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M D L - - - P a g e |1 Primary Skin Lesions A change in skin color with no depression or elevation and is non-palpable. A large macule.

A raised circumscribed area of the skin that is superficial, palpable with no fluid inside. A large papule. Similar to papule but deeper skin layer involvement. A raised circumscribed area of the skin that is superficial, palpable with fluid inside. A large vesicle. A raised circumscribed area of the skin that is superficial, palpable with pus inside. A large body of cavity containing solid, semi-solid, or liquid. A raised, red, flat, circumscribed area of the skin with a depressed, normal center.

Macule Patch Papule Plaque Nodule Vesicle Bulla Pustule Cyst Wheal Teleangiectesia

Secondary Skin Lesions Ulcer Erosion Excoriation Lichenification Crust Scale Atrophy Scar Skin Bleeding Disorders Petechiae Purpura Ecchymosis

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M D L - - - P a g e |3 Complete Blood Count (CBC)

Normal Values 0.5-1.5% Reticulocyte

Effective iron therapy will increase levels.

4-6 milliion/mm3 RBC Hgb Hct MCV 35-50 g/dL 12-18% 80-100% 150,000-400,000 per mm3 Platelets Thrombocytopenia Thrombocytosis

WBC

Normal Values 4,000-10,000/mm3

White Blood Count Differential Leukemia Leukocytos


Increased levels indicate bacterial infection Decreased levels

60-70%
Neutrophils

Increased levels indicate viral infection

20-25%
Lymphocytes
Ultimately functions as a macrophage

3-8%
Monocytes
Increased levels indicate allergic reaction.

2-4%
Eosinophils

0.5-1%
Basophils

Increased levels indicate allergic reaction. Releases histamine

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M D L - - - P a g e |5 Basic Metabolic Panel

Sodium Glucose Potassium Chloride Calcium BUN

Normal Values 135-145 mg/dL 70-110 mg/dL 3.5-5.0 mEq 90-110 mg/dL 6-20

Liver disease Malnutrition Sickle cell anemia SIADH

Reduced effective circulating blood volume (prerenal azotemia) Catabolic states (gastrointestinal bleeding, corticosteroid use) High-protein diets Tetracycline

creatine

06-1.2

pH paCO2 paO2 HCO3

Normal Range 7.35-7.45 35-45 mmHg 80-100 mmHg 22-26 mEq/L

Arterial Blood Gases Acidosis hypoxemia

Alkalosis hypercapnia

Lipid Levels HDL LDL Triglycerides Total Cholesterol Normal values >50 or >40 <100 <150 <200

Virchows Triad

Centor Criteria

Pulmonary Embolism

H-ypercoagulability I-njury S-tasis F-ever A-nterior cervical adenopathy tenderness C-ough absence T-onsillar abscess H-emoptysis A-ngina

Risk of Clotting

Group A strep (GAS) criteria for performing rapid strep test

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D-yspnea Hepatic artery Hepatic portal vein Lymphatic vessels Nervus vagus nerve Bile duct Triglycerides >150mg/dL HDL <40mg/dL or 50mg/dL Fasting BS > 110mg/dL Abdomen >40 in BP >130/85 Pallor Pain Pulsellessness Paraesthesias Paralysis Poikilothermia 2 liters of fluid 2 tylenol #3 2 grams ceftriaxone IV can go home if temp drops 2 degrees and can tolerate 2 glasses of water 2 TMP/SMX DS 2xdaily for 2 weeks Follow up in 2 days

Portal Triad

Metabolic syndrome

Arterial Embolism

The rule of 2s

Treatment of uncomplicated pyelonephritis

Skull Anatomy

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M D L - - - P a g e |9 Non-Steroidal Anti-inflammatory Drugs(NSAID)


Drug Name Ibuprofen Indomethacin Ketorolac Action Inhibits COX1&2 enzymes preventing synthesis of inflammatory mediator prostaglandins Indications Inflammatory associated pain Common side effects GI bleeding Nephrotoxic Hepatotoxic Notes Ibuprofen & Ketorolac have antipyretic effects Indomethacin best used for gouty arthritis

Antihyperuricemics
Drug Name Allopurinol Action Inhibits xanthine oxidase, an enzyme that turns purines to uric acid. Prevents white blood cell inflammatory response to uric acid joint accumulation Increases uric acid secretion in the renal tubules. Indication Prevention of gout attacks Common side effects Rash Aplastic anemia, agranulocytosis, Nausea, vomiting Aplastic anemia Nausea, vomiting Noted Discontinue immediately if rash occurs May use high doses for gout attacks May be combined with penicillin to increase PCN concentration

Colchicine Probenecid

Prevention of acute attack Hyperuricemia

Joint Disorders Disorders Pathophysiology


Osteoarthritis or Disc Degenerative Disease Rheumatoid Arthritis Noninflammatory, disease of aging,, wear and tear of joints. Commonly on weight bearing joints. Autoimmune inflammatory disorder mainly manifests in joints as synovitis. May affect cervical spine. Does not affect the rest of spinal regions. May lead to carpal tunnel due to median nerve compression Inflammatory joint pain due to urate crystals accumulation. Overproduction or under secretion of uric acid Acute attack associated with fluctuating levels of urates. Primary: heredetary Secondary:Drugs (e.g. Thiazides & Loop), alcohol, purine diet. Joint pain & inflammation associated with calcium metabolic disorders resulting in calcium deposits in joints Mostly seen on patients age 60 or older.

Signs & Symptoms


Heberdens and Bouchards nodes Monoarticular Starts distal (PIP,DIP) Morning stiffness and joint pain (early) Swan neck/Boutonniere Symmetric, polyarticular Starts proximal (MCP) Phalangeal ulnar deviation Usually monoarticular 1st metetarsophalangeal joint is common (Podagra)

Diagnostic
X-ray shows joint space narrowing with osteophytes Rheumatoid factor

Treatment
Non weight-bearing exercises. Drugs: NSAIDs other analgesics 1st DMARDs slows progression NSAIDS (used in conjunction only)

Gouty Arthritis

Joint fluid: Needleshaped urate crystals (white,chalky,crystals) or tophi. Abnormal urate serum levels Acute attack: ESR and WBC Joint Fluid: Rhomboidshaped calcium salts Normal urate serum Calcifications in xray

Acute attack: 1st NSAIDs (indomethacin), corticosteroids alternatively Control: Allopurinol, colchicine, probenecid *Asymptomatic hyperurecemia is not treated NSAIDs or COX-2 inhibitor (if NSAID not tolerated due to GI problems)

Pseudogout

Commonly seen in large weight-bearing joints & wrist

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M D L - - - P a g e | 11 Joint Infections (Infectious Arthritis) Disease Pathophysiology


Nongonococcal Arthritis (Acute bacterial arthritis or Septic arthritis) Articular infection usually caused by underlying infection outside the joints. At risk: Immunocompromised Common cause: Gram +: S.aureus Gram -: E.coli, P.aeruginosa At risk: Healthy young women during menses or pregnancy Pathogen: N.gonorrheae

Signs and symptoms


Acute onset Monoarticular Commonly seen in large weight-bearing joints & wrist Joint pain, swelling Fever, Chills Prodromal migratory polyarthralgia Tenosynovitis Suppurative synovial fluid Necrotic pustules on palms and soles

Diagnostic
Joint fluid: WBC >50,000/mcl gram stain Blood culture

Treatment
Splint and elevate Empiric treatment with antibiotics and drainage Broad-spectrum abx until culture results If MRSA:Vancomycin

Gonococcal Arthritis

Joint fluid: WBC 30,000-60,000/mcL gram stain Blood,Urethral,Throat and Rectal cultures

Ceftriaxone 1gm IV

Types of Headache Headaches Description


Mostly affects women Most common but less commonly seen in clinics due to OTC treatment Worse at the end of the day or during stress

Signs and symptoms


Non pulsatile, vise-like,band-like Generalized, but more prominent on neck and occipital area No nausea and vomiting No aura

Treatment
OTC analgesics (NSAIDs, acetaminophen, aspirin) and/or caffeine

Tension

Migraine

Mostly affects women Commonly seen in office visits due to severity and ineffective OTC control

Usually pulsatile Mostly unilateral, may be periorbital Nausea & vomiting are common May be preceded by aura or visual disturbances

Cluster

Seen mostly in middle-aged men Pain occurs sama time each day

Severe pain Unilateral, periorbital Ipsilateral rhinorrhea, facial erythema, eye redness, tearing Associated with Horner syndrome

Avoidance of noxious stimuli Abortive(acute): 1st sumatriptan or other 5HT1 antagonist (-triptans) may combine naproxen Ergotamine (avoid in pregnancy) may be combined with caffeine Preventative: -blockers, Calcium channel blockers, antidepressants, antiseizure, botulinum toxin injection Oxygen Sumatriptan or other 5HT1 antagonist Preventive: Ergotamine, corticosteroids, calcium channel blockers, lithium

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M D L - - - P a g e | 13 Central Nervous System Infections Disorders Pathophysiology


Bacterial Meningitis Bacterial infection of meninges, results to inflammation. Complications: Brain abscess2 (commonly S.aureus) Common pathogens: S.pneumoniae, N.meningitidis Common form of meningitis Viral infection of meninges, results in inflammation. Complications: Brain abscess2 Common pathogens: Enteroviruses, HSV2 Viral infection of the cerebral cortex, results in inflammation

Signs and symptoms


Nuchal rigidity Petechial rash Headache Fever Nausea and vomiting

Diagnostic
CT head1 Lumbar puncture(LP) CSF analysis: -Glucose: -PMN-type pleocytosis Microscopy smear: pos Culture: negative Blood cultures CT head1 Lumbar puncture(LP) CSF analysis: -Glucose:Normal -lymphocytic pleocytosis Microscopy smear: neg Culture: negative CT head1 Lumbar Puncture -normal to lymphocytic -DNA PCR

Treatment
If severe, do not delay antibiotics Cefotaxime or ceftriaxone add Vancomycin as needed add Ampicillinas needed intracranial pressure(ICP): Hyperventilation, Mannitol, Corticosteroids Self-limiting Mainly observation

Viral Meningitis (aka Aseptic Meningitis)

Nuchal rigidity Petechial rash, occasional Headache Fever Nausea and vomiting If HSV2, genital lesions

High mortality if not treated Empiric parenteral Complication acyclovir every 8 hours Brain hemorrhage (10mg/kg) Common pathogens: *Brain biopsy if not May have residual/sequela Herpes simplex virus 1(HSV1) responding to treatment symptoms after treatment 1 CT head prior to LP if evidence of ICP (e.g. papilledema, seizures, focal or lateral neurological deficits) to avoid cerebral herniation. Common CT findings that might contraindicate LP includes, but not limited to, space-occupying lesions, mass, or abscess. 2 Brain abscess or cerebritis requires empiric treatment of metronidazole and ceftriaxone with or without vancomycin. If severe, consider drainage. Viral Encephalitis Flu-like prodrome Marked neurologic deficit Altered to comatose Grand mal or focal seizures Headache Fever

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M D L - - - P a g e | 15 Ear Disorders Disorders


Otitis Externa (OE) (aka Swimmers ear) Acute Otitis media(AOM)

Pathophysiology
External ear infection commonly caused by Pseudomonas aeruginosa, related to prolonged moisture. Usually preceded by URI causing Eustachian tube dysfunction, increased pressure, serous fluid retention, and bacterial growth commonly: S.pneumoniae, H.influezae

Signs & symptoms


Otalgia, erythema, edema, pruritus on ear canal, pinna. Tympanic membrane may be erythematous. Fever Erythema and immobile tympanic membrane Otalgia, decreased hearing

Diagnostic
Primarily by visual examination using otoscope.

Treatment
Polymyxin B, neomycin drops May use hydrocortisone in conjunction Oral ciprofloxacin Drugs: 1st Amoxicillin -Erythromycin(if hypersensitive) 2nd Cefaclor or Amoxicillinclavulanate Recurrent: Low dose Bactrim or Amoxicillin

Primarily by visual examination using otoscope. May perform tympanocentesis for culture & sensitivity (C&S) of prolonged AOM.

Serous Otitis Media (SOM)

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M D L - - - P a g e | 17 Throat Disorders Disorders Pathophysiology

Signs & symptoms

Diagnostic

Treatment

No

I II III IV V VI VII VIII IX X XI XII

Name Olfactory Optic Occulomotor Trochlear Ophthalmic Maxillary Trigeminal Mandibular Abducens Facial Vestibular Auditory Cochlear Glossopharyngeal Vagus Accessory Hypoglossal

Cranial Nerves Function


Transmits impulse for smell (and taste) Transmits impulse for vision Innervation: superior,medial, inferior recti, inferior oblique, and levator palpebrae superioris Innervation: Superior oblique Transmits sensation of the face on the upper portion Transmits sensation of the face on the middle portion Innervation: muscles for mastication, tensor tympani Transmits sensation of the face on the middle portion Innervation: lateral rectus Innervation: facial muscles Stapedius muscle Transmits impulse for balance Transmits impulse for hearing Innervation Innervation Innervation: Sternocleidomastoid and trapezius Innervation: Most tongue muscles

Sensory

Motor

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Lung anatomy

Main complaint Body type Hemoglobin Lung auscultation PaO2 PaCO2 Diaphragm
1

Emphysema Alveolar malformation due to destruction of supporting inner walls of the air sacs resulting from alveolar collapse (atelectasis). Mostly associated with alpha-1 antitrypsin deficiency1. Dyspnea Thin normal Diminished Normal to slightly reduced Normal to slightly reduced flattened

Chronic Bronchitis Chronic inflammation of the airways with severe mucus production for 3 months or more within at least 2 years consecutively. Chronic productive cough Frequently overweight Usually elevated Noisy, rhonchi, wheezing Decreased Decreased Not flattened

Alpha-1 antitrypsin- inhibits trypsin. Controls extreme breaking down of the alveolar walls by trypsin. Trypsin- enzyme that is constantly excreted by the respiratory tract to destroy alveolar lining which is constantly replaced.

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Treatments

Long acting -adrenergics

Inhaled corticosteroids
-adrenergics

high moderate low

Severity Number of episodes

Step 1 intermittent
Less than 2 per week

Step 2 mild
More than 2 per week

Step 3 moderate
daily

Step 4 severe
Throughout the day

Beta adrenergic agonists


Drug Name Rapid acting Short acting Long acting Epinephrine Albuterol Levalbuterol Salmeterol Actions Smooth muscle relaxation Bronchodilation Indications Bronchoconstriction Asthma or reactive airway disease Common Side Effects Tachycardia palpitations Anxiety tremors Notes

Leukotriene inhibitors
Drug Name zafirlukast montelukast Actions Blocks leukotrienes inflammation Mucous production bronchoconstriction Indications Chronic asthma Common Side Effects Headache Cough GI upset Notes

Mast Cell Stabilizers


Drug Name Cromolyn Nedocromil Actions Indications Common Side Effects Notes

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M D L - - - P a g e | 23 Glucocorticosteroids
Drug Name oral inhaled Prednisone Dexamethasone Fluticasone propionate Budesonide Beclomethasone Methylprednisolone Dexamethasone Hydrocortisone Actions Antiinflammatory effect Indications Controls chronic inflammation Common Side Effects Hyperglycemia GI ulceration Insomnia Osteoporosis Mood swings Hunger Notes

IV

Antihistamines
Drug Name Diphenhydramine Loratadine Fexofenadine cetirizine Actions Blocks histamine receptors Sedation Dries mucosa Indications Allergy Insomnia Common Side Effects Dry mucus membranes Sedative effect Notes

Decongestants
Drug Name Pseudoephedrine phenylephrine Oxymetazoline Budesonide Fluticasone propionate Actions Decrease swelling of nasal blood vessels Indications Common Side Effects Notes

Anticholinergics Drug Name


Ipratropium tiotropium

Actions
Blocks parasympathetic response

Indications
Control asthma And COPD

Common Side Effects


Drying of mucosa Headache GI upset

Notes

Xathines Drug Name


Theophylline Aminophylline

Actions
Bronchodilation

Indications
Mild asthma Concurrent treatment for COPD

Common Side Effects


Tachycardia Palpitations headache

Notes
Theophylline therapeutic drug level: 10-20 mcg/mL

Antitussives
Drug Name
narcotic

Actions Codeine Suppress cough reflex in medulla

Indications Non-productive cough

Common Side Effects Itching,rash Constipation Sedation

Notes

Nonnarcotics

Dextromethorphan Benzonatate Numbs stretch receptors in respiratory tract

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Expectorant
Drug Name Guaifenesin Actions Thin mucous secretion Indications Productive cough Common Side Effects N/V Notes

Mucolytics
Drug Name acetylcysteine Dornase alfa Actions Breaks down pulmonary secretions Indications Thick productive cough Common Side Effects N/V Notes Used as antidote for acetaminophenl overdose

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M D L - - - P a g e | 27 JNC7 Hypertension classifications Systolic Prehypertension 120-139 Stage 1 140-159 Stage 2 >160

Diastolic 80-89 90-99 >100

Primary complaint Associated complaints Common cause

Right Sided Failure Fatigue Edema LVHF

Left Sided Failure Dyspnea Hypertension

Note: In general, Right sided = Body, Left sided = Lungs

Skin color Skin character Pedal Pulses Walking Edema Skin temp Leg elevation

Arterial Insufficiency Pallor Thin and shiny Diminished to absent Increased pain None Cool to touch Increased pain

Venous Insufficiency Brown/Dusky Dry, scaly Palpable constant Present Normal Decreased pain

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M D L - - - P a g e | 29 Angiotensin I Converting Enzyme Inhibitor (ACE-I) (-pril)


Drug Name Lisinopril Captopril Enalaprilat Actions Indications Common Side Effects Hypotension Cough Angioedema Notes

Angiotensin II Receptor Blockers (ARB) (-sartan)


Drug Name Valsartan Losartan Actions Indications Common Side Effects Notes

Beta-Blocker (-olol)
Drug Name Metoprolol Atenolol Timolol Actions Negative chronotropic and inotropic effects Indications Common Side Effects Bradycardia Hypotension Notes

Calcium Channel Blockers


Drug Name Diltiazem Verapamil Nefedipine Actions Indications Common Side Effects Notes

Diuretics
Drug Name Furosemide
Loop

Actions

Indications

Common side effects Hypokalemia Hearing loss

Notes

Bumetanide Hydrochlorothiazide
Thiazides

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Aldactone
Potassium Sparing

Hyperkalemia

Spironolactone

Aldosterone antagonists

HMG Co-enzyme A reductase Inhibitor (-statin)


Drug Name Simvastatin Rosuvastatin Atorvastatin Pravastatin Actions Indications Common Side Effects Myalagia Muscle weakness Notes

Fibrates
Drug Name gemfibrozil Actions Indications Common Side Effects Notes

Bile acid sequestrans


Drug Name Cholesteramine Actions Indications Common Side Effects Notes

Niacin
Drug Name NIacin Actions Indications Common Side Effects Notes

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Associated Diseases
Staphylococcus aureus epidermidis saprophyticus -hemolytic -hemolytic Clostridium Skin infections, diarrhea(toxin) UTI Pharyngitis, Rheumatic fever Pneumonia, Otitis media, sinusitis, meningitis

Streptococcus

Gram Positive

Corynebacterium Bacillus Listeria Actinomyces Nocardia

Group A Group B pneumoniae viridan botulinum perfringens tetani diptheriae monocytogenes

cocci

pyogenes agalactiae

Gangrene Tetanus Diptheria

Bacilli

Associated Diseases
Haemophilus Bordatella Legionella Klebsiella Serratia Proteus Enterobacter Yersinia Francisella Pasteurella rods influenzae pertussis pneumoniae Mirabilis pestis Plague Tularemia Dog/cat bites epiglotitis pertussis pneumonia

anaerobic

facultative
cocci

moraxella Neiseria

catarrhalis gonorrhea meningitidis aeruginosa

Otitis media Gonorrhea Meningitis Otitis externa

Gram Negative

rods

Pseudomonas

Aerobic

cocci

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M D L - - - P a g e | 35 Beta Lactam Antibiotics


Drug Name Penicillins Penicilin G Penicillin V K Amoxicillin Ampicillin Cephalosphorins(by generations) 1st Cephalexin Cefazolin 2nd Cefaclor Cefamandole cefoxitin Ceftibuten Ceftriaxone Cefepime Actions Prevents bacterial wall synthesis Indications Primarily Gram positive infections Common Side Effects Anaphylaxis Notes

Primarily Gram positive infections Moderate Gram positive & negative infections Primarily Gram negative infections Penetrates CSF

-lactamase susceptible -lactamase resistance

3rd 4th

Macrolides (-thromycin)
Drug Name Erythromycin Azithromycin Clarithromycin Actions Indications Gram positive, spirochetes, N.gonorrhea, C.trachomatis Common Side Effects GI upset Antibiotic-associated colitis Notes 2nd line therapy if PCN allergic Avoid use with antifungals

Aminoglycosides (-mycin)
Drug Name Gentamycin Actions Indications Broad spectrum Severe systemic infections Common Side Effects Ototoxic Nephrotoxic Notes Monitor tinnitus, vertigo, hearing loss, BUN, creatinine, urine output Monitor peak & trough levels

Tobramycin Garamycin

Tetracyclines (-cycline)
Drug Name Doxycyclines Tetracycline Actions Indications Common Side Effects Notes

Flouroquinolones/quinolones (-ofloxacin)
Drug Name Levofloxacin Ciprofloxacin Moxifloxacin Actions Indications Broad spectrum Levo: Gram positive & negative, respiratory tract infections Cipro: Gram negative infections , urinary tract infections Common Side Effects Tendon rupture Nephrotoxic Cardiotoxic Peripheral neuropathy Notes Avoid in pregnancy Monitor renal function Cipro: meningitis and anthrax prophylaxis.

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Sulfonamides
Drug Name Sulfamethoxazole Sulfasalazine Actions Inhibits enzymes necessary for folate synthesis Indications Gram positive and negative infections MRSA Prophylactic therapy for UTI, Otitis Media Common Side Effects Hypersensitivity GI upset Pancytopenia Neonatal Jaundice Folic acid deficiency Notes Avoid with sulfa drugs sensitivity & its derivatives: (thiazide & loop diuretics, COX2 inhibitors, sulfonylureas) Avoid in pregnancy, neonates Sulfasalazine: mostly used as anti-inflammatory agent for Crohns disease & ulcerative colitis Sulfamethoxazole: combined with trimethoprim

Antitubercular
Drug Name Isoniazid Rifampin Ethambutol Pyrazinamide Actions Indications Common Side Effects Notes

Key Concepts: Small intestines-watery diarrhea Large intestine or colon bloody diarrhea

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Viral gastroenteritis
Pathogens Description Transmission Populations at risk Signs and symptoms Incubation Duration Climate Associated Places Vaccine availability Treatment Rotavirus Most common endemic gastroenteritis in infants Fecal-oral Infants and young children vomiting, watery diarrhea (mild to severe) 1 to 3 days 1 to 3 days Peaks in cooler months Infant-care, Child-care settings Yes (RotaTeq) Rehydration Norovirus Major cause of epidemic gastroenteritis outbreaks Fecal-oral Greater than 5 years of age Nausea/vomiting, diarrhea(mild), abdominal cramping 12 to 48 hours 5 to 7 days Peak in winter months Cruise ships, military, athletic gyms None Rehydrate as needed Adenovirus 2nd most common endemic gastroenteritis in infants Person to person Children less than 2 years old Fever Watery diarrhea more than 10 days Temperate climates Day care None

Bacterial Gastroenteritis
Pathogens Salmonella Typhoid S.typhi, S.paratyphi Nontyphoid S.enteritidis, S.typhimurium 8 to 24 hrs 0 to 3 days 104 to 108 Foodborne -undercooked poultry,meat Waterborne S.typhi Sensitive pea soup S.enterica -bloody flu-like prodrome Blood culture Shigella S.flexneri, S.sonnei most common in US May cause dysenteric colitis, toxic megacolon 36 to 72 hrs 2 to 7 days <100 Shiga toxin Person to person Campylobacter C.jejuni C.coli Leading cause of foodborne Vibrio V.cholerae Yersenia Y.enterocolitica Polyarthritis & erythema nodosum in children 24 to 48 hours 1 to 3 weeks 109 Foodborne Clostridium C.difficile May cause Fulminant colitis and Toxic megacolon dependent dependent Cytotoxin Antibiotic associated S.aureus Common cause food poisoning

General

Incubation Duration virulence Toxin

2 to 4 days 5 to 7 days More than 104 Foodborne -50% of poultry products

8 to 72 hrs 5 to 7 days 102 to 106 Cholera toxin Waterborne Foodborne

1 to 8 hrs 24 hours preformed Foods (Sugar and cream)

Route

Stool Signs & symptoms Diagnostic

Resistant Watery then Bloody, mucoid Tenesmus high fever Stool culture

sensitive HematocheziaBloody stool

Severe watery stool rice water Mimics appendicitis Stool culture

Mucoid, bloody

Watery stool Afebrile Severe n/v

Stool culture

Stool culture

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Climate Treatment Summer Ciprofloxacin or ceftriaxone Summer Tetracycline Winter Prompt Hydration Azithromycin

Hydration Bactrim or Ciprofloxacin

Tetracycline or quinolones

Flagyl or Vanco

Escherichiae Coli Gastroenteritis


Pathogens
General Incubation Duration virulence Toxin Route Gastric Acid Signs & symptoms Stool PMNs Climate Treatment ETEC EHEC EIEC

Parasitic Gastroenteritis
Pathogens
General Entamoeba hystolitica Amebiasis or Amoebic dysentery Least common in US May cause ulceration May migrate to liver and cause hepatic abscess, hepatomegaly 2 to 4 weeks Fecally contaminated water or food Gradual onset Mild to severe bloody diarrhea Abdominal pain Microscopy: cysts and tropozoites Serologic and antigen test Extraintestinal amebaiasis: leukocytosis, LFT Asymptomatic: Diloxadine Furoate(Luminal agent) Mild to Severe or Hepatic abscess: Metronidazole Giardia lambia Giardiasis nd 2 common parasitic gastroenteritis Cysts: infectious form Trophozoite: sensitive to gastric acid Malabsorption leads to diarrhea 1 to 3 weeks Fecal-oral untreated water sources (e.g. wilderness) Acute profuse and watery diarrhea Chronic greasy, malodorous diarrhea Abdominal cramping, bloating, malaise Microscopy: cysts and tropozoites Antigen test Cryptosporidium hominis Zoonotic Most common cause of parasitic gastroenteritis Acute and chronic diarrhea in immunocompromised patients 1 to 14 days Foodborne and waterborne Acute watery diarrhea Abdominal pain and cramps

Incubation Route

Signs & symptoms

Diagnostic

Microscopy acid-fast stain Antigen test

Treatment

Metronidazole or tinidazole

Paromomycin and nitazoxanide

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Pancreatic Disorder
Disorder Acute Pancreatitis Pathogenesis Pancreatic inflammation often associated with alcohol intake or a passed gallstone Signs and symptoms Severe epigastric pain radiating to back Seating & leaning forward relieves pain Hypoactive Bowel sounds Nausea and vomiting Fever Mild jaundice Diagnostic Leukocytosis lipase, amylase Treatment

Biliary Disorder
Disorder Cholelithiasis Pathogenesis Biliary stone formation, either calcium bilirubinate and/or cholesterol, due to over accumulation. At risk: Sickle cell, Diabetes, Obesity, Female, Native American, Rapid weight loss, pregnancy Caffeine use decreases risk Presence of Ca bilirubinate suggests hereditary disease. Complications: Pancreatitis, cholecystitis Gallbladder inflammation due mostly to duct blockage. Often precipitated by large/high fat meals Complications: Gallbladder Gangrene Chronic Gallbladder Signs and symptom Asymptomatic until obstruction. Biliary colicky pain Radiating to right scapula. Diagnostic Ultrasound X-ray: Calcium bilirubinate Treatment Laparoscopic cholecystectomy No treatment for asymptomatic cholelithiasis unless calcified, over 3cm, or other risks.

Acute Cholecystitis

Fever Nausea and vomiting Severe constant pain in RUQ or epigastrum Murphys sign

Ultrasound, HIDA scan Leukocytosis ALT,AST,amylase

Conservative: NPO, analgesics, cefoperazone and metronidazole Severe: Flouroquinolones and metronidazole Laparoscopic cholecystectomy

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M D L - - - P a g e | 45 Disorder Pathophysiology Signs and symptoms Diagnostic Treatment

Anorectal Disorders Disorder

Pathophysiology

Signs and symptoms

Diagnostic

Treatment

Gastrointestinal Disorders Disorder Pathophysiology


Irritable Bowel Syndrome At risk: late teens to 20s Idiopathic chronic intermittent abdominal pain. Related to abnormal motility, hypersensitivity of the viscera, post-infective gastroenteritis, and psychosomatic disorder. Types: IBS with diarrhea IBS with constipation IBS with mixed Break in mucosa due to impaired defenses or hyperacidity. Classified by anatomical involvement: Gastric & Duodenal ulcer Common cause: NSAIDs, H.pylori, hyperacidity Duodenal ulcer: Most common Adult men most at risk

Signs and symptoms


Pain relieved after defecation Change in stool appearance and frequency with onset Crampy, lower abdominal pain Nocturnal attacks not common Dyspepsia Non-cardiac chest pain Headache Fatigue General: Dyspepsia Duodenal: Pain relieved by food Pain after meals may disturb sleep Overweight Gastric: Pain exacerbated by food Pain with meals

Diagnostic
Presumptive Symptoms at least 3 mos. Avoid overtesting

Treatment
Supportive Dietary changes Symptomatic Drug Thearaphies: Antispasmodics Antidiarrheals Cathartics Neuroleptics Nonabsorbable abx(Rifaximin) 5HT3receptor agonist/antagonist Probiotics H.pylori Proton Pump Inhibitor (PPI), Clarithromycin, and Amoxicillin Non-H.pylori PPI or H2 receptor blocker

*Must perform tests only if symptoms warrant further investigation. EGD(diagnostic) Biopsy Gastric ulcer CBC: Anemia Blood Loss CBC: Leukocytosis Ulcer Perforation amylase Pancreatic

Peptic Ulcer Disease

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Bulb: most common Gastric ulcer: Older men most at risk Antrum: most common No sleep disturbance Anorexia H.pylori: Nausea perforation

Peptic Ulcer Disease Disorders Pathophysiology


Signs and symptoms

Diagnostic

Treatment

Dietary Disorders Disorders Pathophysiology


Celiac disease (Celiac sprue) Lactose Intolerance

Signs and symptoms

Diagnostic

Treatment

Inflammatory Bowel Diseases Disorders Pathophysiology


Crohns Disease Idiopathic regional GI tract inflammation and deep ulceration. Affects entire GI tract (commonly, terminal ileum and iliocecum) At risk population: 25-35y.o. Jewish, White male Complications: abscess, fistula, strictures, and perianal diseases Ulcerative Colitis Idiopathic mucosal inflammation of colon. confined in colon At risk population: 25-35y.o. Jewish,

Signs and symptoms


Insidious onset Chronic, recurrent Low grade fever Mainly non-bloody diarrhea RLQ abdominal pain May have autoimmune manifestations.

Diagnostic
Colonoscopy -Patchy inflammation may have anemia, hypoalbuminemia if severe ESR stool culture (usually positive) Biopsy- Granulomas *If significant fever,abd pain, leukocytosis. order CT to rule out abscess Sigmoidoscopy -Diffuse inflammation (avoid in severe) Anemia, hypoalbuminemia, ESR

Treatment
Diet: low-roughage,low lactose Malnutrition:NG feeding or TPN Drugs 1st line: Meselamine(mild to moderate) 2nd line:DMARDs(moderate to severe) Others: Anti-inflammatory (corticosteroids, sulfasalazine) Antibiotics (metronidazole,ciprofloxacin) Antineoplastics Parenteral Vitamin B12 Abcess: antibiotics or surgery Obstruction: fluids with NGT on suction Fistula: antineoplastics or surgery Mild to moderate: Proctitis,/sigmoiditis: meselamine or corticosteroid suppositories or PO if distal or unresponsive to therapy. Severe or unresponsive: NPO (24 to 48 hrs or until improved)

*Smoking increases severity of symptoms Chronic, recurrent Usually afebrile Bloody diarrhea Lower abdominal cramping Tenesmus (due to rectal inflammation)

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White male Complications: Fulminant colitis and Toxic megacolon stool culture (usually negative) *Smoking decreases severity of symptoms Avoid opiods and anticholinergics Parenteral corticosteroids, antineoplastics, and DMARDs Surgery curative, many complications Other treatments: Anti-inflammatory (sulfasalazine)

Antacids
Drug Name Magnesium Hydroxide Aluminum Carbonate Aluminum Hydroxide Calcium Carbonate Actions Neutralize gastric acid Indications Hyperacidity related symptoms: GERD, Peptic ulcer Disease(PUD) Common Side Effects Metabolic Alkalosis Constipation* Calcium: Rebound hyperacidity Notes *Magnesium may cause hypermagnesemia in RF and does not cause constipation. Calcium used in hypocalcemia

Histamine (H2) receptor blockers (-tidine)


Drug Name Famotidine Cimetidine Ranitidine Nizatidine Actions Blocks HCl secretion of parietal cells by binding to its H2 receptors Indications Hyperacidity related symptoms (GERD, PUD, Duodenal Ulcer, erosive esophagitis) Common Side Effects Thrombocytopenia Diarrhea, abdominal cramps, Azotemia Notes Can be used to manage urticaria

Proton-pump inhibitors (-prazole)


Drug Name Pantoprazole Omeprazole Lansoprazole Esomeprazole Actions Permanently blocks proton pump in parietal cells Indications Hyperacidity related symptoms (GERD, PUD,DU, erosive esophagitis) Common Side Effects GI upsets Notes Also used concurrently with antibiotics for treatment of H.pylori

Prostaglandins
Drug Name Misoprostol Actions Increase mucous and bicarbonate secretion Indications NSAID-related ulcer prevention Common Side Effects Miscarriage Notes Category X

GI protectant
Drug Name sucralfate Actions Provides protective coating on GI lining Indications existing GI ulcers Common Side Effects constipation Notes May be used with NSAID as ulcer prevention

Laxatives
Drug Name Psyllium Methylcellulose Bisacodyl Castor oil sennoside Docusate sodium Mineral oil Lactulose Sorbitol Polyethylene glycol Magnesium citrate Milk of magnesia Phosphate/Biphosphate Actions Increased bulk by binding with water present in GI tract Stimulates peristalsis Increase lipid contents in GI tract Increase water content by pulling water in GI tract Prevent water absorption in the GI tract Indications Common Side Effects GI obstruction Diarrhea Abdominal cramping Abdominal cramps Diarrhea Diarrhea Glycol used for bowel prep constipation Diarrhea Phosphate used for bowel prep may cause diarrhea PO:prevents constipation Enema:lubricate stool Lactulose used in hyperkalemia Notes Must drink plenty of water with medication for efficacy prevent side effect

Bulk forming

constipation

Stimulant Lubricant Hyperosmotic

constipation constipation constipation

Saline

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Emetics
Drug Name Ipecac syrup Actions Stimulates chemoreceptor trigger zone(CTZ) in CNS, inducing vomiting Indications Overdose/poison ingestion Common Side Effects Notes

Anti-emetics
Drug Name Anticholinergics Scopolamine Actions Inhibit muscarinic activity of acetylcholine Blocks H1 receptor In CNS to decrease stimulation Depresses (CTZ) in CNS inhibiting vomiting Peristalsis stimulation of upper GI tract Blocks serotonin receptors in CTZ and in vagal nerve terminals of GI tract Indications Nausea/vomiting Motion sickness Nausea/vomiting Motion sickness Common Side Effects Drowsiness Tachycardia,Dry mouth, urinary retention Drowsiness Neuroleptic malignant syndrome Extrapyramidal effects Neuroleptic malignant syndrome Extrapyramidal effects Headache Constipation Diarrhea Notes

Antihistamines

Promethazine Meclizine Prochlorperazine Droperidol Metoclopramide Ondansetron Dolasetron Palonosetron

Meclizine used also in vertigo -Has anticholinergic effects -Used also as antipsychotic and anxiolytic Also used in hiccups

Neuroleptics

Nausea/vomiting Nausea/vomiting Gastroparesis

Prokinetics 5-HT3 antagonists (--setron)

Nausea/vomiting

Cannabinoids

Dronabinol

CNS depression of vomiting in medulla oblangata

Intractable nausea/vomiting usually due chemotheraphy

Dry mouth CNS depression

-Active ingredient of marijuana -Used with AIDS patient (increases appetitie)

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Glomerular Disorders Disorders Pathophysiology


Nephritic syndrome Acute inflammation of glomeruli leading to decreased GFR. Decreased GFR increases sodium and water retention Volume overload resulting in increased vascular pressure. Marked protein loss due to enlarged podocyte pores of the glomeruli hypercoagulability state due to antithrombin loss *may lead to renal/ deep vein thrombosis ,PE

Signs & symptoms


edema(starts in periorbital & scrotal) Hypertensive

Diagnostic
red cell casts Urinalysis-Hematuria, mild proteinuria, may see pyuria. dysmorphic red cells Biopsy (if no risks) Serum creatine *Lordotic position may help increase red cell cast in sample Severe proteinuria (>3.5g/1.73m2/24hr) Hypoalbuminemia Hyperlipidemia Lipiduria-microscopy may show maltese-cross or grape clusters due to lipids

Treatment
Sodium restriction Water restriction Drugs Diuretics Corticosteroids (high dose) *Plasma exchange for Goodpasture disease Protein restriction Sodium restriction Drugs Diuretics Lipid lowering agents (if hyperlipidemic) Anticoagulants

Nephrotic syndrome (nephrosis)

Peripheral edema (sodium retention) Hypertensive *edema may progress leading to pleural effusion, pulmonary edema, ascites

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M D L - - - P a g e | 55 Urologic Disorders Disorders Pathophysiology


Urethral inflammation commonly caused by UTI pathogens Common pathogens: E.coli, S.saprophyticus STDs Candida, Trichomonas, Gonorrhea Urinary bladder infection commonly seen in women Related with sexual intercourse Greater than 3 per year needs prophylactic therapy Common pathogens: E.coli, enterococcus(Gram+)

Signs & symptoms


likely asymptomatic Dysuria Urethral meatus erythema Discharge likely afebrile Dysuria Suprapubic pain Gross hematuria

Diagnostic
Urine culture Urinalysis (UA)-Pyuria, Bacteriuria, Hematuria *Negative culture suggests STD infection Urinalysis (UA)-Pyuria, Bacteriuria, hematuria, nitrites, proteinuria

Treatment
Treatment of antibiotics must be based on culture Phenazopyridine for pain control

Urethritis

Cystitis (complicated or uncomplicated)

Fever, chills, HR Dysuria Usually unilateral Pyelonephritis costovertebral(CVA) tenderness (flank pain) Nausea and vomiting Altered mental status in elderly * CT/US if resistant *Empiric treatment approach used with both Cystitis (complicated or uncomplicated) and Pyelonephritis. *Non-empiric treatment approach used with Urethritis Renal pelvis and parenchyma bacterial infection via ureter (S.aureus via blood circulation) Common pathogens: Gram -:E.coli, Proteus, Klebsiella, Enterobacter, and Pseudomonas Gram +: enterococci(S.saprophyticus), S.aureus

*urine culture if resistant or complicated * Ultrasound and/or cystoscopy in men Urine culture Blood culture CBC-leukocytosis Urinalysis (UA)- Pyuria, Bacteriuria, hematuria Microscopy-WBC cast

Phenazopyridine (pain relief) Uncomplicated: quinolones, nitrofurantoin, Complicated: Quinolones Prophylaxis:Bactrim, Nitrofurantoin, Cephalexin *cultures after treatment Complicated: IV Ampicillin and aminoglycoside rule of 2s Uncomplicated: quinolones, nitrofurantoin * cultures after treatment *admit if pregnant

Gynecologic Disorders Disorders Pathophysiology


Pelvic Inflammatory Disease (Salphingitis, Endometritis) Polymicrobial infection of upper genital tract. Common pathogens: N.gonorrhea, C.trachomatis, H.influenzae Complications: Tubo-ovarian abscess Perihepatitis (Fitz-Hugh & Curtis syndrome) Most common cause of secondary dysmenorrhea. Extrauterine migration of endometrial tissue. Increased risk of infertility (may be curable with ablation)

Signs and Symptoms


Fever and chills Menstrual disorders Purulent cervical discharge Uterine, Adnexal, Cervical motion tenderness

Diagnostic
ESR CRP Cervical culture If uncertain: Biopsy Transvaginal sonography or MRI Laparoscopy Presumptive diagnosis and laparoscopy

Treatment
1st Cefoxitin 2gm IV q6h or Cefotetan 2 gm IV q12h Add: Doxycycline 100mg bid Tubo-ovarian abscess: Substitute doxycycline with Clindamycin *consider metronidazole 500mg bid for better anaerobic coverage Oral contraceptives Analgesics such as NSAIDs Surgical Implant ablation Total hysterectomy

Endometriosis

Pelvic pain w/ menstruation Dyspareunia Adnexal mass or tenderness Uterine retroversion

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M D L - - - P a g e | 57 Male Reproductive infection Disorders Pathophysiology


Acute Bacterial Prostatitis Bacterial infection of prostate via prostatic duct from urethra. Common causes: E.coli, Pseudomonas

Signs & symptoms


Fever Dysuria Perineal, suprapubic, pain Painful prostate on rectal exam(avoid massage) Urinary retention(avoid Foley) May be asymptomatic afebrile Dysuria Perineal, suprapubic, discomfort dull and boggy prostate on rectal exam Fever Unilateral testicular pain and palpable swelling May have tender prostate May be associated with UTI symptoms

Diagnostic
Urine culture Urinalysis (UA)-Pyuria, Bacteriuria, hematuria

Treatment
Emperic IV ampicillin & aminoglycoside then PO abx (quinolones) if afebrile Percutaneous suprapubic catheter for retention *Must perform cultures and prostatic secretion studies after treatment. Trimetoprim-sulbactam (good prostate penetration) others: carbenicillin, erythromycin, cephalexin, and quinolones

Chronic Bacterial Prostatitis

May be a complication of untreated acute prostatitis. Common causes: E.coli, Pseudomonas

Prostatic secretion culture Urinalysis (UA)-Normal

Acute Epididymitis

Acute inflammation and infection of the epididymis Common causes for <40 years old: STD-related pathogens (N.gonorrheae,C.trachomatis) > 40 years old: UTI-related pathogens

CBC-left shift Microscopy diplococci-N.gonorrhea only WBC-C.trachomatis UA-pyuria,bacteriuria, hematuria(UTI) Urine culture(UTI)

Scrotal elevation (trendelenburg) Treatment depends on pathogens. STD requires treatment of partners

Bacterial Sexually Transmitted Diseases Diseases Pathophysiology Signs and symptoms


Chlamydia Chlamydia trachomatis Most common Neonates may exhibit URI symptoms. Complications: Reiters syndrome Complications: Septic arthritis and Disseminated Gonorrhea Urethral discharge Dysuria, pyuria Unilateral tender fluctuant inguinal lymph node Afebrile May have vaginal discharge Urethral discharge yellow to green, profuse Dysuria, pyuria Tender inguinal lymph node May have vaginal discharge Dessiminated Gonorrhea: Fever, maculopapular rash Dysuria, pyuria Fever Insignificant penile discharge Primary Painless ulcer (chancre) Painless enlarged inguinal nodes Secondary Generalized skin and mucosal lesions, Condylomata lata Palmar and plantar rash Latent

Diagnostic
NAAT Microscopy shows presence of WBC, without pathogen. NAAT Microscopy shows diplococci Discharge culture

Treatment
Doxycycline 100mg bid x7days or Azithromycin 1gm PO single dose

*Empiric treatment Gonococcal Urethritis: Ceftriaxone and azithromycin Septic Arthritis and Disseminated Gonococcal: IV Ceftriaxone 1 gram *Empiric treatment Primary, secondary, early latent: Penicillin G 2.4mil U IM single dose Latent: Penicillin G 2.4mil U IM weekly x 3 Neurosyphillis: Parenteral Penicillin G Pregnant PCN-sensitive with neurosyphilis Desensitization to PCN titrate until 1.2mil units

Gonorrhea Neisseria gonorrhea

Syphillis (Treponema pallidum)

Dark field microscopy -ulcer swab shows spirochetes Serology VDRL & RPR(screening) FTA-ABS(confirmatory) * If asymptomatic with latent suspicion, perform confirmatory tests before treatment. *VDRL & RPR after treatment

*Empiric treatment if symptomatic.

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M D L - - - P a g e | 59 Viral Sexually Transmitted Diseases Pathogens


Herpes Simplex I Human Papilloma Virus

Signs and symptoms


Painful skin lesion

Treatment

Vaginitis Normal
Pathogens Pathogenesis

Bacterial
Multiple Overgrowth of pathogenic bacteria in the vaginal canal replacing normal flora, Lactobacillus, resulting to infection and inflammation Fishy odor

Candidiasis
Candida.albicans Excoriation, erythema on external genitalia Vulvovagintis Intense vulvar pruritus with Burning pain if excoriated Odorless White curd-like, cheesy Less than or equal to 4.5 KOH wet mount: Budding forms Branching form of hyphae or pseudohyphae Antifungal creams or Miconazole 1200mg vaginal suppository x1 Corticosteroid creams for relief Not recommended

Trichomonas
Trichomonas vaginalis Inflammation of labia and perineum. May be pruritic Petechiael cervix with erythema strawberry cervix Non-specific odor Yellow to green Frothy Greater than 4.5 Saline wet mount: Presence of mobile Flagellates Metronidazole 2gm PO x1 or Metronidazole 500mg PO bid x 7days

Whiff test (KOH) Discharge pH Microscopy

Clear to white 3.5 to 4.5

Non viscous White to gray discharge Greater than 4.5 Saline wet mount: Greater than 20% clue cells on HPF Decreased lactobacilli Metronidazole 500mg po bid x7 days or Metronidazole 5gm cream daily x5 days or Clindamycin 5gm cream qhs x5 days Not recommended

Presence of Lactobacillus Patient Treatment N/A

Partner treatment

N/A

Yes, with condom use or abstinence until cleared

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M D L - - - P a g e | 61 Immune Disorders Disorder Pathophysiology


Systemic Lupus Erythmatosus Chronic systemic autoimmune inflammatory disease. At risk: Young non-white women Complications: Glomerulonephritis, CNS Disease, Antiphospholipid syndrome

Signs and symptoms


Malar Rash, Discoid Rash (Sunlight exposed areas) Non-deforming Polyarthralgia Alopecia Oral ulcers Nervous system disorders Serousitis (e.g. pleura, pericardium) Reynauds phenomenon

Diagnostic
CBC-Hemolytic anemia, Leukopenia, thrombocytopenia ESR Serologic studies (e.g. ANA,anticardiolipin) VDRL(false positive) Renal studies (proteinuria, casts) *Monitor progress: C2,C3

Treatment
Rash and arthralgia (mild): Hydroxychloroquine or DHEA Severe: General: Corticosteroids Nephritis Immunosuppressives (e.g.Cyclophosphamide) Antiphopholipid syndrome Anticoagulants (e.g.coumadin)