OB/GYN

Naegles rule = 1st day of last menstrual period + 7 days - 3 months + 1 year

Turners syndrome
Classic findings webbed neck, shielded chest, short stature, cubitus valgus, and sexual
infantilism
Cardiac abnormalities coarctation of aorta, bicuspid aortic valve, aortic dissection,
hypoplastic left heart syndrome, and hypertension

Congenital rubella
Women should be screened for rubella immunity at initial prenatal appointments

Cysts
Bartholin cyst
o Fluid filled cyst caused by blockage of Bartholin gland
o Larger cysts may cause discomfort during sex, sitting, and ambulating
o PE remarkable for unilateral, soft and painless mass medial to labia minora
o Can progress to abscess PAINFUL!!
Epidermal inclusion cyst
o Benign, fluid filled cyst that can be found on the skin
o Lined with cornified epithelim and contains lamellated keratin
o Can be part of Gardners syndrome (with osteomas of skull and polyposis)
AD disease with mutation on APC gene on chromosome 5
Gartner cyst
o Usually form on the lateral or posterior vaginal walls
o May present as difficulty inserting tampon or dyspareunia but typically asymptomatic
Hidradenitis suppurativa
o Chronic follicular disease that affects apocrine and sebaceous glands
o Can present as painful, deep seated nodules located in gluteal cleft
o Found in the axillary, groin, perianal, perineal, and mammary areas
Pilonidal cyst
o Risk factors = obesity, local irritation, deep gluteal cleft, and sedentary lifestyle
o Acute sudden onset of pain w/ stretching of skin in intergluteal area
o PE remarkable for tender mass or pit located midline in gluteal cleft
Trichemmal cyst
o Mobile mass that contains fibrous tissue and fluid
o Risk factors = blocked sebaceous glands, inflamed hair follicles and excessive
testosterone production
o Hairy areas susceptible because these cysts form at root sheath of hair follicle

Breast masses
Breast abscess
o Develop as complication of mastitis
o Most commonly occurs during the second postpartum week
o Most common bacterial organism = S. aureus
 Fat necrosis
o Benign condition that most commonly occurs as result of blunt trauma to breast (or
surgical intervention)
o Biopsy of mass is warranted to investigate pathological findings
Fibroadenoma
o Usuall present in women <30 as a non-tender, well-defined, highly mobile mass on
physical examination
o Simple are composed of stromal and epithelial tissue
o Complex will have proliferative changes (e.g. sclerosing, duct hyperplasia, etc)
Associated with slightly increased risk of cancer
Fibrocystic changes
o Are the most common mass found in women and are a benign process
o Presents as a bilateral, tender, mobile nodule which will vary in menstrual cycle
Most will complain of cyclical breast pain
Malignancy
o Risk factors = 50, familial BRCA1/2 mutation, exposure to ionization radiation,
nullparity, or first childbirth after 30, h/o breast cancer in 1 relative, hormone therapy,
obesity
o Types include: ductal, lobular, inflammatory
Can be subdivided by level of invasiveness

Uterine atony
Is the most common cause of postpartum hemorrhage
Failure of the myometrium to contract prevents constriction of the vascular sinuses within the
uterine cavity, allowing continued flow of blood through spiral arterioles
Hemorrhage usually begins shortly after delivery of placenta and is associated with an
enlarged, nontender, boggy uterus

Treatment for uterine atony

Oxytocin = 1st line tx and stimulates uterine contraction
o Can cause hypotension from relaxation of vascular smooth muscle tone
o High doses can cause hyponatremia due to ADH similarity
If high-dose needed for labor induction, NEED TO REPLACE SODIUM!!!
Ritodrine and Terbutaline = selective 2-agonists and used to inhibit contractions
o If used prior to delivery, increases atony risk
o Will promote bronchodilation
o Can cause hyperglycemia or hypoglycemia in diabetic mothers
Methylergonovine = ergot derivative that results in uterine contraction
o Can cause severe HTN from smooth mm contraction
o Should be AVOIDED in HTN or pre-eclamptic pts
o IV can precipitate HTN crisis
Carboprost is an PG-F2a analogue that can promote uterine contraction
o Should be AVOIDED in patients with asthmas because it can cause acute
bronchoconstriction!

Postpartum hemorrhage
Most common cause is uterine atony
 Is considered a medical emergency because it can quickly lead to hypovolemic shock
Patient w/ uterine atony w/ stable vitals, most appropriate = bimanual uterine massage
o By placing one hand in the vagina and pushing against body of uterus while other hand
compresses fundus from above through abdominal wall
If doesnt stop uterotonic agents to stimulate myometrium and constrict arterioles
Misoprostol is effective at controlling PPH refractory to massage and IV oxytocin and is used 2nd
line alternative to methylergonovine
o Rectal administration is preferred b/c of less side effects than oral and vaginal

Types of spontaneous abortion termination <20 weeks GA or fetus weighing <500g

Complete = passage of ALL products of conception
o US would NOT show evidence of fetal tissues but may have hyperechoic areas, due to
retained clots
Incomplete = passage of some products of conception
o Cervical os is open
o Typically presents with rhythmic abdominal cramping and vaginal bleeding
Missed = has dead POC with closed cervical os
o US will show a fetus with lack of heartbeat, confirming embryonic death
Threatened = has closed os and vaginal bleeding that may have abdominal pain
o US would show evidence of fetal tissue
Septic = when the POCs become infected and spreads to uterus and other parts
o S/S include: fever, severe abdominal pain, foul smelling discharge, hypotension
Inevitable = will have an open cervix with pain and uterine contractions

Common infections
Bacterial vaginosis
o One of the most common causes of vaginitis
o Caused by overgrowth of normal bacteria, especially gardnerella vaginalis
o Patient often complains of: itching, irritation, discharge
Discharge is thin, white discharge
o Wet mount will show clue cells
Chancroid
o Caused by Haemophilus ducreyi (gram-negative rod)
o Will develop a papule painful ulcer
o Approximately patients will have painful inguinal LAD, can lead to bubo
Chlamydia
o One of the most common causes of cervicitis and a complication is PID
o Treatment is with doxy or azithro
o Complication is PID
Gonorrhea
o Can cause cervicitis and a complication is PID
o Treatment is with ceftriaxone
o Can be cultured on Thayer-Martin agar
HSV
o Cause painful vesicles that erupt and leave small ulcers
o Tzank smear will show multinucleated giant cells
o Acyclovir is a common antiviral shown to minimize S/S and exacerbation
 HPV
o Dx made by examination of warts and application of acetic acid and biopsy
Syphilis
o Caused by treponema pallidum
o 1 = painless chancre ; 2 = generalized rash; 3 = gumma and neurosyphillis
o Screening = VDRL and RPR ; Confirmation = FTA-ABS
o Dark-field microscopy will show spirochetes
Trichomoniasis
o Patient complains of irritation and itching as well as frothy, greenish discharge
o Wet mount will show motile trichomonads
o Tx is with metronidazole to patient AND partner
Vaginal candidiasis
o The fungal cause of vaginitis
o Common in pts with DM, HIV, multiple partners, and patients that douch
o Presentation is with vaginal irritation and itching with a thick, white discharge
o Wet mount will demonstrate pseudohyphae
o Vaginal pH will be lower than normal
o Tx is single dose of fluconazole or topical antifungals

Pap smears
Recommended at the age of 21 and every 3 years until 30
After 30 can have every 5 years with concomitant HPV testing
o should continue until 65
Abnormal pap should warrant HPV testing and possible colposcopy

Hypertension in pregnancy
Chronic HTN is when it predates conception or detected <20 weeks GA
Gestational HTN is when it occurs in a previously normotensive patient 20 weeks GA
o They will have NO signs of proteinuria or end-organ damage
o It may be a sign of future chronic hypertension
o If BP fails to normalize postpartum, then the dx changed to chronic HTN
Preeclampsia will have HTN and proteinuria
o Look for signs of end-organ dysfunction
o Tx of magnesium sulfate to prevent eclampsia (i.e. seizures)
Overdose of magnesium treat with calcium gluconate

Anemia in pregnancy the most common hematologic abnormality of pregnancy

Physiologic changes
o Iron requirements increase during, and failure to maintain = adverse effects
o Blood volume expands 50%, however RBC mass expands only 25%
Levels <33% in 1st and 3rd; <32% in 2nd
Patients will typically benefit with oral iron supplementation

Group B Strep
Penicillin is drug of choice for prophylaxis
In penicillin-allergic patients, cefazolin is appropriate
GERD there is an increased risk
Progesterone-mediated smooth mm decreases LES and impairs esophageal peristalsis and
intestinal motility
Pharm therapy should begin with antacids followed by sucralfate
o If failure to respond, histamine-2-antagonists and PPIs used to control symptoms

Fetal heart monitoring

Late decelerations are indicative of uteroplacental insufficiency
o Occur in response to fetal hypoxia
o Repetitive or persistent, should begin resuscitative measures
If further unsuccessful = emergent C-sections
Early decelerations are indicative of fetal head compression
o They are a normal finding that represents vaginal nerve stimulation in response to
uterine contractions exerting pressure on the fetal head as it descends into the vaginal
canal
o The increase in vagal tone causes a transient slowing of FHR
Variable decelerations are indicative of umbilical cord compression
o It represents a disruption of fetal blood flow
o If prolonged, large drop from baseline, or repetitive = possible fetal distress

Tocolytics
Nifedipine
o Ca2+ channel blocker that will inhibit smooth mm contraction by preventing influx of
calcium into the uterine smooth mm
Indomethacin
o 1st line tx for cessation of labor less than 32 weeks
o It is inappropriate to use in pts with PUD, renal or hepatic disease, and bleeding
disorders
Magnesium
o It is contraindicated in MG patients because it will promote hypotonia
Ritodrine & Terbutaline are 2-agonists
o Can cause hyperglycemia or hypoglycemia in diabetic mothers

Cervical insufficiency
Defined as recurrent painless cervical dilation in the absence of contractions, infection,
placental abruption, or uterine anomaly
It is a diagnosis of exclusion
Risk factors will include: prior cervical laceration, h/o cervical conization, multiple
terminations w/ mechanical dilation, congenital anomaly, collagen abnormalities
o Remember, that those with prior h/o of CIN likely underwent excision or ablation
If patient is threatening preterm deliver, antenatal corticosteroids should be given to reduce
risk of RDS, IVH, and neonatal death

Uterine leiomyomas
Benign tumors that originate from the smooth muscle within the uterine myometrium
They are estrogen and progesterone sensitive
o Will tend to grow during pregnancy and shrink after menopause
 They present with: AUB (most common), pelvic pain or heaviness, dysmenorrhea, anemia, back
pain, and/or premature labor
Physical findings include: enlarged, irregularly contoured uterus
Treatment
o Manage = NSAIDs for pain, OCPs for bleeding, GnRH agonists to decrease size
o Definitive = hysterectomy

Screenings
HIV should be screened at prenatal appointment
Anatomic screen should take place between 18-20 weeks
GTT should take place to screen for GDM at 24-28 weeks
GBS should take place between 32-36 weeks

Incontinence
Stress occurs when the bladder pressure > urethral closing pressure
o Most common when intra-abdominal pressure is increased (i.e. cough, sneeze)
o Risk factors = multiparity, obesity, chronic pulmonary conditions (e.g. asthma)
o Initial treatment = bladder training (i.e. Kegel exercises)
Urge is defined as involuntary loss of urine with a strong desire to void
o Testing would show involuntary detrusor contractions on bladder filling resulting in
urine leakage
Overactive is defined as urinary urgency w/ or w/o incontinence
o Usually accompanied by nocturia and urinary frequency

Phyllodes tumor
Histologically similar to fibroadenoma, but much larger and rapidly expand
Typically present as smooth, polylobulated mass
Treatment is with wide local excision

Retained placenta
The lack of complete expulsion w/in 30 minutes of delivery
Causes include: trapped placenta behind closed cervix, adherent to wall, villi penetration, or villi
anchoring
Nitroglycerin is the 1st line tx for uterine relaxation for retained placenta

Mucocutaneous lesions
Malar (butterfly) rash erythematous rash over sparing nasolabial folds
Discoid rash erythematous raised patches with adherent keratosis scaling
o Can present on face, neck, or scalp
Photosensitivity rashes will worsen or manifest after sun exposure
Oral ulcers

SLE
Chronic autoimmune inflammatory disease characterized by multi-organ involvement
Classic S/S include: fever, malaise, joint pain, and rash
 At least 4 out of 11 criteria MUST be met for diagnosis
o Includes: mucocutaneous manifestations, evidence of serositis and arthritis, renal
failure, neurologic manifestations, hematological and/or immunological markers
Hematological criteria include: hemolytic anemia w/ reticulocytosis,
leukopenia, lymphopenia, and thrombocytopenia
Renal failure lupus nephritis
Diagnosed by abnormal UA showing proteinuria and/or hematuria with
elevated creatinine
Progress with capillary thickening (i.e. wire looping)
Other findings include: diffuse granular IgG and C3 deposits
Four common antibodies Anti-smith, anti-dsDNA, antiphospholipid, ANA
o Anti-smith remain positive whose disease is quiescent
o Anti-dsDNA titers will correlate with disease activity (especially lupus nephritis)
o Antiphospholipid in 1/3 of patients, and can cause blood-clotting complications
o

Bishop Score
0 points 1 point 2 points 3 points
Dilation 0 cm 1-2 cm 3-4 cm 5-6 cm
Effacement 0-30% 40-50% 60-70% 80%
Station -3 -2 -1 and 0 +1 and +2
Consistency Firm Medium Soft
Position Posterior Mid Anterior
Vaginal cancers in postmenopausal women
Most common are squamous cell carcinomas
o Associated with HPV infection
o Risk factors include: long-term pessary use, prolapse, multiple sexual partners, DES
exposure
o Treatment will include combination of radiation & surgery
Clear cell adenocarcinoma at risk in those with DES exposure in utero
Adenocarcinoma, endodermal sinus tumor, and rhabdomyosarcoma possible but rare, more
common in young premenopausal women

PID
Ascending polymicrobial infection that affects uterus, ovaries, and possibly peritoneum
Common pathogens: N.gonorrhoeae, C.trachomatis, & endogenous aerobes/anaerobes
S/S: lower abdominal pain, uterine/adnexal tenderness, cervical motion tenderness
Consequences chronic pelvic pain, ectopic, infertility, Fitz-Hugh-Curtis syndrome
Treatment will include IM ceftriaxone and PO doxycycline

Asymptomatic bacteriuria
Defined as presence of >100k units of a single bacterial species in absence of S/S of UTI
It is associated with increased risk of cystitis and carries 30-40% risk of progressing to acute
pyelo, which holds significant maternal and fetal morbidity

Maternal mortality
 Risk factors include: advanced maternal age, AA or Hispanic race, obesity, multifetal gestation

Salpingotomy
Surgical procedure creating an opening in fallopian tube, allowing removal of conceptus, but
tube itself is NOT removed
Preferred treatment of ectopic pregnancy in patients whom future fertility is desired
This allows a higher rate of subsequent intrauterine pregnancies by allowing preservation of the
fallopian tube

Cardinal movements of labor

Refer to changes in position of fetal head during passage through birth canal
Order of movements engagement, descent, flexion, IR, extension, ER, expulsion
o Engagement is descent of biparietal diameter below plane of pelvic inlet
Can occur before onset of true labor, especially nulliparous
o Descent occurs mainly during deceleration phase of stage 1 & during stage 2
o Flexion is a passive movement permitting smallest diameter of head to pass through
maternal pelvis
o External rotation, the fetus resumes its face-forward position, with occiput and spine
lying in same plane
Labetalol
Should be avoided in asthmatic patients as the beta-blocking properties may exacerbate
asthma symptoms

Dexa scan and t-scores

> -1 = normal
-1 - -2.5 = osteopenia
< -2.5 = osteoporosis
< 2.5 + fractures = severe osteoporosis

Abnormal placentation
All disorders will increase risk of peripartum hemorrhage
Placenta previa = leading cause of antepartum hemorrhage and is risk factor for placenta
accreta
Placenta accreta, increta, percreta can be associated with massive hemorrhage and will usually
require C-section w/ hysterectomy

DHEA-S
Produced by adrenal glands and NOT ovaries
High levels consistent with hyperandrogenism from adrenal source, and NOT PCOS
Androgen secreting tumors are rare, but this diagnosis should be ruled out in all patients
presenting with signs of hyperandrogenism

Gestational diabetes
Guidelines for starting insulin therapy after dietary changes
o Fasting glucose 95
o One hour postprandial glucose 120
Screening for high risk with 50g non-fasting one-hour challenge
 o If >130, then proceed to three hour
Three hour test if 140
Diagnostic criteria
o Fasting 95
o One hour 180
o Two hour 155
o Three hour 140

Features of severe preeclampsia

Systolic 160 or diastolic 110 on two occasions at least 4 hours apart
Thrombocytopenia (platelets <100k)
Elevated liver enzymes or impaired liver function, severe URQ or epigastric pain
Renal insufficiency (serum creatinine >1.1 or doubling in absence of other disease)
Pulmonary edema
New onset cerebral or visual disturbances

Chorioamnionitis
Presents with fever, abdominal pain, and fetal tachycardia
Greatest risk in patients that premature rupture of membranes
 PEDS
Testicular pathology
Spermatocele retention cyst of the epididymis
o Presents as cystic, mobile, smooth nodule that is posterior and superior to testes
Hydrocele collection of fluid between parietal and visceral layers of tunica vaginalis
o Present as soft, non-tender, fluctuate scrotal masses that are usually unilateral
o Diagnosis is clinical and supported by transillumination of scrotum
Varicocele congenital condition which involves abnormal dilation of pampiniform plexus due
to scrotal vein valvular incompetence
o Present as painless scrotal masses that are classically described as bag of worms on
exam
Will be more prominent when standing
o Surgery may be necessary if scrotum becomes hypertrophic
Infections epididymitis ascending infection from urethra into epididymis
o Presents with scrotal pain, erythema, and edema
o After puberty, often sexually transmitted ; most often chlamydia or gonorrhea

Tetralogy of Fallot
Characterized by: irritability, tachypnea, and cyanosis which are brought on exertion
o Thought to be due to increased peripheral vasodilation or hyperventilation
Four components pulmonic stenosis, overriding aorta, VSD, RVH
Placing child in squatted position will cause increased systemic resistance
o Which will reduce R L shunt leading to improve pulmonary blood flow

Cephalohematoma is a subperiosteal collection of blood

Caused by blood vessel rupture beneath periosteum
Presents as a bump or swelling which is limited to suture lines
Potential complications include: anemia, hypovolemia, skull fracture, hyperbilirubinemia
UNLIKE caput succedaneum & subgaleal hemorrhage which are NOT limited by sutures

Subgaleal hemorrhage
Collection of blood beneath the aponeurosis of the scalp
Occurs commonly in infants who have required vacuum assisted delivery
Presents as a firm, fluctuant mass which increase in size
Can lead to significant hypovolemia and anemia

Bacterial pneumonia IV ampicillin + gentamicin (or cefotaxime) is the 1st line empiric tx

Liddle syndrome is an AD disease that may be found incidentally due to HTN in child
Caused by a genetic activating mutation of ENaC
Present with HTN, hypo[K], hyper[Na], metabolic alkalosis with low aldosterone
Bartter syndrome is an AR disease that is a defect in sodium chloride reabsorption in TaLH
May be associated with hypokalemia and metabolic alkalosis
Gitelman syndrome is an AR disease that presents with hypo[K], hypo[Mg], hypocalciuria, and
metabolic alkalosis
Unlike Liddles, they will have low to normal blood pressure

Brain anomalies
Hydranencephaly is a congenital defect of brain characterized by fluid-filled cavities replacing
cerebral hemispheres
o Pathogenesis likely involves massive brain infarction with subsequent cerebral cortex
necrosis or primary agenesis of neural wall
Dandy-Walker malformation is a complex anomaly of brain with various types
o Key features include: 4th ventricle enlargement, vermis absence (partial or complete),
and cyst formation near internal base of skull
o S/S include: macrocephaly, increased ICP, seizures, ataxia, or abnormal eye movement
Lissencephaly is characterized by lack of development of gyri or sulci
o Often associated findings including: anencephaly, ventriculomegaly, partial or complete
agenesis of corpus callosum
o Patients head will NOT transilluminate
o Children will have severe neurologic impairment
Schizencephaly is characterized by one or more fluid-filled clefts in hemispheres that
communicate with lateral ventricle
o Microcephaly is a common finding and it should NOT transilluminate
o Is associated with: developmental delay, neurologic impairment, and seizures

Gastrochisis = by involution of 2nd umbilical vein and causes defect to right of umbilicus

Zero One Two

Appearance Blue throughout Blue extremities Pink
Pulse Absent <100 bpm 100 bpm
Grimace Flaccid Grimace / reflex irritability Active motion
Activity Absent Arms and legs flexed Active movement
Respiration Absent Slow and irregular Vigorous cry

Muscular issues
Duchennes MD
o X-linked recessive ; absence of dystrophin gene
o Physical signs include: hyperlordosis or scoliosis of spine (due to truncal mm weakness),
calf pseudohypertrophy, and progressive, symmetric, proximal muscle weakness
o Patients will have a classic Gowers sign use arms to climb up legs and body
o Lab values will show elevated CK
o Diagnosis is confirmed via DNA testing
o Death usually occurs in 3rd decade due to respiratory failure or cardiomyopathy
Beckers MD
o X-linked recessive; dystrophin mutation, but still some production
o S/S dont begin til later and progress slower
o Life span longer
Charcot-Marie-Tooth
 o Hereditary sensory neuropathy that is characterized by: weakness and wasting of distal
limb muscles
o S/S begin in preschool years with pes cavus deformity with frequent tripping
o Treatment is supportive with bracing and physical therapy
Limb-girdle dystrophy
o AR disease, presenting with proximal leg and arm weakness
o Most patients are wheelchair bound by mid-adulthood
Myotonic dystrophy
o AD genetic disease ; CTG triple repeat coding for myotonin protein kinase
o Can present at:
Birth severe generalized hypotonia and weakness
Adolescence slow, progressive facial and distal extremity weakness and
myotonia
o Characteristic facial features include: hollowing of temple muscles, jaw, neck as well as
ptosis, facial weakness, and lower lip drooping

Nursemaids elbow results from a subluxation of the radial head

Radial head will dislocate from the annular ligament when significant force is applied
It is the number one injury to the upper extremity in children
Presentation will be child that is holding arm in slightly flexed position at the elbow, and
pressed up against torso
o Places joint in least amount of stress
Manual reduction requires the following: flex elbow 90 while also supinating
o Support of childs arm at elbow and exertion of pressure on radial head with one finger
o Other hand examiner holds distal forearm and pulls with gentle traction
o Examiner will then fully supinate forearm and then fully flex elbow

Volvulus
S/S include: abdominal cramping, bilious vomiting (usually), intestinal dilation
Upper GI series under fluoroscopy is the dx study for midgut volvulus w/ malrotation

Clavicle fracture will result in absent Moro reflex on affected side along with SCM spasm
Chile is typically unable to move ipsilateral arm, and crepitus and irregularities present
Treatment is generally immobilization

Neonatal hypoglycemia
Common complication of diabetic pregnancy
o Typically manifests 1-2 hrs after birth or 12-24 hrs after poor enteral intake
S/S include: poor feeding, jitteriness, hypotonia, lethargy, and hypothermia
Unrecognized, can progress to seizure, coma, and permanent damage
1st line tx is 5 or 10% dextrose for several days, until hyperinslulinemia resolves
Other electrolyte disturbances will include hypocalcemia and hypomagnesemia
 Age Gross Motor Fine Motor Language Social
3 month Hold head up when prone Coos Social smile
Brings hands to mouth
6 month Sits w/o support Transfers objects btwn Babbles Responds to
hands parents
Raking grasp expression
Stranger anxiety
begins
9 month Crawling Pincer grasp Nonspecific Waves goodbye
mama,
dada
1 year Walks Throws objects Uses two Anxiety when
Drinks from cup words separated

21-hydroxylase deficiency = most common form of CAH

The most common
Diagnostic = elevated 17-hydroxyprogesterone
Leads to hyponatremia and hyperkalemia SALT WASTING!!
o Because they are unable to produce aldosterone & cortisol
Lab values
o Estradiol and testosterone will be increased
o 11-deoxycortisone will be decreased
o 18-hydroxycortiosterone will be decreased

Cardiac anatomic variants

TAPVR
o The four pulmonary veins fail to make their normal connection to the left atrium and
ALL drain into systemic circulation
o Persistent left SVC occurs when left brachiocephalic vein DOES NOT form properly
Left arm and head and neck drain into the coronary sinus and right atrium
massive coronary sinus dilation
Coarctation of aorta
o Impairs blood flow differential in UE and LE blood pressures
o Commonly associated with: bicuspid aortic valve, persistent PDA, and/or VSD
o Increased UE flow pressure, epistaxis, headache, LE ischemic symptoms, dilated
costal arteries, and CHF
Ostium primum
o ASD in inferior portion of septum
o Associated with clefts in anterior leaflet of mitral valve
Ostium secundum
o 75% of ASDs
o Located in mid-portion of intra-atrial septum in region of fossa ovalis
o Associated with MVP and MR
Transposition
o Reversal of aorta and main pulmonary artery
o Aorta is positioned anteriorly ; pulmonary artery is posterior
VSDs
Muscular
o Lower in ventricular septum closer to apex of heart
o 20-30% of all VSDs
o Murmur may occur only in early systole since the contraction of septum during systole
may close the defect
Perimembranous
o Represent 70-80% of VSDs and the most common congenital anomaly at birth
o Occur in the upper ventricular septum close to aortic and/or mitral valve
o Will shunt blood across LV outflow tract into RV at level of tricuspid valve
o S/S begin to develop when pulmonary vascular resistance declines enough to permit
LR shunting
Typical presentation is discovering murmur day 4-10 of life
o High frequency decrescendo murmur

Ebsteins anomaly
Defect is an anomaly of the tricuspid valve and RV
Can occur if mother takes lithium during pregnancy
As many as 80% of patients with Ebsteins anomaly will also have ASD and severe TR

PDA
Connection between main pulmonary artery and aortic arch stays open
o Producing LR shunt
PE will have a continuous, machine-like murmur
Use indomethacin to close (vice-versa, use PGE2 to keep open)

Bicuspid aortic valve

Occurs when two of valve leaflets fuse during development
It is the most common cardiac valvular anomaly
There are number of syndromes whose cardiac involvement includes BAV
o Shones syndrome multiple left-sided lesions of inflow & outflow obstruction
o Turner syndrome with coarctation of aorta
o Williams-Beuren syndrome characterized by mental retardation, Elfin facies,
supravalvular aortic stenosis, HTN, short stature, other multi-system disorders

Apthous stomatitis
Are painful oral ulcers (i.e canker sores), that are localized, shallow with grayish base
Most will resolve w/in 14 days but are often recurrent
Risk factors = emotional stress, familial tendency, HIV, and other conditions

M-CHAT
Goal is to detect cases of ASD as early as possible to allow for early intervention
Consists of a list of behaviors that, if present, increase likelihood of having autism
ALL patients with abnormal M-CHAT should be referred for appropriate diagnostic testing by a
physician that specializes in diagnosis and management of autism

ASQ:SE
 Screening tool used to identify children at risk for social and/or emotional problems
Consists of eight questionnaires
Specificity of 90-98% and sensitivity of 80-85% for detecting children with problems

Connors Rating Scale (CRS) and Vanderbilt ADHD Parent Rating Scale (VADPRS)
Used to assess behavioral problems in children and aid in the diagnosis of ADHD
Screening most commonly performed in children 3-17 years of age
Will evaluate specific symptoms inattention, cognitive problems, hyperactivity, and
oppositional behaviors

Febrile seizures
Occur in children age 6 months 5 years in the setting of a fever 38C
Simple febrile seizure is a generalized, often tonic-clonic seizure single episode
o Thorough H&P are crucial to r/o other etiologies
o Reassurance should be provided
Complex is prolonged (>15 minutes), focal, and/or recurs w/in 24 hr period
o Require more work-up

Pyloric stenosis is consistent with a hypochloremic, hypokalemic metabolic alkalosis

Presents with a palpable, olive-like mass in the RUQ
S/S include: non-bilious projectile vomiting

Metabolic errors
Glutathione synthetase deficiency
o Characterized by severe metabolic acidosis in 1st few days of life, as well as jaundice,
and mild-moderate hemolytic anemia (2 to glutathione deficiency)
Glycogen storage disease
o Deficiencies in various enzymes or proteins in glycogen metabolism
o Most common are Type I (glucose-6-phosphatase), II (lysosomal alpha-glucosidase), III
(debrancher), IV (liver phosphorylase)
Hartnup disorder
o Defect in the transport of neutral amino acids
o Leads to decreased availability of tryptophan in body for niacin synthesis
o Major clinical manifestation is cutaneous photosensitivity (but rare!)
Histidine decarboxylase deficiency
o Deficiency leads to inability to produce histamine
o Has been associated with development of familial type Tourettes syndrome
Homocystinuria
o Clinical manifestations during infancy will include: FTT, developmental delay, lens
subluxation down, skeletal abnormalities, and thromboembolic episodes
Hyperprolinemia
o Rare AR disease caused by deficiency of proline oxidase
o Presentation often includes: seizures and psychomotor retardation
o Diagnosis is made by high concentrations of proline in plasma, urine, and CSF
Phenylketonuria
o Deficiency of phenylalanine hydroxylase or cofactor tetrahydrobiopterin
Results in accumulation of phenylalanine
 o S/S include: fair skin, growth retardation, mental retardation, and eczema
o Children will typically have a musty or mousy order
o Treatment is phenylalanine restriction and tyrosine supplementation

Imperforate hymen
Obstructive lesion of female genital tract
Adolescent female symptoms include: primary amenorrhea, cyclic abdominal or pelvic pain,
back pain, and difficulty urinating
o Symptoms due to collection of menstrual blood causing vaginal distension (i.e.
hematocolpos)
PE reveals bulging hymenal membrane with bluish hue

Neonatal abstinence syndrome

Common symptoms include: high-pitched cry, restlessness, feeding changes, hyperactive
reflexes, nasal flaring, tremor, yawning, seizures
Symptoms from methadone use appear 1-4 weeks after birth
Symptoms from heroin use appear 1st few days
Treatment
o 1st line = tincture of opium w/ slow weaning
o 2nd line = phenobarbital (especially if seizures occur) and clonidine

G6PD deficiency
X-linked recessive common in individuals of African and Mediterranean descent
Oxidative stress hemoglobin oxidized to methemoglobin Heinz bodies
Clinical manifestations include: jaundice, dark urine, LBP, splenomegaly, risk of gallstone
Common triggers = bacterial infections, meds (sulfa, nitrofurantoin, malaria drugs, dapsone,
aspirin)
Management includes prevention by avoiding offending agents and supportive care during
acute attack

Respiratory Distress Syndrome

Due to deficiency of pulmonary surfactant
Incidence increases with decreasing GA because surfactant production begins ~30-36
Acid-base disturbance found in RDS is a mixed metabolic and respiratory acidosis

Salter-Harris classification
I = transverse fracture going through physis, but NOT involving epiphysis or metaphysis
II = will extend through physis into metaphysis, but spares epiphysis
o It is the most common type of physeal fracture in children and adolescents
III = fracture through physis and epiphysis, but spares metaphysis
IV = fracture line through epiphysis, across plate and through metaphysis
o Will involve ALL three elements
V = a compression fracture of growth plate
o Thought to be caused by force transmitted through epiphysis and physis
o Will lead to growth arrest and has a poor prognosis
SCFE
Common adolescent hip disorder caused by separation of proximal femoral epiphysis through
growth plate
o leading to inferior and posterior displacement of femoral head
Risk factors include: obesity, Down syndrome, endocrine disorders
S/S include: hip, groin, thigh, knee pain and possibly painful limp w/ decreased hip ROM
Physical findings include: limited IR and Abd of hip
o The patient will hold leg in ER, which is increased with hip flexion
Treatment is to restrict weight bearing and surgical correction via internal fixation

Newborn skin conditions

Erythema toxicum neonatorum
o Lesions are numerous and small, described as erythematous macules and papules
which progress rapidly to pustules on erythematous base
Skin biopsy reveals many eosinophils w/o presence of organisms
Miliaria crystallina
o Presents with clear, pinpoint vesicles over large areas of body surface
o Rash results from retention of sweat in occluded sweat ducts
Neonatal cephalic pustulosis (i.e. acne)
o Benign rash without clear etiology
o Typically presents ~3 weeks and is limited to face, cheeks, and scalp
Sebaceous hyperplasia
o Benign newborn skin eruption with profuse, small yellow-white papules
o Usually found on the nose, forehead, lips, and cheeks
o Lesions are due to hyperplastic sebaceous glands and are present at birth
Transient pustular melanosis
o Characterized by small pustules present at birth that are NOT erythematous
o Lesions will typically progress to erythematous and then hyperpigmented
o Skin biopsy of pustular contents reveals numerous neutrophils
OME = otitis media w/ effusion
Complication of acute otitis media
Caused by persistent, sterile serous fluid in middle ear after infection
PE reveals: dull, retracted TM with air-fluid levels behind it
Major complication = permanent hearing loss!!
o Typanostomy tube placement has been shown to decreased hearing loss

Henoch-Scholein purpura
A vasculitis that affects children ~5-7 years
Pathophysiology involves IgA and C3 deposition in small vessels
Characterized by palpable purpura on depended areas, such as, legs and buttocks
S/S include: abdominal pain, joint pain, and renal involvement

Neonatal conjunctivitis
Neisseria gonorrhoeae
o Has an early onset of delivery 5 days old
o Treatment is topical erythromycin and IM ceftriaxone
Chlamydia trachomatis
 o Has a late onset of 5 days 2 weeks
o Treatment is oral erythromycin

Asthma severity
Intermittent is characterized by daytime asthma symptoms occurring 2x/wk, 2 nocturnal
wakes per month, and the use of SABA <2x/week
o If any category is more severe, rating should be on that category
Mild persistent is characterized by >2x/week, with 3-4 nocturnal wakes per month
o Typically have minor interferences with normal activities
Moderate persistent is characterized by daily asthma symptoms with nocturnal wakes
>1/week
o Typically has some limitation with normal activities
Severe persistent is characterized by symptoms throughout day and daily nocturnal wakes
o There is extreme limitation in normal activity

Tanner staging female

1 = prepubertal breast development & presence of vellus or no pubic hair
2 = Breast buds, areolar enlargement & sparse growth of lightly pigmented pubic hair
3 = Enlargement of breast w/o separation of contour & sparse, darker, coarse pubic hair
4 = areola & papilla forming 2nd mound & adult pubic hair NOT spreading to thighs
5 = mature breast development & adult pubic hair spreading to thighs

Fragile X Syndrome
Characteristic features include: mental retardation, long face w/ large ears, autistic-like
behavior, macraorchidism, MVP
Caused by a CGG repeat in the FMR1 region of the X chromosome

3-year-old developmentally
Should be able to: stack 9 blocks, copy circle, ascend stairs, ride tricycle, count 3 objects, name
colors, group play, and toilet training

Down syndrome quad screen

Increased -hcG and inhibin A
Decreased AFP and uE3

Fluid maintenance
Infants 3.5kg 10kg, the fluid requirement is 100 mL/kg
Children 11kg 20kg, the fluid requirement is 1000 mL + 50 mL/kg for every kg over 10
Children >20kg, the fluid requirement is 1500 mL + 20 mL/kg for every kg > 20
o Up to a maximum of 2400 mL daily

Von Gierkes
An AR disease with a deficiency in glucose-6-phosphatase
Presents with frequent feedings, rapid breathing, doll-like facies, hypotonia and thin limbs, as
well as hypoglycemia, elevated lactate and uric acid
o Associated with hypertriglyceridemia can cause xanthoma formation
Episodes of hyperglycemia during fasting lactic acidosis & Kussmaul breathing
 Diagnosis is confirmed by liver biopsy and glucost-6-phosphatase assay

Choanal atresia
Suspect in infant with noisy breathing, cyanosis with feeding, and inability to pass catheter
through nares

Beckwith-Wiedmann syndrome
Presents with: overgrowth, macroglossia, anterior abdominal wall defects, hepatomegaly, and
pitting of external ears as well as neonatal hypoglycemia!
o As the child gets older, mental retardation and embryonal tumors present
Requires serial abdominal US to screen for tumor development

Torsion of testicular appendages

Presents with gradual testicular pain and swelling of scrotum
PE reveals a palpable, small, tender, and indurated mass on the upper pole of testis
o May be visible as a blueish dot on scrotal skin
Vitamin D deficiency rickets
S/S include: FTT, weakness, rachitic rosary, Harrison groove, scoliosis,
o Harrison groove is a horizontal groove along the lower border of the thorax
corresponding to the costal insertion of the diaphragm
Caused by chronic asthma or obstructive restrictive disease
Also appears in rickets b/c pt lacks the mineralized calcium in bones that is
necessary to harden them
Children with nutritional vitamin D deficiency should receive vitamin D and adequate nutritional
intake of calcium and phosphorus

Disease Etiology Rash Clinically

Roseola HHV-6 Mild, diffuse, High fever 3-5 days,
maculopapular rash following fever
Chicken Pox VZV Vesicular, pruritic
Measles (Rubeola) Paramyxo Erythematous, Prodrome of cough,
macular; starts on head coryza, and
& neck conjunctivitis; koplik
spots; fever
Rubella Toga Rose-pink Low-grade fever;
maculopapular; posterior auricular
spreads craniocaudal adenopathy
HFM Coxsackie Buccal mucosa, hands, Fever
and feet
Scarlatina Group A Strep Diffuse, erythematous, Fever, tonsillar
rough sandpaper exudate, cervical
texture adenopathy, ABSENCE
of cough
Kawasaki Unknown Polymorphus, High fever lasting at
nonspecific least 5 days; cervical
adenopathy;
conjuctivitis
Positive pressure ventilation
If infant has continued apnea, cyanosis, bradycardia, poor muscle tone
Then should have simultaneous evaluation of HR, respiratory rate, and oxygenation

Intussusception
Present as triad of: abdominal pain, palpable sausage-like mass, & currant jelly stools
In stable patients with NO signs of perforation, air contrast enema can be diagnostic and
therapeutic

Bartter syndrome
An AR disorder that produces defective chloride channels resulting in defective sodium
reabsorption in TALH
Result in hypovolemia and RAAS activation
Characterized by polyhydramnios, premature delivery and SEVERE hypokalemia,
hypochloremia, and metabolic alkalosis

Gitelman syndrome
Will have low urinary excretion of calcium and high urinary excretion of magnesium
Will tend to present later in life
Patients will have hypokalemia and hypochloremic metabolic alkalosis

Gullner syndrome
Form of familial hypokalemic alkalosis due to proximal tubule defect hypouricemia

Liddle syndrome
Occurs due to dysregulation of ENaC channel leading to increased Na+ reabsorption and
increased K+ secretion
Patients will have decreased serum renin and aldosterone
Will have hypokalemia and metabolic alkalosis as well as HTN at young age

Stills murmur
Most common innocent murmur and is usually hear in children 3-6 years old
Has a low-pitched, musical or vibratory sound
Best heard at the left lower sternal border or between left border and apex
Murmur is increased in supine position, with fevers and anemia
o Will decrease in upright

Venous hum
Has a soft quality of sound that lacks radiation
There is continuous humming sound through the ENTIRE cardiac cycle that is best heard in
infraclavicular region (R > L)
Murmur is louder when upright and disappears in supine
o The murmur will also disappear with compression of jugular vein (differentiates it from
pathological murmur)
Congenital hypothyroidism
Most commonly caused by impaired thyroid gland development or ectopic gland location
Clinical manifestations include: pot-belly, macroglossia, and edema
o S/S typically NOT present at birth and can take several weeks or months
Delayed diagnosis can result in irreversible cognitive and structural impairment
TFTs will show elevated TSH and low total thyroxine levels

Ataxia-telangiectasia
Present with ataxia, telangiectasia, and recurrent sinopulmonary infections
Typically have decreased or undetectable IgA, normal/low IgG, elevated/normal IgM
 OMM
**SACRAL DIAGNOSES**
L-on-L forward sacral torsion will have:
o Positive seated flexion
o Right deep sacral sulcus
o Left ILA posterior and inferior
o Negative spring and sphinx/backward bend test
R-on-L forward sacral torsion will have:
o Positive seated flexion
o Left deep sacral sulcus
o Right ILA posterior and inferior
o Positive sphinx/backward bend test
Unilateral extension
o Positive seated
o Sacral sulcus deep on contralateral side and anterior on ipsilateral side
o ILA posterior and inferior on the contralateral side
o Spring and sphinx test positive
Tests
o Spring test
Negative for forward torsion or flexion
Positive for backward torsion or extension
Torsion rules
o Sidebending of L5 and sacral oblique axis must be engaged on the same side
o Sacrum rotations in the opposite direction of L5
o Seated flexion test must be positive for the diagnosis of sacral torsion
o Seated flexion test will be positive on the side opposite of the oblique axis

**PELVIC DIAGNOSES**

**CRANIAL**
Axis of rotations
o Torsion
AP axis, rotation of both sphenoid and occiput in opposite directions
o Shear
Two transverse axes one though sphenoid, one through occiput
o Sidebending rotation
3 separate axes
One AP axis, sphenoid and occiput rotate in same direction
Two vertical axes, one through sphenoid and one through foramen
magnum
o Lateral
Two vertical axes both rotate in the same direction (normally it is in opposite)
Causing basiocciput and basisphenoid to go in opposite directions at the
SBS and presents as a parallelogram head when palpated
 Movement
o Cranium
Flexion = SBS elevates, increasing upward convexity
Extension = SBS depression
Occiput and sphenoid rotate in opposite directions
o Sacrum
Flexion / counter-nutation = base moving posterior and superior
Extension / nutation = base moving anterior and inferior

Scheurmann kyphosis
Characterized by rigid curvature that is NOT corrected by position change
Radiographic findings include anterior wedging of at least 3 adjacent vertebral bodies and
endplate abnormalities
Schmorls nodes are small protrusions of intervertebral discs into vertebral bodies
Etiology is unknown but disease is typically diagnosed in adolescent boys during rapid growth
period

OA treatment
Targets the vagus nerve and increases its activity INCREASED PARASYMPATHETIC
Causes variety of effects
o Bronchiolar smooth muscle to enhance respiration
o Decreased goblet cell production and thins secretions
o Increases mucociliary clearance
o Constrict bronchioles

Anatomic short leg syndrome will present with typical characteristics:

Sacral base unleveling with the lower base on the ipsilateral side
Pelvic shift AWAY from the side
Inominate anteriorly rotated on the ipsilateral side
Contralateral leg will be internally rotated with pronated foot
SI & ILL will be more stressed and tense on the ipsilateral side

Scapular winging can have varying types

Medial is due to serratus anterior paralysis
o Caused by injury to long thoracic nerve
Comprised of nerve roots C5-C7
o Usually due to acute or repetitive sports trauma
Lateral is much less common and due to trapezius paralysis
o Usually from spinal accessory injury during a radical neck dissection surgery

Shoulder dislocation
Anterior result in external rotation of arm and patients have axillary nerve injury risk
o Many patients will have deltoid and upper arm sensation loss
Posterior results in internal rotation of arm
o Patient presents with arm held in adduction & internal rotation
o Usually by electrocution or tonic-clonic seizure (via violent muscle contraction)
Acute low back pain
NSAIDs are the typical first-line
o Do carry increased risk of GI bleed and renal toxicity
o Meloxicam
Low doses COX-2 selective
High doses non-selective
Corticosteroids can be used, NOT first-line
Opiods are occasionally used, but last resort

TMJ
Chin deviation presence indicates an asymmetric tone of the lateral pterygoid muscle
o Origin - lateral pterygoid plate of the sphenoid
o Insertion mandibular neck
o ONLY muscle involved in opening of the jaw
o Concentric contraction, this muscle lowers the mandible
o Unilateral contraction of jaw will cause deviation to the contralateral side
Tenderpoint
o Can present with any points involved in opening or closing the jaw
o Masseter tenderpoint is located anterior to ascending ramus of mandible
Hypertonicity can also cause jaw deviation to the ipsilateral side when lowering
the jaw

Mesenteric release is a lymphatic drainage technique used to relieve tension of mesentery to posterior
abdominal wall
Used for wide variety of GI problems

Pterygopalatine fossa will house the pterogopalatine/sphenopalatine ganglion

OMM directed to this area because stimulation causes PNS response and will encourage
production of profuse, thin nasal secretions
o Eventually leading to reduced sinus congestion and pain

Posterior radial head commonly results from patient falling forward on outstretched hand
The translated force thrusts the head of the radius posterior in relation to the elbow
Patient typically reports pain when supinating forearm
o Pronation is typically more comfortable
OMM positioning for direct treatment is supination approximating head of radius with the
barrier to anterior motion

FPR technique acts on the alpha afferent and gamma efferent activity
It is performed by placing the area into a neutral position and applying a compressive force
while the SD is in position of ease
Held for about 3-5 seconds and then released and retested

Percutaenous reflex of Morley is the increasing intensity of acute abdominal pain and rebound
tenderness that is in response to visceral pathology
Also results in abdominal muscular contraction guarding
Spencer technique is a series of articulatory/muscle energy techniques that is indicated for adhesive
capsulitis
Order = extension, flexion, circumduction w/ compression then traction, abduction, internal
rotation, pump
Takes the shoulder through all ROM exercises

Inguinal ligament attaches to the pubis and the ipsilateral ASIS

Tension of this ligament would cause pubis to be superior

Travells trigger point at the right pectoralis major can have a causative or perpetuating role in causing
SVTs
If this trigger point is the cause, treating the trigger point may cause the arrhythmia to stop

Scoliosis
Most common = thoracic curvature convex on the right
Will be named according to the direction of the convexity of the spinal curve
Dextroscoliosis is one that has a curve sidebent to the left
Lumbar scoliosis is third most common and associated with arthritic change
Scoliosis is a pathological Fryette type I spinal mechanics
Asymmetric paravertebral prominence is a result from rotational component of spinal group
curves

Ulnar nerve damage can occur from a medial epicondyle fracture

Can result in claw deformity
o Due to loss of innervation to the lumbricals of 4th and 5th which allow unopposed action
of extensor muscles
Comprised of nerve roots C8-T1 and responsible for abduction and adduction of fingers
Innervates the adductor pollicis muscle that is responsible for thumb adduction
o ONLY muscle of the thenar muscle innervated by ulnar, the rest are from median
Post-partum patients can have variety of somatic dysfunction including bilateral sacral flexion
Patients will present with low back pain that is worse with backward bending
Physical exam will show bilateral deep sulci and posterior ILA points
o Patients may also have increased back curvature and have negative spring test

Psoas spasm
Psoas actions are hip flexion and external rotation of the leg
Spasm leads to: bent at waist, hip externally rotated and flexed

Pedal pump is CONTRAINDICATED in patients who recently underwent abdominal surgery

Due to tendency to augment thoracoabdominal pressure
Cause potential endangerment of stability of operative site
 PSYCH
Charles Bonnet syndrome is a condition seen in visually impaired patients
Characterized by the presence of visual deprivation hallucinations that are complex in nature
Hallucinations are 2/2 sensory deprivation leading to false perceptions rather than psychosis

Somatization disorder is defined as multiple physical complaints with no medical condition or

substance explaining the symptoms
Diagnosed when patient has had four pain complaints, two GI complaints, one sexual
symptom, and one pseudoneurological symptom
Symptoms are NOT intentionally produced
Treatment includes scheduling regular visits, limiting tests and referrals, and reassuring the
patient that grave medical diseases have been rules out
o Making functional improvement the goal of treatment
- If diagnosis not met, patient can be diagnosed with undifferentiated somatoform disorder
- Can also be a pain disorder, where the symptoms are predominately pain causing significant
distress or impairment

Acute stress disorder involves exposure to traumatic event and subsequent response of internal fear,
helplessness, or horror
Symptoms occur w/in 4 weeks of event and persist for at least 2 days and up to 4 weeks
- If > 4 weeks = PTSD

Adjustment disorder is the development of symptoms in response to identifiable stressor

Occurs within 3 months of stressor onset and should resolve within 6 months
Symptoms or behaviors results in marked distress as well as impairment in social or
occupational functioning

Schizoaffective disorder
Must have minimum of two episodes
o One in which it is just psychosis that lasts 2 weeks
o Second where there is a concurrent mood disorder (mania or depression)
Symptoms DO fulfill criterion A of schizophrenia ( 2 of delusions, hallucination, disorganized
speech, disorganized or catatonic behavior, negative symptoms)

Schizophrenia
Positive symptoms are things they have that they shouldnt and include:
o Delusions, hallucinations, disorganized speech and psychomotor agitation
o Associated with dopamine receptors
Negative symptoms are things that they dont have that they should and include:
o Flat affect, social withdrawal, anhedonia, and apathy
o Associated with muscarinic receptors

Schizotypal personality disorder is one of the cluster A disorders (along with schizoid and paranoid)
Have a pervasive patther of both eccentric behavior and unusual thoughts that are often
thought of as weird or strange
 They typically have deficits in ability to have close relationships and typically have peculiar
ideations as well as an unusual appearance and behavior
Diagnosis requires five or more of the following:
o Odd beliefs or magical thinking
o Ideas of reference
o Unusual perceptual experiences
o Excessive social anxiety
o Suspiciousness of others
o Odd or strange appearance and behavior
o Few close personal relationships
o Odd thinking or speech
o Inappropriate or restricted affect
Treatment of choice is psychotherapy

Alcoholic complications
Minor alcohol withdrawal presents with an onset of 8-9 hours after last drink
o Symptoms include: tremulousness, flushness, anxiety, headache, GI upset, insomnia,
hallucinations, diaphoresis, seizures
Alcoholic hallucinosis is something that occurs during alcohol withdrawal
o Occurs within 12-48 hours after cessation
o Symptoms include tactile, visual, and/or auditory hallucinations
o Treatment is with supportive therapy (which can include IV fluids and electrolyte
replacement)
Delirium tremens has an onset of 48-96 hours after last drink and cessation from heavy
drinking
o Symptoms include: tremors, psychomotor agitation, hallucinations, confusion,
increased autonomic activity (tachycardia, hyperhidrosis, fever, dilated pupils)
o Treatment is with IV BZDs as well as supportive measures
If severe, patients may need intubation to establish airway

MAOIs and SSRIs: can cause serotonin syndrome if taken together

If switching meds, should wait 14 days after MAO discontinuation before starting SSRI

Hypersomnolence disorder, previously known as primary or secondary insomnia that has the diagnostic
criteria of:
Excessive sleepiness despite >7 hours of sleep with at least one of the following
o Recurrent sleep or lapses of sleep during the day
o Prolonged main sleep episode of >9 hours that is nonrestorative
o Difficulty being fully awake after abrupt wakening
Occurs at least 3x/week for 3 months
Accompanied by distress or impairment of cognitive, social, occupational, or other areas of
functioning

Play therapy is generally used with children ages 3-11

Allows them to express themselves and their emotions, feelings, and experiences through a
natural and self-guided process
 Often begins with first observing the child playing with the toys to elicit cause of stressor or
disturbed behaviors

Anticholinergic toxicity is commonly seen with low potency, atypical antipsychotics

Symptoms include:
o Red as a beet caused by cutaneous vasodilation
o Dry as a bone referring to anhidrosis and dry mucous membranes
o Hot as a hare secondary to anhidrotic hyperthermia
o Blind as a bat referring to nonreactive mydriasis (pupillary dilation)
o Mad as a hatter presentation of delirium and/or hallucinations
o Full as a flask referring to urinary retention
Treatment is often with physostigmine, a reversible cholinesterase inhibitor
o Patients who are agitated and/or seizing should FIRST receive BZDs

Lithium overdose can cause: nephrogenic DI, HYPERreflexia, tremor, ataxia, nystagmus, and seizure
Acetaminophen overdose can cause: abdominal pain, n/v, and liver toxicity
Salicylate overdose can cause: tinnitus, n/v, AGMA, respiratory alkalosis, seizure, coma, and death
CCB overdose will produce many cardiovascular effects including: peripheral vasodilation, negative
chronotropy, negative inotropy, and delayed cardiac conduction
Typical presentation is hypotension and bradycardia with relatively preserved mentation
Treatment is supportive, as there is no antidote, and mortality is high

Amphetamine intoxication is characterized by autonomic hyperactivity with HTN, tachycardia,

diaphoresis, mydriasis and psychomotor agitation
Treatment consists of BZDs for agitation and phentolamine for HTN
Beta-blockers should be AVOIDED as they lead to unopposed alpha-adrenergic stimulation
hypertensive crisis
Opioid intoxication presents with signs of pupillary constriction, itching, nausea, constipation,
respiratory depression, slurred speech, hypotension, bradycardia, and hypothermia
Respiratory depression is the most sensitive sign
o Severe intoxication may require intubation to protect airway
Treatment is with naloxone and it acts as an opiate antagonist

Functional neurological symptoms disorder (Conversion disorder)

Characterized by S/S that suggest neurological disorder and are preceded by conflict or stress
Patients will have at least one neurologic symptoms (sensory or motor)
o They are unusually calm or unconcerned when describing symptoms
Symptoms will usually resolve w/in a month, and ~25% will have recurrent episodes
Treatment is with patient education and possible adjuvant medications (for mood and anxiety)

Sleep terror disorder occurs during stage III or IV sleep

Typically occurs in children, and more common in boys
Events of the dream are either not recalled or only distantly remembered
Includes both autonomic and behavioral manifestation of fear
Patients will often remain unresponsive to external stimuli
Occurs during the non-REM stages of sleep and is NOT associated with dreaming
- Different from nightmare disorder that is when there are frightening dreams during REM sleep and
the patients are easily aroused (vs. sleep terrors)
- REM sleep behavior disorder occurs during REM sleep and is characterized by acting out dreams

Speech patterns
Tangentiality is when the responses to questions never reach the goal of answering
o Describes the speech of patients who talk past the point
o Patients will have a clearly recognizable link between their ideas
Circumstantiality, the patient will include extra and unnecessary details to their responses but
they will eventually answer a questions
o The patient just takes longer to get to the point
Flight of ideas, the patient will speak rapidly and abruptly change topics based on links or
similarities
o It is commonly seen in mania and is often accompanied by pressured speech
Looseness of associations refers to disruption of of the logical connection between the
thoughts, and the patient is unaware and it is difficult to understand for the interviewer
o Often a feature of mania
Word salad is an incoherent and illogical speech that will lack meaningful connection
o It represents an EXTREME form of loose association
o Commonly in schizophrenia

Retts disorder is an X-linked dominant disorder due to a MECP2 gene mutation on ch Xq28 that occurs
almost exclusively in females
Individuals will have normal prenatal, perinatal, and psychomotor development through the first
five months after birth
There will be regression of development after period of normal development
Onset of all of the following:
o Head growth deceleration between ages 5-48 months
o Loss of previously acquired hand skills between ages 5-30 months
Along with the development of stereotyped hand movements (i.e. wringing,
flapping)
o Loss of social engagement early in the course
o Appearance of poorly coordinated gait or trunk movements
o Severely impaired receptive and expressive language development with severe
psychomotor retardation

Lennox-Gastaut syndrome is a pediatrics syndrome that is associated with severe seizures in childhood
Characterized by multiple types of seizures
Manifests with progressive intellectual disabilities that are w/ or w/o neurologic abnormalities

Smith-Lemli-Opitz is an autosomal recessive disorder of cholesterol biosynthesis

Caused by genetic mutation in the 7-dehydrocholesterol reductase gene which creates the
enzyme that 7-dehydrocholesterol cholesterol
Symptoms include: microcephaly, micrognathia, low-set posteriorly rotated ears, and
syndactyly of 2nd and 3rd toes
o Affected males have either ambiguous genitalia or nearly normal-appearing female
external genitalia
 o Number of patients have presented with primary adrenal insufficiency symptoms

Agoraphobia involves the fear of being in a place where escape might be difficult
Fears typically involve being afraid to go outside alone, being in a crowded place, standing in
line, traveling on a bus/train, or being on a bridge
Feared situation is avoided or endured with marked distress

Hyperadrenergic crisis
Can result from being on an MAOI with combination of tyramine
Normally MAOIs inhibit GI MAO system, which detoxifies tyramine containing foods
o Tyramine will act as an indirect sympathomimetic causing increased catecholamine
release
Patients will typically present with hypertensive urgency/emergency which can lead to possible
stroke or MI

Dystonia is defined as an extrapyramidal motor disturbance that consists of slow, painful, or sustained
contractions of axial or appendicular musculature
Characterized by intermittent spasmodic or sustained involuntary contractions
They are caused by medications that antagonize the dopamine pathway (e.g. haloperidol,
fluphenazine, other antipsychotics)
Reactions include: torticollis, buccolingual crisis, trismus, oculogyric crisis, and facial grimacing
Treatment is with benztropine and/or diphenhydramine

SSRIs (especially fluoxetine and paroxetine) can increase risk of abnormal bleeding
Thought to be caused by two mechanisms:
o Serotonin is known to directly promote platelet aggregation
SSRIs are though to limit uptake of blood serotonin by platelets
This decreased amount taken up by platelets may increase risk of abnormal
bleeding
o SSRIs will inhibit liver microsomal enzymes (i.e. P450 2D6)
Elevations of other drugs metabolized (i.e. warfarin) can elevate
Should be cautious with other anticoagulant medications, especially aspirin,
NSAIDS, warfarin
Side effects include: sexual disturbances, GI effects, insomnia, tremor, and agitation
o Risk of serotonin syndrome if used in conjunction with MAOIs or other serotonin
modulators (i.e. TCAs, SSRIs, SNRIs)
Considered first-line therapy for depression, anxiety, and panic disorder (NOTE that BZDs are
preferred for acute management of a panic attack)

Vascular dementia comprises of a step-wise progression of cognitive impairments

Evidenced by memory impairment and one or more of the following disturbances:
o Aphasia disturbance in the formulation and comprehension of language
o Apraxia inability to execute learned purposeful movements
o Agnosia inability to recognize objection
o Disturbance in executive functioning
Risk factors include those associated with vascular disease, vasculitis, or embolic disease
 o Patients will usually have a cardiac history or risk factors (i.e. HTN, heart disease,
hypercholesterolemia, diabetes)

Borderline personality disorder is one of the cluster B personality disorders

Patients will have unstable moods, unpredictable personalities, and unstable interpersonal
relationships
They will be impulsive, attention-seeking, and have poor self-esteem
o Will often have recurrent suicidal threats and resort to self-mutilation
Will often display splitting as a defense mechanism
o Situation is black and white, no shades of gray people are seen as good or bad

Defense mechanisms
Displacement is where a person shifts a negative feeling from one thing to another
o Example person angry at his boss goes home and yells at his children
Regression is a where a person deals with a problem by reverting to activities which would be
more appropriate for an earlier state of development
o Example person who returns to bedwetting after an emotional trauma
Suppression is when one consciously makes an effort to not think about or remember an
emotional trauma
Repression is where one unconsciously does not think or remember of an emotional trauma
Isolation of affect is the unconscious limitation of the emotion that is associated with a
stressful life event

Cyclothymic disorder is a combination of hypomania and dysthymia

Patients will have a chronic, fluctuating mood disturbance involving numerous periods of
hypomanic symptoms and periods of depressive symptoms
DSM-5 criteria includes:
o For at least 2 years (1 year in children and adolescents) there have been periods of
hypomanic symptoms that DO NOT meet criteria for hypomanic episode as well as
depressive symptoms that DO NOT meet criteria for MDD
o During the 2-year period, the hypomanic and depressive periods have been present for
at least half the time and the individual has not been w/o symptoms for >2 months at
a time
 INTERNAL MEDICINE
Gout
Presents with sudden onset pain and swelling and is typically monoarthritis
Caused by sodium urate crystal deposition
o Will be negatively birefringent needle-shaped crystals (will be yellow when parallel)
Risk factors include: male, diuretic use, excess alcohol, renal disease, and urate underexcretion
MC joint affected is the 1st metatarsophalangeal joint
Treatment of:
o Acute is aimed at pain and inflammation with indomethacin
o Chronic is to prevent future attacks with lifestyle modification as well as allopurinol
and probenacid

Pseudogout
Caused by the deposition of calcium pyrophosphate
o Will be rhomboid shaped and typically positive birefringent (will be blue when parallel)
The MC joint affected is the knee
Treatment is NSAIDs or colchicine

Septic arthritis
Will typically occur from hematogenous spread
MC organism is via S. aureus
o In young sexually active adults, think N. gonorrhea
Physical exam will reveal a warm, erythematous, tender joint with a limited ROM
CBC will show an elevated white count and other tests will show elevated ESR and CRP
Joint aspiration will show leukocytes >50k
Treatment will depend on organism:
o N. gonorrhea ceftriaxone and azith/doxy (for chlamydia coverage)
o S. aureus may end up involving percutaneous or surgical drainage and IV abx

If total parenteral nutrition, then excess protein administration should be AVOIDED to prevent
worsening azotemia
Dietary protein restriction has been shown to decrease rate of CKD progression

Pre-renal azotemia
Will have a FENa < 1% as well as a BUN/Cr > 20:1
If on diuretics, will have to use FEUrea < 35% to distinguish pre-renal
Urine Na is usually <20 mmol/L in pre-renal and it is >40 mmol/L in ATN and post-renal

Kidney stones
Calcium oxalate is the most common type of kidney stone
o Shape will depend on whether monohydrate or dehydrate:
Monohydrate dumbbell or needle shaped
Dihydrate envelope-shaped
o They for in acidic urine and are more common when urine volumes are low
Calcium phosphate is the 2nd most common
o Will form in alkaline urine
o Are radiopaque and can be seen on plain film X-ray
o Preferred imaging is with helical CT
o Prevention focuses on adequate hydration with urine acidification as well as correction
of low urine volume