COMLEX II & USMLE II CRAM SHEETS Obesity

-GASTROENTEROLOGY
mild 20-40%, moderate 41-100, severe <101%; age,
Vitamins black women, low income

Vitamin A BMI= body wt (kg)/Ht (mm2) Normal 20-25

Night blindness, conjunctival dryness, corneal Pickwickian Syndrome = obesity, dyspnea, hypovent,
keratinization CO2 retention, hypoxia

Vitamin D Boerhaave's Syndrome

Ricketts - kids, long bone bowing; Osteomalacia-adults, esophageal rupture due to forceful vomit;
demineralization Gastromediastinal fistula, dyspnea w/o hemetemesis, +
Hammonds sign = pneumomediastinum, L lung effusion
Vitamin K
Dysphagia
Clotting deficiency with prolonged PT
Obstructive - solids 1st; Motor -solids = liquids
Thiamine (B1)
Infectious Esophagitis
Beriberi - peripheral neuropathy, Cardiomyopathy - dry
or wet (high output failure) Candida (thrush), HSV, CMV, immunocomp, diabetics,
Dysphagia & odynophagia
Wernicke-Korsakoff - Alcoholics, confabulation,
nystagmus, confusion Esophageal Atresia

Niacin Proximal esophagus, blind pouch

Pellagra - Diarrhea, dermatitis, dementia, death Trachesoph Fistula

Pyroxidone (B6) Congenital defect, distal esoph, coughing & cyanosis

when feeding, abd distention
Rare, neuropathy, Cheilosis (swollen cracked bright red
lips) Achalasia

Cobalamin (B12) Dysphagia for solids & liquids, nocturnal cough,

aspiration; Absent peristalsis & tight LES, "Beak" esoph
Macrocytosis, Pernicious Anemia- megaloblastic, neuro on x-ray, 20-40 yrs old
chg. ataxia, Schilling test
Esophageal Cancer
Folate
squamous 90%
Macrocytosis, megaloblastic anemia w/o neuro chgs.,
common in alcoholics Dysphagia solids 1st, Cough & hoarse = laryngeal nerve,
constricting bands = annular lesion, Risk factors=
Vitamin C smoking, alcohol, GERD, Barretts Esoph = adeno CA

Scurvy, bleeding gums, Connective Tissue problems, Gastritis

Can manifest 1 yr post defic.
Antral Creep=fundal tissue replaced by antral mucosa,
Failure to Thrive Not preCA,

Org.= wt gain w/ other disease; Nonorg.=growth failure Risk Factors = NSAIDS, Alcohol, H.Pylori
due to neglect stimulation
PUD
< 80% wt for Ht
Gastric = NSAIDS, eating no help, COPD,blood type A; bowel with thin mucosal folds; most common cause of
25% malbsorption

Duodenal = H.Pylori, better w/ food, Liver cirrhosis, Tropical Sprue

Blood type O ; 75%
nutritional defic, small bowel mucosal abnormal;
Cullen's Sign Acquired - Caribbean, India, SE Asia; Megaloblastic
Anemia, glossitis, diarrhea, wt loss Tx Folic Acid &
Periumbilical cyanosis d/t hemoperitoneum = Tetracycline
hemorrhagic pancreatitis, ruptured ectopic, ruptured
spleen Whipple's Disease

Zollinger-Ellison Synd. Infectious; middle aged men; multi-organ; Thickened

mucosal folds, Foamy macrophage with rod shaped
Gastrinoma ( gastrin); recurrent ulcers, are malignant bacilli that stain w/periodic acid (Schiff's Reagent)

Gastric CA Intestinal Lymphangiectasia

Adeno, H.Pylori gastritis, Virchow's Nodes, Types = Children & young adults; cong or acquired telangiectasia
ulcerating (shallow edges); polyploid (intraluminal late of intramucosal lymphatic
mets); superficial (early CA) ; Linitus Plastica (all layers
elasticity) Mets to ovary = Krukenberg Tumor Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/
triglyceride supplement
Diarrhea
Toxic Megacolon
Osmotic = H2O lumen solutes in bowel; Secretory =
electrolytes & H2O secreted not absorbed; Dilation > 6cm, Adults preceded by IBD (UC or Crohn's)
Malabsorption; Exudative secretion of blood plasma & Kids preceded by Hirschsprungs Ds; Sx: severely ill,
mucus (mucosal inflammation); transit time (short temp, abd pain, rebound, leukocytosis; X-ray -
bowel); transit (bact. Proliferation) intraluminal gas along continuous seg of dilated bowel;
Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids,
Ischemic Colitis Rectal tube may alleviate but can cause perforation

Vascular compromise (atherosclerotic or embolic); Inguinal Hernia

abrupt abd pain after eating, bloody diarrhea, systemic
sx.; Barium X-Ray - Thumbprint = pseudo tumor Indirect = infants, persistent processus vaginalis,
protrudes thru ring, lateral Inf Epig.
Irritable Bowel Synd.
Direct = Adults, medial to ing ring & inf epig artery,
Dx of exclusion (psych?); Tx: bulk supp, anticholinergics, Weakness in Hesselbach's
antidiarrheals, TCA
Ulcerative Colitis
Colonic Polyps
Colon & Terminal Ileum w/o skip lesions, w/ rectal
villous>tubular ; sessile>pedunculated for being CA; bleeding, "lead Pipe" on X-ray (shortened, narrowed,
familial adeno polyps autodom. loses haustrations) Tx: Sulfasalazine, steroids,
Immunosuppresents; Complications=perf, hemorrhage,
Toxic Megacolon, Colon CA
Lactose Intolerance

Diverticular Disease
Lactase deficiency, bloating & explosive diarrhea after
milk; Ages 10-20
Diverticulosis = false diverticulae, pearl sign on xray
Celiac Sprue
Diverticulitis = infection, acute abd pain usually on left,
st may form fistulas to bladder, vagina or skin, CT w/ water
Gluten sensitivity (wheat, rye, barley); amenorrhea 1 sx
soluble contrast during acute attack
girls, Infants = FTT, abnormal stool, bloating, Adults =
malabsorption, vit deficiency; X-ray - dilated loops of
Crohn's Disease
Granulomatous colitis; No bloody stools, 1st in terminal Norwalk = yr round, Rota (kids) = winter; Coxsackie A1;
ileum, transmural, skip lesions, cobblestoning: echo, adeno
Complications=small bowel abscess, obstruction,
perianal disease, malabsorption, toxic megacolo, Colon Botulism
CA. Surgery is not curative
Clostridium Botulinum, neuromuscular; onset 12-36 hrs;
Colon CA N/V/D, cranial nerve palsy, fixed dilated pupils, resp
failure, no fever, Wound induced = neuro w/o gi sx
Right Sided=napkin ring, anemia Left Sided=Apple core,
pencil stools; Genetic; Annual rectal>40, Annual Guaiac Infants constipation 1st=> cranial nerve sx => cranial
>50; Flex Sig q3-5y >50; Rectal CA-hematochezia nerve Sx => Neuromuscular

Volvulus Hemorrhagic Colitis

Rotation of Bowel; Newborns & elderly; Double Bubble; E coli 157, cramps, => watery diarrhea => bloody
Birds Beak on Barium Enema, Tx: Left Sided = diarrhea Complications= Hemolytic-Uremic Syndrome,
decompression; Rt sided & kids = surgery thrombotic thrombocytopenic pupura

Intussusception Pseudomembraneous Colitis

Telescoping of large bowel into an adjacent section; Antibiotic induced (clindamycin, ampicillin,
most common cause of obstruction in kids under 2; cephalosporin) C. Diff; mail -> severe bloody diarrhea;
Episodic Abd pain 1-2 min. Reflex = early vomit; Tx: stop antibiotics, oral metronidazole in severe cases
Obstructive = omit late; Currant Jelly Stool; Small Infants
= Pallor, sweating, and vomiting. Leukocytosis with Acute Pancreatitis
hemoconcentration, BE to reduce x 2 before surgery
Pain radiates to back w/ N/V; Grey Turner's Sign (blue
Necrotizing Enterocolitis flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase
;
Premature, birth weight, older infants with malnutrition;
bilious vomit, abd distention, bloody stool, lethargy; Ranson's Criteria: 3 or more = incr mortality
Thrombocytopenia; Small Bowel Distention;
pneumatosis (air in bowel wall) TX; NG, TPN, IV
antibiotics, surgical Rx necrotic part Admission: >55, gluc>200, LDH >350, AST >250 WBC >
16000
Cholera
Within 48 hrs: Hct 10%, BUN >5, Ca< 8, PaO2 < 60,
Base Def > 4, Fluid Seq>6L
Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic
gulfcoast, Asia, Africa, Mid East; Severe dehydration,
Metabolic Acidosis, Tx: Tetracycline or Doxycycline Chronic Pancreatitis

Shigella Dysentery ERCP to Dx; Alcoholics, Malabsorption & diabetes are

results
Small bact dose needed, Blood & mucous, Kids worse
than adults, Fluid Replacement & Ciprofloxacin Hepatitis

Staph Enteritis Hep A = Fecal oral, shedding before Sx; IG to travelers &
contact with HAV infected
Onset 3-6 hrs; "Church Picnic epidemic; N/V/D, HA,
fever recovery w/in 24 hrs Heb B= Blood & STD; HbsAg early if persists = carrier;
HbcIGM then HbcIgG for life
Salmonella Enteritis
HBIG for needle sticks and infants born to + moms;
assoc w/ hepatocell CA
Undercooked Poultry; nausea & cramps => watery &/or
bloody diarrhea; No antibiotics prolongs excretion of the
organism Hep C Most common post transfusion hepatitis

Viral Enteritis Hep D = Co infection with B; Hep E = fecal oral

Cholelithiasis glucose-6-phosphatase def.; big liver & kidneys, growth
retardation, electrolyte prob.
Female, fertile, fat, forty; Ultrasound, RUQ pain after
fatty meals, Calcified = preCA McArdles Disease

Cholangitis musclephosphorylase is absent, muscle cramps &

myoglobin after exercise
Charcot's Triad = Biliary Colic, Jaundice, Fever;
Leukocytosis, Alk Phos Jaundice

Hepatocellular CA Prehepatic = hemolysis, gilbert's disease, Crigler Najjar;

Hepatic = hepatocellular or cholestatic; Post Hepatic =
Mets 2x more than primary CA (breast, lung, colon), Biliary obstruction, AST & LDH also ;
Budd Chari-thrombosis hep V.
unconj prehepatic; conj = intrahepatic cholestasis or post
Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins hepatic disease
(fungal metabolites)
all fractions = hepatocellular, hyperbilirubinuria = conj bili
Benign Hep Adenomas water soluble

oral contraceptives ETOH Hepatic Disease

Exocrine Pancreatic CA Fatty liver => ETOH hepatitis => cirrhosis; AST > ALT ;
PT; II, VII, IX, X Clot
Ductal CA, Courvoiser's Law=palpable nontender GB in
a jaundiced patient is a head of Pancreas tumor. Tumor Cirrhosis
Body or Tail=splenic vein obstruction=> splenomegaly,
gastritis, esoph varices necrosis and fibrosis, serum albumin, anemia PT, Not
curable or reversible

Insulinoma Esophageal Varices

Insulin hypersecretion, hypoglycemic symptoms, Insulin veins that expand to circumvent congested hepatic flow;
levels still after fasting Tx: vasopressin, balloon tamponade, endoscopic
sclerotherapy, transjugular hepatoporto shunt (TIPS
Whipple Triad: confirms hypoglycemia as source of Sx 1.
Hypoglycemia, 2. Relieved with carb ingestion 3. Sx Hepatic Encephalopathy
occur while fasting
altered consciousness, ammonia glutamine in CSF, EEG
VIPoma abnormal

Makes Vasoactive peptide (VIP); Sx WDHA (watery Ascites

diarrhea, hypokalemia, achlohydria; unexplained
secretory diarrhea; laparoscopy for Dx Complication of hepatic disease; Paracentesis to
examine ascitic fluid values should equal serum if
Glucagonoma albumin = malignant; LDH > 60% of serum = malig or
infective;
tumor of alpha islet cells; 80% women; 80% malignant;
Necrolytic Exfoliating Erythema characteristic exfoliating WBC = infection
lesion of the extremities
GI Bleeding
Pompe's Disease
Upper GI = melaena (black tarry) ; Lower GI =
1,4 glucosidase deficiency; fatal by age 2 hematochezia (bright red) Lig Trietz

VonGierke's Disease Intestinal Obstruction

Vomiting common in small bowel, late in lg bowel, High Pulmonic Stenosis
pitched "tinkling" BS.
R=>L, Early systolic click, High pitched systolic ejection
X-ray - prox dist = lg bowel; dilated loops of bowel with murmur, soft or absent S2
air fluid levels = sm bowel
Coarction of the Aorta
Ileus
HTN arms but not legs, murmur heard on back, X-ray
Paralytic obstruction of bowel due to loss of peristalsis scalloping of ribs,

Pyloric Stenosis Bacterial Endocarditis

Projectile vomit in neonates, visible peristaltic wave, Acute: S.aureus, Group A strep, N Gonh., Sub acute:
String Sign Strep Viridans; New heart murmurs, petechia over half of
body, Splinter hemorrhages on fingernails, Osler's
Meconium Ileus Nodules (nodules on fingertips) Roth's Spots (retinal
hemorrhages)
Abnormal thick Meconium with undigested protein,
associated with CF Noninfective Endocarditis

Hirschsprung's Disease Libman Sacks Disease associated with SLE

No autonomic nerves in colon, Obstipation, late vomit, Aortic Aneurysm

Megacolon, Toxic Enterocolitis if left untreated, BE
proximal dilated & distal narrow, Abdominal = pulsatile mass on exam, atherosclerosis,
ColostomyCARDIOVASCULAR smoking HTN >4 cm = surgery Thoracic =Marfan's &
syphilis >7c = surgery; Dissecting =split between medial
Contraindications to BP meds & adventitial layers "ripping in chest" Normal EKG vs
abnormal in MI
Asthma/COPD = Bblockers, DM = Thiazides &
Bblockers, Cardiac Failure = Bblockers & Ca Channel Peripheral Vascular Disease
Blockers; Pregnancy = Thiazides & ACE
Weak pulses, Atrophic skin, Little Hair growth,
Rheumatic Fever Nonhealing ulcers, intermittent claudication 5P's = pallor,
pain, pulseless, parathesia, paralysis
post strep infection, migratory arthritis, endocardits,
subcutaneous nodules on extensor surface, chorea, Raynaud's Phenomenon
erythema marginatum, Sed, WBC & ASO
Pallor, cyanosis, erythema of fingers, most are
ASD idiopathic, others related to collagen vascular disease Tx
vasodialators
L=>R; Wide split & fixed S2; patent foramen ovale
Heart Dysfunction
VSD
Diastolic = difficulty filling ventricles; Systolic = problem
ejecting blood from ventricle
L=>R; pansystolic murmur left sternal border, thrill; most
common defect; Eisenmenger's Syndrome = shunt
direction reversed due to pulm vasc resistance Polyarteritis Nodosa

Patent Ductus Arterio inflamed medium arteries->ischemia in tissues; men 3x>

women, usually 40-50; Dx confirmed by biopsy or
angiography showing aneurysm of medium arteries
L=> R; Continuous machinery murmur; Indomethacin
inject may close
Giant Cell Arteritis
Tetralogy of Fallot
Temporal Arteritis; women >50; severe temporal or
occipital HA, Amaurosis Fugax (temp blindness 1 eye)
VSD, RVH, Pulmonic Stenosis, Overriding Aorta
Temporal artery swollen & tender, Dx confirmed by Congestive Cardiomyopathy
biopsy
Alcohol = chronic; Infection Coxsackie B or
Cor Pulmonale Trypanosoma cruzi (Chagas Disease)

COPD most common cause; Dyspnea & syncope on Hypertrophic Cardiomyopathy

exertion, S/Sx Rt heart failure
Cong or acquired VH with normal afterload; venous
Mitral Stenosis pressure, JVD, ascites, edema, edema, pleural effusion,
S4 on exam
Mitral facies = red rash on cheekbones, Loud S1 and
opening snap after S2; Right heart failure TX with Chronic Pericardtis
diuretics; LAH=>Pulm HTN=>RVH Bblockers & Ca
Channel Blockers to HR & preload; Progressive Causes right sided failure; Kussmaul's Sign ( neck vein
Dyspnea distention on exertion) Dyspnea on exertion and
Orthopnea; pulsus paradoxus; Surg removal of
Mitral Regurge pericardium is curative.

Midsystolic click; Harsh blowing holosystolic murmur; Pericardial Effusion

MVP; LAH & LVH; wide S2 that widens more with
inspiration; Bblockers for Sx Valve replacement Friction rub, distant heart sounds, "water bottle" on x-ray;
acute pericarditis = exudate; neoplasm or fibrosis
Aortic Stenosis =transudate; symmetrically enlarged cardiac silhouette

Triad = Angina, Syncope & Dyspnea on exertion; Cong Cardiac Tamponade

bicuspid valve, weak long pulse, LVH T wave invesions;
Left sided failure; Bblockers HR & coronary flow Pulsus paradoxus, Kussmauls Absent; pericardial fluid
compresses heart, Becks Triad = Hypotension, ( pulse
Aortic Regurge pressure), JVD, Muffled heart signs

Decrescendo murmur, widened pulse pressure, "Water Heart Murmurs

Hammer Pulse" (rapid up & down stroke); "Pistol Shot
over femoral Artery; 2o Austin Flint murmur= diastolic AI: precordium, early diastolic, >S2, + heave; AS: 2nd R
murmur as blood goes thru AV to hit MV. Kids = cong ICS & radiates to carotids, harsh, < S2; Diastolic = r/o
VSD w/ MVP malignancy, check BP both arms; MR: Apex radiates to
axilla, + heave, assoc w/ sever anterior MI, endocarditis
Supraventricular Tachycardia prophylaxisis; MS: Apex, late diastolic, opening snap
after S2; MVP: Apex, blowing, holosystolic, w/ valsalva;
Sudden attacks due to reentry rhythm, P on T on EKG; PR: 2nd L ICS, pulm HTN, clubbing, PE; PS: harsh; TR:
#1 AV Nodal Reentry #2 Wolff Parkinson White = reentry 4th L ICS, loud w/ inspiration; bounding JVD, pulsatile
thru accessory muscle bundle, can cause V fib in a Pt liver; VSD: loud holoystolic, assoc w/
with Afib; Torsades De Point is drug induced Down'sRESPIRATORY

Left Sided Failure Peritonsillar Abscess

Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, uvula away; Head tilted toward, Trismus (can't open
LVH mouth)Strep or Bacteroides

Right Sided Failure Epiglottitis

Most common cause is Left sided failure; Neck vein H.flu type B, Insp. Stridor, Dysphagia with drooling,
distention, Liver big, Edema Thumbprint sign on xray

MI Larengitracheitis

ST elevation, T wave inversion; CPK-MB 12 - 40 hr for Croup; Paraflu #1, RSV, Flu, barking cough, stridor
peak; LDH peaks 3-6 days hoarse, r/o epiglottitis
Acute Bronchitis Extrapulmonary manifestations= meningitis, pericarditis,
bone invasion (Pott's Disease)
non smokers = M. pneumonia; smokers=S.pneumonia &
H.flu Bronchiectasis

Bronchiolitis chronic destructive; dilation of bronchial tree, cough with

sputum, dyspnea, hemoptysis, Xray = bronchial
Circumoral cyanosis (blue around mouth) RSV; kids < 2 markings, "honeycombing"

Strep Pneumonia Emphysema

Red-brown sputum, lobar pneumonia, most common Destroyed alveolar walls, Risks: smoking, alpha 1
adult community acquired antitrypsin deficiency;

Pneumovax vaccine = >65, immunocompromised, PFTS: FEV1; VC, FEV1/FVC < 60% normal
chronic disease
Blue Bloaters
H.Flu Pneumonia
Bronchitis>Emphysema; cough w/ mucous 3mos/yr x 2y;
COPD, children, slow onset with URI sx 1st, patchy cyanosis, pulm HTN
bronchial infiltration on xray
Pink Puffers
Viral Pneumonia
Emphysema >Bronchitis; gradual dyspnea not hypoxic,
Most common cause in kids, flu like prodrome, patchy underweight
infiltrates; WBC not a lot
Cystic Fibrosis
Klebsiella Pneumonia
auto recessive, COPD, Pancreatic insufficiency;
Alcoholics, aspiration, Currant Jelly Sputum, meconium illeus, sweat chloride
Encapsulated gram neg rod
Sarcoidosis
Staph Pneumonia
non caseating granulomatous, increased Calcium,
Salmon colored sputum, Nosocomial, pneumatoceles on ground glass, bilateral hilar & paratracheal adenopathy
xray are pathognomic is pathognomic

Mycoplasma Pneumonia Asbestosis

atypical no cell wall to stain, young adults in close Increased risk of lung CA & mesothelioma, gradual
contact; xray worse than pt looks dyspnea, nonproductive cough; no wheeze; diffuse
linear opacities on xray
Pseudomonas Pneum.
Silicosis
hospital acquired, CF, immunocompromised
increased risk of TB, SiO2 inhalation; metal mining;
multiple small nodules & calcification of hilar lymph
Legionella Pneumonia
nodes
atypical, CNS & GI sx; confusion & ataxia, aerosolized
Resp Failure
water (air conditioning)

ABG=> PO2 50-60 mmHg; PCO2 >45 mmHg

TB

Laryngeal CA
fever, night sweats, wt loss, bloody sputum, Miliary =
disseminated; Acid fast stain, PPD>10mm
nonimmunocompromised; ppd>5mm AIDS; squamous cell, smoking & alcohol, hoarsness for several
weeks
Lung CA <37 wks gestation, Lung maturity: L/S ratio >2, + PG;
Beclomethasone hastens maturity; artificial surfactant for
squamous>adeno>small(oat) cell; Squamous = hilar; kid
Adeno = peripheral; Horner's Syndrome=invasion of the
cervical symp. Ganglion= miosis, ptosis, anhydrosis Pulm HTN

Pancoast tumor = Horners + pain in arm or shoulder on Primary = dx of exclusion; secondary valvular heart
affected side disease, L=>R shunt, chronic ateletasis (localized
collapse of alveoli)ENDOCRINOLOGY
Asthma
Hypothyroid
PFTs FEV1; ABG resp alkalosis, CO2; If CO2 or normal
resp failure imminet Weight gain, Lethargy, Coarse hair & dry skin, irregular
menses, cold intolerance, myxedema; Acquired =
Massive Hemoptysis Hashimoto's; Congenital = cretinism, severe I deficiency
= hoarse cry; resp distress, cyanosis, poor feeding, decr
bone growth, T4 TSH
>600 ml blood in 24 hrs; trauma; PE, aortic aneurysm,
heart failure
Wolff Chaikoff effect = inhibition of thyroid hormone
release due to high doses of I during thyroid scan
Pneumothorax

Hyperthyroid
Spontaneous = 15-35 y/o males; Tension = pressure in
pleural spaces; displaces heart & lungs (mediastinal
shift) = surgical emergency 1. GRAVES: most common, autoimmune, antibodies
bind to TSH receptors; incr thyroid hormone, pretibial
myxedema, Incr radio I uptake
ARDS

2. SUBACUTE THYROIDITIS: tender, enlarged, Decr

acute lung injury with non-cardiogenic pulm edema, ABG
Radio I uptake, Sed Rate up, maybe followed by period
=acute resp alkalosis (O2 & CO2; Xray =pulm edema
of hypothyroid
with normal cardiac silhouette, Positive pressure or
PEEP ventilatory support
3. SILENT LYMPHOCYTIC THYRODITIS: transient,
postpartum, no pain or fever, Radio I uptake decr,
Pleural Effusions
lymphocytic infiltration, Tx Bblockers
tactile fremitus; dull; egophony (incr resonance; chg
4. TOXIC ADENOMA: multinodular goiter; nodules
voice to high pitched)
function autonomously, Excess T3 & T4; Scan shows a
few hot spots with cold background
Transudates: <3g protein, Plasma/serum protein<0.5;
Plasma/serum LDH <0.6 caused by CHF, cirrhosis,
5. THYROTOXICOSIS FACTITIA: exogenous thyroid
nephrotic syndrome
hormone, no goiter
Exudates:Reverse labs; neoplasms & infections;
6. PLUMMERS : multinodular goiter, nodules become
triglycerides = chylous effusion; Pus = empyema (s.
autonomous and secrete thyroxine
Aureus); Meiggs syndrome = pleural eff, ascites pelvic
tumors)
Sick Euthyroid
Pulmonary Edema
acutely ill patients; T3&T4 decr due to chgs in hormone
metabolism; TSH not decreased => not truly hypothyroid
Pink, frothy sputum, Kerley B lines on xray; Incr cardiac
silhouette if cardiac origin
Thyroid CA
Pulmonary Embolism
Papillary = most common, best prognosis, Follicular =
older, hematogenous spread to bone, lung, brain, liver;
DVT (iliac & femoral) V/Q useful, angiography is god std
Anaplastic = worse prognosis, local invasion, hoarse &
for dx
dysphagia; Medullary= Calcitonin producing Cells, MEN
Type II(parafollicularC cells)
RDS
Diabetes #2 Ectopic- ACTH from lung tumor, #3 Adrenal Cortical
tumor- cortisol, ACTH suppressible, cortisol not #4
Dx: elevated random glucose sx, fasting BS > 140 x 2 Chronic glucocorticoid Tx
days; Oral challenge >200 after 2 hrs; Type I: alpha islet
cells, HLADR3, HLADR4, HLADQ, ketoacidosis Waterhouse Friedrickson Syndrome

Type II: insulin resistance; no HLA association, hemorrhagic infarct of adrenals, assoc w/
endogenous production enough so no ketoacidosis but meningococcemia
do get hyperosmolar coma(dehydrated, glucose 600-
2000 Pheochromocytoma

Parathyroid Hormone Episodic HTN, Dx by urinary catecholamines

Ca mobilization from bones, Vit D production phos Familial Hypercholesterolemia

reabsorption in distal tubules = serum phos.
Autosomal dominant, Xanthomas (lipid on tendons)
Hypoparathyroidism Xanthelasmas (lipids on eyelids) MI's in 40's,
Homozygous usually has total cholesterol
PTH, Ca, Phos, Tingling, tetany, Chvostek's sign (tap on
face & get muscle spasm) ; Trousseau's Sign (BP cuff up Familial Hypertriglyceridemia
3min => carpal tunnel sx; Mg in alcoholics can lead to
Ca due to PTH secretions Trig , LDL normal, Autosomal dominant, Pancreatitis,
milky serum
Hyperparathyroid
Familial Combined Hyperlipidemia
Bones, stones, abd. Groans and psychic moans; 1o =
excess PTH; 80% benign adenoma; 2o due to serum Auto dominant, trig and cholesterol; no xanthomas
Ca=> vit D defic, renal tube prob and Ca loss
Familial Dysbetalipo-proteinemia
Diabetes Insipidus
rare, problem with lipoproetin catabolism; palmar or
Lack of ADH, polyuria and polydypsia tuberous xanthomas, risk periph vasc disease & CAD,
Abn VLDL, cholesterol & triglycerides
Kallman's Syndrome
MEN I
Male, anosmic, small testicles, azospermic d/t head
trauma; FSH & LH, no GNRH Parathyroid , pituitary & Pancreatic tumors

SIADH MEN II

Excess ADH, Tumor, trauma, pulm disease, drugs; Pheochromocytoma, Parathyroid & medullary thyroid
Hypoatremia, Conc. urine; tumors

Acromegaly Hemochromatosis

Excess GH; bone & tissue enlargement; glucose Auto recessive, GI absorption of Fe; Excessive Fe,
intolerance, osteoarthritis Ferritin, Transferrin saturation, cirrhosis, diabetes,
bronze skin
Addison's Disease
Wilson's Disease
Decreased cortisol (aldosterone) Wt loss, fatigue, skin
pigmentation, eosinophilia; Decr aldosterone, decr Na, Auto recessive, excessive Cu accumulation, ataxia &
incr K; Give ACTH if cortisol doesn't increase Dx made dementia, Kayser Fleisher rings on cornea

Cushing's Syndrome Hyperaldosteronism

Incr cortisol, Buffalo hump, moon facies, central obesity,

Osteoporosis, #1 Cushing disease due to pit. Adenoma,
Aldosterone works on distal renal tubule to facilitate Na Ca = Calcium stones; Struvite Stones = post UTI w/ urea
retention and K loss splitting bact (proteus or pseudo) when urine basic
MgNH4PO4 (struvite) stones ppt.
excretion due to Na, BP (renin angio), K
Uremic Syndrome
1o Conn's Syndrome = adrenal hyperplasia, adrenal
adenoma Tx: spironolactone Symptomatic renal failure = GFR< 20 ml/min; CNS chgs,
asterixis (flapping tremor) pericarditis, N/V, yellow-brown
2o renin angiotensin system activity => skin (uremic frost) Normochromic, normocytic anemia
BPGENTOURINARY due to erythropoietin; Phos & Ca = renal osteodystrophy

Neurogenic Bladder Glomerulonephritis

Bladder control requires: intact sensation(full) motor Hematuria, proteinuria, RBC casts: Post strep = give
function (start void) Cerebral control (timing) Antibiotics only if still strep +, steroids no help;
Goodpastures- autoimmune, high dose steroids, uremia
3-9 mos.
Atonic, distended with overflow= acute spinal cord injury
or sensory impaired
Nephrotic Syndrome
Motor defect = sense full bladder but can't start emptying
Proteinuria > 3g/day, Edema, hypoalbuminemia &
hyperlipidemia (milky serum); minimal chg disease in
Autonomous = spinal cord injuries after acute; bladder
kids; idiopathic Glomerulonephritis in adults
fills & empties reflexively

Acute Tubular Necrosis

Hydronephrosis

most common cause of acute renal failure; ischemia or

dilation of renal pelvis, pressure in urinary system w/ or
toxins; resolves in several weeks may need dialysis
w/o ureter dilation

Polycystic Kidney Disease

Fanconi's Syndrome

Auto dominant; multiple bilateral renal cysts; gross

renal tubule defect; Urinary excretion of glucose, phos,
hematuria, proteinuria, pyuria, HTN, UTI's; asymptomatic
AA; Tx: Vitamin D
until adult; 15% have associated subarachnoid
hemorrhage
Pyelonephritis & Pyelitis
Alport's Syndrome
Pyelonephritis = dilation of renal parenchyma, pyelitis =
dilation of renal pelvis; E. coli; Different from cystitis
X-linked, Type IV collage, deafness & renal failure in
since there are WBC casts not just WBC's
males
Cystitis
Wilm's Tumor
WBC in spun sample, E. coli, freq, urge, dysuria &
nephroblastoma, kids < 4yrs commonly, hematuria, abd
suprapubic pain
mass; resection & chemo
Bladder Ca
Renal CA
transitional cell CA; Risk factors = smoking,
adenocarcinoma; Triad: hematuria, abd mass & flank
schistosomiasis, aniline dyes
pain
Renal Artery Stenosis
Chronic Renal Failure
Cause of 2o HTN; Fibromuscular dysplasia (young
>90% glomeruli destroyed; uremia K, Na phos, Ca =
women) Atherosclerosis (older)
renal osteodystrophy
Urolithiasis
Hypernatremia
> 155 mEq/L; due to dehydration, CNS depression BPH
(neuronal shrinkage); Diabetes Insipidus= decr ADH =
lots of dilute urine = dehydration = urine output incr. Enlarged rubbery prostate on rectal; Urinary retention,
blockers; TURP, transrectal US more sensitive for Dx;
Hyponatremia PSA can be falsely elevated

<135 mEq/L; pseudo if lipids are high to displace polar Prostate Ca

Na; Osmotic = diabetes Na 1.6 for 100 mg/dl glucose
value is above 140.; SIADH, Central Pontine Myelinosis Firm, nodular irregular prostate, Bone mets; Alk Phos
if corrected to fast and PSA are

Hyperkalemia Bacters Syndrome

> 5.5 mEq/L; muscle weakness, cardiac arrhythmia, met pre-auricular skin tag and kidney agenesis
acidosis, oliguria, K sparring diuretics
INFECTIOUS DISEASES & IMMUNOLOGY
Hypokalaemia
Fever
<3.5 mEq/L; muscle weakness, cardiac arrhythmias,
resp failure, GI or renal loss most common cause immed post op = atelectasis; 3-5
days postop = infection; > 2 wks post op = PE or
Urethritis thrombophlebitis

GC (gram - rodds in WBC, + thayer martin culture); Fever of Unknown Origin

nonGC = chlamydial; coinfection, Ceftrixone for GC,
Doxycycline for Chlamydia > 100F for > 3 weeks despite active search for cause for
> 1 week; need to get CBC w/diff, blood cultures; kids =
Epididymitis usually infection; adults = infectious, neoplasm,
autoimmune
Induration & tenderness of spermatic cord; support
relieves pain Inflamation

Torsion of the Testes Rubor, Tumor, Calor, Dolor

adolescents, swelling & tenderness, superior Types of Immunity

displacement, support does not relieve pain, Emergent
SURGERY Active Acquired= direct exposure - infection or
vaccination; Passive Acquired = temporary, serum Ab
Hydrocele given (IG, breast milk)

Painless lump, can be transilluminated; congenital Bacteremia

process vaginalis remains in communication w/
abdomen = indirect inguinal hernias bacteria in blood but asymptomatic

Varicocele Septicemia

"bag of worms", assoc w/ infertility bacteria in blood with symptoms

Seminoma Immunizations in Kids

Painless lump; does not transilluminate, most common HEP B = mom + HbsAG = HBIG & 1st Hep B vaccine at
testicular neoplasm in men < 30; Undescended testes at birth
greater risk even after surgical correction
DTP = contraindications => progressive neuro disorder,
Prostatitis Hx encephalopathy w/ in 7 days of previous dose;
Pertussis not given if > 7 y/o or if currently have
Nonbacterial > bacterial (GI organisms); recurrent UTIs; pertussis
Rectal - warm, tender, boggy prostate; Tx TMP/SMX
H FLU = not in kids > 5 Severe Combined Immunodeficiency

POLIO = IPV if immunocompromised Deficits of B & T cells, IgA deficiency, recurrent infections
esp resp & GI, IG administration
MMR = not effective before age 1; don't give if less than contraindicatedHEMATOLOGY & ONCOLOGY
3 months since transfussion or IG use; ok for HIV +;
suppresses TB - give Tine(PPD) & MMR at same time or Microcytic Anemia
4-6 weeks apart.
MCV < 80; IRON DEFICIENCY = ferritin; CHRONIC
Adult Immunizations DISEASE Fe, Transferrin, Ferritin; LEAD POISONING;
THALASSEMIA
TETANUS = booster q10y, No Hx immunization 2 td 1-2
mos apart then booster at 6-12 mos then on normal 10 y Normocytic Anemia
cycle
MCV 80 - 100; Hemolysis, Chronic disease, Bone
FLU = chronic resp problems, metabolic diseases, adults marrow suppression (drugs, leukemia) (aplastic)
> 65; can cause false positive HIV test
Macrocytic Anemia
HIV/AIDS
MCV > 100; FOLATE DEF. = most common cause,
RNA retro, CD4 cells, Dx based on concurrent related folate normal B12;
diseases &/or CD4 , 200 cells/mm3; Flu-like illness,
antibodies 1 - 6 months after infection B12 DEFICIENCY: B12 absorbed when linked with IF
from parietal cells, neuro sx,
AIDS related infections
Alpha Thalassemia
CMV, HSV, VZV, EBV, TB, mycoplasma avium-
intracellular, candida coccidioides, histoplasmosis, Acanthocytes (rounded projections from cells);
cryptococcus, Pneumocystic carnii (protozoa) Poikilocytosis (variable size); target cells, Very low MCV
Toxoplasmosis, cryptosporidiosis, Giardiasis but mild anemia, Hemoglobin H = chain missing; Asians,
Dx by Hb electrophoresis,
DeGeorge's Syndrome
Beta Thalassemia
Thymic aplasia, Absent T cells, congenital heart disease,
craniofacial abnormalities
Peripheral Smear = basophillic stippling, nucleated RBC,
Wiskcott- Aldrich Syndrome anisocytosis (chgs in size) Mediterranean & African
heritage; Minor = heterozygous, Major = homozygous
X linked, no antibodies against encapsulated bacteria,
eczema, platelets, Sickle Cell Anemia

Chronic Granulamatous Disease sickled cells, Hct & reticulocyte count, electrophoresis
HbS + HbA neg. Salmonella osteomyelitis, S.
Autosomal recessive, defect in phagocytic enzymes, pneumonia sepsis.
recurrent bacterial & fungal infections
Hemophilia
Chediak-Higashi Syndrome
X linked factor VIII (A) or IX (B) deficiency; Prolonged
Autosomal recessive, recurrent strep & staph infections PTT, Joint & soft tissue bleeding; Tx cryoprecipitate &
FFP
Bruton's Disease
Von Willebrand's Disease
x-liked, agammaglobulinemia, N B cells or antibodies
autosomal dominant deficiency of VIII & vWF, epistaxis,
Ataxia Telangectasia menorrhagia, bruising, increased PTT & bleeding time

Auto recessive, lymphopenia & IgA deficiency; gait Eosinophilia

abnormal, telangiectasia
Allergic Drug Reaction; NAACP = neoplasm, 80% childhood leukemia, peak age 3 - 7; usually B cell
asthma/allergies, Addison's disease, connective tissue origin; lymphoblasts, few other cells on bone marrow
disorders, parasites biopsy

Thrombotic Thrombocytopenic Pupura Acute Myelocytic Leukemia

adults > kids, women > men; platelets consumed in affects myeloid cells (N,B,E,erythrocytes,
clotting reactions, Fluctuating neurologic defects, megakarocytes) adults > kids; DIC possible, gram neg
platelets, HCT, retic count, LDH, acute onset not and fungal infections, Auer Rods (red staining
autoimmune intracellular inclusions.

Idiopathic Thrombocytopenic Pupura Chronic Myelocytic Leukemia

kids > adults, autoimmune destruction of platelets, Philadelphia Chromosome (acquired translocation
Purpurea & Petechia , Platelets<10000, Epistaxis, chromosome 9 & 22), tumor cells are more mature, Dx in
menorrhagia middle aged, WBC > 150000; uric acid, B12 (B12 carrier
protein produced by WBC); leukocyte alkaline phos decr
Hemolytic Uremic Syndrome or absent, RBC normal

Usually caused by E. coli toxin, RBC fragments on Blast crisis transforms it to acute leukemia
smear, RBC destruction => acute renal failure, 2o
thrombocytopenia, abd pain & diarrhea after a flu or URI Chronic Lymphocytic Leukemia
prodrome; platelets derc, LDH greatly increased
Disorder of mature B cells (rarely T); B cells don't
Hodgkin's Lymphoma differentiate into plasma cells, men > women; usually >
50; No Blast Crisis
Painless cervical lymphadenopathy, Reed Sternberg
cells (multinucleated reticular cells), 80% survival Hairy Cell Leukemia

Burkitt's Lymphoma B cell transformed into tumor cell with fine hair like
projections; pancytopenia, red pulp of spleen infiltrated
B cell lymphoma, Associated with Epstein-Barr virus,
children & young adults Multiple Myeloma

Hereditary Spherocytosis Plasma cell proliferation and monoclonal IG; men =

women; peak 50 - 60, 1 - 3 year survival; xrays show
dominant deficit in RBC membrane proteins, damaged osteolytic bone lesions, Increased urine protein (Bence
cells get trapped in spleen. Spherical RBC & Jones)
reticulocytosis on smear. Coombs neg.
Waldenstrom's Macroglobulinemia
G-6-PDase Deficiency
single B cell line = monoclonal IM over production; RBC
X linked hemoglobin accumulates in RBC (Heinz bodies) with normal WBC & platelets; Rouleau Formation = RBC
hemolysis occurs after ingestion of oxidant pile up forming cylinders

Agranulocytosis Mycosis Fungoides

neutrophils = decr production or incr destruction Clonal proliferation of CD4 T cells; infiltrates dermis &
epidermis, thickened & nodular skin lesions
DIC
Polycythemia Vera
wide spread activation of coagulation cascade. platelets,
fragmented RBC, PT & PTT ; fibrinogen, Pregnancy, overproduction of all 3 cell lines; RBC > 1,000,000, Hct >
malignancy, infections, massive trauma 60%; men & women peak age 60; Bone biopsy-
hypercellular with absent Fe stores; R/O spurious
polycythemia = RBC due to dehydration; R/O 2o
Acute Lymphocytic Leukemia
polycythemia = RBC mass due to oxygenation.
Eaton Lambert NEVI

90% assoc w/ small cell CA, presynaptic Ca release = PIGMENTED: (Benign) sun exposed areas in children &
proximal muscle weakness; hyporeflexia, dysautonomia, adolescents
function w/ stimulation; weakest in AM (opposite MG) Tx
Tubocurare DYSPLASTIC: 2-12 mm, more irregular, unexposed
areas, Multiple dysplastic Nevi = familial risk of
DERMATOLOGYSeborrheic Dermatitis melanoma

Red skin with greasy scales, worse in winter & when Hemangiomas
under stress, Se or Tar soap
NEVUS FLAMMEUS: Port wine stain - flat, purple, does
Psoriasis not fade

HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled CAPILLARY: strawberry mark, raised, bright red, regress
plaques w/ sharp demarcations, Pitted fingernails spontaneously by age 5

Pilonidal Cyst CAVERNOUS: Raised red or purple, enlarged vascular

spaces
Hair lined tract in sacral area = "Jeep Seat"
MUSCULOSKELETAL & CONNECTIVE TISSUE
Actinic Keratoses
Osteoarthritis
Firm, yellow scale, Due to sun exposure, can lead to
squamous cell CA morning stiffness, bone spurs, osteophytes, DIP =
heberdon's nodes, PIP = Bouchard's nodes, also affects
Skin CA hips, knees, spine

Basal Cell > Squamous; Basal Cell = pearly papule w/ Rheumatoid Arthritis
dilated blood vessels and central depression; Squamous
Cell: Red papule w/ crusted surface, later nodular and Symmetric, PIP & MCP joints NOT DIP, Subcutaneous
ulcerated, rarely mets; Assoc w/ sun exposure nodules, 70% +RF

Malignant Melanoma Gout

Change in size, shape or color of a mole, Usually Affects big toe (Podagra), pinna of ear; Negatively
superficial spreading, Mets as invasion goes deeper birefringent crystals; Sodium urate; Colchicine or
than 0.76 mm; itchy & ulcerated NASIDS for acute attacks

Contact Dermatitis Pseudo Gout

1o = irritant contact - direct injury, all w/ contact affected, Calcium pyrophosphate dihydrate; Knee most affected;
Occurs w/ 1st exposure Positively birefringent

Allergic = type IV hypersensitivity, T cell medicated, Phocomelia

Never 1st exposure
Hands & feet attached to trunk, Thalidomide
Carbuncle
Slipped Capital Femoral Epiphysis
Abscess of skin caused by several boils coming together
Overweight Teens; stiffness=>weakness=>pain radiating
Dermatopytoses down anteromed thigh to knee, ext rot of leg; avascular
necrosis
TINEA CORPORIS: ring worm of body (round lesion w/
raised borders, spreads peripherally w/ central clearing) Lyme Disease
TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot;
TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm
of scalp;
Borrelia burgdorfi, Ixodes tick, arthralgias, Rash w/ Osteochondritis
central clearing = erythema chronicum migrans, CNS
chgs 1 month after exposure Inflammation of bone & cartilage; Osgood Schlaters -
teens, tibial tubercle, pain& swelling at the insertion of
Osteoporosis the patellar tendon

mass of bone; hip & wrist fx most common; estrogen, Ca Osteomyelitis

& Phos normal; Risk factors = post menopause,
Caucasian, Asian, smoking, alcohol, corticosteroids, Bone infection; Local or hemtogenous spread;
Cushings, hyperparathyroid, hyperthyroid; Etidronate - Prepuberty infection is in metaphysis; Salmonella -
inhibits osteoclast activity, used for men & women who sicklers; S. aureus; pseudomonas; ESR; WBC;
can't take estrogen Radionucleotide bone scan w/ in 72 hrs; 4-6 wks
organism specific antibiotics
Systemic Lupus Erythematosus
Septic Arthritis
Malar (butterfly) rash, arthralgias (raynauds), ANA
sensitive; Anti dsDNA specific; Neuro = HA, psychosis, S, aureus = most common; N. Gon most common
seizures, aseptic meningitis; Check for hemolytic anemia sexually active; synovial fluid = WBC and + culture;
w/ Coombs; Renal = BUN Cr, + protein = immune Ceftriaxone NG infection; Nafcillin for others
complex glomerulonephritis
Degenerative Disk
Polymyositis & Dermatomyositis
Nucleus Pulposa herniates post or postlat.; Lumbosacral
inflammation of skeletal muscles; violet discoloration of = sciatics = L3L4; + pain on straight leg raise;
eyelids (heliotrope rash), elevated muscle enzymes
(CPK, SGOT, SGPT, LDH) symetric proximal muscle CaudaEquina Syndrome
weakness; hips & shoulders 1st
Lg midline post. Hemorrhage compressing C.E. Urinary
Ankylosing Spondylitis and bowel incontinence; bilateral leg weakness

"Bamboo shoots" = vertebral squaring w/ bony Polymyalgia Rheumatica

outgrowths, paraspinal lig. Calcifications on xray;
sacroiliac involvement is diagnostic; HLA-B27; ESR
older women; assoc w/ temporal arteritis; Morning
stiffness; swelling 1-2 joints; no weakness; ESR; neg.
Shoulder Hand Syndrome Rheum factor; steroid response immediate

Pain, stiffness, swelling in hand and shoulder; Occurs 1 Fibromyalgia

month after MI or other acute disease
"Trigger Points" reduce pain, IBS, depression, anxiety
Bone Mets from Primary
Osteosarcoma
breast, lung, prostate, kidney, thyroid
teenage boys, distal femur & proximal tibia; mets to
Paget's Disease lungs

Osteolytic => osteoblastic; Frontal "bosing" (enlarged Eosinophillic Granuloma

skull with rounded forehead) bow legs and shortened
spine; alk phos, Ca & phosphorus levels normal; "Cotton
Wool" appearance on skull xray; high output cardiac 20-40; granuloma w/ histiocytes, eosinophilic infiltrate &
failure fibrosis; multifocal = poor prognosis

Congenital Hip NEUROLOGY

Femoral head partially or completely dislocated from Blindness

acetabulum; BARLOWS: dislocates hip when abducted
and pressure; ORTOLANI'S: reduces dislocation by visual acuity 20/400 with best possible correction
abduction and flexion
Open Angle Glaucoma
Increased intraocular pressure, gradual, bilateral vision Childhood malignancy of immature retina, associated
loss => tunnel vision, elderly, diabetics, African with other malignancies later in life, "white reflex or "cat's
Americans, familial; halos around lights, cuping of ocular eye.
disc, Beta Adrenergic blockers to treat; amt aqueous
humor produces Hearing Loss

Closed Angle Glaucoma Rinne's Test: hold against mastoid process then adjacent
to pinna, norm = pinna louder, if not maybe conductive
Rapid rise in pressure due to blockage of aqueous loss; Weber Test: Midline of forehead, unilateral
drainage in the eye; Severe pain, blurred vision, halos, conductive loss = louder in affected ear; unilateral
Nausea, Abd pain; Reddened eye, upper lid edema, sensorineural = louder in unaffected ear
steamy cornea, dilated non-reactive pupil; mannitol, oral
glycerin or carbonic anhydrase in acute attack, Beta Presbycusis
adrenergic blockers for prevention
normal loss of hearing associated with age,
Diabetic Retinopathy sensorineural

Black spots, "cobwebs", flashing lights; cotton wool Mastoiditis

spots (infarct of vessel wall) neovascularization, hard
yellow exudates Usually following otitis media, Redness & swelling w/
fever & pain; X ray = destroyed mastoid air cells & fluid
Cataracts in the air pockets, IV antibiotics

Painless clouding of lens; Age most common cause, Meniere's Disease

Assoc. W/ smoking & alcohol; Absent red reflex.
Severe vertigo w/ N/V, hearing loss, tinnitus worse
Senile Macular Degeneration during attack of vertigo

Main cause of vision loss in the elderly; Atrophic Acoustic Neuroma

degeneration or Leakage of Retinal Vessels , gradual
loss of VA, Decr central vision, hemorrhagic or Vestibular Schwannoma; tumor of CN VIII; Hearing loss,
pigmented regions in the macula; Neovascular dizziness, tinnitus;
Membranes (Bruch's membrane)
Migraine
Conjunctivitis
2x women : men; Age of onset 10 - 30; gone by age 50;
Acute inflammation, Adenovirus, a lot of discharge, no family Hx; stress, bright lights, menstruation, fatigue,
blurring, purulent if bacteria tyramine, monosodium glutamate, nitrites; Aura prior to
onset; visual, scintillating scotomas (small areas of
Uveitis visual loss) , dull throbbing, unilateral; N/V, photo &
sound sensitivity;
Inflammation of the uveal tract (iris, ciliary body &
choriod layer), haziness, floating spots; Photophobia & Cluster Headache
redness = iridocyclitis; "salt & pepper fundus = syphillis
Men age 20-50; alcohol & vasodilators; severe,
Central Retinal Occlusion nonthrobbing, unilateral, recur same time each day for
weeks, Horners syndrome & periorbital pain; Tx: ergot &
sudden painless loss of sight in one eye, Pale fundus, lidocaine
cherry red spot fovea & boxcar appearance of veins
Tension Headache
Central Vein Occlusion
cause unknown, most common type; bilateral, occipital,
unilateral loss of sight that is more gradual, Swelling of constant; muscles tight
optic disc, cotton wool spots & tortuous dilated veins
Tumor Associated Headaches
Retinoblastoma
progressive, increasing, dull, nonthrobbing, worse w/
postural chgs, exertion. Disrupt sleep, assoc w/ N/V
Trigeminal Neuralgia Intracerebral Hemorrhage

Tic douloureux; severe, "lightening" pain in V1 & V2 Chronic HTN or local thrombus 2o to ischemia;
distribution of CN V; Trigger Pts Supratentorial: transtentorial herniation, w/ brainstem
compression & midbrain bleeding, hemiparesis;
Tx: carbamazepine & phenytoin; Surgical Cerebellar : acute hydrocephalus due to CFS flow
decompression of CN V blockage; Acute onset HA w/ progressive neurological
chgs.
Partial Seizures
Stroke
Simple = focal sx, conscious, Jacksonian = simple
muscle twitch that spreads progressively; 2o Middle Cerebral: most often, contralateral limb
generalization = simple becomes grand mal; Complex weakness, sensory loss, homonymous hemianopsia,
Partial = automatism, olfactory hallucinations, fear, deja dominant hemisphere = aphasia, nondominant =
vu, loss of contact w/ environment; postictal confussion sensory neglect & apraxia

Generalized Seizures Posterior Cerebral: contralateral homonymous

hemianopsia & sensory loss, thalamic pain, hemiballistic
movement disorder
Absence = petit mal; brief, freq. Loss of consciousness
w/o loss of muscle tone, rapid eye blinks, no aura, no
postictal Vertebrobasilar artery: fatal, unilateral occlusion =
ipsilateral CN abnormalities, contralateral weakness;
Complete occlusion = opthalmoplegia, defective pupil
Grand Mal= tonic clonic, preceded by GI upset or mood
constriction, bilateral weakness, paralysis, decreased
chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax &
consciousness, dysphagia & dysarthria; completed =
contract of muscles, unconscious, then confussion &
neuro stable; Evolution = progressive signs over 1-2
postictal
days
Status Epilepticus
CT positive 48 - 72 hrs after onset.
continuous seizures w/o regained consciousness, grand
Cavernous Sinus Thrombosis
mal progress or withdrawal of anticonvulsants;
Complications = high fever, circulatory collapse, brain
damage; Diazapam until controlled, Treat potential CN palsies, fever, exophthalmos, papilledema, HA,
causes (glucose, thiamine, narcan) consciousness, occasional seizures; IV antibiotics
immediately
TIA
Acute Subdural Hematoma
sudden, brief, emboli or arterial stenosis, Risks: obesity,
smoking, DM, hyperlipidemia, Carotid artery= unilateral, rapid bleed between arachnoid & dural layers; Tearing of
contralateral hemiparesis & parathesia w/ ipsilateral bridging veins, Sx slower to progress, Signs of
blindness; Aphasia if dominant hemisphere involved, transtentorial herniation w/ deepening coma, progression
Vertebrobasillar = brainstem dysfunction => vertigo, from decorticate to decerebrate posture, mid position or
confusion, blindness, diplopia, weakness, parathesia of fixed & dilated pupils, spastic hemiplegia w/ DTR. LP is
extremities contraindicated because may lead to herniation

Aneurysm Chronic Subdural Hematoma

localized vessel dilation, Berry Aneurysm = circle of Delayed formation of a subdural clot, Sx weeks after
Willis assoc w/ polycystic kidney disease & coarction of head injury, Elderly & alcoholics; Progressive daily HA,
aorta fluctuating consciousness & mild hemeparesis

Subarachnoid Hemorrhage Epidural Hematoma

between pia & arachoid; usually rupture of a cerebral Between dura & skull, less common than subdural, injury
artery aneurysm or AV malformation; Worst HA, to arteries (middle meningeal); Rapid brain compression,
syncope, nuchal rigidity, vomiting, nonfocal permanent neurological problems or death; Brief lucid
abnormalities, decr consciousness, CT first if neg then period after head injury; progressive neuro signs
lumbar puncture mandatory.
Concussion
Injury due to blunt trauma; short loss of consciousness nonbacterial meningeal irritation; CSF = lymphocytes,
w/ intact brainstem function; post traumatic confussion normal glucose, neg gram stain & bacterial cultures, mild
syndrome w/ transient retrograde or anterograde protein, normal opening pressure; supportive Tx
amnesia; HA, vertigo, mild cognitive dysfunction
Fungal/TB Meningitis
Toxic Vestibulopathies
CSF: lymphocytes, glucose, protein, opening pressure;
Alcohol: positional vertigo & nystagmus w/ in 2 hrs of AIDS = cryptococcal meningitis
ingestion
Encephalitis
Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 1-
2 wks after ending tx Inflammation of brain tissue; Viral etiology = CSF
lymphocytes, normal glucose & negative bacterial
Salicylates: reversible vertigo, tinnitus, sensorineural cultures; Acylcovir x10 days
hearing loss
Reye's Syndrome
Quinine & Quinidine: cinchonism (color vision defects,
tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain follows viral infection; fatty infiltrate of organs; Usually
& sweating kids; Salicylates can induce

Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing Sudden onset of encephalopathy, severe vomiting, &
loss, sensory neuropathy liver dysfunction; liver biopsy w/ fatty infiltrates confirms
Dx.
Toxic Neuropathies
Neurosyphillis
Lead: multi motor neuropathy; acute encephalopathy in
children Argyll Robertson Pupil (small, reacts to light but not
accommodation); Psych disorders, Tabes Dorsalis; Tx:
Organophosphates: delayed motor neuropathies, Procaine Penn G x 21 days; Examine CSF q 3-6 months
cholinergic crisis until normal x 2 yrs.

Arsenic and Thallium: acute onset symetrical Rabies

sensorimotor polyneuropathy
Dogs worldwide; wild animals in US, Sx: malaise, fever,
Isoniazid: Reversible sensory polyneuropathy reversible restlessness 1st. Sx progress to extreme excitement w/
w/ concurrent pyridoxine painful laryngeal & pharyngeal spasms, Tx: Passive IG
and active vaccine
Gold: symetrical polyneuropathy

Bacterial Meningitis Polio

1st month life = group B strep & E. coli; Older kids = H. Fecal-oral; aseptic meningitis, paralysis w/o loss of
flu; Adults = S. pneumonia sensation; Asymmetric paralysis during a febrile illness
suggests it; Tx is palliative; OPV for all except
N. meningiditis at any age = 50% have petechial rash immunocompromised who get IPV

Brudzinski sign = neck flexion when supine causes Primary Neoplasms

involuntary hip & knee flexion
Glioblastoma Multiforme: most common in adults, high
Kernig's Sign: extension of knee in pt w/ flexed hip is mortality; Meningioma: most common benign tumor in
painful adults; Cerebellar Astrocytoma & Medulloblastoma: most
common in kids
CSF: glucose, neutrophils, protein, opening pressure;
Tx: ampicillin & cefotaxime = infants; 3rd generation Huntington's Disease
cephlosporin in kids > 3mos and adults
Autosomal dominant, Age 30-50; subtle dementia,
Aseptic Meningitis irritability, antisocial, chorea, death 10-15 yrs after onset,
atrophy of caudate nucleus & cerebral cortex, Tx D2- diplopia, dysarthria, enhanced muscle fatigue, thymoma
receptor antagonists (haloperidol) on chest x-ray; Tx exogenous anticholinesterase
(edrophonium or neostigmine); Thymectomy in pts < 60;
Parkinsonism steroids or azathioprine if unresponsive to tx

Idiopathic - loss of dopaminergic cells in substantia Muscular Dystrophy

nigra; Pin rolling temor, masklike facies, lack of arm
swing when walking, cogwheel rigidity, difficulty initiating Duchenne most common type; X linked recessive,
movement, small shuffling steps w/ increasing speed mutation in dystrophin gene; CK before onset of sx; By
(festinating gait). Tx: Levadopa (dopamine precursor), age 5 toe walking, waddling gait, can't run; Prox legs 1st
Amantadine, bromocriptine (dopaminergic agonists), then prox arms; Pseudohypertrophy of calves = fat
Benzotropine (anticholinergic) infiltrates in muscles;

ALS Coma

Lou Gehrig's Disease dysfunction both cerebral hemispheres or RAS; Acute

onset = subarachnoid hemorrhage or brainstem infarct;
Progressive loss of anterior horn cell function; Initially = progressive min-> hours = Intracerebral hemorrhage;
LMN dysfuntion w/ hand & foot weakness & atrophy; days => weeks = chronic subdural hematoma, tumor or
asymmetric progression, No sensory abnormalities; abscess; No laterialization following delirium =
Later= UMN dysfunction w/ muscle spasticity, DTR, metabolic; Pupil size: dilated nonreactive = at or below
extensor plantar reflexes midbrain, pinpoint = pontine; opiod OD, Constriction
intact w or w/o extraoccular impairment = metabolic;
Localizing response to pain = superficial coma;
Tay Sachs Disease
Decorticate (flex @ elbow, ext leg) = thalamic lesion of
compression; Decerebrate (elbow & leg extension) =
Autosomal recessive; Eastern Europe jews & french midbrain; No response to pain = pontine or medullary
Canadians; Absence of Hexosaminidase A, can't
metabolizes lipid gangliosides, build up in brain;
Gait Abnormality
Progressive dev. delay, paralysis, blindness, dementia;
death by age 4
Cerebellar lesions = truncal ataxia, broad based,
unsteady, irregular; can't turn
Multiple Sclerosis

Corticospinal = affected leg circumducts as it steps

Progressive demyelinating, women>men; Peak onset 20
forward, scissors if bilateral
- 40; Gradual & variable CNS sx suggest dx; CSF = mild
proteins, mild lymphocytes , oligoclonal bands, MRI =
multi plaques in white matter Extrapyramidal = festinating gait, flexed posture, small
rapid steps, no arm swing
Guillain-Barre Syndrome
Motor System = Footdrop - anterior tibial; Calf muscle -
can't toe walk; Pelvic muscle - waddling gait.
polyneuropathy after mild viral illness, inoculation or
surgery; Most common acquired demyelinating disorder;
progressive bilateral weakness of legs, proximal Arnold Chiari Syndrome
weakness, abnormal DTR, instability of temp & BP; CSF
= protein w/ normal pressure, glucose & cell numbers; Cong. Protrusion of medulla thru foramen magnum;
Plasmaphresis speeds recovery; Corticosteroids are unusual sensory & motor chgs, Onset ~ 40
contraindicated
Cold Calorics
Cerebral Palsy
Test vestibular system, Slow deviation toward ear w/
CNS damage before age 5; Risks: Prematurity, IUGR, cold water = brainstem intact, fast nystagmus away =
inutero complcations, neonatal jaundice, birth trauma, contralateral cortex intact; COWS = cold opposite Warm
asphyxia, spastic syndrome, DTR, tone, weakness, toe same for fast component
walking, scissors gait
GYN
Myasthenia Gravis
Trichomonas Vaginitis
autoimmune, antibodies against acetylcholine receptors
at neuromuscular junctions, women, age 20 - 40; Ptosis,
Yellow green discharge, Strawberry patches, Motile Paget's Disease of Breast
flagellated, Tx: Metronidazole
Intraductal Ca in main excretory ducts; crusting erosion
Gardenerella Vaginitis of nipples w/ or w/o discharge

KOH whiff test = fish; Clue cells, most common Polycystic Ovarian Disease
symptomatic infection; Metronidazole
LH, or normal FSH; hirsutism, obesity, menstrual
Condyloma Acuminata irregularities, infertility

Warts, HPV 6, 11, Not assoc w/ cervical cancer Menopause

PID Avg age =51; FSH & LH; Hot flashes, Atrophic vaginal
epithelium
Cervical motion tenderness, Purulent discharge, assoc
w/ ectopic pregnancy & infertility; Leukocytosis, Urinary Incontinence
neutrophilia, ESR
Stress = intra abd pressure, leak small amts of urine;
Candida Kegel exercises, estrogen

cottage cheese, red vulva; Pseudohypahe & spores on Urge = detrussor instability; lg amts of urine leaked
wet mount, DM, antibiotics, OC, pregnancy immediately after urge to void

UTI 1o Amenorrhea

E coli, Dysuria, frequency, urgency; Tx: TMP-SMX, Absence age 16 w/ 2o sex development or absence by
Bactrim, Septra age 14 w/o 2o characteristics

Toxic Shock Syndrome Anatomic Abnormalities; Ovary Failure ( FSH & LH,
estradiol) (XO, turners, no ovary); Pituitary =
Staph aureus exotoxin, rash, high fever, hypotensive Prolactinoma presents w/ galactorrhea (Bromocriptine to
shock Tx), Hypothalamic = FSH & LH, (anorexia, exercise,
stress); XY karotype
Chancroid
2o Amenorrhea
H. Ducreyi, tropical & sub tropical climates, gram neg; Tx
Emycin or Ceftriaxne Absence for 6 mos if prev normal; absence for 12
months if prev oligomenorrhea; r/o pregnancy;
Galactorrhea = prolactinoma; Hirsutism = polycystic
Chlamydia Trachomatis
ovarian; Tx: 1st = progestin challenge (bleed w/ in 2 wks)
if no bleed measure FSH levels
Intracellular, columnar epithelium, mucopurulent,
Immunofluoresent discharge, Tx: Doxycycline (Emycine
1o Dysmenorrhea
if pregnant)

correlates w/ 1st day of menses, cyclic, begins in

Herpes Genitalis
adolescence, low back & abd pain, N/V/D, fatigue, HA
HSV II clear sores , multinucleated giant cells w/ intracell
2o Dysmenorrhea
inclusions; Tzanck smear

acquired, Sx don't correlate w/ 1st day of cycle,

Molluscum Contagiosum
Endometriosis most common cause
umbilicated nodule, remove & cauterize
Asherman's Syndrome
Endometriosis
intrauterine adhesions after D&C; destruction of
endometrium => amenorrhea
Ectopic endometrium tissue, Dysmenorrhea,
Dyspareunia, infertility
Fibroademoma
Age 19 -29, stromal fibrosis; nontender, estrogen Abd./pelvic mass, ascites, early satiety, CA125, CEA,
sensitive, regress w/ menopause CA19-9, 75% w/ stage 3; Path types = Serous
(psammoma bodies), Mucinous, Endometroid, Clear Cell
Fibrocystic Breast Disease (hobnail bodies) Brenner; Staging: 1A= 1 ovary, 1B =
both ovaries; 1C= + wash, tumor rupture; IIA = fall
tubes/uterus, IIB other pelvic structures, IIB + wash
Age 29 - 39, may have green nipple discharge; tender w/
rupture w/ spread; IIIA gros in pelvis, micro to diaphragm
ovulation, regress w/ pregnancy,
or omentum, IIIB Intra abd < 2 cm, IIIC: intra abd > 2cm,
pelvic/aortic nodes, inguinal nodes; IV = distant spread,
Breast Disease Age 39-49 pleural effusion w/ malig cells, liver/spleen mets; Tx:
debulk tumor surgery, Chemo = cisplatin/cytotoxin, taxol;
malignant = intraductal Ca (bloody nipple discharge); Radiation (bowel obstruction);
Papillary #1 cause of nipple discharge; Sclerosing
Adenitis Teratomas

Breast Ca immature (neuro epithelial); mature (dermoid)=95% of all

teratomas, hemolytic anemia; LDH elev, CA125
Upper outer quadrant, Mets = bone, liver, lung, brain;
Risks: Family Hx, menarche < 12, 1st pregnancy > 35; Dysgerminomas
late menopause, null parity, obesity, other breast,
radiation, reserpine
most common malignant, 15% bilateral, radiosensitive
PAP Smear
Endodermal Sinus Tumor
Atypia = inflamm, infection HPV (16 & 18); Mild
Schiller Duvall Body, AFP
Dysplasia = lowgrade epithelial lesion; Mod/Severe=high
grade intraepithelial;
Embryonal CA
Carcinoma in situ
HCG, AFP, CA125
nuclear/cytoplasm, dense chromatin, crowding, mitosis;
Koilocytes = HPV, pyknotic nucleus, perinuclear halo; Choriocarcinoma
Risks: early sex, multi partners, smoking, social class,
HPV; Culposcopy = white epithelium, mosiacism, HCG
punctation, atypical vessels
Sexcord-Stromal Tuors
Cervical CA
Granulosa: 50% post menopause, estrogen, Call-Exner
90% squamous cell; s/sx: Early = postcoital bleeding, bodies
intermenstral bleed, Late= backache, leg pain, edema,
hematuria Tx: Ia=TAH, iB & IIA = rad hysto & pelvic Sertoli-Leydig: most often virilizing; Gonado Blastoma:
lymph nodes, IIB -IVA = Radiation - Brachytherapy => gonadal dysgenesis
Radium, Cesium
Krukenburg Tumor:
Endometrium CA
Ovarian mets from GI & breast; Signet ring cells
most common gyn malignancy; Risks: obesity, DM, HTN,
anovulation, early menses, later menopause, nullparous, Vulvar CA
unopposed estrogen; Dx : abnormal menses, post
menopausal bleeding; EMB, D&C; Histologic= grade 1-3
based on differentiation; TNM staging, squamous cell, Vulvar pruritus; Pagets=
adenoca of vulva, 20% assoc w/ breast, GI, cervical CA
AdenoCA=70%; Adenocanthoma=benign squamous,
best prog; adenosquamous= malig squam, poor prog; Gestational Trophoblastic -
Papillary Serous = acts like ovarian CA, Clear Cell =
poorest prog, older, DES, least common Tx; TAH/BSO, Benign: Complete Mole = 46 XX, paternal, no
perioneal wash, pelvic & aortic nodes, Adjuvant Rad if + embryonic tissue; Incomplete = 69 XXY triploid, paternal,
nodes, cervical +, > myometrium, higrade no fetal/ embryonic tissue

Ovarian CA
Malignant: Invasive= molar villi; Choriocarcinoma = no Adv maternal age, abn AFP - Spina bifida, Down's,
villi, any pregnancy; Placental Site = non molar detect lung maturity, early 2nd trimester
gestations
CVS
S/Sx: size > dates, hyperemesis, hyperthyroid, large
theca lutein cyst Adv. Maternal age, late 1st trimester

F/U = CBC. Liver function, BUN, CR, TSH, HCG, US, Non stress Test
CXR; TX = D&C
> 2 fetal movements accompanied by FHR of 15 bpm for
Weekly HCG' until 3 values that are non detectable then at least 15 sec w/ in 20 min period
1/mo x 1yr, BCP x 1 yr
Contraction Stress Test
Ca in Pregnancy
Negative = 3 contractions in 10 min, lasting 40 sec w/o
Melanoma = worsened by preg, can met to placenta or late decelerations
fetus
Positive = consistent & late decelerations
Breast CA = most common CA in pregnancy
Biophysical Profile
Chemotherapy
Nonstress test, fetal breathing, movement, adeq,
Cyclophosphamide (Cytoxan) = ovarian, hem, cystits, amniotic fluid, limb extension
alopecia, bone marrow, N/V
Fetal HR
Cisplatinum = ovaian, renal toxic, ototoxic, bone
marrow , N/V normal 120-160, Brady = mild 100-120, < 100 severe;
Tachy = mild 161-180; severe > 180
Adrimycin (Doxyrubicin)= endomet, ovarian; cardiotoxic
(heart failure) Decelerations

Bleomycin= cervical, germ cell, Pulmonary fibrosis Early = shape is mirror of contraction, head compression

Vincristine= cervical germ cell; neurotoxic Variable = shape varies, cord compression

Methotrexate = GTN, germ cell, hepatic & renal toxic, Late = starts as contraction peaks, recovery after
bone marrow contraction is terminated, uteroplacental insufficiency

OBSTETRICS Placental Previa

Hydantiform Mole Partial - partially over os; Complete= covers OS,

Marginal = at edge of OS, Complete Previa is indication
Preeclampsia 1st TM, Very high Beta HCG, Snowstorm for C section
on US
Placental Abruption
Ectopic Pregnancy
Premature separation of a normally implanted placenta,
Beta HCG rises slowly, Amenorrhea, spotting, pain, vag bleed, uterine tenderness, back pain, hypertonic
Empty gestational sac on ultrasound, Ampulla of uterus, fetal distress
fallopian tube is most common site
Preeclampsia
Gestational Age
HTN w/ proteinuria & edema after 20 wks gestation
Nagel's = Add 7 days to FDLMP subtract 3 months;
fundal ht in cm after 13 weeks Eclampsia

Amniocentesis Preeclampsia + seizures

Gestational Diabetes Premature Rupture of Membranes

1 hr > 140 then do 3 hr; 3hr test = fast > 120, 1 hr > 190; Pooling of fluid in vagina, + nitrazine test, + ferning test,
2 hr > 165, 3 hr > 145; Macrosomia, RSD, Cong risk of endometritis
abnormalities
Polyhydraminos
Types of Pelvises
Duodenal Atresia, Tracheoesophageal fistula,
Gynecoid = round inlet, nonprominent spines, wide Anencephaly
subpubic angle
Oligohydraminos
Anthropoid = heart shaped inlet, transverse and AP
diameters, subpubic angle Renal Agenesis, Pulmonary hypoplasia

Android= triangular inlet, subpubic angle, prominent PEDIATRICS

spines
Fetal Alcohol Syndrome
Platypoid= transverse and AP diameters
IUGR, Microcephaly, Short palpebral fissures & philtrum,
Leopold's Maneuvers Cardiac Abnormalities, SGA, mental retardation,
microencephaly
fundal palpation, sides of uterus from feet of mother,
lower part of uterus, sides of uterus from head of mother Fetal Narcotic Exposure

Stages of Labor Hypertonicity, Sweating, Stuffy Nose

1. Onset contract => full dilation 2. Full dilation to Fetal Cocaine Exposure
delivery of head 3. Delivery of fetus to delivery of
placenta 4. Delivery of placenta to 1 hr later Limb reduction malformations, Intestinal Atresia, Jittery,
tremors
Cardinal Movements
Grey Baby Syndrome
Engagement, descent, flexion, int rotation, extension, ext
rotation, expulsion chloramphenicol use, metabolism due to immature liver,
CV collapse, maybe fatal
Post Partum Hemorrhage
Erythroblastosis Fetalis
Uterine Atony (most common); Placental Accreta:
Accreta = superficial invasion into myometrium, Increta = Rh neg mom Rh + baby; Subsequent Rh + babies are at
deeper, Percreta = invasion to serosa of uterus; risk; Give RhoGam - binds to fetal RBC, prevents
Undiagnosed lacerations, Coag defect; Retained Antibodies from being made
placental fragments
Beckwith Weiderman
Apgar Scoring
neonatal hypoglycemia d/t hyperinsulinemia,
Heart Rate, Resp. Effort, Muscle Tone, Reflex Irritability, macroglossia, giantism, omphalocele, kidney anomalies,
Color facial nevus flammus, poor prognosis

Shoulder Dystocia Apt Test

Maternal obesity, diabetes mellitus, postterm pregnancy Determine cause of neonatal rectal bleed; differentiates
adult vs fetal hemoglobin
Cesarean Section Indications
Dubin Johnson
Health of mom or baby endangered by labor, Dystocia
precludes vag delivery, Emergent situation, Herpes, Prev Chronic idiopathic jaundice
C section if contributing factor still exists,
Malpresentation of fetus
Erb Duchenne unbound bili crosses blood brain barrier resulting in
neuro problems or death
C5-C6, flail arm (int rotation & abduction) due to traction
on head during delivery; If c4 involved - paralytic Prolonged Hyperbili
diaphragm also present
Bili > 10 at 10 days of life
Henoch Schoenlein Pupura
Photo therapy can be used as long as direct isn't > 1 mg
kids, allergic vasculitis, non-blanching petechiae or %
pupura on lower extremities only, arthralgias, abd pain,
hematuria, proteinuria, coag & platelets are WNL; Hemorrhagic Disease of Newborn
Immune mediated after virus or strep
Deficiency of vitamin K dependent factors (2-7-9-10)
Kawasaki's
Intrauterine Shunts
look sick w/ fever > 5d, truncal rash, cervical nodes, URI
sx, "glove" desquamation on palms, feet, lips; Assoc w/ placental, ductus venousus , foramen ovale, ductus
coronary artery aneurysm; TX: High dose asa, IV arteriosus
gammaglobin, Steroids contraindicated
Ductus venosus = ligamentum venosus; Ductus
4 out of 5 =bulbar conjunctivitis, erythematous mouth, Arteriosus = Ligamentum Arteriosus
lips & tongue; polymorphous erythematous rash,
induration of hands & feet w/ erythema, solitary unilateral
cervical lymph node < 1.5 cm; Thrombocytosis after 10 th Growth & Development
dy is common
1st teeth - 6-9 mos; Neuromuscular development in
Kleinfeltters cephalocaudid direction; 4 wks regard face, smile 4-6
wks, social laugh 4-5 mos; 15 mos stack 2 blocks; 18
mos stack 3 blocks; walk up stairs 20 mos ; w/ alt feet 3
XXY, most common hypogonadal syndrome; + BARR yrs;
body, small firm testicle, azospermia, FSH
Drawing = circle 2.5-3; cross 3-4; Square 4-5; Triangle 5;
Meckel's Diverticulum Diamond 6 yr

2 ft from ileocoecal valve, 2 in long, 2& population, 2 Wt Gain = BW by 10d; 15 lbs 1st yr, 6-7 lb 2nd yr
tissue types (gastric or pancreatic) sx before 2 yrs old
Length = 10 in 1st yr, 5 in 2nd yr; < 2in / yr is abnormal
Newborn Blood
Head Circumference: 0-35; 3-40, 9-45, 3-50, 9-55 cm
85 cc/kg, Hgb 14 - 22 gms/dl HCT 44-64%; alk phos
than adults & is until adolescent growth spurt
# Alveoli increase as lungs grow; # nephrons don't
increase after term
TORCH
ADHD
Toxoplasmosis, syphillis, rubella, CMV, herpes
3x more male than female; inattentiveness, impulsivity,
CMV hyperactivity

maybe asymptomatic or deafness, blindness, jaundice, SIDS

petechia, fever, seizure, mental retardation, IUGR;
Transplacental passage of virus
Peak 2-4 mos, declines after 6 mos; 60:40 male:female;
Cong. Rubella
Risk Factors: < 20yrs old, poverty, smoking
IUGR, cataracts, glaucoma, microphthalmia uveitis,
retinitis Apnea of prematurity in infants < 34 wks gestation; Tx:
tactile stimulation, decr environmental temp, incr O 2,
transfuse to get Hct to 45%; CPAP, theophylline, last
Kernicterus resort = mech vent
Special Human IG x linked recessive, renal ADH receptors; Sx polyuria,
polydipsia, FTT; r/o psychogenic polydipsia; Due to
hepatitis B, Rabies, Tetanus, Varicella Zoster, CMV hypofunctioning hypothalamus or posterior pituitary w/
ADH deficiency
CHF in Peds
Rashes
cardiomegaly, tachypnea, hepatomegaly
Measles (rubeola); Face then body; Cough, Coryza,
Conjunctivitis, Koplik's spots
Noncyanotic Cong Heart Disease

Scarlet Fever= red skin folds (Pastia sign), strawberry

ASD, VSD, AV septal defect, PDA, coarction of aorta,
tongue, sandy exanthum on trunk => flexor surfaces
aortic stenosis, MVP

German Measles (Rubella)

Cyanotic Heart Disease

Filatov Dukes Disease (4th. No longer used)

Tetralogy of fallot, pulm Atresia w/ VSD, tricuspid Atresia,
hypoplastic left heart, transposition of great vessels,
anomalous pul venous return, truncus arteriosus Erythema Infectiosus (5th disease) parvo B19, slapped
cheek; circumoral pallor => lacy reticular rash
Rheumatic Fever
Roseola infantum (herpes 6)High fever then after fever
get rash 1st on trunk then face
carditis, polyartheritis, sydenham chorea, erythema
marginatum, subcutaneous nodules; Mitral
insuffucuency most common valvular residual = Carey Rash on face 1st = measles, 5ths, Rubella
Coombs murmur
Rash on Trunk 1st = Scarletina, Roseolla, Chickenpox
Acute Myocarditis
Rashes on Palms & Soles = Erythema Multiforme
Coxsackie B #1, Coxsackie A, CMV, mumps, herpes, (Stevens Johnson); Hand Foot & Mouth (Coxsackie A19;
adenovirus Kawasaki, Rocky Mt Spotted Fever, 2o syphillis, TEN,
Dermatomyositis
Otitis Media
Infectious Mono
Moraxella Catarrhalis #1 cause of bacterial in infants <
18 mos EBV, Dx by positive heterophile test (Paul Brunnel Ab);
hepatosplenomegaly
Epiglotitis
Conjunctivitis
prior to vaccine H. flu most common cause; peak ages
3-8 ys Neonatal infectious = Chlamydia trachomatis,minimal
discharge, congestion & edema 7-14 days after birth
Resp Infections < 5
Rocky Mountain Spotted Fever
Viral pneumonia = RSV, Bacterial pneumonia = strep;
Lower resp infection = mycoplasma pneumonia ( Eaton Rickettsia rickettsii, high fever, peripheral rash, Atlantic
Agent, 1o atypical pneumonia or walking pneumonia); seaboard, wood & dog ticks
Croup = rhino, RSV #2;
Cat Scratch Disease
Pyelonephritis
R. Henselae; regional lymphadenitis; Chemical = silver
poor feeding, irritability, and seizure ; r/o sepsis nitrate

Hemorrhagic Cystitis PKU

Adenovirus blonde hair, MRDD, seizures, eczemoid rash

Neurogenic Diabetes Insipidus Galactosemia

Auto recessive, n/v/d, jaundice, hepatomegally, cirrhosis Neural crest of sympathetic ganglia or adrenal medulla;
& cataracts if untreated 50% before age 2; 90% before age 5; and mass that
crosses the midline
Homocysteinuria
Nephroblastoma
tall thin stature w/ MRDD sublaxation, lens, genu valgum
(knock knee), pectus carinatum asymptomatic abd mass; HTN, Ages 2-5; Aniridia (loss
of iris) hemihypertrophy Also called Wilm's Tumor
Lesch Nyhan
Rhabdosarcoma
Purine metabolism; normal until 6-8 mos; loss of motor
milestones; spasticity, self mutilation without loss of Most common soft tissue sarcoma; < 10yrs old; nasal,
sensory feeling; Urine has orange uric acid crystals aural, anus or vaginal area

Self mutilation w/ loss of sensory = familial Ewing Sarcoma

dysautonomia
diaphyses
Hurler's Syndrome
Osteosarcoma
mucopolysaceharidosis, grotesque coarse features,
skeletal anomalies, dead by age 10 Metaphyses, #1 site distal femur

Glycogen Storage Disease Retinoblastoma

Von Gierke, Pompe, Forbes Neuroectodermal malignancy , most occur before age 5;
Leukocoria (white pupil reflex)
Tay Sachs
G6PDase Defic
Lipid Storage, Jewish , defic of hexosaminidase A;
normal at birth then loss of motor milestones & most common red cell enzyme deficiency that causes
hypotonia at 6 mos, Death by age 2; Cherry red macula hemolytic anemia; usually asymptomatic until exposed to
stress, infection or certain foods; Cause of
ALL hyperbilirubinemia in Chinese or Mediterranean but NOT
BLACK infants; Avoid sulfa drugs
most common malig of childhood, peak at age 4;
thrombocytopenia, anemia, elevated uric acid & LDH; Dx PSYCH
by bone marrow biopsy showing infiltration of leukemia
blast cells; CXR = mediastinal mass or widening, 2o ary Axis Determination
to lymphadenopathy
I = clinical psych disorders II personality disorders, III
Brain Tumors Coexisting medical conditions IV psychosocial stressors,
V global assessment of functioning
most common solid tumor of childhood; < 2 intratentorial
tumors > 2 supreatntorial tumors Schizophrenia

Morning vomiting = posterior fossa ependymoma Positive Sx: delusions, hallucinations, bizarre behavior;
Negative Sx: alteration of affect, ambivalence, apathy,
Astrocytoma most common brain tumor loosening of associations; males=females; industrial
nations have prevalence; Misalignment of cells in cortex;
Hodgkins Lymphoma ventricle size; activity in frontal cortex on PET scan.

Reed Sternberg Cells; Painless cervical Disorganized: insidious, incoherent, inappropriate affect,
lymphadenopathy social impaired

Neuroblastoma Catatonic: rigidity, posturing or excitement, negativism

Paranoid: highest functioning type, grandiose, jealous,

persecution
Undifferentiated: not defined by other subtypes repetitive, purposeful intentional behaviors meant to
decrease tension caused by the obsessive thoughts;
Melerill = Retrograde ejaculation, Tx: Respiradol (Best genetic Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI)
side effect profile), Clozaril (agranulocytosis w/ weekly
CBC) prescribed weekly, PTSD

Neurolyptic Malignant Syndrome = temp, CPK, rigidity intrusive recollections, daydreams, nightmares, poor
concentration, psychic numbing; Tx: don't treat w/ meds
Schizophrenifrom unless compulsion component

same sx as schizophrenia but have lasted for less than 6 Studies: Buffalo Creek Disaster, Beverly Hills Nightclub
months
Dissociative Disorder
Schizoaffective
Amnesia = loss of memory, Fugue = assoc w/ physical
mood disorder and separate psychotic sx. Must flight, Identity Disorder = multiple ego states;
experience 2 weeks of psychotic sx w/o mood Depersonalization = feelings of self estrangement or
impairment for dx to be made; Antidepressants are 1 st unreality
line tx
Whirndingo
Major Depression
Fear of becoming a cannibal
loss of interest in activities, sleep, wt, concentration,
hopelessness, suicidal ideation, nihilism; Seasonal Amok
affective, Vegetative (non functioning can be terminal)
Dysthymia(chronic low level); Reactive related to sudden unprovoked outburst of wild rage usually ending
environment w/o severity id sx; Masked 1o depression in homicide
denied or hidden by other sx
Coprolalia
Depression & anxiety can occur together & can be
treated w/ an antidepressent; Left anterior or rt posterior Feces & filth
stroke => possibility of depression; Tx: 1st Tricyclic
(Imiprimine); SSRI = side effects; Trazadone=priapism
Koro
Asendin (Amoxipine) = Extrapyramidal Symptoms
penis is shrinking and may disappear
BiPolar
Latah
Bimodal peak 20's & 30'sCycling mood= highs w/
euphoria, hyperactive, pressured speech, flight of ideas, imitate words or actions to which they are exposed
decr need for sleep, delusions, inflated self esteem,
risks, poor judgement; Lows are major depressive Piblotko
episodes tx: lithium
Run around in snow naked
Panic Attacks
White Out Syndrome
Sudden, unprovoked onset of fear, impending doom,
palpitations, SOB, chest pain, smothering, dizziness. lack of diverse stimuli in snow clad environment
May be associated w/ agoraphobia Tx: with SSRI's
Narcolepsy
Phobias
REM sleep, sudden onset of daytime sleep and
Persistent and irrational fear of a specific object or cataplexy; REM sleep is inappropriately present at
activity or situation. Tx like a phobia beginning

Obsessive Compulsive Personality Disorders

Persistent, unwanted thoughts, impulses or images

Cluster A = Bizarre = Paranoid, Schizoid (no close Most common thoracic injury; usually 5-9, local pain
relationships, restricted emotions) Schizotypical worse w/ inspiration
(schizoid + odd or distorted behavior or cognition)
Colles Fx
Cluster B = Over emotional = Antisocial (Disregard for
social norms) Borderline, Histrionic, Narcissistic (self most common wrist fx; breakage & displacement of
centered) distal radius, Attempted to break fall on outstretched
hand
Cluster C = Anxiety & Fear = avoidant, dependent,
Obsessive compulsive Elbow Fx

POISONING & ACCIDENTS <10 yrs old, fall on outstretched hand w/ elbow in full
extension; Compression or radial or median nerve or
Burns brachial artery; Improper care => Volkman's Ischemic
Contracture
1st= only epidermis, red no blister; 2nd = hyperemic,
blister; partial thickness; 3rd = full thickness, leathery no Pelvic Fx
pain; 4th = electrical injuries, damage to nerves & bone;
entry & exit burn; Fluid resc. If > 20% Parkland formula = MVA, 30% blood volume can be lost; Tx as if shock
3-4 ml/kg LR x % burn RULE of 9's: head = 9; ant trunk= victim
18 post trunk = 18, each ext = 9; each ext = 18,
Perineum = 1 Tibial Fx

Common Poisons & Antidotes: Compartment syndrome= bleeding into tight

compartments=> blood supply compression=>muscle
Aspirin = Dialysis; Acetaminophen =N-acetylcystine; ischemia; 6 Ps = pain, pallor, pulselessness, puffiness,
Digitalis = lidocaine; Methanol & Ethylene Glycol = parathesia & paresis (weakness) or paralysis. Surgical
Ethanol; CO = O2; Narcotics = Narcan, Naloxone; Iron = opening of compartment
Deferoxamine; Cu, As, Pb = Penicillamine; Cyanide =
Sodium nitrite, or sodium thiosulfate Sprains

Types of Fx Tx = RICE => Rest, Ice, Compression, Elevation

Open(compound); Simple(closed); Greenstick Concussion

(incomplete, children usually); Spiral (twisting breakage);
Comminuted (multi bone fragments)
transient loss of consciousness; Coup = bruising under
site of injury; Contrecoup = bruising on side contralateral
Vertebral Fx to injury

Most common cause of paraplegia & quadriplegia, Blunt Eye Trauma

Compression Fx seen in elderly due to osteoporosis &
DJD
periorbital echymosis, hyphema (bleed into anterior
chamber; edema; Blowout Fx = Fx of orbital bone;
Hip Fx Aspirin & anticholinergics are contraindicated

Avascular necrosis of femoral head if blood flow is Blunt Ear Trauma

compromised; Tx: immobilization, bedrest, surgery;
Prevention= safety & Ca supplement in women
Auricular Hematoma (cauliflower ear) Tx prompt
drainage to prevent dissolution of cartilage
Skull Fx
Dog & Cat Bites
Signs of Fx: 1.Battle's Sign = discoloration over mastoid
bone; 2. Blood draining from ears, 3. Bruising of orbit,
CN palsies, CSF leakage from ears & nose Pasturella multocida; Tx tetanus & rabies if needed,
antibiotics
Rib Fx
Snake Bite

Splint affected area & transport; In US usually pit vipers

Spider Bite Testiclar = BHCG, AFP, Thyroid = Calcitonin

Black Widow: Vomiting, abd pain, shock; Tx Calcium 10 Biliary Cirrhosis = Anti mitochondrial antibody
gluconate & methocarbamol; Local bite Tx not needed
Wilson's Disease = Ceroluplasmin Antibody
Brown Recluse: bite becomes black scab w/ assoc fever,
rash, vomiting & jaundice; DIC can occur; Tx: Liver = Alpha 1 antitrypsin
Dexamethasone, dapsone, colchcine & total excision of
lesion Thyroid - Antimicrosomal antibody, Thyroglobin antibody

Hypovolemic Shock Incidence # new cases / total population

Hemorrhage, Burns, Vomiting, Diarrhea; pale skin, JVD, Prevalence # cases at a given time / total pop at that
vasc resistance, pulse Tx: rehydrate, transfusions, time

Septic Shock Disease Frequency # people w/ disease / population at

risk
Infection, gangrene, necrosis,CV obstruction; pale/pink
skin; flat neck veins, pulse or vascular resistance Tx Case Fatality # who die in a given period/ # people w/
ventilation, Fluids, antibiotics disease

Cardiogenic Shock
Relative Risk Only from cohort study; a/a+b divided by
Pale skin, flat neck veins, pulse, vascular resistance; Tx: c/c+d; >1 positive assoc, < 1 negative association, =1 no
medication for underlying problem, pacemaker, association ==> disease if exposed /disease if not
exposed
Neurogenic Shock

Spinal cord injuries, drug OD; Pink skin, flat neck veins, Odds Ratio Only from case control; odds of getting if
normal => low pulse, low vascular resistance Tx: exposed / odds of getting if not exposed (ad/bc)
ventilation, fluids, drainage

PUBLIC HEALTH
Mortality Rate # people that die w/ in current population
Levels of Prevention: 1o = actions to incidence of
health problems (prenatal care, immunizations) Std Mortality Rate Adjusted according to age
distribution
2o = interventions at early stage of disease to limit
development (DM screen, PAP)
Attributable Risk exposed rate - unexposed rate
o
3 = interventions to treat problem and prevent further
morbidity & mortality
Sensitivity a/a+c; accurate diagnose ; False +

Special Tests Complement & Complement disorders

C3, C4, CH50 Specificity d/b+d; Prob of neg test in those truly neg;
false neg
Rheumatiod - ANA, RF

Lupus - DNA, Anti Smith Antibody OMM

Scleroderma - Scl-70, Anti Centromere Fryettes Laws

Sjogrens -SSA Anti Ro, Anti LA 1. Side bending then rotation in neutral position

Prostate = PSA, Pancreatic = CA 19-9,Ovarian=CA125; 2. Flexion or extension with rotation then side bending
Breast = CA15-3 & CA27-29
3. Motion free in one direction is restricted in the other Absolute = Weak bony structure, spinal cord, nerve
compressions, Danger of vascular damage;
Ribs
Relative: lax ligament, acute inflammation, pregnancy,
1-5 pump handle, 6-10 bucket handle, 11-12 caliper; Calcification of aorta, Recent MI, spondylosis, Ankylosin
Elevated = expiration restricted Treat lower ribs 1 st; Spondylitis, Osteoporosis, Chronic Steroid use, Acute
Depressed = inhalation restriction, treat upper ribs 1 st disk disease, Extreme scoliosis, Cauda Equina
Syndrome, Adv. Degenerative disease, Severe DM, Hx
or current malignancy, Agenesis Odontoid process,
Flexion Test
Vertigo
Standing = ilia sacral; Seated = sacroiliac; false neg =
Counter Strain
tight hamstrings on standing flexion; False positive =
tight quads on standing flexion
Passive Indirect
Sympathetic Innervations
Put joint into position of greatest comfort; Agonist-
Antagonist pair; Strain due to rapid stretching followed
Head & Neck = T1-4; Lung T2-5 bilat; Heart T2-5 Left,
by protective immediate shortening of agonist along with
Stomach T5-9 Left; Duodenum T10 rt; Gall Bladder T9 rt;
rapid shortening then lengthening of antagonist
Liver T5-9 Rt, Pancreas T6-9 bilat, Kidneys, Ovaries,
Testes T10-L1 of respective side; Adrenals T10-11,
Appendix T11-12 Rt, Bladder L3-4, Uterus L4-5, Rectum Most comfort of pt (70%) Hold for 90 sec (120 secs for
& Anus L4-5 ribs) Reactions to Tx: generalized soreness, treat no
more than 6 TP at a time, 3 days between Tx;
Parasympathetic Innervations
Muscle Energy
Eyes=CN III; Nasal sinuses, Eustachian Tube=CN VII;
Soft Palate, Salivary Glands=CN IX; Thyroid thru Active then passive, direct
Transverse Colon=CN X (Vagus); Right Colon & Pelvis=
Pelvic Splanchnic Nerves S2-4 Type I = Joint mobilization using direct muscle force

Somatic Dysfunction Type II = Muscle lengthening using postisometric

relaxation, "Resetting the Gamma Gap or Synaptic
An altered or impaired function of related components of Fatigue
the somatic system
Type III = Muscle lengthening using Reciprocal Inhibition
Qualities: Texture chg, asymmetry, ROM, tenderness
Type IV = Muscle relaxation using Crossed Extensor
Treatment Types Reflex - Used w/ sever injury (flexor muscle on one
extremity is contracted the flexor on opposite extremity
relaxes & extensor contracts)
Direct = engages restricted barrier & pushes thru it,
Force takes it from where it is to where it will not go
Natural Body Rhythms
Indirect = Move away from the barrier, Leaves the
structure in the position it was Cardiac/Vascular, Ventilatory, Visceral, Cranial Rhythmic
Impulse (CRI), Slow Undulating (Breath of life)
Direct Technique Used For:
Articular Mobility of Cranial Bones
Subacute or chronic, no assoc osseous pathology post
closure of epiphyseal plate, Short restrictors Newborn: Base is cartilage for stability, vault is
membrane for accommodation
Indirect Technique Used For
Sphenoid motion - influences facial & frontal bones;
Occipital Motion - influences temporals (mandible &
Acute, A lot of pain, a lot of restriction, non closure of
hyoid) & parietals
epiphysis

Motion of Sacrum between the Ilium

HVLA Contraindications

Direct, Passive
Superior transverse axis, Located at S2, Only area of
anterior convergence & posterior divergence of the SI
joint

Coordination of motion

Inhalation = midline flex, paired ext rotate, sacral base

post, SBS rises

Exhalation = midline extension, paired int. rotation,

sacral base anterior SBS falls

Sacrum & Temporal follow movement of occiput; Facial

bones follow motion of sphenoid

Strain Patterns

Torsion, Side bending rotation, Vertical Strain, Lateral

Strain, Compression

Naming Convention

Vert unit, AP, side bending, rotation

Type of Motion

C0-C1 (OA) Type I; C1-C2 Rotation; C2-C7 Type II; C7-

L5 Type I & IIACID BASE

pH acedemia <7.35-7.45< alkalemia

pCO2 Resp alkalosis < 35 - 45 < Resp acidosis

HCO3 Metabolic Acidosis < 22-26< Metabolic alkalosis

Anion Gap = (NA) - [(Cl) + (HCO3)]

Primary disorder pCO2 or HCO3 altered same way as pH