COMLEX II & USMLE II CRAM SHEETS -GASTROENTEROLOGY Vitamins Vitamin A Night blindness, conjunctival dryness, corneal keratinization Vitamin

D Ricketts - kids, long bone bowing; Osteomalacia-adults, demineralization Vitamin K

Obesity mild 20-40%, moderate 41-100, severe <101%; age, black women, low income BMI= body wt (kg)/Ht (mm2) Normal 20-25 Pickwickian Syndrome = obesity, dyspnea, hypovent, CO2 retention, hypoxia Boerhaave's Syndrome esophageal rupture due to forceful vomit; Gastromediastinal fistula, dyspnea w/o hemetemesis, + Hammonds sign = pneumomediastinum, L lung effusion 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) Wernicke-Korsakoff - Alcoholics, confabulation, nystagmus, confusion Niacin Pellagra - Diarrhea, dermatitis, dementia, death Pyroxidone (B6) Rare, neuropathy, Cheilosis (swollen cracked bright red lips) Cobalamin (B12) Macrocytosis, Pernicious Anemia- megaloblastic, neuro chg. ataxia, Schilling test Folate squamous 90% Macrocytosis, megaloblastic anemia w/o neuro chgs., common in alcoholics Vitamin C Scurvy, bleeding gums, Connective Tissue problems, Can manifest 1 yr post defic. Failure to Thrive Org.= wt gain w/ other disease; Nonorg.=growth failure due to neglect stimulation < 80% wt for Ht Dysphagia solids 1st, Cough & hoarse = laryngeal nerve, constricting bands = annular lesion, Risk factors= smoking, alcohol, GERD, Barretts Esoph = adeno CA Gastritis Antral Creep=fundal tissue replaced by antral mucosa, Not preCA, Risk Factors = NSAIDS, Alcohol, H.Pylori PUD Candida (thrush), HSV, CMV, immunocomp, diabetics, Dysphagia & odynophagia Esophageal Atresia Proximal esophagus, blind pouch Trachesoph Fistula Congenital defect, distal esoph, coughing & cyanosis when feeding, abd distention Achalasia Dysphagia for solids & liquids, nocturnal cough, aspiration; Absent peristalsis & tight LES, "Beak" esoph on x-ray, 20-40 yrs old Esophageal Cancer

Gastric = NSAIDS, eating no help, COPD,blood type A; 25% Duodenal = H.Pylori, better w/ food, Liver cirrhosis, Blood type O ; 75% Cullen's Sign Periumbilical cyanosis d/t hemoperitoneum = hemorrhagic pancreatitis, ruptured ectopic, ruptured spleen Zollinger-Ellison Synd. Gastrinoma ( gastrin); recurrent ulcers, are malignant Gastric CA Adeno, H.Pylori gastritis, Virchow's Nodes, Types = ulcerating (shallow edges); polyploid (intraluminal late mets); superficial (early CA) ; Linitus Plastica (all layers elasticity) Mets to ovary = Krukenberg Tumor Diarrhea

bowel with thin mucosal folds; most common cause of malbsorption Tropical Sprue nutritional defic, small bowel mucosal abnormal; Acquired - Caribbean, India, SE Asia; Megaloblastic Anemia, glossitis, diarrhea, wt loss Tx Folic Acid & Tetracycline Whipple's Disease Infectious; middle aged men; multi-organ; Thickened mucosal folds, Foamy macrophage with rod shaped bacilli that stain w/periodic acid (Schiff's Reagent) Intestinal Lymphangiectasia Children & young adults; cong or acquired telangiectasia of intramucosal lymphatic Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/ triglyceride supplement Toxic Megacolon

Osmotic = H2O lumen solutes in bowel; Secretory = electrolytes & H2O secreted not absorbed; Malabsorption; Exudative secretion of blood plasma & mucus (mucosal inflammation); transit time (short bowel); transit (bact. Proliferation) Ischemic Colitis Vascular compromise (atherosclerotic or embolic); abrupt abd pain after eating, bloody diarrhea, systemic sx.; Barium X-Ray - Thumbprint = pseudo tumor Irritable Bowel Synd. Dx of exclusion (psych?); Tx: bulk supp, anticholinergics, antidiarrheals, TCA Colonic Polyps villous>tubular ; sessile>pedunculated for being CA; familial adeno polyps autodom. Lactose Intolerance Lactase deficiency, bloating & explosive diarrhea after milk; Ages 10-20 Celiac Sprue Gluten sensitivity (wheat, rye, barley); amenorrhea 1 sx girls, Infants = FTT, abnormal stool, bloating, Adults = malabsorption, vit deficiency; X-ray - dilated loops of
st

Dilation > 6cm, Adults preceded by IBD (UC or Crohn's) Kids preceded by Hirschsprungs Ds; Sx: severely ill, temp, abd pain, rebound, leukocytosis; X-ray intraluminal gas along continuous seg of dilated bowel; Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids, Rectal tube may alleviate but can cause perforation Inguinal Hernia Indirect = infants, persistent processus vaginalis, protrudes thru ring, lateral Inf Epig. Direct = Adults, medial to ing ring & inf epig artery, Weakness in Hesselbach's Ulcerative Colitis Colon & Terminal Ileum w/o skip lesions, w/ rectal bleeding, "lead Pipe" on X-ray (shortened, narrowed, loses haustrations) Tx: Sulfasalazine, steroids, Immunosuppresents; Complications=perf, hemorrhage, Toxic Megacolon, Colon CA Diverticular Disease Diverticulosis = false diverticulae, pearl sign on xray Diverticulitis = infection, acute abd pain usually on left, may form fistulas to bladder, vagina or skin, CT w/ water soluble contrast during acute attack Crohn's Disease

Granulomatous colitis; No bloody stools, 1st in terminal ileum, transmural, skip lesions, cobblestoning: Complications=small bowel abscess, obstruction, perianal disease, malabsorption, toxic megacolo, Colon CA. Surgery is not curative Colon CA Right Sided=napkin ring, anemia Left Sided=Apple core, pencil stools; Genetic; Annual rectal>40, Annual Guaiac >50; Flex Sig q3-5y >50; Rectal CA-hematochezia Volvulus Rotation of Bowel; Newborns & elderly; Double Bubble; Birds Beak on Barium Enema, Tx: Left Sided = decompression; Rt sided & kids = surgery Intussusception Telescoping of large bowel into an adjacent section; most common cause of obstruction in kids under 2; Episodic Abd pain 1-2 min. Reflex = early vomit; Obstructive = omit late; Currant Jelly Stool; Small Infants = Pallor, sweating, and vomiting. Leukocytosis with hemoconcentration, BE to reduce x 2 before surgery Necrotizing Enterocolitis Premature, birth weight, older infants with malnutrition; bilious vomit, abd distention, bloody stool, lethargy; Thrombocytopenia; Small Bowel Distention; pneumatosis (air in bowel wall) TX; NG, TPN, IV antibiotics, surgical Rx necrotic part Cholera Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic gulfcoast, Asia, Africa, Mid East; Severe dehydration, Metabolic Acidosis, Tx: Tetracycline or Doxycycline Shigella Dysentery Small bact dose needed, Blood & mucous, Kids worse than adults, Fluid Replacement & Ciprofloxacin Staph Enteritis Onset 3-6 hrs; "Church Picnic epidemic; N/V/D, HA, fever recovery w/in 24 hrs Salmonella Enteritis Undercooked Poultry; nausea & cramps => watery &/or bloody diarrhea; No antibiotics prolongs excretion of the organism Viral Enteritis

Norwalk = yr round, Rota (kids) = winter; Coxsackie A1; echo, adeno Botulism Clostridium Botulinum, neuromuscular; onset 12-36 hrs; N/V/D, cranial nerve palsy, fixed dilated pupils, resp failure, no fever, Wound induced = neuro w/o gi sx Infants constipation 1st=> cranial nerve sx => cranial nerve Sx => Neuromuscular Hemorrhagic Colitis E coli 157, cramps, => watery diarrhea => bloody diarrhea Complications= Hemolytic-Uremic Syndrome, thrombotic thrombocytopenic pupura Pseudomembraneous Colitis Antibiotic induced (clindamycin, ampicillin, cephalosporin) C. Diff; mail -> severe bloody diarrhea; Tx: stop antibiotics, oral metronidazole in severe cases Acute Pancreatitis Pain radiates to back w/ N/V; Grey Turner's Sign (blue flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase ; Ranson's Criteria: 3 or more = incr mortality Admission: >55, gluc>200, LDH >350, AST >250 WBC > 16000 Within 48 hrs: Hct 10%, BUN >5, Ca< 8, PaO2 < 60, Base Def > 4, Fluid Seq>6L Chronic Pancreatitis ERCP to Dx; Alcoholics, Malabsorption & diabetes are results Hepatitis Hep A = Fecal oral, shedding before Sx; IG to travelers & contact with HAV infected Heb B= Blood & STD; HbsAg early if persists = carrier; HbcIGM then HbcIgG for life HBIG for needle sticks and infants born to + moms; assoc w/ hepatocell CA Hep C Most common post transfusion hepatitis Hep D = Co infection with B; Hep E = fecal oral

Cholelithiasis Female, fertile, fat, forty; Ultrasound, RUQ pain after fatty meals, Calcified = preCA Cholangitis Charcot's Triad = Biliary Colic, Jaundice, Fever; Leukocytosis, Alk Phos Hepatocellular CA Mets 2x more than primary CA (breast, lung, colon), Budd Chari-thrombosis hep V. Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins (fungal metabolites) Benign Hep Adenomas oral contraceptives Exocrine Pancreatic CA Ductal CA, Courvoiser's Law=palpable nontender GB in a jaundiced patient is a head of Pancreas tumor. Tumor Body or Tail=splenic vein obstruction=> splenomegaly, gastritis, esoph varices

glucose-6-phosphatase def.; big liver & kidneys, growth retardation, electrolyte prob. McArdles Disease musclephosphorylase is absent, muscle cramps & myoglobin after exercise Jaundice Prehepatic = hemolysis, gilbert's disease, Crigler Najjar; Hepatic = hepatocellular or cholestatic; Post Hepatic = Biliary obstruction, AST & LDH also ; unconj prehepatic; conj = intrahepatic cholestasis or post hepatic disease all fractions = hepatocellular, hyperbilirubinuria = conj bili water soluble ETOH Hepatic Disease Fatty liver => ETOH hepatitis => cirrhosis; AST > ALT ; PT; II, VII, IX, X Clot Cirrhosis necrosis and fibrosis, serum albumin, anemia PT, Not curable or reversible Esophageal Varices veins that expand to circumvent congested hepatic flow; Tx: vasopressin, balloon tamponade, endoscopic sclerotherapy, transjugular hepatoporto shunt (TIPS Hepatic Encephalopathy altered consciousness, ammonia glutamine in CSF, EEG abnormal Ascites Complication of hepatic disease; Paracentesis to examine ascitic fluid values should equal serum if albumin = malignant; LDH > 60% of serum = malig or infective; WBC = infection GI Bleeding

Insulinoma Insulin hypersecretion, hypoglycemic symptoms, Insulin levels still after fasting Whipple Triad: confirms hypoglycemia as source of Sx 1. Hypoglycemia, 2. Relieved with carb ingestion 3. Sx occur while fasting VIPoma Makes Vasoactive peptide (VIP); Sx WDHA (watery diarrhea, hypokalemia, achlohydria; unexplained secretory diarrhea; laparoscopy for Dx Glucagonoma tumor of alpha islet cells; 80% women; 80% malignant; Necrolytic Exfoliating Erythema characteristic exfoliating lesion of the extremities Pompe's Disease 1,4 glucosidase deficiency; fatal by age 2 VonGierke's Disease

Upper GI = melaena (black tarry) ; Lower GI = hematochezia (bright red) Lig Trietz Intestinal Obstruction

Vomiting common in small bowel, late in lg bowel, High pitched "tinkling" BS. X-ray - prox dist = lg bowel; dilated loops of bowel with air fluid levels = sm bowel Ileus Paralytic obstruction of bowel due to loss of peristalsis Pyloric Stenosis Projectile vomit in neonates, visible peristaltic wave, String Sign Meconium Ileus Abnormal thick Meconium with undigested protein, associated with CF Hirschsprung's Disease No autonomic nerves in colon, Obstipation, late vomit, Megacolon, Toxic Enterocolitis if left untreated, BE proximal dilated & distal narrow, ColostomyCARDIOVASCULAR Contraindications to BP meds Asthma/COPD = Bblockers, DM = Thiazides & Bblockers, Cardiac Failure = Bblockers & Ca Channel Blockers; Pregnancy = Thiazides & ACE Rheumatic Fever post strep infection, migratory arthritis, endocardits, subcutaneous nodules on extensor surface, chorea, erythema marginatum, Sed, WBC & ASO ASD L=>R; Wide split & fixed S2; patent foramen ovale VSD L=>R; pansystolic murmur left sternal border, thrill; most common defect; Eisenmenger's Syndrome = shunt direction reversed due to pulm vasc resistance Patent Ductus Arterio L=> R; Continuous machinery murmur; Indomethacin inject may close Tetralogy of Fallot VSD, RVH, Pulmonic Stenosis, Overriding Aorta

Pulmonic Stenosis R=>L, Early systolic click, High pitched systolic ejection murmur, soft or absent S2 Coarction of the Aorta HTN arms but not legs, murmur heard on back, X-ray scalloping of ribs, Bacterial Endocarditis Acute: S.aureus, Group A strep, N Gonh., Sub acute: Strep Viridans; New heart murmurs, petechia over half of body, Splinter hemorrhages on fingernails, Osler's Nodules (nodules on fingertips) Roth's Spots (retinal hemorrhages) Noninfective Endocarditis Libman Sacks Disease associated with SLE Aortic Aneurysm Abdominal = pulsatile mass on exam, atherosclerosis, smoking HTN >4 cm = surgery Thoracic =Marfan's & syphilis >7c = surgery; Dissecting =split between medial & adventitial layers "ripping in chest" Normal EKG vs abnormal in MI Peripheral Vascular Disease Weak pulses, Atrophic skin, Little Hair growth, Nonhealing ulcers, intermittent claudication 5P's = pallor, pain, pulseless, parathesia, paralysis Raynaud's Phenomenon Pallor, cyanosis, erythema of fingers, most are idiopathic, others related to collagen vascular disease Tx vasodialators Heart Dysfunction Diastolic = difficulty filling ventricles; Systolic = problem ejecting blood from ventricle Polyarteritis Nodosa inflamed medium arteries->ischemia in tissues; men 3x> women, usually 40-50; Dx confirmed by biopsy or angiography showing aneurysm of medium arteries Giant Cell Arteritis Temporal Arteritis; women >50; severe temporal or occipital HA, Amaurosis Fugax (temp blindness 1 eye)

Temporal artery swollen & tender, Dx confirmed by biopsy Cor Pulmonale COPD most common cause; Dyspnea & syncope on exertion, S/Sx Rt heart failure Mitral Stenosis Mitral facies = red rash on cheekbones, Loud S1 and opening snap after S2; Right heart failure TX with diuretics; LAH=>Pulm HTN=>RVH Bblockers & Ca Channel Blockers to HR & preload; Progressive Dyspnea Mitral Regurge Midsystolic click; Harsh blowing holosystolic murmur; MVP; LAH & LVH; wide S2 that widens more with inspiration; Bblockers for Sx Valve replacement Aortic Stenosis Triad = Angina, Syncope & Dyspnea on exertion; Cong bicuspid valve, weak long pulse, LVH T wave invesions; Left sided failure; Bblockers HR & coronary flow Aortic Regurge Decrescendo murmur, widened pulse pressure, "Water Hammer Pulse" (rapid up & down stroke); "Pistol Shot over femoral Artery; 2o Austin Flint murmur= diastolic murmur as blood goes thru AV to hit MV. Kids = cong VSD w/ MVP Supraventricular Tachycardia Sudden attacks due to reentry rhythm, P on T on EKG; #1 AV Nodal Reentry #2 Wolff Parkinson White = reentry thru accessory muscle bundle, can cause V fib in a Pt with Afib; Torsades De Point is drug induced Left Sided Failure Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, LVH Right Sided Failure Most common cause is Left sided failure; Neck vein distention, Liver big, Edema MI ST elevation, T wave inversion; CPK-MB 12 - 40 hr for peak; LDH peaks 3-6 days

Congestive Cardiomyopathy Alcohol = chronic; Infection Coxsackie B or Trypanosoma cruzi (Chagas Disease) Hypertrophic Cardiomyopathy Cong or acquired VH with normal afterload; venous pressure, JVD, ascites, edema, edema, pleural effusion, S4 on exam Chronic Pericardtis Causes right sided failure; Kussmaul's Sign ( neck vein distention on exertion) Dyspnea on exertion and Orthopnea; pulsus paradoxus; Surg removal of pericardium is curative. Pericardial Effusion Friction rub, distant heart sounds, "water bottle" on x-ray; acute pericarditis = exudate; neoplasm or fibrosis =transudate; symmetrically enlarged cardiac silhouette Cardiac Tamponade Pulsus paradoxus, Kussmauls Absent; pericardial fluid compresses heart, Becks Triad = Hypotension, ( pulse pressure), JVD, Muffled heart signs Heart Murmurs AI: precordium, early diastolic, >S2, + heave; AS: 2nd R ICS & radiates to carotids, harsh, < S2; Diastolic = r/o malignancy, check BP both arms; MR: Apex radiates to axilla, + heave, assoc w/ sever anterior MI, endocarditis prophylaxisis; MS: Apex, late diastolic, opening snap after S2; MVP: Apex, blowing, holosystolic, w/ valsalva; PR: 2nd L ICS, pulm HTN, clubbing, PE; PS: harsh; TR: 4th L ICS, loud w/ inspiration; bounding JVD, pulsatile liver; VSD: loud holoystolic, assoc w/ Down'sRESPIRATORY Peritonsillar Abscess uvula away; Head tilted toward, Trismus (can't open mouth)Strep or Bacteroides Epiglottitis H.flu type B, Insp. Stridor, Dysphagia with drooling, Thumbprint sign on xray Larengitracheitis Croup; Paraflu #1, RSV, Flu, barking cough, stridor hoarse, r/o epiglottitis

Acute Bronchitis non smokers = M. pneumonia; smokers=S.pneumonia & H.flu Bronchiolitis Circumoral cyanosis (blue around mouth) RSV; kids < 2 Strep Pneumonia Red-brown sputum, lobar pneumonia, most common adult community acquired Pneumovax vaccine = >65, immunocompromised, chronic disease H.Flu Pneumonia COPD, children, slow onset with URI sx 1st, patchy bronchial infiltration on xray Viral Pneumonia Most common cause in kids, flu like prodrome, patchy infiltrates; WBC not a lot Klebsiella Pneumonia Alcoholics, aspiration, Currant Jelly Sputum, Encapsulated gram neg rod Staph Pneumonia Salmon colored sputum, Nosocomial, pneumatoceles on xray are pathognomic Mycoplasma Pneumonia atypical no cell wall to stain, young adults in close contact; xray worse than pt looks Pseudomonas Pneum. hospital acquired, CF, immunocompromised Legionella Pneumonia atypical, CNS & GI sx; confusion & ataxia, aerosolized water (air conditioning) TB fever, night sweats, wt loss, bloody sputum, Miliary = disseminated; Acid fast stain, PPD>10mm nonimmunocompromised; ppd>5mm AIDS;

Extrapulmonary manifestations= meningitis, pericarditis, bone invasion (Pott's Disease) Bronchiectasis chronic destructive; dilation of bronchial tree, cough with sputum, dyspnea, hemoptysis, Xray = bronchial markings, "honeycombing" Emphysema Destroyed alveolar walls, Risks: smoking, alpha 1 antitrypsin deficiency; PFTS: FEV1; VC, FEV1/FVC < 60% normal Blue Bloaters Bronchitis>Emphysema; cough w/ mucous 3mos/yr x 2y; cyanosis, pulm HTN Pink Puffers Emphysema >Bronchitis; gradual dyspnea not hypoxic, underweight Cystic Fibrosis auto recessive, COPD, Pancreatic insufficiency; meconium illeus, sweat chloride Sarcoidosis non caseating granulomatous, increased Calcium, ground glass, bilateral hilar & paratracheal adenopathy is pathognomic Asbestosis Increased risk of lung CA & mesothelioma, gradual dyspnea, nonproductive cough; no wheeze; diffuse linear opacities on xray Silicosis increased risk of TB, SiO2 inhalation; metal mining; multiple small nodules & calcification of hilar lymph nodes Resp Failure ABG=> PO2 50-60 mmHg; PCO2 >45 mmHg Laryngeal CA squamous cell, smoking & alcohol, hoarsness for several weeks

Lung CA squamous>adeno>small(oat) cell; Squamous = hilar; Adeno = peripheral; Horner's Syndrome=invasion of the cervical symp. Ganglion= miosis, ptosis, anhydrosis Pancoast tumor = Horners + pain in arm or shoulder on affected side Asthma

<37 wks gestation, Lung maturity: L/S ratio >2, + PG; Beclomethasone hastens maturity; artificial surfactant for kid Pulm HTN Primary = dx of exclusion; secondary valvular heart disease, L=>R shunt, chronic ateletasis (localized collapse of alveoli)ENDOCRINOLOGY Hypothyroid

PFTs FEV1; ABG resp alkalosis, CO2; If CO2 or normal resp failure imminet Massive Hemoptysis >600 ml blood in 24 hrs; trauma; PE, aortic aneurysm, heart failure Pneumothorax Spontaneous = 15-35 y/o males; Tension = pressure in pleural spaces; displaces heart & lungs (mediastinal shift) = surgical emergency ARDS acute lung injury with non-cardiogenic pulm edema, ABG =acute resp alkalosis (O2 & CO2; Xray =pulm edema with normal cardiac silhouette, Positive pressure or PEEP ventilatory support Pleural Effusions tactile fremitus; dull; egophony (incr resonance; chg voice to high pitched) Transudates: <3g protein, Plasma/serum protein<0.5; Plasma/serum LDH <0.6 caused by CHF, cirrhosis, nephrotic syndrome Exudates:Reverse labs; neoplasms & infections; triglycerides = chylous effusion; Pus = empyema (s. Aureus); Meiggs syndrome = pleural eff, ascites pelvic tumors) Pulmonary Edema Pink, frothy sputum, Kerley B lines on xray; Incr cardiac silhouette if cardiac origin Pulmonary Embolism DVT (iliac & femoral) V/Q useful, angiography is god std for dx RDS

Weight gain, Lethargy, Coarse hair & dry skin, irregular menses, cold intolerance, myxedema; Acquired = Hashimoto's; Congenital = cretinism, severe I deficiency = hoarse cry; resp distress, cyanosis, poor feeding, decr bone growth, T4 TSH Wolff Chaikoff effect = inhibition of thyroid hormone release due to high doses of I during thyroid scan Hyperthyroid 1. GRAVES: most common, autoimmune, antibodies bind to TSH receptors; incr thyroid hormone, pretibial myxedema, Incr radio I uptake 2. SUBACUTE THYROIDITIS: tender, enlarged, Decr Radio I uptake, Sed Rate up, maybe followed by period of hypothyroid 3. SILENT LYMPHOCYTIC THYRODITIS: transient, postpartum, no pain or fever, Radio I uptake decr, lymphocytic infiltration, Tx Bblockers 4. TOXIC ADENOMA: multinodular goiter; nodules function autonomously, Excess T3 & T4; Scan shows a few hot spots with cold background 5. THYROTOXICOSIS FACTITIA: exogenous thyroid hormone, no goiter 6. PLUMMERS : multinodular goiter, nodules become autonomous and secrete thyroxine Sick Euthyroid acutely ill patients; T3&T4 decr due to chgs in hormone metabolism; TSH not decreased => not truly hypothyroid Thyroid CA Papillary = most common, best prognosis, Follicular = older, hematogenous spread to bone, lung, brain, liver; Anaplastic = worse prognosis, local invasion, hoarse & dysphagia; Medullary= Calcitonin producing Cells, MEN Type II(parafollicularC cells)

Diabetes Dx: elevated random glucose sx, fasting BS > 140 x 2 days; Oral challenge >200 after 2 hrs; Type I: alpha islet cells, HLADR3, HLADR4, HLADQ, ketoacidosis Type II: insulin resistance; no HLA association, endogenous production enough so no ketoacidosis but do get hyperosmolar coma(dehydrated, glucose 6002000 Parathyroid Hormone Ca mobilization from bones, Vit D production phos reabsorption in distal tubules = serum phos. Hypoparathyroidism PTH, Ca, Phos, Tingling, tetany, Chvostek's sign (tap on face & get muscle spasm) ; Trousseau's Sign (BP cuff up 3min => carpal tunnel sx; Mg in alcoholics can lead to Ca due to PTH secretions Hyperparathyroid Bones, stones, abd. Groans and psychic moans; 1o = excess PTH; 80% benign adenoma; 2o due to serum Ca=> vit D defic, renal tube prob and Ca loss Diabetes Insipidus Lack of ADH, polyuria and polydypsia Kallman's Syndrome Male, anosmic, small testicles, azospermic d/t head trauma; FSH & LH, no GNRH SIADH Excess ADH, Tumor, trauma, pulm disease, drugs; Hypoatremia, Conc. urine; Acromegaly Excess GH; bone & tissue enlargement; glucose intolerance, osteoarthritis Addison's Disease Decreased cortisol (aldosterone) Wt loss, fatigue, skin pigmentation, eosinophilia; Decr aldosterone, decr Na, incr K; Give ACTH if cortisol doesn't increase Dx made Cushing's Syndrome Incr cortisol, Buffalo hump, moon facies, central obesity, Osteoporosis, #1 Cushing disease due to pit. Adenoma,

#2 Ectopic- ACTH from lung tumor, #3 Adrenal Cortical tumor- cortisol, ACTH suppressible, cortisol not #4 Chronic glucocorticoid Tx Waterhouse Friedrickson Syndrome hemorrhagic infarct of adrenals, assoc w/ meningococcemia Pheochromocytoma Episodic HTN, Dx by urinary catecholamines Familial Hypercholesterolemia Autosomal dominant, Xanthomas (lipid on tendons) Xanthelasmas (lipids on eyelids) MI's in 40's, Homozygous usually has total cholesterol Familial Hypertriglyceridemia Trig , LDL normal, Autosomal dominant, Pancreatitis, milky serum Familial Combined Hyperlipidemia Auto dominant, trig and cholesterol; no xanthomas Familial Dysbetalipo-proteinemia rare, problem with lipoproetin catabolism; palmar or tuberous xanthomas, risk periph vasc disease & CAD, Abn VLDL, cholesterol & triglycerides MEN I Parathyroid , pituitary & Pancreatic tumors MEN II Pheochromocytoma, Parathyroid & medullary thyroid tumors Hemochromatosis Auto recessive, GI absorption of Fe; Excessive Fe, Ferritin, Transferrin saturation, cirrhosis, diabetes, bronze skin Wilson's Disease Auto recessive, excessive Cu accumulation, ataxia & dementia, Kayser Fleisher rings on cornea Hyperaldosteronism

Aldosterone works on distal renal tubule to facilitate Na retention and K loss excretion due to Na, BP (renin angio), K

Ca = Calcium stones; Struvite Stones = post UTI w/ urea splitting bact (proteus or pseudo) when urine basic MgNH4PO4 (struvite) stones ppt. Uremic Syndrome

1o Conn's Syndrome = adrenal hyperplasia, adrenal adenoma Tx: spironolactone 2o renin angiotensin system activity => BPGENTOURINARY Neurogenic Bladder Bladder control requires: intact sensation(full) motor function (start void) Cerebral control (timing) Atonic, distended with overflow= acute spinal cord injury or sensory impaired Motor defect = sense full bladder but can't start emptying Autonomous = spinal cord injuries after acute; bladder fills & empties reflexively Hydronephrosis dilation of renal pelvis, pressure in urinary system w/ or w/o ureter dilation Fanconi's Syndrome renal tubule defect; Urinary excretion of glucose, phos, AA; Tx: Vitamin D Pyelonephritis & Pyelitis Pyelonephritis = dilation of renal parenchyma, pyelitis = dilation of renal pelvis; E. coli; Different from cystitis since there are WBC casts not just WBC's Cystitis WBC in spun sample, E. coli, freq, urge, dysuria & suprapubic pain Bladder Ca transitional cell CA; Risk factors = smoking, schistosomiasis, aniline dyes Renal Artery Stenosis Cause of 2o HTN; Fibromuscular dysplasia (young women) Atherosclerosis (older) Urolithiasis

Symptomatic renal failure = GFR< 20 ml/min; CNS chgs, asterixis (flapping tremor) pericarditis, N/V, yellow-brown skin (uremic frost) Normochromic, normocytic anemia due to erythropoietin; Phos & Ca = renal osteodystrophy Glomerulonephritis Hematuria, proteinuria, RBC casts: Post strep = give Antibiotics only if still strep +, steroids no help; Goodpastures- autoimmune, high dose steroids, uremia 3-9 mos. Nephrotic Syndrome Proteinuria > 3g/day, Edema, hypoalbuminemia & hyperlipidemia (milky serum); minimal chg disease in kids; idiopathic Glomerulonephritis in adults Acute Tubular Necrosis most common cause of acute renal failure; ischemia or toxins; resolves in several weeks may need dialysis Polycystic Kidney Disease Auto dominant; multiple bilateral renal cysts; gross hematuria, proteinuria, pyuria, HTN, UTI's; asymptomatic until adult; 15% have associated subarachnoid hemorrhage Alport's Syndrome X-linked, Type IV collage, deafness & renal failure in males Wilm's Tumor nephroblastoma, kids < 4yrs commonly, hematuria, abd mass; resection & chemo Renal CA adenocarcinoma; Triad: hematuria, abd mass & flank pain Chronic Renal Failure >90% glomeruli destroyed; uremia K, Na phos, Ca = renal osteodystrophy Hypernatremia

> 155 mEq/L; due to dehydration, CNS depression (neuronal shrinkage); Diabetes Insipidus= decr ADH = lots of dilute urine = dehydration = urine output incr. Hyponatremia <135 mEq/L; pseudo if lipids are high to displace polar Na; Osmotic = diabetes Na 1.6 for 100 mg/dl glucose value is above 140.; SIADH, Central Pontine Myelinosis if corrected to fast Hyperkalemia > 5.5 mEq/L; muscle weakness, cardiac arrhythmia, met acidosis, oliguria, K sparring diuretics Hypokalaemia <3.5 mEq/L; muscle weakness, cardiac arrhythmias, resp failure, GI or renal loss Urethritis GC (gram - rodds in WBC, + thayer martin culture); nonGC = chlamydial; coinfection, Ceftrixone for GC, Doxycycline for Chlamydia Epididymitis Induration & tenderness of spermatic cord; support relieves pain Torsion of the Testes adolescents, swelling & tenderness, superior displacement, support does not relieve pain, Emergent SURGERY Hydrocele Painless lump, can be transilluminated; congenital process vaginalis remains in communication w/ abdomen = indirect inguinal hernias Varicocele "bag of worms", assoc w/ infertility Seminoma Painless lump; does not transilluminate, most common testicular neoplasm in men < 30; Undescended testes at greater risk even after surgical correction Prostatitis Nonbacterial > bacterial (GI organisms); recurrent UTIs; Rectal - warm, tender, boggy prostate; Tx TMP/SMX

BPH Enlarged rubbery prostate on rectal; Urinary retention, blockers; TURP, transrectal US more sensitive for Dx; PSA can be falsely elevated Prostate Ca Firm, nodular irregular prostate, Bone mets; Alk Phos and PSA are Bacters Syndrome pre-auricular skin tag and kidney agenesis INFECTIOUS DISEASES & IMMUNOLOGY Fever most common cause immed post op = atelectasis; 3-5 days postop = infection; > 2 wks post op = PE or thrombophlebitis Fever of Unknown Origin > 100F for > 3 weeks despite active search for cause for > 1 week; need to get CBC w/diff, blood cultures; kids = usually infection; adults = infectious, neoplasm, autoimmune Inflamation Rubor, Tumor, Calor, Dolor Types of Immunity Active Acquired= direct exposure - infection or vaccination; Passive Acquired = temporary, serum Ab given (IG, breast milk) Bacteremia bacteria in blood but asymptomatic Septicemia bacteria in blood with symptoms Immunizations in Kids HEP B = mom + HbsAG = HBIG & 1st Hep B vaccine at birth DTP = contraindications => progressive neuro disorder, Hx encephalopathy w/ in 7 days of previous dose; Pertussis not given if > 7 y/o or if currently have pertussis

H FLU = not in kids > 5 POLIO = IPV if immunocompromised MMR = not effective before age 1; don't give if less than 3 months since transfussion or IG use; ok for HIV +; suppresses TB - give Tine(PPD) & MMR at same time or 4-6 weeks apart. Adult Immunizations TETANUS = booster q10y, No Hx immunization 2 td 1-2 mos apart then booster at 6-12 mos then on normal 10 y cycle FLU = chronic resp problems, metabolic diseases, adults > 65; can cause false positive HIV test HIV/AIDS RNA retro, CD4 cells, Dx based on concurrent related diseases &/or CD4 , 200 cells/mm3; Flu-like illness, antibodies 1 - 6 months after infection AIDS related infections

Severe Combined Immunodeficiency Deficits of B & T cells, IgA deficiency, recurrent infections esp resp & GI, IG administration contraindicatedHEMATOLOGY & ONCOLOGY Microcytic Anemia MCV < 80; IRON DEFICIENCY = ferritin; CHRONIC DISEASE Fe, Transferrin, Ferritin; LEAD POISONING; THALASSEMIA Normocytic Anemia MCV 80 - 100; Hemolysis, Chronic disease, Bone marrow suppression (drugs, leukemia) (aplastic) Macrocytic Anemia MCV > 100; FOLATE DEF. = most common cause, folate normal B12; B12 DEFICIENCY: B12 absorbed when linked with IF from parietal cells, neuro sx, Alpha Thalassemia

CMV, HSV, VZV, EBV, TB, mycoplasma aviumintracellular, candida coccidioides, histoplasmosis, cryptococcus, Pneumocystic carnii (protozoa) Toxoplasmosis, cryptosporidiosis, Giardiasis DeGeorge's Syndrome

Acanthocytes (rounded projections from cells); Poikilocytosis (variable size); target cells, Very low MCV but mild anemia, Hemoglobin H = chain missing; Asians, Dx by Hb electrophoresis, Beta Thalassemia

Thymic aplasia, Absent T cells, congenital heart disease, craniofacial abnormalities Wiskcott- Aldrich Syndrome X linked, no antibodies against encapsulated bacteria, eczema, platelets, Chronic Granulamatous Disease Autosomal recessive, defect in phagocytic enzymes, recurrent bacterial & fungal infections Chediak-Higashi Syndrome Autosomal recessive, recurrent strep & staph infections Bruton's Disease Von Willebrand's Disease x-liked, agammaglobulinemia, N B cells or antibodies Ataxia Telangectasia Auto recessive, lymphopenia & IgA deficiency; gait abnormal, telangiectasia autosomal dominant deficiency of VIII & vWF, epistaxis, menorrhagia, bruising, increased PTT & bleeding time Eosinophilia X linked factor VIII (A) or IX (B) deficiency; Prolonged PTT, Joint & soft tissue bleeding; Tx cryoprecipitate & FFP Peripheral Smear = basophillic stippling, nucleated RBC, anisocytosis (chgs in size) Mediterranean & African heritage; Minor = heterozygous, Major = homozygous Sickle Cell Anemia sickled cells, Hct & reticulocyte count, electrophoresis HbS + HbA neg. Salmonella osteomyelitis, S. pneumonia sepsis. Hemophilia

Allergic Drug Reaction; NAACP = neoplasm, asthma/allergies, Addison's disease, connective tissue disorders, parasites Thrombotic Thrombocytopenic Pupura adults > kids, women > men; platelets consumed in clotting reactions, Fluctuating neurologic defects, platelets, HCT, retic count, LDH, acute onset not autoimmune Idiopathic Thrombocytopenic Pupura kids > adults, autoimmune destruction of platelets, Purpurea & Petechia , Platelets<10000, Epistaxis, menorrhagia Hemolytic Uremic Syndrome Usually caused by E. coli toxin, RBC fragments on smear, RBC destruction => acute renal failure, 2o thrombocytopenia, abd pain & diarrhea after a flu or URI prodrome; platelets derc, LDH greatly increased Hodgkin's Lymphoma Painless cervical lymphadenopathy, Reed Sternberg cells (multinucleated reticular cells), 80% survival Burkitt's Lymphoma B cell lymphoma, Associated with Epstein-Barr virus, children & young adults Hereditary Spherocytosis dominant deficit in RBC membrane proteins, damaged cells get trapped in spleen. Spherical RBC & reticulocytosis on smear. Coombs neg. G-6-PDase Deficiency X linked hemoglobin accumulates in RBC (Heinz bodies) hemolysis occurs after ingestion of oxidant Agranulocytosis neutrophils = decr production or incr destruction DIC wide spread activation of coagulation cascade. platelets, fragmented RBC, PT & PTT ; fibrinogen, Pregnancy, malignancy, infections, massive trauma Acute Lymphocytic Leukemia

80% childhood leukemia, peak age 3 - 7; usually B cell origin; lymphoblasts, few other cells on bone marrow biopsy Acute Myelocytic Leukemia affects myeloid cells (N,B,E,erythrocytes, megakarocytes) adults > kids; DIC possible, gram neg and fungal infections, Auer Rods (red staining intracellular inclusions. Chronic Myelocytic Leukemia Philadelphia Chromosome (acquired translocation chromosome 9 & 22), tumor cells are more mature, Dx in middle aged, WBC > 150000; uric acid, B12 (B12 carrier protein produced by WBC); leukocyte alkaline phos decr or absent, RBC normal Blast crisis transforms it to acute leukemia Chronic Lymphocytic Leukemia Disorder of mature B cells (rarely T); B cells don't differentiate into plasma cells, men > women; usually > 50; No Blast Crisis Hairy Cell Leukemia B cell transformed into tumor cell with fine hair like projections; pancytopenia, red pulp of spleen infiltrated Multiple Myeloma Plasma cell proliferation and monoclonal IG; men = women; peak 50 - 60, 1 - 3 year survival; xrays show osteolytic bone lesions, Increased urine protein (Bence Jones) Waldenstrom's Macroglobulinemia single B cell line = monoclonal IM over production; RBC with normal WBC & platelets; Rouleau Formation = RBC pile up forming cylinders Mycosis Fungoides Clonal proliferation of CD4 T cells; infiltrates dermis & epidermis, thickened & nodular skin lesions Polycythemia Vera overproduction of all 3 cell lines; RBC > 1,000,000, Hct > 60%; men & women peak age 60; Bone biopsyhypercellular with absent Fe stores; R/O spurious polycythemia = RBC due to dehydration; R/O 2o polycythemia = RBC mass due to oxygenation.

Eaton Lambert 90% assoc w/ small cell CA, presynaptic Ca release = proximal muscle weakness; hyporeflexia, dysautonomia, function w/ stimulation; weakest in AM (opposite MG) Tx Tubocurare DERMATOLOGYSeborrheic Dermatitis Red skin with greasy scales, worse in winter & when under stress, Se or Tar soap Psoriasis HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled plaques w/ sharp demarcations, Pitted fingernails Pilonidal Cyst Hair lined tract in sacral area = "Jeep Seat"

NEVI PIGMENTED: (Benign) sun exposed areas in children & adolescents DYSPLASTIC: 2-12 mm, more irregular, unexposed areas, Multiple dysplastic Nevi = familial risk of melanoma Hemangiomas NEVUS FLAMMEUS: Port wine stain - flat, purple, does not fade CAPILLARY: strawberry mark, raised, bright red, regress spontaneously by age 5 CAVERNOUS: Raised red or purple, enlarged vascular spaces MUSCULOSKELETAL & CONNECTIVE TISSUE

Actinic Keratoses Osteoarthritis Firm, yellow scale, Due to sun exposure, can lead to squamous cell CA Skin CA Basal Cell > Squamous; Basal Cell = pearly papule w/ dilated blood vessels and central depression; Squamous Cell: Red papule w/ crusted surface, later nodular and ulcerated, rarely mets; Assoc w/ sun exposure Malignant Melanoma Change in size, shape or color of a mole, Usually superficial spreading, Mets as invasion goes deeper than 0.76 mm; itchy & ulcerated Contact Dermatitis 1o = irritant contact - direct injury, all w/ contact affected, Occurs w/ 1st exposure Allergic = type IV hypersensitivity, T cell medicated, Never 1st exposure Carbuncle Slipped Capital Femoral Epiphysis Abscess of skin caused by several boils coming together Dermatopytoses TINEA CORPORIS: ring worm of body (round lesion w/ raised borders, spreads peripherally w/ central clearing) TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot; TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm of scalp; Overweight Teens; stiffness=>weakness=>pain radiating down anteromed thigh to knee, ext rot of leg; avascular necrosis Lyme Disease morning stiffness, bone spurs, osteophytes, DIP = heberdon's nodes, PIP = Bouchard's nodes, also affects hips, knees, spine Rheumatoid Arthritis Symmetric, PIP & MCP joints NOT DIP, Subcutaneous nodules, 70% +RF Gout Affects big toe (Podagra), pinna of ear; Negatively birefringent crystals; Sodium urate; Colchicine or NASIDS for acute attacks Pseudo Gout Calcium pyrophosphate dihydrate; Knee most affected; Positively birefringent Phocomelia Hands & feet attached to trunk, Thalidomide

Borrelia burgdorfi, Ixodes tick, arthralgias, Rash w/ central clearing = erythema chronicum migrans, CNS chgs 1 month after exposure Osteoporosis mass of bone; hip & wrist fx most common; estrogen, Ca & Phos normal; Risk factors = post menopause, Caucasian, Asian, smoking, alcohol, corticosteroids, Cushings, hyperparathyroid, hyperthyroid; Etidronate inhibits osteoclast activity, used for men & women who can't take estrogen Systemic Lupus Erythematosus

Osteochondritis Inflammation of bone & cartilage; Osgood Schlaters teens, tibial tubercle, pain& swelling at the insertion of the patellar tendon Osteomyelitis Bone infection; Local or hemtogenous spread; Prepuberty infection is in metaphysis; Salmonella sicklers; S. aureus; pseudomonas; ESR; WBC; Radionucleotide bone scan w/ in 72 hrs; 4-6 wks organism specific antibiotics Septic Arthritis

Malar (butterfly) rash, arthralgias (raynauds), ANA sensitive; Anti dsDNA specific; Neuro = HA, psychosis, seizures, aseptic meningitis; Check for hemolytic anemia w/ Coombs; Renal = BUN Cr, + protein = immune complex glomerulonephritis Polymyositis & Dermatomyositis inflammation of skeletal muscles; violet discoloration of eyelids (heliotrope rash), elevated muscle enzymes (CPK, SGOT, SGPT, LDH) symetric proximal muscle weakness; hips & shoulders 1st Ankylosing Spondylitis "Bamboo shoots" = vertebral squaring w/ bony outgrowths, paraspinal lig. Calcifications on xray; sacroiliac involvement is diagnostic; HLA-B27; ESR Shoulder Hand Syndrome Pain, stiffness, swelling in hand and shoulder; Occurs 1 month after MI or other acute disease Bone Mets from Primary breast, lung, prostate, kidney, thyroid Paget's Disease Osteolytic => osteoblastic; Frontal "bosing" (enlarged skull with rounded forehead) bow legs and shortened spine; alk phos, Ca & phosphorus levels normal; "Cotton Wool" appearance on skull xray; high output cardiac failure Congenital Hip Femoral head partially or completely dislocated from acetabulum; BARLOWS: dislocates hip when abducted and pressure; ORTOLANI'S: reduces dislocation by abduction and flexion

S, aureus = most common; N. Gon most common sexually active; synovial fluid = WBC and + culture; Ceftriaxone NG infection; Nafcillin for others Degenerative Disk Nucleus Pulposa herniates post or postlat.; Lumbosacral = sciatics = L3L4; + pain on straight leg raise; CaudaEquina Syndrome Lg midline post. Hemorrhage compressing C.E. Urinary and bowel incontinence; bilateral leg weakness Polymyalgia Rheumatica older women; assoc w/ temporal arteritis; Morning stiffness; swelling 1-2 joints; no weakness; ESR; neg. Rheum factor; steroid response immediate Fibromyalgia "Trigger Points" reduce pain, IBS, depression, anxiety Osteosarcoma teenage boys, distal femur & proximal tibia; mets to lungs Eosinophillic Granuloma 20-40; granuloma w/ histiocytes, eosinophilic infiltrate & fibrosis; multifocal = poor prognosis NEUROLOGY Blindness visual acuity 20/400 with best possible correction Open Angle Glaucoma

Increased intraocular pressure, gradual, bilateral vision loss => tunnel vision, elderly, diabetics, African Americans, familial; halos around lights, cuping of ocular disc, Beta Adrenergic blockers to treat; amt aqueous humor produces Closed Angle Glaucoma Rapid rise in pressure due to blockage of aqueous drainage in the eye; Severe pain, blurred vision, halos, Nausea, Abd pain; Reddened eye, upper lid edema, steamy cornea, dilated non-reactive pupil; mannitol, oral glycerin or carbonic anhydrase in acute attack, Beta adrenergic blockers for prevention Diabetic Retinopathy Black spots, "cobwebs", flashing lights; cotton wool spots (infarct of vessel wall) neovascularization, hard yellow exudates Cataracts Painless clouding of lens; Age most common cause, Assoc. W/ smoking & alcohol; Absent red reflex. Senile Macular Degeneration Main cause of vision loss in the elderly; Atrophic degeneration or Leakage of Retinal Vessels , gradual loss of VA, Decr central vision, hemorrhagic or pigmented regions in the macula; Neovascular Membranes (Bruch's membrane) Conjunctivitis Acute inflammation, Adenovirus, a lot of discharge, no blurring, purulent if bacteria Uveitis Inflammation of the uveal tract (iris, ciliary body & choriod layer), haziness, floating spots; Photophobia & redness = iridocyclitis; "salt & pepper fundus = syphillis Central Retinal Occlusion sudden painless loss of sight in one eye, Pale fundus, cherry red spot fovea & boxcar appearance of veins Central Vein Occlusion unilateral loss of sight that is more gradual, Swelling of optic disc, cotton wool spots & tortuous dilated veins Retinoblastoma

Childhood malignancy of immature retina, associated with other malignancies later in life, "white reflex or "cat's eye. Hearing Loss Rinne's Test: hold against mastoid process then adjacent to pinna, norm = pinna louder, if not maybe conductive loss; Weber Test: Midline of forehead, unilateral conductive loss = louder in affected ear; unilateral sensorineural = louder in unaffected ear Presbycusis normal loss of hearing associated with age, sensorineural Mastoiditis Usually following otitis media, Redness & swelling w/ fever & pain; X ray = destroyed mastoid air cells & fluid in the air pockets, IV antibiotics Meniere's Disease Severe vertigo w/ N/V, hearing loss, tinnitus worse during attack of vertigo Acoustic Neuroma Vestibular Schwannoma; tumor of CN VIII; Hearing loss, dizziness, tinnitus; Migraine 2x women : men; Age of onset 10 - 30; gone by age 50; family Hx; stress, bright lights, menstruation, fatigue, tyramine, monosodium glutamate, nitrites; Aura prior to onset; visual, scintillating scotomas (small areas of visual loss) , dull throbbing, unilateral; N/V, photo & sound sensitivity; Cluster Headache Men age 20-50; alcohol & vasodilators; severe, nonthrobbing, unilateral, recur same time each day for weeks, Horners syndrome & periorbital pain; Tx: ergot & lidocaine Tension Headache cause unknown, most common type; bilateral, occipital, constant; muscles tight Tumor Associated Headaches progressive, increasing, dull, nonthrobbing, worse w/ postural chgs, exertion. Disrupt sleep, assoc w/ N/V

Trigeminal Neuralgia Tic douloureux; severe, "lightening" pain in V1 & V2 distribution of CN V; Trigger Pts Tx: carbamazepine & phenytoin; Surgical decompression of CN V Partial Seizures Simple = focal sx, conscious, Jacksonian = simple muscle twitch that spreads progressively; 2o generalization = simple becomes grand mal; Complex Partial = automatism, olfactory hallucinations, fear, deja vu, loss of contact w/ environment; postictal confussion Generalized Seizures Absence = petit mal; brief, freq. Loss of consciousness w/o loss of muscle tone, rapid eye blinks, no aura, no postictal Grand Mal= tonic clonic, preceded by GI upset or mood chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax & contract of muscles, unconscious, then confussion & postictal Status Epilepticus continuous seizures w/o regained consciousness, grand mal progress or withdrawal of anticonvulsants; Complications = high fever, circulatory collapse, brain damage; Diazapam until controlled, Treat potential causes (glucose, thiamine, narcan) TIA sudden, brief, emboli or arterial stenosis, Risks: obesity, smoking, DM, hyperlipidemia, Carotid artery= unilateral, contralateral hemiparesis & parathesia w/ ipsilateral blindness; Aphasia if dominant hemisphere involved, Vertebrobasillar = brainstem dysfunction => vertigo, confusion, blindness, diplopia, weakness, parathesia of extremities Aneurysm localized vessel dilation, Berry Aneurysm = circle of Willis assoc w/ polycystic kidney disease & coarction of aorta Subarachnoid Hemorrhage between pia & arachoid; usually rupture of a cerebral artery aneurysm or AV malformation; Worst HA, syncope, nuchal rigidity, vomiting, nonfocal abnormalities, decr consciousness, CT first if neg then lumbar puncture mandatory.

Intracerebral Hemorrhage Chronic HTN or local thrombus 2o to ischemia; Supratentorial: transtentorial herniation, w/ brainstem compression & midbrain bleeding, hemiparesis; Cerebellar : acute hydrocephalus due to CFS flow blockage; Acute onset HA w/ progressive neurological chgs. Stroke Middle Cerebral: most often, contralateral limb weakness, sensory loss, homonymous hemianopsia, dominant hemisphere = aphasia, nondominant = sensory neglect & apraxia Posterior Cerebral: contralateral homonymous hemianopsia & sensory loss, thalamic pain, hemiballistic movement disorder Vertebrobasilar artery: fatal, unilateral occlusion = ipsilateral CN abnormalities, contralateral weakness; Complete occlusion = opthalmoplegia, defective pupil constriction, bilateral weakness, paralysis, decreased consciousness, dysphagia & dysarthria; completed = neuro stable; Evolution = progressive signs over 1-2 days CT positive 48 - 72 hrs after onset. Cavernous Sinus Thrombosis CN palsies, fever, exophthalmos, papilledema, HA, consciousness, occasional seizures; IV antibiotics immediately Acute Subdural Hematoma rapid bleed between arachnoid & dural layers; Tearing of bridging veins, Sx slower to progress, Signs of transtentorial herniation w/ deepening coma, progression from decorticate to decerebrate posture, mid position or fixed & dilated pupils, spastic hemiplegia w/ DTR. LP is contraindicated because may lead to herniation Chronic Subdural Hematoma Delayed formation of a subdural clot, Sx weeks after head injury, Elderly & alcoholics; Progressive daily HA, fluctuating consciousness & mild hemeparesis Epidural Hematoma Between dura & skull, less common than subdural, injury to arteries (middle meningeal); Rapid brain compression, permanent neurological problems or death; Brief lucid period after head injury; progressive neuro signs Concussion

Injury due to blunt trauma; short loss of consciousness w/ intact brainstem function; post traumatic confussion syndrome w/ transient retrograde or anterograde amnesia; HA, vertigo, mild cognitive dysfunction Toxic Vestibulopathies Alcohol: positional vertigo & nystagmus w/ in 2 hrs of ingestion Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 12 wks after ending tx Salicylates: reversible vertigo, tinnitus, sensorineural hearing loss Quinine & Quinidine: cinchonism (color vision defects, tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain & sweating Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing loss, sensory neuropathy Toxic Neuropathies

nonbacterial meningeal irritation; CSF = lymphocytes, normal glucose, neg gram stain & bacterial cultures, mild protein, normal opening pressure; supportive Tx Fungal/TB Meningitis CSF: lymphocytes, glucose, protein, opening pressure; AIDS = cryptococcal meningitis Encephalitis Inflammation of brain tissue; Viral etiology = CSF lymphocytes, normal glucose & negative bacterial cultures; Acylcovir x10 days Reye's Syndrome follows viral infection; fatty infiltrate of organs; Usually kids; Salicylates can induce Sudden onset of encephalopathy, severe vomiting, & liver dysfunction; liver biopsy w/ fatty infiltrates confirms Dx. Neurosyphillis

Lead: multi motor neuropathy; acute encephalopathy in children Organophosphates: delayed motor neuropathies, cholinergic crisis Arsenic and Thallium: acute onset symetrical sensorimotor polyneuropathy Isoniazid: Reversible sensory polyneuropathy reversible w/ concurrent pyridoxine Gold: symetrical polyneuropathy Bacterial Meningitis 1st month life = group B strep & E. coli; Older kids = H. flu; Adults = S. pneumonia N. meningiditis at any age = 50% have petechial rash Brudzinski sign = neck flexion when supine causes involuntary hip & knee flexion Kernig's Sign: extension of knee in pt w/ flexed hip is painful CSF: glucose, neutrophils, protein, opening pressure; Tx: ampicillin & cefotaxime = infants; 3rd generation cephlosporin in kids > 3mos and adults Aseptic Meningitis

Argyll Robertson Pupil (small, reacts to light but not accommodation); Psych disorders, Tabes Dorsalis; Tx: Procaine Penn G x 21 days; Examine CSF q 3-6 months until normal x 2 yrs. Rabies Dogs worldwide; wild animals in US, Sx: malaise, fever, restlessness 1st. Sx progress to extreme excitement w/ painful laryngeal & pharyngeal spasms, Tx: Passive IG and active vaccine

Polio Fecal-oral; aseptic meningitis, paralysis w/o loss of sensation; Asymmetric paralysis during a febrile illness suggests it; Tx is palliative; OPV for all except immunocompromised who get IPV Primary Neoplasms Glioblastoma Multiforme: most common in adults, high mortality; Meningioma: most common benign tumor in adults; Cerebellar Astrocytoma & Medulloblastoma: most common in kids Huntington's Disease Autosomal dominant, Age 30-50; subtle dementia, irritability, antisocial, chorea, death 10-15 yrs after onset,

atrophy of caudate nucleus & cerebral cortex, Tx D2receptor antagonists (haloperidol) Parkinsonism Idiopathic - loss of dopaminergic cells in substantia nigra; Pin rolling temor, masklike facies, lack of arm swing when walking, cogwheel rigidity, difficulty initiating movement, small shuffling steps w/ increasing speed (festinating gait). Tx: Levadopa (dopamine precursor), Amantadine, bromocriptine (dopaminergic agonists), Benzotropine (anticholinergic) ALS Lou Gehrig's Disease Progressive loss of anterior horn cell function; Initially = LMN dysfuntion w/ hand & foot weakness & atrophy; asymmetric progression, No sensory abnormalities; Later= UMN dysfunction w/ muscle spasticity, DTR, extensor plantar reflexes Tay Sachs Disease Autosomal recessive; Eastern Europe jews & french Canadians; Absence of Hexosaminidase A, can't metabolizes lipid gangliosides, build up in brain; Progressive dev. delay, paralysis, blindness, dementia; death by age 4 Multiple Sclerosis Progressive demyelinating, women>men; Peak onset 20 - 40; Gradual & variable CNS sx suggest dx; CSF = mild proteins, mild lymphocytes , oligoclonal bands, MRI = multi plaques in white matter Guillain-Barre Syndrome polyneuropathy after mild viral illness, inoculation or surgery; Most common acquired demyelinating disorder; progressive bilateral weakness of legs, proximal weakness, abnormal DTR, instability of temp & BP; CSF = protein w/ normal pressure, glucose & cell numbers; Plasmaphresis speeds recovery; Corticosteroids are contraindicated Cerebral Palsy CNS damage before age 5; Risks: Prematurity, IUGR, inutero complcations, neonatal jaundice, birth trauma, asphyxia, spastic syndrome, DTR, tone, weakness, toe walking, scissors gait Myasthenia Gravis

diplopia, dysarthria, enhanced muscle fatigue, thymoma on chest x-ray; Tx exogenous anticholinesterase (edrophonium or neostigmine); Thymectomy in pts < 60; steroids or azathioprine if unresponsive to tx Muscular Dystrophy Duchenne most common type; X linked recessive, mutation in dystrophin gene; CK before onset of sx; By age 5 toe walking, waddling gait, can't run; Prox legs 1st then prox arms; Pseudohypertrophy of calves = fat infiltrates in muscles; Coma dysfunction both cerebral hemispheres or RAS; Acute onset = subarachnoid hemorrhage or brainstem infarct; progressive min-> hours = Intracerebral hemorrhage; days => weeks = chronic subdural hematoma, tumor or abscess; No laterialization following delirium = metabolic; Pupil size: dilated nonreactive = at or below midbrain, pinpoint = pontine; opiod OD, Constriction intact w or w/o extraoccular impairment = metabolic; Localizing response to pain = superficial coma; Decorticate (flex @ elbow, ext leg) = thalamic lesion of compression; Decerebrate (elbow & leg extension) = midbrain; No response to pain = pontine or medullary Gait Abnormality Cerebellar lesions = truncal ataxia, broad based, unsteady, irregular; can't turn Corticospinal = affected leg circumducts as it steps forward, scissors if bilateral Extrapyramidal = festinating gait, flexed posture, small rapid steps, no arm swing Motor System = Footdrop - anterior tibial; Calf muscle can't toe walk; Pelvic muscle - waddling gait. Arnold Chiari Syndrome Cong. Protrusion of medulla thru foramen magnum; unusual sensory & motor chgs, Onset ~ 40 Cold Calorics Test vestibular system, Slow deviation toward ear w/ cold water = brainstem intact, fast nystagmus away = contralateral cortex intact; COWS = cold opposite Warm same for fast component GYN Trichomonas Vaginitis

autoimmune, antibodies against acetylcholine receptors at neuromuscular junctions, women, age 20 - 40; Ptosis,

Yellow green discharge, Strawberry patches, Motile flagellated, Tx: Metronidazole Gardenerella Vaginitis KOH whiff test = fish; Clue cells, most common symptomatic infection; Metronidazole Condyloma Acuminata Warts, HPV 6, 11, Not assoc w/ cervical cancer PID Cervical motion tenderness, Purulent discharge, assoc w/ ectopic pregnancy & infertility; Leukocytosis, neutrophilia, ESR Candida cottage cheese, red vulva; Pseudohypahe & spores on wet mount, DM, antibiotics, OC, pregnancy UTI E coli, Dysuria, frequency, urgency; Tx: TMP-SMX, Bactrim, Septra Toxic Shock Syndrome Staph aureus exotoxin, rash, high fever, hypotensive shock Chancroid H. Ducreyi, tropical & sub tropical climates, gram neg; Tx Emycin or Ceftriaxne Chlamydia Trachomatis Intracellular, columnar epithelium, mucopurulent, Immunofluoresent discharge, Tx: Doxycycline (Emycine if pregnant) Herpes Genitalis HSV II clear sores , multinucleated giant cells w/ intracell inclusions; Tzanck smear Molluscum Contagiosum umbilicated nodule, remove & cauterize Endometriosis Ectopic endometrium tissue, Dysmenorrhea, Dyspareunia, infertility

Paget's Disease of Breast Intraductal Ca in main excretory ducts; crusting erosion of nipples w/ or w/o discharge Polycystic Ovarian Disease LH, or normal FSH; hirsutism, obesity, menstrual irregularities, infertility Menopause Avg age =51; FSH & LH; Hot flashes, Atrophic vaginal epithelium Urinary Incontinence Stress = intra abd pressure, leak small amts of urine; Kegel exercises, estrogen Urge = detrussor instability; lg amts of urine leaked immediately after urge to void 1o Amenorrhea Absence age 16 w/ 2o sex development or absence by age 14 w/o 2o characteristics Anatomic Abnormalities; Ovary Failure ( FSH & LH, estradiol) (XO, turners, no ovary); Pituitary = Prolactinoma presents w/ galactorrhea (Bromocriptine to Tx), Hypothalamic = FSH & LH, (anorexia, exercise, stress); XY karotype 2o Amenorrhea Absence for 6 mos if prev normal; absence for 12 months if prev oligomenorrhea; r/o pregnancy; Galactorrhea = prolactinoma; Hirsutism = polycystic ovarian; Tx: 1st = progestin challenge (bleed w/ in 2 wks) if no bleed measure FSH levels 1o Dysmenorrhea correlates w/ 1st day of menses, cyclic, begins in adolescence, low back & abd pain, N/V/D, fatigue, HA 2o Dysmenorrhea acquired, Sx don't correlate w/ 1st day of cycle, Endometriosis most common cause Asherman's Syndrome intrauterine adhesions after D&C; destruction of endometrium => amenorrhea Fibroademoma

Age 19 -29, stromal fibrosis; nontender, estrogen sensitive, regress w/ menopause Fibrocystic Breast Disease Age 29 - 39, may have green nipple discharge; tender w/ ovulation, regress w/ pregnancy, Breast Disease Age 39-49 malignant = intraductal Ca (bloody nipple discharge); Papillary #1 cause of nipple discharge; Sclerosing Adenitis Breast Ca Upper outer quadrant, Mets = bone, liver, lung, brain; Risks: Family Hx, menarche < 12, 1st pregnancy > 35; late menopause, null parity, obesity, other breast, radiation, reserpine PAP Smear Atypia = inflamm, infection HPV (16 & 18); Mild Dysplasia = lowgrade epithelial lesion; Mod/Severe=high grade intraepithelial; Carcinoma in situ nuclear/cytoplasm, dense chromatin, crowding, mitosis; Koilocytes = HPV, pyknotic nucleus, perinuclear halo; Risks: early sex, multi partners, smoking, social class, HPV; Culposcopy = white epithelium, mosiacism, punctation, atypical vessels Cervical CA 90% squamous cell; s/sx: Early = postcoital bleeding, intermenstral bleed, Late= backache, leg pain, edema, hematuria Tx: Ia=TAH, iB & IIA = rad hysto & pelvic lymph nodes, IIB -IVA = Radiation - Brachytherapy => Radium, Cesium Endometrium CA most common gyn malignancy; Risks: obesity, DM, HTN, anovulation, early menses, later menopause, nullparous, unopposed estrogen; Dx : abnormal menses, post menopausal bleeding; EMB, D&C; Histologic= grade 1-3 based on differentiation; AdenoCA=70%; Adenocanthoma=benign squamous, best prog; adenosquamous= malig squam, poor prog; Papillary Serous = acts like ovarian CA, Clear Cell = poorest prog, older, DES, least common Tx; TAH/BSO, perioneal wash, pelvic & aortic nodes, Adjuvant Rad if + nodes, cervical +, > myometrium, higrade Ovarian CA

Abd./pelvic mass, ascites, early satiety, CA125, CEA, CA19-9, 75% w/ stage 3; Path types = Serous (psammoma bodies), Mucinous, Endometroid, Clear Cell (hobnail bodies) Brenner; Staging: 1A= 1 ovary, 1B = both ovaries; 1C= + wash, tumor rupture; IIA = fall tubes/uterus, IIB other pelvic structures, IIB + wash rupture w/ spread; IIIA gros in pelvis, micro to diaphragm or omentum, IIIB Intra abd < 2 cm, IIIC: intra abd > 2cm, pelvic/aortic nodes, inguinal nodes; IV = distant spread, pleural effusion w/ malig cells, liver/spleen mets; Tx: debulk tumor surgery, Chemo = cisplatin/cytotoxin, taxol; Radiation (bowel obstruction); Teratomas immature (neuro epithelial); mature (dermoid)=95% of all teratomas, hemolytic anemia; LDH elev, CA125 Dysgerminomas most common malignant, 15% bilateral, radiosensitive Endodermal Sinus Tumor Schiller Duvall Body, AFP Embryonal CA HCG, AFP, CA125 Choriocarcinoma HCG Sexcord-Stromal Tuors Granulosa: 50% post menopause, estrogen, Call-Exner bodies Sertoli-Leydig: most often virilizing; Gonado Blastoma: gonadal dysgenesis Krukenburg Tumor: Ovarian mets from GI & breast; Signet ring cells Vulvar CA TNM staging, squamous cell, Vulvar pruritus; Pagets= adenoca of vulva, 20% assoc w/ breast, GI, cervical CA Gestational Trophoblastic Benign: Complete Mole = 46 XX, paternal, no embryonic tissue; Incomplete = 69 XXY triploid, paternal, no fetal/ embryonic tissue

Malignant: Invasive= molar villi; Choriocarcinoma = no villi, any pregnancy; Placental Site = non molar gestations S/Sx: size > dates, hyperemesis, hyperthyroid, large theca lutein cyst F/U = CBC. Liver function, BUN, CR, TSH, HCG, US, CXR; TX = D&C Weekly HCG' until 3 values that are non detectable then 1/mo x 1yr, BCP x 1 yr Ca in Pregnancy Melanoma = worsened by preg, can met to placenta or fetus Breast CA = most common CA in pregnancy Chemotherapy Cyclophosphamide (Cytoxan) = ovarian, hem, cystits, alopecia, bone marrow, N/V Cisplatinum = ovaian, renal toxic, ototoxic, bone marrow , N/V Adrimycin (Doxyrubicin)= endomet, ovarian; cardiotoxic (heart failure) Bleomycin= cervical, germ cell, Pulmonary fibrosis Vincristine= cervical germ cell; neurotoxic Methotrexate = GTN, germ cell, hepatic & renal toxic, bone marrow OBSTETRICS Hydantiform Mole Preeclampsia 1st TM, Very high Beta HCG, Snowstorm on US Ectopic Pregnancy Beta HCG rises slowly, Amenorrhea, spotting, pain, Empty gestational sac on ultrasound, Ampulla of fallopian tube is most common site Gestational Age Nagel's = Add 7 days to FDLMP subtract 3 months; fundal ht in cm after 13 weeks Amniocentesis

Adv maternal age, abn AFP - Spina bifida, Down's, detect lung maturity, early 2nd trimester CVS Adv. Maternal age, late 1st trimester Non stress Test > 2 fetal movements accompanied by FHR of 15 bpm for at least 15 sec w/ in 20 min period Contraction Stress Test Negative = 3 contractions in 10 min, lasting 40 sec w/o late decelerations Positive = consistent & late decelerations Biophysical Profile Nonstress test, fetal breathing, movement, adeq, amniotic fluid, limb extension Fetal HR normal 120-160, Brady = mild 100-120, < 100 severe; Tachy = mild 161-180; severe > 180 Decelerations Early = shape is mirror of contraction, head compression Variable = shape varies, cord compression Late = starts as contraction peaks, recovery after contraction is terminated, uteroplacental insufficiency Placental Previa Partial - partially over os; Complete= covers OS, Marginal = at edge of OS, Complete Previa is indication for C section Placental Abruption Premature separation of a normally implanted placenta, vag bleed, uterine tenderness, back pain, hypertonic uterus, fetal distress Preeclampsia HTN w/ proteinuria & edema after 20 wks gestation Eclampsia Preeclampsia + seizures

Gestational Diabetes 1 hr > 140 then do 3 hr; 3hr test = fast > 120, 1 hr > 190; 2 hr > 165, 3 hr > 145; Macrosomia, RSD, Cong abnormalities Types of Pelvises Gynecoid = round inlet, nonprominent spines, wide subpubic angle Anthropoid = heart shaped inlet, transverse and AP diameters, subpubic angle Android= triangular inlet, subpubic angle, prominent spines Platypoid= transverse and AP diameters Leopold's Maneuvers fundal palpation, sides of uterus from feet of mother, lower part of uterus, sides of uterus from head of mother Stages of Labor 1. Onset contract => full dilation 2. Full dilation to delivery of head 3. Delivery of fetus to delivery of placenta 4. Delivery of placenta to 1 hr later Cardinal Movements Engagement, descent, flexion, int rotation, extension, ext rotation, expulsion Post Partum Hemorrhage Uterine Atony (most common); Placental Accreta: Accreta = superficial invasion into myometrium, Increta = deeper, Percreta = invasion to serosa of uterus; Undiagnosed lacerations, Coag defect; Retained placental fragments Apgar Scoring Heart Rate, Resp. Effort, Muscle Tone, Reflex Irritability, Color Shoulder Dystocia Maternal obesity, diabetes mellitus, postterm pregnancy Cesarean Section Indications Health of mom or baby endangered by labor, Dystocia precludes vag delivery, Emergent situation, Herpes, Prev C section if contributing factor still exists, Malpresentation of fetus

Premature Rupture of Membranes Pooling of fluid in vagina, + nitrazine test, + ferning test, risk of endometritis Polyhydraminos Duodenal Atresia, Tracheoesophageal fistula, Anencephaly Oligohydraminos Renal Agenesis, Pulmonary hypoplasia PEDIATRICS Fetal Alcohol Syndrome IUGR, Microcephaly, Short palpebral fissures & philtrum, Cardiac Abnormalities, SGA, mental retardation, microencephaly Fetal Narcotic Exposure Hypertonicity, Sweating, Stuffy Nose Fetal Cocaine Exposure Limb reduction malformations, Intestinal Atresia, Jittery, tremors Grey Baby Syndrome chloramphenicol use, metabolism due to immature liver, CV collapse, maybe fatal Erythroblastosis Fetalis Rh neg mom Rh + baby; Subsequent Rh + babies are at risk; Give RhoGam - binds to fetal RBC, prevents Antibodies from being made Beckwith Weiderman neonatal hypoglycemia d/t hyperinsulinemia, macroglossia, giantism, omphalocele, kidney anomalies, facial nevus flammus, poor prognosis Apt Test Determine cause of neonatal rectal bleed; differentiates adult vs fetal hemoglobin Dubin Johnson Chronic idiopathic jaundice

Erb Duchenne C5-C6, flail arm (int rotation & abduction) due to traction on head during delivery; If c4 involved - paralytic diaphragm also present Henoch Schoenlein Pupura kids, allergic vasculitis, non-blanching petechiae or pupura on lower extremities only, arthralgias, abd pain, hematuria, proteinuria, coag & platelets are WNL; Immune mediated after virus or strep Kawasaki's look sick w/ fever > 5d, truncal rash, cervical nodes, URI sx, "glove" desquamation on palms, feet, lips; Assoc w/ coronary artery aneurysm; TX: High dose asa, IV gammaglobin, Steroids contraindicated 4 out of 5 =bulbar conjunctivitis, erythematous mouth, lips & tongue; polymorphous erythematous rash, induration of hands & feet w/ erythema, solitary unilateral cervical lymph node < 1.5 cm; Thrombocytosis after 10th dy is common Kleinfeltters XXY, most common hypogonadal syndrome; + BARR body, small firm testicle, azospermia, FSH Meckel's Diverticulum 2 ft from ileocoecal valve, 2 in long, 2& population, 2 tissue types (gastric or pancreatic) sx before 2 yrs old Newborn Blood 85 cc/kg, Hgb 14 - 22 gms/dl HCT 44-64%; alk phos than adults & is until adolescent growth spurt TORCH Toxoplasmosis, syphillis, rubella, CMV, herpes CMV maybe asymptomatic or deafness, blindness, jaundice, petechia, fever, seizure, mental retardation, IUGR; Transplacental passage of virus Cong. Rubella IUGR, cataracts, glaucoma, microphthalmia uveitis, retinitis Kernicterus

unbound bili crosses blood brain barrier resulting in neuro problems or death Prolonged Hyperbili Bili > 10 at 10 days of life Photo therapy can be used as long as direct isn't > 1 mg % Hemorrhagic Disease of Newborn Deficiency of vitamin K dependent factors (2-7-9-10) Intrauterine Shunts placental, ductus venousus , foramen ovale, ductus arteriosus Ductus venosus = ligamentum venosus; Ductus Arteriosus = Ligamentum Arteriosus Growth & Development 1st teeth - 6-9 mos; Neuromuscular development in 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 yrs; Drawing = circle 2.5-3; cross 3-4; Square 4-5; Triangle 5; Diamond 6 yr Wt Gain = BW by 10d; 15 lbs 1st yr, 6-7 lb 2nd yr Length = 10 in 1st yr, 5 in 2nd yr; < 2in / yr is abnormal Head Circumference: 0-35; 3-40, 9-45, 3-50, 9-55 cm # Alveoli increase as lungs grow; # nephrons don't increase after term ADHD 3x more male than female; inattentiveness, impulsivity, hyperactivity SIDS Peak 2-4 mos, declines after 6 mos; 60:40 male:female; Risk Factors: < 20yrs old, poverty, smoking Apnea of prematurity in infants < 34 wks gestation; Tx: tactile stimulation, decr environmental temp, incr O2, transfuse to get Hct to 45%; CPAP, theophylline, last resort = mech vent

Special Human IG hepatitis B, Rabies, Tetanus, Varicella Zoster, CMV CHF in Peds cardiomegaly, tachypnea, hepatomegaly Noncyanotic Cong Heart Disease ASD, VSD, AV septal defect, PDA, coarction of aorta, aortic stenosis, MVP Cyanotic Heart Disease Tetralogy of fallot, pulm Atresia w/ VSD, tricuspid Atresia, hypoplastic left heart, transposition of great vessels, anomalous pul venous return, truncus arteriosus Rheumatic Fever carditis, polyartheritis, sydenham chorea, erythema marginatum, subcutaneous nodules; Mitral insuffucuency most common valvular residual = Carey Coombs murmur Acute Myocarditis Coxsackie B #1, Coxsackie A, CMV, mumps, herpes, adenovirus Otitis Media Moraxella Catarrhalis #1 cause of bacterial in infants < 18 mos Epiglotitis prior to vaccine H. flu most common cause; peak ages 38 ys Resp Infections < 5 Viral pneumonia = RSV, Bacterial pneumonia = strep; Lower resp infection = mycoplasma pneumonia ( Eaton Agent, 1o atypical pneumonia or walking pneumonia); Croup = rhino, RSV #2; Pyelonephritis poor feeding, irritability, and seizure ; r/o sepsis Hemorrhagic Cystitis

Neurogenic Diabetes Insipidus x linked recessive, renal ADH receptors; Sx polyuria, polydipsia, FTT; r/o psychogenic polydipsia; Due to hypofunctioning hypothalamus or posterior pituitary w/ ADH deficiency Rashes Measles (rubeola); Face then body; Cough, Coryza, Conjunctivitis, Koplik's spots Scarlet Fever= red skin folds (Pastia sign), strawberry tongue, sandy exanthum on trunk => flexor surfaces German Measles (Rubella) Filatov Dukes Disease (4th. No longer used) Erythema Infectiosus (5th disease) parvo B19, slapped cheek; circumoral pallor => lacy reticular rash Roseola infantum (herpes 6)High fever then after fever get rash 1st on trunk then face Rash on face 1st = measles, 5ths, Rubella Rash on Trunk 1st = Scarletina, Roseolla, Chickenpox Rashes on Palms & Soles = Erythema Multiforme (Stevens Johnson); Hand Foot & Mouth (Coxsackie A19; Kawasaki, Rocky Mt Spotted Fever, 2o syphillis, TEN, Dermatomyositis Infectious Mono EBV, Dx by positive heterophile test (Paul Brunnel Ab); hepatosplenomegaly Conjunctivitis Neonatal infectious = Chlamydia trachomatis,minimal discharge, congestion & edema 7-14 days after birth Rocky Mountain Spotted Fever Rickettsia rickettsii, high fever, peripheral rash, Atlantic seaboard, wood & dog ticks Cat Scratch Disease R. Henselae; regional lymphadenitis; Chemical = silver nitrate PKU

Adenovirus blonde hair, MRDD, seizures, eczemoid rash

Galactosemia Auto recessive, n/v/d, jaundice, hepatomegally, cirrhosis & cataracts if untreated Homocysteinuria tall thin stature w/ MRDD sublaxation, lens, genu valgum (knock knee), pectus carinatum Lesch Nyhan Purine metabolism; normal until 6-8 mos; loss of motor milestones; spasticity, self mutilation without loss of sensory feeling; Urine has orange uric acid crystals Self mutilation w/ loss of sensory = familial dysautonomia Hurler's Syndrome

Neural crest of sympathetic ganglia or adrenal medulla; 50% before age 2; 90% before age 5; and mass that crosses the midline Nephroblastoma asymptomatic abd mass; HTN, Ages 2-5; Aniridia (loss of iris) hemihypertrophy Also called Wilm's Tumor Rhabdosarcoma Most common soft tissue sarcoma; < 10yrs old; nasal, aural, anus or vaginal area Ewing Sarcoma diaphyses Osteosarcoma Metaphyses, #1 site distal femur

mucopolysaceharidosis, grotesque coarse features, skeletal anomalies, dead by age 10 Glycogen Storage Disease Von Gierke, Pompe, Forbes

Retinoblastoma Neuroectodermal malignancy , most occur before age 5; Leukocoria (white pupil reflex) G6PDase Defic

Tay Sachs Lipid Storage, Jewish , defic of hexosaminidase A; normal at birth then loss of motor milestones & hypotonia at 6 mos, Death by age 2; Cherry red macula ALL PSYCH most common malig of childhood, peak at age 4; thrombocytopenia, anemia, elevated uric acid & LDH; Dx by bone marrow biopsy showing infiltration of leukemia blast cells; CXR = mediastinal mass or widening, 2o ary to lymphadenopathy Brain Tumors Schizophrenia most common solid tumor of childhood; < 2 intratentorial tumors > 2 supreatntorial tumors Morning vomiting = posterior fossa ependymoma Astrocytoma most common brain tumor Hodgkins Lymphoma Reed Sternberg Cells; Painless cervical lymphadenopathy Neuroblastoma Positive Sx: delusions, hallucinations, bizarre behavior; Negative Sx: alteration of affect, ambivalence, apathy, loosening of associations; males=females; industrial nations have prevalence; Misalignment of cells in cortex; ventricle size; activity in frontal cortex on PET scan. Disorganized: insidious, incoherent, inappropriate affect, social impaired Catatonic: rigidity, posturing or excitement, negativism Paranoid: highest functioning type, grandiose, jealous, persecution Axis Determination I = clinical psych disorders II personality disorders, III Coexisting medical conditions IV psychosocial stressors, V global assessment of functioning most common red cell enzyme deficiency that causes hemolytic anemia; usually asymptomatic until exposed to stress, infection or certain foods; Cause of hyperbilirubinemia in Chinese or Mediterranean but NOT BLACK infants; Avoid sulfa drugs

Undifferentiated: not defined by other subtypes Melerill = Retrograde ejaculation, Tx: Respiradol (Best side effect profile), Clozaril (agranulocytosis w/ weekly CBC) prescribed weekly, Neurolyptic Malignant Syndrome = temp, CPK, rigidity Schizophrenifrom same sx as schizophrenia but have lasted for less than 6 months Schizoaffective mood disorder and separate psychotic sx. Must experience 2 weeks of psychotic sx w/o mood impairment for dx to be made; Antidepressants are 1st line tx Major Depression

repetitive, purposeful intentional behaviors meant to decrease tension caused by the obsessive thoughts; genetic Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI) PTSD intrusive recollections, daydreams, nightmares, poor concentration, psychic numbing; Tx: don't treat w/ meds unless compulsion component Studies: Buffalo Creek Disaster, Beverly Hills Nightclub Dissociative Disorder Amnesia = loss of memory, Fugue = assoc w/ physical flight, Identity Disorder = multiple ego states; Depersonalization = feelings of self estrangement or unreality Whirndingo Fear of becoming a cannibal

loss of interest in activities, sleep, wt, concentration, hopelessness, suicidal ideation, nihilism; Seasonal affective, Vegetative (non functioning can be terminal) Dysthymia(chronic low level); Reactive related to environment w/o severity id sx; Masked 1o depression denied or hidden by other sx Depression & anxiety can occur together & can be treated w/ an antidepressent; Left anterior or rt posterior stroke => possibility of depression; Tx: 1st Tricyclic (Imiprimine); SSRI = side effects; Trazadone=priapism Asendin (Amoxipine) = Extrapyramidal Symptoms BiPolar Bimodal peak 20's & 30'sCycling mood= highs w/ euphoria, hyperactive, pressured speech, flight of ideas, decr need for sleep, delusions, inflated self esteem, risks, poor judgement; Lows are major depressive episodes tx: lithium Panic Attacks

Amok sudden unprovoked outburst of wild rage usually ending in homicide Coprolalia Feces & filth Koro penis is shrinking and may disappear Latah imitate words or actions to which they are exposed Piblotko Run around in snow naked White Out Syndrome

Sudden, unprovoked onset of fear, impending doom, palpitations, SOB, chest pain, smothering, dizziness. May be associated w/ agoraphobia Tx: with SSRI's Phobias Persistent and irrational fear of a specific object or activity or situation. Tx like a phobia Obsessive Compulsive Persistent, unwanted thoughts, impulses or images

lack of diverse stimuli in snow clad environment Narcolepsy REM sleep, sudden onset of daytime sleep and cataplexy; REM sleep is inappropriately present at beginning Personality Disorders

Cluster A = Bizarre = Paranoid, Schizoid (no close relationships, restricted emotions) Schizotypical (schizoid + odd or distorted behavior or cognition) Cluster B = Over emotional = Antisocial (Disregard for social norms) Borderline, Histrionic, Narcissistic (self centered) Cluster C = Anxiety & Fear = avoidant, dependent, Obsessive compulsive POISONING & ACCIDENTS Burns 1st= only epidermis, red no blister; 2nd = hyperemic, blister; partial thickness; 3rd = full thickness, leathery no pain; 4th = electrical injuries, damage to nerves & bone; entry & exit burn; Fluid resc. If > 20% Parkland formula = 3-4 ml/kg LR x % burn RULE of 9's: head = 9; ant trunk= 18 post trunk = 18, each ext = 9; each ext = 18, Perineum = 1 Common Poisons & Antidotes: Aspirin = Dialysis; Acetaminophen =N-acetylcystine; Digitalis = lidocaine; Methanol & Ethylene Glycol = Ethanol; CO = O2; Narcotics = Narcan, Naloxone; Iron = Deferoxamine; Cu, As, Pb = Penicillamine; Cyanide = Sodium nitrite, or sodium thiosulfate Types of Fx Open(compound); Simple(closed); Greenstick (incomplete, children usually); Spiral (twisting breakage); Comminuted (multi bone fragments) Vertebral Fx Most common cause of paraplegia & quadriplegia, Compression Fx seen in elderly due to osteoporosis & DJD Hip Fx Avascular necrosis of femoral head if blood flow is compromised; Tx: immobilization, bedrest, surgery; Prevention= safety & Ca supplement in women Skull Fx 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 Rib Fx

Most common thoracic injury; usually 5-9, local pain worse w/ inspiration Colles Fx most common wrist fx; breakage & displacement of distal radius, Attempted to break fall on outstretched hand Elbow Fx <10 yrs old, fall on outstretched hand w/ elbow in full extension; Compression or radial or median nerve or brachial artery; Improper care => Volkman's Ischemic Contracture Pelvic Fx MVA, 30% blood volume can be lost; Tx as if shock victim Tibial Fx Compartment syndrome= bleeding into tight compartments=> blood supply compression=>muscle ischemia; 6 Ps = pain, pallor, pulselessness, puffiness, parathesia & paresis (weakness) or paralysis. Surgical opening of compartment Sprains Tx = RICE => Rest, Ice, Compression, Elevation Concussion transient loss of consciousness; Coup = bruising under site of injury; Contrecoup = bruising on side contralateral to injury Blunt Eye Trauma periorbital echymosis, hyphema (bleed into anterior chamber; edema; Blowout Fx = Fx of orbital bone; Aspirin & anticholinergics are contraindicated Blunt Ear Trauma Auricular Hematoma (cauliflower ear) Tx prompt drainage to prevent dissolution of cartilage Dog & Cat Bites Pasturella multocida; Tx tetanus & rabies if needed, antibiotics Snake Bite Splint affected area & transport; In US usually pit vipers

Spider Bite Black Widow: Vomiting, abd pain, shock; Tx Calcium gluconate & methocarbamol; Local bite Tx not needed Brown Recluse: bite becomes black scab w/ assoc fever, rash, vomiting & jaundice; DIC can occur; Tx: Dexamethasone, dapsone, colchcine & total excision of lesion Hypovolemic Shock Hemorrhage, Burns, Vomiting, Diarrhea; pale skin, JVD, vasc resistance, pulse Tx: rehydrate, transfusions, Septic Shock Infection, gangrene, necrosis,CV obstruction; pale/pink skin; flat neck veins, pulse or vascular resistance Tx ventilation, Fluids, antibiotics Cardiogenic Shock Pale skin, flat neck veins, pulse, vascular resistance; Tx: medication for underlying problem, pacemaker, Neurogenic Shock Spinal cord injuries, drug OD; Pink skin, flat neck veins, normal => low pulse, low vascular resistance Tx: ventilation, fluids, drainage PUBLIC HEALTH Levels of Prevention: 1o = actions to incidence of health problems (prenatal care, immunizations) 2o = interventions at early stage of disease to limit development (DM screen, PAP) 3 = interventions to treat problem and prevent further morbidity & mortality
o

Testiclar = BHCG, AFP, Thyroid = Calcitonin 10 Biliary Cirrhosis = Anti mitochondrial antibody Wilson's Disease = Ceroluplasmin Antibody Liver = Alpha 1 antitrypsin Thyroid - Antimicrosomal antibody, Thyroglobin antibody Incidence # new cases / total population Prevalence # cases at a given time / total pop at that time Disease Frequency # people w/ disease / population at risk Case Fatality # who die in a given period/ # people w/ disease

Relative Risk Only from cohort study; a/a+b divided by c/c+d; >1 positive assoc, < 1 negative association, =1 no association ==> disease if exposed /disease if not exposed

Odds Ratio Only from case control; odds of getting if exposed / odds of getting if not exposed (ad/bc)

Mortality Rate # people that die w/ in current population Std Mortality Rate Adjusted according to age distribution

Attributable Risk exposed rate - unexposed rate

Sensitivity a/a+c; accurate diagnose ; False + Special Tests Complement & Complement disorders C3, C4, CH50 Rheumatiod - ANA, RF Lupus - DNA, Anti Smith Antibody Scleroderma - Scl-70, Anti Centromere Sjogrens -SSA Anti Ro, Anti LA Prostate = PSA, Pancreatic = CA 19-9,Ovarian=CA125; Breast = CA15-3 & CA27-29 Fryettes Laws 1. Side bending then rotation in neutral position 2. Flexion or extension with rotation then side bending OMM

Specificity d/b+d; Prob of neg test in those truly neg; false neg

3. Motion free in one direction is restricted in the other Ribs 1-5 pump handle, 6-10 bucket handle, 11-12 caliper; Elevated = expiration restricted Treat lower ribs 1st; Depressed = inhalation restriction, treat upper ribs 1st Flexion Test Standing = ilia sacral; Seated = sacroiliac; false neg = tight hamstrings on standing flexion; False positive = tight quads on standing flexion Sympathetic Innervations Head & Neck = T1-4; Lung T2-5 bilat; Heart T2-5 Left, Stomach T5-9 Left; Duodenum T10 rt; Gall Bladder T9 rt; 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 & Anus L4-5 Parasympathetic Innervations Eyes=CN III; Nasal sinuses, Eustachian Tube=CN VII; Soft Palate, Salivary Glands=CN IX; Thyroid thru Transverse Colon=CN X (Vagus); Right Colon & Pelvis= Pelvic Splanchnic Nerves S2-4 Somatic Dysfunction An altered or impaired function of related components of the somatic system Qualities: Texture chg, asymmetry, ROM, tenderness Treatment Types Direct = engages restricted barrier & pushes thru it, Force takes it from where it is to where it will not go Indirect = Move away from the barrier, Leaves the structure in the position it was Direct Technique Used For: Subacute or chronic, no assoc osseous pathology post closure of epiphyseal plate, Short restrictors Indirect Technique Used For Acute, A lot of pain, a lot of restriction, non closure of epiphysis HVLA Contraindications Direct, Passive

Absolute = Weak bony structure, spinal cord, nerve compressions, Danger of vascular damage; Relative: lax ligament, acute inflammation, pregnancy, Calcification of aorta, Recent MI, spondylosis, Ankylosin Spondylitis, Osteoporosis, Chronic Steroid use, Acute disk disease, Extreme scoliosis, Cauda Equina Syndrome, Adv. Degenerative disease, Severe DM, Hx or current malignancy, Agenesis Odontoid process, Vertigo Counter Strain Passive Indirect Put joint into position of greatest comfort; AgonistAntagonist pair; Strain due to rapid stretching followed by protective immediate shortening of agonist along with rapid shortening then lengthening of antagonist Most comfort of pt (70%) Hold for 90 sec (120 secs for ribs) Reactions to Tx: generalized soreness, treat no more than 6 TP at a time, 3 days between Tx; Muscle Energy Active then passive, direct Type I = Joint mobilization using direct muscle force Type II = Muscle lengthening using postisometric relaxation, "Resetting the Gamma Gap or Synaptic Fatigue Type III = Muscle lengthening using Reciprocal Inhibition Type IV = Muscle relaxation using Crossed Extensor Reflex - Used w/ sever injury (flexor muscle on one extremity is contracted the flexor on opposite extremity relaxes & extensor contracts) Natural Body Rhythms Cardiac/Vascular, Ventilatory, Visceral, Cranial Rhythmic Impulse (CRI), Slow Undulating (Breath of life) Articular Mobility of Cranial Bones Newborn: Base is cartilage for stability, vault is membrane for accommodation Sphenoid motion - influences facial & frontal bones; Occipital Motion - influences temporals (mandible & hyoid) & parietals Motion of Sacrum between the Ilium

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; C7L5 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