CARDIOVASCULAR

Pregnancy Considerations
o Preeclampsia
Severe if epigastric pain and HA (indicates that convulsions are
imminent)
Severe if BP 160/110 on 2 separate occasions, 6hrs apart
Treatment is control of symptoms (hospital administration, IV mgSO4),
and planning for prompt delivery (vaginally or via C-section)
o HTN during pregnancy: IV hydralazine, IV labetalol, or oral nifedipine can be
used. Sublingual
o nifedipine can cause severe hypotension
Lower-extremity edema is common in the last trimester of normal pregnancies and
can be treated symptomatically with compression stockings.
o
Hypertension
o MCC in children under 6 is renal parenchymal disease
o MCC adults and adolescents is essential HTN
o Goal BP in patients with CKD is 140/90
o Monotherapy for HTN in African Americans is either a diuretic or a CCB
o Metoprolol and Carvedilol are eliminated by the liver
o BP increases with normal aging
o Isolated Systolic Hypertension in elderly responds best to diuretics, and to a
lesser degree, B-Blockers
o B-blockers can worsen depression
o ACEi are preferred drugs for HTN treatment in diabetic patients
ACEi cause impaired autoregulation of glomerular blood flow
A history of angioneurotic edema is an absolute contraindication to use
of an ACEi
Congestive Heart Failure
o TZDs are associated with fluid retention and can worsen CHF
o Medically refractory CHF is treated with Cardiac Resynchronization therapy
o Echo with Doppler is best tool to evaluate HF
o NSAIDS and ASA should be avoided in patients with CHF because they cause
fluid retention and an increase in SVR, which can lead to decompensation
o B-blockers should not be used to treat CHF when patient has symptomatic
heart block.
Aorta and considerations
o Acute dissection of ascending aorta is A surgical emergency
o Dissections confined to descending aorta are managed medically unless
patient demonstrates progression of disease or continued hemorrhage into
retroperitoneal space or pleura. B-Blocker is 1st line therapy to reduce SBP to
100-120. IV nitroprusside can be added if BP cant be controlled by B-blocker
alone.
o AAA screen should be done in men age 65-75 who have ever smoked
AAA: surgical intervention when size reaches 5.5 cm
Abnormal Heart Rhythms
o Refractory or recurrent SVT (narrow complex QRS, no apparent P waves)
should be controlled with Verapamil or B-blocker. If that is insufficient,
propafenone or flecainiede may be necessary.
o Palpitations should be evaluated with EKG. 50% of palpitations are
diagnosable heart conditions.

A normal EKG does not r/o cardiac arrhythmia. If EKG is normal,

ambulatory EKG monitoring may be warranted.
o A-fib: ventricular rate control with CCB or B-Blocker, and warfarin to
anticoagulated.
Childhood Heart Murmurs
o Stills murmur- systolic murmur best heard in lower pericardium that has a
low, short tone similar to plucking a string instrument. No radiation and it
decreases with inspiration
o Venous Hum- a continuous low-pitched murmur caused by the collapse of
the jugular veins and their subsequent fluttering. It worsens with inspiration or
diastole
o Physiologic peripheral pulmonic stenosis- a systolic murmur due to
physiologic changes in newborns pulmonary vessels. Disappears by 9 months
of age.
o An infant with tachypnea can have CHF if they have a history of Diaphoresis
with feeding
All siblings of a patient with hypertrophic cardiomyopathy should undergo ECHO.
HOCM is AD
Thrombosis treatment and management
o Enoxaparin is eliminated by kidneys and must be adjusted in patients with
renal disease.
o LMWH (Enoxaparin) allows patients with DVTs (given 2x/day subQ) to be
managed as outpatient
o Thrombolytics are not dose adjusted in renal patients, but the risk of
hemorrhage is increased.
o Neurosurgical procedures (esp. ones that penetrate the meninges) have the
highest risk of DVT. Hip and Knee replacements are second highest.
Prophylaxis is indicated with total knee or hip replacements. The two
regimens recommended are lowmolecular-weight heparin and
adjusted-dose warfarin
Myocardial infarction/ Ischemia
o In a patient with acute MI, a new LBBB suggests occlusion of LAD, and
thrombotic therapy is indicated.
In patients with ischemia, but not infarct (ST-Depression only),
thrombotic therapy is harmful.
Arterial Occlusive and Peripheral Venous Diseases
o Patients with significant arterial occlusive disease will have a prominent
decrease in ABI from baseline following exercise, and usually a 20-mm Hg or
greater decrease in systolic blood pressure.
o Best initial test for PVD is an ABI
0.9-1.2 is normal.
o <0.5 indicates severe disease
Aortic valves should be replaced when the aortic-valve gradient exceeds 50mm
Cilostazole (Phosphodiesterase inhibitor) is used tor symptomatic treatment of
arterial occlusive disease and intermittent claudication. It should be avoided in CHF
patients. It has been found to have beneficial effects on HDL cholesterol levels and in
the treatment of third degree heart
RFs for increased peri-operative CV risk (in non-cardiac operations)
o Major: unstable coronary syndrome, decompensated CHF arrhythmia,
valvular disease

Intermediate: mild angina, previous MI, compensated CHG, DM, renal

insufficiency
Use of AED in out-of-hospital setting has been shown to contribute to significant gains
in fill neurologic and functional recovery
Elevated LDL: prior to beginning therapy, need to test for cause of secondary
dyslipidemia
o Causes include DM, Hypothyroidism, obstructive liver disease, CRF, some
meds
Initial exercise routines for the elderly can be as short as 6 minutes in duration
o

ENDOCRINE

Thyroid
o Subclinical hypothyroidism (TSH >10 U/mL) is likely to progress to overt
hypothyroidism, and is associated with increased LDL cholesterol.
o Subclinical hyperthyroidism (TSH <0.1 U/mL) is associated with the
development of atrial fibrillation, decreased bone density, and cardiac
dysfunction
o Secondary hypothyroidism
Low free T4, low TSH
Treatment is replacement therapy.
Only free T4 levels can evaluate the proper dose. TSH is not
useful since the pituitary is malfunctioning.

the initial evaluation of secondary hypothyroidism, a TRH stimulation

test would be useful if TSH failed to rise in response to stimulation
o Red flags indicative for cancer in evaluation of a solitary thyroid
nodule:
Male gender
Age <20 or >65
Rapid growth of nodule
Symptoms of local invasion such as dysphagia, neck pain, and
hoarseness

history of head or neck radiation

a family history of thyroid cancer
a hard, fixed nodule >4 cm
Cervical Lymphadenopathy
chronic excess thyroid hormone replacement over many years can cause bone
mineral resorption, increase serum calcium levels, and lead to osteoporosis in
postmenopausal women
Parathyroid and Calcium Homeostasis
o Serum PTH is indicated in a patient with elevated serum calcium and recurrent
kidney stones. An elevated PTH by immunoassay confirms the diagnosis of
hyperparathyroidism
o Raloxifine has been shown to mildly reduce elevated calcium levels.
o Furosemide is used with saline infusions to significantly elevated calcium
levels
o Conditions mimicking primary hyperparathyroidism
Lithium or thiazide use
Tertiary hyperparathyroidism associated with ESRD
Familial hypocalcuric hypercalcemia
o Indications for parathyroid surgery include kidney stones, age less than 50, a
serum calcium level greater than 1 mg/dL above the upper limit of normal,
and reduced bone density.
Diabetes and Glucose Homeostasis
o Delayed gastric emptying may be caused or exacerbated by medications for
diabetes, including amylin analogues (e.g., pramlintide) and glucagon-like
peptide 1 (e.g., exenatide). Delayed gastric emptying has a direct effect on
glucose. They should be d/ced in patients with diabetic gastroparesis
o Metformin is 1st line for T2DM. it should be started at the same time as
lifestyle modifications, rather than waiting to see if a diet and exercise
regimen alone will work.it does not cause hypoglycemia. It reduces insulin
levels and leads to a weight maintenance or weight loss effect

o Acarbose is an -glucosidase inhibitor that delays glucose absorption

Criteria for diagnosing Diabetis
o Symptoms of diabetes (polyuria, polydipsia, weight loss)
o And ONE of the following: casual glucose level 200 mg/dL; a fasting plasma
glucose level 126 mg/dL; or a 2-hour postprandial glucose level 200 mg/dL
after a 75 gram glucose load
o In the absence of unequivocal hyperglycemia the test must be repeated on a
different day.
o The criteria for impaired glucose homeostasis (pre-diabetes) include
either a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or a
2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test.
o Normal values are now considered <100 mg/dL for fasting glucose and <140
mg/dL for the 2-hour glucose level on an oral glucose tolerance test.
general anesthesia may cause hypotension, which leads to renal hypoperfusion
and peripheral tissue hypoxia, with subsequent lactate accumulation
o metformin should be held before surgery until preserved kidney function is
documented at 24 hrs and 48 hrs after the surgical intervention
Bone age
o Hypothyroidism: Delayed bone age relative to height and chronological age
o CF: equal bone and height age, but both lag behind chronological age
o Height age delayed relative to bone age: seen in chromosomal abnormalities
and maternal substance abuse
Fe-deficiency anemia
o Increased TIBC
o Decreased Ferritin (diagnostic, regardless of phase of Fe-deficiency anemia)
Lithium
o associated with Hypothyroidism. In addition to serum lithium levels, free T4
and TSH need to be obtained yearly
o can elevate calcium levels by elevating PTH secretion from parathyroid gland.
Lab findings will resemble primary hyperparathyroidism. Lithium should be
d/ced before reevaluation

Integumentary

Leukoplakia: a white keratotic lesion seen on mucous membranes due to irritation

from various mechanical and chemical stimuli, including alcohol.
o Can occur in any area of the mouth
o Exhibits benign hyperkeratosis on biopsy
o Can transform to SCC
Hand, foot, and mouth disease is a mild infection occurring in young children, and
is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or
enterovirus. In addition to the oral lesions, vesicular lesions may occur on the feet
and nonvesicular lesions may occur on the buttocks. A low-grade fever may also
develop.
Herpangina is also caused by coxsackieviruses, but it is a more severe illness
characterized by severe sore throat and vesiculo-ulcerative lesions limited to the
tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx.
aphthous stomatitis: canker sore
Herpetic gingivostomatitis: cold sore
Streptococcal pharyngitis is rarely accompanied by ulceration except in agranulocytic
patients.
Keratoacanthoma grows rapidly and may heal within 6 months to a year.
Squamous cell carcinoma may appear grossly and histologically similar to
keratoacanthoma but does not heal spontaneously.
Xerosis: pathologic dryness of the skin that is especially prominent in the elderly
o Worsens in winter due to lower humidity and cold temps
Stasis dermatitis: due to chronic venous insufficiency, appears as a reddish-brown
discoloration of the lower leg
Lichen simplex chronicus: end result of habitual scratching or rubbing,
o presents as isolated hyperpigmented, edematous lesions, which become scaly
and thickened in the center
Rosacea: seen on the face as an erythematous, acneiform eruption, which flushes
easily and is surrounded by telangiectasia
Candidiasis: an opportunistic infection favoring areas that are warm, moist, and
macerated, such as the perianal and inguinal folds, inframammary folds, axillae,
interdigital areas, and corners of the mouth
Melanoma
o Treatment is (elliptical) excisional biopsy.
o A punch biopsy should be used only with discretion when the lesion is too
large for complete excision, or if substantial disfigurement would occur, such
as in the face.
o A shave biopsy should never be done for suspected melanoma, as this is likely
to transect the lesion and destroy evidence concerning its depth, thus making
it difficult to assess the prognosis
o No definitive evidence indicates that screening for melanoma reduces
mortality
pain from infiltration of local anesthetics can be decreased by using a warm
solution, using small needles, and performing the infiltration slowly, injecting the
agent through the edges of the wound, and pretreating the wound with topical
anesthetics. It is also helpful to add sodium bicarbonate to neutralize the anesthetic
since they are shipped at an acidic pH to prolong shelf life
o An exception to use of NaHco3 is bupivicaine (Marciane, Sensorcaine) as it will
precipitate in the presence of sodium bicarbonate

Infantile skin lesions

o Erythema toxicum neonaturum: papules, pustules, and erythema
o Milia: 1- to 2-mm pearly keratin plugs without erythema, and may occur on
the trunk and limbs
o Acne Neonaturum: occurs in up to 20% of newborns. It typically consists of
closed comedones on the forehead, nose, and cheeks, and is thought to result
from stimulation of sebaceous glands by maternal and infant androgens.
Parents should be counseled that lesions usually resolve spontaneously within
4 months without scarring
Cutaneous larva migrans: common condition caused by dog and cat hookworms.
o Fecal matter deposited on soil or sand may contain hookworm eggs that hatch
and release larvae, which then penetrate the skin
Chronic paronychia is a common condition in workers whose hands are exposed to
chemical irritants or are wet for long periods of time
o use of strong topical corticosteroids over several weeks can greatly reduce the
inflammation, allowing the nail folds to return to normal and helping the
cuticles recover their natural barrier to infection
atopic dermatitis (eczema)
o pruritic rash on the face and/or flexural surfaces of the arms and/or legs,
especially in children.
o there often is a family history of atopy or allergies.
o In addition to the regular use of emollients, the mainstay of maintenance
therapy, topical corticosteroids have been shown to be the best first-line
treatment for flare-ups of atopic dermatitis
o Second-line treatment is topical calcineurin inhibitor (i.e. pimecrolimus)
Leishmaniasis:
o caused by an intracellular parasite transmitted by the bite of small sandflies.
o Lesions develop gradually, and are often misdiagnosed as folliculitis or as
infected epidermal inclusion cysts, but they fail to respond to usual skin
antibiotics
o seen in troops returning from Iraq
o Treatment is not always required, as most lesions will resolve over several
months; however, scarring is frequent
o If treatment is indicated, CDC recommends Sodium Stibogluconate
Atypical mycobacterial infection
Epidermal Inclusion cyst
Pyogenic granuloma
Melasma or chloasma is common in pregnancy, with approximately 70% of pregnant
women affected. It is an acquired hypermelanosis of the face, with symmetric
distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip.
o UV sunscreen is important, as sun exposure worsens the condition.
o Often resolves postpartum
o Persistent melasma can be treated with hydroquinone cream, retinoic acid,
and/or chemical peels performed post-partum by a dermatologist
Pemphigoid (herpes) gestationis is a rare autoimmune disease with extremely
pruritic, bullous skin lesions that usually spare the face
Prurigo gestationis involves pruritic papules on the extensor surfaces and is
usually associated with significant excoriation by the uncomfortable patient
Acne
o Mild: few to several papules and pustules, no nodules

Topical treatments including benzoyl peroxide, retinoid, and topical

antibiotics are useful first-line agents in mild acne
Oral antibiotics are used in mild acne when there is inadequate
response to topical agents and as first-line therapy in more severe
acne
o Moderate: several to many papules and pustules with a few to several
nodules
o Severe: many or extensive papules, pustules, and nodules.
Oral Isotretinoin can be used, but Pregnancy test must be done in
women of child-bearing age.
Basal Cell Carcinoma: Total elliptical excisional body down to subq fat. Locally
invasive.
Kawasaki: mucocutaneous lymphnode syndromre. Will desquamate if not intervened
4-5 days out.
Meseals: starts at hairline, spreads down. No LN, no palm and sole involvement. +
koplik spots
Roseola: rash develops after high fever breaks. #1 reason adults are called penicillin
allergic when they are not.
RMSF : Petechial rash that starts at wrists and ankles. Treat w/ doxy (elderly) or
chloramphenicol (kids). Will take days to disappear. Most often is seen in Carolinas.
Scabies
o Treatment if patient is over 5 is 5% permethrin cream
Painful ingrown nails that display granulation tissue and lateral nail fold hypertrophy
are treated with excision of the lateral nail plate and lateral matricectomy
Glass is visible on plain film if it is 2mm or larger, and does not need to contain lead.
o common or highly reactive materials, such as wood, thorns, cactus spines,
some fish bones, other organic matter, and most plastics, are not visible on
plain films
Cellulitis in patients after breast lumpectomy is thought to be related to
lymphedema. Axillary dissection and radiation predispose to these infections.
o Due to nongroup A hemolytic
o
The onset is often several weeks to several months after surgery.
Pneumococcus is more frequently a cause of periorbital cellulitis. It is also seen in
patients who have bacteremia with immunocompromised status.
Immunocompromising conditions would include diabetes mellitus, alcoholism, lupus,
nephritic syndrome, and some hematologic cancers
Clostridium and Escherichia coli are more frequently associated with crepitant
cellulitis and tissue necrosis.
Pasteurella multocida cellulitis is most frequently associated with animal bites,
especially cat bites
herpes gladiatorum (due to HSV) is most common infection transmitted person-toperson in wrestlers
Molluscum contagiosum causes keratinized plugs. Human papillomavirus causes
warts
Tinea corporis is ringworm, which is manifested by round to oval raised areas with
central clearing
Actinic keratosis can lead to SCC with significant morbidity
If zoster affects the nasociallary nerve (side of nose), can affect cornea. Need to get
to ptho ASAP
Bullous impetigo only by Staph.
Chicken pox starts centrally, migrates peripherally

Erythrasma: a corenybacterium that cases a low grade cellulitis. Azithromycin is

treatment of choice.
o No satellites (Vs. Tinea Crurus)
Little dots along outside of central rash. Can occur anywhere.
Can check with Wood Lamp to use fluorescent light to a orange-pink.
Erysipelas: Group A strep cellulitis.
Urticaria: an allergic reaction. Comes and goes, can move around. Itchy.
o Can be caused by pressure, cold (ice), stress
Urticaria becomes Erythema multifimore when target lesions are formed. Becomes
SJS when mucous membranes are involvesd.
Photodermitits: due to OCP, Tetracyclines, etc. Rash only where sun signs
Lyme rash starts at tick bite. Expands outwards and clears centrally.
o Tinea corpus has a similar presentation. Scrape edges, look under microscope.
Erythema Nodosum. Red Knots. Often misdiagnosed for cellulitis. Due to Sarcoid
(MC) also due to sulfa drugs, strep, Tb, pregnancy, etc.
Molloscum contagiosum: Freeze off with nitrogen.

Vitiligo: Autoimmune destruction of melanocytes. Higher risk of other autoimmune

diseases.
Cherry hemangioma
Melasma can occur from OCP use
Lentigo (benign hyper pigmented spots)
Scabies. Between fingers, between beltline.
Corn: callous that shows up on pressure areas
Actinic keratitis: will become SCC. Tx is 5-Fu
Kerion (boggy mass of tinea capitis) is a rash caused by tinea capitis. Tx is
gresiofulvin.
Seborrheic keratosis
Tinea versicolor: hypo pigmented in darker skin, hyper pigmented in lighter skin.
Skin tag: in folds of fat people.
Bot Fly lesion due to dermatobia hominis
Tinea capitis: hair breaks off at surface or skin (Vs. alopecia, which is where hair is
totally broken off.

REPRODUCTIVE

Black Cohosh is a botanical medicine used to alleviate menopausal symptoms and

menstrual dysregulation. It has not been shown to prevent osteoporosis and should
not be used for that reason.
Placenta Previa: manifests as painless bleeding in late second or third trimester.
o Must be considered in all patients beyond 24 weeks gestation who present
with bleeding
o Neonatal morbidity is due to risks associated with preterm birth
o Corticosteroid are given to women who present with placenta Previa between
24-34 weeks gestation.
o If patient experiences pre-term contractions, a tocolytic agent (Mg2+ or CCB)
can be used to prolong pregnancy until fetal lung maturity is achieved.
Suppressive therapy with acyclovir, valacyclovir, or famciclovir reduces, but does not
eliminate, the risk of transmission of HSV to sexual partners
Epidural anesthesia during labor and deliver has been shown to increase the length
of both the first and second stages of labor
Vasomotor symptoms (hot flashes) slowly increase until perimenopausal and then
diminish after menopause. Estrogen is effective in treating hot flashes but should not
be given alone b/c it increases the risk of endometrial cancer.
Metorrhagia: heavy bleeding that requires the use of multiple pads and happens
between normal menstrual bleeding. Potential cause include cervical disease,
problems with IUDs, endometritis, polyps, submucosa myomas, endometrial
hyperplasia, and cancer.
Pap screening is not necessary in women who have undergone hysterectomy
because they no longer have a cervix.
Enlarging postpartum hematomas adjacent to an episiotomy are best treated by
removing the sutures and ligating the specific bleeding sites
An empty uterus presents the highest risk (14%) for ectopic pregnancy in the
presence of elevated B-HCG
Gestational age estimate via US
o First trimester: crown-rump length
o Second trimester biparietal diameter
Inevitable abortion: bleeding, an open Os, and no passage of products of
conception
Incomplete abortion: bleeding, open Os, POCs visible in Os or vaginal vault
Completed abortion: Bleeding, a closed Os, complete passage of POCs
Threatened abortion: Bleeding, closed Os, no passage of POCs
Shoulder dystocia: retraction of the fetal head against the perineum
o McRoberts maneuver: maternal hips are flexed and abducted, placing the
thighs up on the abdomen. This adds suprapubic pressure and can resolve
about 50% of shoulder dystocia.
Treatment of chlamydial infections during pregnancy: 7-day regimen of
erythromycin or amoxicillin, or a single dose of azithromycin.
HRT improves urogenital symptoms of menopause, such as vaginal dryness and
dyspareunia. It has NOT shown a benefit for decreasing coronary events, slowing
Alzheimers, improving depression, or improving urinary continence.
Seat belt use in late pregnancy: position under the abdomen over both the
anterior superior iliac spines and the pubic symphysis; the shoulder harness should
be positioned between the breasts; the belt should be applied as snugly as comfort
will allow

Vulvar cancer: associated with HPV 16,18 in youger women, and Lichens sclerosis
in older women
Fine needle aspirations of breast nodules
o Simple cyst: straw or green fluid with dissapearnce of cyst after drainage
o Bloody or unusual fluid cytological examination (~7% of blood stained
aspirates are associated with cancer)
US to evaluate possibility of multiple gestation
o Uterine size larger than expected
o Excessive pregnancy-associated symptoms
o Women who received fertility treatments
Fetal fibronectin (in cervical or vaginal secretions ) is the most clinically useful test
to differentiate women who are at high risk for impending preterm delivery
Endocervical curettage is contraindicated in pregnancy
Post-term (postdate) pregnancy: one that reaches 42 weeks of amenorrhea.
Perinatal mortality doubles at 42 weeks of gestational age.
2nd stage of labor starts when the uterine cervix is completely dilated
Diagraphm use and maintenance:
o weight change of more than 15 lb, pregnancy, or pelvic surgery may
necessitate refitting
o increase risk of HIV transmission if used with nonoxynol-9
o made of latex or silicone
o contraindicated in Women with history of TSS
Adnexal cyst
o Thin walled, less than 8cm, usually in a younger patient.
o Will spontaneously resolve
o US should be done after 2-3 months to confirm resolution of cyst
Uterine rupture is a potential complication of attempted vaginal birth after cesarean.
A reliable indicator that this occurred is fetal bradycardia
Fibro adenomas the most common breast mass in adolescent girls
Postmenopausal HRT consisting of estrogen AND progestin has increased incidence of
Breast cancer. Risk outweighs benefits
Fetal macrosomia: birthweight above 4000-4500g. US does not provide an accurate
estimate of fetal weight for large fetuses. If these mothers do not go into labor
spontaneously, they will need to be managed as a postdate pregnancy patient
Patients with PID and tube-ovarian abscess and high fever should be hospitalized and
treated for at least 24 hours with intravenous antibiotics
Outpatient treatment of PID: Cefoxitinme IM + Probenecid, or Ceftriaxone (no
probenecid requirement)
Most infants with face presentation, mentum anterior, can be delivered vaginally,
either spontaneously or with low forceps
Cesarean section is indicated for fetal distress and failure to progress
All patients with AGUS should be evaluated by colposcopy and endocervical
curettage.
o Recommendation for endometrial sampling
Age 35 or older
AGUS favoring neoplasia or suggestive of an endometrial source.
o Cervical intraepithelial neoplasia is most common histologic diagnosis found in
patients evaluated for AGUS
Primary Dysmenorrhea: severe cramping pain in the lower abdomen that occurs
during menses or prior to onset of menses in the absence of associated pelvic
pathology

o First tx: Naproxen sodium or other NSAIDS

Pain management in endometriosis: Danazol
Imperforate hymen
o Recurrent crescendo abdominal cramping (representing menstrual shedding
with no egress from the body)
o Retained blood
o Hymenotomy is curative
Genital Wart treatment
o Trichlorocacetic acid for treatment of warts on vaginal or vulvar mucosa is
acceptable, even when pregnancy is a possibility.
o Podofilox and podophyllin in alcohol are not safe for use on mucosa.
o
Imiquimod cream is also not approved for mucosal use.
o Interferon requires injection, has many adverse systemic effects, and is no
longer recommended for routine use in treating genital warts
o Intravaginal genital warts cryotherapy with liquid nitrogen
Trichomonas treatment
o First: 2g Oral Metronidazole in a single dose
o If refractory, Metronidazole 500 mg BID for 7 days
Ansel criteria for diagnosis of bacterial vaginosis (most have 3 of 4)
o pH > 4.5 (most sensitive)
o Clue cells (most specific)
o Homogenous discharge
o Positive whiff test (amine odor with addition of KOH)
Most common manifestation of uterine rupture is fetal distress (prolonged, variable,
or late decelerations and bradycardia)
Vulvar cancer: MC symptom is longstanding pruritus
Before prescribing OCPs, review of medical history and measurement of blood
pressure are necessary
Metronidazole can cause a disulfiram-like reaction
Probability of pregnancy is highest with unprotected intercourse 1 day before
ovulation
Persistent hyper estrogenic states (I.e. PCOS) are at heightened risk or development
of endometrial cancer.
o the chronic anovulation and consequent hyperstimulation of Estrogen
predisposes to endometrial hyperplasia and carcinoma
Screening for ovarian cancer in elderly females at average risk are not recommended
duet la lack of a reliable screening method.
Antenatal screen for GBS: obtaining cultures from rectum and vaginal secretions
at 35-37 weeks gestation
Adnexal torsion is best evaluated with Color Doppler flow, which evaluates blood flow
to the ovary.
a childs vagina and cervix is best visualized without instrumentation when the child
is in the knee-chest position
OCPs are contraindicated in women over 35 who smoke greater than 15 cigs a day.
Benefits of OCPs:
o Reduced risk of ovarian and endometrial cancer (benefit remains for years
after discontinuation)
o Reduction in dysfunctional uterine bleeding and dysmenorrhea
o Lower incidence of ovarian cysts, ectopic pregnancy and being breast disease
o Increase in Hemoglobin concentration

All combination OCPs raise levels of SHBG and decrease free Testosterone,
which can lead to improvements in acne
Cigarette smoking is the only nonsexual behaver that is consistently and strongly
correlated with cervical dysplasia
Leaving diagraphs in place for more than 24 hrs. increases the risk of TSS
ASC-US of undetermined significance management
o Repeat cytology after 4-6 months, immediate colposcopy, or reflex DNA
testing for oncogenic HPV
o If 2 repeat test are negative after 4-6 months duration, return to routine
cytological screenings
o If any repeat test determines more ASC-US, Colposcopy is indicated.
In a viable pregnancy, serum HCG doubles every 2-4 days
Combining serial hCG levels with transvaginal ultrasonography is the best
combination for evaluation of first-trimester problems, as HCG levels correlate with
sonographic landmarks
Medications that can cause galactorrhea
o OCPS that contain estrogen
o Metoclopramide, verapamil, SSRIs, bytrophenones, dopamine receptor
blockers, TCAs, phenothiazine, and thioxanthenes
MCC acute vaginitis (abnormal vaginal discharge) is bacterial vaginosis
Fibroid tumor tx: myomectomy
The finding of a red, raised, friable lesion on the cervix, or a well-demarcated cervical
lesion, mandates a biopsy to exclude cervical carcinoma, and treatment for chronic
cervicitis should not be started until the biopsy results are available
o PAP test is not sufficient is there is a grossly visible lesion, as false-negative
occur in 10-50% of tests
Most reliable predictor of survival in a patient with breast cancer is the cancer stage
at the time of diagnosis
Late decelerations are thought to be associated with uteroplacental insufficiency and
fetal hypoxia due to decreased blood flow in the placenta.
Amenorrhea is an indicator of inadequate calorie intake, which may be related to
either reduced food consumption or increased energy use
o

GASTROINTESTINAL

Jaundice in newborn at 35 weeks or greater gestation

o Treatment is based on total serum bilirubin level, the infants age in hours, and
risk factors
o Phototherapy should not be started based solely on the total serum bilirubin
level
o breastfeeding 8-12 times daily in the first few days of life to prevent
dehydration
Volvulus in neonate
o Can present in one of three ways:
sudden onset of bilious vomiting and abdominal pain in a neonate

a history of feeding problems with bilious vomiting that appears to be

a bowel obstruction
as failure to thrive with severe feeding intolerance
o incidence peaks during 1st month of life, but can present anytime during
childhood
o The classic finding on abdominal plain films is the double bubble sign, which
shows a paucity of gas (airless abdomen) with two air bubbles, one in the
stomach and one in the duodenum, but plain films can be normal
o The upper gastrointestinal contrast study is considered the gold standard for
diagnosing volvulus.
Infantile colic usually begins during the second week of life and typically occurs in
the evening. It is characterized by screaming episodes and a distended or tight
abdomen
o There are no abnormalities on physical examination and ancillary studies, and
symptoms usually resolve spontaneously around 12 weeks of age
o Etiology is unclear
Necrotizing enterocolitis is typically seen in the distressed neonate in the
intensive-care nursery, but it may occasionally be seen in the healthy neonate within
the first 2 weeks of life
o child will appear ill, with symptoms including irritability, poor feeding, a
distended abdomen, and bloody stools. Abdominal plain films will show
pneumatosis intestinalis, caused by gas in the intestinal wall, which is
diagnostic of the condition
Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by
hypertrophy of the musculature. It usually presents during the third to fifth weeks of
life. Projectile vomiting after feeding, weight loss, and dehydration are common. The
vomitus is always nonbilious, because the obstruction is proximal to the duodenum.
If a small olive-size mass cannot be felt in the right upper or middle quadrant,
ultrasonography will confirm the diagnosis
Intussusception is seen most frequently between the ages of 3 months and 5
years,
o Male Predominence
o The classic triad of intermittent colicky abdominal pain, vomiting, and bloody,
mucous stools is encountered in only 20%-40% of cases. At least two of these
findings will be present in approximately 60% of patients.
o The abdomen may be distended and tender, and there may be an elongated
mass in the right upper or lower quadrants.
o
Rectal examination may reveal either occult blood or frankly bloody, foulsmelling stool, classically described as currant jelly.

An air enema using fluoroscopic guidance is useful for both diagnosis

and treatment
Meckels diverticulum is the most common congenital abnormality of the small
intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa.
Abdominal pain, distention, and vomiting may develop if obstruction has occurred,
and the presentation may mimic appendicitis
Rotavirus vaccine (RotaTeq)
o Infants should be vaccinated with 3 doses to be given at 2,4,and 6 months of
age.
o The first dose should be given between 6 and 12 weeks of age, and
subsequent doses should be given at 4- to 10-week intervals, but all three
doses should be administered by 32 weeks of age
Pancreatitis is most closely associated with gallstones, extreme
hypertriglyceridemia, and excessive alcohol use.
Eradication of Helicobacter pylori significantly reduces the risk of ulcer recurrence
and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer
development in patients on chronic NSAID therapy.
Long-standing ulcerative colitis (UC) is associated with an increased risk of colon
cancer.
o Initial colonoscopy for patients with pancolitis of 8-10 years duration
(regardless of the patient's age) should be followed up with surveillance
examinations every 1-2 years, even if the disease is in remission
Chrons: absence of rectal involvement, transmural involvement, skip lesions, fistulas
Oral Metronidazole is 1st line tx for C. diff
Continued oral feeding in diarrhea aids in recovery, and an age-appropriate
diet should be given. Breastfeeding or regular formula should be continued. Foods
with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean
meats, yogurt, fruits, and vegetables are well tolerated.
o Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided
because the osmotic load can worsen the diarrhea. Fatty foods should be
avoided as well
Diagnostic paracentesis is recommended for patients with new onset ascites and
those with chronic ascites who present with new clinical findings such as fever or
abdominal pain.
o A neutrophil count of >250/ml is diagnostic for peritonitis
Once peritonitis is diagnosed, antibiotic therapy should be started
immediately without waiting for culture results.
o Bloody ascites with abnormal cytology may be seen with hepatoma, but is not
typical of peritonitis
o The ascetic fluid pH does not become abnormal until well after the neutrophil
count has risen, so it is a less reliable finding for treatment purposes
o A protein level >1 g/dL is actually evidence against spontaneous bacterial
peritonitis.
Infants born to hepatitis Bpositive mothers should receive both immune
globulin and hepatitis B vaccine. They should receive the entire series of the vaccine,
with testing for seroconversion only after completion of the vaccination series
o
the recommended age for testing is 912 months of age
Organisms that can persist in water environments and survive disinfection, especially
chlorination, are most likely to cause disease outbreaks related to drinking water.
Cryptosporidium oocysts and Giardia cysts are resistant to chlorine and are
o

important causes of gastroenteritis from drinking water. Entamoeba

histolytica and hepatitis A virus are also relatively chlorine resistant.
Screen for HEP C: IVDA, receiving clotting factor produced before 1987, persistent
alanine aminotransferase elevations, or recent needle stick with HCV-positive blood.
o The lifetime transmission risk of hepatitis C in a monogamous relationship is
less than 1%, but the patient should be offered testing because she may
choose to confirm that her test is negative.
o
If the mother is seronegative, the children are at no risk.
Maternal-fetal transmission is rare except in the setting of co-infection
with HIV. Normal liver enzyme levels do not indicate lack of infectivity.
o There is no risk to household contacts
HepB: a vaccinated person has been exposed to a known positive
individual.
o The exposed person should be tested for hepatitis B antibodies; if antibody
levels are inadequate (<10 IU/L by radioimmunoassay, negative by enzyme
immunoassay)
o HBIG should be administered immediately, as well as a hepatitis B vaccine
booster dose
o An unvaccinated individual in this same setting should receive HBIG
immediately (preferably within 24 hours after exposure) followed by the
hepatitis B vaccine series (injection in 1 week or less, followed by a second
dose in 1 month and a third dose in 6 months)
Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic
cancers. It is expressed in normal mucosal cells and is overexpressed in
adenocarcinoma, especially colon cancer.
o Levels above 10 ng/mL are rarely due to benign disease.
o CEA levels typically return to normal within 46 weeks after successful surgical
resection.
o CEA elevation occurs in nearly half of patients with a normal preoperative CEA
level that have cancer recurrence
Cancer antigen 27.29 (CA 27-29) is a tumor marker for breast cancer. It is
elevated in about 33% of early-stage breast cancers and about 67% of late-stage
breast cancers
CA-125 is a marker for ovarian cancer. Although it is elevated in 85% of ovarian
cancers, it is elevated in only 50% of early-stage ovarian cancers
Alpha-fetoprotein is a marker for hepatocellular carcinoma and nonseminomatous
germ cell tumor, and is elevated in 80% of hepatocellular carcinomas
Prostate-specific antigen (PSA) is a marker that is used to screen for prostate cancer.
It is elevated in more than 70% of organ-confined prostate cancers
melanosis coli: describes black or brown discoloration of the mucosa of the colon
o due to presence of dark pigment in large mononuclear cells or macrophages
in the lamina propria of the mucosa
o The condition is thought to result from fecal stasis and the use of anthracene
cathartics such as cascara sagrada, senna, and danthron
Ectopic endometrial tissue (endometriosis) most commonly involves the serosal
layer of those parts of the bowel adjacent to the uterus and fallopian tubes,
particularly the rectosigmoid colon.
Collagenous colitis does not cause mucosal pigmentary changes
Multiple AVMs are more common in the proximal bowel

Barretts esophagus is an acquired intestinal metaplasia of the distal esophagus

associated with longstanding gastroesophageal acid reflux, although a quarter of
patients with Barretts esophagus have no reflux symptoms.
o It is more common in white and Hispanic men over 50 with longstanding
severe reflux symptoms, and possible risk factors include obesity and tobacco
use.
o
It is a risk factor for adenocarcinoma of the esophagus, with a rate of about
one case in every 200 patients with Barretts esophagus per year.
o Treatment is directed at reducing reflux, thus reducing symptoms.
o Neither medical nor surgical treatment has been shown to reduce the
carcinoma risk.
Campylobacter jejuni is MCC of bacterial diarrhea
Thrombosed hemorrhoid
o If patient presents within 48 hours of symptom onset, elliptical excision of the
hemorrhoid and overlying skin under local anesthesia
o Rubber band ligation is an excellent technique for management of internal
hemorrhoids.
Banding an external hemorrhoid would cause exquisite pain.
o When pain is already subsiding or more time has elapsed (in the absence of
necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool
softeners, and local analgesia may all be helpful
Gastroenteritis on cruise ships are due to Norwalk Virus infections due to
waterborne or food borne spread. They have been shown to be responsible for
outbreaks in nursing homes, on cruise ships, at summer camps, and in schools.
Symptomatic treatment is usually appropriate
Gilberts syndrome is the most common inherited disorder of bilirubin metabolism.
In patients with a normal CBC and liver function tests, except for recurrent mildly
elevated total and unconjugated hyperbilirubinemia, the most likely diagnosis is
Gilberts syndrome
IBS is a benign, chronic symptom complex of altered bowel habits and abdominal
pain. It presents as relief of symptoms with defecation, changes of stool consistently
from loos and watery to constipation, Mucus may be passed with bowel movement.
Abdominal bloating is preset.
o Worsening of symptoms at night points towards an alternative diagnosis, not
IBS
Cholelithiasis
o
Plain radiography of the abdomen may reveal radiopaque gallstones, but will
not reveal radiolucent stones or biliary dilatation.
o Although rarely used, oral cholecystography is 98% accurate, but only when
compliance is assured, the contrast agent is absorbed, and liver function is
normal
o Abdominal ultrasonography is considered the best study to confirm this
diagnosis because of its high sensitivity and its accuracy in detecting
gallstones.
Imaging for diagnosis of appendicitis:
o CT has demonstrated superiority over transabdominal ultrasonography for
identifying appendicitis, associated abscess, and alternative diagnoses.
o ultrasonography is indicated for the evaluation of women who are pregnant
and women in whom there is a high degree of suspicion for gynecologic
disease

Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for
homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if
neuroblastoma or pheochromocytoma is suspected; both should be collected
before surgical intervention.
Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present
with anemia or osteoporosis, without gastrointestinal symptoms
o Individuals with more significant mucosal involvement present with watery
diarrhea, weight loss, and vitamin and mineral deficiencies
A patient with a past history of postoperative venous thromboembolism is at risk for
similar events with subsequent major operations.
o The most appropriate treatment of the choices listed would be subcutaneous
enoxaparin.
Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a
higher rate of postoperative hemorrhage
Aspirin is ineffective for prophylaxis of venous thromboembolism
Zenker Diverticulum: halitosis, late regurgitation of undigested food, and choking.
Dysphagia and weight loss are also present.
o Diagnosis is made with barium swallow, and treatment is surgical.

RESPIRATORY

Patients with chronic illness, diabetes mellitus, cerebrospinal fluid leaks, chronic
bronchopulmonary dysplasia, cyanotic congenital heart disease, or cochlear implants
should receive one dose of pneumococcal polysaccharide vaccine after 2 years of
age, and at least 2 months after the last dose of pneumococcal conjugate vaccine
(Prevnar 13).
o
Revaccination with polysaccharide vaccine is not recommended for these
patients.
Individuals with sickle cell disease, those with anatomic or functional asplenia,
immunocompromised persons with renal failure or leukemia, and HIV-infected
persons should receive polysaccharide vaccine on this schedule and should be
revaccinated at least 5 years after the first dose
The live, attenuated influenza vaccine (intranasal) is an option for vaccinating
healthy, nonpregnant individuals age 5-49 years.
o It is not indicated in patients with underlying medical conditions, such as
chronic pulmonary or cardiovascular disease, or in patients with a history of
Guillain-Barr syndrome, pregnant patients, or children and adolescents who
receive long-term aspirin or salicylate therapy.
o
Patients with a history of hypersensitivity to eggs should not receive this
vaccine.
Obstructive sleep apnea-hypopnea syndrome is defined as the presence of at
least five obstructive events per hour with associated daytime sleepiness.
o
The prevalence in men is almost three times that seen in premenopausal
women and twice that of postmenopausal women.
o Other factors associated with an increased prevalence are obesity, older age,
and systemic hypertension
Macrolides are considered first-line therapy for Bordetella pertussis infection.
o Trimethoprim/sulfamethoxazole is considered second-line therapy.
A recently hospitalized patient has a significant pneumonia that requires the initiation
of empiric antibiotics.
o It is important to remember that because this patient was recently in the
hospital, the usual coverage for community-acquired pneumonia is not
adequate.
o Health care-associated pneumonia is more likely to involve severe pathogens
such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter
species.
o Methicillin-resistant Staphylococcus aureus also is a consideration, depending
on local prevalence.
o ceftazidime and gentamicin is a possible treatment for HAP
Exercise-induced bronchoconstriction (EIB) is a very common and
underdiagnosed condition in athletes.
o It is defined as a 10% lowering of FEV1 when challenged with exercise.
o The exercise required to cause bronchoconstriction is 5-8 minutes at 80% of
maximal oxygen consumption.
o A physical examination, as well as pulmonary function tests at rest and before
and after bronchodilators, will be normal unless there is underlying asthma.
Among athletes with EIB, 10% will not have asthma.
o Bronchoprovocative testing can be ordered, but if it is not available a trial with
an albuterol inhaler is reasonable.
small spontaneous pneumothorax: (involves less than 15%-20% of lung volume)
o manage by administering oxygen and observing the patient.

The pneumothorax will usually resorb in about 10 days if no ongoing air leak is
present. Oxygen lowers the pressure gradient for nitrogen and favors transfer
of gas from the pleural space to the capillaries.
o Decompression with anterior placement of an intravenous catheter is usually
reserved for tension pneumothorax.
o Chest tube placement is used if observation is not successful or for larger
pneumothoraces.
acute sinusitis.
o Failure to respond to adequate antibiotic therapy suggests either a
complication, progression to chronic sinusitis, or a different, confounding
diagnosis.
o The diagnostic procedure of choice in this situation is coronal CT of the
sinuses, due to its increased sensitivity and competitive cost when compared
with standard radiographs.
o Cultures of the nasal discharge give unreliable results because of bacterial
contamination from the resident flora of the nose.
Pleural effusions may be exudates or transudates.
o Lights criteria use ratios of fluid/serum values for protein and LDH.
Pleural fluid/serum ratios greater than 0.6 for LDH and 0.5 for protein
are indicative of exudates.
o The vast majority of transudates are due to heart failure, with cirrhosis being
the next most common cause.
o Once there is reasonable certainty that the fluid is a transudate, additional
studies usually are not necessary
Use of an incentive spirometer and similar lung expansion techniques such as chest
physiotherapy have been shown to have significant benefit for reducing
postoperative complications.
o A course of preoperative corticosteroids has been shown to be beneficial for
patients with COPD. Prolonged antibiotic prophylaxis and postoperative total
parenteral nutrition have not been shown to have any benefit
rotavirus vaccine is an oral vaccine recommended for infants in a 3-dose schedule
at ages 2, 4, and 6 months.
o The first dose should be given between 6 and 12 weeks of age, with additional
doses given at 4 to 10-week intervals.
o The vaccine cannot be initiated after 12 weeks of age and should not
be administered after 32 weeks of age.
No medication available in the United States has been shown to effectively treat
cough or cold symptoms in children younger than 2 years of age.
o Nasal saline and bulb suction is the only recommendation for treatment of
cough and cold symptoms in children younger than 2
moderate to severe COPD
o Smoking cessation is the single most important therapeutic intervention in
patients with this condition and should be the priority of care.
o No existing medications have been shown to modify the long-term decline in
lung function that is typical of COPD, but smoking cessation does prevent this
decline.
o Long-term use of oxygen in COPD patients who also have chronic, severe
hypoxia (<88% saturation) can improve quality of life and prolong survival;
however, oxygen cannot prevent further decline in lung function.
o Long-term use of oral corticosteroids is discouraged because of an
unfavorable risk-to-benefit ratio
o

Pulmonary function tests are usually classified as normal, compatible with a

restrictive defect, or consistent with obstructive airway disease.
o In restrictive ventilatory processes, the FVC is decreased, the FEV1 is
decreased or normal, and the absolute FEV1/FVC is >0.7.
When simple spirometry suggests a restrictive ventilatory problem, the
patient should undergo full pulmonary function testing for static lung
volume measurements and diffusing capacity of the lung for carbon
monoxide.
o In obstructive airway problems, findings include a normal or decreased
FVC, a decreased FEV1, and an absolute FEV1/FVC <0.7.
If spirometry suggests an obstructive problem, it should be repeated
after administering an inhaled bronchodilator
Varenicline, a clinically effective smoking-cessation product, has been associated
with patient mood changes following the initiation of therapy, including suicidal
thoughts and aggressive and erratic behavior.
histoplasmosis infection
o Asymptomatic patients with a chest radiograph pattern (lung fields with BBsized calcifications in a military pattern),
o midwestern United States.
o Exposure to bird or bat excrement is a common cause
o treatment is usually not needed
asbestos inhalation
o Development of pleural plaques is the most common pathologic pulmonary
response.
o Due to calcification of deposited collagen delposited in pleura.
o Most plaques are asymptomatic, and there is no evidence that plaques
transform into malignant lesions.
o Plaques occur in approximately 50% of persons with heavy and prolonged
exposure to asbestos and, therefore, are a marker of asbestos exposure.
o This should alert the physician to follow the patient for development of more
serious asbestos-related diseases (e.g., lung cancer and mesothelioma).
severe COPD (stage III): The addition of a corticosteroid inhaler for patients with
severe disease has been found to significantly decrease the number of
exacerbations, but has no effect on overall mortality.
o Side effects of oral candidiasis and easy bruising of the skin are increased.
o Continuous oxygen has been shown to improve overall mortality and
endurance in patients with an oxygen saturation of 88% or less, but has not
been shown to improve quality of life in those with mild hypoxemia or if used
only at night.
o Oral prednisone has been shown to be effective when used to treat acute
exacerbations, but when used on a chronic basis it is no more effective than
corticosteroid inhalers.
Chronic oral prednisone is also associated with significant side effects,
and therefore is not generally recommended
Croup is a syndrome most often caused by viruses, but can occasionally be of
bacterial origin as in laryngotracheitis, laryngotracheobronchitis (LTB),
laryngotracheobroncheopneumonia (LTBP), or laryngeal diphtheria.
o Mild croup is manifested by an occasional barking cough with no stridor at
rest, and mild or absent intercostal retractions.
o Moderate croup presents with a more frequent barking cough, stridor with
suprasternal and sternal retractions at rest, but no agitation.

Severe croup includes more prominent inspiratory and expiratory stridor

with agitation and distress.
o There is good evidence that corticosteroids produce significant improvement.
o The regimens studied most frequently have consisted of single-dose
dexamethasone (0.6 mg/kg orally or intramuscularly), with some studies
including up to four more doses over a 2-day period.
Longer courses of corticosteroids have not proven to be more effective
and may be harmful, leading to secondary infections.
o Racemic epinephrine by nebulization is indicated in severe croup.
o Antibiotics are indicated in LTB and LTBP, which can be diagnosed on the basis
of crackles and wheezing on examination, or by an abnormal chest
radiograph.
Pleurisy:
o patients presenting with pleuritic chest pain may have life-threatening
disorders, and pulmonary embolism, acute myocardial infarction, and
pneumothorax should be excluded.
o If Patients have risk factors for PE, they may need a helical CT scan or other
diagnostic testing.
o an EKG and chest radiograph are recommended in the evaluation of
acute/subacute pleuritic chest pain.
o The chest radiograph will exclude pneumothorax, pleural effusion, or
pneumonia.
o Most cases of acute pleurisy are viral and should be treated with
NSAIDs unless the workup indicates another problem.
In-Patient management acute exacerbations of asthma should include inhaled
short-acting bronchodilators in all patients.
o Systemic corticosteroids are recommended for all patients admitted to the
hospital. The efficacy of oral prednisone has been shown to be equivalent to
that of intravenous methylprednisolone.
o Oxygen should also be considered in most patients.
o Antibiotics are not recommended in the treatment of asthma
exacerbations unless there is a comorbid infection.
o Inhaled ipratropium bromide is recommended for treatment in the emergency
department, but not in the hospital.
o Chest physical therapy and methylxanthines are not recommended in the
treatment of acute asthma exacerbations
child with meconium aspiration syndrome
o CXR will show patchy atelectasis or consolidation. If the child has a normal
chest film and respiratory distress, a noncardiopulmonary source should be
considered (i.e., a neurologic or metabolic etiology).
o The chest film of a child with transient tachypnea of the newborn will show a
wet silhouette around the heart, diffuse parenchymal infiltrates, or intralobar
fluid accumulation.
o Homogeneous opaque infiltrates with air bronchograms on a chest radiograph
are seen with hyaline membrane disease.
MCC Neonatal Respiratory Distress is transient tachypnea of the newborn
o It is a benign condition due to residual pulmonary fluid remaining in the lungs
after delivery. R
o Risk factors include cesarean delivery, macrosomia, male gender, and
maternal asthma and/or diabetes mellitus.
Respiratory syncytial virus (RSV) infection.
o Supportive care is the mainstay of therapy.
o

If the child can take in fluids by mouth and tolerate room air, outpatient
management with close physician contact as needed is reasonable, especially
in the absence of significant underlying risk factors.
o Routine use of corticosteroids is not recommended (SOR B)
Palivizumab is a preventive measure, and is not used for treatment of
the active disease.
It may be considered in select infants and children with
prematurity, chronic lung disease of prematurity, or congenital
heart disease
If used, it should be administered intramuscularly in five
monthly doses of 15 mg/kg,
Although oral antibiotics are overwhelmingly prescribed as initial treatment in acute
sinusitis, it has been shown that the majority of acute illnesses are viral in origin
and that 98% of cases will resolve spontaneously.
o Analgesics are considered the mainstay of therapy for acute sinusitis,
according to evidence-based recommendations.
o There is little evidence of effectiveness for antihistamines, oral decongestants,
or vasoconstrictor sprays.
o There is also little evidence of effectiveness for nasal lavage in acute sinusitis,
although it has an emerging role in chronic sinusitis.
previously healthy patients with CAP and no risk factors for drug resistance:
o a macrolide such as azithromycin is the preferred treatment.
o Doxycycline is also acceptable
Patients who have been treated with antibiotics within the previous 3
months
o treat with a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or
levofloxacin)
o A -lactam plus a macrolide is also an alternative
o The antibiotic chosen should be from a different class than the one
used for the previous infection.
o A respiratory fluoroquinolone or Macrolide + B-Lactamase are also
recommended for those with comorbidities (chronic heart, lung, liver, or renal
disease; diabetes mellitus; alcoholism; malignancies; asplenia;
immunosuppressing conditions or use of immunosuppressing drugs); or other
risk factors for drug-resistant Streptococcus pneumoniae infection
Hemothorax: bleeding into pleural space, often due to rib fracture
o treatment is to remove bloody fluid and expand the lung.
o This therapy is felt to decrease any ongoing blood loss by having the lung
pleura put a direct barrier over the site that is bleeding. It also prevents the
development of empyema or fibrosis, which could occur if the blood were to
remain.
MCC nasal obstruction in all age groups is the common cold, which is classified as
mucosal disease.
MCC unilateral nasal obstruction are anatomical abnormalities (septal deviation is the
most common)
Asthma treatment is based on classification.
o mild persistent asthma: symptoms more than 2 times per week but less
than once a day, symptoms less than 2 nights per month, peak expiratory flow
(PEF) or FEV1 >80% of predicted, and a PEF variability of 20%30%.
o

Asthma controller medications are recommended for all patients with

persistent asthma, and the preferred long-term controller treatment in mild
persistent asthma is a low-dose inhaled corticosteroid.
o Cromolyn, leukotriene modifiers, nedocromil, and sustained-release
theophylline are alternatives, but are not preferred initial agents.
o Quick-acting, quick-relief agents such as short-acting beta-agonists are
appropriate for prompt reversal of acute airflow obstruction.
Pertussis:
o Diagnose by nasopharyngeal culture, but because the disease is uncommon
and the organism is fastidious, laboratory personnel should be advised of the
physicians suspicion of pertussis.
o Treatment includes respiratory and nutritional supportive care, particularly for
infants younger than 6 months.
o Antibiotic therapy is most effective in shortening the illness when given early,
during the upper respiratory phase, but is indicated at any stage to reduce the
spread of disease to others.
o The drug of choice is erythromycin, 4050 mg/kg/day divided into four
doses, for 14 days. Also effective are azithromycin and clarithromycin, which
may be better tolerated with improved compliance.
Two doses of influenza vaccine are recommended for children under the age of 9
years unless they have been vaccinated previously.
o Children 38 years of age should receive one or two 0.5-mL doses of split-virus
vaccine intramuscularly.
In middle aged, heavy smokers, supplementation with beta-carotene is associated
with a higher incidence of lung cancer
PPD testing indications and TB treatment
o Because the risk of developing active disease is highest in patients within 2
years after conversion, recent converters should generally be treated
regardless of age.
o BCG vaccination has a limited effect on PPD reactivity;
Tests should not be interpreted any differently in patients who have
previously received BCG.
The use of a two-step approach (i.e., retesting 14 weeks later in
patients who initially test negative) is designed to decrease the falsenegative rate of PPD testing.
The significance of a positive result on either phase of the test
is the same.
o Patients who are HIV positive are at higher risk for false-negative PPDs and
active disease, but PPD testing is not contraindicated. 5 mm is considered
positive
o 10 mm for Healthcare workers or people at high risk
o 15 mm for general population
o In some persons PPD reactivity wanes with time but can be recalled by a
second skin test administered 1 week or more after the first (i.e., two-step
testing).
o For persons undergoing PPD skin testing, such as health-care workers, initial
two-step testing may preclude misclassification of persons with boosted
reactions as PPD converters.
Pharyngitis is a common complaint, and usually has a viral cause.
o

The key factors in diagnosing streptococcal pharyngitis are a fever over

100.4 degrees F, tonsillar exudates, anterior cervical lymphadenopathy, and
absence of cough.
Age plays a role also, with those <15 years of age more likely to have
streptococcal infection, and those 1025 years of age more likely to have
mononucleosis.

MUSCULOSKELETAL

Secondary osteoporosis can result from a variety of endocrine, nutritional, or

genetic disorders, as well as from prolonged use of certain medications.
o Anticonvulsants such as phenytoin increase the hepatic metabolism of vitamin
D, thereby reducing intestinal calcium absorption.
o Other medications that adversely affect bone mineral density include
glucocorticoids, cyclosporine, phenobarbital, and heparin
Benefits of Estrogen containing Hormone Replacement therapy:
o decrease osteoporosis and bone fracture risk.
o Decrease reisk of CRC after 5 years of use
o The risk for myocardial infarction, stroke, breast cancer, and venous
thromboembolism increases with long-term use
Developmental dysplasia of the hip encompasses both subluxation and
dislocation of the newborn hip, as well as anatomic abnormalities.
o It is more common in firstborns, females, breech presentations,
oligohydramnios, and patients with a family history of developmental
dysplasia.
o ultrasound screening at 6 weeks for breech girls, breech boys (optional), and
girls with a positive family history of developmental dysplasia of the hip.
o Closed reduction and immobilization in a Pavlik harness, with ultrasonography
of the hip to ensure proper positioning, is the treatment of choice until 6
months of age.
Pain involving the big toe is a common problem. The first metatarsophalangeal
(MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of
big-toe injuries.
o Overuse, a sharp blow, and sudden dorsiflexion are the most common
mechanisms of injury.
Mortons neuroma
o commonly occurs between the third and fourth toes
o causes numbness involving the digital nerve in the area
o due to nerve being pinched between metatarsal heads in the center of the
foot.
Breast feeding newborns: Supplement with 200 IU/day of vitamin D beginning at 2
months of age and continuing until the child is consuming at least 500 mL/day of
formula or milk containing vitamin D.
o The purpose of supplementation is to prevent rickets.
Polymyalgia rheumatica:
o A disease of the middle-aged and elderly.
o Discomfort is common in the neck, shoulders, and hip girdle areas. There is
an absence of objective joint swelling, and findings tend to be symmetric.
o Characteristically, the erythrocyte sedimentation rate and C-reactive protein
levels are significantly elevated; however, these tests are nonspecific.
Occasionally there are mild elevations of liver enzymes, but muscle enzymes,
including creatine kinase, are not elevated in this disorder.
o Elevation of muscle enzymes strongly suggests another diagnosis.
Polymyositis and dermatomyositis are associated with variable levels of
muscle enzyme elevations during the active phases of the disease. Druginduced myopathies such as those seen with the cholesterol-lowering statin
medications tend to produce some elevation of muscle enzymes during the
course of the disorder.

Hypothyroidism is associated with creatine kinase elevation. It should

be strongly considered in the patient with unexplained, otherwise
asymptomatic creatine kinase elevation found on a routine chemistry profile.
o Hyperthyroidism may cause muscle disease and loss of muscle, but it is not
associated with creatine kinase elevation.
Risk factors for osteoarthritis of the hip include obesity, high bone mass, old age,
participation in weight-bearing sports, and hypothyroidism.
Vitamn D supplementation:
o 200 IU/day for all women between the ages of 9 and 50 years
Pregnancy or lactation does not affect the recommendation.
o 400 IU daily for women age 51-70
o 600 IU daily for women over the age of 70.
beginning long-term treatment with prednisone (3 months at a dosage 5
mg/day), or an equivalent, receive bisphosphonate therapy in addition to calcium
and vitamin D supplementation, regardless of their DEXA-scan T score.
Polyarticular arthritis often presents with fever, knee and other joint effusions, and
leukocytosis.
o A 24-hour urine collection is not routine, is difficult for the patient, and
typically does not change therapy.
o Especially in cases where a joint effusion is accompanied by fever, diagnostic
arthrocentesis should be performed to help guide therapy.
Allopurinol should not be initiated during an acute gouty attack, but may be started
after a patient has recovered. Diuretics increase uric acid levels.
Slipped capital femoral epiphysis (SCFE)
o Pain with activity is the most common presenting symptom, as opposed to the
nighttime pain that is typical of malignancy.
o Obese males are affected more often.
o The pain is typically in the anterior thigh, but in a high percentage of patients
the pain may be referred to the knee, lower leg, or foot.
o Limited internal rotation of the hip, especially with the hip in 90; flexion, is a
reliable and specific finding for SCFE and should be looked for in all
adolescents with hip, thigh, or knee pain
Meralgia paresthetica is pain in the thigh related to entrapment of the lateral
femoral cutaneous nerve, often attributed to excessively tight clothing.
Legg-Calv-Perthes disease (avascular or aseptic necrosis of the femoral head) is
more likely to occur between the ages of 4 and 8 years.
Juvenile rheumatoid arthritis typically is associated with other constitutional
symptoms including stiffness, fever, and pain in at least one other joint, with the pain
not necessarily
There is not a linear correlation between bone mineral density and fracture
risk.
o Bone architecture may be changed by bisphosphonate therapy, which may
result in a decreased fracture risk.
inflammatory myopathy of the polymyositis/dermatomyositis group.
o Proximal muscle involvement and elevation of serum muscle enzymes such as
creatine kinase and aldolase are characteristic.
o Corticosteroids are the accepted treatment of choice
There is little evidence that femoral anteversion causes long-term
functional problems.
o Studies have shown that shoe wedges, torque heels, and twister cable splints
are not effective.
o

Surgery should be reserved for children 8-10 years of age who still have
cosmetically unacceptable, dysfunctional gaits.
o Major complications of surgery occur in approximately 15% of cases, and can
include residual in-toeing, out-toeing, avascular necrosis of the femoral head,
osteomyelitis, fracture, valgus deformity, and loss of position.
o Thus, observation alone is appropriate treatment for a 5-year-old with
uncomplicated anteversion.
Hydroxychloroquine, is a well-known disease-modifying agent that can slow
the progression of rheumatoid arthritis.
Osteoarthritis causes changes predominantly in the proximal interphalangeal (PIP)
and distal interphalangeal (DIP) joints of the hands known as Bouchards and
Heberdens nodes respectively, and the carpometacarpal joints of the thumbs.
rheumatoid arthritis commonly causes subluxations in the metacarpophalangeal
joints,
Allopurinol can cause temporary wasting of acute gout
A therapeutic exercise program will reduce both pain and disability in patients with
osteoarthritis of the knee.
o There is no evidence to support the use of capsaicin cream, but NSAIDs will
reduce pain and there are proven therapies that will improve function of the
patients knee. While intra-articular corticosteroids are effective in relieving
pain in the short term (up to 4 weeks), there is no evidence for long-term
efficacy. There is not good evidence to support the use of glucosamine for
treating osteoarthritis of the knee.
Acute monoarthritis in adults is most commonly caused by infection, trauma, or
crystal deposition.
o Rheumatoid arthritis seldom presents as monoarthritis, and more often has a
subacute course with multiple, symmetric joints involved. Having a normal
uric acid level suggests against gout, but does not rule it out. Also, gout is
seven times more likely to be seen in males, whereas pseudogout is 1.5 times
more frequent in females. Pseudogout most often affects the elderly, and
usually affects the knee, wrist, and ankle. Gout presents most commonly in
the first metatarsophalangeal joint and insteps of the feet, but also can occur
in the knee, wrist, finger, and olecranon bursa. Differentiating between gout
and pseudogout can be difficult and is best done by analysis of joint fluid.
uncomplicated lateral ankle sprains require minimal intervention.
o The Ottawa ankle rules were developed to determine when radiographs are
needed for ankle sprains.

In summary, ankle radiographs should be done if the patient has:

pain at the medial or lateral malleolus and either bone

tenderness at the back edge or tip of the lateral or medial
malleolus, or an inability to bear weight immediately after the
injury or in the emergency department, or both.
If the patient complains of midfoot pain and/or bone tenderness
at the base of the fifth metatarsal or navicular, or an inability to
bear weight, radiographs should be ordered.
Sprains can be differentiated from major partial or
complete ligamentous tears by anteroposterior, lateral,
and 30 degrees internal oblique (mortise view)
radiographs.
o If the joint cleft between either malleolus and the talus is
>4 mm, a major ligamentous tear is probable. Stress
o

radiographs in forced inversion are sometimes helpful to

demonstrate stability, but ankle instability can be
present with a normal stress radiograph.
o Grade I and II ankle sprains are best treated with RICE
(rest, ice, compression, elevation) and an air splint for
ambulation. NSAIDs are used for control of pain and
inflammation. Heat should not be applied.
o Early range-of-motion exercises should be initiated to
maintain flexibility.
o
Weight bearing is appropriate as tolerated and
functional rehabilitation should be started when pain
permits. Exercises on a balance board will help develop
coordination.
Avascular necrosis is the most serious complication of a slipped capital
femoral epiphysis, and leads to more rapid arthritic deterioration. It may
require hip fusion and total hip replacement early in adulthood
The anterior fontanelle in the newborn is normally 0.63.6 cm, with the mean
size being 2.1 cm. It may actually enlarge the first few months, but the medial age of
closure is 13.8 months.
o The anterior fontanelle closes at 3 months in 1% of cases, and by 1 year, 38%
are closed.
o While early closure of the anterior fontanelle may be normal, the head
circumference must be carefully monitored.
o Monitor for craniosynostosis (premature closure of one or more sutures) and
for abnormal brain development.
When craniosynostosis is suspected, a skull radiograph is useful for
initial evaluation. If craniosynostosis is seen on the film, a CT scan
should be obtained
When the flexion abduction external rotation (FABER) test elicits pain posteriorly, it
indicates sacroiliac involvement. Anterior pain indicates hip involvement.
most common knee conditions in children and adolescents
o patellar subluxation, tibial apophysitis, and patellar tendinitis.
Gout, osteoarthritis, and popliteal cysts present in older adults. Inflammatory
arthritis is more common in adults than in children.
tramadol can be used for management of persistent pain in old people.
o It has an efficacy and safety similar to those of equianalgesic doses of codeine
and hydrocodone.
o
However, because of the threat of seizures (rare but potential), tramadol
should be used with caution in patients with a history of seizure disorder or
those taking other medications that lower seizure thresholds
treatments for male osteoporosis are alendronate and recombinant parathyroid
hormone.
a possible scaphoid fracture. This fracture is important to diagnose and treat
appropriately because of a high rate of non-union.
o If radiographs are negative, the patient should be placed in a thumb spica
splint and have repeat radiographs in 2 weeks, because initial studies may be
negative.
Falling is one of the most common adverse events associated with drugs.
The elderly frequently take many medications; reducing these medications also
reduces the risk of falling. SSRIs, tricyclic antidepressants, benzodiazepines, and
anticonvulsants have the strongest association with falls in the elderly.

The highest risk for falling occurs immediately after hospital stays and lasts
for about a month. Ambulatory blood pressure monitoring is associated with
so many false-negative and false-positive results that it cannot be
recommended for all patients who fall.
Arthritis and vision problems are both strongly associated with an increased
risk of falls

SPECIAL SENSORY
Uncomplicated Acute Otitis Media: treat with Amoxicillin
About 3% of persons over age 55 have glaucoma, making it a leading cause of vision
impairment. Although it is usually asymptomatic, the most common presenting symptom is tunnel
vision, a gradual loss of peripheral vision.
Macular degeneration: MCC cause of blindness in individuals over 65
Penicillin can be used to treat dental infections
prescribe oral fluoride supplementation at currently recommended dosages to preschool-aged
children older than 6 months of age whose primary water source is deficient in fluoride
CMV is the most common congenital infection and occurs in up to 2.2% of newborns.
o It is the leading cause of congenital hearing loss.
Vitreous detachment is very common after age 60 and occurs frequently in younger persons
with myopia.
o The separation of the posterior aspect of the vitreous from the retina exerts traction on
the retina, with the attendant risks of a retinal tear and detachment.
Dental infections complicated by the development of cellulitis should be treated with oral
antibiotic therapy. The antibiotic of choice is penicillin. Clindamycin should be used if a patient is
allergic to penicillin.