinherited) Autoimmune Hemolysis Diagnosis: MostaccuratetestisCoombstest LookforanincreasedLDHandincreasedreticulocytecount Lookattheperipheralsmearforspherocytes Patientoftenhasahistoryofautoimmunediseases,cancers,ormedication use Causedbysicklecelldisease,hemoglobindisease,thalassemias Membranedefectssuchashereditaryspherocytosis,paroxysmalnocturnal hemoglobinopathy EnzymedefectssuchasG6PDdeficiencyandpyruvatekinasedeficiency

Treatment: Thebestinitialtherapyisprednisone Withnoresponsetoprednisone,IVIGcanstopacuteepisodes Withrecurringepisodesofhemolysis,asplenectomyismosteffective

*NOTE:warmantibodiesarethecausehere,whicharealwaysIgG.OnlyIgG respondstosteroidsandsplenectomy.

 ColdInducedHemolysis(Coldagglutinins) Coombstestisnegative ThereisoftenamycoplasmaorEBVinfection Thereisnoresponsetosteroids,splenectomy,orIVIG

Hemolysisduetointrinsicdefects
Glucose6Phosphatedehydrogenasedeficiency Presentswithasevereandacuteonsetofhemolysis Isanxlinkeddisorder,thusseeninmales Mostcommonlythereisahistoryofsulfadrugs,primaquine,ordapsoneuse Ingestionoffavabeansisclassicallyaskedonboardexams

Diagnosis: Treatment: PyruvateKinaseDeficiency PresentsthesamewayasG6PDdeficiency,butthecauseisunknown Avoidanceofoxidativestress The best initial test is the peripheral smear that shows Heinz bodies and bite cells The most accurate diagnostic test is a glucose-6-phosphate level. The problem with this test is that it will only show up after 2 months, and is not a good test early on in an acute haemolytic episode

 HereditarySpherocytosis SignsandSymptoms: Jaundinceinchildhood Splenomegaly Bilirubingallstones Recurrentepisodes

Spherocytes Diagnosis: Themostaccurateandbestinitialtestistheosmoticfragilitytest Peripheralsmearshowingspherocytes

Treatment: Folicacidsupplementation Splenectomyforseveredisease

HemolyticUremicSyndrome(HUS) HUSinkids,thereisusuallyahistoryofE.Coli0157:H7

SignsandSymptom: Acuterenalfailure Abdominalpain

 Bloodydiarrhea Seizures

Treatment: ThromboticThrombocytopenicPurpura(TTP) IsanidiopathicdiseasethatisoftenseeninHIVpatients Dialysisinchildren,adultsthisisntusefulandthereisamuchpoorer prognosis

SignsandSymptoms: Thereisapentadof: Haemolyticanemia Renalfailure Fever Thrombocytopenia Neurologicaldiseases

Treatment: Plasmaexchangeuntilsymptomssubside Withouttreatmentthisisfatal

 ParoxysmalNocturnalhemoglobinuria(PNH) Presentswithrecurringepisodesofdarkurine,mostlyseeninthemorning. SignsandSymptoms: Pancytopenia Recurringepisodesofdarkurineinthemorning Portalveinthrombosisisacomplicationthatleadstodeath Mayprogresstocauseaplasticanemiaand/orAML

Diagnosis: Themostaccuratetestisthepresenceofdecayacceleratingfactorantibody

Treatment: Methemoglobinemia Bloodlockedintheoxidizedstatecannotpickupandtransportoxygen. Patientwillpresentwithshortnessofbreathwithnoreason Prednisoneorothersteroids

SignsandSymptoms: SOBwithnoknowncause(Therewillbeclearlungsonexamwithanormal CXR) Blood(ifseen)willhaveabrownishappearance,whichindicatesitislocked intheoxidizedstate.

 Diagnosis: Lookforexposuretodrugslikenitroglycerin,amylnitrate,ornitroprusside CXRandPEshownoreasonforSOB Lookforahistoryofanestheticuse

Treatment: Givemethyleneblue

Transfusion Reactions
1. ABOincompatibilitypresentswithacutesymptomsofhemolysiswhile thetransfusionishappening.Ex:duringatransfusion,apatientbecomes hypotensiveandtachycardic.Shehasbackandchestpain,andthereisdark urine.LDHandbilirubinareelevated,andhaptoglobinarelow. 2. Transfusionrelatedacutelunginjury(leukoagglutinationrxn) presentswithacuteSOBfromantibodiesinthedonorbloodagainstrecipient whitecells. 3. IgADeficiencypresentswithanaphylaxis.Infutureusedonationfrom IgAdeficientdonororwashedredcells. 4. Febrilenonhemolyticrxnresultsinasmallriseintemperatureand needsnotherapy,thereactionisagainstthedonorswhitecellantigens. Preventbyusingfilteredbloodtransfusioninfuture. 5. Minorbloodgroupincompatibilityresultsindelayedjaundice,no therapyneeded.

Leukemia
Acute leukemias present with signs of pancytopenia, such as fatigue, bleeding, and infections from non-functional white blood cells.

Acute Myelogenous Leukemia AUERRODS Mostlyoccurringinadults(upto80%)

Diagnosis: Thebestinitialtestisperipheralsmearshowingblasts

Treatment: BestinitialtherapyforAMLisIdarubicin(ordaunorubicin)andcytosine arabinoside

Acute Lymphoblastic Leukemia Themostcommonmalignancyinchildren Istheleukemiamostresponsivetotherapy IsaneoplasmofearlylymphocyticBcellprecursors Histologyrevealspredominanceoflymphocytes Poorprognosiswhenage<2or>9,WBCs>10^5,orCNSinvolvement

Diagnosis: Thebestinitialtestisperipheralsmearshowingblasts

Treatment: Idarubicin+cytosinearabinoside+intrathecalmethotrexate.

 AcutePromyelocyticLeukemia(M3) Thisleukemiaisassociatedwithdisseminatedintravascularcoagulopathy Treatment: ChronicMyelogenousLeukemia(CML) SignsandSymptoms: Elevated white cells that are predominantly neutrophils Splenomegaly is frequent. Untreated CML has the highest risk of transformation into acute leukemia of all forms of myeloproliferative disorders. AssociatedwithPhiladelphiaChromosome Idarubicin+cytosinearabinoside+alltransretinoicacid(ATRA)

Diagnosis: BestinitialtestisLeukocytealkalinephosphatasescore(LAPscore).An elevatedPMNcountwithlowLAPscoreisCML.Reactivehighwhitecounts frominfectiongiveanelevatedLAPscore,LAPisupinnormalcells,notCML. ThemostaccuratetestisfindingthePhiladelphiaChromosome

Treatment: BestinitialtreatmentisImatinib(Gleevec) BonemarrowtransplantistheonlycureforCML,butisneverthebestinitial therapy,becauseImatinibleadsto90%hematologicremissionwithnomajor adverseeffects.

 ChronicLymphocyticLeukemia(CLL) Seeninpeopleolderthen50yrofage SignsandSymptoms: Oftenasymptomatic Organomegaly Haemolyticanemia Thrombocytopenia

Diagnosis: Bestinitialtestistheperipheralsmearshowingsmudgecells

Treatment: Atstages0and1,thereisnotreatmentrequired Atadvancedstagesgivefludarabineorchlorambucil

Hairy Cell Leukemia Seeninmiddleagedpeopleandpresentswithmassivesplenomegalyand pancytopenia Diagnosis: Treatment: ThebestinitialtherapyforHairyCellleukemiaiscladribineor2CDA TheMostaccuratetestisthetartrateresistantacidphosphatase(TRAP) smearshowinghairycells

 Myelofibrosis PresentssimilarlytohairycellleukemiaexcepttherewillbeanormalTRAP level Thekeydiagnosticfeatureistheteardropshapedcellsonperipheral smear Thereisnospecifictherapyformyelofibrosis

Polycythemia Vera (Erythrocytosis) Thispresentswithheadache,blurredvision,dizziness,andfatigue.Alldueto thickenedblood SignsandSymptoms: Everythingabove Pruritisfollowinghotshowersorbathsduetohistaminerelease Splenomegaly

Diagnosis: VeryhighhematocritwithalowMCV GetanABGtoruleoutorinhypoxiaasacauseoferythrocytosis

Treatment: Thebestinitialtherapyisphlebotomy Hydroxyureacanbegiventolowerthecellcount Givedailyaspirin

 PLASMA CELL DISORDERS

Multiple Myeloma Thisconditionpresentsmostcommonlywithbonepainduetofracturesoccurring fromnormaluse Diagnosis: Themostspecifictestisabonemarrowbiopsy Skeletalsurveytodetectpunchedoutosteolyticlesions Serumproteinelectrophoresis(SPEP)tolookforelevatedmonoclonal antibody(usuallyIgG) Urineproteinelectrophoresis(UPEP)todetectsBenceJonesproteins Peripheralsmearshowingrouleauxformationofbloodcells. Elevatedcalciumlevelsduetoosteolyticlesions Beta2microglobulinlevelisaprognosticindicator BUNandCreatininetodetectrenalinsufficiency

Treatment: SteroidsandMelphalan Themosteffectivetherapyisbonemarrowtransplant Treatallunderlyingcomorbidities

 Waldenstroms Macroglobulinemia ThisisahyperviscosityofthebloodduetooverproductionofIgM SignsandSymptoms: Blurredvision Confusion Headache Enlargedlymphnodes Splenomegaly

Diagnosis: Thebestinitialtestistheserumviscosity(increasedsignificantly)andSPEP forIgMlevels TherewillbenospecificfindingontheCBC

Treatment: Aplastic Anemia Presentsaspancytopeniawithnoidentifiableetiology. Ifptis<50andhasamatch,besttherapyisBMtransplantation. IfBMtransplantisntanoption(>50),giveantithymocyteglobulinand cyclosporine. Plasmapharesisisthebestinitialtherapy Canalsogivefludarabineorchlorambucil

 LYMPHOMAS

Present with enlarged lymph nodes that are most commonly seen in the cervical area Hodgkins disease occurs in a bimodal age distribution (young and old), and is characterized by Reed-Sternberg cells

Reed-Sternberg Cell

NonHodgkinsdiseaseiscommonlyseeninHIVpatients Diagnosis: Onceexcisionalbiopsyshowsabnormalarchitecture,furthertestingtodetermine stageofthelymphomaneedstobedone. 1. 2. 3. 4. HDandNHLpresentwithstagesasfollows: HD8090%presw/stage1and2 NHL8090%presw/stages3and4 Stage1singlelymphnodegroup Stage22LNgroupsononesideofdiaphragm Stage3LNinvolvementonbothsidesofdiaphragm Stage4widespreaddisease Thebestinitialdiagnostictestforbothtypesoflymphomasislymphnode biopsy

 Howtostage:CXR,CTwithcontrast(Chest/abdomen/pelvis/head),andBMbiopsy. Treatment: 1. Localizeddisease(stage1,2)withoutB symptomsistreatedpredominantlywith radiation. 2. Moreadvancedstages3,4istreatedwith chemotherapy. Specifictreatments: Aresystemicsymptoms suchas: FEVER NIGHTSWEATS BSYMPTOMS:

1. HD:ABVD(adriamycin[doxorubicin],bleomycin,vinblastine,dacarbazine) WEIGHTLOSS 2. NHL:CHOP(cyclophosphamide,hydroxyadriamycin,oncovin[vincristine], andprednisone) *AlsotestforantiCD20antigenandifpresent,addRituximab,whichadds efficacytoCHOP.

 COAGULATION DISORDERS

VonWillebrandsdisease(VWD) Isduetoplateletdysfunction,notalowernumberofplatelets Bleeding from PLT dysfunction, superficial bleeds from skin and mucosal surfaces, such as gingival, gums, and vagina. Epistaxis common Bleedingoftenworsenedwithuseofaspirin PLTcountisnormal

Diagnosis: Treatments: Platelettypebleedingcauses:petechiae,epistaxis,purpura,gingival,gums, vaginal Factortypebleedingcauses:hemarthroses,hematoma IdiopathicThrombocytopenicPurpura(ITP) ITPisadiagnosisofexclusionthatpresentswithplatelettypebleedinganda plateletcountof<50,000 FirstlinetreatmentisdesmopressinorDDAVP,whichcausesthereleaseof subendothelialstoresofVWFandcofactorVIII Ifdesmopressindoesntwork,givefactorVIIIreplacement Bestinitialtestisplateletfunctiontest ThemostaccuratetestisaristocetincofactorassayandaVWFlevel(IfVWF isnormal,ristocetintellsyouifitisworkingproperly)

 Diagnosis: Performasonogramtoassessthesizeofthespleen Checkforantiplateletantibodies Bonemarrowbiopsylookingformegakaryocytes AntibodiestoglycoproteinIIb/IIIareceptors

Treatment: Uremia-Induced PLT dysfunction Thispresentsasplatelettypebleedinginapatientwithrenalfailure,whererenal failurecausesuremia,whichpreventsthedegranulationofplateletsandthusstops themfromworking SignsandSymptoms: Platelettypebleeding WithmildITP(plateletsof~20,000)giveprednisone WithsevereITP(plateletsof<20,000)giveIVimmunoglobulins,whichisthe fastestwaytoincreasetheplateletcount NEVERtransfuseplateletsbecausethisexacerbatesthecondition

Diagnosis: RistocetinandVWFlevels(normal) Checkplateletlevels(Theywillbenormal) Lookforrenalfailure(Thisisthekeytodiagnosing)

Treatment: Desmopressin

 HeparinInducedThrombocytopenia(HIT) Aconditionwhereplateletsdropatleast50%afewdaysaftertheuseofheparin SignsandSymptoms: Diagnosis: Thebestinitialdiagnostictestisplateletfactor4antibodies Otherimportanttestisheparininducedantiplateletantibodies Themostcommonclinicalmanifestationisthrombosis,wherevenous thrombosisisthemostcommontype

Treatment: Thebestinitialtherapyistostopheparinandusedirectthrombininhibitor suchasargatrobanorlepirudin.

Chapter 15
Rheumatology

 RheumatoidArthritis Anautoimmunediseasepresentsmostcommonlyinfemales>50. Jointpainandmorningstiffnessthatissymmetricalandinmultiplejointsof thehands. Lastslongerthan1hrinthemorningwithsymptomaticepisodesgoingonfor atleast6weeks. Oftenaprodromeoffatigueandmalaise,butthisisntenoughforacleardx.

Diagnosisisbasedonhaving4ormoreofthefollowing: Morningstiffnesslastingmorethan1hr Wristandfingerinvolvement Swellingofatleast3joints Symmetricinvolvement Rheumatoidnodules Xrayabnsshowingerosions (+)rheumatoidfactor

Rheumatoidarthritisisagroupofphysicalfindings,jointproblems,andlabtests. Thereisnosinglediagnosticcriteriatoconfirmthediagnosis,noristhereonesingle therapytocontrolandtreatthedisease. Diagnosis: JointFindings: MCPswellingandpain Boutonierredeformity:flexionofPIPw/hyperextensionoftheDIP Swanneckdeformity Bakerscyst Thesinglemostaccuratelabtestistheanticitrullinatedcyclicpeptide(anti CCP) Normocytic,normochromicanemiaisverycharacteristicofrheumatoid arthritis

 Treatment: SeronegativeSpondyloarthropathies 1. 2. 3. 4. Thisgroupofinflammatoryconditionsallthefollowingcharacteristics: NegativeforRF Predilectionforthespine SIjointinvolvement AssociatedwithHLAB27 Ankylosingspondylitis Reactivearthritis(Reiterssyndrome) Psoriaticarthritis JuvenileRA NSAIDsandDiseasemodifyingantirheumaticdrugs(DMARDS) SteroidscanbeusedacutelytohelpcontrolthediseasewhileDMARDstake effect,buttheyareonlyusedasabridgetoDMARDtherapy,notusedlong term C1/C2cervicalspinesubluxation Knee:althoughkneeiscommonlyinvolved,multiplesmalljointsareinvolved morecommonlyovertime.

AnkylosingSpondylitis(AS) ASpresentsinayoungmale(<40)w/spineorbackstiffness. Peripheraljointinvolvementislesscommon Painisworseatnightandrelievedbyleaningforward,whichcanleadto kyphosisanddiminishedchestexpansion. Rarefindingsinclude:uveitisandaortitis.

 Diagnosis: Thebestinitialtestisanxray ThemostaccuratetestisanMRI

Treatment: NSAIDS Sulfasalazine Biologicalagents(Infliximab,Adalimumab)

ReactiveArthritis(formerlyReiterssyndrome): Diagnosis: Clinicaldiagnosisbasedonthepresenceoftheclassictriadofurethritis, conjunctivitis,andarthritis PresentswithasymmetricarthritisandahistoryofurethritisorGIinfection. Patientmayhaveconstitutionalsymptomssuchasfever,malaise,andweight loss.

Treatment: NSAIDs

 PsoriaticArthritis: Presentsasjointinvolvementwithahistoryofpsoriasis. Rheumatoidfactor() SIjointisinvolved.

Keyfeaturesofthisdiseaseare: Pittingofthenails Involvementofthedistalinterphalangealjoints Sausageshapeddigits

Treatment: InitialtreatmentshouldbewithNSAIDs Ifthisisntworking,addbiologicalagentssuchasInfliximab Ifthesedontwork,trymethotrexate

JuvenileRA(akaadultonsetStillsdisease) Thereisnospecificdiagnostictest. JRAischaracterizedbythefollowing: Ferritinlevelsarehigh WBCcountiselevated RF()andANA()

Treatment: NSAIDs IfunresponsivetoNSAIDs,givemethotrexate

 WhipplesDisease Causesdiarrheaandfatmalabsorbtion,andismostcommonlypresented withjointpain Themostspecifictestfordiagnosisisabiopsyofthebowel

Treatment: Osteoarthritis Osteoarthritisisthemostcommonjointabnormalityandisassociatedwith excessivejointusageandincreasedage SignsandSymptoms: Morningstiffnesslasting<30minutes Jointcrepitusseen Affectsthedistalinterphalangealjoint(whereasRAdoesnot) HeberdensnodesareseenasDIPosteophytes BouchardsnodesareseenasPIPosteophytes TMP/SMX

Diagnosis: Thebestinitialdiagnostictestisanxrayofthejoint

Treatment: NSAIDs Glucosaminesulphateandchondroitinsulphateareusedtoslowjoint deterioration.

 MorningStiffness DIP PIP MCP RF,antiCCP Jointfluid OA <30min YES YES NO NO <2000 RA >1hr NO YES YES YES 500050000

 SLE Classically,arash+jointpain+fatigue=Lupus Thereare11criteriaforLUPUS,4mustbepresenttomakethediagnosis. SKIN - MalarRash - Photosensitivityrash - Oralulcersrash - Discoidrash Presentin90%ofpts Leukopenia,thrombocytopenia, hemolysis.Anybloodinvolvement countsas1criteria. VariesfrombenignproteinuriatoESRD. Behaviorchanges,stroke,seizure, meningitis Pericarditis,pleuriticchestpain, pulmonaryHTN,pneumonia, myocarditis. - ANA(95%sensitive) - DSDNA(60%sensitive) Eachoftheserologicabnscountas1 criteria.Ifpersonhasjointpain, rash,andbothANAandDSDNA,the pthas4criteria.

Arthralgias Blood

Renal Cerebral Serositis

Serology

Diagnosis: ThebestinitialdiagnostictestistheANA ThemostspecifictestistheantidsDNAorantiSmithantibody

Howtofollowtheseverityofalupusflareup? 1. Complementlevelswilldropinflareup 2. antidsDNAwillriseinflareup

 Treatment/Management: DruginducedLupus Themostlikelycausesofdruginducedlupusarehydralazine,procainamide,and isoniazid Diagnosis: Therewillbeantihistoneantibodies ThereisneverrenalorCNSinvolvement TherearenormallevelsofcomplementandantidsDNAantibodies Foracuteflareupsgiveprednisoneandotherglucocorticoids GiveNSAIDsforjointpain Ifthereisnoresponsetothosemedications,antimalarialsand hydrochloroquinewillwork Forseverediseasethatrecursgivecyclophosphamideandazthioprine

Sjorgenssyndrome Seenmostcommonlyinwomen(9xgreaterinwomenthanmen) SignsandSymptoms: Dryeyes,drymouth Thereisasensationofsandundertheeyes Dysgeusiaiscommon Commonlyalossofteethduetothelackofadequatesaliva

 Diagnosis: Themostaccuratetestisalipbiopsy TheSchirmertestiswillshowinadequatelacrimation CommonlyseeantiRoorantiLaantibodies

Treatment: Scleroderma Patienthastightskin,heartburn,andRaynaudsphenomenon SignsandSymptoms: Skinfindingsincludeatight,fibrousthickeningthatcausestightand immobilefingersaswellasatightface JointPainthatismildandsymmetrical RaynaudsPhenomenon,mayresultinulcerations PilocarpinetoincreaseAchandthusincreaselacrimationandsalivary secretions

Sclerodermacanpresentdiffuselywiththefollowing: Lungs:fibrosisandpulmonaryHTN(theleadingcausesofdeathinthisdisease) GI:Widemouthcolonicdiverticulaandesophagealdysmotility,leadingtorefluxand Barrettsesophagus.15%ofptsgetprimarybiliarycirrhosis Heart:Restrictivecardiomyopathy

 Renal:mayleadtomalignantHTN. Diagnosis: Thereisnotasinglebestdiagnostictest Thoughnotspecific,ANAisseenin95%ofcases

Treatment: Thereisnotreatmentthatslowstheprogressionortreatsthiscondition IfthereisrenalinvolvementgiveACEIs Ifthereispulmonaryhypertension,giveBosentanandprostacyclinanalogs ForRaynaudsgivecalciumchannelblockers

EosinophilicFasciitis IssimilarinpresentationtosclerodermabutthereisnoRaynauds,noristhereany oftheothersystemicfindings SignsandSymptoms: Thickenedskinsimilartoscleroderma Markedeosinophiliagivestheappearanceofpeaudorange

Treatment: Managethisconditionwithcorticosteroids

 Polymyositis(PM)andDermatomyositis(DM) In both conditions, the patient cannot get up from a seated position without using the arms. There can also be muscle pain and tenderness. ForpolymyositisWeakness+increasedCPK+increasedaldolase FordermatomyositisWeakness+increasedCPK+increasedaldolase+skin rash. Diagnosis: Clinical ShouldorderLFTsandANA

Treatment: Fibromyalgia Apainsyndromeseenmostlyinfemalesthatpresentswithachingmuscles, stiffness,triggerpointsforpain,andsleepthatisntrefreshing SignsandSymptoms: Muscleaches Musclestiffness Depressionand/oranxiety Extremesensitivityandpaintotriggerpointsonthebody Corticosteroids

Diagnosis:

 Normalbloodtestsandnoobjectiveevidenceofdisease

Treatment/Management: Exercisecanhelprelievesomepainandstiffness TCAscanbegiven

PolymyalgiaRheumatica(PMR) Seenmostcommonlyinthose>50yr SignsandSymptoms: Patientolderthan50yrwithsignificantpainandstiffnessoftheproximal muscles(shoulders,pelvicgirdle) Stiffnessisusuallyworseinthemorningandisusuallymorelocalizedtothe muscles Patientmayhavefever,malaise,andweightloss

Diagnosis: CBCwilllikelyshownormocyticanemia Musclebiopsyandlabsareallnormal

 Lackofmuscleatrophy

Treatment:Steroids Followingexplainsdifferencebetweenchronicfatigue,fibromyalgia,andPMR Fatigue/malaise Nonrefreshing sleep Triggerpoints Bloodtests Treatment Vaculitis Commonfeaturesamongdifferenttypesofvasculitisinclude: Fatigue,malaise,wtloss Fever Skinlesionssuchaspalpablepurpuraandrash Jointpain Neuropathy Chronicfatigue syndrome +++++>6mnth +++++ NO Allnormal None Fibromyalgia ++ ++ YES Allnormal Painrelief ++ No NO IncrESR Prednisone Polymyalgia rheumatica

Commonlabfindings: Normocyticanemia ElevatedESR Thrombocytosis

 Diagnosis: Themostaccuratetestisabiopsy

Treatment: Thebestinitialtherapyissteroids

Ifsteroidsarenteffective,alternateand/oradditionaltherapiesarethefollowing Cyclophosphamie Azathioprine/6mercaptopurine Methotrexate

PolyarteritisNodosa(PAN) PANhasallthefeaturesofvasculitisdescribedabove,whatdifferentiatesitisthe uniquefeaturesthataccompanyPAN. Abdominalpain(65%) Renalinvolvement(65%) Testicularinvolve(35%) Pericarditis(35%) HTN(50%)

Diagnosis: Thebestinitialtestisangiographyoftheabdominalvessels Themostaccuratetestisabiopsyofthemuscles,suralnerve,andskin

Treatment: PrednisoneandCyclophosphamide

 WegenersGranulomatosis A disorder that like PAN can affect the majority of the body. Look for the addition of upper and lower respiratory findings and the presence of c-ANCA Diagnosis: The most accurate diagnostic test is a biopsy Upper and lower respiratory findings Presence of c-ANCA

Treatment: ChurgStrauss Canaffectanyorganinthebody,butthekeytomakingitsdiagnosisis presenceofvasculitis,eosinophilia,andasthma. PANCAandantimyeloperoxidasecanbepositivetoo,butthesefindings arentasuniqueasthepresenceofeosinophilia. Mostaccuratetestisbiopsy Treatment involves Prednisone and Cyclophosphamide

Treatment: Steroids

 TemporalArteritis A type of giant cell arteritis, related to PMR. Signs and Symptoms: Fever Malaise Fatigue Weight loss Headache Visual disturbances Jaw claudication

Diagnosis: Elevation of ESR Clinical findings

Treatment: TakayasusArteritis Seeninyoungasianfemales SignsandSymptoms: Dimishespulses Vasculitiscommonlyseenbeforelossofpulse PatientoftengetsTIAand/orstrokecausedbythevascularocclusion Steroids

Diagnosis: MRAorarteriography

 Treatment: Cryoglobulinemia Issimilartotovasculitissyndromes,thedifferenceistheassociationwithhepatitis Candkidneyinvolvement Treatwithinterferonandribavirin BehcetDisease This condition presents in pts of Middle Eastern or Asian ancestry. Signs and Symptoms: Oralandgenitalulcers Ocularinvolvementthatcanleadtoblindness Skinlesions:pathergywhichishyperreactivitytoneedlesticks,resultingin sterileskinabscesses. Diagnosis: Thereisnospecifictestfordiagnosis,wemustusethefeaturesseenabove Steroids

Treatment: Prednisoneandcolchisine

 INFLAMEDJOINTS Thekeytodiagnosinginflamedjointsistolookatthefluidwithinthejoint.Itisthe mostaccuratediagnostictestforgout,pseudogout,andsepticarthritis Synovialfluidcellcount Normal <2000WBCs Gout Look for a man with a sudden onset of severe pain in the toe at night. The toe will be red, swollen, and tender. Things that precipitate a gouty reaction are: Diagnosis: Thebestinitialtestisaspirationofthejointfluid Themostaccuratetestislightexamofthefluidshowingnegatively birefringentneedleshapedcrystals Alcohol ingestion Thiazide diuretics Nicotinic acid Foods high in protein Inflammatory(gout/pseudogout) 200050000WBCs Infectious >50000WBCs

Treatment: ThebestinitialtherapyforanacutegoutyattackisNSAIDs. Givecolchisinewithin24hroftheattack

 Pseudogout(CalciumPyrophosphateDepositionDisease) Involvesmostcommonlythewristandknees,butdoesntinvolvethetoes Onsetismuchslowerthangout,anddoesntacutelyattackthepatient Allopurinolisbestasprophylaxisandpreventionoffutureattacks,which worksbyreducingthelevelsofuricacid

Diagnosis: Treatment: NSAIDsarethebestinitialtherapy Cangivecolchisine,butisnotaseffectivehereasitisingout Aspirationofjointfluidshowspositivelybirefringentrhomboidshaped crystals

SepticArthritis Anyarthriticorprostheticjointputpatientatriskofsepticarthritis Withincreasedjointabnormalitycomesincreasedriskofsepsis

Moreriskfactorsforsepticarthritis: Osteoarthritisismoreofariskthanhavingnormaljoints RAismoreofariskthanosteoarthritis Prostheticjointsaremoreofariskthananythingelse.

SignsandSymptoms: Red,swollen,tender,immobilejoint

 Mostcommoncausesofsepticarthritis: Staphaureus(40%) Strep(30%) Gramvebacilli(20%)

**Septicarthritisrequiresconsultw/orthopaedicsurgeon. Diagnosis: Thebestinitialtestisarthrocentesisshowing>50,000WBC Themostaccuratetestisacultureofthefluid

Treatment: PagetsDiseaseofBone Aconditionwithpain,stiffness,aching,andfracturesassociatedwithsofteningof thebones. SignsandSymptoms: Stiffness Pain Fractures Bowingofthetibias EmpiricIVantibioticssuchasCeftriaxoneandVancomycinoncesuspected

Diagnosis: Thebestinitialtestisfortheelevationofalkalinephosphatase Themostaccuratetestisxrayofthebones

Treatment: Besttreatedwithbisphosphonatesandcalcitonin

 *IncasesofPagets,osteolyticlesionswillbefoundinitially.Thesemaybereplaced withosteoblasticlesions **IfyouseeosteolyticthinkPagetsorosteoporosis ***Ifyouseeosteoblastic,thinkaboutmetastaticprostatecancerindifferential. BakersCyst Aposteriorherniationofthesynoviumoftheknee SignsandSymptoms: Patientoftenhasosteoarthritis Palpationofthesacintheposteriumoftheknee Swellingofthecalfiscommon(excludeaDVTwhenyouseethis)

Treatment: NSAIDSaremainstayoftreatment Severecasesmayrequiresteroidinjections

 PlantarFasciitisandTarsalTunnelSyndrome Followingtablecomparesthetwoconditions: PlantarFasciitis Painonbottomoffoot Verysevereinmorning,betterw/ walkingafewsteps Stretchthefootandcalf Resolvesspontaneouslyovertime Tarsaltunnelsyndrome Painonbottomoffoot Morepainfulw/use;mayhavesole numbness Avoidbootsandhighheels;mayneed steroidinjection Mayneedsurgicalrelease

Chapter 16 Neurology

 StrokesandTIA Strokes: Strokesoccurforgreater24hrandhavepermanentresidualneurological deficits. Causedbyischemiamostcommonly,andhemorrhagic. Ischemicstrokesoccurfromemboliorthrombosis,whichoccurmoreacutely

TIA: Diagnosing: ThebestinitialtestisalwaysaCToftheheadwithoutcontrast Presentsthesameasastrokeexceptitlasts<24hr. Commonlypresentswithalossofvisioninonlyoneeye(Amaurosisfugax), duetoemboliinthefirstbranchoffofthecarotid(Ophthalmicartery) TIAsarealwaysduetoemboliorthrombosis,neverhemorrhage

Treatment: *Thereisnoclearevidencethatheparinbenefitsastroke Ifpossible,givethrombolyticswithin3hrsoftheonsetofsymptomsandthe CThasruledouthemorrhage Aspirinisthebestinitialtherapyforthosewhocomeintoolatefor thrombosis Ifpatientisalreadyonaspirin,cangivedipyridamole(Clopidogrelisan alternative)

 Arteriesandtheirassociatedsymptomsinstroke: CEREBRALARTERY Anteriorcerebralartery SYMPTOMS profoundlowerextremityweakness mildupperextremeweakness personalitychanges urinaryincontinence profoundupperextremity weakness - aphasia - apraxia/neglect - eyesdeviatetowardslesionside* - contralateralhomonymous hemianopiaw/macularsparing - prosopagnosia(cantrecognize faces) - vertigo - N/V - Verticalnystagmus - Dysarthriaanddystonia - Sensorychangesinface/scalp - Ataxia - Labilebloodpressure - mustbeabsenceofcortical deficits** - Parkinsonsigns - Hemiparesis(mostnotablein face) - Sensorydeficits - Possiblebulbarsigns amaurosisfugax -

Middlecerebralartery

Posteriorcerebralartery

Vertebrobasilarartery

Lacunarinfarct

Ophthalmicartery FurthermanagementofaStrokeorTIA:

Afterallinitialmanagementsareimplemented,dothefollowing:

 Echocardiogram CarotidDoppler EKGandHoltermonitoriftheEKGcomesbacknormal

Youngpts<50yrwithnosignificantpastmedicalhistory(DM,HTN)shouldhave followingdone: 1. 2. 3. 4. *Theyoungerthepatient,themorelikelythecauseofstrokeisavasculitisor hypercoagulablestate. ControlHTN,DM,andhyperlipidemiainthispt: Goals: HTN:<130/80 DM:sametightglycemiccontrolasgenpopn Hyperlipidemia:LDL<100 Sedimentaionrate VDRLorRPR ANA,dsDNA ProteinC,proteinS,factorVleidenmutation,antiphospholipidsyndromes

TIA: Samemanagementasperstroke,exceptthrombolyticsarentindicatedbecausethe administrationofthrombolyticsaretoresolvesymptoms,soifsymptomsare resolvedtheyarentnecessary.

 SEIZURES

Forseizuredisorders,theonlycleardiagnosticcriteriaisforapatientundergoing statusepilepticus. Therapyforstatusisasfollows: 1. 2. 3. 4. Diagnosisinapatienthavingaseizure: UrgentCTofthehead Urinetoxicologysecreen Chemistrypanel Calciumlevels Magnesiumlevels BenzodiazepinesuchasAtivan(Lorazepam) Ifseizurepersists,addfosphenytoin Ifseizurepersists,addphenobarbitol Ifseizurepersists,givegeneralanestheticsuchaspentobarbital.

Furthermanagement: Longtermtreatmentoffirsttimeseizures: Chronicantiepileptictherapy: Thereisnosingleagentconsideredtobethebesttherapy. Ifpatientonlyhad1seizure,chronictherapyisnotrequiredunlessthereisa strongfamilyhistory,anabnormalEEG,orstatusepilepticus Ifinitialtestsdontgiveclearcause,doanEEG(shouldntbedonefirst). Neurologyconsultrequiredinanypatienthavingorwhohadaseizure.

 1stlinetherapiesinclude: Valproate,carbamazepine,phenytoin,andlevetiracetamareallequalin efficacy. Lamotriginehassameefficacybutcancausestevenjohnsonsyndrome.

2ndlinetherapies: Gabapentinandphenobarbitol Forabsence/petitmalseizures: Ethosuxamideisbest.

ParkinsonsDisease
Isagaitdisorderwiththefollowingfindings: Cogwheelrigidity Restingtremor Masklikefacies Orthostasis Intactcognitionandmemory

Diagnosis: ThereisnospecifictesttomakethediagnosisofPD,rathertheclinical findingsarewhatisusedtomakethediagnosis

Treatment: Mildsymptoms: Severesymptoms: **Ifthesemedicationdontwork,useCOMTinhibitors(Tolcapone,Entacapone) whichinhibitmetabolismofdopamine,whichextendstheeffectofdopaminebased medication.CanalsotryMAOIs. Levedopa/carbidopahavethegreatestefficacybuthasanonoff phenomenonwithunevenlongtermeffectsandmoresideeffects DopamineagonistssuchasPramiprexole,Ropinerole,andCabergolineare lessefficaciousbuthavefewersideeffects Inapatient<60yrofageAnticholinergicssuchasBenztropineor Hydroxyzine Inapatient>60yrofageAmantadine(Olderpatientscommonlydevelop badreactionfromanticholinergicmedications)

 TREMOR Typeoftremor Restingtremor Intentiontremor Tremoratrest andwith intention Essentialtremor Propranolol

Diagnosis Treatment

Parkinsons Amantadine

Cerebellardisorder Treatetiology

MULTIPLE SCLEROSIS MultipleSclerosispresentswithabnormalitiesofanypartoftheCNS.The symptomsimproveandresolve,onlytohaveanotherdefectdevelopmonthsor yearslater. SignsandSymptoms: Diagnosis: ThebestinitialdiagnostictestisanMRI ThemostaccuratetestisalsotheMRI IftheMRIdoesntgiveyouthediagnosis,doalumbartap Themostcommonabnormalityisopticneuritis Thereiscommonlyfatigue,hyperreflexia,spasticity,and depression Thereisalsocommonlyopticneuritis SIN 1. Scanning speech 2. Intention tremor 3. Nystagmu s Multiple Sclerosis:

Treatment: Steroidsarethebestinitialtherapytoresolveanacuteexacerbation GlatiramerandbetainterferoncanbothdecreasetheprogressionofMS

 CangiveAmantadinetocombatfatigueandBaclofentocombatspasticity

DEMENTIA AlzheimersDisease Isaslowprogressivelossofmemoryexclusivelyinpts>65yrsofage Diagnosis: AnybodywithmemorylostrequiresaCTofthehead,aTSHlevel,andan RPR/VDRL WithAlzheimersdiseaseyouwillonlyseediffuseandsymmetricalatrophy

Treatment FrontotemporalDementia(PickDisease) Personalityandbehaviourbecomeabnormalfirst,thenmemoryloss afterwards. HeadCTorMRIshowsfocalatrophyoffrontalandtemporallobes TreatthislikeAlzheimers,butdonotexpectthesametypeofresponse Anticholinesteraseinhibitorsarethestandardtherapyofchoice

CreutzfeldJakobDisease(CJD) Causedbyprions,whicharetransmissibleproteinparticles. Manifestsasrapidlyprogressivedementiaandpresenceofmyoclonus. ThispresentsinthoseyoungerthantheAlzheimerspatient EEGwillbeabnormal Mostaccuratetestisbrainbiopsy CSF:shows1433protein,thepresenceofthiswillsparethepatientabrain biopsy.

 LewyBodyDementia: IsParkinsonsdisease+dementia. NormalPressureHydrocephalus: Thisconditiongenerallypresentsinoldermales,butitcanaffectwomenas well. Itpresentsasapersonwithincontinence,withgaitabnormalities,andwith cognitiveimpairment

Diagnosis: DiagnosisshouldincludeaheadCTandalumbarpuncture

Treatment: HuntingtonsDisease/Chorea Presentsinyoungpatients(usuallyin30s) Thereisusuallyafamilyhistory Shuntplacement

Symptoms: Dementia Personalitychangesandpsychologicaldisturbance Choreicmovements

Diagnosis: Specificgenetictestingwillshowthatinheritanceisautosomaldominant

 Treatment: Thereisnotreatment

 HEADACHE

Migraine:60%areunilateral,oftentriggeredby:cheese,caffeine,menses,OCPs DoaCTorMRIifHAhasanyofthefollowing: Treatment: Thebestinitialabortivetherapyissumatriptanorergotamine Prophylactictherapytakes46wkstowork,ifpatientgetsfourormoreHA permonth,prophylaxwithpropranolol. AlternateprophylacticswithCCBs,TCAs,orSSRI. Suddenand/orsevere Onsetafter40yr Associatedwithanyneurologicalfindings Maybepreceededbyanauraand/orscotomata(Darkspotsinvisualfield), andabnormalsmells

Cluster:10xmorefrequentinmenthanwomen.Areexclusivelyunilateralw/ rednessandtearingoftheeyeandrhinorrhea. Treatment: Thebestabortivetherapyis100%02. ThistreatmentisuniquetoclusterHAs. Sumatriptancanalsobeusedinsamewayasisinmigraines.

Prophylactictherapy:thereisnonebecausetheseHAsarenumerousbutshortand intense,andtheclusterwouldbeoverbythetimetheprophylaxiskickedin.

 HAType Gender Presentation Abortive Prophylactic *Sumatriptanissimilarto5HT,andworksbycausingvasoconstrictionincerebral arteries. TemporalArteritis Patientwillpresentwithtendernessoverthetemporalareaandmayalsocomplain ofjawclaudication Diagnosis: FirstchecktheESR Themostaccuratetestisabiopsyofthetemporalartery MIGRAINE Unilateralorbilateral, aura Sumatriptan Propranolol CLUSTER Men10xmorethan women Onlyunilateral, tearing/rednessofeye Sumatriptan,Special: 100%02 none

Treatment: Givesteroidsimmediately,donotdelayifthisissuspected

 PseudotumorCerebri Thispresentsmostcommonlyinayoungerwomanwithaheadacheand doublevision,papilledema CT/MRIshowupnormal VitaminAuseisoftenthecause

Diagnosis: LPisthemostaccuratetestbecauseitshowsanelevatedopeningpressure

Treatment: Involvesweightloss Acetazolamidecanalsobegiven

Dizziness/Vertigo Allptswithvertigowillhaveasubjectivesensationoftheroomspinning aroundthem. Oftenassociatedwithnauseaandvomiting Allptswithvertigowillhavenystagmus GenerallyallpatientswtihvertigoshouldhaveMRIoftheinternalauditory canal.

 Followingtablesummarizespresofanumberofvertigocausingconditions: Disease BPV Vestibularneuritis Labyrinthitis Menieresdisease Acousticneuroma Perilymphfistula BPV Vertigoalonew/nolossofhearing,notinnitus,noataxia. Positivedixhallpikemaneuver Treatwithmeclizine(antivert) Characteristics Changesw/position Vertigooccursw/o positionchange Acute Chronic Ataxia Hxoftraum HearingLoss/Tinnitus NO NO YES YES YES YES

VestibularNeuronitis AnidiopathicinflammationofthevestibularportionofCN8. Nohearinglossortinnitusbecauseonlyvestibibularportionisaffected. Mostlikelytobeaviralcause Notrelatedtochangeinposition Treatwithmeclizine

 Labyrinthitis Isinflammationofthecochlearportionoftheinnerear. Thereishearinglossaswellastinnitus. Isacuteandselflimited Treatwithmeclizine

MenieresDisease AcousticNeuroma AtumorofCN8thatcanberelatedtoneurofibromatosis(von Recklinghauss). Presentswithataxiainadditiontohearingloss,tinnitus,andvertigo. Samepresaslabyrinthitis(vertigo,tinnitus,hearingloss)butmenieresis chronicwithremittingandrelapsingepisodes. Treatwithsaltrestrictionanddiuretics.

Diagnosis: MRIofinternalauditorycanal

Treatment: Surgicalresection.

 PerilymphaticFistula Headtraumaoranyformofbarotraumastotheearmayrupturethe tympanicmembraneandleadtoaperilymphfistula.

Wernicke-Korsakoff Syndrome Presentswiththefollowing: 1. 2. 3. 4. 5. 6. Diagnosis: DoaheadCT VitaminB12level TSH/T4level RPR/VDRL Presenceofmemoryloss HistoryofchronicheavyETOHuse Confusionwithconfabulation Ataxia Memoryloss Gazepalsyand/orophthalmoplegia Nystagmus

Treatment: 1stgivethiaminethengiveglucose.

 CNSINFECTIONS OftenwhenaCNSinfectionissuspected,aheadCTshouldbeperformedbeforethe LP. Thisisthecaseinthefollowingcircumstances: AhistoryofCSNdisease Focalneurologicaldeficits Presenceofpapilledema Seizures Alteredconsciousness SignificantdelayinabilitytoperformLP

**Ifthesearepresent,getbloodculturesandstartempiricantibioticsbefore orderingCT. CSF: GettingCSFisthemostaccuratetestforbacteriameningitis,butcannotwait forculturetostarttherapy. Gramstain:only50%sensitive,thusif()cannotexcludeanything.Ishighly specificthough,soif(+)itislikelytobebacteriameningitis.Ie.Goodspec badsensitivity Gram(+)diplococci:pneumococcus Gram(+)bacilli:listeria Gram()diplococci:neisseria Gram()pleomorphic,coccobacillaryorganisms:hemophilus

Protein:AnelevatedproteinlevelinCSFisofmarginaldiagnosticbenefit.Elevated proteinisnonspecificbecauseanyformofCSNinfectioncanelevatetheCSF protein.However,anormalCSFproteinexcludesbacterialmeningitis. Glucose:Levelsbelow60%ofserumlevelsisconsistentw/bacterialmeningitis

 Cellcount:Thisisbestinitialtestforthediagnosisofmeningitis.Ifthousandsof PMNsarepresentstartIVceftriaxone,vancomycin,andsteroids.Thousandof PMNsisbacterialmeningitisuntilprovenotherwise. Cryptococcus(fungalmeningitis) LookforHIV(+)patientwith<100CD4cells. Thisinfectionisslowerthanbacterialmeningitisandmaynotgivesevere meningealsigns(neckstiffness,photophobia,andhighfever,allatsame time).

Diagnosis: ThebestinitialtestistheIndiainkstain Themostaccuratetestisthecryptococcalantigen

Treatment: ThebestinitialtherapyisAmphotericin

*followAmphotericinwithoralFluconazole(continuedindefinitelyuntiltheCD4 countraises),onceCD4count>100,fluconazolecanbediscontinued.

 LymeDisease PatientusuallylivesinConnecticutareaandhasahistoryofcamping,hiking,or beingintallgrass.Thetickexposureisrarelyrememberedbythepatient. Diagnosis: Acentralclearingtargetrashispathognomonic Thereisahistoryofjointpain Bellspalsy

Treatment: Oraldoxycycline IfthereiscardiacinvolvementtreatwithIVceftriaxone

RockyMountainSpottedFever(RMSF) Lookforcamper/hikerwitharashthatstartedonwristsandanklesandmoved centrally. SignsandSymptoms: Fever,headache,andmalaisealwaysprecedetherash

Diagnosis: OralDoxycylcineisthemosteffectivetherapy.

 TBMeningitis Thisisanextremelydifficultdiagnosistopinpoint LookforanimmigrantwithahistoryoflungTB Presentsslowlyoverweekstomonths(IfacutethennotTBmeningitis)

Diagnosis: Treatment: ViralMeningitis Viralmeningitisisingeneraladiagnosisofexclusion. ThereislymphocyticpleocytosisintheCSF. Thereisnospecifictherapyforviralmeningitis. RIPEtreatmentaswithTB,onlydiffisshouldaddsteroidsandextendthe lengthoftherapyformeningitiswhencomparedtothepulmonarydisease. HasaveryhighCSFproteinlevels AcidfaststainofCSFisnotaccurate,needthreehighvolumecentrifuged samplesifgoingtodoacidfaststain.

ListeriaMeningitis *AddAmpicillintoregimenofvancomycin+ceftriaxonewhenListeriaissuspected. SuchasifthereislymphocytosisintheCSF. Lookforelderly,neonatal,andHIV(+)patientsandthosewhohaveno spleen,areonsteroids,orareimmunocomprimisedwithleukemiaor lymphoma.

 NeisseriaMeningitides Treatmentisasfollows: PatientRespiratoryisolation ClosecontactsStartprophylaxiswithrifampinorciprofloxacin. Closecontactsare:householdmembers,peoplewhoshareutensils,cups,kisses. RoutinecontactsRoutineschoolandworkcontactsdonotneedtoreceive prophylaxis. Lookforpatientswhoareadolescents,inthemilitary,areasplenic,orwho haveterminalcomplementdeficiency.

ENCEPHALITIS FEVER+CONFUSION=Encephalitis Diagnosis: ThebestdiagnostictestisaCTscanofthehead ThemostaccuratetestisaPCRoftheCSF Lookforapatientwithafeverandalteredmentalstatusoverafewhours. AlmostallencephalitisintheUSisfromherpes,thepatientdoesnothaveto recallapasthistoryofherpesinordertomakethisdiagnosis

Treatment: Thebestinitialtherapyisacyclovir Foracyclovirresistantpatientsgivefoscarnet

BRAIN ABSCESS Preswithafever,headache,andfocalneurologicaldeficits CTfindsaringakacontrastenhancedlesion Findingaringmeanseithercancerorinfection.

ConsiderHIVstatusincontextofbrainabscessasfollows: ProgressiveMultifocalLeukoencephalopathy(PML) Neurocysticercosis LookforapatientfromMexicowithaseizure HeadCTshowsmultiple1cmcysticlesions,overtimelesionswillcalcify. ThesebrainlesionsinHIV(+)patientsarenotassociatedwithring enhancementormasseffect. Thereisnospecifictherapy. TreattheHIVandraisetheCD4,whentheHIVisimproved,thelesionswill disappear. HIVnegativepatientbrainbiopsyisthenextstep HIVpositivepatientTreatmentfortoxoplasmosiswithpyrimethamine andsulfadiazinefor2wksandrepeattheheadCT

Diagnosis: Confirmwithserology

 Treatment: HeadTraumaandIntracranialHemorrhage Anyheadtraumaresultinginalossofconsciousnessoralteredmentalstatusshould leadtoCTofheadwithoutcontrast Focaldeficit HeadCT Treatmentforvariousheadtraumasareasfollows: 1. Concussion:None 2. Contusion:Admitpatient,vastmajoritygetnotreatment 3. SubduralandEpiduralHematomas:Largeonesdrained,smallonesleft alonetoreabsorbontheirown. 4. Largeintracranialhemorrhagewithmasseffect:1. Intubate/hyperventilatetodecreaseICP,2.DecreasePC02to2530,which constrictscerebralbloodvessels,3.administerMannitolasanosmotic diuretictodecreaseICP,4.Performsurgicalevacuation. Concussion Never Normal Contusion Rarely Ecchymosis Subdural hem. Yesorno Epiduralhem. Yesorno Whenstillactiveanduncalcified,thelesionsaretreatedwithAlbendazole, usesteroidstopreventareactiontodyingparasites.

Crescentshape Lensshaped

 SubarachnoidHemorrhage(SAH) Lookforthefollowingsymptoms: Sudden,severeheadache Stiffneck Photophobia LOCin50%ofpatients Focalneurologicaldeficitsin30%ofpatients SAHislikesuddenonsetofmeningitiswithaLOCbutwithoutfever.

Diagnosis: Treatment: Performangiographytodeterminesiteofbleed Surgicallycliporembolizethesiteofbleeding(Ifpatientrebleedsthereisa 50%changeofdeath). Insertavetriculoperotonealshuntifhydrocephalusdevelops Prescribenimodipineorally;whichisaCCBthatpreventsstroke. ThebestinitialtestisaheadCTwithoutcontrast.Itis95%sensitive,if conclusive,noneedtodoanLP ThemostaccuratediagnostictestisanLP,butnotnecessaryifCTshows blood.

**WhenSAHoccurs,anintensevasospasmcanleadtononhemorrhagic stroke(thusCCBused).

SPINE DISORDERS

Lumbosacral strain Nontender Syringomyelia

Cordcompression Epiduralabscess Tender Tenderandfever

Spinalstenosis Painonwalking downhill.

Isadefectivefluidcavityinthecenterofthecordfromtrauma,tumors,or congenitalproblem. Presentswithalossofsensationofpainandtendernessinacapelike distributionovertheneck,shoulders,anddownbotharms.

Diagnosis: MRI

Treatment: CordCompression Metastaticcancerpressesonthecord,resultinginpainandtendernessofthe spine. Lumbosacralstraindoesntgivetendernessofthespineitself. Surgicalcorrection

Diagnosis: ThebestinitialtestisanMRI Themostaccuratediagnostictestisabiopsy,onlydoneifdiagnosisisnot clearfromthehistory

 Spinal Epidural Abscess Presentswithbackpainwthtendernessandfever ScanspinewithanMRI Giveantibioticsagainststaphylococcussuchasoxacillinornafcillin Largeabscesssrequiresurgicaldrainage.

SpinalStenosis AnteriorSpinalArteryInfarction BrownSequardSyndrome Thisresultsfromtraumaticinjurytothespine,suchasthatfromaknife wound. Patientlosesipsilateralposition,vibratorysense,contralateralpainand temperature Allsensationislostexceptpositionandvibratorysense,whichtraveldown theposteriorcolumnofthespinalcord Nospecifictherapycancorrectthisproblem Presentswithlegpainonwalkingandcanlooklikeperipheralarterial disease Pulseswillbeintactinspinalstenosis Painworsenswhenpatientleansbackwardsand/orwalksinadownward direction,whileitimproveswhenwalkinginanupwarddirection DiagnosewithanMRIandtreatwithsurgicaldecompression

 **Themosturgentmanagementincordcompressionistheadministrationof steroidsassoonaspossibleandtorelievepressureonthecord.Imagingstudiesare doneafteradministrationofsteroids.

AMYOTROPHIC LATERAL SCLEROSIS Isanidiopathicdisorderofbothupperandlowermotorneurons. Treatedwithriluzole,auniqueagentthatblockstheaccumulationof glutamate UMNsigns Hyperreflexia Upgoingtoesonplantarreflex Spasticity Weakness LMNsigns Wasting Fasciculations weakness

PERIPHERAL NEUROPATHIES Diabetes Diabetesisthemostcommoncauseofperipheralneuropathies Specifictestingisnotnecessaryinmostcases.

Treatment: GabapentinorPregabalinareusefulintreatingneuropathies. TCAsarelesseffectiveandhavemoresideeffects

 CarpalTunnelSyndrome RadialNervePalsy Aka Saturday night palsy, results from falling asleep or passing out with pressure on arms underneath the body or outstretched, perhaps draped over back of a chair (classic presentation on exam question) Results in wrist drop, resolves on its own. Lookforpainandweaknessoffirstthreedigitsofhand Symptomsmayworsenwithrepetitiveuse. Initialmgmtisasplint. Steroidinjectionsmaybeusedifsplintsprovidenorelief Ifthesedontwork,canperformsurgerytorelievethepain

PeronealNervePalsy Resultsfromhighbootspressingatthebackoftheknee. Resultsinfootdropandinabilitytoevertthefoot. Thispalsywillresolveonitsown

CN7palsy(Bellspalsy) Treatment: Steroidsandacyclovirorvalcyclovirshouldbegiven Resultsinhemifacialparalysisofbothupperandlowerhalvesofface. Thoughttobeduetoavirus Theremayalsobealossoftasteinanterior2/3oftongue,hyperaccusis,and theinabilitytoclosetheeyeatnight.

 Reflexsympatheticdystrophy(chronicregionalpainsyndrome) Occursinapatientwithapreviousinjurytotheextremity Lighttoughsuchasfromasheettouchingthefoot,resultsinextremepain thatisburninginquality

Treatment: NSAIDs Gabapentin Occasionallyanerveblockmaybedoneifthepreviousmethodsdontwork Surgicalsympathectomymaybenecessarywhenrefractory

RestlessLegSyndrome Uncomfortablefeelinginthelegswhichpatienttriestoshakeoff,which bringsonlytemporaryrelief

Treatment: GuillainBarresyndrome Ascendingparalysis,thoughttobecausedbyaviralinfection. Usuallypresentsweeksafterarespiratoryinfection Pramipexoleorropinerole.

Management/Treatment: Firststepistotakeapeakinspiratorypressure,whichcantelliftheptwill undergorespiratoryfailure. SecondstepistogiveIVIGsand/orperformplasmapharesis.

MYASTHENIA GRAVIS Diagnosis: Treatment: ThebestinitialtherapyisPyridostigmineorNeostigmine Thymectomycanbeperformedifpyridostigmineorneostigminedontwork patients<60yrofageshouldundergothymectomy. GivePrednisoneifthymectomydoesntwork,oriftherearenoresponsesto pyridostigmineorneostigmine,thenprednisoneshouldbestarted. Azathioprineandcyclosporineareusedtotrytokeepthepatientoffoflong termsteroids. Thebestinitialtestistestingforantiacetylcholinereceptor antibodies(ACHR) ThemostaccuratetestisclinicalpresentationandACHR,whichismore sensitiveandspecificthattensilontest. Classicallypresentswithweaknessofthemusclesofmastication,makingit hardtofinishmeals Blurryvisionfromdiplopiaresultsfrominabilitytofocustheeyesonasingle target. Classicallythepatientreportsdroopingoftheeyelidsasthedayprogresses.

Chapter 17 Oncology

 BreastCancerScreening Screeningmammographyasfollows: Startat40 Between4050andevery12yrs At50,startdoingthemeveryyear

Whenamammogramshowsanabnormality? Whatisthesentinelnode? Itisthefirstnodedetectedintheoperativefield,detectedbydye. IfthisnodeisfreeofCA,thenaxillarynodedissectionisnotnecessary,ifthe nodeiscancerous,axillarylymphnodebiopsyisrequired 1stthingistodoabiopsy(showsCAandpresenceofesetrogenand/or progesteronereceptors)

Bestinitialtherapyforbreastcancer? HormonalInhibitionTherapy: Tamoxifenandraloxifeneusedifeitherprogesteroneoresterogen receptorsarepositive.TheySERMs(selectiveesterogenreceptor modulators).AdverseReactions:DVT,hotflashes,endometrialCA. Thesearedifferentfromaromataseinhibitors,whichdonotleadtoDVT, butcauseosteoporosisduetoantagonisticactivityinthebone. Lumpectomywithradiationtreatment(equaltomodifiedradical mastectomy) Ifthereispresenceofestrogenorprogesteronereceptor(+),usetamoxifen orraloxifene Adjuvantchemotherapyusedwhenevertheaxillarynodesare(+)ORthe canceris>1cminsize.

 AdjuvantChemotherapy:Isappropriatewhen, 1. Cancerisintheaxilla 2. Cancerlargerthan1cm 3. Moreefficaciouswhenptstillmenstruation,becauseBRcawontbe controlledwithestrogenantagonistssuchastamoxifen. TRASTUZUMAB:isamonoclonalantibodyagainstbreastCAantigenHER2/NEU, usefulinmetastaticdisease,hasmodestactivitywithfewadversereactions PrimaryPreventativeTherapy:UseTamoxifeninanypatientwithmultiple1st degreerelatives(mom,sister)withbreastCA COLON CANCER Themostimpthingisscreeningscheduleandindicators.. Routineforscreening: 1. Colonoscopy starting at 50, the every 10yrs. If single family member has it, get colonoscopy 10yrs earlier than the age at which that person was diagnosed. Three family members get colonoscopy at 25yr, then every 10yr. FAP do screening sigmoidoscopy at 12yr, then every 1-2yr. 2. Occultbloodtestingstartingat50yr,theneveryyearthereafter. 3. Sigmoidoscopyanddoublecontrastbariumenemaat50,thenq35yr. Coloncanceristreatedwithsurgicalresectionofthecolonand chemotherapycenteredarounda5FUregimen.

 LUNG CANCER Remember that small cell carcinoma releases ectopic ACTH, Squamous cell carcinoma releases PTH-like hormone. Thereisnoscreeningtestforlungcancer Excisionalbiopsyshouldbedoneonsolitarylungnodulesinptswhoare smokerswithnodule>1cm. Calcificationsusuallygoagainstmalignancy,butifthereishistoryof smoking,apatient>50yr,andnodule>1cm,excisioniswarranted.

Lungcancertherapy:Themostimpissueintreatmentiswhetherthediseaseis localizedenoughtobesurgicallyresected.Surgerycannotbedoneisanyofthe followingarepresent: 1. 2. 3. 4. 5. Bilateraldisease Mets Malignantpleuraleffusion Involvementofaorta,venacava,orheart Lesionswithin12cmofcarina.

***Smallcelllungcancerisnonresectablebecause>95%oftimeishasoneof thesefeatures. CERVICAL CANCER Startpapsmearsat21,or3yrsafteronsetofsexualactivity Dopapsmearsevery3yrsuntilage65.Stopat65unlesstherehasbeenno previousscreening. AdministerHPVquadrivalentvaccinetoallwomen1326yr

Followingupanabnormalpapsmear: 1. Anabnormalpapsmearwithlowgradeorhighgradedysplasiashouldbe followedbycolposcopyandbiopsy. 2. Apapsmearshowingatypicalsquamouscellsofundeterminedsignificance (ASCUS),doHPVtesting.IfHPV(+),proceedtocolposcopy,ifHPV(),do repeatpapin6mnth 3. Oncepapsmearnormal,returntoroutinetesting

 *Papsmearslowermortalityinscreenpopulations,butstillnotasmuchas mammographybecauseincidenceofcervicalCAislessthanthatofbreastcancer. PROSTATE CANCER Noprovenscreeningmethodthatlowersmortalityrate.PSAandDREnot proventolowermortality. Donotroutinelyofferthesetests,howeverifptasksforthem,youshould perform.

Treatingprostatecancer: 1. Localized:Surgeryandeitherexternalradiationorimplantedradioactive pellets(nearlyequalinefficacy) 2. Metastatic:Androgenblockadeisstandardofcare,useflutamide (testosteronereceptorblocker)ANDleuprolideorgoserelin(GNRH agonists). *Thereisnogoodchemotherapyformetastaticprostatecancer,treatmentis hormonalinnature. *Rememberthe5alphareductaseinhibitorfinasterideisusedforBPH,not cancer Amanwithprostatecancerpresentswithsevere,suddenbackpain.MRIshows cordcompression,andhesstartedonsteroids.Whatsthenextbeststepin mgmt? FLUTAMIDE(toblocktemporaryflareupinandrogenlevelsthataccompanies GNRHagonisttreatment

OVARIAN CANCER Keyfeatsarewomen>50withincreasingabdominalgirthatsametimeasweight loss. Diagnostictesting: Treatment: TESTICULAR CANCER Presents with painless scrotal lump in a man <35yr. Isextremelycurablewitha9095%5yrsurvivalrate. NEVERdoabiopsyofthetesticle. Treatment is surgical debulking followed by chemotherapy, even in cases of local metastatic disease. Ovarian ca is unique in that surgical resection is beneficial even when theres a large volume of tumor spread through the pelvis and abdomen. If possible, removing all visible tumors helps. Theresnoroutinescreeningtest CA125isamarkerofprogressionandresponsetotherapy,notadiagnostic test

DiagnosticTesting: An inguinal orchiectomy of the affected testicle, never do biopsy. Measure AFP, LDH, and bHCG Stage with CT of abdomen and pelvis.

Treatment: 1. Localdisease:Radiation 2. Widespreaddisease:Chemotherapy,whichiscurativeofevenmetastasisin testicularcancer.

 *Ofalltesticularcancers,95%aregermcelltumors(seminomaandnon seminoma). *AFPsecretedonlybynonseminomas. *MeasureAFP,LDH,andbHCG.

SOME EXTRA PREVENTATIVE MEDICINE Smokingcessation: Screenallandadviseagainstsmoking MosteffectivemethodsareuseoforalmedssuchasBuproprionand Varenicline. Lesseffectivearenicotinepatchandgum(whichshouldbetriedfirst).

*Withbuproprion,patientshouldslowlydecreasecigarettes2wksafterstarting therapy.Usebuproprioninconjunctionwithcounsellingandnicotinereplacement. OsteoporosisScreenallwomenwithDEXAscanat65yrofage. AAAAllmenabout65yrwhowereeversmokersshouldbescreenedoncew/an ultrasound. DMNorecommendationforroutinediabetesscreening HTNAllptsshouldbescreenedateveryvisit. HyperlipidemiaMen>35,Women>45

Chapter18 Dermatology

 UsingTopicalSteroids Potency Low Moderate High VeryHigh Acne Aninfectionofthepilosebaceousglandcausedbythebacteria Propionibacteriumacnes Medication 1%hydrocortisone 0.1%triamcinolone Fluocinonide Diflorasone Use Face,genitalia,andskin Body/Extremities,face, genitalia,andskinfolds Forthickskin. Neveronface Thickskinorseverebody needs

ACNE SignsandSymptoms: Treatment: Milddiseaseshouldbemanagedwithtopicalantibioticssuchasclindamycin, erythromycin,inadditiontobenzoylperoxide Moderatediseaseshouldcombinebenzoylperoxidewithretinoids Severediseaseshouldbemanagedwithoralantibioticsandoralretinoicacid derivatives Blackheads(opencomedones)andwhiteheads(closedcomedones)

BacterialInfectionsoftheSkin
Impetigo Asuperficialskininfectionlimitedtotheepidermis

Impetigo Isoftendescribedasbeinghoneycolored,wheeping,oroozing UsuallycausedbyStaphylococcus,butmayalsobeduetoStrepPyogenes

Treatment: Erysipelas Askininfectionoftheepidermisandthedermis,whichisusuallycausedbyStrep Pyogenes.Thisconditionisoftendescribedasbeingbrightred,angry,andswollen. Mupirocin(Atopicalantibiotic)and/orantistaphylococcaloralantibiotics

Erysipelas Witherysipelasmaycomefeverandchills

Treatment: Cellulitis AninfectioncausedbyStaphylococcusandStreptococcusthatinfectsthedermis andthesubcutaneoustissues.Managedwithantistaphdrugssuchasoxacillinand nafcillin. PenicillinGorampicillinifdiagnosisisStreptococcus

Cellulitis

 Folliculitis Aninfectionofthehairfollicle,mayprogresstoaworseinfectioncalledafuruncle. Usuallycausedbystaphylococcus,ifacquiredfromahottubitcanbedueto Pseudomonas,fungi,orvirus Lookforthisaroundthebeardareawherethereareaccumulationsofpuslike material.

Folliculitis Treatment: Localcareandtopicalmupirocin Severecasesthatprogressrequiresystemicantistaphylococcalantibiotics

 NecrotizingFasciitis Isasevere,lifethreateningskininfection.Itbeginsasacellulitisthatdissectsinto thefascialplanesoftheskin.MCCbystrepandClostridium Presentation: Highfever Extremepainthatisworsethanitlooks Bullae Crepitus

NecrotizingFasciitis Diagnosis: Management/Treatment: Surgicaldebridement Combinationbetalactam/betalactamasemedications IfitiscausedbyStrepPyogenes,giveclindamycin+PCN CTorMRIlookingforairinthetissueand/ornecrosis Elevatedcreatinephosphokinase

 ScarletFever IscausedbyStrepPyogenes,andlookslikeacombinationofarashandgoosebumps

ScarletFever SignsandSymptoms: Treatment: Penicillin Roughskin Strawberrytongue Beefyredpharynx Rashismostintenseintheaxillaandgroin(Inthecreasedareasofskin) Desquamationofhandsandfeetoccursasrashresolves Mayhavefever,chills,sorethroat,cervicaladenopathy Glomerulonephritisisacomplication

CommonDermatologicDisorders
Eczema Isasuperficial,itchy,erythematouslesion Therashdevelopsafteritching Commonlyseenontheflexorsurfaces Diagosisisclinical

Eczema Treatment:Avoidanceofirritantsandtriggers,keepskinsmoisturized, antihistamines/steroidsaregoodforrelieffrominflammationanditching TherearemanyvariationsofEczema,including: 1. AtopicDermatitisthisistheclassicwhereitchingcausesarash 2. Contactdermatitisanitchyrashatthesiteofcontact,classicallycausedby contactwithnickel,chemicals,orpoisonplants 3. Seborrheicdermatitisscalingandflakinginareasofsebaceousglands

 Psoriasis Presentsaspinkplaqueswithsilverscaling Occursontheextensorsurfacessuchastheelbowsandknees Thereisoftenpittingofthefingernails TheclassicfindingisknownasAuspitzSign,whichispinpointbleeding whenthescaleisremoved Thisisdiagnosedclinically

PsoriaticPlaque Treatment: 1stlineisTopicalsteroids 2ndlineisUVAlightandmaybeusedasanadjunct/prophylactic 3rdlineismethotrexateandclyclosporin Urticaria Isaconditioncausedbymastcelldegranulationandhistaminerelease Presentswiththeclassicwhealsthatareintenselyitchy Dermographismisseenwhereyoucanwriteawordwithyourfingeron theskinanditwillremain MostlesionsareIgEmediated(thusatype1sensitivity) Diagnosethisconditionbyscrapings

Urticaria Treatment: Vitiligo Thereisalossofmelanocytesindiscreteareasoftheskin Bordersaresharplydemarcated Usuallyseenindarkerpatients Possiblyautoimmuneinnature Avoidtriggers Giveantihistamines/steroids Thiscanpossiblyaffecttherespiratorytractwhichwouldtheninvolve securinganairway

Vitiligo Treatment: Minigraftingcanrestorepigmenttoareaswhereitislacking

 Albinism Failureofmelanocytestoproducepigment,duetoatyrosinedeficiency Patienthaswhiteskin,iristranslucency,decreasedretinalpigment, nystagmus,andstrabismus Avoidsunexposureandusesunscreenallthetime Thereisanincreasedriskofskincancerduetolackofprotectionfromthe sun

Albinism

BlisteringDisorders
PemphigusVulgaris Arareautoimmunedisorderaffectingpeoplebetween2040yrofage Bullaesloughoffeasilyandleavelargedenudedareasofskin,thisisknowas Nikolskyssign,thispredisposestoanincreasedriskofinfection Fatalconditionifnotmanagedproperly

PemphigusVulgaris Diagnosis: Immunofluorescenceofthesurroundingepidermalcellsshowsa tombstonefluorescentpattern

Treatment: Highdoseoralsteroids

 BullousPemphigoid Anautoimmuneconditionthataffectsmostlytheelderly Lessseverethanpemphigusvulgaris Presentswithhardandtensebullaethatdonotruptureeasily Prognosisismuchbetterthanthatofpemphigusvulgaris

BullousPemphigoid Diagnosis: Skinbiopsyshowingalinearbandalongthebasementmembraneon immunofluorescence Increasedeosinophilsfoundinthedermis

Treatment: ErythemaMultiforme Isahypersensitivityreactiontodrugs,infections,orsystemicdisorders Presentswithdiffuseanderythematoustargetlesionsthatarehighly differinginshape Oralsteroids

ErythemaMultiforme Diagnosis: Isclinicalbutahistoryofherpesinfectionmakesthisalikelydiagnosis

 Treatment: PorphyriaCutaneaTarda Anautosomaldisorderofimpairedhemesynthesis Getblistersonsunexposedareasofthefaceandhands Differentiatethisporphyriabytheabsenceofabdominalpain Stopoffendingcausesandtreatifthereisahistoryofherpeswithacyclovir

PorphyriaCutaneaTarda Diagnosis: Woodslampofurine,wheretheurinefluoresceswithanorangepinkcolor duetotheincreasedlevelsofuroporphyrins

Treatment: Sunscreensusedliberally Phlebotomy Chloroquine Avoidanceofalcohol

ParasiticInfectionsoftheSkin
Scabies Presentsasseverelyitchypapulesandburrowsthatarelocatedalongthe websofthefingers Highlycontagious

Scabiesinfection Diagnosis: IdentifytheSarcoptesScabieimitefromaskinscrapingunderthe microscope

Treatment: PediculosisCapitis(HeadLice) Itchingandswellingofthescalp Commoninschoolagedchildren Permethrin5%createtotheentirebodyforthoseinfectedandclosecontacts for810hr,repeatedinanotherweek Washalllinensandbeddinginhotwaterthesamedayascreamapplication

Diagnosis: Microscopicexamofthehairshaftwillshowliceattachedtoshaft

Treatment: Permethrinshampooorgeltothescalp Repeatapplicationsarecommonlyrequired

 PediculosisPubis(Crabs) Extremelyitchypapulesinthepubicregion Mayalsobealongtheaxilla,buttocks,eyelashes,eyebrows,andperiumbilical area

Diagnosis: Microscopicidentificationoflice

Treatment: CutaneousLarvaMigrans Isasnakelike,threadlikelesionthatmarkstheburrowofthenematode larvae Oftenseenonthehands,back,feet,andbuttocks Iscausedbyhookworms,namelyAncylostoma,Necatar,andStrongyloides Permethrinshampooleftonfor10minutes,andrepeatedagainwithina week

CutaneousLarvaMigrans Diagnosis: Ahistoryofskinbeingexposedtomoistsoilorsand Presenceofclassiclesion

Treatment: IvermectinorallyorThiabendazoletopically

FungalCutaneousDisorders
Disease Tinea Signsand Symptoms Itchy,scaly, well demarcated plaques. Blackdots seenonscalp Itchy,scaly plaques, usuallyin skinfold areas Diagnosis KOHPrep Treatmen t Topical Antifungal s

KOHprep showing budding yeasts+ pseudohyph ae KOHprep showsthe classic Spaghetti and meatball appearance Topical Nystatis orOral Fluconazo le

Candida

Tinea Versicolor

Onychomyco sis

Pityrosporu mOvale. Sharply demarcated hypopigment edmacules onfaceand trunkinthe summer. Maculesdo nottan Thickened, yellowingof the fingernails andtoenails.

Selenium Sulfide shampoo on affected areafor7 days.

Clinical Fluconazo and/orKOH leor prep Itraconazo le

SkinCancer
CancerType Malignant Melanoma Image Signsand Symptoms SeenMCin lightskin peoplewith increasedsun exposure. Fitsall ABCDE criteria Commonin elderly. Onsun exposed areas. Ulcerations andcrusted MCandlooks likeapearly papulewith translucent borders Red/purple plaques. Causedby HHV8. Almost exlusivelyin AIDSpatient Totalbody rashthatis veryitchy Treatment Prognosis

Excision+ Poorwith chemotherapy metastasis ifthereis metastasis

Squamous Cells Carcinoma

Excision+ radiation

Moderate prognosis (betterthan melanoma butworse thanbasal cell) Great prognosis almostnever metastasizes

BasalCell Carcinoma

Excision

Kaposis Sarcoma

Chemotherapy Goodunless andHIV thereis medications associated organdamage

CutaneousT cell Lymphoma

Radiation, 710yr chemotherapy survivalwith notreatment.

Chapter 19
High-Yield Preventative Medicine

 Femalepatients>65yrsofageshouldreceiveaonetimeDEXAbonescan forosteoporosis Anyfemalewhoisatleast60yroldandhas1riskfactorforosteoporosis TheTscoreisusedtoassessbonedensity ATscorebetween[1.5to2.5]isconsideredtobeosteopenia ATscore<2.5isosteoporosis ApatientwithaTscoreof<1.5plusriskfactorsforosteoporosis(smoking, poorcalciumvitaminDlevels,lackofweightbearingexerciseinthehistory, useofalcohol),shouldreceivepreventativemedications,suchasoral bisphosphonatesorRaloxifene RaloxifeneistheonlySERMthatisFDAapprovedtopreventosteoporosis Kidswithcysticfibrosisshouldreceivenormalvaccinationsinadditiontoa fewadditionsyearlyinfluenza,pneumococcalboosters Patientswithaneggallergyshouldavoidtheinfluenzaandyellowfever vaccines,andshouldbecautiouswithMMRaswell The1ststepinmanagementofincreasedLDLislifestylemanagement,ifLDL >100mg/dLandthepatienthasriskfactors,theyshouldbestartedon lifestylemodifications+statindrugs ThedrugofchoiceforincreasingtheHDLisGemfibrozelandnicotinicacids Itisrecommendedthatanymalewhoisanactivesmokerorformersmoker andagedbetween6575begivenaonetimeabdominalultrasoundto evaluateforaAAA Patientswithachronicliverdiseaseshouldreceiveanumberofvaccines (Tetanusevery10yrs+HepA&Byearly,andpneumococcalvaccine)

AdultVaccineRecommendations: Screeningforcervicalcancerwithapapsmearshouldstartat21yrofageor 3yrsaftertheonsetofsexualactivity(whichevercomesfirst) If23normalpapsmearsaredoneinarowandthewomanisina monogamousrelationship,youcanincreasethetimebetweenpapsmearsto every23years. Screeningcanstopat70yrsofage BupropionisFDAapprovedforsmokingcessationandmustbeusedin conjunctionwithcounselingandnicotinereplacement TetanusandDiptheriaevery10yrsafter18yrsofage Influenzatoalladults>50yrortoadultswithchronicdiseases(DM,CHF,etc) Pneumococcalvaccinegiventoalladults>65yrofageortoadultswith chronicdiseases

 HepatitisAvaccineisgiventomenwhohavesexwithmen Meningococcalvaccineisgiventothosewholiveinclosequarterswith others Routinecholesterolscreeningshouldbegininpatientsatriskat35yrofage inmenand45yrofageinwomen,thenevery5yrsafterthat ThemostcommonvaccinepreventablediseaseishepatitisA WhenCD4countdropsbelow200/250,startPCPprophylaxiswithTMPSMX WhenCD4countdropsbelow50,prophylaxformycobacteriumavium complexwithamoxicillin RoutinescreeningforChlamydiaisnowrecommendedforallsexuallyactive femaleswhoare24yrsofage Mammogramsshouldbedoneevery12yrsstartingat40yrinfemaleswith anaverageriskofbreastcancer.Thereisnocleartimewhentheyshould stop,butitshouldbenosoonerthan70yrofage Pneumococcalvaccineisacapsularpolysaccharideofthe23mostcommon typesofpneumococcus,whichyieldaBcellresponseonly,itisTcell independent AnyfemalewithahistoryofbeingtreatedforCIN2/3shouldhavepap smearswithorwithoutcolposcopyandcurettageevery6monthsuntilthree negativeresultsareobtained(patientsmayresumestandardscreenafter meetingthismilestone)