High-Yield Shelf Notes

HIGH-YIELD SHELF NOTES

Surgery
Psychiatry
Obstetrics/gynecology
Medicine
Pediatrics

Young Kim, UCCOM c/o 2013
[email protected]

2 – 26
27 – 51
52 – 92
93 – 150
151 – 170

SURGERY

Surgery – Preoperative Care

––––––––––––––––– CV ISSUES –––––––––––––––––
Goldman’s index: cardiac risk factors in surgery –
JVD (#1), recent MI (#2), PVCs and arrhythmias, age
>70, emergency surgery, aortic stenosis
JVD: indicates CHF, #1 CV risk factor overall, give
β-blockers, Ca2+-channel blockers, digitalis, and
diuretics if possible before surgery
MI: previous MI increases risk of post-op MI, so
consult cards and order a stress test

Previous coronary angioplasty: high risk (33%) of
coronary restenosis, so stress test is indicated; if
angioplasty is recent, delay surgery for several
weeks

Delirium in liver failure: possible causes include
CNS abnormality, electrolyte imbalance, GI
bleeding, sepsis, or bacterial peritonitis; evaluate
for mental status change, and tap the ascites

Angina: indicates coronary artery disease, evaluate
for possible coronary revascularization

Ascitic leakage: high risk of bacterial peritonitis;
manage by sending fluid to lab, giving IV
antibiotics, and urgent hernia repair

AFib: give anticoagulation and β-blockers, and
cardiovert them to normal sinus rhythm
Carotid bruit: indicates carotid stenosis; indicated
for CEA if high grade (>70%) stenosis

MI within 30 days: very high risk, delay surgery
Family Hx of MI: get a concentrated cardiac FHx,
EKG, and exercise stress test to assess risk factors
↑cholesterol: increased risk of coronary artery
disease, but do not postpone surgery

Previous stroke: order a carotid duplex study, in
order to assess the carotid arteries

Hemorrhoids: suspect portal HTN in pt with
cirrhosis + hemorrhoids, high risk of hemorrhage
Malnutrition: indicated by recent weight loss (#1) or
albumin <3.0 (#2); give 7-10 days of pre-op nutritional
support ideally
––––––––––––––––– GU ISSUES –––––––––––––––––

Gangrenous toe: peripheral revascularization is
more urgent than a full cardiac work-up

Dysuria: get urinalysis and urine culture; if positive
for UTI, delay surgery until resolved

––––––––––––– RESPIRATORY ISSUES ––––––––––––
Premature ventricular contractions: at risk of
arrhythmia due to ventricular dysfunction,
indicated for stress test and echo
Ejection fraction: SV/EDV; normal EF >67%, an
EF<35% increases risk of operative MI
Diabetes: should be NPO 8 hours before surgery,
administer IVF with D5, check glucose morning of
surgery; if glucose >250 → 2/3 of insulin, if glucose
<250 → 1/2 of insulin
Hyperglycemia: ideal glucose is 100-250,
delay surgery until glucose is under control
Diabetic coma: absolute contraindication to
surgery; give IVF, correct acidosis and glucose
↓hct: important to determine underlying cause of
anemia, consider possible colorectal cancer

Smoking: up to 6× risk for post-op complications due
to compromised ventilation, must quit smoking for 2
months before surgery
COPD: give bronchodilators and try to improve
pulmonary status as much as possible
Severe COPD: very high risk for acute pulmonary
failure with surgery; teach patient about
incentive spirometry, give bronchodilators, and
mobilize post-op to prevent atelectasis
Green sputum: give oral antibiotics, and schedule
surgery after Tx is complete

Chronic renal failure: delay surgery until pt is stable,
dialysis started, and any other problems resolved
CRF × K+ measurement: needs to be obtained
immediately before surgery, since CRF can result
in rapid electrolyte imbalances
CRF × operative bleeding: renal failure causes
platelet dysfunction secondary to uremia;
give desmopressin or FFP, but not platelets
CRF × operative hypotension: many possible
causes, consider glucocorticoid (aldosterone)
deficiency in a pt who has taken steroids before
Kidney transplant pt: require perioperative steroids

Bloody sputum: indicates active infection or lung
cancer; requires a full work-up including CXR, CT
scan, and bronchoscopy

Post-op hyperkalemia: check EKG for peaked T
waves, Tx C BIG K DIe – calcium gluconate, bicarbinsulin-glucose, kayexalate, and dialysis

–––––––––––– HEPATOBILIARY ISSUES –––––––––––
↑hct: either hypovolemia or polycythemia; if
hypovolemic → delay until hydrated, if polycythemic
→ important to determine underlying cause

Acute cholecystitis: presents as fever, RUQ pain,
WBC>15; get U/S → IVF, abx, lap chole w/in 72 hours

Obesity: higher risk of HTN, cardiovascular disease,
post-op atelectasis, type 2 diabetes, DVTs; require
DVT prophylaxis and aggressive post-op pulmonary
care for preventing atelectasis

Child’s classification: stratifies risk of surgery in pts
with liver failure; measures 3 labs (albumin, bilirubin,
PT) and 3 clinical findings (encephalopathy, ascites,
nutrition)

HTN: diastolic BP >110 is high risk of CV complications,
β-blockers reduce overall risk

–––––––––––––– VALVULAR ISSUES –––––––––––––

Child’s group A: 0-5% mortality
Child’s group B: 10-15% mortality

Atherosclerosis: can present as acute coronary
syndome or peripheral vascular disease, always
evaluate pt’s cardiac risk factors
CV evaluation: EKG (and compare to old EKG),
persantine thallium stress test, dobutamine echo

Child’s group C: >25% mortality; not good surgical
candidates until Child’s status is improved
Alcohol use: delay surgery until pt has undergone
withdrawal, since post-op withdrawal syndrome has
a high risk of morbidity/mortality

LBBB: indicates underlying ischemic heart disease
RBBB: indicates significant pulmonary disease, but
can be normal in up to 10% of pts
Previous CABG: decreases cardiac risk if performed 6
months to 5 years before surgery, effect on cardiac
risk unclear if >5 years

Liver failure: make sure the pt is in a compensated
state, abstain from alcohol for 6-12 weeks, control
ascites, normalize nutrition status and coagulation
factors
Pressure necrosis on hernia: high risk of rupture
with a high mortality rate, requires urgent repair

Mitral stenosis: elevated LA pressure can lead to
cor pulmonale (PH+RVH); management includes
cards consult, prophyactic abx for endocarditis, can
go to surgery if stable
Mitral stenosis × CHF: high risk of mortality;
requires extensive cardiac work-up, EKG, echo,
and operative monitoring of cardiac status
Aortic stenosis: Sx triad of angina, dyspnea, syncope,
and high possibility of sudden death; requires
cardiac work-up and operative monitoring
Endocarditis prophylaxis: recommended for GI
procedures, GU procedures, and HEENT procedures
Cardiomyopathy: high risk of arrhythmias, CHF,
heart failure, and sudden death; manage with cards
consult and full cardiac work-up
–––––––––––––––––– GI ISSUES –––––––––––––––––
Bowel prep: decreases fecal mass and bacterial
content in the colon → prevents colon surgery

Surgery – Preoperative Care

complications; put pt on clears day before surgery,
NPO at midnight, and give a cathartic agent
GoLYTELY: an isotonic formula that causes no
change in electrolyte or water balance; fluid
remains in colon and causes a “volume washout”
Fleet’s Phospho-Soda: a sugar-rich, hypertonic
formula that works by drawing fluid into the GI
tract; risks include dehydration, metabolic
acidosis (loss of bicarb); avoid in diabetics
Magnesium citrate: an osmotic agent that draws
fluid into GI tract (mag is poorly absorbed); risks
include dehydration and hypermagnesemia; avoid
in renal failure
–––––––––––––––– OTHER ISSUES –––––––––––––––
Anesthesia of choice: multiple factors involved, so
it’s best to consult an anesthesiologist
Local anesthesia: ↓systemic effects, ↑pain
Spinal anesthesia: ↓pulmonary complications,
↓control over cardiac or vascular mechanisms
General anesthesia: ↑physiologic control,
↑pulmonary complications, ↓HR/BP
Aspirin use: stop aspirin use 7-10 days prior to
surgery, will affect platelet aggregation
NSAIDs use: stop NSAIDs 2 days prior, will affect
platelet aggregation
Cellulitis: active infections are associated with
higher risk of post-op wound infections; delay
surgery until infection is resolved

Surgery – Postoperative Care

––––––––––––––– POST-OP FLUIDS ––––––––––––––
Post-op fluid management: replace blood lost
during surgery + provide maintenance IVF + make up
for fluid loss in drains/NG tubes/fistulas
Surgical blood loss: replace in a 3:1 ratio with IVF
(e.g. replace 500mL blood loss with 1.5L NS or LR)
Maintenance IVF: administer D5½NS+KCl,
using the 100/50/20 rule for daily fluid
requirements, or 4/2/1 rule for hourly fluids
Drains/NG tubes/fistulas: fluid loss should be
replaced milliliter for milliliter with regard to
specific electrolyte content
Third space: fluid sequestered into ISF due to
inflammation or injury, mobilized 3-5 days after
recovery → requires decrease in IVF rate
––––––––– OPERATIVE COMPLICATIONS ––––––––
Malignant hyperthermia: T>104 following
anesthesia w/ high risk of myoglobinuria; Tx
dantrolene, 100% O2, and cooling blankets
Bacteremia: T>104 and chills within 1 hour of an
invasive procedure; get blood Cx ×3 and start
empiric abx
Aspiration: complication of awake intubations;
leads to sudden death, chemical pneumonitis, or
secondary pneumonia

toilet and incentive spirometry (can develop into
pneumonia on POD #3 if left untreated)

volume depletion (slow) or altered MS (rapid); give
D5½NS to correct imbalance

UTI: Dx urinalysis and urine Cx, Tx abx

Hyponatremia: due to SIADH or isotonic fluid loss w/
free water resorption, presents as coma and
convusions; Tx water restriction and LR/NS

Urosepsis: UTI + septic shock; presents as cloudy
urine, fever, hypotension, and ∆mental status;
Dx urinalysis and urine Cx, Tx empiric abx + IVF
DVT: Dx doppler studies, Tx heparin
Wound infection: Dx examine wound site for
erythema and fluctuance; if cellulitis → abx only,
if abscess → drain pus and BID dressing changes
IV infection: Tx remove catheter and
inflammation should resolve, all IV sites should be
rotated every 4 days for prevention
Suppurative phlebitis: infected thrombus at site
of venipuncture; Tx remove catheter and surgical
excision of infected vein to the first non-infected
branch, leave wound open, and give IV abx
GI fistula: causes leakage of GI contents from wound
site; Tx NPO, TPN, and protect abdominal wall until
body can heal itself
Non-healing fistula: factors that prevent healing
are FRIEND – foreign body, radiation, infection,
epithelialization, neoplasm, distal obstruction
Fistula × peritonitis: requires surgical exploration
Fistula × abscess: requires percutaneous drainage

Aspiration management: prevent via NPO and
antacids before intubating, Tx BAL and bronchodilators (steroids are useless)
Tension PTX: complication of intubation in weak or
traumatized lungs, presents as “difficulty to bag”,
progressive hypotension and JVD; Tx emergent
needle decompression + chest tube

Post-op chest pain: consider MI or massive PE
MI: presents as chest pain +/- other classic signs;
Dx CK-MB or troponin I, treat the complications
Massive PE: presents as chest pain, hypoxia, and
prominent JVD; Dx V-Q scan, Tx heparin → IVC
filter if PE recur while anticoagulated

––––––––––– POST-OP COMPLICATIONS ––––––––––
Normal urine output: at least 0.5-1 mL/kg/hr
Post-op urine retention: presents as a need to
void, but inability to do so; Tx straight cath at 6
shours post-op and Foley after 2nd straight cath

ARDS: presents as hypoxia due to septic shock, Tx
intubation w/ high PEEP and permissive hypercarbia,
then look for source of sepsis
Delirium tremens: presents as hallucinations in an
alcoholic POD #2-3, prevention is key and Tx is
controversial (benzodiazepines if choice is given)

UOP = 0: most likely a kinked or plugged Foley
UOP < 0.5: either fluid deficit (bleeding out) or
acute renal failure; give a bolus of 500mL IVF and
if UOP responds, then it’s due to fluid deficit
Post-op hematuria: consider bladder overdistention,
cancer, infection, kidney stones, trauma, prostatitis,
and cyclophosphamide; get urology consult
Post-op fever: consider the five Ws – wind
(atelectasis POD #1), water (UTI POD #3), walking
(DVT POD #5), wound infection (POD #7+), wonder
drug (drug-induced fever)
Atelectasis: partial lung collapse, Dx bilateral
inspiratory crackles, prevent with pulmonary

Hypokalemia: due to diarrhea or vomiting, give K+ at
a rate of <10 mEq/hr

Hepatic encephalopathy: presents as coma in a liver
failure pt s/p TIPS due to NH4+ toxicity
Wound dehiscence: presents as salmon-colored fluid
soaking dressings s/p open laparatomy POD #5;
stabilize wound site, surgical closure at a later date
Evisceration: dehiscence + intestines spilling out;
keep pt in bed and cover bowel w/ sterile dressings,
emergency surgical closure necessary
––––––––––– FLUIDS & ELECTROLYTES ––––––––––
Hypernatremia: every 3 Na+ over 140 indicates 1L
water loss (e.g. Na+ 146 = 2L water loss), presents as

Hyperkalemia: due to renal failure, aldosterone
blockers, or release from dead tissue (crush injury,
ischemic bowel, etc.); Tx C BIG K DIe – calcium
gluconate, bicarb-insulin-glucose, kayexalate, and
dialysis
Metabolic acidosis: pH<7.4 + HCO3<24, Tx correct
underlying problem (e.g. fluid resuscitation)
Metabolic alkalosis: pH>7.4 + HCO3>24, Tx KCl
Respiratory acidosis: pH<7.4 + CO2>40 due to
hypoventilation, Tx mechanical ventilation
Respiratory alkalosis: pH>7.4 + CO2<40 due to
hyperventilation caused by pain, fever, sepsis or
early ARDS; Tx correct underlying problem

Surgery – Wound Healing

––––––––––––––– WOUND HEALING –––––––––––––
Primary intention: close approximation of wound
edges via sutures or staples
Primary intention timing: epithelialized by POD
#2, max collagen in 5-7 days, avoid weight-lifting
for 4-6 weeks, complete healing by 6 months
(only 60-80% of original strength)
Secondary intention: contamined wounds left open
to prevent abscess formation; granulation tissue
forms first, then contraction via myofibroblasts,
then finally a delayed epithelialization
Third intention: wound initially left open, then
delayed primary closure afterwards
Secondary/tertiary intention timing: much more
delayed than healing by primary intention
Healing growth factors: PDGF, TGF-β, FGF, EGF
Suture knot: hard, knot-like structure below wound
site; absorbable sutures will resolve with time, nonabsorbable sutures can be taken out under lido/epi
Stitch abscess: infected suture that intermittently
drains pus, should be taken out under lido/epi
Incisional hernia: presents as bulging at wound site
with increased abd pressure (e.g. coughing), needs
to be repaired surgically
Red/sensitive scar: assuming no wound infection, it
could be completely normal; observe for 6 months
before considering surgical revision
Hypertrophic scar: raised scar within site of incision;
observe until scar is stable, then steroids + excision
Keloid: raised scar that extends beyond site of
incision; will grow back if excised
–––––––––––––– WOUND INFECTION ––––––––––––
Wound infection: red and tender area on incision
site; Tx drainage and BID wet-to-dry dressing
changes, no antibiotics unless cellulitis is spreading
Post-infection management: observation is slow
and can result in contractions; other options
include skin grafting (must have <105 bacteria per
gram of tissue) or healing by third intention
Wound types: clean, clean-contaminated,
contaminated, infected
Clean wounds: no entry into GI, GU, or
respiratory tracts; <1% infection rate, Tx primary
closure
Clean-contamined wounds: enters GI, GU, or
respiratory tract in a controlled manner;
<10% infection rate, Tx primary closure
Contaminated wounds: major wound
contamination (e.g. bowel spillage or stab
wounds); Tx secondary closure

Prophylactic abx: recommended for any cleancontaminated or contaminated procedures,
insertion of prosthetic material, immunosuppression,
or poor blood supply; give single dose 1 hour pre-op
and single dose post-op

Surgery – Cardiothoracic Surgery

–––––––––––––––– LUNG CANCERS ––––––––––––––

–––––––––––––––– LUNG DISEASES ––––––––––––––

Coin lesion: solitary pulmonary nodule on CXR;
DDx primary lung cancer, granuloma (TB or fungal),
hamartoma, metastatic cancers

Pleural effusion: fluid build-up in pleural space,
cancer in older pt until proven otherwise; DDx CHF,
bronchogenic carcinoma, mesothelioma, empyema,
pneumonia, TB effusions

Coin lesion management: first thing is always to
get an older CXR for comparison studies → if
suspicious, sputum cytology and CT scan

Pleural effusion management: get thoracentesis
and culture pleural fluid, and a pleural biopsy

Off-bypass coronary surgery: grafting of ITA or GSV
to coronary arteries without bypass in order to avoid
complications of bypass (e.g. general inflammatory
response); reserved for high-risk pts
Dilated cardiomyopathy: dilation of myocardium
causes systolic dysfunction leading to progressive
dyspnea and fatigue, often preceded by viral URI
DCM Px: 1/3 recover, 1/3 stay the same, 1/3 die

Benign coin lesions: calcification = granuloma,
bull’s-eye shape, popcorn shape = hamartoma,
air-crescent sign = aspergilloma, Southwest
region = coccidioidomycosis, Ohio river valley =
histoplasmosis
Indeterminate coin lesions: resection indicated
Malignant coin lesions: spiculations or 20+ packyear smoking = primary lung cancer, multiple
lesions = metastatic cancer; resection indicated
Lung cancer management: first thing is always CXR
→ if suspicious, sputum cytology and CT scan → if
still suspicious, bronchoscopy and mediastinoscopy
w/ biopsy (“tissue is the issue”)
NSCLC staging: stage I is local, stage II involves hilar
LN, stage III involves distal LN, stage IV is metastatic
cancer
NSCLC Tx: stage I/II → first get spirometry and
V/Q scans to see if pt is a surgical candidate,
then do pneumonectomy or sleeve lobectomy;
stage III/IV → chemotherapy and radiation
Surgery contraindications: FEV1 <800mL,
mediastinal LN involvement, distal metastases
SCLC staging: limited stage involves ipsilateral lung
only, extensive stage involves contralateral lung
SCLC Tx: chemotherapy and radiation
Pancoast tumor: superior sulcus tumor at the apex
of the lung; presents as Horner syndrome – ipsilateral
ptosis, miosis, anhidrosis, flushing due to loss of
sympathetic tone (invades superior cervical ganglia)

Spontaneous PTX: rupture of apical blebs in healthy
young people causes sudden chest pain and dyspnea;
Tx thoracostomy on water-seal drainage
Recurrent/persistent PTX: indicated for thorascopic
excision of blebs, and pleurodesis (either scraping or
talc application) causing pleural adhesions
Bilateral PTX: dangerous situation, indicated for
pleurodesis to prevent future recurrences
Empyema: collection of pus within pleural cavity;
presents with cough, fever, chest pain, and pleural
effusion on CT scan; MCC is Staph aureus
Empyema Tx: initiate appropriate antibiotics,
insert chest tube, evacuate pus collection, then
re-expand the lung
––––––––––––––– HEART DISEASES ––––––––––––––
Unstable angina: progressive ischemia of
myocardium resulting in increasing angina at rest
and an ischemic EKG pattern
Unstable angina management: cardiac catheter
and evaluate for potential revascularization, Tx
bypass or angioplasty
Ejection fraction: SV/EDV; normal EF is 67%, EF <50%
is abnormal, EF <35% is high-risk for operative MI
Coronary artery disease: blockage of coronary
arteries, high risk of sudden death due to ventricular
arrhythmias; Tx bypass or angioplasty

Bronchial adenoma: tumors that arise from within
bronchi and cause obstruction; MC lung cancer in a
nonsmoker under 30 y/o, Sx hemoptysis and
atelectasis, Dx CT scan and bronchoscopy (beware
of possibility of bleeding)

Heart transplant: remove donor heart and isolate in
hypothermic cardioplegia solution, remove recipient
heart on bypass, suture donor heart in recipient;
MCC of death are infection due to immunosuppression, and accelerated coronary artery
atherosclerosis
Constrictive pericarditis: presents as dyspnea,
hepatomegaly, and ascites due to diastolic failure;
Dx cardiac cath shows “square root sign”, Tx
surgical correction
––––––––––––– VALVULAR DISEASES ––––––––––––
Valvular disease management: first detected on
auscultation → get an echocardiogram
Valve replacement: mechanical valves (durable
but require anticoagulation) and porcine valves
(nonthrombogenic but will deteriorate over time)
Aortic stenosis: angina, dyspnea, syncope, and high
risk of sudden death; Dx harsh mid-systolic murmur,
MCC is congenital bicuspid aortic valve with
dystrophic calcification, Tx valve replacement when
symptomatic
Aortic regurgitation: presents as loud, blowing
diastolic murmur and bounding pulses; if chronic →
valve replacement when symptomatic, if acute →
emergent valve replacement and long-term abx

Left main disease: blockage of only LCA, worst Px
Three-vessel disease: blockage of LAD/RCA/LCX

Pancoast tumor Tx: two stages – irradiation for 6
weeks to shrink tumor, then surgical resection

DCM Tx: β-blockers will improve heart function,
but heart transplant is indicated (requires
chronic immunosuppression)

Mitral stenosis: presents as dyspnea and fatigue,
caused by rheumatic fever, results in cor pulmonale
(RVH+PH) and AFib; Tx valve repair or replacement

Coronary artery bypass: open via median
sternotomy, isolate internal thoracic artery (best
choice) or greater saphenous vein, put on bypass
and stop the heart, sew grafts to arteries, restart the
heart and close up

Mitral regurgitation: presents as dyspnea and
fatigue, caused by MVP, Dx high-pitched holosystolic
murmur; Tx annuloplasty (preferred) or valve
replacement

CABG mortality: 3% overall, greater in high-risk
pts but they benefit the most from the surgery

Mitral prolapse: eccentric closure of mitral leaflets;
common in women, precedes severe disease in men

Bronchial adenoma Tx: lobectomy is curative
Mesothelioma: cancer arising from pleural
mesothelium, shipyards and asbestos exposure are
risk factors, Dx CT scan shows thick pleural walls
Mesothelioma Px: not responsive to medical
therapy, most pts have <1 year to live w/o surgery
Mesothelioma Tx: extrapleural pneumonectomy
is curative, but high rate of morbidity/mortality

Coronary angioplasty: insertion of stent to prolong
patency of clogged coronary arteries, 33% rate of
restenosis in 1 year
Cardioplegia solution: solution used to stop heart
mid-diastole to protect it from ischemia and provide
a motionless field; often used with hypothermia to
prolong time of safe ischemia (up to 2.5 hours)

––––––––––– MEDIASTINAL DISEASES –––––––––––
Anterior mediastinal mass: thymomas, lymphomas,
teratomas, other metastatic germ cell neoplasms
Thymoma: often presents with progressive
muscle weakness secondary to myasthenia gravis,
Tx surgical removal via median sternotomy
Lymphoma: Tx radiation and chemotherapy

Surgery – Cardiothoracic Surgery

Teratoma: contains hair and teeth, Tx surgical
removal via median sternotomy
Middle mediastinal mass: lymphomas, bronchogenic
cysts, pericardial cysts
Bronchogenic cysts: develop from foregut
remnants, Tx surgical removal via thoracotomy
Pericardial cysts: typical water bottle appearance,
Tx surgical removal via thoracotomy
Posterior mediastinal mass: neurogenic tumors
(MCC is neurilemoma)
Neurilemoma: dumbbell-shaped tumor found
adjacent to vertebral bodies, develops from
nerves and nerve sheathes, Tx surgical removal
via thoracotomy

Surgery – Vascular Surgery

–––––––––––––– CAROTID DISEASES –––––––––––––
Atherosclerosis: systemic disease that has multiple
manifestations (stroke, TIA, CAD, MI, mesenteric
ischemia, AAA, PVD); presence of any one of these
should raise suspicion for the others
Stroke: a neurologic deficit that doesn’t resolve
within 24 hours, Tx t-PA only within 3 hours
Stroke management: carotid duplex study,
observation for improvement; CEA is not
indicated until pt has stabilized
Transient ischemic attack: brief neurologic deficit
that fully resolves within 24 hours; due to thromboembolus from internal carotid arteries

Ankle-brachial index: ratio of BP in arm vs. leg;
ABI >1.0 is normal, ischemic ABI is 0.6-0.8
(claudication) or 0.3-0.5 (rest pain)
Doppler tracing: normally triphasic due to systolic
flow → elastic recoil → diastolic flow; ischemic
signal is either biphasic (mild) or monophasic (severe)
Claudication: exercise-induced ischemia that causes
reversible calf pain, MCC is an atherosclerotic SFA
Claudication management: if mild → not
indicated for surgery, so exercise and lifestyle
changes are recommended; if severe → get
Doppler tracing, then arteriogram to localize
Claudication Px: 1/3 improve on a non-op exercise
program, 1/3 stay the same, 1/3 get worse

TIA management: physical exam (check carotid
bruids, neuro, cardiovascular) + carotid duplex;
Tx aspirin or carotid endarterectomy

Aortoiliac stenosis: presents as triad of claudication
+ absent femoral pulse + impotence

TIA × amaurosis fugax: emboli from carotid
travels to retina causing transient blindness;
Dx fundoscopic exam reveals Hollenhorst plaque,
a bright shiny spot in a retinal artery

Aortoiliac stenosis Tx: depends on case;
bilateral loss of femoral pulse → aortofemoral
bypass graft, single segment iliac stenosis →
angioplasty, high risk pt → lifestyle changes

TIA × aphasia: emboli from left carotid travels to
speech center located in left hemisphere

Severe claudication: presents as claudication + rest
pain or foot ulcers, common in diabetics; get a
vascular work-up and arteriogram to determine level
of occlusion, and assess general medical status

CEA: indicated for >70% carotid stenosis with either
neurologic sx or asymptomatic bruits; complications
include 1-3% risk of perioperative stroke, or injury to
facial, vagus, or hypoglossal nerves
Post-CEA management: start aspirin, encourage
lifestyle modifications (e.g. diet and exercise, quit
smoking) since patient is still high-risk for MI
Asymptomatic carotid bruit: get a carotid duplex
study, indicated for CEA if >70% stenosis
–––––––––––– PERIPHERAL DISEASES –––––––––––
Subclavian steal syndrome: presents as nothing at
rest, but arm claudication and CNS sx with arm
activity due to subclavian artery atherosclerosis; Dx
arteriogram, Tx bypass surgery
Arterial embolus: presents as the 6 P’s – pain, pallor,
parasthesias, poikilothermia, pulselessness, paralysis;
clot source is usually Afib or recent MI
Embolus Tx: requires urgent revascularization
within 6 hours; give heparin and go to OR for
balloon catheter embolectomy +/- fasciotomy
Embolus post-op: start warfarin for anticoagulation, then get CT scan or aortography to
search for source of emboli
Compartment syndrome: revascularization of
acutely ischemic limb results in ischemia-reperfusion
injury, causing muscle edema within fascial compartment and the 6 P’s
Compartment syndrome Tx: fasciotomy

AAA: presents as painless pulsatile abdominal mass;
management is getting ultrasound and CT scan, then
elective graft repair if aorta is >5 cm
AAA repair post-op: major fluid shifts (third-space
loss on POD#1/2, third-space mobilization on
POD#3), cardiac problems due to aortic clamping,
and impotence due to damage of hypogastric
circulation or autonomic nerves around IMA
Ruptured AAA: presents as pulsatile mass, back and
abdominal pain, and hypotension; if unstable → OR,
if stable → get CT scan or ultrasound, then OR
Ruptured AAA repair: clamp aorta at level of
diaphragm to stop bleeding, then proceed with
repair; 80% risk of death by bleeding out in the OR
AAA repair × bloody diarrhea: indicates ischemic
colitis due to interrupted IMA; Dx sigmoidoscopy,
Tx bowel rest if limited to mucosa, colectomy and
colostomy if full-thickness involvement
AAA repair × delayed fever: indicates vascular
graft infection via S. aureus or S. epidermidis;
Dx CT scan, Tx graft removal, debridement, and
IV antibiotics
AAA repair × UGI bleed: indicates aortoduodenal
fistula, usually a small bleed followed 1-2 days
later by massive bleeding; Dx CT scan, Tx graft
removal and GI repair

SFA stenosis Tx: reverse GSV to SFA graft
Iliac stenosis Tx: surgical revascularization or
balloon dilation
SFA + iliac stenosis Tx: both of the above, either
at the same time or sequentially (iliac first)
SFA + popliteal stenosis Tx: femoropopliteal
bypass to the best artery continuous with the
foot, failure likely in distal and severe disease
Multiple obstructions Tx: reconstruction may not
be possible, limb amputation indicated
Bypass pre-op: 10% risk of MI, arrhythmias, or heart
failure; requires evaluation of cardiac status (get
dipyridamole-thallium scintigraphy to rule out CAD)
Pre-op reveals <30% ejection fraction: high risk of
post-op heart failure
Pre-op reveals CAD: cancel or delay surgery,
perform a less invasive procedure, pre-op CABG
or PTCA, or intensive intraoperative monitoring

Mesenteric ischemia: presents as postprandial abd
pain, weight loss, and multiple abd bruits due to
atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx
mesenteric angiogram, Tx revascularization;
follow-up with aspirin and evaluation for other
atherosclerotic diseases
Aortic dissection: presents as acute onset tearing
chest/back pain due to severe HTN (200/140), CXR
shows widened mediastinum
Aortic dissection management: Dx MRI, spiral CT,
transesophageal echo, or arteriography; if
ascending aorta → go to OR for surgical repair, if
descending aorta → β-blockers
–––––––––––––– VENOUS DISEASES –––––––––––––
Deep venous thrombosis: presents as acute onset
dull leg pain, unilateral swelling, and Homans’ sign
DVT risk factors: Virchow’s triad – stasis,
endothelial damage, and hypercoagulability

Pre-op reveals recent MI: delay surgery for 3 mo
Bypass post-op: daily duplex studies to check for
graft stenosis, give aspirin, educate on lipid control
and foot care; MCC death is CAD
Trash foot: post-op embolization of atherosclerotic
debris following bypass results in cyanotic toe;
Tx heparinization of clot and long-term aspirin use
–––––––––––– ABDOMINAL DISEASES –––––––––––

DVT management: Dx duplex ultrasound, Tx
therapeutic heparin or LMWH, followed by longterm warfarin therapy (follow INR)
Post-thrombotic syndrome: occurs in 10% of DVT pts,
presents as severe leg edema and ulceration around
ankle area due to chronic venous HTN

Surgery – Vascular Surgery

Post-thrombotic syndrome management:
prevention via chronic use of support hose, heal
ulcers if they’ve already developed
DVT prophylaxis: indicated if pt is at risk for DVT;
includes leg compression devices and subcutaneous
low-dose heparin
DVT prophylaxis for hip fx: fondaparinux and leg
compression devices
Pulmonary embolus: presents as acute onset chest
pain, dyspnea, and hyperventilation (↓PCO2), due to
DVT embolization into lung → wedge-shaped area of
lung infarction, S1Q3T3 on EKG
PE management: get EKG to rule out MI, ABGs
(shows ↓PCO2), CXR, and pulse oximeter;
mismatch on a V/Q scan is diagnostic, Tx identical
to DVT Tx
Recurrent PE: due to failure of heparin therapy;
indicated for IVC interruption with a metal filter
Anticoagulation: therapeutic/high-dose heparin or
LMWH for Tx DVT/PE, low-dose for prophylaxis;
IVC filters when anticoagulation fails or is contraindicated
Anticoagulation × HIT: rare heparin side-effects
include thrombocytopenia and paradoxical
arterial clots, d/c heparin immediately
Anticoagulation × skin necroses: rare side-effect
of warfarin therapy, start warfarin along with
heparin to prevent this from happening
Anticoagulation × UGI bleed: life-threatening
condition that requires immediate d/c, give pt a
metal filter instead for PE prophylaxis
Phlegmasia cerulea dolens: presents as acute onset
leg edema with pain and cyanosis due to venous
outflow obstruction, high risk of nerve damage and
venous gangrene
PCD management: elevate leg and immediate
anticoagulation, then order duplex ultrasound
and pelvic CT scan to confirm the Dx
–––––––––– OTHER VASCULAR DISEASES –––––––––
Temporal arteritis: presents as severe, unilateral
headache, visual changes, and nodularity of
temporal artery; give high-dose steroids right away
to prevent blindness

Surgery – Upper GI Surgery

–––––––––––– ESOPHAGEAL CANCERS –––––––––––
Dysphagia: management includes barium swallow
and esophagoscopy w/ biopsy; DDx achalasia,
Zenker diverticulum, esophageal cancers, strictures
Esophageal cancer: SCC in upper 2/3 due to cigs and
EtOH, adenocarcinoma in lower 1/3 due to Barrett’s,
Sx progressive dysphagia and weight loss
EC management: esophagoscopy and biopsy,
then staging via endoscopic ultrasound and CT
scan, then specific Tx
EC staging: stage I invades submucosa only, stage
II invades muscularis +/- LN, stage III invades
adventitia + adjacent structures, stage IV is
metastatic
EC prevalence: adeno MC in US, SCC elsewhere
EC Tx: upper 1/3 – chemo and radiation only;
middle 1/3 – chemo and radiation to shrink the
tumor, then esophagectomy; lower 1/3 –
esophagectomy and proximal gastrectomy; never
operate on stage IV cancer
Advanced esophageal cancer: Sx severe dysphagia
and chronic cough (due to aspiration from TE fistula),
management is palliative care b/c surgery won’t help

Pain × PMHx: gallstones or alcoholism = acute
pancreatitis (order amylase/lipase levels), NSAIDs
or steroid use = PUD
Esophageal varices: present as UGIB due to portal
HTN, often alongside coagulopathy (liver failure)
EV management: band the bleeding varices,
correct any coagulopathy, IV octreotide to lower
portal pressure → if bleeding continues, repeat
endoscopic banding → if bleeding continues,
TIPS or gastric balloon tamponade
EV follow-up: β-blockers to lessen chance of
rebleeding; good liver function → elective TIPS,
bad liver function → liver transplant
Mallory-Weiss syndrome: presents as UGIB due to
retching lacerating the lower esophagus, bleeding
usually stops spontaneously
Boerhaave syndrome: presents as epigastric pain
and fever due to retching perforating the esophagus;
Dx contrast swallow, Tx emergent surgical repair
Instrumental perforation: presents as retrosternal
pain, fever, and pneumomediastinum s/p upper GI
endoscopy; Dx contrast swallow, Tx surgical repair
GERD: presents as heartburn, regurgitation,
waterbrash (sour taste), dysphagia, cough

––––––––––– ESOPHAGEAL DISEASES –––––––––––
Zenker diverticulum: pulsion diverticulum that
develops at upper esophagus due to abnormal
coordination of cricopharyngeal constriction;
Sx dysphagia, regurgitation, and bad breath
Zenker management: Dx barium swallow, Tx
cricopharyngeus myotomy
Traction diverticulum: diverticulum at middle
esophagus due to LN traction, indicates cancer
Esophageal motility disorders: achalasia (only one
treated surgically), nutcracker esophagus, spasms,
hypertensive LES
Achalasia: hypertonic and non-relaxing LES w/
poorly relaxing esophagus, Sx dysphagia of
liquids > solids
Achalasia management: Dx bird’s beak on barium
swallow and ↑LES pressure on manometry, Tx
Heller myotomy
Nutcracker esophagus: painful swallowing due to
high amplitude action potentials, Tx nifedipine
Diffuse esophageal spasms: uncoordinated 3°
peristalsis, Tx medically
Hypertensive LES: high LES pressure at baseline
but relaxes with swallow, Tx medically
Acute epigastric pain: DDx acute pancreatitis, GERD,
PUD (gastric ulcers or duodenal ulcers), cholelithiasis,
gastroenteritis

GERD Tx: PPIs → if it persists after six weeks, do
EGD w/ biopsy to see what’s going on
Normal EGD: PPIs or elective lap Nissen
Esophagitis: multiple, nonulcerating erosions in
stomach; mild to moderate esophagitis → PPIs
for 8-12 weeks, severe esophagitis → lap Nissen,
uncontrollable bleeding esophagitis → subtotal
gastrectomy
Barrett esophagus: intestinal metaplasia of
esophageal epithelium; no dysplasia → Tx PPIs or
lap Nissen; low-grade dysplasia → Tx lap Nissen +
annual surveillance; high-grade dysplasia → Tx
esophagectomy
Lap Nissen fundoplication: wraps fundus of stomach
around LES to keep it in abdominal cavity (must
check for intact esophageal peristalsis first); contraindicated in morbidly obese (gastric bypass instead)
Hiatal hernia: hernia from abdominal cavity, through
diaphragm, into chest cavity
Type 1 hiatal hernia: sliding hernia, risk of reflux
esophagitis, Tx PPIs
Type 2 hiatal hernia: paraesophageal hernia, risk
of incarceration/strangulation, Tx surgical repair
Type 3 hiatal hernia: presence of both types 1+2,
Tx surgical repair
–––––––– GASTRIC/DUODENAL DISEASES ––––––––
Peptic ulcer disease: gastric ulcers, duodenal ulcers

PUD surgery indications: intractability,
perforation, obstruction, bleeding
Duodenal ulcers: caused by ↑acid secretion; most
commonly in 1st part of duodenum, DU in 2nd-4th part
indicates Zollinger-Ellison syndrome (gastrinoma)
DU types: posterior ulcers bleed due to gastroduodenal artery, anterior ulcers perforate
DU Tx: triple therapy → if ulcer persists, surgery
is indicated (HSV > TV+P >> TV+A), also get serum
gastrin levels to rule out Z-E syndrome
Perforated DU: CXR shows free air under
diaphragm; use omentum to patch the ulcer
(Graham patch), then stop acid w/ PPIs or HSV
Perforated DU × sepsis: complete Graham patch
as soon as possible, give PPIs and IV abx, then
monitor in ICU and plan surgery for a later date
Bleeding DU: due to posterior ulceration into
GDA; Tx oversew the ulcer, then stop acid w/ PPIs
Gastric ulcers: caused by ↓mucosal protection; type I
– lesser curvature at incisure, type II – duodenum
and stomach, type III – pylorus, type IV – GE junction
GU Tx: PPIs → if ulcer persists after six weeks, do
endoscopy and multiple marginal biopsies for
possibility of gastric cancer; if ulcer persists after
18 weeks, surgery is indicated
GU surgery: wedge resection or distal
gastrectomy (due to possibility of cancer), TV+P
for types II and III due to ↑acid production
Bleeding GU: Tx excision rather than oversewing
Gastric cancers: lymphoma, adenocarcinoma, GIST
(e.g. sarcomas and lipomas)
Gastric adenocarcinoma: often spreads to left
supraclavicular (Virchow’s) node and ovaries;
Tx proximal → total gastrectomy, if distal →
distal gastrectomy w/ anastomosis; take out D1
LN at lesser curvature
Linitis plastica: infiltrating carcinoma with desmoplastic reaction causing stomach to look fixed
and rigid; Tx total gastrectomy w/ splenectomy
Gastric lymphoma: first determine cancer stage
(CT scan, LN biopsy, and bone marrow Bx);
Tx partial thickness → radiation, full thickness →
surgical resection
GIST: any soft tissue tumor of stomach; Tx wedge
resection w/ 1 cm negative margins (no LN)
Gastric varices: present as UGIB due to portal HTN,
Tx uncontrollable bleeding w/ TIPS or splenectomy
instead of banding

Surgery – Pancreatic/Hepatic Surgery

––––––––––––– GB/BILIARY DISEASES ––––––––––––

–––––––––––––––––– JAUNDICE –––––––––––––––––

Biliary disease progression: cholelithiasis → biliary
colic → acute cholecystitis; choledocholithiasis →
ascending cholangitis or gallstone pancreatitis

Jaundice: elevated bilirubin and yellowing of skin;
three types – hemolytic, obstructive, hepatocellular

Cholelithiasis: presents as nausea, vomiting, RUQ
pain w/o fever; only 15-20% are symptomatic
Cholelithiasis in pregnancy: manage non-op if
possible (hydration and pain meds), elective lap
chole can be done after delivery
Biliary colic: fatty meal → CCK release → gall
bladder contraction against non-lodged stone
resulting in transient RUQ pain for <6 hours; labs are
usually normal if episode has passed
Cholecystitis: presents as fever, WBC>15, RUQ pain
>6 hours; MC bacteria are E. coli, Bacteroides fragilis,
Klebsiella, Enterococcus
Cholecystitis management: Dx abdominal U/S,
order CBC and LFTs, Tx lap chole within 72 hrs

––––––––––––––– LIVER DISEASES ––––––––––––––
Hemolytic jaundice: ↑bilirubin (direct <20%),
search for what’s killing the RBCs
Hepatocellular jaundice: ↑bilirubin (direct 20-50%)
and ↑AST/ALT, consider HBV/HCV and alcoholism
Obstructive jaundice: ↑bilirubin (direct >50%) and
↑alk phos, caused by CBD stones and cancers
Painless jaundice: caused by biliary obstructive
tumors (ampullary cancer, duodenal cancer,
cholangiocarcinoma, pancreatic adenocarcinoma)
Painless jaundice management: Dx CT scan then
ERCP, Tx Whipple if no mets or local invasion
Painless jaundice × occult bleed: indicates
ampullary cancer, get CT scan then Whipple
–––––––––––– PANCREATIC DISEASES –––––––––––

Cholecystitis in elderly: elderly pts respond to
sepsis with hypothermia and ↓WBC
Cholecystitis antibiotics: ciprofloxacin (Cipro)
and metronidazole (Flagyl) to cover GNR and
anaerobes; abx not indicated for cholelithiasis
Cholecystectomy indications: symptomatic
cholelithiasis, acute cholecystitis, and cholangitis;
do not operate on asx stones
Cholecystectomy complications: nicking the CBD
(jaundice) or right hepatic artery (hepatitis)
Post-op biliary leak: presents as Charcot’s triad;
get an U/S and HIDA scan → Tx biliary drainage
and temporary stent during ERCP
Post-op obstruction: presents as Charcot’s triad
due to stricture or retained stone; get an U/S and
HIDA scan → Tx biliary drainage and choledochojejunostomy
Choledocholithiasis: presents as transient jaundice
and ↑alk phos; Dx U/S shows dilated bile ducts +/ERCP, Tx lap chole w/ CBD exploration
Acute cholangitis: presents as Charcot’s triad
(jaundice, fever, RUQ pain) or Reynold’s pentad
(shock, ∆MS) due to choledocholithiasis
Acute cholangitis management: IVF, antibiotics,
and U/S → ERCP to decompress biliary tree →
finally lap chole w/ CBD exploration
GB polyps: <2 cm observe, >2 cm take it out due to
risk of adenocarcinoma
GB adenocarcinoma: presents as mass in GB fossa;
Dx CT scan, Tx open chole + hilar LN resection + liver
resection w/ negative margins
Porcelain GB: dystrophic calcification of GB has 50%
risk of adenocarcinoma, take it out

Chronic pancreatitis: presents as constant epigastric
pain, steatorrhea, and diabetes in a chronic alcoholic;
Tx insulin and pancreatic enzyme replacement

Pancreatic head mass: check for metastases, then
perform Whipple if no mets
Pancreatic adenocarcinoma: presents as obstructive
jaundice, get a CT scan; cancer in head → Tx Whipple,
in body or tail → distal pancreatectomy, mets or
local invasion → palliative care (no surgery)
Acute pancreatitis: presents as epigastric pain
boring through to the back w/ ↑lipase/amylase;
amylase levels do not correlate with severity
Pancreatitis causes: I GET SMASHED – Idiopathic,
Gallstones (#1), EtOH (#2), Trauma, Steroids,
Mumps, Autoimmune, Scorpion sting, Hypertriglyceridemia (#3), Hypercalcemia, ERCP, Drugs
Edematous pancreatitis: get amylase/lipase,
then NPO, IVF, pain meds
Hemorrhagic pancreatitis: presents as MSOF,
ARDS, and hemodynamic instability; send to ICU
for resuscitation and serial CTs
Ischemic pancreatitis: Dx no blood flow to
pancreas on contrast CT, Tx IV abx and resection
Gallstone pancreatitis: if amylase returns to
normal → lap chole + cholangiogram; if
complicated → ERCP to remove stone
Pancreatic abscess: presents as septic shock 2 weeks
after acute pancreatitis; Dx dynamic CT scan, Tx perc
drain + antibiotics
Pseudocyst: abdominal pain and early satiety 5
weeks after acute pancreatitis, Tx cystogastrostomy
only if it’s symptomatic and has been present for 6+
weeks (must get Bx w/ frozen epithelial section and
see no epithelial lining before the ostomy since
epithelium indicates cancer)

Liver cyst: simple cyst, leave it alone
Echinococcal cyst: multilocular cyst w/ calcified walls
due to parasite Echinococcus granulosus; inject
hypertonic saline inside cyst and carefully excise it
Liver abscess: multiple/small bacterial abscesses →
IV antibiotics; single/large bacterial abscess → perc
drain; amebic abscess (Mexicans) → metronidazole
Liver cancers: hepatic adenoma, focal nodular
hyperplasia, hemangioma, hepatoma
Hepatic adenoma: often presents as hypovolemic
shock and distended abdomen, related to OCPs
and anabolic steroid abuse; Tx d/c OCP → if it
persists, resect due to possibility of rupture
FNH: Dx central stellate scar or sunburst pattern
on CT scan, no OCP relationship, leave alone even
if symptomatic
Hemangioma: leave alone even if symptomatic,
never spontaneously rupture, do not needle
biopsy due to possibility of rupture
Hepatoma: presents as vague RUQ pain and mass
related to HBV/HCV and cirrhosis w/ ↑αFP; Dx CT
scan then Tx resection w/ negative margins
indicated as long as there’s no mets
Portal HTN: Sx esophageal varices, caput medusa,
hemorrhoids; Tx TIPS (connect portal vein to hepatic
vein to relieve pressure) as a “bridge to liver txp”

Surgery – Lower GI Surgery

––––––––––– SMALL BOWEL DISEASES –––––––––––
Small bowel obstruction: presents as colicky abd
pain, nausea/vomiting, and constipation; MCC are
adhesions from previous surgery and hernias
SBO management: get KUB → Dx air-fluid levels
and dilated loops; Tx NPO, NG suction, IVF, and
initially observation
SBO × electrolyte imbalance: “hypokalemic,
hypochloremic metabolic alkalosis” due to emesis
SBO × bloody diarrhea: indicates obstructive
tumor or ischemic bowel; Dx sigmoidoscopy →
observe if mucosal, resection if full-thickness
SBO × flatus: indicates partial SBO since gas can
get through, more likely to resolve w/o surgery
SBO × diarrhea: indicates partial SBO due to fecal
impaction and severe constipation

Mesenteric ischemia × peritonitis: presents as
rebound tenderness, ↑WBC, fever, or metabolic
acidosis due to necrotic bowel; ex lap indicated
Mesenteric ischemia × AFib: indicates emboli
shooting from left atrium to celiac trunk or SMA
Mesenteric ischemia × ↑hct: polycythemia due to
severe dehydration requires IV fluid resuscitation
Mesenteric ischemia × CHF: ischemia may be
secondary to a low-flow, nonocclusive state;
indicated for mesenteric vasodilation and
improve cardiac output
Mesenteric ischemia × aortic dissection:
dissected aorta can occlude mesenteric vessels;
Dx angiography, Tx surgical repair
Mesenteric ischemia × ↓BP: either ischemic
bowel causing septic shock, or hypotension
causing low-flow, nonocclusive ischemia

SBO × inguinal hernia: requires urgent hernia
repair to relieve strangulation

Left colon necrosis: bowel resection → anastomosis
if stable, otherwise colostomy and Hartmann pouch

SBO × melanoma: melanoma is the MC tumor
that metastasizes to intestine, surgery indicated
since these don’t resolve spontaneously

Long segment necrosis: bowel resection → small
bowel syndrome requiring chronic TPN or transplant

SBO × other cancers: surgery indicated since
these don’t resolve spontaneously
SBO × peritonitis: presents as rebound tenderness, ↑WBC, fever, or metabolic acidosis due to
necrotic bowel; indicated for ex lap
SBO × adhesions: indicated for ex lap → lysis of
adhesions
SBO × closed loop obstruction: usually due to
adhesive band occluding two segments of bowel;
indicated for ex lap → lysis of adhesions,
resection of any dead bowel, and “second look”
operation if bowel viability is indeterminate
SBO × pneumoperitoneum: indicates perforation
due to ischemic or overdistended bowel;
indicated for ex lap → dead bowel resection
Nicked bowel during LOA: small hole → primary
repair, large or multiple holes → bowel resection;
high risk of leakage and EC fistula formation
Uncertain about SBO: get an upper GI series w/ small
bowel follow-through, barium contrast will stop at
site of obstruction if SBO exists
Mesenteric ischemia: presents as postprandial abd
pain, weight loss, SBO, and multiple abd bruits
usually due to atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx
mesenteric angiogram, Tx revascularization;
follow-up with aspirin and evaluation for other
atherosclerotic diseases

Short segment necrosis: bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Small punctate necroses: indicates multiple small
emboli or low-flow state; bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Bowel ischemia but no necrosis: try to revascularize
the bowel via removing or bypassing the occlusion
Low-flow but no necrosis: non-op management of
hemodynamic status, surgery should be avoided

Crohn’s × rectal disease: rare, indicated for
subtotal colectomy and ileostomy
Ulcerative colitis: inflammatory disease involving
rectum and continuous proximal extension, Bx
shows mucosal involvement + crypt abscesses +
pseudopolyps, Dx lead pipe sign on CT scan
UC management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups, annual
colonoscopy for possibility of cancer
UC × severe dysplasia: total proctocolectomy,
ileal pouch formation, and ileo-anal anastomosis;
no further cancer surveillance needed
Pouchitis: presents as fever, bloody diarrhea, and
pain on defecation s/p ileal pouch formation for UC;
Tx metronidazole
Toxic megacolon: presents as fever, bloody diarrhea,
pain, and abdominal distention in a pt w/ UC
TM management: get KUB for confirmation, then
NPO, IVF, NG suction, IV steroids and abx;
improves → no surgery, stays the same or gets
worse → surgery necessary
TM × perforation: shows free air on upright CXR,
indicated for total colectomy and ileostomy w/
Hartmann pouch
TM × impending perforation: shows pneumatosis
on CT scan, indicated for surgery (see above)
––––––––––––––– APPENDICITIS –––––––––––––––
Appendicitis: presents as RLQ pain, low grade fever
and leukocytosis; MCC lymphoid hyperplasia
Appendicitis management: get CT scan or U/S
(U/S is cheaper); if uncomplicated → app’y, if
abscess (↑↑fever/↑↑WBC) → perc drain, interval
app’y

––––––– INFLAMMATORY BOWEL DISEASE –––––––
Inflammatory bowel disease: Crohn’s disease and
ulcerative colitis; presents as crampy abdominal pain,
bloody diarrhea, and recent weight loss
IBD management: colonoscopy to determine if
it’s UC, Crohn’s, or something else → abdominal
CT scan for confirmation of IBD
Crohn’s disease: inflammatory disease involving full
GI tract with skip lesions (terminal ileum is MC site),
Bx shows full thickness + noncaseating granulomas +
creeping fat, Dx terminal ileum string sign on CT scan
Crohn’s management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups
Crohn’s × SBO: due to stenotic terminal ileum;
manage with NPO, TPN, and observation → if it
fails to resolve, surgical stricturoplasty indicated
Crohn’s × perianal disease: metronidazole

Appendicitis in kids: children with appendicitis
present more often with a ruptured appendix
Appendicitis in elderly: older pts usually don’t
have classic presentation of appendicitis, but
rather vague abdominal complaints, sepsis,
altered MS, or failure to thrive
Appendicitis in pregnancy: enlarged uterus can
push appendix upwards → RUQ pain; appy can
be performed safely w/o risk to mom or child
RLQ pain × dysuria: indicates appendicits, UTI, or
appendiceal abscess next to bladder
RLQ pain × minimal dysuria: likely appendicitis
RLQ pain × hematuria: indicates severe UTI or a
kidney stone
RLQ pain × h/o PID: could be appendicitis, recurrent
PID, or an ectopic; PID confirmed by cervical or
adnexal tenderness, or cervical discharge (get gyn
consult and stain discharge)

Surgery – Lower GI Surgery

RLQ pain × h/o gastroenteritis: could be appendicitis
but likely gastroenteritis
RLQ pain × R pelvic tenderness: likely retrocecal
appendicitis, go to the OR
RLQ pain × BPH Sx: likely bladder outlet obstruction
due to enlarged prostate, Tx Foley catheter
RLQ pain × h/o IBD: IBD can present similarly to
appendicitis, get colonoscopy and CT scan and
manage appropriately
RLQ pain × crampy pain/diarrhea: indicates IBD,
constipation, or cancer rather than appendicitis
RLQ pain × corticosteroids: steroids can mask all Sx
of inflammation, be cautious since most steroid pts
won’t present until perforation occurs
App’y findings: inflamed appendix, perforated
appendix, normal appendix, inflamed cecum,
fecalith, carcinoid tumor, other tumors
Inflamed appendix: take it out
Normal appendix: take it out anyways unless
cecum is inflamed, check other areas for
abnormalities (terminal ileum for Crohn’s or
Meckel’s, perforated gastric or duodenal ulcer,
ovaries, etc.)
Inflamed appendix/cecum: take them both out
via right colectomy

Diverticulitis complications: abscess (Tx perc drain),
obstructions, fistula (pneumaturia or fecaluria, Tx
surgical separation of colon from bladder)
––––––––––– LARGE BOWEL DISEASES ––––––––––
Pseudomembranous colitis: watery diarrhea and
↑↑WBC due to clindamycin-related C. diff overgrowth;
Dx stool toxin or colonoscopy, Tx stop clindamycin
and start metronidazole or vancomycin

Perforated appendix: take it out, I/D the abscess,
and leave a drain in to prevent wound infection
Appendiceal carcinoid: <2cm appendectomy,
>2cm right hemicolectomy; can present w/
carcinoid syndrome due to liver metastasis
Terminal ileal carcinoid: resection and check the
rest of bowel for other carcinoids; can present
w/ carcinoid syndrome due to liver metastasis
––––––––––––––– DIVERTICULITIS –––––––––––––––
Diverticulosis: presents as LGIB, 85% stop
spontaneously, may develop into diverticulitis
Diverticulitis: presents like left-sided appendicitis,
get CT scan and manage non-op if possible (IVF, NPO,
IV antibiotics) even with signs of LLQ peritonitis

Polyps: tubular/pedunculated have a stalk,
sessile/villous are flattened; progression from polyp
to cancer takes ~10 years
Pedunculated polyp: polypectomy w/ biopsy →
if dysplasia is not localized to head of polyp, then
segmental colectomy
Sessile polyp: biopsy → if any high grade
dysplasia, then colectomy
Benign polyps: juvenile, Peutz-Jeghers,
inflammatory, hyperplastic; leave these alone
Colon cancer: left side obstructs, right side bleeds;
Dx “apple core” lesion on barium enema, 99%
garden variety (∆MCC, ∆DCC, ∆RAS, ∆p53) and 1%
familial inheritance (FAP, HNPCC)

Stage III: LN involvement, Tx colectomy and
chemo (5-FU + levimasole, only stage that chemo
will improve survival rates)
Stage IV: distal metastasis, Tx palliative chemo
unless there is a resectable mass in liver or lung
Colectomy: requires 12-14 LN removal for adequate
procedure; requires pre-op bowel prep and abx
Post-op wound infection: open fascia to make
sure it’s intact, then local wound care
Post-op feculent leak: indicates anastomotic leak,
get abd CT scan to check for undrained collection,
then NPO/IVF is sufficient for most cases
Post-op feculent vomit: indicates either post-op
ileus (due to leakage) or mechanical obstruction;
Tx NPO/IVF and NG tube
Post-op abscess: Dx CT scan, Tx perc drain

Diverticulitis f/u: colonoscopy to confirm
presence of diverticula and absence of cancer
Surgery indications: uncontained perforation
that presents as 4-quadrant peritonitis or
pneumoperitoneum (air under diaphragm)
Elective surgery indications: recurrent episodes
(2x in 6 months, 3x in a year)

HNPCC: ∆MLH or ∆MSH mismatch repair genes →
microsatellite instability, Tx total abdominal
colectomy + ileorectal anastomosis
Colon cancer recurrence: f/u with colonoscopy, CEA
marker, CXR for lung mets, and LFTs for liver mets
–––––––––––– ANORECTAL DISEASES –––––––––––

Colon cancer screening: anyone above 50 y/o should
get yearly fecal occult blood test (flex sig and
colonoscopy also used, but less commonly)

Stage I/II: localized cancer, Tx colectomy
Inflamed appendix + fecalith: confirms
appendicitis

FAP pts should always get upper endoscopy and
remove the duodenal polyps

Post-op constipation: indicates either stricture or
cancer recurrence; Dx colonoscopy
FAP: ∆APC on chromosome 5p, autosomal dominant,
presents as >100 polyps in colon; Tx either total
proctocolectomy, or total abdominal colectomy +
strip anal mucosa + ileoanal anastomosis
Gardner syndrome: FAP + polyps in stomach (not
premalignant) and duodenum (premalignant);

All anorectal diseases: first step in management is to
scope and rule out cancer
Hemorrhoids: presents as blood streaks in stool and
extreme pain (external); Tx scope to r/o cancer →
fiber/stool softeners → if it keeps bleeding, excision
or banding
Non-healing hemorrhoids: indicates anal canal
cancer; Tx chemoradiation (5-FU) → APR if it
persists or recurs
LAR vs. APR: LAR is low anterior resection (high in
rectum), APR is abdominoperineal resection (low in
rectum)
Rectal cancer: Dx colonoscopy to r/o cancer, then
endoscopic U/S for staging → Tx depends on stage
Rectal cancer T1: transanal resection
Rectal cancer >T1: neoadjuvant chemoradiation
for 6 weeks to shrink the tumor → then LAR with
2cm distal margins → APR if margins not possible
Anal cancer: presentation is non-specific (bleeding,
pain, drainage, itching) and requires biopsy
Small anal cancer: Tx resection w/ negative
margins
Large anal cancer: often mistaken as “nonhealing hemorrhoids”, Tx chemoradiation (Nigro
protocol) → APR if it persists or recurs
Perirectal abscess: Tx I&D → 40% will develop a
fistula according to Goodsall’s rule (anterior straight
tract, posterior curved tract) → Tx fistulotomy
Pilonidal abscess: abscess in sacrococcygeal area of
lower back, Tx I&D and removal of hair
Anal fissure: presents as pain and blood with BM
due to increased sphincter tone; Tx fiber/stool
softeners → if it won’t heal, botox → still won’t heal,
lateral internal sphincterotomy
Recurring anal fissure: probably Crohn’s; biopsy
first for possible cancer, then Tx metronidazole if
biopsy reveals Crohn’s
Rectal prolapse: presents as rectal protrusion
following defecation; internal prolapse → high-fiber
diet to normalize BM, external/bleeding prolapse →
rectopexy or LAR

Surgery – Lower GI Surgery

–––––––––––––––– GI BLEEDING ––––––––––––––––
Hematemesis: bloody vomiting, always UGIB
Melena: coffee ground blood in stool, usually UGIB
but can also be from ascending colon
Hematochezia: BRBPR, can be either UGIB or LGIB;
NG tube aspirate/lavage → LGIB if –blood/+bile,
UGIB if +blood, indeterminate if –blood/–bile
UGIB: GI bleeding proximal to Ligament of Treitz,
management is EGD
UGIB in ICU pt: most likely a stress ulcer
LGIB: GI bleeding distal to Ligament of Treitz, 85%
stop spontaneously; MCC are AVM, diverticulosis,
and colon cancer
LGIB management: must localize site of bleeding
w/ tagged RBCs (<1 cc/min) or angiography (>1
cc/min); if not currently bleeding, get upper and
lower endoscopy since localization won’t help
LGIB surgery indications: “hemodynamic
instability despite transfusion”, loss of 4-6 units in
24 hrs or 8-10 units in 48 hrs
LGIB scenario: GI bleed stops spontaneously →
get colonoscopy to determine cause and rule out
possibility of colon cancer → coagulate if AVM,
leave alone if diverticulosis
LGIB scenario: unstable patient, massive BRBPR,
no imaging to localize site of bleeding → total
colectomy since 85% of bleeding is from the colon
LGIB in kids: indicates Meckel’s diverticulum, Dx
technetium uptake into ectopic gastric mucosa
Dx tagged RBCs: sensitive for LGIB at 0.1 cc/min, but
not specific for localizing site of LGIB; bladder always
lights up first so ignore that part
Dx angiogram: less sensitive for LGIB at 1.0 cc/min,
but more specific for localizing site of LGIB; allows
for smaller LGI resection in surgery if necessary
––––––––––––– OTHER GI DISEASES ––––––––––––
Sigmoid volvulus: twisting of sigmoid colon around
mesentery results in closed-loop obstruction; Tx
“detorse” the colon via rigid scope and rectal tube,
then elective sigmoid colectomy
Cecal volvulus: twisting of cecum; Tx right
colectomy since detorsion usually won’t work
Ogilvie’s syndrome: pseudoobstruction and massive
colon dilation w/o mechanical obstruction; Tx
endoscopic decompression or neostigmine if >11 cm
due to possibility of cecal perforation
Constipation: do a rectal exam to make sure stool
isn’t impacted, then give enemas from below

Surgery – Endocrine Surgery

–––––––––––––– THYROID DISEASES–––––––––––––
Thyroid embryology: derivative of foramen cecum
from the base of the tongue
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Thyroid nodule management: first get TSH levels →
if euthyroid, get FNA for cancer Dx; otherwise, work
up for hypo- or hyperthyroidism
Risk of malignancy: solid nodules, cold nodules
(lack of radioiodine uptake), size > 1.5 cm
Colloid nodule: benign nodule, manage medically
Hyperthyroidism: Graves’ disease (most common),
toxic adenoma (#2), toxic multinodular goiter (#3)

Papillary cancer Tx: total thyroidectomy w/
central LN excision → modified radical neck
dissection if LN are positive for cancer

DiGeorge syndrome: congenital absence of both 3rd
and 4th branchial pouches → hypocalcemia, thymic
aplasia

Follicular cancer: endemic to iodine-deficient
regions, hematogenous spread, 2nd best Px

PTH: secreted from chief cells; three functions –
renal ↑Ca++/↓P, bone ↑Ca++/↑P, stimulates 1αhydroxylase to activate vitamin D for indirect GI
resorption of Ca++

Follicular cancer Tx: hemilobectomy with biopsy
because 80% are benign adenomas and 20% are
malignant carcinomas, total thyroidectomy if Bx
reveals malignant carcinoma
Medullary cancer: AD inheritance with MEN2A/2B
syndromes, Δret proto-oncogene, both lymphatic
and hematogenous spread, Bx amyloid deposits,
3rd best Px
Medullary cancer Tx: total thyroidectomy for
both cancer and ret+ prophylaxis w/ central LN
excision → modified radical neck dissection if LN
are positive for cancer

Graves’ disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing
exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women

Anaplastic cancer: rare, worst Px

Graves’ disease Tx: oral radioiodine (no surgical
risks) or surgery (won’t become hypothyroid)

Thyroid lymphoma: associated w/ chronic
Hashimoto’s thyroiditis, Tx radiation therapy

Thyroid storm Tx: β-blockers, antithyroid drugs

Post-thyroidectomy f/u: take patient off T4 for 6
weeks (use T3 instead for its shorter T½), increase
TSH level, and make sure total thyroidectomy was
performed; give radioactive iodine exam after 6
weeks to check if any metastases will light up

Antithyroid drugs: propylthiouracil (PTU) and
methimazole block peroxidase, PTU also blocks
peripheral conversion of T4 to T3
Toxic adenoma: Dx hot nodule on scan with
peripheral suppression, Tx lobectomy if >2 cm,
radio-iodine if <2 cm

Anaplastic cancer Tx: palliative (e.g.
tracheostomy)

Positive for metastases: get CT scan, macro →
excision, micro → oral radio-iodine therapy
Papillary cancer f/u: follow thyroglobulin levels

Toxic multinodular goiter: Tx surgical excision if
>2cm, radio-iodine if <2 cm
Hypothyroidism: chronic/Hashimoto thyroiditis
(most common), subacute/De Quervain thyroiditis,
acute bacterial thyroiditis
Hashimoto thyroiditis: autoimmune disease with
lymphocytic infiltration, Tx Synthroid
Hashimoto thyroiditis antibodies: anti-TSH,
anti-microsomal, anti-thyroglobulin, antiperoxidase
De Quervain thyroiditis: subacute, painful
granulomatous inflammation following viral URI,
Tx observation (condition will self-resolve)
Acute thyroiditis: painful, swollen, tender thyroid
mass due to Staph/Strep infection, Tx I&D
Thyroid cancers: 80% papillary, 10% follicular, 4%
medullary, 1% anaplastic; FNA can be used to Dx
papillary and medullary but not follicular (must see
capsular invasion to DDx adenoma vs. carcinoma)
Papillary cancer: associated with radiation,
lymphatic spread, best Px overall, Bx shows
Orphan Annie nuclei with psamomma bodies

Follicular cancer f/u: follow thyroglobulin levels
Medullary cancer f/u: 24-hour urine for VMA or
metanephrines (MEN syndrome can present with
pheochromocytoma), follow calcitonin levels
Modified radical neck dissection: like radical neck
dissection, but spares sternocleidomastoid muscle,
CN XI, and internal jugular vein
Thyroid cancer Px: MACIS system – Metastasis (nonlymph nodal), Age (<45 is better), Completeness of
resection, Invasion, Size (>2 cm has worse Px)
Thyroid surgery risk factors: superior laryngeal
nerve (soft/deep voice), recurrent laryngeal nerve
(hoarseness unilateral, dyspnea bilateral), parathyroid glands (hypoparathyroidism)

Osteitis fibrosa cystica: rapid, painful loss of bone
due to HPTH; “moth eaten skull”
Calciphylaxis: calcium deposition in soft tissue due
to HPTH
Multiple myeloma: punched-out lesions of bone due
to a B-cell neoplasm
Hypercalcemia Sx: kidney stones, painful bones,
abdominal groans (peptic ulcers, pancreatitis,
cholelithiasis), psychic overtones (↓mental status)
Hypercalcemia DDx: parathyroid adenoma (MCC
outpatient), metastases to bone (MCC inpatient)
1° HPTH: ↑PTH/↑Ca++/↓P, most sensitive test is Cl:P
ratio >33:1; causes include 90% adenoma, 9% hyperplasia, 1% carcinoma
1° HPTH management: straight to surgery if
symptomatic (4-gland exploration or minimally
invasive surgery), no imaging necessary
4-gland exploration: open exploration of neck
area; adenoma → take it out; hyperplasia → take
3½ glands out, or take all 4 out and autotransplant ½ gland back in; carcinoma → en bloc
resection of parathyroid and ipsi thyroid lobe
Minimally invasive surgery: needs positive
Sestamibi scan pre-op, big/abnormal gland during
exploration, and intra-operative decrease in PTH
levels by >50% following excision
2° HPTH: ↑↑PTH/↓Ca++/↑P, due to renal failure
2° HPTH management: medical management, 3½
gland excision if complications exist
3° HPTH: ↑PTH/↑Ca++/↓P, found in renal transplant
pts whose parathyroid glands work autonomously
3° HPTH management: 3½ gland excision if HPTH
persists for 1 year following transplant
Sestamibi scan: “lighting up” in parathyroid gland is
85% accurate for Dx parathyroid adenoma

––––––––––––– PARATHYROID DISEASES –––––––––

Hypercalcemic crisis: Ca++>15 indicating carcinoma;
Tx flush with NS, then drain with furosemide (Lasix),
then treat the underlying cause

Parathyroid glands: 30-50 mg each, brownish-yellow
color, sinks in water (to differentiate from fat)

Parathyroid nodule: probably a thyroid nodule,
unless Ca++ ~15 indicating parathyroid carcinoma

Parathyroid embryology: 3rd branchial pouch
becomes inferior glands and thymus, 4th becomes
superior glands

2nd operation s/p adenoma removal: requires
localization studies, don’t just go back in there

Surgery – Endocrine Surgery

Missing parathyroid glands: check thymus (MC
location/15%), up and down neck, open carotid
sheath, retro-esophageal area, esophageal groove,
and inside the thyroid gland itself
Median sternotomy: only indicated if pt is in a lifethreatening hypercalcemic crisis
–––––– MULTIPLE ENDOCRINE NEOPLASIA ––––––
MEN1 (Wermer): pituitary adenoma, pancreatic
endocrine cancer (MC gastrinoma), parathyroid
hyperplasia
MEN1 Tx: excise parathyroid first since hypercalcemia can cause ↑gastrin levels; if Z-E can’t be
controlled w/ PPIs → total gastrectomy since
MEN gastrinomas are multifocal

Pituitary Cushing: due to ↑ACTH secretion,
suppressable by high dose dexamethasone;
Dx MRI, Tx transsphenoid hypophysectomy
Adrenal Cushing: due to ↑cortisol secretion
(causes ↓ACTH); Dx CT scan, Tx adrenalectomy
Ectopic Cushing: due to ↑ACTH secretion usually
from SCLC, not suppressable by high dose dexa
Adrenal gland tumors: aldosteronoma, cortisoloma,
sex hormone-secreting tumor, pheochromocytoma,
incidentaloma
Aldosteronoma: presents as ↑Na, ↓K, ↓H, ↓renin;
Dx CT scan for mass (if no mass present or ↑renin,
think RA stenosis), Tx adrenalectomy (adenoma)
or aldactone (hyperplasia)

MEN2A (Sipple): parathyroid hyperplasia,
pheochromocytoma, thyroid medullary cancer

Cortisoloma: presents as adrenal Cushing’s, Tx
adrenalectomy

MEN2B: pheochromocytoma, thyroid medullary
cancer, mucosal neuromas, Marfanoid habitus

Sex hormone-secreting tumor: Tx adrenalectomy

MEN2A/2B Tx: excise pheochromocytoma first
since it can be life-threatening
Gastrinoma: give PPIs → if acid persists, get serum
gastrin levels → <200 absent, >500 present, 200-500
indeterminate and requires secretin stimulation test
→ if paradoxical ↑gastrin w/ secretin, present → get
CT scan to localize and cut it out
VIPoma: presents as “rice water” diarrhea; get CT
scan to localize and cut it out
Insulinoma: presents as hypoglycemia, Dx ↑Cpeptide levels or monitored fasting (to see if they’re
“faking it”); get CT scan and cut it out
Glucagonoma: presents as new-onset diabetes and
migratory rash from lower body upwards, Dx
glucose challenge test; get CT scan and cut it out
Metastatic glucagonoma: give somatostatin and
streptozocin since surgery is contraindicated
Nesidioblastosis: presents as hypersecretion of
insulin in a newborn; Tx 95% pancreatectomy
–––––––––– OTHER ENDOCRINE DISEASES –––––––––
Pituitary adenoma: prolactinoma (#1), null cell tumor
(#2), ACTH (#3), GH (#4); may present as bitemporal
hemianopsia ◐◑ due to optic chiasm compression
Prolactinoma: presents with galactorrhea and
amenorrhea, Tx bromocriptine
Null cell tumor: doesn’t secrete anything
Cushing syndrome: presents as truncal obesity, abd
striae, buffalo hump, hyperglycemia, osteoporosis,
HTN, and immunosuppression due to ↑cortisol
Cushing causes: MCC is exogenous steroid use;
intrinsic causes include pituitary adenoma,
adrenal adenoma, and ectopic secretion of ACTH

Pheochromocytoma: presents with HA, HTN,
palpitations, etc.; Dx 24 hour urinary VMA or
metanephrines, Tx α-blockers (phenoxybenzamine) then β-blockers then adrenalectomy
Intraoperative hypotension: give IVF
Incidentaloma: make sure it’s not secreting
hormones then work-up based on size; <5 cm →
leave alone, >5 cm → resection + check other organs
since adrenals are common site of metastasis
Aortic coarctation: presents as HTN in arms but
normal BP in legs; get CXR (scalloping of ribs) then
confirm w/ spiral CT, then surgical correction
Renovascular HTN: presents as HTN + abd bruits,
secondary to fibromuscular dysplasia (young women)
or atherosclerosis (old men) of the renal arteries;
get a doppler of renal vessels, then either balloon
dilation or surgical correction

Surgery – Skin/Soft Tissue Surgery

––––––––––––––– SKIN CANCERS –––––––––––––––
Skin cancers: basal cell carcinoma (50%), squamous
cell carcinoma (25%), malignant melanoma (15%);
management is full-thickness incisional biopsy at
border of the lesion
Basal cell carcinoma: raised waxy lesion or nonhealing ulcer in upper face, doesn’t spread; Tx local
excision w/ 1 mm margins
Squamous cell carcinoma: non-healing ulcer in lower
face, spreads to LN; Tx local excision w/ 1 cm margins
and LN excision
SCC risk factors: draining fistulas, arsenic
exposure
Keratoacanthoma: variant of SCC that grows
rapidly and then dies off spontaneously
Dysplastic nevus: atypical mole, precursor of
malignant melanomas, requires close observation
Melanoma: ABCDE – Asymmetric, irregular Borders,
different Colors, Diameter >5mm, Evolving; Px
related to depth, highly metastatic and will be found
in weird places
Ulcerated melanoma: 1/3 reduction in survival
Depth <0.75 mm: Tx excision w/ 1 cm margin,
good prognosis
Depth 0.76-3.99 mm: Tx excision w/ 2 cm margin,
palpable LN → removal, no palpable LN →
sentinel LN biopsy w/ elective removal
Depth >4 mm: Tx excision w/ 2 cm margin,
remove palpable LN, pt will likely die from mets
Melanoma × LN involvement: remove regional LN,
then complete staging for mets (CXR, CT scan, LFTs,
brain MRI)
Melanoma × metastases: Tx radiation and
chemotherapy (interferons)

–––––––––––––––– SARCOMAS ––––––––––––––––
Sarcomas: present as firm, painless masses; Px
depends on size, grade, and distant metastases (no
LN since sarcomas spread hematogenously)
Sarcoma management: Dx incisional biopsy
parallel to resection margins, chest CT for mets,
Tx resection w/ 1 cm negative margins
High-grade sarcomas: Tx radical amputation w/
post-op radiation therapy

McVay repair w/ relaxing incision: cut
transversus abdominis aponeurosis to relax
tension on sutures

Sarcoma × liver mets: biopsy for confirmation → Tx
hepatic wedge resection or formal lobectomy

Lichtenstein repair: tension-free repair w/ mesh;
fixes direct, indirect, and femoral hernias

––––––––––––––––– HERNIAS –––––––––––––––––

TAPP and TEP: TransAbdominal PrePeritoneal
and Totally ExtraPeritoneal lap procedures;
have steep learning curve and unproven results

Hernia surgery indications: all abdominal hernias
due to possibility of strangulation, except sliding
esophageal hernias (Tx PPIs) and umbilical hernias in
pts <2 yo (simple observation)
Umbilical hernia management: <2cm watch,
>2cm fix, fix if it doesn’t regress before kindergarten regardless
Hernia × SBO: presents as abdominal distention,
nausea, and vomiting due to incarcerated or
strangulated hernia; Tx emergent hernia repair
Hernia × strangulation: presents as firm/tender
mass w/ fever, ↑WBC, metabolic acidosis; Tx
emergent hernia repair
Indirect hernia: through internal ring lateral to
inferior epigastrics vessels, due to patent processus
vaginalis; most common hernia overall (even in
women and elderly)
Indirect hernia in kids: high incidence of
bilaterality, repair is limited to high ligation of sac
w/o abdominal wall repair

Acral lentiginous melanoma: melanoma on pale
areas of dark-skinned pts (sole of feet, palm of hand),
worst prognosis due to depth

Femoral hernia: below inguinal ligament into
femoral triangle, more common in women, highest
risk of strangulation (50% of all strangulations)

Subungual melanoma: melanoma under fingernail or
toenail, Tx DIP amputation

Sliding hernia: involves other viscera as part of the
hernia wall (e.g. bladder, cecum, sigmoid colon),
important to recognize sliding hernias as not to
injure any contained structures

Melanoma × SBO: presents as abd distention,
nausea and vomiting due to metastatic melanoma in
peritoneal cavity; Tx ex lap w/ excision

McVay repair: Cooper’s ligament to conjoint
tendon; fixes direct, indirect, and femoral hernias

Shouldice repair: inguinal ligament to reinforced
transversalis fascia in two layers

Direct hernia: medial to inferior epigastric vessels,
due to weakening abdominal wall; more common in
elderly

Melanoma in anus: all mucosal melanomas have bad
prognosis, Tx APR w/ palpable LN excision

Bassini repair: inguinal ligament to conjoint
tendon, high tension, fixes direct and indirect
hernias

Sarcoma × lung mets: get chest CT to characterize
lesion and look for others → needle biopsy for
confirmation → Tx thoracic wedge resection

Lentigo maligna melanoma: superficial, spreading
melanoma on the face, good prognosis overall, Tx
excision w/ narrow margin

Melanoma on face: Tx excision w/ smaller margins
for cosmetic purposes, consult plastic surgery

Hernia surgery types: open (Bassini, McVay,
Shouldice, Lichtenstein), laparoscopic (TAPP, TEP)

Ventral hernia: hernia through incision site at linea
alba; Tx primary closure (small) or mesh repair (large)
Rare hernia causes: anything that increases
abdominal pressure – obesity, COPD, ascites, BPH
causing bladder obstruction, constipation, ascites;
these require further evaluation before surgery

Hernia surgery complications: damage to genital
branch of genitofemoral nerve, ilioinguinal,
iliohypogastric, or lateral femoral cutaneous nerves
causing pain and sensory defects
Hernia surgery post-op: avoid lifting for 6 weeks so
incision site has time to regain strength

Surgery – Breast Surgery

–––––––––––– BREAST MANAGEMENT –––––––––––

–––––––– MALIGNANT BREAST DISEASES –––––––

Breast cancer screening: monthly self-exam, yearly
breast exam, yearly mammogram if >40 y/o (earlier if
there is a strong family Hx)

Breast cancer buzzwords: family history, ill-defined
or fixed mass, skin or nipple retraction, peau
d’orange, nipple eczema, and palpable axillary LN

Breast mass on exam: first, get mammogram to
characterize mass and rule out other masses →
get core needle biopsy → excisional biopsy if
needle inadequate

Breast cancer Tx: identical for all cancers (except
inflammatory, LCIS, DCIS); depends on cancer stage

Abnormality on mammogram: ‘probably benign’
→ follow-up; ‘suspicious’ → core needle biopsy,
excisional biopsy if needle inadequate

Stage I-II: lumpectomy w/ 1 cm negative margins
+ axillary LN samping + post-op radiation; or
modified radical mastectomy
Stage III-IV: systemic chemotherapy

Breast cancer risk factors: family Hx (#1), BRCA1 and
BRCA2 genes, old age

Axillary LN involvement: Tx chemotherapy if premenopausal, tamoxifen if post-menopausal

MC breast masses: <25 fibroadenoma, 25-50 fibrocystic change, >50 infiltrating ductal carcinoma

Breast cancer × pregnancy: work-up and Tx is
identical, except no chemo during 1st trimester
and no radiation anytime; if stage III or IV,
chemoradiation is essential and abortion may be
necessary

–––––––––– BENIGN BREAST DISEASES –––––––––
Fibroadenoma: firm, mobile, rubbery mass in young
women; Dx FNA and U/S, Tx elective removal
Giant juvenile fibroadenoma: seen in teens with
rapid breast growth; Tx excision to avoid breast
deformity
Phyllodes tumor: huge, benign tumors that distort
the breast; Dx core or incisional biopsy since FNA is
insufficient, Tx excision w/ negative margins

Breast cancer × men: work-up and Tx is identical
Paget’s disease: presents as “crusty” nipple eczema,
indicates underlying infiltrating ductal carcinoma
Inflammatory cancer: resembles cellulitis w/ peau
d’orange, “tumor cells in dermal lymphatics”, Tx
requires pre-op chemo
DCIS: Tx simple mastectomy

Fibrocystic change: multiple, bilateral lumps that
vary with menstrual cycle; if dominant or persistent
lump → aspiration → excisional biopsy if mass
recurs or persists
Sclerosing adenosis: Tx careful observation or
prophylactic bilateral simple mastectomy; not
precancerous, but is a risk factor of cancers
Atypical ductal hyperplasia: Tx excision; not
precancerous, but high risk of becoming a cancer
Intraductal papilloma: presents as bloody nipple
discharge; Tx galactogram/ductogram-guided
excision (due to small risk of carcinoma)
Acute mastitis: breastfeeding women get
Staph/Strep infection through cracks in nipple w/
yellowish discharge, Tx antibiotics and warm
compresses, may develop into breast abscess
Breast abscess: pus pocket in lactating women;
Tx I&D and biopsy to rule out possible cancer

LCIS: Tx careful observation or prophylactic bilateral
simple mastectomy; not precancerous, but is a risk
factor of breast cancers
–––––––– POST-SURGERY COMPLICATIONS –––––––
Small ipsilateral nodule: local recurrence until
proven otherwise, work-up like any other mass
Contralateral finding: most likely a new primary
cancer, work-up like any other mass
Elevated LFTs: indicates liver mets, get abd CT scan
Back pain: indicates bone mets, get bone scan then
X-ray
Pathologic fracture: indicates bone mets, get bone
scan then X-ray
Sensorimotor defects: indicates spine mets, get MRI
Severe headache: indicates brain mets, get MRI

Periductal mastitis: subareolar infection in smokers,
both males and females affected
Gynecomastia: breast tissue hypertrophy in males;
common in puberty (will resolve spontaneously) and
older men (excision if it doesn’t regress on its own)
Dystrophic calcification: presents as breast lump
following trauma, but work up as a cancer until
proven otherwise (trick question!)

New-onset seizures: indicates brain mets, get MRI
New-onset coma: indicates acute hypercalcemia due
to bone mets, get a renal panel for confirmation

Surgery – Acute/Critical Care Surgery

–––––––––––– TRAUMA EVALUATION ––––––––––––
Evaluation of trauma pt: primary survey, get an
“ample” Hx, secondary survey
Primary survey: initial evaluation of trauma pt;
ABCDE – airway, breathing, circulation, disability
(neurological), environment/exposure

C-spine injury: suspected with neurological Sx,
radiological abnormalities, or C-spine tenderness;
intubation requires extreme caution

Stab × hemiparesis: suggests injury to the carotid
artery; get angiogram and either vascular or
neurosurg consult

Priapism: indicates fresh spinal cord injury; check
for anal sphincter tone, bradycardia, and possibly
neurogenic shock

Neck GSW: exploration of neck is mandatory in zone
2, observe if stable in zones 1+3

––––––––––––––– HEAD TRAUMA –––––––––––––––
Ample Hx: things to ask a trauma pt – allergies,
meds, previous illnesses, last meal, events
surrounding injury
Secondary survey: full inspection of trauma pt
following clearance of life-threatening issues,
continual reassessment is necessary for changes
Airway: determine if airway is clear, quickest way to
evaluate is to see if pt can talk; use intubation,
cricothyroidotomy, or tracheostomy if obstructed
Blunt trauma to neck: consider possibility of
laryngeal edema developing into airway
obstruction
Breathing: evaluate via lung auscultation, CXR, and
pulse oximetry
Circulation: stop external hemorrhage, 2 large-bore
IV lines (14 or 16-gauge) w/ 2L crystalloid, followed
by packed RBC (type O–) if necessary
Cardiac tamponade: presents with Beck’s triad –
JVD, muffled heart sounds, hypotension;
Tx subxiphoid pericardiocentesis and go to OR
Hypovolemic shock: class I <15% and lactic acid;
class II 15-30% and ↑HR; class III 30-40% and ↓BP;
class IV >40% with lethargy and anuria
Hypovolemic shock Tx: 2 large-bore IV lines and
2L crystalloid infusion, resuscitation measured by
urine output, HR, BP, and mental status
Hypovolemic shock Tx unresponsive: search for
underlying cause, ex lap or thoracotomy may be
indicated for continuous internal bleeding
Closed head injury: brain edema and ischemia
causes Cushing reflex – peripheral vasoconstriction (↑BP), bradycardia (↓HR), and
respiratory depression (↓RR)
Circulation × pregnancy: ↑HR is normal and may
not indicate shock, ↓hct of 31-35% is normal, best
evaluated laying on her left side
Disability: evaluate with GCS; 15 max, ≤8 coma, 3
nearly dead
Disability × awake: stabilize C-spine, palpate
posterior neck for tenderness, assess extremities
for motor/sensory function, and get lateral Cspine imaging
Disability × comatose: C-spine cannot be cleared,
so precautions must continue

Head trauma evaluation: begin with primary survey
(ABCs) → rapid neuro exam if stable → if any neuro
sx, get head CT and neurosurg consult
Rapid neuro exam: check pupils, cranial nerves,
peripheral motor/sensory function, and rate level of
consciousness via GCS
EDH: head CT shows convex lens hematoma;
presents as LOC → lucid interval → LOC →
ipsilateral fixed/dilated pupil, Tx craniotomy
SDH: head CT shows crescent moon hematoma,
high risk for brain herniation; Tx head elevation,
hyperventilate, sedate, mannitol + furosemide
Diffuse axonal injury: head CT shows blurred
gray-white junction and small punctate
hemorrhages; management is prevention of ↑ICP
Head trauma × hypovolemic shock: look for another
source of bleeding
Basal skull fx: raccoon eyes, hemotympanum,
otorrhea, rhinorrhea, ecchymosis behind the ear
(Battle’s sign); neurosurg consult is indicated
––––––––––––––– NECK TRAUMA –––––––––––––––
Neck stab wound: begin with primary survey (ABCs),
then careful exam for injured structures
Surgery indications: expanding hematoma,
deteriorating vital signs, coughing blood,
subcutaneous emphysema, all GSW and stab
wounds in zone 2 (zones 1+3 can be observed if
stable)
Stab × zone 1: below cricoid (includes lung);
observation and pre-op angiogram if stable,
otherwise exploration of neck is necessary
Stab × zone 2: between mandible and cricoid;
exploration of neck is mandatory
Stab × zone 3: above mandible; observation and
pre-op angiogram if stable, otherwise exploration
of neck is necessary
Stab × dysphagia: suggests injury to the
esophagus, Dx esophagoscopy or barium
swallow
Stab × hoarseness: suggests injury to the airway,
larynx (voicebox), or recurrent laryngeal nerve;
Dx laryngoscopy or exploration

Neck blunt trauma: at risk of carotid dissection (Tx
anticoagulation) or laryngeal edema (Tx intubation)
––––––––––––––– SPINAL TRAUMA ––––––––––––––
Spinal cord injury management: get MRI to look at
spinal cord, then immediate high-dose steroids
Hemisection syndrome: always due to stab
wounds in posterior neck area, presents as ipsi
DCML/motor loss and contra ACL loss
Anterior cord syndrome: usually seen w/
vertebral burst fractures, presents as bilateral
ALS/motor loss but intact DCML
Central cord syndrome: usually seen w/ whiplash
(e.g. rear end collisions), presents as UE burning
pain and paralysis, but LE nerves intact
––––––––––––––– CHEST TRAUMA ––––––––––––––
Rib fx: painful breathing leads to shallow breaths →
atelectasis → pneumonia, Tx local nerve block
Chest stab wounds: suspect HTX or PTX, chest tube
insertion is indicated
Infraclavicular stab wounds: suspect injury to
subclavicular artery or vein, Dx angiogram if pt is
stable or urgent exploration if unstable
Nipple-level stab wounds: suspect additional
injury to diaphragm/abdominal organs, ex lap
indicated for abdominal organ damage
PTX: air in pleural space; insert a finger to make sure
of pleural space, then insert a chest tube, remove
when lung is fully inflated and no air leak present
Small PTX: simple observation is okay if it’s
asymptomatic, no free fluid present, not
expanding, and no other significant injuries
Sucking chest wound: seal with occlusive
dressing, insert chest tube in different location
Nonfunctioning chest tube: chest tube is in the
wrong location or not working properly;
reposition or replace chest tube
Continuous air leak into chest tube: major airway
injury with disruption of bronchus or trachea
Tension PTX: mediastinal shift, hypotension, JVD,
absent breath sounds, and hyperresonant to
percussion; Tx emergent needle aspiration and
chest tube insertion (do not wait for CXR or ABG)
HTX: blood in pleural space, go to OR if chest tube
drains 1.5L or >200 mL/hr for 3 hours

Surgery – Acute/Critical Care Surgery

HTX × hypotension: suspect blood loss in left
chest, indicated for left chest tube insertion
Thoracic GSW: GSW is managed differently due to
unpredictable path of bullets vs. knife, mark both
entrance/exit sites and get imaging
Thoracic blunt trauma: suspect HPTX, chest tube
insertion is indicated; emergent thoracotomy if >1.5L
or >200mL/hr blood is extracted from tube
Aortic transection: presents as widened mediastinum on CXR, confirm w/ aortic angiography or
chest CT → go to OR if transected
Flail chest: presents w/ paradoxic chest wall
movements due to multiple rib fx, suspect lung
contusions and aortic transection; manage by
inserting bilateral chest tubes and serial ABGs
Pulmonary contusions: presents as deteriorating
ABGs and “white out” of lungs on CXR; Tx colloid
(not crystalloid) + diuretics + fluid restriction
Ruptured diaphragm: CXR reveals stomach in left
chest; rapid eval of non-abd injuries → go to OR

Trauma × perforated viscera: CXR reveals free air
in abdomen; rapid eval of non-abd injuries →
repair perforated viscera in the OR
Trauma × hypotensive w/o hemorrhage:
indicated for FAST or DPL → ex lap in OR if
positive; CT scan inappropriate for unstable pts
Trauma × hypotensive w/ pelvic fx: suspect
vascular injury from branch of internal iliac, Dx
FAST, Tx control by embolization

Air embolus: presents as sudden death in an
intubated/respirator pt; management is immediate
Trendelenburg position + cardiac massage
Fat embolus: presents as RDS and petechiae in
neck/axilla due to bone marrow embolization from
long bone fx; management is respiratory support
––––––––––––– ABDOMINAL TRAUMA –––––––––––
Abdominal GSW: mandatory OR for ex lap for all
GSW below nipple level
Abdominal stab wound: mandatory OR if stab
wound penetrates peritoneum (e.g. protruding
viscera, peritonitis, hemodynamic instability);
otherwise, digital exploration and observation
Abdominal blunt trauma: mandatory OR if signs of
peritonitis or hemodynamic instability despite
transfusion; otherwise, CT scan can be done safely
before proceeding
Trauma × flat/nontender abd: observe if no
mechanism, imaging if mechanism exists

Dx CT scan: useful for stable pts, avoid in
unstable or severely injured pts
Splenic laceration: ex lap if unstable, preserve
spleen if possible to avoid post-splenectomy sepsis,
avoid blood transfusion if possible, splenectomy
requires vaccination for SHiN bacteria

Mesentery injury: difficult to detect on CT so
mechanism must evoke suspicion, co-exists with
bowel injury since mesentery is tougher than bowel
Renal laceration: stable → angiography and planned
operative repair; unstable → IV pyelo to detect if
two kidneys present, then OR for nephrectomy
Hematoma in SMA region: suggests major injury to
abd aorta, major aortic branches, pancreas, or
duodenum; stable → angiography and assessment
before operation, unstable → urgent ex lap
Pancreatic transection: mandatory ex lap; minor
injury → debride and drain, major injury → resection
of devitalized pancreatic tissue and repair of
duodenal injury
Duodenal hematoma: common in kids hitting abd on
bicycle handlebars, hematoma causes GI obstruction;
Tx NPO/IVF, will resolve spontaneously in 5-7 days

↓CO/↑CVP: cardiogenic shock (e.g. CHF, MI, tension
PTX, pericardial tamponade)

Retroperitoneal zones: central is zone 1, flank is
zone 2, pelvis is zone 3
Surgery indications: all zone 1 hematomas, zone 2
and 3 hematomas only if penetrating trauma
Zone 1 (central hematoma): may involve injury to
major vascular structure, indicated for ex lap
Zone 2 (flank hematoma): no exploration
warranted unless penetrating trauma, because
peritoneum will tamponade bleeding
Zone 3 (pelvic hematoma): no exploration
warranted unless penetrating trauma, because
peritoneum will tamponade bleeding
––––––––––––– UROLOGIC TRAUMA ––––––––––––
Urologic surgery indications: all GSW, stab wounds,
and other penetrating injuries
Urethral injury: presents as blood on meatus, scrotal
hematoma, and “high-riding” prostate; get a
retrograde urethrogram and suprapubic catheter
instead of Foley (may compound injury)
Bladder injury: associated w/ seatbelt trauma in
adults; get a retrograde cystogram and post-void
films, then surgical repair
Renal injury: associated w/ blunt trauma to back and
lower rib fx; get CT scan, manage non-op if possible
Scrotal hematoma: manage non-op unless testicle is
ruptured (seen on U/S)

Blood in ex lap: stop bleeding by packing all four
quadrants with gauze packs → attack injuries in
order of severity and attempt hemostasis → inspect
remainder of abd contents and repair injuries

Penis fx: associated w/ cowgirl sex; insert a
suprapubic catheter then repair surgically

Triad of death: acidosis, coagulopathy, hypothermia

Penetrating limb trauma: no vascular injury → give
tetanus PPx and clean wound; vascular injury
present → arteriogram if stable, OR if unstable

Trauma × severe abd pain: suspect peritoneal
irritation due to blood or intestinal contents, Dx
FAST or CT → indicated for ex lap if positive

Hemorrhage × hypothermia: can lead to
coagulopathy due to platelet dysfunction and
PT/PTT prolongation; rewarming indicated

Trauma × tire mark across abd: indicates severe
direct trauma, high suspicion of internal injury

Hemorrhage × low platelets: loss of platelets due
to hemorrhage puts pt at risk for coagulopathy;
platelet transfusion indicated

Trauma × coma: abd imaging mandatory since
physical exam is impossible on a comatose pt

↓CO/↓CVP: hypovolemic shock, neurogenic shock
(e.g. spinal cord trauma, anaphylaxis)

––––––––– RETROPERITONEAL TRAUMA ––––––––
Dx DPL/FAST: diagnostic peritoneal lavage (DPL)
or ultrasound (FAST) useful for quick Dx of
internal free fluid → positive DPL/FAST is
indicated for ex lap; may be false negative in
retroperitoneal injuries

Liver laceration: ex lap if unstable, observe if stable
Ruptured trachea/bronchi: presents as
continuous air leak into chest tube and
subcutaneous emphysema; go to OR

Hemorrhage × abd distention: bleeding into abd
cavity can lead to abd compartment syndrome,
which can cause decreased renal blood flow
(oliguria) and dyspnea (elevated diaphragm)

Hemorrhage × metabolic acidosis: results from
decreased tissue perfusion causing lactic acidosis;
crystalloid infusion indicated

–––––––––––––––– LIMB TRAUMA –––––––––––––––

Combined limb trauma: order of repair is bone first,
then vascular repair, nerve last; fasciotomy required
to prevent compartment syndrome
Limb GSW: may require extensive debridements and
amputation if unsalvageable
Crushing limb trauma: high risk of myoglobinuria
leading to acute renal failure; Tx IV fluids + mannitol
+ acetazolamide to maintain a high urine output

Surgery – Acute/Critical Care Surgery

––––––––––––––––––– BURNS ––––––––––––––––––
Burn assessment: determine depth of burn, type of
burn, and body surface area (%BSA) burned
First-degree burns: epidermis only, painful
Second-degree burns: extends into dermis,
causes pain and blistering, may develop into
third-degree burns w/o proper management
Third-degree burns: full thickness, painless
Burn management: tetanus PPx, IV pain meds,
topical agents (silver sulfadiazine is default, mafenide
acetate for deep penetration, triple abx ointment for
the eyes)
Rule of 9’s: estimates %BSA burned; head and upper
extremities are 9% each; anterior trunk, posterior
trunk, and lower extremities are 18% each; and
perineum is the last 1%
Parkland formula: estimates fluid replacement in
burn victims, LR volume = %BSA × kg × 4mL/kg;
give 50%LR in first 8 hours, 50%LR in next 16 hours
Fluid for infants: 20 mL/kg if BSA>20%
Chemical burns: alkaline burns are worse than acids
Chemical burn management: massive tap water
irrigation, don’t try acid-base neutralization,
except in ingestion – orange juice for alkali, milk
for acids
Electrical burns: may appear benign on surface, but
masks large amounts of interior damage to muscles,
nerves, and vessels; at risk of cardiac injury
(arrhythmias) and muscle injury (myoglobinuria)
Electrical burn management: IV fluids + mannitol
+ acetazolamide to maintain a high urine output
Inhalation burns: suspected with carbonaceous
sputum, facial burns, singed facial/nasal hairs,
hoarseness, etc. due to smoke inhalation
Inhalation burn management: confirm w/
fiberoptic bronchoscopy and order serial ABGs;
high COHb levels → Tx 100% O2
Circumferential burns: rapidly become thick and
contracted, causing restricted ventilation in the
chest and ischemia in extremities; Tx escharotomy

Snake bites: don’t always result in envenomation; if
signs of venom evident (pain, swelling, discoloration)
then draw blood for labs and Tx anti-venin
Bee stings: may present as anaphylactic shock
(“warm and pink”) secondary to allergic response;
Tx stinger removal and epinephrine
Spider bites: black widows have neurotoxins, brown
recluses have necrotoxins
Black widow spiders: present w/ severe muscle
cramps, acute abdomen, and nausea/vomiting;
give IV calcium gluconate + muscle relaxants
Brown recluse spiders: present as an ulcerated
lesion; excise ulcer and skin graft
Human bites: requires extensive irrigation and
debridement due to high amounts of bacteria
––––––––––––––––– NUTRITION ––––––––––––––––
TPN: indicated for nutrition when gut is nonfunctional or not availble, requires personalization of
formula for nutrition status
TPN × fever: examine catheter site for infection,
obtain cultures from catheter site and blood;
if –bacteria → change catheter site, if +bacteria
→ change catheter site and start antibiotics
TPN × metabolic coma: hyperglycemic,
hyperosmolar, nonketotic coma is commonly due
to excessive osmolar diuresis in hyperglycemia
TPN × elevated LFTs: very common (up to 30%),
TPN can cause fatty liver, structural liver damage,
and even cirrhosis with prolonged TPN
TPN × dry/scaly skin: indicates free fatty acid
deficiency, Tx FFA administration
Nitrogen in TPN: positive nitrogen balance is the
goal, since negative nitrogen balance indicates a
catabolic state; severity of injury correlates with a
higher amino acid requirement
BEE: basal energy expenditure, equal to (body
weight × 25 kcal/kg/day)
Nondepleted pts: 1.2× BEE calories needed; good
nutritional status before surgery
Depleted pts: 1.2-1.5× BEE calories needed;
malnourished before surgery

Scalding burns in kids: consider child abuse
Burns × methemoglobinemia: Sx chocolate-brown
blood, central cyanosis of trunk, arrhythmias,
seizures, coma; Dx ABGs (pulse ox is unreliable), Tx
IV methylene blue
––––––––––––––– BITES & STINGS ––––––––––––––
Bite management: all require tetanus PPx
Dog bites: rabies PPx only required if bite was
unprovoked and dog isn’t available for brain Bx

Hypermetabolic pts: 1.5-2× BEE calories needed;
severely stressed catabolic state due to trauma,
burns, sepsis, cancer, etc.
Macronutrients: carbs (4 kcal/gm), protein (4
kcal/gm), fat (9 kcal/gm), etoh (7 kcal/gm)

Surgery –Subspecialty Surgery

––––––––––––– PEDIATRIC SURGERY ––––––––––––
VACTERL syndrome: vertebral, anal atresia, cardiac,
TE fistula, esophageal atresia, renal, limbs (radius);
presence of any of these requires checking for the
others
Esophageal atresia: presents as excess salivation,
choking spells, coiling NG tube, and often a TE
fistula; Tx surgical repair (if delay is necessary,
gastrostomy)
Anal atresia: high rectal pouch → colostomy then
delayed repair, low rectal pouch → repair, if anofistula present → delay repair since further
growth may correct condition
Congenital diaphragmatic hernia: presents as RDS
due to hypoplastic left lung; Dx CXR shows bowel in
left chest, Tx intubation w/ low-pressure ventilation
Gastroschisis: midline hernia to left of umbilical cord
tearing through peritoneum; Tx closure if small, silo
if large, and TPN for a month since GI doesn’t work
Omphalocele: midline hernia through the cord with
peritoneal covering; Tx closure if small, silo if large

Vascular rings: presents as stridor, RDS, crowing
respiration, and dysphagia in an infant due to
compression of trachea and esophagus; Dx barium
swallow and bronchoscopy, Tx surgical correction
Cardiac anomalies: all require prophylactic antibiotics for subacute bacterial endocarditis
L→R shunts: all present with murmurs and lateonset cyanosis due to Eisenmenger syndrome
(pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur,
fixed S2, and frequent colds; Dx echo, Tx surgery
VSD: presents as pansystolic harsh-sounding
murmur with failure to thrive; Dx echo, Tx surgery
PDA: presents with machinery-like murmur, often
seen with congenital rubella syndrome; Dx echo,
Tx indomethacin or surgery
R→L shunts: all present with murmurs and earlyonset cyanosis

Embolic occlusion of retinal artery: presents as
sudden unilateral loss of vision; Tx breathe into
paper bag and repeatedly press on eye to shake clot
into a more distal branch of retinal artery
––––––––––––– OTOLARYNGOLOGY ––––––––––––
Neck masses: three types – congenital, inflammatory,
neoplastic; differentiate via onset and resolution
Congenital neck masses: thyroglossal duct cyst
(midline), branchial cleft cyst (lateral), cystic
hygroma (base of neck)
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Branchial cleft cyst: lateral mass at anterior edge
of SCM, may have a small opening and blind tract
Cystic hygroma: dilated lymphatic duct at base of
neck, common in Turner syndrome, get CT scan
to find extent of mass before surgical removal

Tetralogy of Fallot: presents as cyanosis and
clubbing in a 5 y/o child who squats for relief;
Px determined by degree of pulmonary stenosis,
Dx echo shows RVH, Tx surgery

LN DDx: cancers are large (>2 cm), painless, fixed,
insidious onset, unusual site; infectious LN are small
(<2 cm), painful, rapid onset, mobile, normal site

Malrotation: presents as biliary vomiting and
double-bubble on X-ray; Dx contrast enema or
upper GI study, Tx emergency surgical correction

Transposition of great vessels: presents as lifethreatening cyanosis in a newborn; Dx echo, Tx
surgery

Lymphomas: presents with multiple swollen LN,
fever, and night sweats; get excisional biopsy, then
Tx chemo

–––––––––––––– OPHTHALMOLOGY –––––––––––––

Supraclavicular metastases: MC primary sites are
pancreas and stomach; get excisional biopsy for Dx

Intestinal atresia: presents as biliary vomiting and
multiple air-fluid levels on X-ray, aka apple-peel
atresia due to vascular accident in utero

Strabismus: misaligned eyes due to uncoordinated
extraocular muscles; Tx surgical extraocular muscle
manipulation to prevent ambylopia

Biliary vomiting: indicates SBO distal to ampulla of
Vater; DDx duodenal atresia, intestinal atresia
annular pancreas, or malrotation

Necrotizing enterocolitis: presents as feeding
intolerance, abd distention, and ↓platelets in
premies; Tx NPO, IVF, TPN, IV abx → surgical repair if
signs of intestinal necrosis/perforation present
Pyloric stenosis: presents as non-bilious projectile
vomiting in first-born boys; Dx palpable epigastric
olive, Tx rehydration and pyloromyotomy
Biliary atresia: presents as progressive jaundice in a
1-2 month old due to lack of CBD; Dx HIDA scan +
phenobarbital (to stimulate GB contraction), Tx liver
transplant
Hirschsprung’s disease: presents as chronic
constipation due to lack of nerves in distal colon,
rectal exam can decompress bowel; Dx X-ray shows
distended proximal colon, Tx surgical pull-through
Intussusception: presents as colicky abd pain that
lasts 1 minute then resolves, and currant jelly stools;
Dx/Tx barium or air enema (surgery if it doesn’t work)
Child abuse: presents as retinal hemorrhages, SDH,
multiple healed fx, and scalding burns; call child
protective services
Meckel’s diverticulum: presents as LGIB in a child,
Dx technetium uptake for ectopic gastric mucosa

Amblyopia: vision impairment usually due to
strabismus in kids, Tx eyepatch the good eye to
develop the impaired one
Retinoblastoma: presents as a leukocoria in a baby,
Tx surgical enucleation (remove the eye)
Narrow-angle glaucoma: presents as severe eye pain,
headache, “seeing halos around lights”, eye feels as
hard as a rock; Tx iridotomy (give pilocarpine, acetazolamide, or mannitol as first aid)
Orbital cellulitis: presents as cellulitis of eyelids w/
fixed/dilated pupil and limited eye ROM; get CT scan
then drain the pus
Chemical burns of eye: irrigate w/ plain water ASAP,
at hospital – irrigate w/ saline, remove corrosive
particles, and test pH before sending home; alkaline
burns are worse than acid burns
Retinal detachment: presents as flashes and floaters,
and a dark curtain being pulled down over the eye;
Tx emergency laser “spot welding”
Amaurosis fugax: emboli from carotid travels to
retina causing transient blindness; Dx fundoscopic
exam reveals Hollenhorst plaque, a bright shiny spot
in a retinal artery

Head/neck SCC: presents as persistent hoarseness,
painless ulcer in floor of mouth, or unilateral earache;
risk factors are EtOH, smoking, and AIDS
SCC management: get triple endoscopy to look
for primary tumor → biopsy tumor → CT scan to
determine stage; Tx resection, radical neck
dissection, cisplatin-based chemo
Acoustic neuroma: presents as unilateral deafness
due to Schwann cell proliferation on CN VIII, get MRI
Facial nerve tumor: presents as gradual-onset
unilateral facial paralysis (sudden-onset is Bell’s
palsy), get MRI
Parotid tumors: present as masses around angle of
mandible, two types – pleomorphic adenomas
(benign, painless) and mucoepidermoid carcinomas
(malignant, painful)
Parotid tumor management: get FNA or formal
superficial parotidectomy (open biopsy contraindicated due to CN VII)
Foreign bodies: any toddler w/ unilateral ENT sx
(earache, rhinorrhea, wheezing) has a toy stuck in
there; do endoscopy under anesthesia to remove
Ludwig angina: abscess in floor of mouth due to
tooth infection, Tx I&D and tracheostomy

Surgery –Subspecialty Surgery

Bell’s palsy: sudden CN VII paralysis for no evident
reason, Tx antivirals immediately
CN VII trauma: sudden CN VII paralysis following
facial trauma, will resolve spontaneously
Cavernous sinus thrombosis: presents as diplopia in
a pt w/ sinusitis due to nerve (CN III/IV/VI) injury, Tx
antibiotics, CT scan, and drainage of abscess
Epistaxis: nosebleed has different causes and
management depending on pt’s age
Epistaxis × children: due to nosepicking, Tx local
pressure and phenylephrine nasal spray
Epistaxis × teens: either cocaine abuse and septal
perforation (requires packing) or juvenile
nasopharyngeal angiofibroma (surgical resection)
Epistaxis × elderly: due to HTN; requires packing,
BP control, and often surgical ligation of vessels
Vertigo: dizziness can be attributed to diseases of
inner ear or brain itself
Vertigo × inner ear: “room is spinning”, Tx
meclizine, phenergan, or diazepam
Vertigo × brain: “room is stable, but patient is
spinning”, do a neurologic work-up

then resect (give mannitol, hyperventilate, and highdose steroids while waiting)
Frontal lobe tumors: present as disinhibition,
anosmia (CN I), ipsilateral blindness (CN II), and
contralateral papilledema
Craniopharyngioma: presents as GH deficit and
bitemporal hemianopsia ◐◑ in a kid, Dx calcified
lesion in sella turcica
Prolactinoma: presents as amenorrhea and
galactorrhea in a young woman, consider
possibility of MEN1 syndrome, Tx bromocriptine
Acromegaly: presents as huge hands, feet,
tongue, and jaws in a tall man due to ↑GH; Dx get
somatomedin C levels and MRI, then resection
Nelson syndrome: presents as bitemporal
hemianopsia ◐◑ and hyperpigmentation in an
adult due to pituitary microadenomas that grew
to full size; Dx MRI then Tx surgical resection
Pituitary apoplexy: presents with typical pituitary
adenoma sx, then sudden onset headache and
CNS sx due to bleeding into tumor; Dx MRI then
emergent steroid replacement
Pinealoma: presents as loss of upper gaze and
“sunset eyes” due to compression of vertical
gaze center in superior colliculi

Vascular CNS diseases: TIA, ischemic stroke,
hemorrhagic stroke, subarachnoid hemorrhage
TIA: brief neurologic deficit that fully resolves
within 24 hours; due to thromboembolus from
internal carotid arteries
TIA management: carotid duplex, then aspirin
and elective CEA (if >70% stenosis)
Ischemic stroke: a neurologic deficit that doesn’t
resolve within 24 hours due to thromboembolus
from internal carotid arteries, Tx t-PA within 3
hours, otherwise observe and rehab
Hemorrhagic stroke: severe headache and
neurologic deficit that doesn’t resolve within 24
hours in uncontrolled HTN; Dx CT scan, Tx rehab
and control of HTN
SAH: “worst headache of my life” due to rupture
of Charcot-Bouchard aneurysm in lenticulostriate
arteries; Dx CT scan to confirm SAH, then arteriogram to locate aneurysm, then surgical clipping

Lower UTI: presents as dysuria and cloudy, stinky
urine but no fever, chills, or flank pain; common in
young women, give antibiotics
Pyelonephritis: UTI that has ascended to the kidneys,
presents with fever, chills, flank pain; Dx urologic
work-up and Tx antibiotics
Prostatitis: presents as fever, chills, dysuria, back
pain, and tender prostate on rectal exam; give antibiotics and don’t do any more rectal exams
Urologic workup in kids: indicated for traumatic
hematuria and UTIs, since it may indicate congenital
abnormalities otherwise undiagnosed
Congenital malformations: posterior urethral valves,
hypospadias, epispadias, vesicoureteral reflex, low
implantation of ureter, ureteropelvic obstruction
Posterior urethral valves: presents as anuria in a
newborn boy; cathereterize to empty bladder,
then Dx voiding cystourethrogram, Tx resection
Hypospadias: presents as urethral opening on
ventral side of penis, never circumcise since
prepuce is needed for surgical correction
Epispadias: urethral opening on dorsal penis

––––––––––––––– NEUROSURGERY ––––––––––––––
CNS diseases: vascular (sudden onset), metabolic
(hours), infectious (days-weeks), tumors (months),
degenerative disease (years)

surgical emergency that requires immediate
decompression (stent or perc nephrostomy) in
addition to IV antibiotics

Brain tumors in kids: present as cerebellar sx and
headaches relieved by knee-chest position, due to
posterior fossa lesions; Dx MRI, Tx resection
Spinal cord tumors: present as back pain in
someone who’s been treated for other cancers
(spine is a common site of mets); Dx MRI, Tx neurosurgical decompression
Neurogenic claudication: presents with pain on
exertion and relief with rest, but pain is positiondependent and pulses are intact; Dx MRI, Tx neurosurgical decompression
Trigeminal neuralgia: severe facial pain lasting 60
seconds; Dx MRI to r/o organic cause, then Tx anticonvulsants (radiofrequency ablation as backup)
Reflex sympathetic dystrophy: presents as severe
pain months after a crush injury w/ sympathetic
overload (cold, cyanotic, moist); Dx sympathetic
block, Tx surgical sympathectomy
–––––––––––––––––– UROLOGY –––––––––––––––––
Testicular torsion: presents as severe testicular pain
and “high riding testicle with horizontal lie” due to
twisting of the cord; Tx emergent surgical detorsion,
then orchiopexy (do not do any Dx tests)

CNS abscess: presents as space-occupying lesions
but short-onset (weeks) and w/ nearby infections
(otitis media, mastoiditis); get CT scan then resect

Epididymitis: presents like testicular torsion but w/
fever, pyuria, and cord is also tender; Dx U/S to rule
out torsion, then Tx antibiotics

CNS tumors: presents as space-occupying lesions
and progressive headache over months; get MRI

Obstructive UTI: presents as sepsis (fever, chills,
flank pain) in someone passing a kidney stone;

VUR: presents as dysuria, fever, chills, and flank
pain in kids due to ascending UTI; give antibiotics
and Dx IV pyelo and voiding cystogram to look for
reflux, long-term abx until child “grows out of it”
Low implantation of ureter: asymptomatic in
boys, “wet with urine all the time” in girls b/c
ureter drips into vagina instead of bladder; Dx
physical exam or IV pyelo, Tx surgical correction
Ureteropelvic obstruction: usually asymptomatic,
but presents with colicky pain with large diuresis
(e.g. colicky pain following “beer drinking binge”)
Hematuria: always get IV pyelo (CT scan if allergic or
poor renal function) and cystoscopy to r/o cancers
Urologic cancers: renal cell carcinoma, transitional
cell carcinoma, prostatic cancer, testicular cancer
RCC: presents as hematuria, flank mass/pain, and
paraneoplastic syndromes (PAPER – PTHrP, ACTH,
prolactin, EPO, renin); get CT scan if suspected,
Tx surgical resection
Bladder TCC: presents as painless hematuria in
smokers; get IV pyelo and cystoscopy, then Tx
surgical resection, then lifelong f/u for high-rate
of local recurrence
Prostatic cancer: asymptomatic, detected as
rock-hard nodule on rectal exam; get U/S-guided
needle biopsy, then TURP or radiation therapy
(Tx flutamide and leuprolide if metastatic)

Surgery –Subspecialty Surgery

Testicular cancer: presents as painless testicular
mass that doesn’t transilluminate; get radical
orchiectomy w/ biopsy, then f/u αFP or βHCG for
recurrence (Tx cisplatin or radiation if metastatic)
BPH: presents as dribbing, nocturia, and difficulty
voiding in an old man; put in Foley for 3 days, and Tx
α-blockers (tamsuosin), 5αR-blockers (finasteride)
+/- surgical prostate resection
Post-op urine retention: presents as a need to void,
but inability to do so; Tx straight cath at 6 hours
post-op and Foley after 2nd straight cath
Stress incontinence: presents as urine leaking w/
abd pressure due to weakened pelvic floor in a
multigravid woman; Tx surgical repair of pelvic floor
Kidney stones: presents as colicky flank pain and
hematuria +/- radiation to inner thigh, Dx plain X-rays;
Tx analgesics, fluids, and observation (<3 mm) or
shockwave lithotripsy (>3 mm)
Impotence: two types – organic and psychogenic,
management depends based on etiology
Psychogenic impotence: sudden onset w/o
traumatic cause, specific to partner or situation;
Tx psychotherapy
Organic impotence: sudden onset (trauma) or
gradual onset (atherosclerosis, diabetes); firstline Tx is PDE5-blockers (sildenafil, Viagra)
–––––––––––– TRANSPLANT SURGERY –––––––––––
Transplant donors: almost everyone including braindead pts, Hep and HIV pts to each other, metastatic
cancer pts for corneas
Transplant rejection: hyperacute (minutes), acute
(days/months), chronic (years)
Hyperacute rejection: preformed ab’s against donor
organ causes vascular thrombosis within minutes;
never seen since type-and-cross prevents this from
happening
Acute rejection: HLA mismatch causes macrophage
attack on donor tissue with lymphocytic infiltrate,
confirmed by biopsy
Liver rejection: indicated by elevated LFTs, first
step is to get U/S and Doppler to rule out biliary
obstruction and vascular thrombosis
Heart rejection: indicated by progressive heart
failure; management is getting routine ventricular
biopsies and Tx steroid bolus + OKT3
Chronic rejection: gradual deterioration of organ
function due to polymorphisms, irreversible and no
Tx available

Surgery – Orthopedic Surgery

–––––––––––– PEDIATRIC DISEASES ––––––––––––
Congenital hip dysplasia: presents as uneven gluteal
folds, posterior dislocating hips (with “snapping”) in
a newborn; Dx U/S since hip isn’t calcified for X-ray,
Tx splinting
Avascular necrosis of femoral head: presents in a kid
w/ limping, hip pain, and limited hip ROM; Dx X-ray,
Tx cast + crutches

Anterior shoulder dislocation: presents w/ outward
rotated arm + deltoid numbness due to axillary palsy

Open fx: require cleaning and reduction within 6
hours to prevent ischemia of distal limb

Posterior shoulder dislocation: rare, presents w/
internally rotated arm held close to body

Gas gangrene: presents as tender, swollen,
discolored wound site w/ crepitus following a
penetrating injury; Tx high-dose penicillin G,
hyperbaric oxygen, and debridement

Colles fx: distal radial fx in osteoporotic women
falling on outstretched hand; Tx reduction + cast
Monteggia fx: diaphyseal fx of proximal ulna + radial
dislocation, following direct trauma to ulna

Hip dislocation: presents as a chubby kid limping
due to groin pain, hip has limited internal rotation;
Dx X-ray, Tx pin femoral head back in place

Galeazzi fx: diaphyseal fx of distal radius + ulnar
dislocation, following direct trauma to radius

Septic hip: presents in toddlers who refuse to move
hip following a septic illness; Dx hip aspiration unter
anesthesia, Tx perc drain

Scaphoid fx: presents as wrist pain and tender
anatomic snuffbox in a young person falling on
outstretched hand; Tx thumb spica cast

Osteomyelitis: presents in kids w/ severe localized
bone pain following a septic illness; Dx bone scan
since X-ray will be false negative, Tx antibiotics

Metacarpal neck fx: presents as swollen and tender
hand after punching a wall; Tx splint or plate

Genu varum: aka bowlegs, <3 y/o observe since it’s
normal, >3 y/o surgical correction
Genu valgus: aka knock-knee, observation okay
Osgood-Schlatter disease: presents in teens w/
persistent pain over tibial tubercle, aggravated by
quad contraction; Tx immobilization in cast
Club foot: presents as bilateral inverted feet in a
newborn; Tx serial plaster casts on adducted
forefoot → hindfoot varus → equinus
Scoliosis: laterally curved spine, common in teenage
girls; Tx spine brace until mature, surgery if severe
––––––––––––––– BONE TUMORS –––––––––––––––
Osteosarcoma: presents as low-grade knee pain in a
10-25 y/o, X-ray shows Codman’s triangle and
sunburst appearance; consult a specialist
Ewing sarcoma: presents as low-grade epiphyseal
pain in a child, X-ray shows onion skinning, due to
t(11;22); consult a specialist
Metastatic bone cancers: usually from breast (lytic)
and prostate (blastic), causing bone pain and pathologic fx; Dx bone scan, Tx chemoradiation
Multiple myeloma: plasma B-cell tumor results in
CRAB – hyperCalcemia, Renal failure, Anemia, and
Bone pain (X-ray shows punched-out lesions); Dx
urinary Bence-Jones protein, Tx chemotherapy
–––––––––––– ORTHOPEDIC TRAUMA ––––––––––––
Fractures: all require 2 X-rays (90° from each other)
including joints above and below fractured bone;
anticoagulation of choice is fondaparinux + leg
compression devices
Clavicular fx: typically between mid-to-distal third of
clavicle; Tx figure-of-eight device for 4-6 weeks

Hip fx: presents as shortened and externally rotated
hip in an osteoporotic woman; Tx depends on
location of fx
Femoral neck fx: may lead to avascular necrosis of
femoral head; Tx prosthetic replacement of head
Intertrochanteric fx: less likely to cause avascular
necrosis; Tx ORIF
Femoral shaft fx: Tx intramedullary rod fixation,
high risk of hypovolemic shock and fat embolisms
Knee injury: all severe knee injuries present w/
swelling, and first step in management is an MRI
Unhappy triad: injury to ACL, MCL, and medial
meniscus following blow to lateral leg; Tx surgical
repair
ACL tear: presents as swelling, pain, and positive
anterior drawer sign; Dx MRI, Tx immobilization
and rehab
Meniscal tear: presents as pain, swelling, and
“clicking” of knee w/ forceful extension; Tx
arthroscopic repair to salvage meniscus
Tibial stress fx: presents as localized tibial pain in a
soldier following a long march; Tx cast and f/u X-ray
in 2 weeks
Leg fx: common in pedestrian vs. car accidents; Tx
cast for easily reduced fx, intramedullary nailing
otherwise, high risk of compartment syndrome
Achilles tendon rupture: presents as “popping noise”
in ankle following exertion w/ pain and swelling; Tx
cast or surgery
Ankle fx: common after falling on inverted or
everted foot; Tx ORIF
––––––––– ORTHOPEDIC EMERGENCIES –––––––––
Pain under cast: remove cast to examine

PSYCHIATRY

Ψ – Examination and Diagnosis

––––––– MENTAL STATUS EXAMINATION –––––––
Appearance: objective description of pt
Appearance buzzwords: pupil size = drug abuse
or withdrawal, bruises = abuse, needle
marks/tracks = drug abuse, eroding enamel =
bulimia, superficial cuts on arms = self-harm
Activity: amount/type of motor movement

Word salad: incoherent collection of words
Clang associations: rhyming and punning (think
hip-hop)
Thought blocking: abrupt cessation of speech
before idea is finished
Tangentiality: never gets to goal, keeps breaking
off on a tangent

Psychomotor agitation: excess, non-productive
motor activity in response to inner tension

Circumstantiality: overinclusion of trivial or
irrelevant details

Psychomotor retardation: visible slowing of
thoughts, speech, movement

Perseveration: inability to change the topic, or
giving the same response to different questions

Tics: involuntary, spasmodic motor movement
Akathisia: subjective feeling of muscular tension
resulting in restlessness, pacing, repeated sitting
and standing

Thought content: what the pt thinks
Poverty of thought vs. overabundance: too few
or too many ideas expressed
Delusions: fixed, false beliefs

Stereotypic movements: repetitive, fixed pattern
of physical action or speech (e.g. head banging)
Tardive dyskinesia: involuntary choreoathetoid
movements of head/limbs/trunk, due to
prolonged use of antipsychotics

Suicidal/homicidal ideation: thoughts about
wanting to kill self or others; assess by directly
asking about suicide, not just “do you want to
hurt yourself?”
Phobias: persistent, irrational fears

Echopraxia: imitating movements

Memory: controlled by temporal lobes; three
main types – immediate, short-term (recent),
long-term (remote)
Fund of knowledge: ask pt about simple facts
(e.g. “who is the current president?”)
Concentration: ask pt to “spell WORLD forwards
and backwards” or do serial 7 test
Abstraction: ask pt to interpret a proverb, and
explain similarities between objects; lack of
abstraction → concrete thinking
Insight: pt’s awareness and understanding of his/her
own problem
Judgment: pt’s ability to understand the outcome of
his/her actions
–––––––––––––––– DIAGNOSIS ––––––––––––––––
DSM-IV: axis I – mental illnesses, axis II –personality
d/o and mental retardation, axis III – medical
conditions, axis IV – psychosocial stressors, axis V –
global assessment of function (scale 0-100)
GAF ≤30: criteria for hospitalization
Intelligence quotient: [IQ = 100 × (mental age /
chronological age)], mean IQ is 100 w/ standard
deviation of 15

Echolalia: imitating speech

Obsessions: persistent, intrusive thoughts that
can’t be repressed, associated w/ anxiety

Dystonia: slow, sustained contraction of trunk or
limbs, usually a side-effect of drugs

Compulsions: repetitive behaviors (often acting
upon obsessions)

IQ tests: Stanford-Binet test for kids age 2-18,
Wechsler Aduit Intelligence Scale (WAIS) for adults
age 16-75

Ideas of reference: false belief that others are
talking about him/her

Mental retardation: IQ < 70 and deficits in
adaptive skills

Speech: pt’s ability to articulate thoughts; measured
in terms of rate, amount, volume, articulation, tone
Pressured speech: pt is uninterruptible and feels
compelled to continue speaking
Mood: what the pt feels in his own words; to assess
mood, ask “how are you feeling today?” or “rate your
mood on a scale of 1 to 10”
Affect: how pt’s mood appears to the examiner

Ruminations: mood-congruent concerns that
accompany state of depression/anxiety
Perception: mental process by which sensory stimuli
are brought to awareness
Hallucinations: perceptions w/o external stimuli;
five types – auditory (risk factor for SI/HI), visual,
taste, olfactory, tactile

Labile affect: laughing one moment, then crying
the next

Illusions: misperception of external stimuli

Flat affect: pt remains expressionless and
monotone despite gravity of situation

Agnosia: inability to recognize people or objects
even w/ intact sensory function

Inappropriate affect: pt laughs when told he has
a serious illness, or told he faces criminal charges

Depersonalization: feeling that one is falling
apart, fragmenting, detached, not oneself, etc.

Personality tests: Minnesota Multiphasic Personality
Inventory (MMPI), Thematic Apperception Test (TAT),
Rorschach test
MMPI: objective personality test used to identify
both personality d/o and other psychopathology
TAT: pt creates stories based on pictures of
people in various situations, used to evaluate
motivation behind behaviors
Rorschach test: interpretation of inkblots

Thought process: how the pt thinks
Goal-directed: normal thought process
Loosening of associations: no logical connection
from one thought to another
Flight of ideas: thoughts change rapidly from one
to another, characteristic of mania
Neologisms: made-up words

Derealization: feeling that the world is not real
Synesthesia: sensation of one modality perceived
by another (e.g. seeing sounds)
Cognition: pt’s ability to perform mental tasks
Alert + oriented x3: alertness controlled by
reticular activating system; orientation refers to
person, place, time

NSAID use: can ↓lithium excretion → ↑lithium
concentrations (except sulindac and aspirin)

Ψ – Psychotic Disorders

–––––––––––––––– PSYCHOSIS ––––––––––––––––
Psychosis: distorted perception of reality presenting
as delusions, hallucinations, or severely disorganized
thought/behavior

SCZ phases: prodromal phase (prepsychotic
decline in functioning), psychotic phase, residual
phase (negative sx b/t episodes of psychosis)
Schizophrenia subtypes: paranoid, disorganized,
catatonic, residual, undifferentiated

Psychosis in elderly: evaluate for delirium w/ EEG
Psychosis-exacerbating drugs: β-blockers,
digoxin, steroids, anticholinergics
Delusion: fixed, false belief; two types – bizarre
(impossible) and nonbizarre (could be true)

PSCZ: characterized by delusions and AH/CH,
deafness is a risk factor
DSCZ: characterized by disorganized speech,
behavior, and flat or inappropriate affect

Paranoid/persecution delusion: irrational belief
that one is being persecuted (e.g. CIA phone-tap)

CSCZ: characterized by rigid posture,
inappropriate or repetitive movements,
echolalia/echopraxia, and waxy flexibility

Delusion of reference: belief that cues in
external environment are directed at individual

RSCZ: prominent negative sx (5 As – Anhedonia,
flat Affect, Alogia, Avolition, poor Attention)

Delusion of control: thought insertion, thought
withdrawal, and thought broadcasting are unique
to SCZ

USCZ: doesn’t fulfill criteria for any other subtype

Schizoaffective disorder: SCZ + mood sx (either
manic, depressive, or mixed episode), delusions or
hallucinations w/o mood sx for 2 weeks; Tx
antipsychotics + mood stabilizers + supportive
psychotherapy
SAD vs. mood disorders: SAD has 2 week period of
psychotic sx w/o mood sx; worse Px than mood d/o
Delusional disorder: nonbizarre, fixed delusions for
1+ month w/o functional impairment; 4 subtypes –
paranoid, erotomaniac, jealous, somatic
Paranoid/persecution delusions: irrational belief
that one is being persecuted (e.g. CIA phone-tap)
Erotomaniac delusions: delusions regarding love

Delusion of grandeur: belief that one has
superpowers, or inflated self-esteem
Delusion of guilt: false belief that one is
responsible or guilty for something
Somatic delusion: false belief that one is
infected or has a certain illness
Illusion: misinterpretation of sensory stimulus
Hallucination: sensory perception w/o stimulus
Auditory hallucination: most common in
schizophrenia, command hallucinations are
specific AH that tell pt to do things
Visual hallucination: drug intoxication,
drug/alcohol withdrawal, delirium, Lewy body
dementia
Tactile hallucination: cocaine or amphetamine
intoxication, alcohol withdrawal
Olfactory hallucination: seizure disorder, must
r/o medical conditions
Gustatory hallucination: r/o medical conditions

SCZ gender: men = women but men have earlier
onset (20 y/o) than women (30 y/o), winter/early
spring birthdays have ↑incidence (due to ↓sunlight
→ ↓vit D)
SCZ prevalence: 1% overall, 10% siblings, 50% twins
Postpsychotic depression: major depressive
episode after resolution of psychotic symptoms
Downward drift: ↑SCZ prevalence in lower socioeconomic groups (can’t hold onto good jobs)
SCZ pathophysiology: ↑dopamine in mesolimbic
pathway (positive sx), ↓dopamine in prefrontal ctx
(negative sx); also ↑5-HT, ↑NE, ↓GABA, ↓glutamate
SCZ brain: diffuse cortical atrophy w/ enlarged
ventricles
SCZ Px: good prognosis w/ later onset, good social
support, positive sx, mood sx, acute onset, females,
↓relapses, and good premorbid function; 10% suicide
SCZ Tx: atypicals first-line, typicals second-line,
clozapine if other antipsychotics don’t work
Antipsychotic side-effects: EPS (parkinsonism,
akathisia, dystonia), NMS, tardive dyskinesia, antiHAM, metabolic syndrome, ↑prolactin, etc.

Psychosis 2/2 GMC: CNS diseases, endocrinopathy,
B3/B9/B12 deficiency, lupus, or porphyrias; an axis I
disorder but the GMC goes on axis III

SCZ × bad family: increased relapse rate

Substance-induced psychotic disorder: prescription
meds, alcohol, cocaine, hallucinogens, marijuana,
sedative-hypnotics, or PCP

Brief psychotic disorder: SCZ-like for <1 month;
Tx antipsychotics + supportive psychotherapy

–––––––––––––– SCHIZOPHRENIA ––––––––––––––
Schizophrenia: >6 months with 2/5 for at least 1
month – delusions, hallucinations, disorganized
speech, disorganized/catatonic behavior, negative
symptoms

–––––––– OTHER PSYCHOTIC DISORDERS ––––––––

Brief psychotic vs. BPD: BPD can have brief, stressrelated psychoses that are part of the personality
d/o and not brief psychotic d/o
Schizophreniform disorder: SCZ-like for 1-6 months;
Tx antipsychotics + supportive psychotherapy

Jealous delusions: aka Othello syndrome,
delusions of unfaithfulness
Somatic delusion: false belief that one is
infected or has a certain illness (e.g. parasitosis)
Delusional disorder Tx: psychotherapy (drugs
ineffective)
Shared psychotic disorder (folie á deux): pt picks up
identical delusions as a significant other; Tx
separation + psychotherapy, antipsychotics if not
improved in 1-2 weeks following separation

Ψ – Mood Disorders

–––––––––––––––––– MOOD ––––––––––––––––––
Mood: inner emotional state

Antidepressants: all equally effective and take 4-8
weeks for effect, SSRI/SNRI are first-line, maintain
for 6-9 months

Bipolar II disorder: 1 hypomanic episode + 1 major
depressive episode, no full manic episodes
BII Tx: mood stabilizers (see BI)

Mood episode: distinct period of abnormal mood;
includes major depressive, manic, hypomanic, and
mixed episodes
Mood disorder: loss of control over mood and
subsequent functional impairment; includes MDD,
bipolar I/II, dysthymic, and cyclothymic disorders
–––––––––––––– MOOD EPISODES ––––––––––––––

MDD in kids: presents as irritability and short temper,
rather than sadness or depression
MDD in elderly: MC psychiatric disorder in elderly,
↑incidence s/p MI, stroke, and new admits to nursing
homes
MDD subtypes: melancholic, atypical, catatonic,
psychotic, postpartum, seasonal affective disorder

Rapid cycling disorder: 4+ mood episodes in 1 year
Rapid cycling Tx: carbamazepine
Cyclothymic disorder: alternating hypomania and
dysthymia for 2 years, no asx interval of >2 months,
and no major depressive or manic episodes
CtD Tx: mood stabilizers (see BI)

Major depressive episode: 5/9 SIGECAPS (including
depressed mood or anhedonia) for 2 weeks –
depressed mood, Sleep, Interest, Guilt, Energy,
Concentration, Appetite, Psychomotor activity,
Suicidal ideation
Manic episode: 3/7 DIGFAST (4/7 if irritable mood) for
1 week – Distractibility, Insomnia, Grandiosity, FOI,
↑Activity, Speech pressured, Thoughtlessness
Hypomanic episode: 3/7 DIGFAST (4/7 if irritable
mood) for 4+ days, no functional impairment or
psychotic features (vs. manic episodes)
Mixed episode: 5/9 SIGECAPS + 3/7 DIGFAST for every
day of 1 week

Melancholic depression: characterized by
anhedonia, excess guilt, anorexia, early morning
awakenings, and psychomotor disturbance
Atypical depression: characterized by hypersomnia, hyperphagia, reactive mood, leaden
paralysis, hypersensitivity to rejection; Tx MAOIs
Catatonic depression: rare, characterized by
catalepsy, purposeless movements, bizarre
postures, and echolalia; Tx ECT
Psychotic depression: MDD + delusions or
hallucinations; Tx SSRI + antipsychotic
Postpartum major depression: onset within 4
weeks of delivery, resolves w/o meds

––––––––––––– MOOD DISORDERS –––––––––––––
Mood disorder 2/2 GMC: must have direct causal,
physiologic relationship to mood sx
Substance-induced mood disorder: β-blockers
(depression), steroids, levodopa, cocaine (mania),
OCP (depression)
Major depressive disorder: 1 major depressive
episode, no manic or hypomanic episodes
MDD prevalence: 16.2% (25-50% in elderly)
MDD risk factors: stroke (30-50%, lasts 2 years),
pancreatic cancer, loss of parent before age 11,
genetics (70% in twins)
MDD × sleep: difficulty falling asleep, multiple
awakenings, and early morning awakenings;
hypersomnia characteristic of atypical depression
MDD etiology: monoamine hypothesis is most
popular (↓5-HT/DA/NE), other causes include
↑cortisol, ↓thyroid, psychosocial and genetics
MDD brain: reduced frontal lobe blood flow and
metabolism
MDD Px: 15% suicide, 30-40% alcoholism, only 50%
receive Tx, 50-85% have another episode
MDD Dx: Beck depression inventory
MDD Tx: antidepressants ± psychotherapy; acute
risk → hospitalization, elderly → use lower dose,
unresponsive to drugs → add lithium or try ECT

Seasonal affective disorder: 2 consecutive years of 2
major depressive episodes during the same season,
Sx triad – irritability, carb cravings, hypersomnia; Tx
light therapy
Dysthymic disorder: depressive sx for 2 years (1 year
in kids) without overt major depressive episodes
DtD Tx: antidepressants ± CBT
DtD × psychosis: dysthymia can never have
psychotic features, consider another diagnosis
Double depression: major depressive disorder +
dysthymic disorder during residual periods
Grief: aka bereavement, normal reaction to a major
loss, does not present w/ SI or disorganization
Kübler-Ross stages of grief: denial, anger,
bargaining, depression, acceptance
Grief vs. depression: grief lasts <2 months and
has illusions but no delusions, hallucinations, or SI
Bipolar I disorder: aka manic depression, 1 manic or
mixed episode; 1% lifetime prevalence, 5-10% with
first-degree relatives
BI Tx: mood stabilizers (lithium ↓ suicidality,
carbamazepine for rapid cyclers, valproate for kids
<12); pregnant mania → atypicals, h/o postpartum
mania → lithium PPx but c/i to breastfeeding
BI × antidepressants: will flip into manic mode

Minor depressive disorder: 2-4/9 SIGECAPS w/
functional impairment, euthymic periods also seen
(vs. dysthymic disorder), 20% progress to MDD
Suicide risk factors: SAD PERSONS – Sex (male), Age
(<19 or >45), Depression, Previous attempt, EtOH or
drugs, Rational thinking loss, Sickness, Organized
plan, No spouse, Social support loss
#1 suicide risk factor: previous attempt

Ψ – Anxiety and Adjustment Disorders

–––––––––––––––––– ANXIETY ––––––––––––––––––
Anxiety: subjective experience of fear and its
sympathetic response (e.g. ↑HR, ↑BP, SOB, etc.)
Pathological anxiety: inappropriate to situation
and interferes w/ daily functioning

Specific phobia Tx: CBT + desensitization is firstline, BDZs and β-blockers help w/ autonomic sx
Social phobia: aka social anxiety disorder, same as
specific phobia but related to social settings

Generalized anxiety disorder: excess anxiety + 3/6
DRIFTS for 6 months – Difficulty concentrating,
Restlessness, Irritability, Fatigue, Tense muscles,
Sleep disturbance

Common social phobias: public speaking, eating
out, using public restrooms

GAD epidemiology: 45% prevalence, women >
men; frequently comorbid w/ MDD, dysthymia, or
other anxiety disorders

Social phobia vs. shyness: shyness + impairment
of daily function = social phobia

GAD Tx: CBT + drugs (SSRIs, buspirone,
venlafaxine)

Anxiety NTs: ↑NE, ↓GABA/5-HT
Anxiety 2/2 GMC: hyperthyroidism, Graves disease,
Sjogren syndrome, PE, pheochromocytoma, seizure
disorders
Substance-induced anxiety disorder: caffeine,
theophylline, alcohol/sedative withdrawal, mercury,
arsenic, benzene, organophosphates, penicillin,
sulfonamides, sympathomimetics, antidepressants

Social phobia Tx: SSRI (paroxetine) + CBT is firstline, BDZs and β-blockers help w/ performance
anxiety

–––––––––– ADJUSTMENT DISORDERS ––––––––––
Obsession: intrusive, repetitive thought
Compulsion: ritualistic behavior

–––––––––––– ANXIETY DISORDERS ––––––––––––
Anxiety disorders: panic disorder, agoraphobia,
specific and social phobias, OCD, PTSD, ASD, GAD,
anxiety 2/2 GMC or substance use
Anxiety d/o prevalence: 30% women > 19% men,
more frequent in higher socioeconomic groups

GAD vs. phobias: anxiety is free-floating in GAD,
rather than being fixed to specific situation

Obsessions of contamination: followed by
excessive hand-washing or avoidance of feared
contaminant
Obsessions of doubt: followed by repeated
checking to avoid potential danger (e.g. turning
off stove, locking the door)

Adjustment disorder: behavioral or emotional sx
following stressful life event, begins within 3 months
after the event and ends within 6 months
AD etiology: triggered by a non-life threatening
psychosocial stressor
AD Tx: psychotherapy, should resolve in 6
months by definition
Adjustment vs. GAD: no stressor in GAD

Panic attack: peak in 10 min and last <25 min; 4 of
the following PANICS – Palpitations, Abdominal
distress, Numbness/nausea, Intense fear of death,
Choking/chills/chest pain, Sweating/shaking/SOB
PA risk factors: mitral valve Prolapse, Pulmonary
embolus, Asthma, Angina, Anaphylaxis
PA management: order labs (TSH, metanephrine,
B12, etc.) to r/o medical and substance causes
Panic disorder: PA + 1 of the following for 1 month –
persistent concern of another PA, worry about
implications of PA, change in behavior due to PA;
may present as chest pain + normal EKG
PD etiology: dysregulation of autonomic nervous
system w/ NT imbalance (↑NE, ↓GABA/5-HT)
PD Tx: high-dose SSRI for 8-12 months + CBT,
short-term BDZs for immediate relief of attacks
Agoraphobia: anxiety in places where escape is
difficult or help is not readily available → avoidance
of situation
Common agoraphobias: bridges, crowds, buses,
trains, open areas outside the home

Obsessions of symmetry/order: compulsively
slow performance of task

Adjustment vs. PTSD: life-threatening event in PTSD

Intrusive thoughts: often sexual or violent
thoughts → distress but no compulsion

Adjustment vs. MDD: consider MDD if sx last over 6
months

Somatic obsessions: cause pts to view parts of
their body, waste, or secretions as abnormal

Adjustment vs. normal experience: adjustment has
impaired level of social or occupational functioning

Obsessive-compulsive disorder: ego-dystonic
obsessions → compulsions
OCD etiology: abnormal 5-HT regulation,
associated w/ head injury, epilepsy, basal ganglia
d/o, and postpartum conditions; onset triggered
by stressful life event in 60% of pts
OCD epidemiology: 2.5% prevalence, frequently
comorbid w/ ADHD and Tourette syndrome
OCD vs. OCPD: OCD is ego-dystonic (marked
distress over sx), OCPD is ego-syntonic
OCD Tx: SSRI (fluvoxamine) is DOC, clomipramine
is second line, last-resort is ECT or cingulotomy
Acute stress disorder: PTSD for 2 days – 1 month
ASD Tx: mobilize social supports

Specific phobia: persistent fear of object/situation
→ avoidance or tolerated w/ intense anxiety, must
be >6 months if <18 y/o, common comorbidities
include MDD and substance abuse
Common specific phobias: animals, blood or
needles, death, flying, heights, illness or injury
Specific phobia epidemiology: most common
mental disorder in the US, women > men

Post-traumatic stress disorder: traumatic event →
intense fear for >1 month; characterized by RAIN –
Re-experiencing the event, Avoidance of stimuli,
Increased arousal, Numbing of responsiveness
PTSD epidemiology: high MDD and substance
abuse
PTSD Tx: SSRIs are DOC, β-blockers good for
hyperarousal sx

Ψ – Personality Disorders

–––––––––– PERSONALITY DISORDERS ––––––––––

––––––––––––––––– CLUSTER B –––––––––––––––––

Personality: stable, predictable emotional and
behavioral traits

Antisocial personality disorder: selfish disregard for
others → CONDUCT – Capriciousness, Oppressive,
Nonconfrontational, Deceitful, Unlawful, Carefree,
Temper issues

Personality disorder: maladaptive, ego-syntonic
personality traits → functional impairment; 10-20%
prevalence
Cluster A: schizoid, schizotypal, paranoid;
↑association w/ psychotic disorders
Cluster B: antisocial, borderline, histrionic,
narcissistic; ↑association w/ mood disorders
Cluster C: avoidant, dependent, obsessivecompulsive; ↑association w/ anxiety disorders
PD-NOS: passive-aggressive, depressive, sadistic,
self-defeating/masochistic

ASPD epidemiology: ↑incidence in prisoners and
poor urban areas, high genetic component
ASPD vs. conduct disorder: conduct disorder if
<18 y/o, ASPD if ≥18 y/o
ASPD vs. drug abuse: antisocial behavior may be
2/2 drug use, need to find out which came first
ASPD Tx: psychotherapy is useless; SSRIs and
mood stabilizers help w/ reducing aggression

AVPD vs. SPD: SPD want to be alone, AVPD want
friends but are too shy to make any
AVPD vs. social phobia: social phobia is a fear of
embarrassment, AVPD is more a fear of rejection
AVPD vs. DPD: both cling to relationships, but
AVPD are slow to get involved while DPD actively
and aggressively seek relationships
AVPD Tx: psychotherapy + assertiveness training
Dependent personality disorder: excessive need to
be taken care of → OBEDIENT – Obsessive about
approval, Bound by others’ decisions, Enterprises
rarely initiated, Difficulty decision-making, Invalid
feelings while alone, Engrossed w/ fears, Needs to
be in a relationship, Tentative about decisions
DPD defense mechanism: regression (reverting
back to childlike behavior)

PD Tx: psychotherapy for all PDs except borderline
(use DBT) and antisocial

Borderline personality disorder: IMPULSIVE –
Impulsive, Moody, Paranoid, Unstable self-image,
Labile relationships, Suicidal, Inappropriate anger,
Vulnerable to abandonment, Emptiness

Personality traits vs. PD: PDs show impairment of
social or occupational functioning, traits don’t

BPD buzzwords: “best doctor ever”, multiple
meds don’t work, >5 allergies, h/o cutting

––––––––––––––––– CLUSTER A –––––––––––––––––

BPD epidemiology: women > men, high rate of
childhood sexual abuse, 10% suicide rate

DPD vs. BPD/HPD: DPD have long-lasting
relationships w/ one person, BPD/HPD are unable
to maintain a long-lasting relationship

BPD defense mechanism: splitting (people are all
good or bad, no in-betweens)

DPD Tx: psychotherapy (especially groups and
social skills training)

Paranoid personality disorder: general distrust of
others → suspicious of spouse and others, grudges,
preoccupied w/ doubts, non-trusting, quick to
counterattack, etc.
PPD defense mechanism: projection (attributing
inappropriate thoughts/emotions onto another)
PPD vs. social isolation: pts w/o social support
system can react w/ suspicion to others, DDx by
getting collateral regarding baseline
PPD Tx: psychotherapy
Schizoid personality disorder: voluntary social
withdrawal → ↓friends, ↓sexual interest, emotional
detachment, indifferent to others, anhedonia, etc.
SPD defense mechanism: fantasy (imagination
used as an escape where others aren’t needed
for emotional fulfillment)
SPD vs. AVPD: SPD want to be alone, AVPD want
friends but are too shy to make any

BPD Tx: dialectical behavior therapy (DBT) +
setting clear boundaries
Histrionic personality disorder: excessive attentionseeking and emotionality, inappropriately seductive,
flirtatious, exaggeration-prone
HPD defense mechanism: regression (reverting
back to childlike behavior) and repression
(unconsciously avoiding bad thoughts)
HPD vs. BPD: HPD pts generally more functional;
BPD pts more likely to have MDD, brief psychotic
episodes, and attempt suicide

Obsessive-compulsive personality disorder: preoccupation w/ orderliness, control, and perfection at
the expense of efficacy
OCPD epidemiology: men > women, oldest child
OCPD vs. OCD: OCD is ego-dystonic (marked
distress over sx), OCPD is ego-syntonic
OCPD vs. NPD: both involve achievement, but
OCPD loves the work and NPD loves the status
OCPD Tx: psychotherapy
–––––––––––––––––– PD-NOS ––––––––––––––––––

HPD Tx: psychotherapy + setting clear boundaries
Narcissistic personality disorder: poor self-esteem
→ need for admiration, lack of empathy, sense of
entitlement, arrogance, “fishing for compliments”,
takes advantage of others, etc.

Passive-aggressive personality disorder: stubborn,
inefficient procrastinors that alternate between
compliance and defiance, make excuses and
manipulate others into doing their chores/errands
PAPD Tx: psychotherapy

SPD Tx: psychotherapy
Schizotypal personality disorder: eccentric thoughts
or behavior + discomfort w/ close relationships →
↓friends, ideas of reference, suspiciousness,
inappropriate/restricted affect, excessive social
anxiety, magical thinking, etc.

DPD vs. AVPD: both cling to relationships, but
AVPD are slow to get involved while DPD actively
and aggressively seek relationships

NPD vs. ASPD: both characterized by exploiting
others, but NPD is for self-elevation and ASPD is
for material gain or subjugation of others
NPD Tx: psychotherapy ± group therapy to learn
empathy

STPD vs. SPD: SPD + eccentric behavior = STPD

––––––––––––––––– CLUSTER C –––––––––––––––––

STPD Tx: psychotherapy

Avoidant personality disorder: intense fear of
rejection → AFRAID – Avoids occupation w/ others,
Fear of criticism, Reserved unless sure of being liked,
Always thinking rejection, Isolated from
relationships, Distant from others

Depressive personality disorder: chronically
unhappy, pessimistic, self-doubting, distressed, etc.

Ψ – Substance-Related Disorders

–––––– SUBSTANCE ABUSE & DEPENDENCE ––––––

EtOH × metronidazole/sulfa drugs: N/V

Abuse: 1/4 WILD for 1 year – Work/school/home
obligation failure, Interpersonal consequences,
Legal problems, Dangerous use

EtOH × pregnancy: fetal alcohol syndrome,
leading cause of MR/DD in US
Banana bag: thiamine + folate + MVI + MgSO4 + IVF

Dependence: 3/7 for 1 year – tolerance, withdrawal,
time-consuming, can’t cut down, ↓activities, use >
intended amount, use despite problems

Alcohol withdrawal: starts in 6-24 hrs and lasts 1 wk;
mild sx = irritability, hand tremors, insomnia;
moderate sx = ↑sympathetic activity; severe = DTs

Tolerance: need ↑amount to achieve same effect
Withdrawal: substance-specific syndrome due to
cesssation following heavy and prolonged use
Substance-use epidemiology: 17% prevalence, MC
substances are alcohol and nicotine, men > women
(think VA population)
Substance types: sedatives, stimulants, opioids,
hallucinogens
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs
and barbiturates), inhalants
Stimulants: strong – cocaine, amphetamines,
MDMA/MDEA; weak – caffeine, nicotine
Opioids: heroin, oxycodone, codeine,
dextromethorphan (cough syrup), morphine,
methadone, meperidine (Demerol)
Hallucinogens: phencyclidine (PCP), ketamine,
psilocybin, mescaline, LSD, marijuana

EtOH withdrawal Tx: BDZ taper, banana bag,
monitor sx w/ CIWA scale
Alcohol dependence: 2/4 CAGE – Cut down, Annoyed
by criticism, Guilty about drinking, Eye opener
EtOH dependence Tx: disulfiram (Antabuse)
blocks aldehyde DH → aversive reaction;
naltrexone blocks opioid-R → ↓cravings;
acamprosate → ↑GABA/↓glu → ↓cravings
Wernicke-Korsakoff syndrome: COAT RACK
Wernicke encephalopathy: acute thiamine
deficiency → reversible Confusion, Ophthalmoplegia (CN6 palsy), Ataxia, Thought disturbances;
Tx IV thiamine
Korsakoff psychosis: chronic thiamine deficiency
→ irreversible Retrograde /Anterograde amnesia,
Confabulations
Sedative-hypnotics: BDZs, barbiturates, zolpidem,
zaleplon, GHB, meprobamate, etc.
BDZs: ↑GABA frequency, used for anxiety

Alcohol: potent CNS depressant (↑GABA, ↑5-HT,
↓VGCC, ↓glu), MC abused substance in the US
Alcohol metabolism: alcohol + dehydrogenase →
acetaldehyde + dehydrogenase → acetic acid;
common cause of ↑anion gap metabolic acidosis
Alcohol intoxication: ↓fine motor control (BAL 2050), ↓judgment and coordination (50-100), ataxic
gait and balance (100-150), lethargy and amnesia
(150-250), possible coma and death (>300)
EtOH intoxication Dx: breathalyzer test,
blood/urine testing (more accurate); labs show
↑LFTs (AST:ALT >2, ↑GGT, ↑CDT) + ↑MCV
EtOH intoxication Tx: ABCs and banana bag;
possible injury → head CT, massive EtOH within
past hour → GI evacuation

Inhalant OD: death 2/2 ↓RR or arrhythmias
Inhalant intoxication Tx: ABCs, identify solvent
b/c some (e.g. leaded gas) may require chelation
Inhalant withdrawal: rare
–––––––––––––––– STIMULANTS ––––––––––––––––

Delirium tremens: delirium, VH/TH, gross tremor,
autonomic instability, seizures → 15-25% mortality

––––––––––––––––– SEDATIVES –––––––––––––––––
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs
and barbiturates), inhalants

Inhalant intoxication: perceptual disturbances,
psychosis, N/V, euphoria, lethargy → stupor → coma

Barbiturates: ↑GABA duration, used as
anesthetics and antiepileptics, lower margin of
safety vs. BDZs
Sedative-hypnotic intoxication: drowsiness,
confusion, slurred speech, incoordination, ataxia, etc.
SH intoxication Dx: +UDS for variable amount of
time

Stimulants: strong – cocaine, amphetamines,
MDMA/MDEA; weak – caffeine, nicotine
Cocaine: blocks DA reuptake → stimulant effect +
activates reward system; blocks NE reuptake →
vasoconstriction
Cocaine intoxication: euphoria, ↑self-esteem,
↑sympathetic activity, TH, paranoia; possible death
by MI, stroke, seizure, arrhythmia, or ↓RR
Cocaine intoxication Dx: +UDS for 2-4 days
Cocaine intoxication Tx: mild agitation/anxiety →
BDZs, severe agitation/psychosis → haloperidol,
T>102 → ice bath or cooling blanket
Cocaine × alcohol: cocaethylene metabolite has
24× mortality vs. cocaine alone
Cocaine dependence: purely psychological
Cocaine dependence Tx: psychotherapy, no FDAapproved pharmacotherapy exists
Cocaine withdrawal: aka crash, non-life threatening,
extreme exhaustion following coke binge, severe
depression → risk of suicide
Cocaine withdrawal Tx: refer to Narcotics
Anonmyous, resolves w/o meds
Amphetamines: D-amphetamine, methylphenidate,
methamphetamine; blocks DA/NE reuptake and
causes DA/NE release → stimulant effect
Amphetamine intoxication: dilated pupils, ↑libido,
sweating, ↓RR, chest pain; heavy use →
amphetamine psychosis (mimics SCZ)

SH OD: respiratory depression → death,
especially when combined w/ EtOH

Amphetamine intoxication Dx: +UDS for 1-3 days

SH intoxication Tx: BDZs → flumazenil,
barbiturates → IV NaHCO3

Amphetamine OD: hyperthermia, dehydration,
rhabdomyolysis → renal failure

Sedative-hypnotic withdrawal: life-threatening,
presents similar to alcohol withdrawal; barbiturate
withdrawal has highest mortality rate of all drugs

EtOH × H2-blockers: ↑EtOH levels

Amphetamine intoxication Tx: IVF + electrolytes,
treat hyperthermia
Chronic amphetamine use: acne + meth mouth

SH withdrawal Tx: BDZ taper
EtOH × sedative-hypnotics: respiratory
depression → death
EtOH × NSAIDs: GI bleeding
EtOH × acetaminophen/INH: hepatotoxicity

Amphetamine withdrawal: prolonged depression
GHB: aka sodium oxybate, CNS depressant that
causes memory loss, respiratory distress, coma;
common date rape drug, used to Tx cataplexy
Inhalants: CNS depressants; includes solvents, glue,
paint thinners, fuels, isobutyl nitrates

MDMA/MDEA: aka ecstasy and eve, both stimulants
and hallucinogens that induce sense of closeness w/
others, associated w/ clubs and raves
MDMA/MDEA × SSRI: serotonin syndrome

Ψ – Substance-Related Disorders

Caffeine: adenosine antagonist + PDE blocker →
↑cAMP, stimulant effect via dopaminergic system
Caffeine intoxication: ↑sympathetic activity, anxiety,
diuresis, insomnia, GI distress
Caffeine OD: tinnitus, severe agitation, and
arrhythmias (>1 g); seizures → death (>10 g)

Hallucinogen intoxication: perceptual changes,
labile affect, dilated pupils, ↑RR/↑BP/↑HR usually
lasting 6-12 hrs
Hallucinogen intoxication Tx: monitor closely,
agitated psychosis → BDZ or antipsychotics
Hallucinogen withdrawal: no withdrawal syndrome,
but LSD flashbacks can occur due to storage in fat

Caffeine intoxication Tx: supportive care
PCP: aka angel dust, NMDA antagonist
Caffeine withdrawal: headache, fatigue, irritability,
drowsiness, mild depression
Caffeine withdrawal Tx: self-resolves in 1 week
Nicotine: nicotinic agonist, addictive effect through
the dopaminergic system
Nicotine prevalence: 21%, MCC of preventable
morbidity and mortality in US
Nicotine withdrawal: intense craving and dysphoria,
anxiety, irritability, restlessness
Nicotine withdrawal Tx: varenciline (Chantix) and
buproprion (Zyban) are partial nicotinic agonists;
nicotine patch or gum

PCP intoxication: RED DANES – Rage, Erythema,
Dilated pupils, Delusions, Amnesia, Nystagmus
(vertical or rotary is pathognomonic), Excitation,
Skin dryness
PCP intoxication Dx: +UDS for 3-8 days, labs show
↑CPK and ↑AST
PCP OD: seizures, coma, possible death
PCP intoxication Tx: monitor closely; mild
agitation/anxiety → lorazepam, severe
agitation or psychosis → haloperidol
PCP withdrawal: no withdrawal syndrome, but
flashbacks can occur due to storage in body fat

Nicotine × pregnancy: low birth weight and chronic
pulmonary hypertension

Ketamine: aka special K, NMDA antagonist but less
potent than PCP, often used as a date rape drug

–––––––––––––––––– OPIOIDS ––––––––––––––––––

Ketamine intoxication: tachycardia, tachypnea,
hallucinations, and amnesia

Opioids: opiate receptor (μ/κ/δ) agonists; heroin,
oxycodone, codeine, dextromethorphan (cough
syrup), morphine, methadone, meperidine (Demerol)
Opioid intoxication: respiratory depression,
pupillary constriction (except Demerol → Dilation),
sedation, ↓pain, ↓GI motility
Opioid intoxication Dx: +UDS for 2-4 days;
methadone and oxycodone are false negatives,
poppy seed bagels are false positive

Marijuana: aka weed, main ingredient is THC →
cannabinoid receptor agonist → inhibit adenylate
cyclase → ↓cAMP
Marijuana intoxication: euphoria, red eyes, dry
mouth, munchies, anxiety, perceptual disturbances
MJ intoxication Dx: +UDS for 3 days (single use)
to 4 weeks (heavy users)
MJ intoxication Tx: psychosocial interventions

Opioid OD: classic triad RAM – Respiratory
depression, Altered mental status, Miosis
Opioid intoxication Tx: ABCs, naloxone or
naltrexone will help respiratory depression but
can precipitate withdrawal syndrome

Chronic MJ use: respiratory sx + gynecomastia
Marijuana withdrawal: irritability, anxiety,
restlessness, depression, headaches, etc.
MJ withdrawal Tx: supportive care

Meperidine × MAOI: serotonin syndrome
Opioid withdrawal: violent yawning, dilated pupils,
abdominal cramps, ↑secretions (lacrimation,
rhinorrhea, sweating, nausea/vomiting, diarrhea);
not life-threatening
Opioid withdrawal Tx: moderate → CLIP –
Clonidine, Loperamide, Ibuprofen, Promethazine;
severe → methadone or buprenorphine detox,
monitor sx w/ COWS scale
–––––––––––––– HALLUCINOGENS ––––––––––––––
Hallucinogens: psilocybin (shrooms), mescaline
(peyote cactus), LSD (acid); LSD acts on 5-HT system

Dronabinol (Marinol): pill-form of THC used to Tx
anorexia in AIDS pts and N/V in chemotherapy pts

Ψ – Cognitive Disorders

Cognitive disorder: significant change in cognition
from previous level of functioning; two types –
delirium and dementia

Definition

Onset
Duration
Px
Amnesia
Alert
Oriented
Dx

Delirium
waxing-andwaning change in
pt’s level of
consciousness
acute
3 days – 2 wks
reversible
immediate and
recent memory
no
no
abnormal EEG

Dementia
impairment in
memory and
other cognitive
functions
chronic
months – yrs
irreversible
recent and
remote memory
yes
sometimes
abnormal MRI

Dementia × hypothyroidism: reversible, presents
as obesity, coarse hair, constipation, and cold
intolerance; Dx TSH and T4 levels
Dementia × ↓B12: presents as diminshed position
and vibration sensation; Dx B12 levels
Dementia × neurosyphilis: presents as diminshed
position and vibration sensation, and ArgyllRobertson pupils (accomodates but doesn’t
respond to light); Dx CSF FTA-ABS or VDRL levels
Dementia × Wilson disease: presents as tremor,
↑LFTs, and Kayser-Fleischer corneal rings; Dx
↓serum ceruloplasmin levels

––––––––––––––––– DELIRIUM –––––––––––––––––

Mini Mental State Exam (MMSE): screening test to
Dx dementia; 30 is perfect score, <25 is dementia

Delirium: aka encephalopathy, waxing-and-waning
change in pt’s level of consciousness; commonly
presents w/ VH, short attention span, and impaired
recent memory

Alzheimer disease: MCC dementia → gradual
progressive decline in memory and other cognitive
functions, average 10 yrs from onset to death

Delirium risk factors: common in elderly, ICU pts,
s/p surgery pts, and cancer pts
Delirium management: r/o life-threatening
causes, then ID and Tx the underlying cause
Delirium causes: AEIOU TIPS – Alcohol/drug toxicity
or withdrawal, Electrolyte imbalance, Iatrogenic,
Oxygen hypoxia, Uremia/hepatic encephalopathy,
Trauma, Infection, Poison, Seizures, Stroke
Delirium × CVA/mass lesion: presents as focal
neuro sx (e.g. hemiparesis); Dx brain CT/MRI
Delirium × HTN encephalopathy: presents as ↑BP
and papilledema; Dx brain CT/MRI
Delirium × drug intoxication: presents as ↑HR
and dilated pupils; Dx urine toxicology screen
Delirium × meningitis: presents as fever, nuchal
rigidity, and photophobia; Dx lumbar puncture
Delirium × thyrotoxicosis: presents as ↑HR,
tremor, and thyromegaly; Dx TSH and T4 levels
Delirium × hepatic encephalopathy: due to
↑ammonia, Tx lactulose + neomycin

Dementia: progressive and irreversible impairment
in memory and other cognitive functions w/o change
in level of consciousness
Dementia epidemiology: prevalence doubles
every 5 years (1.5% at 60, 40% at 90)
Dementia management: r/o reversible causes
Dementia types: Alzheimer (#1), vascular (#2), Lewy
body (#3), Pick/FTD, HIV-associated, Huntington,
Cruetzfeldt-Jakob, normal pressure hydrocephalus

Pick disease/frontotemporal dementia: diverse
group of dementias, average 5 yrs from onset to
death (more rapid than Alzhimer)
Pick/FTD Sx: profound changes in personality and
social conduct, disinhibition, hyperorality, hypersexuality; good memory and language though
Pick/FTD brain: gross – marked atrophy of frontal
and temporal lobes; microscopic – neuronal loss
and astrocytosis of cortical layer II
Pick/FTD Tx: anticholinergics and antidepressants
help w/ behavior but not cognition
HIV-associated dementia: MCC dementia due to
infectious disease, neutropenia → infection →
dementia

AD NTs: ↓ChAT → ↓ACh synthesis

HAD Sx: rapid decline in memory, cognition,
behavior, and motor skills; depression and social
withdrawal also common

AD etiology: amyloid cascade hypothesis – high
risk genes (presenilin I, presenilin II, APP, and
apoE4) predispose to excess Aβ-amyloidosis

HAD Tx: HAART

AD Dx: diagnosis of exclusion, definitive diagnosis
requires brain biopsy
AD brain: gross – diffuse atrophy with enlarged
ventricles and flattened sulci; microscopic – senile
plaques, neural plaques, and neurofibrillary
tangles (not specific to Alzheimer)

Huntington disease: AD disorder due to CAG
trinucleotide repeats on chromosome 4, shows
anticipation (longer CAG repeats correlates with
earlier age of onset)
HD Sx: chorea, apathy, depression, and dementia
with onset at 35-50 y/o, ↑rate of suicide
HD brain: atrophy of caudate nucleus

AD Tx: AChE-inhibitors for mild-to-moderate AD
(tacrine, donepezil, rivastigmine, galantamine),
NMDA antagonist for moderate-to-severe AD
(memantine)
Alzheimer × Down syndrome: trisomy 21 → triple
apoE4 expression → inevitable Alzheimer by 40 y/o
Vascular dementia: 2nd MCC dementia, due to
accumulation of multiple small infarcts → stepwise
loss of function + focal neurological sx
VD Dx: multiple small lacunar infarcts on CT scan,
sensitive but not specific for vascular dementia

Parkinson disease: loss of dopaminergic neurons →
both physical and cognitive impairment

VD risk factors: previous stroke, diabetes, HTN

PD Sx: early PD presents as TRAP – Tremor,
Rigidity, Akinesia, Postural instability; late PD
presents as Alzheimer-like dementia

VD Tx: no effective cure; AChE-inhibitors and
antihypertensives can help

PD brain: neuronal death in substantia nigra,
senile plaques, and neurofibrillary tangles

Sundowning: worsening of delirium at night
––––––––––––––––– DEMENTIA –––––––––––––––––

LBD Tx: AChE-inhibitors for VH, antiparkinsonians
and psychostimulants for motor sx

VD × frontal lobe infarct: sx of schizophrenia,
depression, and bipolar I disorder
Lewy body dementia: 3rd MCC dementia, due to
Lewy body and neurite accumulations in the basal
ganglia
LBD Sx: presents as waxing-and-waning
parkinsonism, VH, and antipsychotic sensitivity
LBD Dx: onset of dementia within 12 mo of
parkinsonism (after 12 mo of onset is Parkinson’s)

PD Tx: early PD → carbidopa + levodopa
(Sinemet), late PD → subthalamic nucleus deep
brain stimulation; antipsychotics will exacerbate
dementia due to PD
Prion diseases: Creutzfeldt-Jakob disease, kuru,
Gerstmann-Straussler syndrome, fatal familial
insomnia, bovine spongiform encephalopathy
Creutzfeldt-Jakob disease: rapidly progressive CNS
degeneration due to abnormal prion accumulation;
either inherited, sporadic, or acquired

Ψ – Cognitive Disorders

CJD Sx: rapidly progressive dementia, myoclonus
(muscle spasms), and personality changes
CJD Dx: probable – clinical picture + periodic
generalized sharp waves on EEG; definitive –
spongiform change on brain biopsy
Normal pressure hydrocephalus: potentially
reversible dementia due to ↑CSF pressure →
enlarged ventricles
NPH Sx: 3 Ws – Wet (urinary incontinence),
Wobbly (gait apraxia), Wacky (dementia)
NPH Tx: CSF shunt to relieve pressure
Pellagra: vitamin B3 (niacin) deficiency → 3 Ds –
Diarrhea, Dermatitis, Dementia
Herpes encephalopathy: involves temporal lobes

Ψ – Geriatric Psychiatry

––––––––––––– GEROPSYCHIATRY –––––––––––––
Normal aging: ↓brain volume w/ enlarged ventricles,
↓muscle, ↑fat, ↓vision/hearing, minor forgetfulness
Elderly × MDD: MC psychiatric disorder in elderly,
↑incidence s/p MI, stroke, and new admits to nursing
homes
Elderly × suicide: white elderly males have highest
rate of successful suicides

Definition

Onset
Features

Tx

Pseudodementia
MDD + cognitive
defects due to
underlying
depression
acute
often answers “I
don’t know”,
aware of
problems
cognitive defects
respond to antidepressants

Dementia
impairment in
memory and
other cognitive
functions
chronic
confabulates
answers,
unaware of
problems
cognitive
defects persist
despite antidepressants

Pseudodementia: MDD + cognitive defects due to
underlying depression, often mistaken for dementia
Pseudodementia Tx: supportive psychotherapy +
low-dose antidepressants (SSRIs > TCAs/MAOIs,
use nortriptyline if TCA is preferred); depression +
low appetite + insomnia → mirtazapine
Dementia: progressive and irreversible impairment
in memory and other cognitive functions w/o change
in level of consciousness
Dementia epidemiology: prevalence doubles
every 5 years (1.5% at 60, 40% at 90)
Dementia types: Alzheimer (#1), vascular (#2),
Lewy body (#3), Pick/FTD, HIV-associated,
Huntington, Cruetzfeldt-Jakob, normal pressure
hydrocephalus
Dementia Tx: behavioral and environmental Tx
preferred over pharmacotherapy (see cognitive
disorders for specifics)
Grief: aka bereavement, normal reaction to a major
loss, does not present w/ SI or disorganization
Kübler-Ross stages of grief: denial, anger,
bargaining, depression, acceptance
Normal grief: normal response to loss, lasts <2
months and has illusions but no delusions,
hallucinations, or SI
Complicated grief: lasts ≥6 months and 4/8 Tired
And NUMBED – Trouble accepting loss, Agitation,
Numbness, Untrusting, Meaninglessness, Bitterness,
Emptiness, Difficulty moving on
Bereavement-associated depression: essentially
MDD following death or loss, similar to complicated
grief but may have delusions, hallucinations, or SI

BAD Tx: antidepressants ± psychotherapy; acute
risk → hospitalization, unresponsive to drugs →
ECT (safe and effective in elderly)
Elderly × alcohol abuse: elderly have ↓alcohol
dehydrogenase → ↑BAL w/ fewer drinks; ↑CNS
sensitivity to alcohol
Medical conditions worsened by alcohol: liver
diseases, GI diseases, CV diseases, gout, diabetes,
depression, anxiety
Elderly × sleep: ↓sleep efficiency and ↓total sleep
(↑stage 1-2, ↓stage 3-4, ↓REM latency, ↓total REM);
↑incidence of sleep disorders
Periodic leg movements: restless leg movements
during sleep, due to dopamine imbalance
Sleep disturbance Tx: fix sleep hygiene, stop
drinking, stop napping, fix underlying causes;
hydroxyzine or trazodone are second-line
Elderly × antidepressants: elderly are very sensitive
to anticholinergic side-effects, including dry mouth,
constipation, blurry vision, etc.
–––––––––– OTHER GERIATRIC ISSUES ––––––––––
Restraints: should be used as a last resort in nonemergency situations, consider pt health and safety
Medications: polypharmacy is common in elderly,
↑side-effects due to ↓liver/kidney function and ↓lean
body mass
Elderly abuse: 10% incidence, perpetrator is usually
the caregiver of the victim; can be physical, psychological, neglect, or exploitation (rarely sexual)
Nursing homes: provide care and rehab for both
chronically ill and short-term care pts; 50% stay on
permanently, 50% are d/c after a few months

Ψ – Child Psychiatry

––––––––––– MENTAL RETARDATION –––––––––––
Mental retardation: IQ ≤ 70 and deficits in adaptive
skills, with onset before 18 y/o
MR/DD types: profound <25, severe 25-40,
moderate 40-55, mild 55-70 (intervals of 15)
MR/DD causes: 50% idiopathic, Down syndrome (MC
genetic), Fragile X (MC inherited), fetal alcohol
syndrome (overall MCC); prenatal, perinatal, or
postnatal pathology
TORCHES complex: perinatal infections than can
lead to MR/DD, includes Toxoplasmosis, Rubella,
CMV, Herpes simplex, Syphilis
Prader-Willi syndrome: partial deletion of 15q →
MR/DD, obesity, hypogonadism, almond eyes
Fragile X syndrome: MC inherited form of MR/DD;
X-linked CGG trinucleotide expansion in FMR1
gene causes DSM-IV – Discontinued chromosomal
staining, Shows anticipation, Males, Mental
retardation, Macrognathia, Macroorchidism
Learning disorders: achievement in reading, writing,
or math that is significantly lower than expected;
must r/o sensory deficits first
Learning disorder types: reading disorder (MC),
mathematics disorder, writing disorder
Learning disorder Tx: remedial education
–––––– DISRUPTIVE BEHAVIOR DISORDERS ––––––
Disruptive behavior disorders: includes oppositional
defiant disorder and conduct disorder
Oppositional defiant disorder: >6 months of hostile
and defiant behavior towards parents/teachers, but
perfectly fine w/ peers
ODD Tx: individual psychotherapy + family
involvement
Conduct disorder: hostile and defiant behavior
towards everyone
CD in boys: cruelty to animals, fighting, stealing,
fire-setting, vandalism
CD in girls: lying, running away, promiscuity
CD Px: 40% of conduct d/o → ASPD
CD Tx: multimodal approach w/ family and
teacher involvement
CD vs. ASPD: conduct disorder <18 y/o, ASPD ≥18 y/o
CD vs. ODD: unlike conduct disorder, ODD doesn’t
involve physical aggression or violation of basic
rights of others
CD vs. pyromania: pyromaniacs light things on fire
due to inner tension, not out of anger issues

Attention deficit disorder: >6 months of hyperactivity, inattentiveness, or both; onset before 7 y/o
ADHD types: inattentive type, hyperactiveimpulsive type, combined type
ADHD prevalence: boys > girls, >50% have
comorbid psychiatric diagnosis

CDD vs. Rett: similar loss of previously acquired skills,
but CDD has no ↓head growth or hand wringing
–––––––– OTHER PEDIATRIC DISORDERS ––––––––
Tic disorders: characterized by sudden, repetitive,
involuntary movements (motor tics) or vocalizations
(vocal tics); one of few DSM-IV Dx that don’t require
significant distress as a qualifier

ADHD Px: 50% go onto adulthood untreated
Coprolalia: repetitive speaking of obscene words
ADHD Tx: CNS stimulants are DOC w/ 75% success
rate, second-line is atomoxetine and α2-agonists
(clonidine, guanfacine)
ADHD vs. MR/DD: both struggle w/ academic
performance, so differentiate via IQ tests

Echolalia: exact repetition of words
Tourette disorder: most severe tic disorder w/
multiple daily motor/vocal tics, onset before 18 y/o

––– PERVASIVE DEVELOPMENTAL DISORDERS –––

Tourette prevalence: very rare; ↑rate of comorbid
OCD (40%) and ADHD (50%)

Pervasive developmental disorders: includes autism,
Asperger, Rett, and childhood disintegrative d/o

Tourette etiology: multifactorial, involves
impaired dopamine regulation in caudate nucleus

Autistic disorder: characterized by problems w/
social interaction, impaired communication, and
repetitive/stereotyped patterns of behavior and
activity; must be present by 3 y/o

Tourette Tx: risperidone and α2-agonists
(clonidine, guanfacine) are DOC; severe cases →
typical antipsychotics, tics+OCD → SSRIs

Autism prevalence: 70% meet criteria for MR/DD;
associated w/ fragile X syndrome, tuberous
sclerosis, and seizures
Autism Px: most important predictors of adult
outcome are intelligence and communication
Autism Tx: no cure, but remedial education and
behavioral therapy can help w/ developing skills
Autism vs. deafness: toddler w/ ↓communication
skills needs hearing test to r/o deafness
Asperger disorder: mild autism w/ normal language
skills and cognitive development, often rigid and
overly formal in social interaction

Enuresis: involuntary urination (bed-wetting) after 5
y/o, ≥2/week for 3 months
Enuresis etiology: genetics, stress (MC), small
bladder, or ↓nocturnal ADH
Enuresis Tx: DDAVP is DOC, imipramine is secondline
Encopresis: involuntary defecation after 5 y/o,
≥1/month for 3 months
Encopresis etiology: genetics, stress, lack of
sphincter control, or constipation w/ overflow
incontinence (MC)
Encopresis Tx: usually remits spontaneously,
bowel catharsis + stool softeners if it doesn’t

Aspie Tx: supportive Tx similar to autism
Rett disorder: normal development for 5 months,
followed by ↓rate of head growth and loss of
purposeful hand movements; then ataxia, ↓language
skills, and “hand wringing”
Rett etiology: ΔMECP2 on X chromosome (only
girls get the disease, guys all die in utero)
Rett Px: cognitive development never progresses
beyond first year of life, ↑risk of sudden death

Selective mutism: refusal to speak in certain
situations for ≥1 month despite normal language and
comprehension skills
Mutism Tx: psychotherapy, behavioral therapy,
management of anxiety
Separation anxiety disorder: excessive fear of
leaving parents or other figures for ≥4 weeks
SAD Px: risk factor for development of panic d/o
or agoraphobia as an adult

Rett Tx: supportive care
Childhood disintegrative disorder: normal development for >2 years, then loss of previously acquired
skills before 10 y/o
CDD prevalence: boys > girls, ↑rate of abnormal
EEG and seizures
CDD Tx: supportive care

SAD Tx: family therapy, CBT, low-dose
antidepressants
Child abuse: either physical abuse, emotional abuse,
sexual abuse, or neglect (MC); doctors must report
to child protective services
Sexual abuse prevalence: 15-25%, perpetrator is
usually the child’s parent

Ψ – Dissociative Disorders

–––––––––– DISSOCIATIVE DISORDERS ––––––––––
Dissociation: loss of memory, identity, or sense of
self; often following trauma, may involve NE + glu
Abreaction: strong reaction pts get when retrieving
traumatic memories
Dissociative disorders: dissociative amnesia,
dissociative fugue, dissociative identity disorder,
depersonalization disorder, dissociative disorder
NOS
Dissociative amnesia: 1+ episode of inability to recall
personal information; not due to TBI, medical
condition, substance abuse, or ordinary amnesia
DA epidemiology: MC dissociative disorder,
↑incidence of MDD and anxiety disorders
DA Tx: psychotherapy; most acute cases return to
normal after min-days, lorazepam or amobarbital
often used to help pt talk freely during interview
DA vs. dementia: DA can’t recall common personal
info but can remember obscure details, dementia
can remember personal info but not obscure details
Dissociative fugue: sudden, unexpected travel away
from home + inability to recall one’s past
DF epidemiology: rare, usually follows stressful
life event or personal conflict
DF Tx: same as DA
DF vs. DA: DA pts are aware of what they can’t seem
to remember, DF don’t acknowledge the amnesia
DF vs. transient global amnesia: DA pts show loss of
identity, global amnesia have difficulty with more
recent events but identity remains intact
Dissociative identity disorder: 2+ distinct identities +
inability to recall information about non-dominant
personalities; not due to substance abuse or medical
condition, existence is controversial
DID epidemiology: usually women w/ prior
trauma (e.g. childhood sexual abuse); ↑incidence
of MDD, anxiety, BPD, substance abuse, suicide
DID Tx: psychotherapy; worst Px of all
dissociative disorders
DID DDx: DID-like sx may be seen in BPD, psychosis,
or malingering (factitious disorder)
Depersonalization: feeling that one is falling apart,
fragmenting, detached, not oneself, etc.
Derealization: feeling that the world is not real
Depersonalization disorder: persistent or recurrent
episodes of being detached from one’s body or
mental processes; not due to substance use or
medical condition

DPD epidemiology: women > men, severe stress
is a risk factor, ↑incidence of MDD and anxiety
disorders
DPD Tx: usually chronic, anxiety or MDD →
anxiolytics or SSRIs
DPD vs. normal stress: transient depersonalization is
common during times of stress
Dissociative disorder NOS: loss of memory, identity,
or sense of self; but doesn’t meet criteria for other
dissociative disorders
Ataque de nervios: Puerto Rican culturally-bound
trance disorder that consists of convulsive
movements, fainting, crying, and visual problems
Ganser syndrome: giving of approximate answers
to simple questions (e.g. “how many legs do you
have?”)

Ψ – Somatoform and Factitious Disorders

––––––––––––––––––– GAIN –––––––––––––––––––
Primary gain: internal motives (e.g. stress, anxiety)
as the cause of symptoms
Secondary gain: external motives (e.g. attention,
money, avoiding law) as the cause of symptoms
Münchhausen syndrome: aka factitious disorder,
consciously feigning symptoms to play the sick role
(primary gain)
Münchhausen Sx: triad of 3 Ps – Peregrination,
Pseudologia phantastica, Polysurgery
Münchhausen Tx: establish therapeutic alliance,
avoid confrontation and unnecessary procedures
Münchhausen by proxy: intentionally producing
symptoms in someone else, usually one’s children →
must report child abuse
Malingering: consciously feigning symptoms for
external motives (secondary gain), presents w/
multiple vague complaints and a long medical hx
–––––––––– SOMATOFORM DISORDERS ––––––––––
Somatoform disorders: not consciously feigning
symptoms, though no direct link to medical cause;
50% have comorbid anxiety d/o or MDD
Somatoform disorders × gender: women > men,
except hypochondriasis where women = men
Somatization disorder: onset before 30 y/o with
multiple sx (4 pain + 2 GI + 1 sexual/GU + 1 neuro)
that are not intentionally produced
Somatization Px: chronic and debilitating, worse
under stress
Somatization Tx: r/o potential medical causes,
regularly scheduled visits w/ a single PCP who
limits extensive medical work-ups
Somatization vs. conversion: somatization pts are
concerned over condition, conversion don’t care
Conversion disorder: conversion of a psych issue
into a neurological one, not limited to pain or sexual
dysfunction, preceeded by conflict or stressors
Conversion Sx: commonly paralysis, blindness,
mutism, parasthesias, seizures, globus hystericus
La belle indifference: apathy despite severity of
condition
Conversion Tx: most spontaneously recover;
if it persists → insight-oriented psychotherapy,
hypnosis, or relaxation therapy
Conversion in elderly: high chance of real neuro
deficit, get a neuro consult
Conversion × seizures: use EEG to differentiate
between epileptic vs. nonepileptic seizures

Conversion × neuropathy: consider multiple
sclerosis
Hypochondriasis: preoccupation w/ fear of having or
contracting a disease, based on misinterpretation of
bodily sx, for >6 months
Hypochondriasis epidemiology: 80% have
comorbid GAD or MDD (vs. 50% in other somatoform d/o), men = women (vs. women > men in
other somatoform d/o)
Hypochondriasis Tx: regularly scheduled visits w/
a single PCP
Hypochondriasis vs. somatization: somatization pts
have a long list of sx, hypochondriacs are worried
about a specific disease
Hypochondriasis vs. BDD: hypochondriasis + about a
specific body part = body dysmorphic disorder
Body dysmorphic disorder: self-consciousness +
preoccupation w/ imagined defect in appearance
BDD Tx: optional CBT ± SSRIs, avoid cosmetic
procedures
Pain disorder: significant pain as the CC, not fully
accounted for by a medical condition, not feigned,
and not regarding sex only (dyspareunia); acute if <6
months, chronic if >6 months
Pain Tx: validate pt’s pain, moderate →
biofeedback and relaxation techniques, severe →
antidepressants (not analgesics)

Ψ – Impulse Control Disorders

–––––––– IMPULSE CONTROL DISORDERS ––––––––
Impulse control disorders: IED, kleptomania,
pathological gambling, trichotillomania, pyromania
Core qualities: anxiety before act, repetitive or
compulsive act in spite of consequences, lack of
control during act, relief or satisfaction after act
Intermittent explosive disorder: recurrent episodes
outbursts of aggression against people or property
that remit quickly and spontaneously
IED Dx: ↓5-HIAA in CSF
IED Tx: SSRIs + lithium + propanolol; individual
psychotherapy is difficult and ineffective
IED vs. amok: amok has amnesia and only in Asians
Kleptomania: inability to resist urges to steal objects
not needed for personal use or monetary reasons
Klepto etiology: multifactorial but ↑ with stress;
↑incidence of OCD, mood disorders, and eating
disorders (25% of bulimics are klepto)
Klepto Tx: insight-oriented psychotherapy +
behavioral therapy + SSRIs; anecdotal evidence
exists for naltrexone
Pathological gambling: persistent and recurrent
maladaptive gambling behavior
Gambling etiology: multifactorial; ↑incidence of
OCD, mood disorders, and anxiety disorders
Gambling Tx: Gamblers Anonymous is first-line,
after 3 months of abstinence → insight-oriented
psychotherapy, treat comorbid problems
Trichotillomania: recurrent, repetitive, intentional
pulling out of one’s hair causing visible hair loss
Tricho etiology: multifactorial; ↑incidence of
OCD/OCPD, borderline PD, and mood disorders
Tricho Tx: behavioral therapy + SSRIs, lithium, or
antipsychotics
Pyromania: 1+ episode of deliberate fire setting +
fascination or attraction to fire; not for monetary
gain, expression of anger, or political statement
Pyro Tx: supervision + behavioral therapy + SSRIs

Ψ – Eating Disorders

––––––––––––– EATING DISORDERS –––––––––––––
Eating disorders: anorexia nervosa, bulimia nervosa,
binge-eating disorder (eating disorder NOS)
Anorexia nervosa: fear of being fat → <85% ideal
body weight, amenorrhea in postmenarchal females

Bulimia complications: SPARKED – Sialadenosis,
Petechiae, Aspirations, Arrhythmias due to ↓K+,
Russell’s sign, Kleptomania (25%), Esophagitis,
Edema, Dental erosions or caries
Russell’s sign: calloused knuckles due to hitting
incisor teeth when inducing the gag reflex

Anorexia subtypes: restrictive type doesn’t eat
and has OCPD traits; binge/purge type binge eats
followed by vomiting or exercising

Bulimia lab values: vomiting → contraction alkalosis,
laxatives → metabolic acidosis; ↑BUN, ↑HCO3-,
↑amylase, ΔT4/T3, Δcortisol

Anorexia prevalence: 1%, most commonly in
women in industrialized countries

Bulimia vs. binge-eating disorder: both like to binge,
but bulimics try to control their weight afterwards

Anorexia Px: 10% mortality due to starvation,
suicide (57× normal rate), or cardiac failure

Binge-eating: excessive food intake within 2 hr
period + sense of lack of control

Anorexia Tx: food (behavioral therapy + family
therapy + supervised weight-gain programs);
excessive weight preoccupation → low-dose 2G
antipsychotics, preprandial anxiety → BDZs

Binge-eating disorder: recurrent binge-eating w/o
compensatory behavior, 2/wk for 6 months

Anorexia complications: BATCH – Bone loss
(osteopenia/osteoporosis), Amenorrhea, ↓Thyroid,
Constipation, Heart problems (cardiomyopathy, ACS,
MVP, arrhythmias due to ↓K+)
Anorexia lab values: ↑cortisol, QTc, chol, BUN, GH;
↓RBC/WBC, LH/FSH, E/T, T4/T3, glucose
Anorexia × purging: contraction (hypokalemic,
hypochloremic metabolic) alkalosis
Anorexia DDx: endocrine disorders, GI diseases,
genetic disorders, cachexia (due to cancer/AIDS),
MDD, bulimia
Anorexia vs. bulimia: both may binge and purge, but
bulimics are normal weight and anorexics are <85%
Anorexia vs. MDD: both may refuse to eat, but
anorexics starve in spite of a good appetite and MDD
have poor appetite
Refeeding syndrome: occurs when severely
malnourished pts are refed too quickly → fluid
retention and ↓Ca/Mg/Ph → RADS – Respiratory
failure, Arrhythmias, Delirium, Seizures
Refeeding syndrome Tx: slow feedings and
replace electrolytes
Bulimia nervosa: binge eating + behaviors intended
to counteract weight gain, 2/wk for 3 months
Bulimia subtypes: purging type involves vomiting,
laxatives, enemas, or diuretics; nonpurging type
involves excessive exercise or fasting
Bulimia prevalence: 1-4%, most commonly in
women in industrialized countries
Bulimia Px: chronic and relapsing, but better Px
than anorexia nervosa
Bulimia Tx: SSRIs (fluoxetine) + therapy (CBT);
avoid buproprion which can ↓seizure threshold

BED Tx: psychotherapy + behavioral therapy +
diet/exercise program; drugs can be used as an
adjunct (stimulants, orlistat, sibutramine)

Ψ – Sleep Disorders

––––––––––––––––––– SLEEP –––––––––––––––––––
Normal sleep cycle: non-rapid eye movement sleep
(stages 1-4) alternating w/ REM sleep every 90 min
NREM: deeper sleep progression through stages;
stage 2 is tooth grinding, stage ¾ (delta sleep) is
sleepwalking, bedwetting, and sleep terrors
REM: dreaming, loss of motor tone, erections,
sympathetic activity (↑HR, ↑RR, ↑BP)
Sleep EEG waveforms: BATS Drink Blood – Beta
(awake), Alpha (resting), Theta (1), Sleep spindles
and K complexes (2), Delta (¾), Beta (REM)
Sleep disorders: dyssomnias and parasomnias
––––––––––––––– DYSSOMNIAS –––––––––––––––
Dyssomnias: ↑/↓ or altered timing of sleep
Primary insomnia: ↓sleep duration and/or quality;
acute insomnia 1-4 wks, chronic insomnia >1 month
PI subtypes: sleep-onset insomnia (can’t go to sleep),
sleep-maintenance insomnia (can’t stay asleep),
sleep-offset insomnia (early morning awakenings),
nonrestorative sleep (wake up still tired)
PI etiology: usually poor sleep hygiene
PI Tx: fix sleep hygiene, Chronic insomnia → CBT,
acute insomnia → long-term BDZs or non-BDZ
hypnotics, insomnia + depression → trazodone
Obstructive sleep apnea: difficulty breathing during
sleep → snoring and apneic episodes → sleep
fragmentation → excessive daytime sleepiness
OSA etiology: repetitive upper airway collapse
due to obesity and/or airway narrowing
OSA Tx: first-line is weight loss and exercise,
second-line is CPAP or BiPAP, third-line is surgery
Narcolepsy: excess daytime sleepiness, cataplexy
(suddenly fainting w/ intense emotion), hypnogogic
and hypnopompic hallucinations
Narcolepsy etiology: loss of hypothalamic
neurons that contain hypocretin, may have autoimmune component

Circadian rhythm sleep disorders: caused by defect
in circadian pacemaker or impaired entrainment;
includes DPSD, APSD, SWD, and jet lag disorders
Delayed sleep phase disorder: sleep onset and
awakening are delayed, but normal duration/quality
DPSD Tx: bright light phototherapy in the
morning, melatonin in the evening
Advanced sleep phase disorder: sleep onset and
awakening are early, but normal duration/quality
APSD Tx: bright light phototherapy in the evening
Shift-work disorder: sleep schedule is messed up
due to nontraditional work hours
SWD Tx: avoid risk factors, severe → modafinil
Jet lag disorder: sleep schedule is messed up due to
travel across multiple time zones
Jet lag Tx: resolves by itself 2-3 days after travel
––––––––––––––– PARASOMNIAS –––––––––––––––
Parasomnias: unusual sleep-related behaviors (e.g.
movements, emotions, dreams, autonomic activity)
Sleepwalking: walking around during stage ¾ sleep
with “glassy look” on eyes, confusion or violence on
forced awakening, amnesia for episode
Sleepwalking etiology: unknown, usually not
associated w/ any psychiatric problems
Sleepwalking Tx: ensure child safety and wait;
refractory cases → BDZs (clonazepam) or TCAs
Sleep terrors: sudden arousal w/ screaming during
stage ¾ sleep, sympathetic activity, confusion or
violence on forced awakening, amnesia for episode
Sleep terror etiology: ↑comorbidity w/ restless
leg syndrome and sleep-disordered breathing
Sleep terror Tx: ensure child safety and wait;
refractory cases → BDZs (clonazepam)
Nightmare disorder: recurrent nightmares w/ vivid
recall, no confusion or disorientation on awakening
Nightmare etiology: seen in >50% PTSD pts

Narcolepsy Tx: fix sleep hygiene, excess daytime
sleepiness → stimulants (e.g. amphetamines,
modafinil), cataplexy → sodium oxybate (GHB)
Idiopathic hypersomnia: excess daytime sleepiness,
prolonged nocturnal sleep, frequent urges to nap
Kleine-Levin syndrome: excess daytime sleepiness,
aggression, hyperphagia, hypersexuality
Circadian rhythm: sleep-wake cycle controlled by
suprachiasmic nucleus (SCN) in the hypothalamus

Nightmare Tx: image rehearsal therapy (IRT),
severe → antidepressants
REM sleep behavior disorder: dream enactment
(talking, yelling, walking, punching, etc.) that often
presents as injury to the pt or bed partner
RBD etiology: unknown, usually in senior males
RBD Tx: clonazepam, ensure safety
Restless leg syndrome: irresistable urge to move
one’s legs while going to sleep; caused by pregnancy,
anemia, renal failure, or other metabolic d/o

Periodic limb movement disorder: aka nocturnal
myoclonus, frequent limb movement during sleep

Ψ – Sexual Disorders

–––––––––––– NORMAL SEXUALITY ––––––––––––
Sexual response cycle: desire to EXPLORE – desire,
EXcitement, PLateau, Orgasm, REsolution
Refractory period: post-resolution period in
which men can’t reexperience orgasm
Sex × male aging: desire unchanged but requires
↑stimulation and time to orgasm, ↓intensity of
ejaculation, ↑refractory period
Sex × female aging: desire unchanged but ↓estrogen
levels → vaginal dryness and thinning
Sex × drugs: ↑libido – cocaine, amphetamines,
marijuana, and acute alcohol use; ↓libido – narcotics
and chronic alcohol use
Sex × NTs: DA ↑libido, 5-HT inhibits sexual function
Sex × hormones: testosterone ↑libido, progesterone
↓libido, postmenopausal ↓estrogen levels → vaginal
dryness and thinning
Substance-induced sexual dysfunction: anti-HTN,
anticholinergics, antipsychotics, antidepressants
(esp. SSRIs), or substance abuse
Sexual dysfunction 2/2 GMC: atherosclerosis (ED),
diabetes (ED + neuropathy), pelvic adhesions
(dyspareunia), depression or anxiety

Orgasmic disorder: can’t orgasm or achieves orgasm
w/ great difficulty
Male OD Tx: gradually progress from extravaginal
ejaculation (via masturbation) to intravaginal

Fetishism: sexual preference for inanimate
objects (e.g. women’s shoes)

Female OD Tx: masturbation ± vibrator

Transvestic fetishism: sexual gratification in men
from wearing women’s clothing

Dyspareunia: genital pain before, during, or after
sexual intercourse; women > men, often associated
w/ vaginismus
Dyspareunia Tx: gradual desensitization to
achieve intercourse (muscle relaxation → erotic
massage → sexual intercourse)
Vaginismus: involuntary muscle contraction of
outer 1/3 of vagina during insertion; ↑incidence in
higher socioeconomic groups and strict religious
upbringing
Vaginismus Tx: manual dilation
Homosexuality: sexual/romantic desire for same sex,
not a sexual disorder, etiology unknown
Homosexual × depression: consider MDD or
adjustment d/o due to conflict w/ societal values;
homosexuality is not a disorder
Homosexual × prepuberty: same-sex exploratory
activities are common in prepubescent kids and
don’t signify latent homosexuality

––––––––––––– SEXUAL DISORDERS –––––––––––––
Sexual disorders: problems involving any stage of
sexual response cycle or pain during intercourse, not
due to substance use or GMC
MC sexual disorders: premature ejaculation and 2°
ED in men, HSDD and orgasmic disorder in women
Hypoactive sexual desire disorder: deficient or
absent libido
HSDD Tx: hormone replacement therapy
Sexual aversion disorder: avoidance of genital
contact w/ sexual partner
Erectile dysfunction: aka impotence, can’t get it up,
either 1° (never had one) or 2° (had it but lost it)
ED Tx: PDE5-inhibitors (sildenafil) or alprostadil
injection are first-line; vacuum pumps, surgical
tube insertion, or constrictive rings
ED vs. psychological condition: men w/ psych
condition can get it up at other times (e.g. other
partners, masturbating, morning wood)
Sexual arousal disorder: can’t get it wet
Premature ejaculation: ejaculation earlier than
expected
Premature ejaculation Tx: SSRIs or TCAs can
prolong time to ejaculation

Masochism: sexual excitement from being hurt
or humiliated

Transsexuality: aka gender identity disorder, strong
cross-gender identification + persistent discomfort
w/ own sex
Transsexuality Tx: therapy, family involvement
for younger pts, possibly sex reassignment
Transsexual vs. transvestite: transsexuals identify
with the other sex, transvestites like to wear other
gender’s vestments (clothing)
–––––––––––––––– PARAPHILIAS ––––––––––––––––
Paraphilias: engagement or preoccupation w/
unusual sexual urges or fantasies, must last >6
months and interfere w/ daily life
MC paraphilias: pedophilia, voyeurism, exhibitionism
Pedophilia: getting turned on by kids <13 y/o,
pedophile must be >16 y/o and at least 5 years
older than the child
Frotteurism: sexual pleasure from touching or
rubbing up against a nonconsenting person
Voyeurism: watching unsuspecting nude people
for sexual pleasure
Exhibitionism: exposing self to others
Sadism: sexual excitement from hurting or
humiliating others

Necrophilia: sexual pleasure from f-ing a corpse
Telephone scatologia: sexual excitement from
calling unsuspecting women and having phone
sex with them
Paraphilia Px: good prognosis w/ self-referral (vs.
police arrest), sense of guilt, and low frequency of
behavior
Paraphilia Tx: insight-oriented psychotherapy +
aversion therapy; antiandrogens for refractory
hypersexual paraphilias in men
Paraphilia vs. normal fantasy: occasional fantasies
are normal if <6 months and don’t interfere w/ daily
functioning
Transvestic fetishism vs. homosexuality: dressing up
as a woman doesn’t mean you’re turned on by men
–––––– TREATMENT OF SEXUAL DISORDERS ––––––
Sexual disorder Tx: psychotherapy, medications,
and mechanical therapy all play a role
Psychotherapy: dual sex therapy for marriage or
couple issues, behavioral therapy for maladaptive
behaviors, hypnosis for anxiety
Pharmacotherapy: (see specific disorders)
Mechanical therapy: (see specific disorders)

Ψ – Psychotherapy

––––––––––––– FREUD’S THEORIES –––––––––––––
Topographic theory: mind is composed of three
types of thoughts – conscious, preconscious, and
unconscious
Conscious thoughts: current thoughts and 2°
process thinking (logical, mature, organized, etc.)
Preconscious thoughts: memories that are not
immediately aware but easy to recall
Unconscious thoughts: repressed thoughts that
are out of one’s awareness, involves 1° process
thinking (primitive and pleasure-seeking)
Structural theory: mind is composed of three
identities – id, ego, and super-ego

Displacement: redirecting thoughts or feelings
about one thing onto something more tolerable
Isolation of affect: separation of an unpleasant
idea from the feelings it evokes
Controlling: regulating aspects of external
environment to relieve anxiety
Immature defenses: acting out, denial, distortion,
fantasy, regression, passive aggression, projection,
projective identification, splitting, undoing
Acting out: giving into an impulse, even if it’s
socially inappropriate
Denial: not accepting reality that is too painful,
first stage of Kubler-Ross grief model

Id: primitive; involves sexual/aggressive urges
and 1° process thinking

Distortion: grossly reshaping external reality to
suit inner needs

Ego: realistic; mediates id, super-ego, and
external environment using defense mechanisms

Fantasy: substituting fantasy for reality to resolve
inner conflicts; characteristic of schizoid PD

Super-ego: idealistic; represents morals, society,
and parental teaching

Regression: reverting back to childlike behavior;
characteristic of histrionic PD and dependent PD

Normal development: id is present at birth, ego
develops after birth, superego begins at age 6
––––––––––– DEFENSE MECHANISMS –––––––––––
Defense mechanisms: used by ego to mediate id,
super-ego, and external environment; three types –
mature, neurotic, and immature
Mature defenses: mature women wear a SASH –
Sublimation, Altruism, Suppression, Humor
Sublimation: satisfying socially objectionable
impulses in an acceptable manner
Altruism: performing acts that benefit others to
feel better about oneself

Passive aggression: nonconfrontational
expression of aggression towards others
Projection: attributing one’s inappropriate
thoughts or emotions onto another (e.g. stealing
from a friend you suspect is stealing from you)
Projective identification: attributing one’s
inappropriate thoughts onto another, then
identifying with the countertransference
Splitting: labelling people as all good or all bad;
characteristic of borderline PD
Undoing: attempting to reverse a situation by
adopting a new behavior

Countertransference: doctor projects unconscious
feelings onto pt (e.g. all antisocial pts are
malingering for benzos)
Psychoanalysis-related therapies: brief dynamic
(psychoanalytically-oriented) therapy, interpersonal
therapy, supportive therapy
Brief dynamic therapy: like psychoanalysis but
briefer and face-to-face instead of lying on a
couch
Interpersonal therapy: focuses on development
of social skills
Supportive therapy: focuses on helping pt feel
safe during a difficult time, builds up healthy
defense mechanisms, not insight-oriented
–––––––––– OTHER PSYCHOTHERAPIES ––––––––––
Behavioral therapy: uses learning theory to get rid of
bad behaviors and replace w/ healthy alternatives
Learning theory: behaviors can be learned by
conditioning, and extinguished by deconditioning
Classical conditioning: stimulus can eventually
evoke a conditioned response (e.g. Pavlov’s dog)
Operant conditioning: uses positive (rewards)
or negative reinforcement (removing an aversive
stimulus) to encourage behavior
Systematic desensitization: pt uses relaxation
techniques while being exposed to increasing
doses of anxiety-provoking stimuli
Flooding and implosion: pt is exposed to real
(flooding) or imagined (implosion) anxietyprovoking stimuli and not allowed to withdraw
until he/she feels calm and in control
Aversion therapy: uses punishment to
discourage behavior (e.g. electric shock)

–––––––––––––– PSYCHOANALYSIS ––––––––––––––
Suppression: consciously avoiding unacceptable
impulse or emotion (vs. repression)
Humor: using comedy to express thoughts or
feelings w/o discomfort to self or others
Neurotic defenses: RIDICulous – Rationalization,
Reaction formation, Repression, Intellectualization,
Displacement, Isolation of affect, Controlling
Rationalization: making reassuring but incorrect
explanations for outcome or behavior
Reaction formation: doing the exact opposite of
an unacceptable impulse
Repression: unconsciously avoiding unacceptable
impulse or emotion (vs. suppression)
Intellectualization: using excessive abstract
thinking to avoid experiencing disturbing feelings

Split treatment: one psychiatrist provides
medication, another provides the therapy
Psychoanalysis: resolving unconscious conflicts by
making pt aware of repressed experiences and
feelings, then integrating them into consciousness;
an insight-oriented approach, 5 times/wk for years
Psychoanalysis techniques: free association, dream
interpretation, therapeutic alliance, interpretation of
transference

Token economy: rewards (tokens) given after
specific behaviors for positive reinforcement
Biofeedback: vital signs given to pts as they try to
mentally control physiological states
Negative reinforcement vs. aversion therapy:
negative reinforcement removes aversive stimulus
to encourage behavior, aversion therapy adds an
aversive stimulus to discourage behavior
Cognitive therapy: identifying bad thoughts and
replacing them w/ positive ones

Free association: pt says whatever comes to mind
Dream interpretation: dreams represent conflict
between urges and fears, interpret for resolution
Therapeutic alliance: bond between pt and
therapist
Transference: pt projects unconscious feelings onto
doctor (e.g. therapist seen as father figure)

Cognitive behavioral therapy: identifying bad
thoughts, making the connection w/ bad behaviors,
then setting an agenda to change thoughts in order
to change behavior
Dialectical behavioral therapy: CBT subtype used to
↓self-destructive behavior, ideal Tx for borderline PD

Ψ – Psychotherapy

Group therapy: 3+ pts w/ similar problems meet w/
therapist for behavioral, cognitive, or supportive
therapy; useful for substance abuse, adjustment d/o,
and personality d/o
Peer led group therapy: no therapist (e.g. AA)
Family therapy: sessions w/ entire family to reduce
conflict, help understand each others’ needs (mutual
accomodation), and cope w/ internally destructive
forces
Boundaries and triangles: boundaries between
family members may be too rigid or permeable;
triangles are two family members against a third
Couples therapy: used to address conflicts, sexual
problems, and communication issues within couples
Couples therapy types: conjoint therapy (see
couple together), concurrent therapy (see both
separately), collaborative therapy (one therapist
per pt), four-way therapy (all of the above)

Ψ – Psychopharmacology

––––––––––– NEUROTRANSMITTERS –––––––––––
Anti-H2: sedation, weight gain
Anti-A1: orthostatic hypotension, sexual dysfunction
Anti-M: dry mouth, blurry vision, constipation,
urinary retention, exacerbates Alzheimer disease

CYP450: liver enzymes that metabolize drugs;
CYP450 inducers ↓drug levels, CYP450 inhibitors
↑drug levels
CYP450 inducers: smoking, carbamazepine,
barbiturates, St. John’s wort
CYP450 inhibitors: fluvoxamine, fluoxetine,
paroxetine, duloxetine, sertraline

Anti-D2: anti-psychosis, EPS, ↑prolactin
Anti-5-HT1c: weight gain

Teratogenic drugs: TCAs (fetal limb defects), VPA
(neural tube defects), lithium (Ebstein’s anomaly),
BDZs (cleft palate + FAS facies)

5-HT2: agitation, akathisia

Mirtazapine (Remeron): can cause weight-gain and
sedation
TCAs: inhibit 5-HT/NE reuptake, rarely first-line since
OD can be lethal (Tx NaHCO3); three types – tertiary
tricyclics, secondary tricyclics, tetracyclics
TCA side-effects: anti-HAM + 3 Cs – Cardiotoxicity
(↑QTc), Convulsions, Coma; lots of interactions
(highly protein bound) and lethal in OD
2° vs. 3° TCAs: tertiary are more anticholinergic
and sedating, and more lethal in OD; secondary
are active metabolites of tertiary amines

––––––––––––– ANTIDEPRESSANTS –––––––––––––
Imipramine (Tofranil): Tx enuresis

5-HT3: diarrhea, nausea/vomiting
––––––––––––––– SIDE-EFFECTS –––––––––––––––
Anti-HAM side-effects: TCAs and low-potency antipsychotics can cause anti-H2, anti-α1, anti-M
Serotonin syndrome: ↑5-HT → fever, confusion,
flushing, sweats, tremor, hypertonicity, rhabdomyolysis → renal failure, death
Serotonin syndrome combos: SSRI+MAOI,
SSRI+OTC cough medicine, SSRI+linezolid,
MAOI+meperidine, MAOI+MDMA/MDEA
Serotonin syndrome Tx: cyproheptadine or BDZ,
avoid taking within 5 weeks of each other
Hypertensive crisis: MAOI+tyramines or sympathomimetics can cause ↑NE/↑epi (severe HTN)
Extrapyramidal side-effects: high-potency typical
antipsychotics can cause Parkinsonism, akathisia,
and dystonia within days
EPS Tx: acute dystonia → benztropine or
diphenhydramine, akathisia → β-blockers or BDZ,
Parkinsonism → levodopa or amantadine
Tardive dyskinesia: high-potency typical antipsychotics can cause choreoathetosis of mouth and
tongue after years of use
TD Tx: irreversible, so monitor sx with AIMS
(abnormal involuntary movement scale)

Antidepressants: SSRIs, TCAs, MAOIs, and atypicals;
all have similar efficacy but differ in side-effect
profile, require 3-4 week trial to take effect, none
cause elation or have abuse potential

Amitriptyline (Elavil): strong anticholinergic sideeffects
Clomipramine (Anafranil): very sedating, Tx OCD

Withdrawal phenomenon: dizziness, headache,
N/V, insomnia, malaise after stopping most antidepressant use; may require tapering
SSRIs: first-line for MDD due to low incidence of
side-effects and safe in OD; includes fluoxetine,
sertraline, paroxetine, fluvoxamine, (es)citalopram
SSRI side-effects: sexual dysfunction, GI distress,
serotonin syndrome, black box for suicidality

Doxepin (Sinequan): very sedating, useful as a
sleep aid in low doses
Nortriptyline (Pamelor, Aventyl): fewest antiHAM side-effects
Desipramine (Norpramin): more activating, less
sedating, least anticholinergic

SSRI × sexual dysfunction: switch to bupropion

Amoxapine (Asendin): metabolite of loxapine,
only antidepressant that can cause EPS

Fluoxetine (Prozac): longest T½ (fewest
withdrawal sx)

Maprotiline (Ludiomil): ↑rate of seizures,
arrhythmias, and fatality w/ OD

Sertraline (Zoloft): highest GI distress
Paroxetine (Paxil): shortest T½ (highest
withdrawal sx), most anticholinergic side-effects
Fluvoxamine (Luvox): Tx OCD
Citalopram (Celexa): fewest drug interactions,
fewest sexual side-effects
Escitalopram (Lexapro): L-enantiomer of
citalopram, even fewer side-effects but more $$$

MAOIs: not first-line due to side-effects but useful
for atypical depression; includes phenelzine (Nardil),
tranylcypromine (Parnate), isocarboxazid (Marplan),
selegiline (Emsam)
MAOI side-effects: serotonin syndrome (MAOI+
SSRI within 5 weeks), HTN crisis (MAOI+tyramine)
–––––––––––––– ANTIPSYCHOTICS ––––––––––––––
Antipsychotics: typical (1G) and atypical (2G) are
both good for positive psychotic sx, but atypicals are
better for negative psychotic sx

Venlafaxine (Effexor): SNRI, ↑↑BP
Withdrawal dyskinesia: tendency for TD to
temporarily increase following d/c antipsychotic
Hyperprolactinemia: high-potency antipsychotics
and risperidone can ↑prolactin (galactorrhea,
amenorrhea, ↓libido, infertility), due to ↓dopamine in
tuberoinfundibular pathway
Neuroleptic malignant syndrome: all antipsychotics
can cause FALTER – Fever, Autonomic instability,
Leukocytosis, Tremor, Elevated CPK, “lead pipe”
Rigidity; mortality rate is 20%

Desvenlafaxine (Pristiq): SNRI, active metabolite of
venlafaxine, more $$$
Duloxetine (Cymbalta): SNRI, good for painful
diabetic neuropathy, more $$$
Buproprion (Wellbutrin): no sexual side-effects,
contraindicated with seizures and eating disorders
(↑risk of seizures)
Trazodone (Desyrel): can cause sedation and
priapism (Tx epi injection into penis)

NMS Tx: dantrolene or bromocriptine
Metabolic syndrome: atypical antipsychotics can
↑BP, ↑insulin, ↑body fat, ↑risk of CAD/stroke/diabetes;
switch to typical antipsychotic if pt is at risk

Nefazodone (Serzone): can cause sedation, black
box for hepatotoxicity

Depot antipsychotics: long-acting decanoate forms
ideal for noncompliant psychotic pts; includes
haloperidol, fluphenazine, risperidone, paliperidone
Typical vs. atypicals: typicals have more EPS, tardive
dyskinesia, anti-HAM, and lethality in OD due to QTc
prolongation; atypicals have more weight gain, DKA,
and metabolic syndrome
Typical antipsychotics: blocks DA only
Typical side-effects: EPS (parkinsonism +
akathisia + dystonia), ↑prolactin, anti-HAM,
tardive dyskinesia (1% annual incidence), NMS
Low potency: ↑anti-HAM, ↓EPS and TD; includes
chlorpromazine (corneal pigmentation + photo-

Ψ – Psychopharmacology

sensitivity) and thioridazine (retinal pigmentation →
night blindness)
Mid-potency: midrange properties; includes
loxapine (↑seizures), thiothixene (ocular
pigmentation), trifluoperazine (↓anxiety), and
perphenazine
High potency: ↑EPS and TD, ↓anti-HAM;
includes haloperidol, fluphenazine, pimozide
Atypical antipsychotics: blocks both DA and 5-HT
Atypical side-effects: weight gain, DKA,
metabolic syndrome (monitor weight and lipids)
Clozapine (Clozaril): ↓suicide but ↑weight gain,
seizures, agranulocytosis (requires weekly WBC
counts), R-sided obstipation
Risperidone (Risperdal): #1 for ↑prolactin and
dystonic reactions

––––––––––––– ANTICONVULSANTS –––––––––––––
Anticonvulsants: includes carbamazepine,
oxcarbazepine, valproic acid, lamotrigine,
gabapentin, pregabalin, tiagabine, topiramate

Ramelteon (Rozerem): melatonin MT-2/3 agonist
used for sedation, no tolerance/depedence

Carbamazepine (Tegretol): good for rapid-cycling
bipolar disorder and trigeminal neuralgia; takes 5-7
days for onset and requires CBC/LFT monitoring

Buspirone (BuSpar): 5-HT1A partial agonist given for
anxiety, useful in alcoholics (no EtOH potentiation
like BDZ)

CBZ side-effects: BATHS – Blood dyscrasias,
P450 Autoinduction, Teratogenic, Hepatotoxic,
Stevens-Johnson syndrome
Valproic acid (Depakote): requires CBC/LFT/VPA
monitoring
VPA side-effects: 4 Fs – Fat (weight gain), Farts
(GI distress), Fatal hepatotoxicity, Fetal teratogen
(neural tube defects)
Lamotrigine (Lamictal): can ↓VPA levels, causes
Stevens-Johnson syndrome so raise levels slowly

Paliperidone (Invega): metabolite of risperidone
Quetiapine (Seroquel): can cause sedation and
orthostatic hypotension

Chloral hydrate (Somnote): sedative, rarely used due
to tolerance/depedence and liver toxicity

Topiramate (Topamax): causes weight loss,
cognitive slowing (aka Dopamax), kidney stones
Gabapentin (Neurontin): good for chronic pain

Diphenhydramine (Benadryl): antihistamine given
for sedation, ↑anticholinergic side-effects
Hydroxyzine (Atarax): antihistamine given for
anxiety, ↑anticholinergic side-effects
Propanolol: β-blocker used to Tx panic attacks,
performance anxiety, and akathisia
––––––––––––––– OTHER DRUGS –––––––––––––––
Psychostimulants: Tx ADHD and refractory
depression; includes D-amphetamine, amphetamine
salts, methylphenidate, atomoxetine, modafanil
Amphetamines (Dexedrine, Adderall): schedule II
(↑abuse potential), monitor BP and watch for weight
loss, insomnia

Olanzapine (Zyprexa): ↑weight gain
Oxcarbazepine (Trileptal): rarely used
Ziprasidone (Geodon): ↓weight gain
Pregabalin (Lyrica): rarely used
Aripiprazole (Abilify): #1 for akathisia (Tx βblockers or BDZ)
Ziprasidone doesn’t work: pt wasn’t eating, food is
required to activate Geodon in the body
––––––––––––– MOOD STABILIZERS –––––––––––––
Mood stabilizers: Tx acute mania and prevent
relapses of manic episodes, includes lithium and
anticonvulsants (valproic acid, lamotrigine,
carbamazepine)

Tiagabine (Gabatril): rarely used

Li+ side-effects: LMNOP – Lithium causes
Movement (tremors → Tx propanolol),
Nephrogenic DI, Narrow TI (0.6-1.2),
hypOthyroidism (Tx Synthroid), Pregnancy
problems (Ebstein’s anomaly)
Li+ level factors: NSAIDs (↑ except aspirin),
dehydration (↑), salt deprivation (↑), sweating
(↑), renal failure (↑), diuretics (↑)

Modafanil (Provigil): used in narcolepsy
Anxiolytics: benzodiazepines, barbiturates, and nonbenzodiazepine hypnotics/anxiolytics
Benzodiazepines: three types based on T½ (<6 hrs,
6-20 hrs, >20 hrs), choice of BDZ depends on onset,
duration, and metabolism

Non-liver metabolized BDZ: LOT – Lorazepam,
Oxazepam, Temazepam
Long-acting BDZ: T½ >20 hrs; includes diazepam
(Valium) and clonazepam (Klonopin)

Lithium × HTN: Tx Ca2+-channel blockers

Cognitive enhancers: used in dementia
AChE inhibitors: Tx mild Alzheimer disease; includes
donepezil, galantamine, rivastigmine, tacrine
Memantine (Namenda): NMDA blocker used for
moderate-severe Alzheimer disease
–––––––––––– OTHER TREATMENTS ––––––––––––
Electroconvulsive therapy: Tx refractory depression;
8-12 sessions given 3/week then monthly ECT to
prevent relapse; safe for pregnant and elderly

Intermediate-acting BDZ: T½ 6-20 hrs; includes
alprazolam (Xanax), lorazepam (Ativan), oxazepam
(Serax), and temazepam (Restoril)

ECT method: pt put under general anesthesia and
muscle relaxant, then electrodes induce a seizure;
efficacy based on length of postictal suppression

Short-acting BDZ: T½ <6 hrs; includes triazolam
(Halcion) and midazolam (Versed), used mainly in
medical and surgical settings

ECT side-effects: amnesia (MC), headaches,
muscle soreness, confusion

Barbiturates: rarely used b/c lethal in overdose

ECT electrodes: bilateral electrodes ↓number of
sessions but ↑amnesia and confusion

Barbiturate overdose: Tx IV NaHCO3

ECT efficacy: 75%

Non-benzo hypnotics: zolpidem (Ambien), zaleplon
(Sonata), and eszopiclone (Lunesta); Tx short-term
insomnia, no tolerance/dependence

ECT c/i: recent MI, anything w/ possibility of
hemorrhagic stroke (raised ICP, aneurysms,
bleeding d/o, BBB distruption)

Lithium overdose: if blood level >4.0, hemodialysis
Lithium duration: maintain use for 1 year following
single episode, maintain for lifetime if 3+ relapses

Atomoxetine (Stattera): ↓appetite suppression and
insomnia, but ↑hepatotoxicity and SI in adolescents

–––––––––––––––– ANXIOLYTICS ––––––––––––––––

BDZ overdose: give flumazenil
Lithium: DOC for acute mania and PPx for manic
episodes, takes 5-7 days for onset, only mood
stabilizer to ↓suicidality

Methylphenidate (Ritalin, Concerta): schedule II
(↑abuse potential), monitor BP/CBC/LFTs and watch
for weight loss, insomnia

Ψ – Psychopharmacology

Deep brain stimulation: Tx chronic pain, Parkinson’s
disease, tremor, and dystonia
DBS method: implant device in brain that sends
regular electrical impulses to specific regions,
high risk of surgical complications
Repetitive transcranial magnetic stimulation:
noninvasive method to excite neurons via electromagnetic induction, Tx psychiatric conditions but
modest effects at best
rTMS side-effects: rare seizures, discomfort at
the delivery site
Light therapy: Tx seasonal affective disorder

Ψ – Forensic Psychiatry

––––––––––––––– LEGAL ISSUES –––––––––––––––

Parens patriae: protecting citizens who can’t care
for themselves

Forensic psychiatry: psychiatry + legal issues
––––––––––– DISABILITY & INSANITY –––––––––––
Legal issues: two types – criminal if being charged
with a crime, civil if other rights are violated
Standard of care: skill level and knowledge base of
the average psychiatrist

Mental impairment: loss or derangement of a
mental function
Mental disability: inability to meet personal, social,
or occupational demands due to mental impairment

Negligence: practicing below standard of care
Malpractice: act of being negligent as a doctor;
must meet the 4 Ds – Deviation (neglect) from
Duty that was the Direct cause of Damage
Damages: reward for malpractice case, includes
compensatory damages (financial reimbursement)
and punitive damages (money awarded to punish
the doctor)
Confidentiality: nondisclosure of information except
to another authorized person

Competence: legal term for pt’s ability to make
informed treatment decisions; 6th + 14th amendments
require competence to stand trial
6th amendment: right to counsel and to confront
witnesses
14th amendment: right to due process of law
Conviction: judgment of guilty in a criminal case;
requires both actus reus (evil deed) and mens rea
(evil intent)

Exceptions: COPS – Child abuse, Other staff
involved in pt’s care, Potential harm to others,
Subpoena, Suicidality

Insanity defense: if someone is declared legally
insane, they are not criminally responsible for the act
(i.e. not guilty by reason of insanity, NGRI)

Tarasoff duty: legal obligation to breach patient
confidentiality and warn potential victims about a
pt who may physically harm them

Insanity defense standards: M’Naghten rules,
American Law Institute (ALI) model, Durham test

Child abuse: doctors are required to contact child
protective services, lawyers are not
Informed consent: pt knowingly and voluntarily
agrees to a treatment or procedure; includes 4 Rs –
Reason for Tx, Risks and benefits, Reasonable
alternatives, and Refused Tx consequences
Exceptions: medical emergencies, suicide or
homicide prevention, unemancipated minors
receiving obstetric care, STD Tx, or substance
abuse Tx
Emancipated minors: do not need parental consent
to make medical decisions; minors are emancipated
if self-supporting, military, married, or have children
Capacity vs. competence: both refer to pt’s ability to
make informed treatment decisions, but capacity is a
medical term and competence is a legal term
Decisional capacity: task specific
Guardian: appointed to make treatment decisions
for incompetent pts
Voluntary admission: pt checks self into psych ward,
may not have the right to be discharged immediately
upon request
Involuntary admission: pt checked in for potential
harm or inability to provide for basic needs;
supported by legal principles of police power and
parens patriae
Police power: protecting citizens from each other

M’Naghten Rules: person does not understand
what he was doing or its wrongfulness
ALI Model: person could not appreciate right
from wrong or could not control his/her actions
(aka “irresistible impulse” test)
Durham Test: person’s criminal act has resulted
from mental illness
Violence risk assessment: h/o violence (#1 factor),
h/o impulsivity, specific threat w/ a plan, psychiatric
illness, substance abuse
––––––––––––––– OTHER ISSUES –––––––––––––––
Expert witness standards: evidence must be
accepted by appropriate scientific community (Frye
1923), and judge decides if evidence is based on
relevant and reliable science (Daubert 1993)
Malingering: feigning or exaggerating sx for
secondary gain (e.g. money, drugs, avoiding work)
Malingering buzzwords: ASPD, h/o substance
abuse, “doctor shopping”, textbook description
of illness, symptomatic only when observed
Child forensic psychiatry: involves child custody,
child abuse/neglect, termination of parental rights
Correctional psychiatry: involves balancing
confidentiality vs. violence

Ψ – Additional Notes

–––––––– EXAMINATION AND DIAGNOSIS ––––––––
Prevention: PDR – 1° is Prevention, 2° is Detecting
disease, 3° is Reduction of disability

Kluver-Bucy syndrome: presents as docility,
hyperphagia, hypersexuality, and disinhibition due to
bilateral amygdala lesions

Suicidal pt: admit to inpatient care (against will if
necessary)
Homicidal pt: admit to inpatient care

––––––––––––– MOOD DISORDERS –––––––––––––
Circumlocution: substitution of a word or
description for a word that can’t be recalled (e.g.
“that thing you write with”)
Tangentiality vs. circumstantiality: tangentiality
never comes back to original topic, circumstantiality
eventually does
Abuse vs. dependence: inability to quit despite
knowledge of harm best indicates dependence over
abuse

Psychotic pt: acknowledge pt’s distress
Postpartum blues: 20-40%, dysthymia that lasts <2
weeks, resolves spontaneously
Postpartum depression: 10-15%, resembles MDD
Postpartum psychosis: 0.1%, a subtype of bipolar
disorder, admit into inpatient care → Tx antipsychotic + antidepressant
Bipolar disorder: 25% among relatives, average age
of onset is 30 y/o

Verbigeration: repetitive, meaningless talking
Glossolalia: ability to speak a new language suddenly
––––––––––– PSYCHOTIC DISORDERS –––––––––––

Porphyria: presents as psychotic or manic sx +
abdominal pain → get urinary porphobilinogen
Hamilton Depression Scale: used to measure
depressive sx

Dementia praecox: another name for SCZ
––––––– SUBSTANCE-RELATED DISORDERS –––––––
Psychogenic polydipsia: SCZ pt drinks too much
water causing hyponatremia (Na+ <135)

Angry pt: encourage discussion about what’s
bothering the pt
Inappropriate pt: respond firmly but politely, remain
professional
Anorexic pt: admit to inpatient care if <75% ideal
body weight and/or medical complications
Abused pt: ask about abuse in an empathetic, openended question
Suspected child abuse: complete a thorough
physical exam, then get X-rays, then call child
protective services if necessary
Breaking bad news: set the stage and assess pt’s
comprehension, then deliver news in empathetic
manner

Nasal septum erythema: cocaine abuse
Medical error: admit the mistake and apologize

SCZ brain: diffuse atrophy with decreased size of
hippocampus, parahippocampal gyrus, amygdala

Rotary or vertical nystagmus: PCP abuse
Injected eyes: marijuana (cannabis) abuse

Koro: Asian pt believes that his penis is shrinking and
will disappear causing his death

––––––––––– COGNITIVE DISORDERS –––––––––––

Amok: sudden unprovoked outbursts of violence of
which the person has no recollection (think “to run
amok”)

Delirium Dx: abnormal EEG

Brain fag: headache, fatigue, and visual disturbances
in African male students

Multiple sclerosis brain: multiple plaques of frontal
white matter

Ataque de nervios: Puerto Rican trance d/o with
convulsions, fainting, crying, and visual problems

Pseudoseizure: resembles seizure but normal EEG

Dementia Dx: MRI

Colleague makes medical error: always act in pt’s
best interest
Pt refuses tx: respect pt wishes, unless it puts others
at risk (e.g. infx) → requires involunary admit
Parents refuse tx for minor: nonemergent and not
fatal → respect parent wishes; nonemergent but
potentially fatal → get court order; emergent →
proceed w/ tx; one parent agrees → proceed w/ tx
Kid w/ imaginary friends: completely normal
Teen w/ behavioral changes: get urine tox screen

Mal de ojo: Mediterranean “evil eye”

Localized amnesia: memory loss surrounding a
discrete period of time

Pt requests medical records: give it to them

Sangue dormido: Portugese d/o with numbness,
tremors, paralysis, convulsions, stroke, heart attack

Selective amnesia: inability to recall certain aspects
of an event

Relative requests dx not be revealed to pt: ask
relative about reasoning, since pt has right to know

Dhat: anxiety and hypochondriasis regarding semen
discharge

–––––––––– PSYCHOPHARMACOLOGY ––––––––––
Placebos: 33% efficacy for depression

Windigo: Native American d/o regarding possession
by a demon that murders and eats human flesh
Autoscopic psychosis: VH of transparent phantom of
one’s own body, aka doppleganger

Antidepressants: 70% efficacy for depression
ECT: 75% efficacy for depression
NE: synthesized in locus ceruleus

Capgras syndrome: delusion that friends/family have
been replaced by identical impostors
Lycanthropy: delusion that one is a werewolf (or
another animal)

5-HT: synthesized in raphe nucleus
DA: synthesized in substantia nigra
ACh: synthesized in nucleus accumbens

Cotard syndrome: delusion that one has lost
everything, including one’s internal organs

–––––––––––––––––– ETHICS ––––––––––––––––––
Depressed pt: ask about suicidal ideation

Family disagrees w/ advance directives: discuss
situation w/ family, if unresolved after meeting →
call ethics committee
Pregnant woman vs. fetus: woman has right to
refuse tx, even if it puts the fetus at risk

OBSTETRICS/GYNECOLOGY

OB 1 – Pregnancy

Terminology

Embryo: 0-8 wk
Fetus: 8 wk – delivery
Infant: delivery – 1 yr

GXPTPAL

Gravidity: number of times a woman’s been pregnant
Parity: number of times a woman’s delivered
T: >37 wk
P: 20-36 wk
A: <20 wk
L: living births
Grand multip: parity ≥5

Pregnancy signs

Chadwick sign: bluish discoloration of vagina/cervix
Goodell sign: softening of cervix
Hegar/Ladin sign: softening of uterus

Fetal dating

Naegele’s rule: EDC = LMP + 1y – 3m + 7d
U/S indications: not mandatory, but useful for uncertain gestational age, size/date discrepancies, multiple gestations, etc.
Physical landmarks: pubic symphysis at 12 wk, umbilicus at 20 wk

Physiologic changes

CV: hyperdynamic (↑CO), hypotensive (↓SVR → ↓BP) state
Pulmonary: ↑TV creates ↑CO2 gradient w/ fetus for gas exchange
GI: ↑E/P/hCG results in morning sickness, hyperemesis gravidarum if severe
Renal: ↑GFR by 50%, ↑risk of pyelonephritis
Blood: hypercoagulable, dilutional anemia (due to ↑↑plasma despite ↑RBC)
Endocrine: ↑E/P, ↑hCG, ↑hPL, ↑TBG
hCG: doubles every 48 hrs until peaking at 10-12 wks, then declines to steady state at 15 wk
hPL: maintains fetal nutrition (lipolysis → ↑FFA), blocks insulin (can cause GDM)
MSK: hyperlordosis (due to lower center of gravity)
Skin: ↑E causes spider angiomata and palmar erythema, ↑MSH causes linea nigra and melasma/chloasma

Nutrition

↑: kcal, folate (neural tube defects), iron (RBC), vitamin C, Ω3 fatty acids
↓: vitamin A (teratogenic), calcium (need more but chelates iron)

Common pregnancy
complaints

Complaint
Lower back pain
Constipation
Braxton-Hicks contractions
Dehydration
Edema
GERD
Hemorrhoids
PICA
Round ligament pain
Urinary frequency
Varicose veins
Hyperemesis gravidarum

Prenatal labs

Management
d/t hyperlordosis; Tx mild exercise + stretching, Tylenol
Tx fluids, exercise, fiber supplement
irregular contractions w/o cervical dilatation, normal
Tx PO fluids
Tx leg elevation + r/o preeclampsia
Tx antacids, PPIs or H2-blockers if severe
Tx topical steroids, fiber, stool softeners, sitz baths
eating inedible items; Tx encourage immediate cessation + toxicology
consult
shooting pelvic pain due to ligament stretching; Tx Tylenol + warm
compresses
normal, but get UA/UCx to r/o UTI
Tx leg elevation + pressure stockings
Tx NPO ×3 days, IV fluids + antiemetics; if severe → doxylamine + vitamin B6

Prenatal visits: first visit in first trimester, then q4wks until 28th, q2wks until 36th, and qwk until delivery
Lab test
CBC
Blood type
Rh status
HBsAg
HIV ELISA
RPR-VDRL
UA/UCx
Rubella Ab
GC/chlamydia

Management
check for anemia or hemoglobinopathies
for future transfusion
if Rh–, give RhoGAM at week 28 and postpartum (if fetus is Rh+)
if HBsAg+, get LFTs and hepatitis panel to determine acute vs. chronic infx;
Tx infant HBIG and HBV vaccine
if ELISA+, confirm w/ Western blot; if WB+ then give anti-HIV meds, elective
C/S, or IV ZDV during labor
if RPR+, confirm with FTA-ABS; if FTA-ABS+ then determine syphilis stage and
Tx benzathine PCN G
if positive, Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN
during labor
if rubella ab–, stay away from sick ppl and vaccinate postpartum
if GC/CT+, Tx ceftriaxone + azithromycin

Antenatal assessment NST (non-stress test): continuous fetal monitoring (toco + HR), look for reactivity (2×15×15)
BPP (biophysical profile): U/S evaluation on a 10 pt scale
BPP >8: normal
BPP =6: get CST
BPP <4: deliver
CST/OCT (ctx stress test/oxytocin challenge test): give oxytocin, look for 3 ctx/10 min w/o late decels

OB 2 – Pregnancy × Early Complications

Ectopic pregnancy

Ectopic pregnancy: Implantation outside uterine cavity, MC site is fallopian tube
Heterotopic pregnancy: one normal + one ectopic pregnancy
Sx: unilateral abd pain ± vaginal bleeding
Risk factors: prior ectopic, tubal scarring (STIs or PID), IUD, assisted fertility, endometriosis
Incidence: 1:100 pregnancies
Management:
Ectopic pregnancy?
screen ↑β-HCG
confirm TV U/S
yes

r/o ectopic

ruptured

not ruptured

stabilize w/ IVF
ex lap

if no definitive dx,
f/u serial β-HCG Q 48hrs

Tx MTX

if β-HCG doesn’t fall 15%
in 4-7 days, repeat MTX

1st trimester SAB

Sx: vaginal bleeding, abdominal pain, cramping, ↓sx of pregnancy
Causes: abnormal chromosomes (MCC)
Management:
1st trimester abortion?
labs: β-HCG, CBC, type/cross
pelvic exam to r/o other sources of bleed
stabilize w/ IVF
complete abortion

incomplete abortion
inevitable abortion
missed abortion

f/u for recurrent bleed or signs of infx

2nd trimester SAB

Tx D+C, prostaglandins,
or allow to finish on its own

threatened abortion

f/u for continued bleeding
give RhoGAM if Rh-

Sx: vaginal bleeding, abdominal pain, cramping, ↓sx of pregnancy
Causes: anatomic defects (MCC), infx, maternal disease, trauma, fetotoxic agents
Management:
2nd trimester abortion?
r/o PTL + incompetent cervix
Tx D+E, high-dose oxytocin,
or prostaglandins

Incompetent cervix

Incompetent cervix: painless dilation and cervical effacement before term, usually 2nd trimester
Causes: surgery or trauma (MCC), uterine abnormalities, DES exposure
Management:
Incompetent cervix?
Dx dilated cervix on PE,
or hourglass membranes on U/S
viable (>24 wks)
Tx betamethasone +
strict bed rest

previable (<24 wks)
emergent cerclage

if cerclage fails,
transabdominal cerclage
Hx of incompetent cervix: offer elective prophylactic cerclage at 12-14 wks
Cerclage: surgical closure of cervix at external os (McDonald) or internal os (Shirokar)
Complications: rupture of membranes, PTL, infx

OB 2 – Pregnancy × Early Complications

Recurrent preg loss

Recurrent pregnancy loss: 3+ consecutive SABs
Causes: APA syndrome (↑clots) and luteal phase defect (↓P) are MCC
Management: look for etiology, then Tx accordingly
Etiology
Abnormal chromosomes
Anatomy (e.g. bicornuate uterus)
APA syndrome
Luteal phase defect
Infection
Hypothyroidism

Dx
karyotype of both parents
screen w/ HSG (hysterosalpingogram),
confirm w/ hysteroscopic or ex lap
RPR-VDRL, lupus anticoagulant, ANA,
coag panel, anticardiolipin antibody
↓progesterone levels
cx cervix, vagina, endometrium
↑TSH, ↓T4

Tx
IVF or preimplantation dx
surgery (may not be correctable)
low-dose aspirin
progesterone
abx
Synthroid

OB 3 – Prenatal Diseases

Epidemiology
Dx+
Dx–

Disease+
TP
FN (type II)

Disease–
FP (type I)
TN

Sensitivity: TP / (TP+FN)
Specificity: TN / (TN+FP)
PPV: TP / (TP+FP)
NPV: TN / (TN+FN)
Cystic fibrosis

Cystic fibrosis: AR ΔCFTR (Cl- channel) → thicker mucus →

Sickle-cell disease

Sickle-cell disease: AR ΔHbE6V (hemoglobin β-chain) → hemolytic anemia, vasoocclusive crises, autosplenic infarction
Dx: screen mom w/ Hb electrophoresis, then dad if positive, then confirm w/ fetal dx
Epidemiology: heterozygote advantage – allows for resistance to P. vivax malaria in Africans

Tay-Sachs disease

Tay-Sachs disease: AR ΔHexA → ganglioside accumulation → progressive neurodegeneration
developmental delay
“cherry red spot” on macula
onion-skin lysosomes
Dx: screen all high-risk carriers, confirm w/ fetal dx
Epidemiology: founder effect – high frequency in Ashkenazi Jews due to small ancestral group

β-thalassemia

β-thalassemia: AR deletion of β-chain → ↑α:β ratio
Dx: screen w/ CBC, if microcytic anemia then confirm w/ Hb electrophoresis

α-thalassemia

α-thalassemia: cumulative deletions of α-chain → ↓α:β ratio
Silent carrier: 1-2 gene deletion; asx
HbH disease: 3 gene deletion → ↑HbH (β4) → severe microcytic anemia
Barts disease: 4 gene deletion → ↑HbBarts (γ4) → hydrops fetalis (IUFD)
Dx: screen w/ CBC, if microcytic anemia then confirm w/ Hb electrophoresis

Chromosomal defects

chronic bronchitis
recurrent Pseudomonas pneumonia
bronchiectasis
pancreatic insufficiency
male infertility
ADEK deficiency
meconium ileus
Dx: screen mom and dad for ΔF508/G542X, confirm w/ fetal dx
Tx: N-acetylcysteine loosens mucus plugs, pancreatic enzyme replacement

Disease
Down syndrome

Δ
trisomy 21

Sx
flat facies, epicanthal folds, simian crease,
Alzheimer by 40 y/o, MR

Edwards syndrome

trisomy 18

Patau syndrome

trisomy 13

Turner syndrome

45/X

Klinefelter syndrome

47/XXY

Cri-du-chat syndrome

5p-

Williams syndrome

7q-

DiGeorge & velocardiofacial syndrome

22q11

micrognathia, clenched hands, rocker-bottom
feet, MR; death by 1 y/o
cleft lip/Palate, holoProsencephaly, Polydactyly,
rocker-bottom feet, MR; death by 1 y/o
Coarctation of aorta
Lymphedema
Ovarian dysgenesis
Webbed neck (cystic hygroma)
Nipples spread (shield chest)
Short stature
female traits on a man (long legs, gyno, highpitched voice, female habitus, etc.)
microcephaly, cardiac problems, high-pitched
meowing, epicanthal folds, MR
Elfin facies, Extreme friendliness w/ strangers,
well-developed English, MR
Cleft palate
Abnormal facies
Thymic aplasia
Cardiac defects
Hypocalcemia

Dx
quad screen at 15-20 wk (↑β-HCG, ↑inhibin,
↓αFP, ↓estriol) + nuchal translucency on
U/S ; MCC abnormal value is error in dating
triple screen (↓β-HCG, ↓αFP, ↓estriol)
found on routine U/S
---

---------

OB 3 – Prenatal Diseases

Embryogenesis

Week 0
Week 1
Week 2
Week 3
Week 3-8
Week 4
Week 8

fertilization, cell division (blastula → morula → blastocyst)
implantation + β-HCG secretion
bilaminar disc (epiblast + hypoblast)
gastrulation (3 tissues), neurulation
organogenesis (most susceptible to teratogens)
heart (4 chambers), limbs (4 limbs)
fetus

Endoderm: becomes GI and respiratory systems
Mesoderm: becomes CV, MSK, GU systems
Ectoderm: becomes CNS, skin, etc.
Neural tube defects

NTDs: ↓folate → defective neural tube closure at 4 wk
Etiology: low dietary folate, Δmethyl-THF reductase
Myelomeningocele: Dx screen ↑αFP, confirm U/S shows lemon sign (concave frontal bones) and banana sign (flat caudal cerebellum); Tx surgery in utero
Spina bifida occulta: asx lumbar tuft of hair

Cardiac defects

Echogenic intracardiac focus (EIF): calcification of papillary muscle on U/S, usually insignificant
L→R shunts: all present with murmurs + late-onset cyanosis due to Eisenmenger syndrome (pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur, fixed S2, and frequent colds
VSD: presents as pansystolic harsh-sounding murmur with failure to thrive
PDA: presents with machinery-like murmur, often seen with Congenital Rubella Syndrome
R→L shunts: all present with murmurs + early-onset cyanosis
Tetralogy of Fallot: presents as cyanosis and clubbing in a 5 y/o child who squats for relief; Px determined by degree of pulmonary stenosis
Transposition of great vessels: presents as life-threatening cyanosis in a newborn
Dx: fetal echocardiogram
Tx: surgery, indomethacin for PDA

Potter syndrome

Potter syndrome: failure of mesonephros and metanephros to meet at ureteropelvic junction → bilateral renal agenesis → anhydramnios (no amniotic fluid)
→ pulmonary hypoplasia + limb contractures
Dx: U/S shows anhydramnios or oligohydramnios (AFI <5)
Tx: none available

Prenatal diagnosis

Prenatal sampling: amniocentesis, chorionic blood sampling (CVS), percutaneous umbilical blood sampling (PUBS)
Method
Amniocentesis
CVS
PUBS

Technique
insert needle transabdominally into uterus
and withdraw amniotic fluid
insert catheter into intrauterine cavity and
aspirate chorionic villi from placenta
insert needle transabdominally into uterus
and withdraw umbilical cord blood

Prenatal imaging: level-I U/S at 18-22 wk is standard of care

Advantages/disadvantages
+ 1:200 risk of PTL, PROM, injury
– 2nd trimester
+ 1st trimester
– >1:200 risk of PTL, PROM, injury
+ rapid karyotype analysis
– may take maternal blood

OB 4 – L&D

Labor

Labor: ctx + cervical dilation
Timing:
preterm
<37 wks
term
37-42 wks
postterm >42 wks
Prodromal (false) labor: irregular Braxton-Hicks ctx w/o cervical dilation

3 Ps of labor

3 Ps of labor: Power, Passenger, Passage determine progression of labor
Power: ctx frequency + intensity + duration
Adequate ctx: 3-5 ctx/10 min + >200 MVU
Passenger: fetus
Fetal lie: longitudinal, transverse, or oblique
Fetal presentation: first part in vagina; cephalic/vertex or breech
Fetal position: depends on occiput position…
Leopold maneuver: used to determine presentation, position, engagement
fetal position
Passage: pelvis type
Gynecoid: MC type, best px
Platypelloid: seen in Asians, can lead to deep transverse arrest

pelvis types
Induction of labor

Induction of labor: attempt to begin labor in nonlaboring pt
Methods: prostaglandins (Cytotec), oxytocin (Pitocin), or amniotomy (AROM)
Indications: postterm (>42 wk), PROM (≥34 wk), preeclampsia, IUGR, nonreassuring fetal testing
PGE contraindications: maternal asthma or glaucoma, >1 prior C/S
IOL success: vaginal delivery; progress measured by Bishop score
Augmentation of labor: increasing ctx in already laboring pt
Bishop score: cervical exam w/ 5 components – dilation, effacement, station, position, consistency
Dilation: diameter of internal os (range 0-10 cm)
Effacement: thinning out of cervix (range 0-100%)
Station: 0 station (midpoint) is ischial spines, measure in cm above/below (range -5 to +5 cm)
Position: advancement of cervix as labor progresses (range posterior to anterior)
Consistency: softening of cervix as labor progresses (Hegar or Ladin sign)
Progress of labor:

Bishop score
0-4
5-9
10+

Management
cytotec
pitocin
expectant management

OB 4 – L&D
Stages of labor

Stage 1: onset to complete dilation (10 cm)
Phases: latent phase is 0-4 cm and slow, active phase is >4 cm and rapid
Active phase arrest: no change in dilation or station for 2 hrs, indicated for C/S
Stage 2: dilation to delivery
Prolonged stage 2: >2 hrs if nulliparous, >1 hr if multiparous (add 1 hr w/ epidural)
Ritgen maneuver: pressure on fetal head to help shoulders pass through
Stage 3: delivery to placenta delivery (10 min)
Retained placenta: stage 3 lasts >30 min; Tx manual extraction + abx
Signs of placental separation: gush of blood, lengthening of cord, change in shape of uterine fundus
Too much traction: ↑risk of cord avulsion, uterine inversion
Stage 4: placenta delivery to 2 hrs postpartum
Episiotomy: incision in perineum to facilitate delivery, two types – median and mediolateral
Lamaze method: classes to teach natural birthing techniques (relaxation, breathing, etc.)

Cardinal movements

Cardinal movements:

1. Engagement (0 station)
2. Flexion
3. Descent
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion

Operative vaginal
delivery

Operative vaginal delivery: usage of forceps or vacuum to deliver fetus
Forceps: ↑risk of CN VII palsy
Vacuum: ↑risk of cephalohematoma and shoulder dystocia
Conditions: experienced operator (most important), full dilation, ruptured membranes, engaged w/ >2 station, knowledge of fetal position, anesthesia, empty
bladder, no evidence of cephalopelvic distortion

Perineal lacerations

1st degree: superficial tear
2nd degree: extends into perineal body
3rd degree: extends into anal sphincter
4th degree: extends into rectum

Caesarian section

C/S: delivery by uterine incision
Indications: MC primary is failure to progress in labor, MC overall is prior C/S
VBAC: vaginal birth after C/S; only true c/i is previous vertical (classical) C/S
TOLAC: trial of labor after C/S, MC complication is rupture of uterine scar
Rupture sx: sudden onset severe abd pain ± vaginal bleed, subjective “pop” sensation

Anesthesia

Pudendal block: indicated for operative vaginal delivery, direct needle towards jxn of ischial spine and sacrospinous ligament
Local anesthesia: indicated for episiotomy and laceration repairs
Epidural anesthesia: more commonly used during labor, can lengthen stage 2
Spinal anesthesia: more commonly used during C/S

OB 4 – L&D
Fetal HR

Fetal HR: baseline + variability + periodic changes
Baseline HR: normal is 110-160 bpm; tachy >160 for 10 min, brady <110 for 10 min
Variability: determined by SNS-PSNS interplay; ↑↑ and ↓ variability is bad sign

Periodic changes

Early decel: along w/ ctx, due to head compression → CN X stimulation
Variable decel: no relation w/ ctx, due to cord compression (possibly oligohydramnios)
Late decel: happens after ctx, due to uteroplacental insufficiency
Prolonged decel: >15 bpm for 2-10 min
Accelerations: reactive if 2× (15 bpm × 15 sec) / 20 min
Sinusoidal pattern: sine-wave shaped, due to fetal anemia (e.g. fetal vx rupture)

Category 1 (best): FHR 110-160, moderate variability, no late/var decels
Category 2: everything else
Category 3 (worst): absent variability + recurrent late/var decels, bradycardia, sinusoidal pattern
FHR tracing management:
obtain FHR pattern
category 1

category 2

routine mgmt

evaluation and
surveillance

category 3
resuscitative measures,
prepare for delivery

if no accels or variability,
resuscitative measures
if not improved, prompt delivery
Resuscitative measures: give O2 + change maternal position

OB 5 – Antepartum Hemorrhage
Terminology

Placenta previa: placenta develops over internal os
Placenta accreta: placenta adheres to uterine wall
Placenta increta: placenta invades into myometrium
Placenta percreta: placenta penetrates through to uterine serosa
Circumvallate placenta: membranes form dense ring around placenta
Vasa previa: fetal vessels develop over internal os
Velamentous placenta: fetal vessels insert between amnion and chorion
Succenturiate placenta: extra lobe of placenta ± blood fetal vessels between two lobes
Abruptio placentae: premature separation of placenta from uterine wall

Antepartum
hemorrhage

Obstetric causes: placenta previa (20%), abruptio placentae (30%), fetal vessel rupture, uterine rupture
Non-obstetric causes: cervical/vaginal lacerations, hemorrhoids, infx, neoplasms
DDx: present as spotting (not frank bleeding), no contractions or abdominal pain
Px: simple management, good outcomes (vs. obstetric causes)

Placenta previa

Placenta previa: placenta develops over internal os
Subtypes: complete, partial, marginal
Sx: painless vaginal bleeding + risk of hemorrhagic shock
Previa management:
Placenta previa?
Dx transabdominal or translabial U/S
(vaginal exam is c/i due to hemorrhage)
if prior to 3rd trimester,
repeat U/S to see if it’s resolved
labs: H+H, type/cross
give RhoGAM if Rhunstable

stable

stabilize w/ IVF
emergent C/S

expectant management
tocolytics + betamethasone (<34 wk)

Placenta accreta

Placenta accreta: placenta adheres to uterine wall
Placenta increta: placenta invades into myometrium
Placenta percreta: placenta penetrates through to uterine serosa
Sx: usually asx during pregnancy, presents as vaginal bleed + inability to separate placenta after delivery
Tx: puerperal hysterectomy

Abruptio placentae

Abruptio placentae: premature separation of placenta from uterine wall
Subtypes: revealed/external (80%), concealed (20%)
Sx: 3rd trimester vaginal bleeding + severe abd pain, strong ctx
Complications: hemorrhagic shock, DIC, premature delivery, uterine tetany, fetal death (35%)
Risk factors: HTN (#1), trauma, previous abruption, smoking, cocaine
Abruption management:
Abruptio placentae?
Dx clinical presentation
stabilize w/ IVF
labs: H+H, type/cross
RhoGAM if Rhbetamethasone (<34 wk)
delivery (unstable or FHR nonreassuring)

Uterine rupture

Uterine rupture: rupture of uterus associated w/ prior uterine scar (C/S or other surgery)
Sx: sudden onset severe abd pain ± vaginal bleeding, subjective “pop” sensation
Tx: emergent ex lap and delivery

Fetal vessel rupture

Vessel rupture causes: velamentous placenta, succenturiate placenta, vasa previa
Vasa previa: fetal vessels develop over internal os
Velamentous placenta: fetal vessels insert between amnion and chorion
Succenturiate placenta: extra lobe of placenta ± blood fetal vessels between two lobes
Sx: vaginal bleeding + sinusoidal pattern on FHR [tachy → brady → sinusoidal]
Dx: Apt test (examine blood for fetal/nucleated RBCs, pink indicates fetal blood)
Tx: emergent C/S

OB 6 – L&D × Complications
Preterm labor

PTL: labor <37 wks
PTL management: tocolytics + betamethasone for lung maturity
PTD: delivery <37 wks, occurs in 10% of pregnancies
Complications: RDS, intraventricular hemorrhage, necrotizing enterocolitis

Tocolysis

Premature rupture
of membranes

Tocolysis: delaying premature labor for 48 hrs, to allow for fetal lung maturity w/ betamethasone
Tocolytic
Nifedipine
MgSO4

MOA
Ca-channel blocker (1st line)
competes w/ Ca2+ for Ca-channels

Terbutaline
Ritodrine
Indomethacin

β2-agonist
β2-agonist
NSAID (blocks PGF2α production)

Side-effects
headache, flushing, dizziness
headache, flushing, dizziness, pulmonary edema,
cardiac arrest (high dose)
headache, tachycardia, anxiety
headache, tachycardia, anxiety
fetal PDA closure, pulmonary hypertension, renal
failure → oligohydramnios

ROM: disruption of the amniotic sac
ROM Dx: pool test (visualize fluid pooling)
nitrazine test (alkaline pH turns nitrazine paper blue)
fern test (see ferning under scope)
amnio dye/tampon test (inject dilute indigo-carmine dye into amniotic sac and look for leakage into tampon)
PROM: rupture >1 hr before labor, ↑risk of infx
Risk factors: smoking, chorioamnionitis (Tx IV abx + delivery), ↑latency w/ ↓GA
PROM management: depends on GA…
≥34 wk: delivery
24-33 wk: expectant management, tocolytics + betamethasone
<24 wk: pt counseling, expectant management or induced labor
Prolonged PROM: rupture >18 hrs before labor, ↑↑risk of infx
PPROM: rupture >1 hr before labor, preterm

Cephalopelvic
disproportion

CPD: fetal head is too big to pass through maternal pelvis; MCC active phase prolongation
CPD management: suspected CPD → trial of labor anyways, if CPD confirmed by CT or U/S → C/S

Breech presentation

Breech presentation: fetus presents w/ buttocks first, 2%
Complete breech: thighs and legs flexed
Frank breech: thighs flexed, legs straight
Incomplete (footling) breech: feet first
Breech management: Dx Leopold maneuvers, vaginal exam, or U/S →
Tx external version to vertex, C/S, or breech delivery (rare)
Complications of breech delivery: cord prolapse, head entrapment, neurologic injury

Malpresentation of
vertex

Malpresentation: includes face, brow, compound, persistent OP and OT
Face presentation: face first
Brow presentation: orbital ridge first
Compound presentation: vertex/breech + limb, high-risk for cord prolapse
Persistent OP: facing anterior, may require external version to OA
Persistent OT: facing sideways, high-risk of deep transverse arrest w/ platypelloid pelvis type
Malpresentation management: vaginal delivery but needs close monitoring

Fetal bradycardia

Bradycardia: <110 bpm for >10 min (2-10 min is prolonged decel)
Preuterine causes: maternal hypotension or hypoxia (seizure, PE, AFE, MI, etc.)
Uteroplacental causes: placental abruption, infx, hemorrhage
Postplacental causes: cord prolapse, cord compression, fetal vx rupture
Bradycardia management: place in LLD/RLD → start 2L O2 NC → look for cause → Tx appropriately

OB 6 – L&D × Complications
Shoulder dystocia

Shoulder dystocia: anterior shoulder gets caught behind pubic symphysis
Complications: fetal humerus/clavicle fx, brachial plexus injury, phrenic nerve palsy, hypoxia → brain injury → death
Risk factors: previous dystocia, ↑fetal size (macrosomia, diabetes, maternal obesity, postterm delivery), prolonged stage 2
Dystocia management: special maneuvers → if failed, cut clavicle or pubic symphysis → if failed, Zavanelli maneuver
Suprapubic pressure: add pressure to dislodge anterior shoulder
McRoberts maneuver: sharp flexion of maternal hips increases pelvic AP diameter
Rubin maneuver: apply pressure behind either shoulder to decrease fetal diameter
Wood corkscrew: apply pressure behind posterior shoulder to rotate infant
Posterior arm delivery: deliver posterior arm first, then rotate infant to for anterior shoulder
Zavanelli maneuver: push head back in + perform C/S

Hypotension

Hypotension: maternal BP <80/40; causes include regional anesthesia, hemorrhage, vasovagal events, AFE, anaphylaxis
Hypotension management: start IV fluids + ephedrine, then Tx cause (e.g. Benadryl for anaphylaxis)
AFE: high mortality rate, Dx fetal cells in pulmonary vasculature at autopsy

Seizure

Seizure vs. syncope: check for postictal disorientation (found in sz but not syncope)
Seizure management: Tx IV or IM MgSO4, get PEII panel, consult neuro if negative for eclampsia

OB 7 – Pregnancy × Complications
Fetal growth

SGA: <10th percentile, either symmetric or asymmetric
LGA: >90th percentile
Macrosomia: >4500 g
LBW: <2500 g

SGA & LBW

SGA: <10th percentile, two types – IUGR and ↓growth potential
↓growth potential: congenital abnormalities (chromosomal d/o), infx (CMV, rubella), teratogens (EtOH, cigs)
MCC: cigarettes
IUGR: intrauterine growth restriction, unable to achieve potential size despite good growth potential
Etiology: maternal systemic dz → ↓placental perfusion → IUGR
SGA management: confirm accuracy of dating → Dx serial U/S + umbilical artery doppler → check for underlying etiology
Serial U/S results: low growth potential stays small, IUGR progressively falls off growth curve
Doppler results: low or absent diastolic flow indicates ↓placental resistance, reversed diastolic flow is high-risk for IUFD

LGA & macrosomia

LGA: >90th percentile
Risk factors: diabetes, maternal obesity, postterm pregnancy, multiparity, advanced maternal age
Complications: birth trauma, hypoglycemia, jaundice, ↓Apgar scores, childhood tumors, shoulder dystocia
LGA management: confirm accuracy of dating → Dx U/S → consider IOL prior to macrosomic status

Amniotic fluid

Amniotic fluid physiology: produced by fetal kidneys, resorbed by fetal swallowing
Amniotic fluid index: measure of fluid in quadrants via U/S; AFI <5 is oligo, AFI >20 is poly

Oligohydramnios

Oligohydramnios: AFI <5, FHR shows variable decels
Causes: ROM (MCC), ↓placental perfusion, ↓fetal fluid production, renal malformations (e.g. Potter syndrome)
Complications: pulmonary hypoplasia, limb contractures, cord compression → fetal asphyxiation → death
Oligo management:
Oligohydramnios?
Dx AFI <5
preterm

term/postterm

ROM

congenital anomaly

expectant
management

deliver

induce labor

compatible
w/ life

incompatible
w/ life

genetic counseling

meconium in
amniotic fluid
amnioinfusion

deliver

Polyhydramnios

Polyhydramnios: AFI >20
Causes: congenital abnormalities, diabetes, TTTS, hydrops fetalis
Complications: cord prolapse
Poly management: careful verification of presentation, observe for cord prolapse

Erythroblastosis
fetalis

Erythroblastosis fetalis: Rh– woman w/ Rh+ fetus → anti-Rh IgG crosses placenta → hemolytic anemia → hydrops fetalis (edema, ascites, heart failure)
Rh– prevalence: 15% in caucasians, lower in other races
Rh– management:
Rh– woman

Intrauterine fetal
demise

unsensitized

sensitized

give RhoGAM at week 28 and
postpartum (if fetus is Rh+)

follow closely w/ serial U/S
and amniocentesis (for bilirubin
levels indicating hemolysis)

IUFD: fetal death in utero
Causes: usually unknown, often chronic placental insufficiency or “cord accident”
Retained IUFD: high-risk of DIC if fetus is left >3 wks
IUFD management: Dx U/S → Tx delivery (not emergent) → f/u autopsy to search for cause

OB 7 – Pregnancy × Complications
Postterm pregnancy

Postterm pregnancy: gestational age >42 wks
Complications: macrosomia, oligohydramnios, meconium aspiration, IUFD, dysmaturity syndrome
Dysmaturity syndrome: chronic IUGR from uteroplacental insufficiency
MCC: inaccurate dating
Management: get accurate dating → induce labor, increased fetal surveillance

Cleavage

Cleavage: chorion separates day 4, amnion separates day 8
Di-Di twins: cleavage b/t day 1-3
Mo-Di twins: cleavage b/t day 4-8, at risk for TTTS
Mo-Mo twins: cleavage b/t day 8-13
Siamese twins: cleavage b/t day 13-15

Multiple gestations

Multiple gestations: two types – monozygotic and dizygotic
Monozygotic twins: 1 sperm + 1 ova → identical DNA; no predisposing factors
Dizygotic twins: 2 sperm + 2 ova → separate DNA; ↑ in Africans, IVF, clomiphene citrate
Complications: PTL, placenta previa, postpartum hemorrhage, preeclampsia, cord prolapse, malpresentation, GDM, incompetent cervix
Management:
Siamese twins → C/S
Mo-Mo twins → C/S
vertex/vertex twins → vaginal delivery
vertex/nonvertex twins → vaginal delivery or C/S
nonvertex/nonvertex twins → C/S
triplets and above → C/S ± selective reduction

TTTS

TTTS: unequal blood flow in shared placenta of Mo-Di twins → small/anemic twin + large/polycythemic twin
TTTS management: serial U/S Q 2 wks in all Mo-Di twins → Tx serial amnioreduction in larger twin

OB 8 – Pregnancy × HTN
Gestational HTN

Gestational HTN: HTN (>140/90) without proteinuria (<300 mg/day)
GHTN management: labetalol, nifedipine

Preeclampsia

Preeclampsia: HTN (>140/90) + proteinuria (>300 mg/day) + edema
Etiology: multiorgan vasospasm → brain (severe HA, seizure, stroke)
liver (liver damage, RUQ pain, n/v)
kidneys (renal failure, proteinuria, edema)
placenta (IUGR, IUFD)
small vx (thrombocytopenia, DIC)
Risk factors: nulliparity, multiple gestation, chronic HTN, family hx
Preeclampsia management: Dx PEII panel (labs + 24hr urine protein) → Tx control HTN (labetalol, nifedipine) + seizure ppx (MgSO4 – 4g load + 2g/hr) +
delivery if term or unstable
Severe preeclampsia: severe HTN (>160/110), proteinuria (>5 g/day or 3+ dipstick), presence of other complications; must deliver (IOL > C/S)
First-trimester preeclampsia: consider hydatidiform moles

HELLP syndrome

HELLP syndrome: Hemolysis (schistocytes, ↑LDH, ↑bilirubin), Elevated LFTs, Low Platelets in preeclamptic pts

Acute Fatty Liver of
Pregnancy

AFLP: fatty liver + HTN (>140/90) ± proteinuria
AFLP management: supportive care, liver txp if necessary

Eclampsia

Eclampsia: tonic-clonic (grand mal) seizures in preeclamptic pts
Seizure timing: ¼ before labor, ½ during, ¼ afterwards
Eclampsia management: control HTN (hydralazine) + seizure ppx (MgSO4) + delivery after pt is stabilized
MgSO4 side-effects: pulmonary edema
MgSO4 overdose: DTR depression (first sign), respiratory depression, coma, cardiac arrest; Tx calcium gluconate

Chronic HTN

Chronic HTN: HTN occuring before conception, before 20 wks GA, or lasting >6 wks postpartum
Chronic HTN management: control HTN (labetalol, nifedipine) + baseline EKG + 24hr urine protein
Superimposed preeclampsia: 24hr urine protein >300 mg in previously HTN pt

OB 9 – Pregnancy × DM
Pregestational DM

Pregestational DM: diabetes diagnosed prior to pregnancy

GDM

GDM pathophysiology: ↑hPL/E/P → insulin antagonism
Epidemiology: 5-8% incidence, ↑risk of developing T2DM later in life
Risk factors: prior GDM, family hx, obesity, race (non-whites)
Maternal complications: polyhydramnios, preeclampsia, miscarriage, etc.
Fetal complications: macrosomia → shoulder dystocia, hypOcalcemia, hypOglycemia, polycythemia → hyperviscosity
Fetal malformations: CV defects, NTDs, caudal regression syndrome, situs inversus, duplex ureter, IUGR
GDM Dx: screen w/ GCT at week 26-28 → if ≥140 mg/dL, confirm w/ OGTT
GDM management: tight glucose control w/ diet (1st line), insulin (2nd line), glyburide (3rd line); induce at 39-40 wk, C/S if macrosomic
Ideal glucose: between 70-110 mg/dL
Ideal HbA1c: less than 6.5%

White classification
of diabetes

Class
A1
A2
B
C
D
F
R
RF
H
T

Definition
GDM, diet controlled
GDM, insulin controlled
onset >20 y/o, duration <10 yrs
onset 10-19 y/o, duration 10-19 yrs
onset <10 y/o, duration >20 yrs
neFropathy
Retinopathy
Retinopathy + neFropathy
ischemic Heart disease
prior renal Txp

OB 10 – Pregnancy × Infx
UTIs

UTI: presents as dysuria, urinary frequency/urgency, suprapubic tenderness
Etiology: E. coli (MCC), S. saprophyticus (#2), Enterococcus (#3), other GNB
Complications: septic shock (urosepsis), ARDS
Management: Dx UA/UCx →
Tx Bactrim or Cipro (not pregnant)
Tx nitrofurantoin (pregnant)
Tx IV cephalosporins + admit (upper UTI)
Asymptomatic bacteriuria: >105 CFU on UA
Management: Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN during labor

Chorioamnionitis

Other infections

Chorioamnionitis: presents as maternal fever, uterine tenderness, ↑WBC, ↑fetal HR
Etiology: MCC are GBS and E. coli
Management: Dx amniocentesis and cx amniotic fluid → Tx IV abx + delivery
Infx
Bacterial vaginosis
(Gardnerella vaginalis)

HBV

Presentation
thin homogenous vaginal discharge + fishy
odor; complications include preterm
delivery, PPROM, and puerperal infx
subclinical illness or mono-like syndrome
Cytomegalic Inclusion Disease (CID):
“blueberry muffin” rash, hepatosplenomegaly, jaundice, thrombocytopenia, periventricular calcifications
UTIs, chorioamnionitis, endomyometritis,
neonatal sepsis (MCC)
Neonatal GC/chlamydia: conjunctivitis,
ophthalmia, otitis externa, pneumonia
---

HIV

(usually asx)

HSV

fluid-filled vesicles and irritation
Neonatal herpes: skin lesions, viral sepsis,
pneumonia, herpes encephalitis
Erythema infectiosum: slapped cheek rash
in kids
hydrops fetalis in pregnant women

CMV

GBS
GC/chlamydia

Parvovirus B19

Rubella

rash, arthritis/arthralgia, diffuse LN-opathy
Congenital Rubella Syndrome (CRS):
cataracts + PDA + deafness

Syphilis

Early congenital syphilis: rash, snuffles,
hepatosplenomegaly, jaundice, LN-opathy
Late congenital syphilis: CN VIII deafness,
saber shins, mulberry molar, Hutchinson’s
teeth, saddle nose
Congenital toxoplasmosis: fever, seizure,
chorioretinitis, microcephaly, jaundice,
head CT shows ring-enhancing lesions
chickenpox or shingles
Congenital varicella syndrome: fulminant
disseminated infx → death

Toxoplasmosis

VZV

Management
Dx “clue cells” on wet prep → Tx
PO metronidazole
postpartum GCV
no tx exists

routine screening at 35-37 wk → if
GBS+, Tx IV PCN during labor
screen mom for STDs → Tx
ceftriaxone + azithromycin
screen mom w/ HBsAg → get LFTs
and hepatitis panel to determine
acute vs. chronic infx → Tx infant
HBIG and HBV vaccine
screen mom w/ ELISA → confirm
with Western blot → Tx anti-HIV
meds, elective C-section, or IV ZDV
during labor
deliver by C/S or Tx IV ACV
Dx viral cx of herpetic lesions → Tx
IV ACV
--if suspected, Dx parvo IgM → Tx
serial U/S + fetal transfusion w/
signs of hydrops
--if mom is rubella ab negative, stay
away from sick ppl and vaccinate
postpartum
screen mom w/ RPR-VDRL →
confirm with FTA-ABS → determine
syphilis stage and Tx benzathine
PCN G
pregnant women should avoid
cats/cat litter; Dx amniocentesis →
Tx pyrimethamine + sulfadiazine
--Tx VZIG for both mom and fetus

OB 11 – Pregnancy × Complications
Hyperemesis
gravidarum

Hyperemesis gravidarum: severe n/v + intolerance of PO diet
HG management: Tx NPO ×3 days, IV fluids + antiemetics; if severe → doxylamine + vitamin B6; get β-HCG to r/o moles
Morning sickness: n/v in pregnancy is common and resolves by week 16, HG is more severe and has PO intolerance
Boerhaave syndrome: rupture of esophagus following severe emesis

Seizure d/o

Seizure d/o: both seizures and AEDs can cause fetal malformations, pregnancy is a ↑seizure state
Etiology: either ↑AED metabolism, ↓pt compliance, ↓seizure threshold, or hormonal changes
AED teratogenicity: folate antagonism → NTDs, epoxide generation (fetal hydantoin syndrome)
Sz d/o management:

Heart disease

monotherapy w/ lowest AED dose
level II U/S at 19-20 wk (look for congenital anomalies)
folate supplement
vit K supplement at 27 wk

High-risk heart dz: primary PH, Eisenmenger syndrome, severe MS or AS, Marfan syndrome
Marfan syndrome: AD Δfibrillin → elastic tissue dysfxn → MVP, aortic aneurysms (cystic medial necrosis), or aortic dissection
Heart dz management: terminate pregnancy (first line)
baseline EKG + medical stabilization
d/c teratogenic drugs (ACEI/ARBs, diuretics, coumadin)
if severe MS/AS → surgical or valvuloplasty repair (1 yr prior)
if delivering → early epidural, careful fluid monitoring, assisted vaginal delivery, abx ppx for SBE
Peripartum cardiomyopathy: dilated cardiomyopathy 2/2 pregnancy, presents w/ sx of CHF (dyspnea/orthopnea/PND)
PPCM management: Dx echo shows dilated heart w/ EF <40% → deliver if ≥34 wk, medical mgmt if <34 wk

Renal disease

CKD stages: stage 1 is GFR 90-100
stage 2 is GFR 60-89
stage 3 is GFR 30-59
stage 4 is GFR 15-29
stage 5 (ESRD) is GFR <15 or dialysis
Mild renal dz: ↑risk of preeclampsia and IUGR
Moderate/severe renal dz: ↑↑risk of preeclampsia and IUGR, and worsening of renal dz postpartum
Renal dz management: careful monitoring of renal fxn and fetal status
Renal txp management: requires ↑immunosuppressants (e.g. prednisone) dosage due to ↑risk of acute rejection

Coagulation d/o

Coagulation d/o: pregnancy is a hypercoagulable state; increased risk for SVT, DVT, PE
Virchow’s triad: ↑risk of blood clots w/ stasis, hypercoagulability (pregnancy), endothelial damage
Coagulation d/o
SVT
DVT

PE

Presentation
painful, palpable, venous cord w/ local erythema
and edema
acute onset dull leg pain, unilateral swelling, and
Homans’ sign (calf pain w/ dorsiflexion)
acute onset chest pain, dyspnea, and
hyperventilation (↓PCO2); right-sided heart failure
→ MCC maternal death

Management
Tx warm compresses + analgesics
Dx duplex U/S → Tx heparin or
Lovenox (enoxaparin); warfarin is
contraindicated in pregnancy
Dx D-dimer to r/in, V/Q scan to r/o
→ Tx heparin or Lovenox; t-PA if <3
hrs and no contraindications

Hyperthyroidism

Hyperthyroidism: Graves’ disease (MCC), toxic adenoma (#2), toxic multinodular goiter (#3)
Graves’ disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women
Thyroid storm Tx: β-blockers
Hyperthyroidism management: screen for TSIs → if elevated, Tx PTU + monitor fetus for goiter and IUGR
Infantile hyperthyroidism: maternal TSI (IgG) crosses placenta and attacks fetal thyroid gland

Hypothyroidism

Hypothyroidism: Hashimoto thyroiditis (MCC), surgical thyroidectomy (#2)
Hypothyroidism management: requires ↑Synthroid dosage

OB 11 – Pregnancy × Complications
SLE

SLE: I’M DAMN SHARP – Immunoglobulins
Serositis (pleuritis, pericarditis)
Malar rash
Hematologic d/o
Discoid rash
Arthritis
ANA
Renal d/o
Mucositis (oropharyngeal ulcers)
Photosensitivity
Neurologic d/o
Complications: ↑risk of preeclampsia, IUGR, and spontaneous abortion
1/3 rule: 1/3 of SLE improves, 1/3 stays the same, 1/3 gets worse
SLE antibodies: ANA (sensitive), anti-dsDNA or anti-smith (specific), antihistone (drug-induced lupus)
SLE management: low-dose aspirin, heparin, or corticosteroids for ppx
Lupus flare vs. preeclampsia: can present similarly, DDx w/ complement levels (SLE has ↓C3-C5)
Lupus flare management: Tx high-dose corticosteroids, cyclophosphamide if unresponsive

Neonatal lupus

Substance abuse

Neonatal lupus syndrome: maternal ag-ab complexes cross placenta and cause lupus in neonate
Congenital heart block: anti-Ro (SSA) can cross placenta and attack fetal heart → 3° heart block
Substance
Alcohol
Caffeine
Cocaine
Nicotine
Opiates (heroin,
methadone)

Presentation
Fetal Alcohol Syndrome: abnormal facies,
IUGR, MR, cardiac teratogenic effects
↑risk of SAB w/ >150 mg/day
placental abruption, MR
IUGR, placental abruption, preterm
delivery, fetal death
no teratogenic effects w/ opiate abuse; but
withdrawal can cause miscarriage, preterm
delivery, fetal death

Management
stop use
reduce to <150 mg/day
stop use
stop use
enroll in methadone program
(opiate withdrawal is worse for
fetus than chronic abuse)

OB 12 – Postpartum
Postpartum care

Postpartum period: first 6 wks after delivery
S/p SVD: issues include pain control + perineal care
S/p C/S: issues include pain control + wound care
Breastfeeding benefits: ↓childhood infx dz (maternal IgA in milk), maternal weight loss, ↓risk of future T2DM
Breastfeeding c/i: only c/i are HIV and active HBV infx

Postpartum
contraception

Postpartum intercourse: pelvic rest recommended until after 6 wks
Postpartum tubal ligation: very effective, permanent
Condom use: can be used by anyone
Diaphragms/cervical cap use: requires refitting after 6 wks, due to dilated cervix
IUD use: best placed after 6 wks, due to dilated cervix
OCP use: use progestin-only pills if breastfeeding, wait til 4-6 wks to use combined pills if not

Postpartum
hemorrhage

PPH: >500 mL s/p SVD, >1000 mL s/p C/S
PPH causes: consider placenta accreta and 4 Ts – Tone (uterine atony, MCC)
Tissue (retained POCs)
Trauma (cervical or vaginal lacerations, uterine rupture, uterine inversion)
Thrombin (bleeding d/o)
Placenta accreta: presents as vaginal bleed + inability to separate placenta after delivery; Tx puerperal hysterectomy
Uterine atony: Tx IV oxytocin + bimanual uterine massage (1st line), methylergonovine (c/i with HTN), carboprost (c/i with asthma)
Risk factors: tocolytics, increased uterine size (multifetal gestation, polyhydramnios, macrosomia)
Retained POCs: Tx manual extraction; if unsuccessful → D+C and abx
Vaginal/cervical lac: Tx surgical repair
Uterine rupture: sudden onset severe abd pain ± vaginal bleeding, subjective “pop” sensation; Tx emergent ex lap and delivery
Uterine inversion: due to pulling too hard on cord; Tx manual replacement of uterus, if unsuccessful → laparotomy
Sheehan syndrome: pituitary infarction, usually w/ PP hypovolemia; presents as acute cessation of lactation

Postpartum fever

Postpartum fever: consider endometriitis, acute mastitis, and the 5 Ws – Wind (atelectasis POD #1)
Water (UTI POD #3)
Walking (DVT POD #5)
Wound infx (POD #7+)
Wonder drug (drug-induced fever)
Disease
Endometritis
Acute mastitis
Atelectasis

UTI
Urosepsis
DVT
Wound cellulitis
Wound abscess
Wound
dehiscence

Postpartum mood
changes

Presentation
polymicrobial infx → fever, uterine tenderness,
foul-smelling lochia
breastfeeding women get Staph/Strep infection
through cracks in nipple w/ yellowish discharge
partial lung collapse

dysuria, urinary frequency + urgency
UTI + septic shock
acute onset dull leg pain, unilateral swelling, and
Homans’ sign (calf pain w/ dorsiflexion)
pain, swelling, erythema, heat at incision site
pain, swelling, erythema, heat, fluctuance at
incision site
separation of incision site → salmon-colored fluid
soaking dressings

Management
Tx clindamycin + gentamicin
Tx dicloxacillin, do not stop breastfeeding
Dx bilateral inspiratory crackles;
prevent with pulmonary toilet and
incentive spirometry
Dx UA/UCx, Tx Cipro or Bactrim
Dx UA/UCx, Tx empiric abx + IVF
Dx duplex U/S → Tx IV heparin or
Lovenox
Tx Bactrim or Keflex
Tx I+D and BID dressing change
Tx stabilize wound site, surgical
closure at a later date

Postpartum mood d/o: three types – blues (30-70%), depression (10-20%), psychosis (0.1%)
Postpartum blues: self-resolves by day 10
Postpartum depression: Tx SSRIs (sertraline)
Postpartum psychosis: admit and consult psych

GYN 1 – Lower GU

Vulva/vagina
congenital anomalies

Labial fusion: due to excess androgen exposure (MC overall) or to 21-hydroxylase deficiency (MC endogenous)
Excess androgens: Tx d/c androgens + reconstructive surgery
21-OH deficiency: Dx ↑17-OHP → Tx cortisol + reconstructive surgery
Imperforate hymen: presents as primary amenorrhea + cyclic abdominal pain; Dx mucocolpos/hematocolpos → Tx surgery
Transverse vaginal septum: presents as primary amenorrhea + cyclic abdominal pain; Dx short vagina that ends in blind pouch → Tx surgery
Imperforate hymen vs. septum: presence of hymenal ring indicates transverse vaginal septum
Vaginal atresia: failure of lower vagina to develop, presents as primary amenorrhea + cyclic abdominal pain; Dx U/S or MRI → Tx surgery (pull-through)
Vaginal agenesis: aka MRKH syndrome, absence of vagina w/ partial uterus and tubes; Tx surgery (create neovagina w/ McIndoe procedure)

Vulvar/vaginal
epithelial disorders

Epithelial d/o management: Dx palpation + colpo + bx to r/o cancer; Tx (see below)
Disorder
Lichen sclerosis
Atopic eczema (squamous
cell hyperplasia)
Lichen simplex chronicus
Lichen planus
Vulvar psoriasis
Vaginal adenosis
Atrophic vaginitis

Presentation
vaginal thinning and atrophy in postmenopausal
women, 10% associated w/ cancer
chronic irritation → pruritis w/ hyperkeratotic
changes
chronic irritation → pruritis w/ reactive changes
shiny purple papules ± vaginal adesions
silvery scaling plaques, Auspitz sign (bleeding when
plaques are removed)
red spots/patches in upper 1/3 vagina due to DES
exposure in utero; precursor for clear cell adeno
vaginal dryness ± bleeding in postmenopausal
women

Tx
topical steroids
topical steroids
topical steroids
steroid suppository +
surgery for adhesions
topical steroids or UV
light
close f/u
topical estrogen

Vulvar/vaginal cysts

Epidermal inclusion cysts: MC vulvar cyst, due to blocked hair follicle; Tx I+D or excision if infected
Sebaceous cysts: due to blocked sebaceous gland, often multiple and asx; Tx I+D if infected
Apocrine cysts: due to blocked apocrine sweat glands; found only on groin and axillary region
Hidradenitis suppurativa: superinfx of apocrine cysts → abscess formation; Tx I+D or excision
Fox-Fordyce disease: multiple pruritic apocrine cysts
Skene cysts: appear at 12-o’clock
Bartholin cysts/abscess: appear at 4- and 8-o’clock
Bartholin management: usually self-resolves; if >40 y/o → bx to r/o cancer; if large/symptomatic → I+D w/ Word catheter or marsupialization
Gartner duct cysts: remnant of mesonephric (Wolffian) ducts; Tx excision

Cervical lesions

DES-associated anomalies: vaginal adenosis, clear cell adenocarcinoma, other cervical or uterine anomalies
Nabothian cysts: benign; occurs when ectocervix (strat squamous) overgrows endocervix (simple columnar)
Cervical endometriosis: reddish-purple, presents w/ sx of endometriosis (dyspareunia/dyschezia/dysmenorrhea)
Cervical polyps: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources
Cervical fibroids: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources
Cervical stenosis: Tx cervical dilataion

GYN 2 – Upper GU

Uterine anatomic
anomalies

Uterine anomalies: septate uterus (#1), bicornuate uterus, uterus didelphys; associated w/ urinary tract anomalies and inguinal hernias
Etiology: problems in fusion of paramesonephric (Mullerian) ducts
Sx: amenorrhea, dysmenorrhea, infertility, recurrent pregnancy loss (2nd trimester), PTL
Management: Dx imaging (pelvic U/S, CT, MRI, HSG, etc.) → leave alone if asx
Tx surgery for septate uterus and bicornuate uterus

Leiomyoma
(uterine fibroids)

Fibroids: benign, estrogen-sensitive smooth muscle proliferation of myometrium
Pseudocapsule: compressed smooth muscle cells surrounding fibroids
Degenerative changes: fibroid outgrows blood supply → infarction and degeneration → pelvic pain
Incidence: 20-30% of reproductive-age women; 50% of black women
Subtypes: submucosal (most likely to bleed), intramural (MC), subserosal, pedunculated
Sx: usually asx; can cause menorrhagia (MC), pelvic pain and pressure, infertility (rare)
Management: Dx pelvic U/S →
leave alone if asx
temporary shrinkage w/ ↓E (progesterone, danazol, leuprolide)
Tx myomectomy if fertility desired
Tx hysterectomy (definitive)
Tx uterine artery embolization if bad surgical candidate
Leiomyosarcoma: sarcoma of uterine smooth muscle, no relation to fibroids

Endometrial polyps

Endometrial polyps: benign overgrowth of endometrial glands/stroma
Sx: vaginal bleeding between periods (metrorrhagia)
Management: Dx pelvic U/S → Tx D+C + bx to r/o cancer

Endometrial
hyperplasia

Endometrial hyperplasia: presents as vaginal bleeding; precursor to endometrial cancer
“Penny, nickel, dime, quarter”:
simple hyperplasia w/o atypia = 1% progression to cancer
complex hyperplasia w/o atypia = 3-5%
simple hyperplasia w/ atypia = 8-10%
complex hyperplasia w/ atypia = 25-30%
Risk factors: ↑E levels – unopposed E therapy (↑E w/o P)
tamoxifen use (weak E)
obesity/HTN/DM (↑aromatase in fat cells)
PCOS/chronic anovulation (↑E w/o P)
nulliparity (↑total cycles)
early menarche/late menopause (↑total cycles)
granulosa cell tumor (↑E synthesis)
Protective factors:
COC/POP/combination HRT (↑P)
multiparity (↓total cycles)
diet and exercise (↓fat cells)
Management: Dx endometrial bx or D+C → Tx progestins for 3 mo + repeat endo bx; hysterectomy if complex/atypia

Ovarian cysts

Ovarian mass management:
Palpable ovarian/adnexal mass?
low-risk

high-risk
(premenarchal, postmenopausal,
size >8 cm, or persists >60 days)

Dx pelvic U/S

ex lap for cancer

Follicular cysts: MC ovarian cyst, due to unruptured follicle, usually asx
Management: observe for 8-12 wks, then repeat pelvic U/S; if unresolved → Tx cystectomy or oophorectomy
Corpus luteum cysts: due to hemorrhage into persistent corpus luteum, presents as dull abd pain (unruptured) or acute abdomen (ruptured)
Management: resolves spontaneously, if recurrent → suppress w/ OCPs
Theca-lutein cysts: multiple/bilateral due to FSH/LH stimulation; associated w/ moles and choriocarcinoma
Chocolate cysts: ovarian endometriosis
PCOS: enlarged ovaries w/ multiple subcortical cysts

GYN 3 – Endometriosis & Adenomyosis

Endometriosis

Endometriosis: presence of endometrial tissue outside endometrial cavity
Etiology: three mechanisms – coelomic metaplasia, reverse menses, lymphatic/hematogenous spread
Incidence: 10-15% of reproductive-age women
Sx: 3 Ds – dysmenorrhea (hallmark = cyclic pelvic pain, worst 1-2 days before menses)
dyspareunia
dyschezia (due to endometrial implants in pouch of Douglas)
Physical exam: uterosacral nodularity on rectovaginal exam, fixed retroverted uterus
Complications: intraabdominal inflammation → scarring + adhesions → chronic pelvic pain, infertility
Management: Dx requires direct visualization → temporary relief w/ ↓E (progesterone, danazol, leuprolide) + NSAIDs
Tx surgical ablation if fertility desired
Tx hysterectomy + LOA + removal of implants (definitive)
Endometrioma: endometriosis in the ovary, aka chocolate cyst

Adenomyosis

Adenomyosis: extension of endometrial tissue into myometrium
Etiology: ↑E → hyperplasia of stratum basalis of endometrium → myometrial invasion
Incidence: 10-15% of reproductive-age women
Sx: dysmenorrhea, menorrhagia, or both
Physical exam: diffusely enlarged, boggy uterus
Management: Dx pelvic U/S →
temporary relief w/ ↓E (progesterone, danazol, leuprolide) + NSAIDs
Tx hysterectomy (definitive)
Adenomyoma: well-circumscribed endometrial tissue collection in myometrium, not encapsulated (vs. intramural fibroids)

GYN 4 – Lower GU × Infx

UTI

STDs and other
genital infx

UTI: presents as dysuria, urinary frequency/urgency, suprapubic tenderness
Etiology: E. coli (MCC), S. saprophyticus (#2), Enterococcus (#3), other GNB
Complications: septic shock (urosepsis), ARDS
Management: Dx UA/UCx →
Tx Bactrim or Cipro (not pregnant)
Tx nitrofurantoin (pregnant)
Tx IV cephalosporins + admit (upper UTI)
Infx
Candidiasis

Bug
Candida albicans

Presentation
thick, white curd-like discharge,
itching, satellite lesions, no odor

Syphilis

Treponema pallidum

1° syphilis: painless chancre +
inguinal LN-opathy
2° syphilis: palmar/plantar rash,
fever, LN-opathy, condyloma lata
3° syphilis: neurosyphilis (tabes
dorsalis), CV syphilis, gummas
recurrent, painful oral/genital
vesicles that can rupture
painful chancre + inguinal LNopathy

HSV

HSV-1/2

Chancroid

Haemophilus ducreyi

LGV

Chlamydia trachomatis,
L1-L3 serotypes

Condyloma acuminata
Molluscum contagiosum

HPV-6/11
MCV

Scabies vs. pediculosis
Bacterial vaginosis

Sarcoptes scabiei vs.
Phthirus pubis
Gardnerella vaginalis

Trichomoniasis

Trichomonas vaginalis

Gonorrhea

Neisseria gonorrhoeae

Chlamydia

Chlamydia trachomatis

1° LGV: transient, painless ulcer
2° LGV: painful LN-opathy
3° LGV: anogenital syndrome
(proctocolitis, rectal stricture,
rectovaginal fistula, elephantiasis)
genital warts (MC overall STD)
domed papule w/ umbilicated
center
itching, irritation, vesicles,
burrows
thin homogenous discharge, fishy
odor
green-gray frothy discharge, odor,
strawberry cervix (petechiae)
cervicitis, PID, TOA, Bartholin
abscess
cervicitis, PID, TOA, usually asx
(MC bacterial STD)

Management
Dx budding yeast + pseudohyphae on KOH prep → Tx
fluconazole (Diflucan)
Dx screen w/ RPR-VDRL →
confirm w/ FTA-ABS → Tx
benzathine penicillin G
Tx IV penicillin G
Dx Tzanck smear or viral cx →
Tx ACV/VACV + palliative care
Dx “school of fish” on Gram
stain → Tx azithromycin or
ceftriaxone
Dx PE or complement fixation
→ Tx doxycycline

Dx PE → Tx removal
Dx PE → Tx removal
Dx PE → Tx permethrin cream
Dx “clue cells” on wet prep →
Tx metronidazole
Dx mobile trichomonads on
wet prep → Tx metronidazole
Tx ceftriazone (± azithromycin)
Tx azithromycin (± ceftriaxone)

Jarisch-Herxheimer rxn: acute febrile rxn s/p syphilis tx (MC w/ 2° syphilis), due to dead spirochetes → endotoxin release

GYN 5 – Upper GU × Infx

Endometritis

Endometritis: polymicrobial infx → fever, uterine tenderness, ↑WBC, foul-smelling lochia
Risk factors: postpartum period, instrumentation of endometrial cavity
Management: Dx clinical judgment → if sure, Tx clindamycin + gentamicin
if unsure, get endometrial bx showing plasma cells

PID

PID: Chlamydia or GC infx → inflammation of uterus, fallopian tubes, ovaries
Risk factors: MC in sexually active women <25 y/o
Complications: infertility, chronic pelvic pain, adhesions, ectopic pregnancy, TOA/TOC, Fitz-Hugh-Curtis syndrome
Management: Dx pelvic/abd pain + cervical, adnexal, or uterine motion tenderness → Tx clindamycin + gentamicin (pregnant)
Tx ceftriaxone + doxycycline (not pregnant)
Chronic cervicitis: cervicitis has cervical motion tenderness but rest of exam is benign (vs. PID); Tx azithro + ceftriaxone

Tubo-ovarian
abscess

TOA: abscess in tubes/ovary in the setting of PID
Management: Dx adnexal mass w/ PID sx → confirm w/ pelvic U/S → Tx admit + IV abx → drainage if unresponsive

Toxic shock
syndrome

TSS: S. aureus → TSST-1 exotoxin → fever, rash, desquamation of palms/soles
Risk factors: tampons
Management: Dx clinical judgment → Tx admit + stabilize + IV nafcillin (prevents recurrence, not current toxin-mediated illness)

HIV

HIV: retroviral virus infects CD4+ TH cells → ↓cellular immunity → AIDS-related opportunistic infx → death
Primary HIV infx: presents as mono-like syndrome ± maculopapular rash
Latent stage: CD4+ >500, asymptomatic
Symptomatic stage: CD4+ 200-500, mild HIV sx
AIDS: CD4 + <200 or presence of AIDS OI
Transmission: sexual, parenteral, vertical or via breast milk
Management: Dx ELISA screen → confirm w/ WB → Tx HAART (2 NRTIs + 1 NNRTI or PI) + OI tx/ppx
HIV+ during pregnancy: give anti-HIV meds, elective C/S, or IV ZDV during labor
HIV+ postpartum: avoid breastfeeding

GYN 6 – Prolapse

Pelvic organ prolapse

Pelvic floor: levator muscles + fascia + ligaments + nerves
Pelvic organ prolapse: weakened pelvic floor → bladder prolapse (cystocele)
urethra prolapse (urethrocele)
rectum prolapse (rectocele)
bowel prolapse (enterocele)
uterine prolapse (procidentia)
Vaginal vault prolapse: inversion of vagina into vaginal canal; MC s/p hysterectomy
1° prolapse: in upper 2/3 of vagina
2° prolapse: down to introitus
3° prolapse: protrudes outside vagina (partial)
4° prolapse: entire structure outside vagina (complete)
chronic ↑ abdominal pressure (cough, constipation, heavy lifting, tumors)
pelvic floor weakness (intrinsic weakness, birth trauma, atrophy w/ aging)
Sx: pelvic pressure/pain, dyspareunia, bowel or bladder dysfxn, urinary incontinence
Management: Dx H+P → imaging as needed → nonsurgical tx (Kegel exercises, pessaries, E replacement)
cystocele → anterior colporrhaphy
rectocele → posterior colporrhaphy
procidentia → hysterectomy
vaginal vault prolapse → vaginal suspension
Etiology:

GYN 7 – Incontinence

Continence

Continence: voluntary control of urination
Sympathetic: hypogastric n → α1R → detrusor relaxation, int sphincter constriction
Parasympathetic: pelvic splanchnic n → MAChR → detrusor constriction, int sphincter relaxation
Somatic: pudendal n → ext sphincter constriction

Incontinence

Incontinence: involuntary urine leakage
Management: first step is always to get UA/UCx to r/o UTI
Type
Stress incontinence

Definition
urine leakage w/ exertion or
straining

Urge incontinence

urine leakage d/t involuntary
bladder contractions
(detrusor overactivity)

Mixed incontinence
Overflow incontinence

stress + urge incontinence
urine leakage d/t urinary
retention and overdistention

Bypass incontinence

urine leakage d/t fistula
following pelvic surgery or
pelvic radiation
urine leakage d/t physical or
psychological issues;
common in nursing home or
gero pts

Functional incontinence

Etiology
chronic ↑ abdominal
pressure, pelvic relaxation,
old age (↓estrogen → loss of
mucosal coaptation)
idiopathic (MCC), UTIs,
bladder stones or cancer,
urethral diverticula, foreign
bodies
--medications, neurologic
disease

vesicovaginal, urethrovaginal,
or ureterovaginal fistulas
physical impairment,
dementia or delirium,
medications

Management
surgery to stabilize
hypermobile urethra (best),
Kegel exercises, pessaries
anticholinergics (oxybutinin),
TCAs (imipramine)

--intermittent self-cath,
cholinergics (↑bladder
contactility) + α1-blockers
(↑urethral resistance)
Dx methylene blue or indigo
carmine dye → Tx surgery to
repair fistula
Tx underlying cause

GYN 8 – Menstrual Cycle

Puberty

Adrenarche: regeneration of adrenal gland zona reticularis
Gonadarche: pulsatile GnRH starts → gonadal development
Thelarche: breast development, measured by Tanner stages
Pubarche: growth of pubic hair ± axillary hair
Menarche: onset of menstruation, 2½ yrs after thelarche
Puberty timing:

Tanner stages

Stage 1
Stage 2
Stage 3
Stage 4
Stage 5

HPO axis

“Always
go
(to)
adrenarche gonadarche

the
thelarche

at 7 y/o

at 10 y/o

at 8 y/o

---

pub,
men.”
pubarche/ menarche
peak growth
at 11 y/o
at 12 y/o

kid
breast buds
breast elevation
areolar mound (look 4 big nipples)
adult
GnRH

DA

TRH

FSH/LH

PRL

TSH

E2/P4

stimulates
inhibits

T3/T4

Hypothyroidism × infertility: ↓T3/T4 → ↑TRH → ↑prolactin → ↓GnRH; Tx replacement T3/T4 (Synthroid)
Hyperprolactinemia × infertility: ↑prolactin → ↓GnRH; Tx dopamine analogs (cabergoline, bromocriptine) vs. surgery
Kallman syndrome: congenital ↓GnRH
Menstrual cycle

Ovarian follicle:

Endometrium:

Hormones:

Theca/granulosa cells

Theca cells: stimulated by LH to make desmolase (cholesterol → androgens)
Granulosa cells: stimulated by FSH to make aromatase (androgens → estrogens)

Menopause

Menopause: cessation of menses and estrogen-deficient state for >12 months; avg age is 51 y/o
Sx: HAVOC – hot flashes, atrophy of vagina, osteoporosis, coronary artery dz
Management: Dx ↑FSH, Tx lowest dose HRT (estrogen + progesterone) for only 6-12 months
HRT benefits: prevention of osteoporosis, relief of menopausal sx
HRT risks: ↑risk of endometrial hyperplasia/cancer
HRT contraindications: h/o clotting dz, liver dz, pregnancy, estrogen-dependent neoplasm, undiagnosed vaginal bleeding

GYN 9 – Amenorrhea

Amenorrhea

1° amenorrhea: absence of menarche by age 16, or 4 yrs after thelarche
2° amenorrhea: absence of menses for 6 months, had periods at one time

1° amenorrhea

1° amenorrhea: absence of menarche by age 16, or 4 yrs after thelarche
Etiology: three types – outflow tract obstruction, end-organ d/o, central regulatory d/o
Outflow tract obstruction: something getting in the way of blood from leaking out
Imperforate hymen: Dx PE shows bulging red/purple membrane (hematocolpos), Tx surgery (hymenotomy)
Transverse vaginal septum: Dx PE shows septum and presence of hymenal ring, Tx surgery
MRKH syndrome: mullerian agenesis or dysgenesis → lack of uterus and upper vagina
Vaginal atresia: distal vagina fibrosed but mullerian system intact, Tx surgery
Androgen insensitivity syndrome: ΔT-receptor → 46/XY female w/ blind pouch vagina, Tx surgery
Central regulatory d/o: something wrong with either GnRH or FSH/LH release
Kallmann syndrome: lack arcuate + olfactory nuclei (no GnRH + anosmia), Dx olfactory challenge, Tx exogenous GnRH (pulsatile)
Craniopharyngioma: Rathke’s pouch tumor → pituitary compression; Dx supracellar calficied cysts
End-organ d/o: ovaries won’t respond to FSH/LH
Savage syndrome: ΔFSH/LH-receptor → primary ovarian failure
Turner syndrome: 45/XO → rapid ovarian atresia → streak gonads w/o oocytes left; Tx GH + estrogen
17α-hydroxylase deficiency: can’t produce testosterone but still have MIF → 46/XY female w/ blind pouch vagina
Swyer syndrome: male w/o testes → 46/XY female w/ both internal and external female genitalia
1° amenorrhea management:

1° amenorrhea labs:
1° amenorrhea?
uterus
(lacks MIF)
vagina

no uterus
(MIF present)

no vagina

Central d/o: ↓FSH/LH, ↓E2
Ovarian d/o: ↑FSH/LH, ↓E2
Outflow d/o: normal FSH/LH, normal E2

Dx karyotype …… …...
(46/XY females)

outflow tract
breasts no breasts obstruction
(E present) (lacks E)
P challenge
2° amenorrhea

P challenge negative

2° amenorrhea: absence of menses for 6 months, had periods at one time
Etiology: four types – pregnancy (MC), acquired abnormalities, hyperprolactinemia, HPO axis d/o
Pregnancy: MCC secondary amenorrhea, always r/o w/ ↑β-HCG
Acquired abnormalities: either anatomic or ovarian abnormalities causing 2° amenorrhea
Asherman syndrome: D+C, surgery, or endometritis → intrauterine adhesions ; Tx lysis of adhesions + estrogen
Cervical stenosis: surgical or obstetric trauma → scarring of cervical os; Tx surgical dilation or laminaria
PCOS: ↑LH, ↓FSH, ↑T/E → anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss
Hyperprolactinemia: anything that elevates prolactin inhibits GnRH (↑TSH, ↓DA, tumors)
Progesterone challenge test: give P for 1-2 wks and check for withdrawal bleeding afterwards (checks to see if endometrium is estrogenized)
2° amenorrhea management:
2° amenorrhea?
β-HCG (r/o preg)
↑prolactin

prolactin normal

TSH normal

↑TSH

get cone view and
prolactin levels

Tx Synthroid

cone view normal
and prolactin <100

cone view abnormal
or prolactin >50 or visual sx

repeat prolactin q 6 mo,
cone views q 1-2 yrs

head CT or MRI

P challenge test
negative
r/o Asherman syndrome
and cervical stenosis
FSH >40

microadenoma (<10 mm)
or hyperplasia
Tx bromocriptine
or cabergoline

positive

FSH <40

hirsute

ovarian failure severe hypothalamic
dysfunction
macroadenoma (>10 mm)
PCOS

Tx surgery

nonhirsute

mild hypothalamic
dysfunction

GYN 10 – Menstrual Abnormalities
Dysmenorrhea

Dysmenorrhea: pain and cramping during menstruation that interferes w/ normal activity
1° dysmenorrhea: ↑PGF2α → uterine ctx → dysmenorrhea w/o organic cause; Tx NSAIDs and/or COCs
2° dysmenorrhea: dysmenorrhea 2/2 endometriosis, adenomyosis, fibroids, cervical stenosis, pelvic adhesions
Cervical stenosis: surgical or obstetric trauma → scarring of cervical os; Tx surgical dilation or laminaria
Pelvic adhesions: infx (PID), inflammation, or prior surgery → scarring of endometrium; Dx/Tx laparoscopy

PMS/PMDD

AUB

PMS/PMDD: luteal phase sx (HA, bloating, weight gain, dysphoric mood) for 2+ consecutive cycles
Etiology: interaction between 5-HT and E/P
Management: Dx menstrual diary → Tx SSRI/SNRI, Xanax (alprazolam), Yaz OCP (E + drospirenone), diet and exercise
AUB
Normal menses
Menorrhagia
Hypomenorrhea
Metrorrhagia
Menometrorrhagia
Oligomenorrhea
Polymenorrhea
DUB

Pattern
3-5 days Q 4 wks, 30-50 mL/cycle
heavy flow
light flow
irregular timing
heavy flow + irregular timing
slow cycles (>5 wks, <6 months)
fast cycles (<3 wks)
heavy or irregular bleeding w/o
identifiable cause, dx of exclusion

MCC
--cervical or endometrial lesions
hypogonadotropic hypogonadism in athletes/anorexics
cervical or endometrial lesions
cervical or endometrial lesions
anovulation, PCOS, pregnancy, thyroid dz
anovulation
anovulation

AUB management: Dx labs (β-HCG, TSH, prolactin, FSH) + endometrial bx (>35 or obese) + pelvic U/S; Tx the underlying cause
Fibroids: Tx myomectomy vs. hysterectomy
Adenomyosis: Tx NSAID/OCP vs. hysterectomy
Cervical polyps: Tx polypectomy
Endometrial polyps: Tx hysteroscopy vs. polypectomy ± D+C
Endometrial hyperplasia: Tx progestins vs. hysterectomy
Endometrial cancer: Tx hysterectomy + BSO + radiation
Pregnancy: Tx expectant management vs. delivery
Miscarriage: Tx expectant management vs. D+C
Ectopic pregnancy: Tx MTX vs. surgery
Hypothyroidism: Tx Synthroid
Hyperprolactinemia: Tx bromocriptine or cabergoline
Anovulation: Tx cyclic OCP or progestins
DUB

DUB: heavy or irregular bleeding w/o identifiable cause, dx of exclusion
Etiology: anovulatory cycles (endometrium continues to grow w/o progesterone, sloughs off at random intervals)
DUB management:
DUB?
r/o AUB w/ labs (β-HCG, TSH, prolactin, FSH) +
endometrial bx (>35 or obese) + pelvic U/S
acute hemorrhage

chronic DUB

Tx 25mg IV estrogen

Tx NSAIDs + COC
(POP if estrogen c/i)

surgery if not responsive to meds
(D+C, endometrial ablation, hysterectomy)
Postmenopausal
bleeding

Postmenopausal bleeding: any vaginal bleeding 12+ months after LMP
Etiology: vaginal/endometrial atrophy and exogenous estrogens are MCC, must r/o endometrial cancer
Postmenopausal bleeding management: Dx labs (CBC, TSH, prolactin, FSH) + endometrial bx + pelvic U/S; Tx the underlying cause
Lacerations: Tx repair
Vaginal atrophy: Tx estrogen cream
Cervical polyps: Tx polypectomy
Endometrial polyps: Tx hysteroscopy vs. polypectomy ± D+C
Endometrial hyperplasia: Tx progestins vs. hysterectomy
Endometrial cancer: TAHBSO ± pelvic/paraaortic LN-ectomy and radiation (if high-risk)

GYN 11 – Hirsutism/Virilization
Hirsutism vs.
virilization

Hirsutism: excess male-pattern hair growth
Virilization: hirsutism + secondary male sex characteristics (clitoromegaly, deep voice, etc.)
Initial management:
Hirsutism or virilization?
Labs: free T, DHEAS, 17-OHP, ±cortisol
If adrenal, CT scan for adrenal tumor
If ovarian, pelvic U/S or CT for ovarian tumor
Tx underlying cause
Cosmetic tx of hirsutism

Hirsutism labs

Hirsutism diseases

↑free T: either adrenal or ovarian source
↑DHEAS: adrenal source
↑17-OHP: indicates congenital adrenal hyperplasia
↑cortisol: indicates Cushing syndrome
Disease
Cushing syndrome
CAH
PCOS

Theca-lutein cysts
Stromal
hyperthecosis
Sertoli-Leydig cell
tumors
Exogenous
hirsutism
Idiopathic hirsutism

Mechanism/presentation
excess production of cortisol from pituitary adenomas,
adrenal tumors, or paraneoplastic syndromes
congenital deficiency of 21α-hydroxylase (MC), 11βhydroxylase, or 3β-HSD
Rotterdam criteria: 2/3 of the following – polycystic
ovaries on U/S, anovulation, signs of hyperandrogenism
↑LH or βHCG (pregnancy, moles) → bilateral ovarian
cysts → possible androgen production
ovarian hyperplasia in postmenopausal women →
possible androgen production
androblastoma, secretes testosterone
due to drug use
absence of adrenal or ovarian causes, not drug-induced

Management
Dx ↑cortisol → dexamethasone
suppression test to confirm → Tx surgery
Dx ↑DHEAS + ↑17-OHP → Tx cortisol
replacement, consult endocrinology
Dx LH:FSH ratio >3:1 + ↑estrone → Tx
OCPs, clomiphene, metformin, weightloss; and screen for fasting blood sugars
Dx ovarian bx → should resolve
postpartum or s/p mole removal
Dx ovarian bx
Dx pelvic U/S → Tx unilateral salpingooophrectomy
Tx d/c meds
Dx normal T and DHEAS → look for
increased peripheral 5-αR activity → Tx
finasteride (5αR blocker) if elevated

GYN 12 – Contraception
Contraception
and sterilization

Method
COC

Mechanism
blocks LH surge, thickens
cervical mucus, slows tubal
peristalsis, creates hostile
environment

Failure rate
~1%

Benefits
 normalizes cycles
 ↓cervical and
ovarian cancer
 ↓benign breast dz
 ↓dysmenorrhea
 ↓PID
 ↓acne

Risks
 $30/month
 hypercoagulability
 hepatic adenoma

Contraindications
smokers >35, clotting
dz (PE, DVT, stroke,
CAD), uncontrolled
HTN, migraines w/
aura, CHF, estrogendependent cancers,
pregnancy, liver dz

Ortho Evra

COC as a transdermal patch;
3 weeks on, 1 week off
COC as a vaginal ring;
3 weeks in, 1 week out
thickens cervical mucus

“

“

“

women >198 lbs

“

“

“

---

0.3%

 indicated for
lactating women
 indicated for
women >40 y/o

---

Depo-Provera

thickens cervical mucus,
injection Q 12-14 wks

0.3%

 effective

Implanon

thickens cervical mucus,
implantable rod in arm

---

Condoms

prevent sperm and ova from
mating
prevent sperm and ova from
mating

~5%

 good for 3 yrs
 no weight gain,
depression, or bone
demineralization
 low cost
 STI prophylaxis
 low cost

 must take at same
time everyday
 irregular vaginal
bleeding
 reversible bone
demineralization
 prolonged
amenorrhea
 weight gain
 depression
 irregular vaginal
bleeding
 reversible bone
demineralization
 prolonged
amenorrhea
 weight gain
 depression
---

---

-----

Cervical caps

prevent sperm and ova from
mating

~10% nullip
~25% multip

 low cost

Nonoxynol-9,
octoxynol-9
Mirena IUD
(levonorgestrel)

spermicide

20-30%

inhibits sperm motility,
creates hostile environment

<1%

 used in combo w/
other methods
 indicated for
monogamous pts
 good for 5 yrs
 low maintenance
 ↓menstrual flow

 toxic shock
syndrome
 ↑UTIs
 must leave inside
6-8 hrs after sex
 needs to be fitted
by MD
 ↑↑failure rate
 needs to be fitted
by MD
 must have nl Pap
 ↑STI susceptibility

pregnancy, uterine
anomalies, infx,
unresolved vaginal
bleeding, breast
cancer

ParaGard IUD
(copper-T)

inhibits sperm motility,
creates hostile environment

<1%

 indicated for
monogamous pts
 good for 10 yrs
 low mainenance

Natural family
planning

periodic abstinence measured
by basal body temperature or
cervical mucus methods
prolactin-induced GnRH
suppression

~20%

 free
 self-managed

---

 free

plan B (levonorgestrel) given
within 72 hrs, or copper IUD
inserted within 5 days
blocks ova passage

---

 90% effective
 not abortifacient

~1%

 99% effective

blocks sperm passage, must
use alternative methods for
90 days while sperm die off

~1%

 99% effective
 more reversible
than tubal ligation
 safer and more
effective than tubals

 ↑ratio of ectopics
 ↑cramping
 needs to be placed
by MD
 risk of PID, uterine
perforation, SAB
 ↑menstrual flow
 ↑ratio of ectopics
 ↑cramping
 needs to be placed
by MD
 risk of PID, uterine
perforation, SAB
 ↑↑failure rate
 variability
between cycles
 ↑↑failure rate
 only use for max
of 6 months
 nausea/vomiting
 headache
 breast tenderness
 permanent
 surgical risks
 risk of regret (1015%)
 no STD protection
 permanent
 surgical risks
 no STD protection
 must wait 3
months before sex

NuvaRing
POP

Diaphragms

Lactational
amenorrhea
Emergency
contraception
Tubal ligation

Vasectomy

~5%

---

---

---

---

pregnancy, uterine
anomalies, infx,
unresolved vaginal
bleeding, copper
allergy or Wilson dz

---

>5 days

women <25 y/o,
uninformed about
other methods,
making decision
under pressure
men <25 y/o,
uninformed about
other methods,
making decision
under pressure

GYN 13 – Abortion

1st trimester abortion

1st trimester abortion: suction D+C (MC), manual vacuum extraction, medical abortion (≤7 wk)
MCC death during abortion: general anesthesia
Suction D+C: 90% of all abortions, safest method, most effective 7-13 wk
Medical abortion: indicated ≤7 wk only, requires f/u in 2 wks for β-HCG levels
Mifepristone (RU-486): blocks progesterone stimulation → embryo detachment
Methotrexate: blocks DHF reductase → ↓cell division → blocks placental proliferation
Misoprostol: ripens cervix; use w/ MTX or RU-486 to ↑efficacy rates
Side-effects: abd pain/cramps, uterine bleeding, nausea/vomiting

2nd trimester abortion 2nd trimester abortion: D+E or induction of labor (IOL is better, since intact fetus can be used for autopsy)
D+E: like D+C, but requires wider cervical dilation + use of special forceps to extract fetal parts
Complications: trauma, infx, retained tissue, uterine perforation
Induction: cervical ripening w/ misoprostol (Cytotec) → amniotomy → induction w/ high-dose oxytocin (Pitocin)
Complications: trauma, infx, retained tissue
3rd trimester abortion

3nd trimester abortion: illegal ≥24 wk, unless necessary for preservation of maternal life

GYN 14 – Infertility

Infertility

Infertility: failure to conceive after 12 mo of unprotected sex (6 mo if woman >35 y/o)
Fecundability: ability to get pregnant in one cycle
Categories: male factor (35%)
female factor (45-55%)
combined (10-20%)
unexplained (10%)
Infertility management:

Female factor
infertility

Category
Ovarian factors

Disease
PCOS

Tubal factors

Advanced maternal age
PMOF
Hyperprolactinemia
Hypothyroidism
Endometriosis
Pelvic adhesions
PID

Uterine factors

Cervical factors

Tubal ligation
Asherman syndrome
Polyps
Submucosal fibroids
Congenital malformations
Endometritis
Cervical stenosis
Chronic cervicitis
DES exposure
Congenital malformations

Tx
OCPs, clomiphene, metformin, weight-loss, and screen for
fasting blood sugars
ART
ART
cabergoline or bromocriptine
Synthroid
surgical ablation (if fertility desired)
hysterectomy + LOA + removal of implants (definitive)
surgery (lysis of adhesions)
IV clindamycin + gentamicin (pregnant)
IV ceftriaxone + doxycycline (not pregnant)
IVF/ICSI
hysteroscopic lysis of adhesions + estrogen
hysteroscopic polypectomy
hysteroscopic myomectomy
surgery, may not be treatable
IV clindamycin + gentamicin
cervical dilation or IUI
IVF/ICSI
none
surgery, may not be treatable

Male factor
infertility

Male factor infertility: 3 categories – sexual problems, endocrine d/o, sperm abnormalities
Management: stay away from risk factors (drugs, radiation, heat) + Tx underlying cause

Unexplained
infertility

Unexplained infertility: no underlying cause found during initial assessment
Management: refer to REI clinic → Tx IVF/ICSI or use donor sperm

Assisted reproductive ART: any therapy where sperm/egg are handled for increasing rate of conception
technologies
Clomiphene: blocks E-receptors in hypothalamus → ↑FSH/LH → promotes ovulation
Indications: chronic anovulation, hypothalamic insufficiency
Letrozole: aromatase inhibitor → ↓E → ↑FSH/LH → promotes ovulation
HMGs: FSH/LH analogs → promotes ovulation
Indications: second line to Clomid
Complications: antiestrogen effects, ovarian hyperstimulation syndrome (OHSS), multiple gestation
OHSS: overstimulation of ovaries → ↑risk of torsion or rupture
IVF: insert fertilized gamete into uterus
ICSI: inject sperm into oocyte before IVF

ONC 1 – Vulvar/Vaginal Cancer

Squamous neoplasia

Squamous neoplasia: defined by depth of epithelial involvement (xIN if not invasive, SCC if invasive)
Risk factors: multiple sexual partners (#1), sex at young age, high-risk HPV strains, smoking, immunosuppression, other xINs

VIN

VIN: premalignant dz of vulvar epithelium, three grades (VIN I-III)
Sx: usually asx but can have vulvar itching and irritation; classic presentation is “fungal infx” that doesn’t resolve w/ antifungal cream
Management: Dx vulvar bx → Tx wide local excision if unifocal, vulvectomy or laser ablation if multifocal

Vulvar SCC

Vulvar SCC: malignant dz of vulvar epithelium, 90% are unifocal
Sx: vulvar itching, pain, bleeding, ulceration
Management: Dx vulvar bx → Tx (see below)
Px: depends on LN+ status – good if 0-2, <15% if 3+
Stage
Ia
Ib
II
III

TNM criteria
<2 cm, <1 mm depth
<2 cm, >1 mm depth
>2 cm
LN+ or local spread (lower urethra, distal vagina, anus)

IVa
IVb

local met+ (bladder or rectum)
distal met+

Tx
wide local excision + ipsi LN-ectomy
"
radical vulvectomy + bilat LN-ectomy
radical vulvectomy + bilat LN-ectomy +
pelvic exenteration
"
"

Verrucous carcinoma: well-differentiated subtype of vulvar SCC, good px
VAIN

VAIN: premalignant dz of vaginal epithelium, 50-90% associated w/ VIN or CIN
Sx: usually asx but can have vaginal discharge or postcoital spotting; classic presentation is persistent abnl Pap but nl cervical bx
Management: Dx colpo-directed bx → Tx local excision, laser ablation, or topical 5-FU

Vaginal SCC

Vaginal SCC: malignant dz of vaginal epithelium, usually in upper 1/3 and posterior wall
Sx: usually asx but can have vaginal discharge, itching, or bleeding
Management: Dx colpo-directed bx + check for spread (CXR/cystoscopy/proctosigmoidoscopy/IVP) → Tx (see below)
Stage
0
I
II
III
IVa
IVb

TNM criteria
carcinoma in situ
within vaginal wall
spread into subvaginal tissue
spread into pelvic wall
local met+ (bladder or rectum)
distal met+

Tx
surgical resection
"
radiation tx
"
"
"

Vaginal clear cell
adenocarcinoma

Vaginal adenosis: red/superficial ulcer, precursor to clear cell adenocarcinoma
Clear cell adenocarcinoma: vaginal cancer in women <20 y/o w/ in utero DES exposure

Extramammary
Paget disease

Paget disease: red, velvety lesions + scarred white plaques; 20% associated w/ underlying adenocarcinoma
Paget vs. melanoma: Paget “halo” cells are PAS+, mucicarmine+, Alcian blue+; melanoma cells are PASSx: classic presentation is vulvar itching and pain in women >60 y/o
Management: Dx vulvar bx → Tx wide local excision + r/o underlying adeno
Px: high local recurrence rate, fatal if LN+

Sarcoma botryoides

Sarcoma botryoides: embryonal rhabdomyosarcoma, resembles grape-like mass protruding from vagina in girls <5 y/o
Management: Dx bx shows desmin+ spindle-shaped rhabdomyoblasts, Tx excision

ONC 2 – Cervical Cancer

HPV

HPV-1-4: verruca vulgaris (common warts)
HPV-6/11: low-risk strains cause condyloma acuminata (genital warts)
HPV-16-18/31/33/45: high-risk strains cause cervical dysplasia/cancer
Gardasil: quadrivalent 3-series HPV vaccine for strains 6/11/16/18; indicated for women 11-26 y/o

Pap smears

Pap smear: scrape transformation zone w/ spatula, then sample endocervical canal w/ brush
Screening protocol: start age 21, Q2 yrs 21-29 y/o, Q3 yrs >30 y/o after 3 negative Paps
Exceptions: annual if HIV, immunosuppressed, DES, previous CIN II+; don’t need s/p total hysterectomy

Bethesda system

Pap result
ASC-US

Definition
atypical squamous cells, undetermined significance

ASC-H
LSIL
HSIL
SCC
AGC

atypical squamous cells, can’t r/o high grade
low-grade squamous intraepithelial lesion = CIN I
high-grade squamous intraepithelial lesion = CIN II-III
squamous cell carcinoma
atypical glandular cells

Management
HPV DNA testing → repeat Pap in 1 yr if
HPV–, colpo + cervical bx if HPV+
colpo + cervical bx
"
"
"
"

Diagnostic cone bx

Cone indications:

Microinvasion <3mm
ECC positive
Discrepancy of 2 steps (high-grade Pap, not confirmed on bx)
Inadequate colpo (can’t see all borders of TZ or lesion)
Adenocarcinoma in situ
Cone complications: bleeding or infx (common), cervical stenosis, incompetent cervix, PROM/PTL

CIN

CIN: premalignant dz of cervical epithelium due to high-risk HPV strains, three grades (CIN I-III)
MC timing: during menarche and after pregnancy
MC location: anterior lip of transformation zone, multifocal
Stage
CIN I

Definition
dysplasia in basal 1/3 of epithelium, mild

Management
repeat Pap Q 6 mo ×2 or HPV testing in
12 mo (65% regression rate) → LEEP if
persistent for 2 yrs
LEEP
LEEP
diagnostic cone bx

CIN II
dysplasia in basal 2/3 of epithelium, moderate
CIN III
dysplasia >2/3 to full epithelium, severe
2-step discrepancy (e.g. HGSIL on pap but normal bx)
Cervical SCC

Cervical SCC: malignant dz of cervical epithelium defined by basement membrane invasion
Epidemiology: US incidence ↓↓ after Pap smear; #1 cancer killer of women in 3rd world countries
Sx: usually asx, can present as postcoital bleeding
Stage
0
Ia
Ib
IIa
IIb

TNM criteria
carcinoma in situ
cervix only,<7 mm
cervix only, >7 mm or visible lesion
involves upper 2/3 vagina, no parametrium
involves upper 2/3 vagina, parametrium

IIIa
IIIb

involves lower 1/3 vagina, no pelvic wall
involves lower 1/3 vagina, pelvic wall and/or
hydronephrosis or nonfunctional kidney
local met+ (bladder or rectum)
distal met+

IVa
IVb

Tx
simple hysterectomy or cold knife cone
"
radical hysterectomy or radiation tx
"
chemoradiation (external and internal
radiation + cisplatin chemotherapy)
"
"

Px (5 yr)
-->80%
"
60%
"

"
"

20%
"

40%
"

Simple hysterectomy: removes uterus only
Radical hysterectomy: removes uterus + parametria, upper vaginal cuff, uterosacral/cardinal ligaments, local vascular and lymphatic supply

ONC 3 – Endometrial Cancer

Endometrial
hyperplasia

Endometrial hyperplasia: precursor to type I endometrial cancer
“Penny, nickel, dime, quarter”:
simple hyperplasia w/o atypia = 1% progression to cancer
complex hyperplasia w/o atypia = 3-5%
simple hyperplasia w/ atypia = 8-10%
complex hyperplasia w/ atypia = 25-30%
Risk factors: ↑E levels – unopposed E therapy (↑E w/o P)
tamoxifen use (weak E)
obesity/HTN/DM (↑aromatase in fat cells)
PCOS/chronic anovulation (↑E w/o P)
nulliparity (↑total cycles)
early menarche/late menopause (↑total cycles)
granulosa cell tumor (↑E synthesis)
Protective factors:
COC/POP/combination HRT (↑P)
multiparity (↓total cycles)
diet and exercise (↓fat cells)
HNPCC/Lynch II syndrome: high-risk for colon, endometrial, ovarian cancer; get annual endo bx ≥35 y/o

Endometrial cancer

Endometrial cancer types:
Type
Type I
Type II

Etiology
E-dependent neoplasm preceded by hyperplasia
E-independent neoplasm, not preceded by
hyperplasia (papillary serous or clear-cell)

%
80%
20%

Race
white
black,
asian

Age
perimenopausal
postmenopausal

Px
good
bad

Sx: presents as postmenopausal bleeding or other abnormal vaginal bleeding
Management: (premenopausal) Dx endometrial bx → Tx (see below)
(postmenopausal) Dx U/S → if endometrial stripe >5 mm then endometrial bx → Tx (see below)
Stage
Ia

TNM criteria
uterus, endometrium only

Ib
uterus, <50% myometrial invasion
Ic
uterus, >50% myometrial invasion
IIa
endocervix, glands only
IIb
endocervix, stroma
IIIa
in serosa
IIIb
in vagina
IIIc
pelvic/paraaortic LN+
IVa
spread beyond true pelvis, or in bladder or rectum
IVb
distal met+
Pelvic recurrence
Vaginal recurrence

Tx
TAHBSO ± pelvic/paraaortic LN-ectomy
and radiation (if high-risk)
"
"
"
"
"
"
"
"
"
High-dose progestins ± chemotherapy
Vaginal radiation

Px: grade is #1 factor; three grades – G1 shows <5% solid growth pattern, G2 6-50%, G3 >50%
High-risk endo cancers: >50% myometrial invasion
type 2 (papillary serous or clear-cell)
grade 3 (>50% solid growth)
stage 3+
size >2 cm
LN+

ONC 4 – Ovarian/FT Cancer

Ovarian cancer

Ovarian cancer: four types – epithelial (90%), germ cell, sex-cord stromal, metastatic
Sx: asx in early stages; present w/ vague abd pain, bloating, distention, early satiety in later stages
Etiology: chronic uninterrupted ovulation → ↑cellular repair → ↑opportunities for gene deletion/mutation
CA-125: ovarian tumor marker useful for testing tx response and recurrence, but not screening or dx
Risk factors: family hx (#1), familial ovarian cancer syndrome, uninterruped ovulation, old age
Familial ovarian cancer syndrome: BRCA1/2, HNPCC (Lynch II)
Uninterrupted ovulation: nulliparity, infertility, early menarche, late menopause
Protective factors: OCPs, multiparity, breastfeeding, chronic anovulation (all ↓ ovulation)
Management: Dx pelvic U/S → stage → Tx (see below)
Stage
Ia
Ib
Ic
IIa
IIb
IIc
IIIa
IIIb
IIIc
IV

TNM criteria
one ovary
two ovaries
Ia/Ib + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+
invades FT or uterus
invades other pelvic tissue
IIa/IIb + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+
abd peritoneal met+, <2 cm
abd peritoneal met+, >2 cm
pelvic/paraaortic/inguinal LN+
distal met+

Class
Epithelial
Germ cell
Sex-cord stromal

Tx
surgery (TAHBSO, omentectomy, pelvic/paraaortic LN-ectomy) + carboplatin/paclitaxel
USO + BEP (bleomycin/etoposide/cisplatin)
USO only

Ovarian cancer
complications

Carcinomatous ileus: intraperitoneal tumor spread → ascites and bowel encasement → intermittent bowel obstruction
Sister-Mary-Joseph nodule: ovarian cancer metastasis to umbilicus
Pseudomyxoma peritonei: “jelly belly” associated w/ appendiceal carcinoma and mucinous cystadenocarcinoma
Meigs syndrome: fibroma + ascites + right-sided hydrothorax
Latzko triad: pain, profuse watery d/c, pelvic mass; associated w/ FT adenocarcinoma
Precocious puberty: granulosa cell tumor

Epithelial tumors

Epithelial tumors: slow growing and usually asx, thus found at stage III+
MC type: serous cystadenocarcinoma
Serous cystadenoma: bilateral, lined w/ FT-like epithelium
Serous (papillary) cystadenocarcinoma: bilateral, Dx Psamomma bodies
Mucinous cystadenoma: multilocular cyst lined w/ mucus-secreting epithelium
Mucinous cystadenocarcinoma: pseudomyxoma peritonei
Endometrioid carcinoma: resembles endometrial cancer, good px
Clear cell carcinoma: masses of glycogen-filled clear cells, poor px
Brenner tumor: benign, resembles bladder (transitional epithelium)

Psammoma body

Germ cell tumors: rapidly growing in women <20 y/o, thus found at early stages
MC type: mature teratoma aka dermoid cyst (MC overall), dysgerminomas (MC malignant)
Teratoma: tumor of totipotent fetal tissue
Mature teratoma: benign, contains hair/teeth/calcifications
Immature teratoma: aggressively malignant, contains neural tissue
Struma ovarii: monodermal, contains thyroid tissue
Dysgerminoma: ↑LDH, associated w/ Turner syndrome (45/XO), good px due to radiosensitivity
Endodermal sinus (yolk sac) tumor: ↑AFP, Dx Schiller-Duval bodies resembling primitive glomeruli
Choriocarcinoma: ↑β-hCG, also a malignant type of GTD

Schiller-Duval body

Germ cell tumors

Sex-cord stromal
tumors

Sex-cord stromal tumors: slow growing, steroid hormone secreting tumors
MC type: granulosa cell tumor
Granulosa cell tumor: secretes estrogen → ↑risk of endometrial hyperplasia, Dx Call-Exner bodies
Fibroma: pulling sensation in groin, Dx bundles of spindle-shaped fibroblasts
Sertoli-Leydig cell tumor: androblastoma, secretes testosterone → virilization

Metastatic tumors

Krukenberg tumor: metastatic stomach cancer, Dx mucin-containing signet ring cells

FT cancer

FT adenocarcinoma: very rare (0.5%), mets to FT are more common than primary FT cancer
Sx: 15% present as Latzko’s triad – Pain, Profuse watery discharge (hydrops tubae profluens), Pelvic mass
Management: Dx pelvic U/S → Tx same as epithelial ovarian cancers

Call-Exner body

ONC 5 – Gestational Trophoblastic Disease

GTD

GTD: group of diseases 2/2 abnl proliferation of trophoblastic (placental) tissue
Benign GTD: complete and partial hydatidiform moles (80%)
Malignant GTD: persistent/invasive moles (15%), choriocarcinoma (<5%), PSTTs (rare)

Benign GTD

Hydatidiform moles: two types – complete (90%) and partial (10%)
Epidemiology: highest incidence in Asian women
Risk factors: extremes in age, prior GTD, nulliparity, low β-carotene/folate/fat diet
Etiology
Karyotype
β-hCG
Pathology
Presentation
Other sx

Malignant potential
Management

Malignant GTD

Complete moles (90%)
empty egg + sperm
46/xx (both paternal)
↑↑↑ (>100,000),
14 wks to return to normal
enlarged uterus + “grape cluster” villi ±
bilateral theca-lutein cysts
presents as abnormal vaginal bleeding
severe hyperemesis gravidarum, 1st
trimester preeclampsia, hyperthyroidism,
anemia (all related to ↑β-hCG)
15-20% overall, 2% choriocarcinoma
Dx ↑↑↑β-hCG and pelvic U/S showing
“snowstorm” pattern → Tx D+C ±
oxytocin → f/u serial β-hCG and reliable
contraception for 6 months

Partial moles (10%)
egg + 2 sperm
69/XXY
normal or slightly ↑,
8 wks to return to normal
normal-sized uterus, fetal parts found
on autopsy of abortion prodcuts
presents as a missed abortion
rare

<5% overall, no choriocarcinoma
Dx pelvic U/S shows “swiss cheese”
uterus → Tx D+C ± oxytocin → f/u serial
β-hCG and reliable contraception for 6
months

Nonmetastatic: confined to uterus
Metastatic: spread beyond uterus
Low-risk: duration <4 mo, β-hCG <40k, liver/brain met–, no prior chemo
High-risk: duration >4 mo, β-hCG >40k, liver/brain met+, failed chemo, GTD following pregnancy
Persistent/invasive moles
remnant of benign
hydatidiform moles

Choriocarcinoma
malignant, necrotizing tumor

Presentation

presents as plateauing or ↑βhCG s/p molar evacuation

Management

Dx ↑β-hCG and pelvic U/S →
Tx single-agent chemo (nonmet or low-risk), multi-agent
chemo (high-risk) → f/u serial
β-hCG and reliable
contraception for 6 months

presents w/ sx of metastasis
(lungs, vagina, liver, brain,
kidneys)
Dx ↑β-hCG and pelvic U/S →
check for mets → Tx singleagent chemo (non-met or
low-risk), multi-agent chemo
(high-risk) → f/u serial β-hCG
and reliable contraception for
6 months

Etiology

PSTTs
rare tumors that arise
from placental invasion
site, have no villi
presents as abnormal
vaginal bleeding
Dx ↓β-hCG (persistently
<100) and pelvic U/S →
Tx hysterectomy + multiagent chemo

ONC 6 – Breast Disease/Cancer

Breast anatomy
and physiology

Blood supply: internal mammary (off subclavian) + lateral thoracic (off axillary) arteries
Lymph drainage: axillary LN (97%) + internal mammary LN (3%)
Estrogen: promotes ductal development + fat deposition
Progesterone: promotes lobular-alveolar (stromal) development
Prolactin: promotes milk production
Oxytocin: promotes milk letdown, uterine ctx

Breast pain

Breast pain management:
Breast pain?
H+P
likely benign

h/o trauma

reassurance, NSAIDs,
sports bra, compresses

high-risk

U/S

mammogram

Nipple discharge

Bloody discharge: intraductal papilloma
Milky discharge: pregnancy, hyperprolactinemia, hypothyroidism, drug-induced (e.g. antipsychotics)
Yellowish discharge: fibrocystic change, galactocele, acute mastitis
Green/sticky discharge: mammary duct ectasia
Purulent discharge: breast abscess

Breast cancer

Incidence: 1 in 8 women
Screening: annual mammogram (>50, >40 if strong family hx); monthly self-exam + annual physician exam (>20)
Risk factors: family hx (#1), previous breast cancer, old age, BRCA1 and BRCA2 genes (only 5-10% are genetic)
MC location: upper outer quadrant (has most breast tissue)
Mets sx:
bone → pathologic fx, back pain, coma (hypercalcemia)
liver → jaundice, elevated LFTs
lung → dyspnea, cough, hemoptysis
brain → severe HA, seizures
pleura → pleuritic chest pain

Breast masses

MC breast masses:

<25 y/o
fibroadenoma
25-50 y/o fibrocystic change
>50 y/o
infiltrating ductal carcinoma
Benign masses: soft/rubbery, smooth surface, mobile, painful, <50 y/o
Malignant masses: firm/hard, irregular surface, fixed, painless, >50 y/o
Breast mass management:
Breast mass?
<30 y/o

≥30 y/o
Nonpalpable abnormal
mammogram finding?

U/S
cystic

solid
wire-guided excision

needle drainage
resolves
f/u in 4 wks

BI-RADS

Cat
0
1
2
3
4
5
6

Definition
incomplete
negative
benign
probably benign
suspicious of malignancy
probably malignant
malignant

FNA
bloody/recurrent
core needle bx

mammogram +
core needle bx

excisional bx if
nondiagnostic

Management
additional imaging needed
routine f/u
routine f/u
short-term f/u (6 mo)
core needle bx
core needle bx
tx

Risk of malignancy
--0%
0%
≤2%
2-95%
≥95%
100%

ONC 6 – Breast Disease/Cancer

Benign tumors

Fibroadenoma: firm, mobile, rubbery mass <5 cm in young women; Tx elective removal
Giant juvenile fibroadenoma: ≥5 cm, seen in teens with rapid breast growth; Tx excision to avoid breast deformity
Intraductal papilloma: presents as bloody nipple discharge; Tx galactogram/ductogram-guided excision (due to small risk of carcinoma)
Phyllodes tumor: huge, benign tumors that distort the breast; Dx core or incisional biopsy since FNA is insufficient, Tx excision w/ negative margins

Malignant tumors

DCIS: mammogram shows clustered microcalcifications, Tx simple mastectomy
LCIS: multiple/bilateral; Tx close observation ± tamoxifen
Infiltrating ductal carcinoma: MC breast cancer, Tx (see below)
Infiltrating lobular carcinoma: multiple/bilateral, Tx (see below)
Paget disease: “crusty” nipple eczema, indicates underlying infiltrating ductal carcinoma, Tx (see below)
Inflammatory carcinoma: resembles cellulitis w/ peau d’orange, “tumor cells in dermal lymphatics”, Tx pre-op chemo + (see below)

Breast cancer Tx

Stage
I

TNM criteria
T1 (<2 cm)

II
III
IV

T2+ (>2 cm) or N1 (mobile ipsi ALN+)
N2+ (fixed ipsi ALN+)
M1 (distal met+)

Tx
lumpectomy + ALND/SLN + post-op radiation;
or modified radical mastectomy
"
chemotherapy
"

ALND/SLN+: indicates LN involvement; Tx chemotherapy
ER/PR–: indicates poor px; Tx chemotherapy
ER/PR+: indicates good px; Tx tamoxifen or aromatase inhibitors (letrozole, anastrazole, exemstane)
HER2/neu+: indicates poor px; Tx trastuzumab (Herceptin), most associated w/ comedocarcinomas
Modified radical mastectomy: removes breast + pectoralis major/minor + axillary LN
Complications: winged scapula (cut long thoracic nerve), arm lymphedema (lymphatic blockage)
Breast reconstruction: add implants or autogenous tissue, good for psychosocial benefits
Breast diseases

Fibrocystic change: painful, multiple/bilateral lumps that vary with menstrual cycle; Tx reduction in tea/caffeine/chocolate
Dominant lump: Tx aspiration → excision if mass recurs or persists
Atypical ductal hyperplasia: Tx excision; not precancerous, but high risk of becoming a cancer
Acute mastitis: breastfeeding women get Staph/Strep infection through cracks in nipple w/ yellowish discharge, Tx dicloxacillin + continue breastfeeding
Periductal mastitis: subareolar infection in smokers, both males and females affected
Breast abscess: pus pocket in lactating women; Tx I&D + biopsy to r/o possible cancer
Mammary duct ectasia: bilateral breast pain and green/sticky discharge in perimenopausal women; Tx excision + biopsy to r/o possible cancer
Dystrophic calcification: presents as breast lump following trauma, but work up as a cancer until proven otherwise (trick question!)

INTERNAL MEDICINE

MEDICINE × CV
ISCHEMIC HEART DZ

Coronary artery dz: atherosclerotic occlusion of coronary vx → asx
stable angina
increasing
unstable angina
severity
acute MI
sudden cardiac death
Acute coronary syndrome: ruptured atherosclerotic plaque → unstable angina or acute MI
Dz
Stable angina

Acute coronary syndrome

Presentation
substernal “gripping” chest
pain or pressure on exertion,
relieved w/ rest or NTG

unstable angina
↓ +biomarkers
NSTEMI
↓ +EKG change
STEMI
Unstable angina: ruptured
atherosclerotic plaque →
increasing pain or pain at rest
NSTEMI/STEMI: ruptured
atherosclerotic plaque →
typical MI-pattern chest pain;
can be asx in elderly, diabetics,
women, s/p heart txp

Prinzmetal (variant) angina
CHF

transient coronary vasospasm
→ episodic angina at rest
Left-sided CHF: dyspnea,
orthopnea, PND
Right-sided CHF: pitting edema,
hepatic congestion, JVD, ascites
NYHA class I: sx only w/
vigorous activity (e.g. sports)
NYHA class II: sx w/ moderate
activity (e.g. stairs)
NYHA class III: sx w/ ADLs
NYHA class IV: sx at rest

CARDIAC DRUGS

Adenosine toxicity: HA, flushing, nausea, SOB, chest pressure
Nitrate toxicity: headache, orthostatic hypotension, tolerance, syncope
Digoxin toxicity: atrial tachycardia w/ AV block

Management
EKG
normal

abnl ST or T-wave

exercise stress test
(pharmacological if
unable to exercise)

Tx for unstable angina

positive

negative

catheterization

close f/u

• mild (1 vx) → Tx β-blocker + aspirin + nitrates
• moderate (2 vx) → Tx (above) vs. PTCA/CABG
• severe (3 vx) → Tx CABG
• Dx EKG + cardiac enzymes
• Tx MONABASH – Morphine (analgesia)
O2
Nitrates (analgesia)
Aspirin ± clopidogrel
β-blockers
ACE inhibitor (remodeling)
Statins
Heparin vs. enoxaparin
• (only ASA, β-blockers, ACEI reduce mortality)
• angina/NSTEMI → medical management
• STEMI → call cath lab for PTCA or CABG

Other
Positive stress test: chest pain,
ST depression, hypotension, or
significant arrhythmias
Pharmacological stress test: IV
adenosine, dipyridamole, or
dobutamine can stress the heart
in place of exercise
Coronary steal: dipyridamole
causes blood flow redistribution
to nondiseased vx in stress test

CK-MB: peaks in 24 hrs and lasts
2-3 days, good for recurrence
Troponin I: peaks in 24 hrs and
lasts 1-2 weeks, most specific
EKG changes: peaked T waves,
ST-elevation, ST-depression, Q
waves, T wave inversion
Lateral: I, aVL
Inferior: II, III, aVF
Anterior: V1-V4
Posterior: V1-V2
Complications: CHF, arrhythmias,
recurrent infarction, free wall
rupture, papillary muscle
rupture, acute pericarditis,
tamponade, Dressler syndrome

• Dx EKG (ST-elevation during episode),
• inducible by IV ergonovine
• Dx EKG + cardiac enzymes (r/o MI) + ↑BNP +
• echo (best test, estimates EF)
• class I → Tx loop diuretic + ACE inhibitor
• class II-III → add β-blocker
• class IV → add digoxin

Frank-Starling curve: normal
heart has ↑contractility with
↑preload, but impaired in CHF
Systolic etiology: post-MI (MCC)
Diastolic etiology: LVH due to
chronic HTN (MCC)

MEDICINE × CV
ARRHYTHMIAS

Arrhythmia
PAC
PVC

EKG tracing
early P wave that looks differently than other P waves
wide QRS without preceding P wave

AFib

“irregularly irregular” rhythm

AFlutter

MAT

saw-tooth baseline w/ HR = 150
looks like AFib but the P waves are variable, need 3 different P waves for dx

Management/Other
• reassurance
• no risk factors → reassurance
• recurrrent PVCs w/ underlying
• heart dz → implantable defib
Couplet: 2 PVCs
Bigeminy: sinus beat + PVC
Trigeminy: sinus beat + 2 PVCs
• acute, stable → anticoagulate +
• rate control w/ Ca-blockers
• then cardioversion
• acute, unstable → immediate
• cardioversion
• chronic → anticoagulate +
• rate control w/ Ca-blockers
• (same as AFib)

• Tx improve oxygenation
Etiology: end-stage COPD (MCC)
• Tx IV adenosine if stable, •
• cardioversion if unstable

PSVT

HR > 200
• Tx ablation

WPW syndrome

“delta wave” reflects accessory conduction pathway from atria to ventricles
• sustained → Tx IV amiodarone
• nonsustained → reassurance
• torsades → Tx IV mag sulfate

VTach

Sustained VTach: lasts >30 sec, always symptomatic
Nonsustained VTach: lasts <30 sec, usually asx
Torsades de pointes: rapid, polymorphic VTach due to QT prolongation
• Tx immediate defib + CPR, then
• continue IV amiodarone

VFib

Sinus bradycardia

sinus rate <60 bpm

Sick sinus syndrome
1° AV block

persistent sinus bradycardia; presents as dizziness, syncope, fatigue

Pulseless electrical activity: EKG
shows activity but no pulses felt
• usually insignificant; if sx → Tx
• atropine (blocks vagus nerve)
• Tx pacemaker
• reassurance

PR interval >0.2 sec (1 block)
• reassurance

2° AV block (Mobitz type 1)
progressive PR prolongation until QRS drops, dz in AV node

• Tx pacemaker (can convert to
• 3° w/o Tx)

2° AV block (Mobitz type 2)

random QRS drop, dz in bundle of His
• Tx pacemaker

3° AV block (complete)

P waves and QRS complexes function independently

MEDICINE × CV
MYOCARDIAL DZ

Dz
DCM

Presentation
↓contractility → CHF sx

HCM

exertional dyspnea, angina,
syncope, “sudden death in a
young athlete”, murmur
enhanced by ↓preload (e.g.
handgrip, Valsalva)
infiltration of myocardium →
↓compliance → CHF sx

RCM

PERICARDIAL DZ

Other
Etiology: MI (MCC), infx, alcohol,
doxorubicin (Adriamycin), etc.
Etiology: most are autosomal
dominant, few are sporadic

• Dx echo + endomyocardial bx to find cause
• Tx underlying cause

Etiology: CASHES – carcinoid
syndrome, amyloid, sarcoid,
hemochromatosis, endocardial
fibroelastosis (kids), scleroderma
Etiology: coxsackie B virus (MCC)

Myocarditis

usually asx, can present w/
fever, chest pain, pericarditis

• Dx ↑cardiac enzymes, ↑ESR
• Tx underlying cause

Dz
Acute pericarditis

Presentation
pleuritic positional chest pain
(relieved by leaning forward),
pericardial friction rub; can lead
to pericardial effusion and
cardiac tamponade
fibrous pericardial scarring →
↑systemic venous pressure →
edema, ascites, hepatic
congestion, JVD, pericardial
knock, Kussmaul sign
muffled heart sounds, soft PMI,
±pericardial friction rub

Management
• Dx EKG (diffuse ST elevation + PR dePRession)
• Tx NSAIDs

Constrictive pericarditis

Pericardial effusion

Cardiac tamponade

VALVULAR DZ

Management
• Dx echo + CXR
• Tx for CHF + heart txp (MC indication)
• Dx echo + family hx
• asx → avoid exercise
• sx → β-blockers vs. myomectomy vs.
• pacemaker implantation

pulsus paradoxus + Beck’s triad
(hypotension, JVD, muffled
heart sounds)

• pericarditis + uremia → Tx hemodialysis
• Dx EKG shows AFib, cardiac cath shows
• “square root sign”
• Tx pericardiectomy

• Dx echo (gold standard), CXR shows “water
• bottle” silhouette
• small/asx → repeat echo in 1-2 wks
• rapidly developing → pericardiocentesis
• Dx echo (gold standard), EKG shows electrical
• alternans
• nonhemorrhagic, stable → close monitoring
• nonhemorrhagic, unstable →
• pericardiocentesis
• hemorrhagic → ER thoracotomy

Other
Etiology: coxsackie B virus (MCC)
Dressler syndrome: post-MI
pericarditis, “feels like a second
heart attack”; Tx NSAIDs
Constrictive pericarditis vs.
tamponade: pericarditis fills
rapidly then stops suddenly,
tamponade fills slowly throughout diastole
Etiology: acute pericarditis
(MCC)

Etiology: trauma, pericarditis,
post-MI w/ free wall rupture
Rate vs. amount: rate is more
important than amount b/c
pericardium has ability to stretch

Valvular dz: all require warfarin (anticoagulate) + amoxicillin (SBE ppx)
Dz
Mitral stenosis

Presentation
loud S1, opening snap w/ late
diastolic rumble

Management
• asx → nothing
• sx → Tx balloon valvuloplasty

Other
Etiology: rheumatic heart
disease (MCC)

Mitral regurgitation

holosystolic blowing murmur

• asx → medical management
• sx → Tx valve replacement

Etiology: ischemic heart dz, MVP,
LV dilation

Aortic stenosis

systolic crescendo-decrescendo
murmur following opening
snap, “parvus et tardus”; triad
of angina, syncope, dyspnea

• asx → nothing
• sx → Tx valve replacement

Etiology: calcified tricuspid valve
(old), calcified bicuspid aortic
valve (young)
Px: usually asx until old age, then
1-3 yrs after development of sx

Aortic regurgitation

high-pitched blowing diastolic
murmur, wide pulse pressures,
head bobbing, pulsating uvula,
pistol-shot over femoral arteries

• asx → medical management
• sx → Tx valve replacement
• acute-onset → emergent valve replacement

Etiology: bicuspid aortic valve,
syphilitic aortitis, rheumatic fever

Tricuspid regurgitation

holosystolic blowing murmur,
pulsatile liver

• asx → medical management
• sx → Tx valve replacement

Etiology: tricuspid endocarditis
(IVDA), RV dilation

Mitral valve prolapse

midsystolic click, late systolic
crescendo murmur; enhanced
by ↑TPR (Valsalva, hand grip)

• reassurance

Etiology: connective tissue d/o,
MCC Marfan’s

MEDICINE × CV
ENDOCARDITIS

Endocarditis: diseases of endocardial lining of heart, most commonly in valves
Dz
Rheumatic fever

Rheumatic heart disease
Infx endocarditis

Marantic (thrombotic)
endocarditis
Libman-Sacks endocarditis

CONGENITAL HEART DZ

Presentation
strep throat (GAS) → anti-M ab
→ type 2 hypersensitivity →
FEVERSS – fever, erythema
marginatum, valvular damage,
↑ESR, red-hot joints (migratory
polyarthritis), subcutaneous
nodules, Sydenham chorea
repeated episodes of rheumatic
fever → scarring of mitral valve
Acute: S. aureus on normal
valves → rapid onset
Subacute: dental procedures →
S. viridans (or GU/GI procedures
→ enterococcus) on damaged
valves → insidious onset

Management
• Dx ASO titers
• strep throat → Tx PCN or erythromycin
• rheumatic fever → Tx steroids

Other
MC murmur: mitral regurgitation

• Tx valve repair

MC murmur: mitral stenosis

• Dx Duke’s criteria (sustained bacteremia,
• endocardial involvement, fever, immune or
• vascular phenomena, +blood cx, +echo)
• Tx IV abx

Rapid onset: S. aureus
Dental procedures: S. viridans
GI/GU procedures: enterococcus
Colon cancer: Strep bovis,
Clostridium septicum
IVDA: S. aureus on tricuspid valve
>> Pseudomonas, Candida
Prosthetic valves: S. epidermidis
Cx-negative: HACEK group

metastatic cancer → hypercoagulable state → clots form
on valves → can embolize
SLE → wart-like vegetations on
both sides of mitral valve →
mitral regurg > mitral stenosis

• Tx heparin (controversial)

• Dx ANA
• Tx underlying SLE + anticoagulate

CHD × endocarditis: all CHD require amoxicillin (SBE ppx) before dental procedures
Eisenmenger syndrome: L-to-R shunts → pulmonary HTN → reversal of shunting → late-onset cyanosis
Dz
ASD

Presentation
low-grade diastolic rumble
murmur w/ fixed split S2

VSD

holosystolic murmur at mid-LSB

PDA

continuous, machinery-like
murmur

Aortic coarctation

HTN in upper extremities,
hypotension in lower
extremities; midsystolic
murmur heard over back

Management
• Dx echo
• asx → reassurance
• sx → Tx surgical repair
• Dx echo
• asx → reassurance
• sx → Tx surgical repair
• Dx echo
• infants → Tx indomethacin
• adults w/o Eisenmenger → surgical ligation
• adults w/ Eisenmenger → surgery is •
• contraindicated
• Dx CXR (rib notching + “figure 3” aorta)
• Tx surgical decompression

Other
Paradoxical emboli: venous clots
can travel through ASD and
cause stroke instead of PE

Congenital rubella syndrome:
PDA + deafness + cataracts
MCC death: heart failure,
infectious endocarditis
Aortic coarctation in short
women: Turner syndrome

MEDICINE × CV
ARTERIAL DZ

(vasculitides in MSK section)
Dz
HTN urgency
HTN emergency

Aortic dissection

AAA

Management
• lower BP gradually over 24 hrs w/ PO meds
• lower BP by 25% in 1-2 hrs w/ IV nitroprusside
• severe HA → get head CT to r/o intracranial
• bleeding → lumbar puncture if CT is negative
• Dx screen w/ CXR (widened mediastinum),
• confirm w/ TEE or CT scan
• type A → Tx β-blockers + surgery
• type B → Tx β-blockers

usually asx, can present as
pulsatile mass on abd exam

• Dx abdominal U/S
• <5 cm → close f/u vs. elective repair
• >5 cm or sx → Tx synthetic graft

Ruptured AAA

triad of tearing abdominal pain,
hypotension, pulsatile mass

• Tx emergency laparotomy (don’t waste time
• on dx tests)

Peripheral vascular dz

peripheral atherosclerosis →
intermittent claducation (mild),
rest pain and ischemic ulcers
(severe)

• Dx arteriogram (gold standard)
• Dx ABI (normal ≥1.0, mild <0.7, severe <0.4;
• calcified arteries give false readings)
• mild → conservative management
• severe → bypass graft vs. angioplasty

Acute arterial occlusion

Cholesterol embolization
syndrome

Mycotic aneurysm
Luetic heart

VENOUS DZ

Presentation
BP >220/120
BP >220/120 + end-organ
damage (e.g. headache, renal
failure, pulmonary edema)
acute-onset tearing chest pain
(type A) or interscapular back
pain (type B), asymmetric BP, pt
usually in severe distress

emboli → arterial occlusion →
6 Ps – pain, pallor, paralysis,
parasthesias, poikilothermia,
pulselessness
surgical or radiographic
procedure → disruption of
atherosclerotic plaque →
cholesterol emboli → small
areas of tissue ischemia (e.g.
black/blue spots on toes)
bacterial (not fungal) infx →
aortic aneurysm
tertiary syphilis → aortic
aneurysm + aortic regurg +
coronary artery stenosis

• Dx arteriogram
• Tx IV heparin + surgical embolectomy (<6 hrs)
• vs. amputation (>6 hrs)
• Tx fasciotomy for compartment syndrome ppx
• Tx supportive care
• severe → amputation

Other

Etiology: HTN, connective tissue
diseases
Stanford classification: type A
involves Ascending aorta, type B
involves descending aorta
MC site: below the renal arteries
MC pts: old smoking men
Aortoenteric fistula: small herald
bleed followed by massive UGIB
s/p aortic graft placement
Signs of impending rupture:
Cullen sign (umbilical
ecchymoses), Grey-Turner sign
(flank ecchymoses)
MC site: superficial femoral
artery
Risk factors: diabetes, smoking
Leriche syndrome: PVD of distal
aorta above bifurcation →
bilateral claudication, impotence,
↓femoral pulses
Etiology: AFib (MCC)
MC site: common femoral artery

• Tx IV abx + surgical excision
• Tx IV PCN G + surgical repair

Virchow’s triad: ↑risk of blood clots w/ stasis, hypercoagulability, endothelial damage
Heparin vs. enoxaparin: enoxaparin (Lovenox) and dalteparin (Fragmin) have longer T½ for qday dosing, more $$$
Dz
SVT

Presentation
painful, palpable venous cord
w/ local erythema and edema

DVT

acute-onset dull leg pain,
unilateral swelling, and
Homans’ sign (calf pain w/
dorsiflexion)
acute-onset chest pain,
dyspnea, hyperventilation,
hemoptysis, right-sided heart
failure → death

PE

Phlegmasia cerulea dolens

Post-thrombotic syndrome
(chronic venous insufficiency)

venous outflow obstruction →
acute onset leg edema with
pain and cyanosis
DVT damages valves → chronic
venous HTN → severe leg
edema and ulceration around
ankle area

Management
• mild → Tx aspirin
• severe → Tx aspirin + warm compresses
• septic → remove IV cath + give IV abx
• Dx duplex U/S
• Tx heparin + warfarin
• PPx compression boots + early ambulation ±
• heparin/LMWH
• Dx D-dimer to r/o, spiral CT or V/Q to confirm
• Tx heparin + warfarin
• Tx tPA to speed up clot resolution (massive
• PE, unstable, right heart failure, no c/i)
• recurrent PE → Tx IVC filter
• Dx duplex U/S or pelvic CT scan
• Tx heparin + venous thrombectomy
• Tx compression stockings + leg elevation;
• wet-to-dry TID for ulcers

Other
Migratory SVT: consider
pancreatic cancer (Trousseau
phenomenon)

PE on EKG: sinus tachycardia is
more common than S1Q3T3

MEDICINE × CV
SHOCK

Shock: inadequate tissue perfusion
Types of shock: cardiogenic (JVD)
hypovolemic
septic (warm skin)
neurogenic (↑CO, warm skin)
Initial shock management: ABCs → 2 large-bore IVs + 2L IV fluids (except cardiogenic) → EKG, CXR, labs (CBC/renal/coags)
Dz
Cardiogenic shock

Presentation
typical shock sx (∆MS, ↓BP/↑HR,
pale cool skin) + JVD

Hypovolemic shock

Class I: <15% + asx
Class II: 15-30% + ↑HR
Class III: 30-40% + ↓BP
Class IV: >40% + ∆MS, anuria
SIRS: 2+ of the following – ↑/↓T,
↑RR, ↑HR, ↑/↓WBC
Sepsis: SIRS + positive blood cx
Septic shock: sepsis + ↓BP
MODS: multiple organ dysfxn
syndrome 2/2 septic shock
sympathetic denervation →
loss of vascular tone → typical
shock sx (∆MS, ↓BP/↑HR, warm
skin)

Septic shock

Neurogenic shock

CARDIAC NEOPLASMS

Dz
Cardiac metastases

Presentation
---

Atrial myxoma

pedunculated, benign mass that
presents like intermittent mitral
stenosis
MC heart tumor in kids

Cardiac rhabdomyoma

EKG READING

Management
• (initial shock management) but use dopamine
• or IABP instead of IV fluids
• Dx EKG + echo to find underlying cause
• Tx underlying cause
• (initial shock management)
• hemorrhagic → find and stop source of bleed
• nonhemorrhagic → stabilize w/ IVF + close
• monitoring for improvement
• (initial shock management)
• Tx IV abx + IV fluids, dopamine (2nd line)

Other
Etiology: acute MI (MCC),
cardiac tamponade, tension PTX,
massive PE, etc.

Complications: septic shock is
MCC of ARDS + ICU death

• (initial shock management)
• Tx IV fluids + supine or T-berg position

Management
• Dx CT scan
• Tx surgical excision

Other
more common than primary
tumors (75%)
Etiology: most are sporadic, few
are autosomal dominant
Etiology: associated w/ tuberous
sclerosis

EKG reading: 0. find old EKG for comparison
1. Rate: use 300-150-100-75-60-50 rule, or count long strip x12
2. Rhythm: look at long strip
• Irregularly irregular: AFib or MAT
3. Axis: look at leads I and II
• I+/II+: normal
• I+/II–: left-axis deviation
• I–/II+: right-axis deviation
4. Intervals: look at PR interval, QRS complex, QT interval
• PR interval: normal <0.2 sec, heart block >0.2 sec
• QRS complex: normal <0.12 sec
• LBBB: WiLLiaM – W in V1-V2, M in V3-V6
• RBBB: MaRRoW – M in V1-V2, W in V3-V6
• QT interval: normal if T-wave doesn’t go past mid QRS-QRS, prolonged QT is risk of torsades de pointes
5. Waves: look for chamber enlargement and signs of ischemia/infarct
• LAE: lead II wide P-wave (>0.12 sec)
• RAE: lead II tall P-wave (>2.5 mm)
• LVH: left-axis deviation + V1/V2 and V5/V6 overlapping
• RVH: right-axis deviation + lead V1 R-wave >7 mm
• Ischemia: T-wave inversion, ST elevation or depression
• Infarct: T-wave inversion, ST elevation, significant Q waves

MEDICINE × PULMONARY
OBSTRUCTIVE LUNG DZ

Lung volumes:

Obstructive lung dz: ↑TLC, ↓FEV1/FVC (<70%), ↑compliance, ↓elasticity
Restrictive lung dz: ↓TLC, ↑FEV1/FVC, ↓compliance, ↑elasticity
COPD: emphysema + chronic bronchitis, commonly coexist, MCC of both is smoking
Dz
Emphysema

Presentation
destruction of alveolar walls →
permanent alveolar dilation →
“pink puffers”, thin w/ barrel
chest, expiration w/ pursed lips

Management
• Dx spirometry shows FEV1/FVC <70%
• Dx CXR shows hyperinflated lungs and
• increased AP diameter (emphysema only)
• <50 y/o → Dx A1AT levels

Chronic bronchitis

chronic productive cough of 3
months/year for 2 years →
“blue bloaters”, overweight
and cyanotic, may have signs of
cor pulmonale

• stage I (FEV1 ≥80%) → Tx short-acting
• bronchodilators (albuterol, ipratropium)
• stage II (FEV1 50-80%) → add long-acting
• bronchodilators (salmeterol, tiotropium)
• stage III (FEV1 30-50%) → add inhaled steroids
• (fluticasone, triamcinolone)
• stage IV (FEV1 <30% or <5o% w/ hypoxia) →
• add O2 therapy for 18 hrs/day

Asthma

Asthma attack: airway
inflammation → reversible
airflow obstruction →
wheezing, shortness of breath,
cough, chest tightness

• COPD exacerbation → Tx bronchodilators +
• abx + systemic steroids + O2 therapy
• Dx spirometry shows reversible FEV1/FVC <70%
• 1-2 atk/wk → prn SABA (albuterol)
• 2+ atk/wk → add low-dose inhaled steroids
• daily atk → add LABA (salmeterol)
• continuous → add high-dose inhaled steroids

Status asthmaticus: sustained
asthmatic state, not responsive
to meds

Bronchiectasis

destruction of bronchial walls
→ permanent bronchiolar
dilation → chronic cough w/
“cupfuls” of sputum, dyspnea,
hemoptysis, recurrent
Pseudomonas pneumonia

• Dx high-res CT scan shows “signet rings”
• Tx bronchodilators + abx for acute
• exacerbations

Other
Etiology: smoking causes centriacinar emphysema in upper
lungs; A1AT deficiency causes
panacinar emphysema in lower
lungs in pts <50 y/o
Etiology: smoking (MCC)

Extrinsic asthma: IgE-mediated
rxn to environmental triggers
Intrinsic asthma: not related to
triggers or atopy
Atopy: asthma + allergic rhinitis +
atopic dermatitis (eczema)
Triad asthma: asthma + aspirin
sensitivity (↑LT) + nasal polyps
ABPA: asthma + pulmonary
infiltrates + Aspergillus allergy
Churg-Strauss syndrome:
asthma + eosinophilia +
granulomatous vasculitis
Etiology: cystic fibrosis (MCC),
Kartagener syndrome (∆dynein)

MEDICINE × PULMONARY
LUNG NEOPLASMS

Dz
Lung cancer

Solitary pulmonary nodule
(“coin lesion”)

Presentation
cough, hemoptysis, dyspnea,
wheezing, recurrent PNA in
same lobe

Management
• Dx CXR → if suspicious, sputum cytology and
• CT scan → if still suspicious, bronchoscopy and
• mediastinoscopy w/ biopsy (“tissue is the
• issue”)

Pancoast tumor: superior sulcus
tumor at the apex of the lung;
presents as Horner syndrome –
ipsilateral ptosis, miosis,
anhidrosis, flushing due to loss
of sympathetic tone (invades
superior cervical ganglia)

• NSCLC stage I (local) → pneumonectomy vs.
• sleeve lobectomy
• NSCLC stage II (hilar LN) → pneumonectomy
• vs. sleeve lobectomy
• NSCLC stage III (distal LN) → chemo/radiation
• NSCLC stage IV (mets) → chemo/radiation

Bronchial adenoma: MC cancer
in women and nonsmokers

• SCLC limited (ipsi) → chemo/radiation
• SCLC extensive (contra) → chemo/radiation

solitary pulmonary nodule
found incidentally on a CXR;
DDx primary lung cancer,
granuloma (TB or fungal),
hamartoma, metastatic cancers

Other
Complications: SPHERE – SVC
syndrome, Pancoast tumor →
Horner syndrome, Endocrine
(paraneoplastic), Recurrent
laryngeal nerve (hoarseness),
Effusions (pleural or pericardial)
Lambert-Eaton myasthenic
syndrome (LEMS): SCLC → antiVGCC antibodies → myasthenia
gravis-like presentation
Paraneoplastic syndromes:
squamous cell makes PTH-rP,
SCLC makes ADH and ACTH

• Bronchial adenoma → lobectomy is curative
• Pancoast tumor → irradiation for 6 weeks to
• shrink tumor, then surgical resection
• Dx get an older CXR for comparison studies →
• if suspicious, sputum cytology and CT scan
• Benign coin lesions (calcification = granuloma,
• bull’s-eye shape, popcorn shape = hamartoma,
• air-crescent or halo sign = aspergilloma,
• Southwest region = coccidioidomycosis, Ohio
• river valley = histoplasmosis) → leave alone
• Indeterminate coin lesions → resection
• indicated
• Malignant coin lesions (spiculations or 20+
• pack-year smoking = primary lung cancer,
• multiple lesions = metastatic cancer) →
• resection indicated

PLEURAL DZ

Dz
Pleural effusion

Presentation
fluid build-up in pleural space;
two types – transudative (thin)
and exudative (thick)

Management
• Dx CXR shows blunting of costophrenic angle
• Dx thoracentesis + 4 Cs – chemistry (glucose,
• protein), cytology, CBC+diff, culture
• transudative → Tx diuretics + Na+ restriction
• exudative → Tx underlying disease
• parapneumonic → abx ± chest tube drainage

Empyema

PTX

Tension PTX

Mesothelioma

collection of pus within pleural
cavity → nonproductive cough,
fever, chest pain
air pocket in pleural space →
chest pain, cough, dyspnea

PTX + building pressure →
mediastinal shift, hypOtension,
JVD, absent breath sounds,
hyperresonance to percussion
cancer of mesothelial lining →
dyspnea, cough, weight loss

• Dx CXR or CT scan
• Tx abx + insert chest tube, evacuate pus
• collection, then re-expand the lung
• Dx CXR shows visceral pleura line or deep
• sulcus sign
• small/asx → observation
• large or sx → Tx chest tube drainage
• recurrent → Tx pleurodesis (scraping vs. talc)
• always get CXR after transthoracic needle
• aspiration, chest tube, or central line to r/o
• Dx H+P, do not get a CXR
• Tx immediate needle decompression (2nd •
• intercostal space) + chest tube
• Dx CT scan shows thick pleural walls
• Tx extrapleural pneumonectomy (high rate of
• morbidity/mortality)

Other
Light’s criteria: pleural fluid is
exudative if any of the following
– p/s protein <0.5, p/s LDH <0.6,
p LDH at upper 2/3 of normal
Pleural fluid analysis:
• amylase = esophageal rupture,
• pancreatitis, malignancy
• milky fluid = chylothorax
• purulent fluid = empyema
• bloody fluid = cancer
• lymphocytic fluid = TB
• pH <7.2 = empyema or
• parapneumonic effusion
• glucose <60 = r/o RA
Etiology: Staph aureus is MCC

1° spontaneous PTX: rupture of
apical blebs in healthy young
people
2° spontaneous PTX: due to
underlying lung dz (MCC COPD)
Traumatic PTX: s/p transthoracic
needle aspiration, chest tube, or
central line

Etiology: asbestos exposure
(especially shipyards, rooftops)

MEDICINE × PULMONARY
INTERSTITIAL LUNG DZ

ILD presentation: dyspnea, nonproductive cough, fatigue
ILD management: Dx spirometry (↓TLC, ↑FEV1/FVC) → get CXR + tissue bx + UA if hematuria
Honeycomb lung: end-stage ILD → scarred, shrunken lung w/ dilated air spaces
Dz
Drug-induced pulmonary
fibrosis
Sarcoidosis

Presentation
(classic ILD sx) s/p amiodarone,
busulfan, bleomycin, MTX, or
nitrofurantoin
young black female w/
respiratory complaints,
erythema nodosum, and blurry
vision (anterior uveitis)

Histiocytosis X

(classic ILD sx)

Wegener granulomatosis

triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract, and
necrotizing glomerulonephritis
→ hematuria + hemoptysis
triad of asthma + eosinophilia +
necrotizing vasculitis
inhalation of coal dust
containing carbon and silica →
(classic ILD sx)
inhalation of asbestos →
fibrosis of lower lungs + pleural
plaques

Churg-Strauss syndrome
Coal worker pneumoconiosis

Asbestosis

Silicosis

inhalation of silicon → fibrosis
of upper lungs

Berylliosis

inhalation of beryllium →
sarcoidosis-like presentation
Acute form: inhalation of
antigenic agent (e.g. bird
droppings) → type III and IV
hypersensitivity → flu-like sx
Chronic form: (classic ILD sx)
(classic ILD sx) + fever +
eosinophilia

Hypersensitivity pneumonitis
(extrinsic allergic alveolitis)

Eosinophilic pneumonia

Goodpasture syndrome

Pulmonary alveolar proteinosis

anti-GBM antibodies attack
alveolar and glomerular
basement membrane (type II)
→ hematuria + hemoptysis
accumulation of surfactant-like
protein and phospholipids in
alveoli → (classic ILD sx)

Idiopathic pulmonary fibrosis
(IPF)

(classic ILD sx) → death in 3-7
yrs

Cryptogenic organizing
pneumonitis (COP)

infectious pneumonia-like
presentation (cough, dyspnea,
flu-like sx) but unresponsive to
abx
s/p thoracic radiation for lung or
breast cancer → alveolar
thickening and pulmonary
fibrosis → (classic ILD sx)

Radiation pneumonitis

Management
• Tx d/c meds

Other

• Dx CXR shows bilateral hilar LN-opathy
• (pulmonary fibrosis is end-stage finding)
• Dx tissue bx shows noncaseating granulomas
• w/ Schaumann and asteroid bodies
• Tx steroids
• Dx CXR shows honeycomb lung
• Dx tissue bx shows eosinophilic granulomas
• Tx steroids vs. lung txp (if not responding)
• Dx ↑c-ANCA
• Dx tissue bx shows necrotizing granulomas
• Tx cyclophosphamide

Complications: GRAINeD – ↑IgG,
rheumatoid arthritis, ↑ACE, ILD,
noncaseating granulomas, ↑1αhydroxylase → ↑vitamin D

• Dx ↑p-ANCA
• Tx steroids
---

• Dx CXR shows lower lung fibrosis + pleural
• plaques
• Dx tissue bx shows ferruginous bodies
• Tx supportive care
• Dx CXR shows upper lung fibrosis + “egg shell”
• calcifications
• Tx supportive care
• Dx beryllium lymphocyte proliferation test
• Tx steroids
• Dx CXR shows pulmonary infiltrates (acute
• form), interstitial fibrosis (chronic form)
• Tx steroids + avoid birds

• Dx CXR shows peripheral infiltrates, CBC+diff
• shows eosinophilia
• get p-ANCA to r/o Churg-Strauss
• Tx steroids
• Dx tissue bx shows linear staining
• get c-ANCA to r/o Wegener
• Tx steroids + cyclophosphamide +
• plasmapheresis
• Dx CXR shows ground glass appearance w/
• bat-shaped bilateral alveolar infiltrates
• Dx tissue bx (definitive)
• Tx lung lavage vs. GM-CSF
• Dx CXR shows honeycomb lungs w/ temporal
• heterogeneity
• Dx tissue bx shows UIP (usual interstitial PNA)
• Tx steroids (temporizing), lung txp
• Dx CXR shows bilateral patchy infiltrates
• Tx steroids

• Dx CT scan shows diffuse infiltrates (CXR is
• usually normal)
• Tx steroids
• PPx not useful

Caplan syndrome: rheumatoid
nodules + pneumoconiosis
Etiology: shipyards, naval bases,
rooftops
Complications: bronchogenic
carcinoma >> mesothelioma
Etiology: mining, stone cutting,
glass manufacturing

MEDICINE × PULMONARY
RESPIRATORY

FAILURE

Dz
Acute respiratory failure

Presentation
dyspnea (first sx), cough,
respiratory distress, etc.
Types: hypoxia (PaO2 <60),
hypercapnia (PCO2 >50)

Management
• Dx ABG analysis…

↑A-a
A-a nl

ARDS

diffuse inflammatory response
→ neutrophil activation →
interstitial damage and alveolar
collapse → massive shunting →
dyspnea + respiratory distress
Neonatal RDS: due to preterm
birth <34 wks w/o surfactant

VENTILATION

↑CO2
CO2 nl
V/Q mismatch vs. shunting
(DDx w/ supplemental O2)
hypoventilation
↓inspired PaO2

• Dx CXR, CBC/renal, cardiac enzymes if needed
• Tx underlying cause, supplemental O2,
• CPAP/BIPAP if conscious, ventilation if not
• Dx CXR shows diffuse bilateral pulmonary
• infiltrates (white-out of lungs)
• Dx ABG shows hypoxia (PaO2 <60) not
• responsive to O2 therapy
• Dx PCWP shows no evidence of CHF

Other
V/Q mismatch: imbalance
between lung perfusion and
ventilation, presents as ↓O2 but
nl CO2
Shunting: lack of ventilation in
well-perfused areas (e.g. PNA,
atelectasis); not responsive to
supplemental O2
Hypoventilation: not breathing
↓inspired PaO2: high altitudes
Etiology: septic shock (MCC),
aspiration pneumonia, trauma

• Tx ventilation w/ ↓FiO2, ↑PEEP

Ventilation goals: maintain alveolar ventilation, correct hypoxia
Ventilator settings: 1. AC (assisted control) – has backup RR, gives preset VT per attempted breath
2. SIMV (synchronous intermittent mandatory ventilation) – has backup RR, does not have preset VT per breath
3. CPAP (continuous positive airway pressure) – no backup RR, continuous PEEP support
4. PSV (pressure support ventilation) – PEEP support only with attempted breath
Key parameters:

RR and VT control CO2
FiO2 and PEEP control O2

Tracheomalacia: softening of tracheal cartilage w/ prolonged ventilation; PPx tracheostomy if ventilator-dependent for 2+ wks

PULMONARY VX DZ

Dz
Pulmonary HTN

Presentation
PA pressure >25 mmHg (rest) or
>30 mmHg (exercise) →
presents as exertional dyspnea,
fatigue, chest pain, ±syncope
pulmonary HTN w/o identifiable
cause (a dx of exclusion)

Management
• Dx loud P2 + subtle sternal lift on auscultation
• Dx find the underlying cause via CXR, PFTs,
• ABG, EKG, echo, catheterization
• Tx underlying cause + bosentan
• Dx (see above)
• Tx pulmonary vasodilators (CCB) + lung txp

Cor pulmonale

pulmonary HTN + RVH

• Dx (see above)
• Tx underlying cause + bosentan

PE

acute onset chest pain,
dyspnea, hyperventilation,
hemoptysis, right-sided heart
failure → death

• Dx D-dimer to r/o, spiral CT or V/Q scan to r/in
• Tx heparin + warfarin
• Tx tPA to speed up clot resolution (massive
• PE, unstable, right heart failure, no c/i)
• recurrent PE → Tx IVC filter

Dz
Pulmonary aspiration

Presentation
either acute onset respiratory
distress, or delayed onset of
respiratory sx (cough, SOB,
fever, tachypnea, dypsnea, etc.)

Management
• Dx CXR + H+P
• Tx ABCs, O2 mask, supportive care
• aspiration pneumonia → Tx abx
• obstruction → Tx bronchoscopy

1° pulmonary HTN (PPH)

OTHER LUNG PROBLEMS

Other

Etiology: ∆BMPR2 → uninhibited
smooth muscle growth →
↑pulmonary resistance
Px: mean survival 2-3 yrs
Etiology: COPD (MCC), recurrent
PE, ILD, asthma, sleep apnea, CF,
pneumoconioses
PE on EKG: sinus tachycardia is
more common than S1Q3T3
Fat embolism: dyspnea, ∆MS,
petechiae in a pt w/ long bone fx
Amniotic fluid embolism: intraor postpartum, or amniocentesis

Other
Etiology: gastric aspirates (can
lead to ARDS), oral flora (can
lead to abscess), foreign bodies
Risk factors: ∆MS, alcoholics,
instrumentation, esophageal d/o

MEDICINE × GI
ABDOMINAL PAIN

RUQ pain:

RLQ pain:

COLON DZ

• liver (hepatitis)
• common bile duct (cholecystitis, cholangitis)
• lungs (PE, pneumonia)
• duodenum (ulcer)
• bowels (appendicitis, perforated ulcer, IBD,
• inguinal hernia)
• male GU (testicular torsion)
• female GU (ectopic, PID, ovarian cyst)
• ureters (ureterolithiasis)

Dz
Colorectal cancer

Presentation
Proximal colon: bleeding →
melena, iron-deficiency anemia,
fatigue, dull pain

LUQ pain:

• pancreas (pancreatitis)
• spleen (splenic dz)
• lungs (PE, pneumonia, subphrenic abscess)

LLQ pain:

• bowels (diverticulitis, IBD, inguinal hernia)
• male GU (testicular torsion)
• female GU (ectopic, PID, ovarian cyst)
• ureters (ureterolithiasis)

Management
• >50 y/o → colonoscopy screen q 10 yrs
• Dx barium enema (“apple core”) + CEA marker

Distal colon: obstruction →
constipation, colicky pain,
hematochezia
Rectal cancer: hematochezia,
rectal mass, tenesmus
Metastatic: portal drainage to
liver → jaundice, ↑LFTs

•

Polyps

asx

• Dx colonoscopy
• Tx polypectomy

Diverticulosis

low-fiber diet → need more
strain to poop → outpouching
of sigmoid colon → erosion →
painless rectal bleeding
fecalith impacts in diverticula →
necrosis → infx → LLQ pain,
fever, ↑WBC (no bleeding)
AV malformation in submucosa
of colon wall → erosion → LGI
bleed (MCC)
compromised blood supply to
SMA or SMV → ischemia ±
infarction → acute onset severe
abd pain

• Dx barium enema
• Tx stool softeners (high-fiber diet, psyllium)

Diverticulitis

Angiodysplasia (vascular
ectasia, AVM)
Acute mesenteric ischemia

Chronic mesenteric ischemia

Ogilvie syndrome

Pseudomembranous colitis

Volvulus

Arterial embolism: MCC, most
sudden and severe
Arterial thrombosis: gradual
onset and less severe
Nonocclusive ischemia: due to
↓CO, seen in critically ill pts
Venous thrombosis: rare,
slowest onset and least severe
atherosclerosis of celiac artery,
SMA, or IMA → postprandial
dull abd pain
colonic pseudoobstruction w/o
mechanical cause → bloating,
obstipation, nausea/vomiting
abx use → kills off colonic flora
and allows C. diff overgrowth →
profuse watery diarrhea
twisting of redundant bowel →
acute-onset colicky pain,
obstipation, nausea/vomiting

• Duke stage A (local) → Tx surgery
• Duke stage B (invasive) → Tx surgery
• Duke stage C (LN) → Tx surgery + chemo
• (5-FU, leucovorin) + Radiation if Rectal
• Duke stage D (mets) → Tx surgery + chemo
• (5-FU, leucovorin) + Radiation if Rectal

Other
Risk factors: old age (>50),
villous adenomas, IBD, family hx,
low-fiber diet, major polyposis
syndromes
FAP: AD ∆APC → thousands of
polyps → 100% progression to
CRC; Tx ppx colectomy
Gardner syndrome: FAP +
osteomas, soft tissue tumors
Turcot syndrome: FAP + CNS
tumors
Peutz-Jeghers syndrome:
multiple nonmalignant
hamartomas throughout GI tract
w/ pigmented spots around
mucus surfaces
HNPCC/Lynch syndrome: AD
∆DNA repair genes → hundreds
of polyps → 80% progression to
CRC
Hyperplastic polyps: MC type,
leave alone, no malig potential
Juvenile polyps: polyps in kids,
remove due to vascularity
Inflammatory (pseudo) polyps:
associated w/ UC
Adenomatous polyps: high risk
of malig potential, worst types
are large villous polyps
Complications: hypovolemic
shock, diverticulitis

• Dx CT scan
• first episode → Tx IVF, NPO, IV abx
• recurrent episodes →Tx surgery
• Dx colonoscopy
• Tx observation (90% stop spontaneously),
• colonoscopy w/ coagulation (2nd line)
• Dx screen w/ ↑LDH, confirm w/ mesenteric
• angiography
• Tx IVF, NPO, IV abx; intra-arterial papaverine if
• arterial, heparin if venous
• dead bowel → Tx surgery

Complications: abscess, bowel
obstruction, colovesical fistulas,
perforation
Heyde syndrome: angiodysplasia
+ aortic stenosis

• Dx mesenteric angiography
• Tx surgical revascularization

(equivalent to stable angina of
the bowels)

• Dx of exclusion (r/o other causes)
• Tx underlying cause, decompressive
• colonoscopy (2nd line), neostigmine (3rd line)
• colon >10 cm → Tx emergent decompression
• Dx C. diff stool toxins
• Tx Flagyl (1st line), PO vancomycin (2nd line)

Etiology: surgery or trauma,
serious medical illnesses, drugs
(e.g. opiates)

• Dx KUB shows Omega loop sign (dilated
• sigmoid colon) or coffee bean sign (cecal
• volvulus causing RLQ air-fluid level)
• sigmoid volvulus → Tx sigmoidoscopy w/
• decompression ± elective surgery
• cecal volvulus → Tx emergent surgery

MC site: sigmoid colon

(equivalent to MI or unstable
angina of the bowels)

Complications: toxic megacolon,
perforation

MEDICINE × GI
APPENDICEAL DZ

Dz
Acute appendicitis

Carcinoid tumor

STOMACH DZ

Dz
Peptic ulcer disease (PUD)

Acute gastritis

Chronic gastritis

Gastric adenocarcinoma

Presentation
lymphoid hyperplasia or fecalith
in appendix → ischemia → infx
and necrosis → perforation →
peritonitis
Nonruptured sx: umbilical abd
pain that migrates to RLQ,
anorexia, n/v
Ruptured sx: severe abd pain w/
guarding in all 4 quadrants
neuroendocrine tumor that
secretes 5-HT, most commonly
found in appendix (no systemic
effects b/c liver metabolism)
Carcinoid syndrome: metastasis
of carcinoid tumor to liver →
systemic 5-HT effects → flush +
diarrhea + wheezing + TIPS
(tricuspid insufficiency,
pulmonary stenosis)

Management
• Dx CT scan + CBC (↑WBC) + β-HCG (r/o ectopic
• in females)
• Tx appendectomy

Other
Rovsing sign: LLQ pressure
causes referred RLQ pain
Psoas sign: right psoas flexion
causes RLQ pain
Obturator sign: right obturator
flexion causes RLQ pain
McBurney point: 2/3 distance
from umbilicus to right ASIS

• Dx CT scan
• Tx appendectomy (<2 cm), right
• hemicolectomy (>2 cm)
• Dx urinary 5-HIAA
• Tx resection

Presentation
aching or gnawing epigastric
pain, either relieved (DU) or
exacerbated (GU) by eating

Management
• Dx EGD
• H. pylori → Dx stool ag > urease breath test,
• Tx triple or quad therapy

Duodenal ulcers: due to ↑acid
secretion; most commonly in 1st
part of duodenum, DU in 2nd-4th
part indicates Z-E syndrome
Gastric ulcers: due to ↓mucosal
protection; type I – lesser
curvature, type II – duodenum
and stomach, type III – pylorus,
type IV – GE junction
Perforated ulcer: severe abd
pain, hemodynamic instability
Gastric outlet obstruction: early
satiety, nausea/vomiting
Bleeding ulcer: iron-deficiency
anemia (slow) or hypovolemic
shock (rapid)
inflammation of gastric mucosa
→ aching or gnawing epigastric
pain
either H. pylori or pernicious
anemia → atrophy of gastric
mucosa → aching or gnawing
epigastric pain
presents as epigastric abd pain,
weight loss, early satiety, etc.

• Tx triple therapy → if ulcer persists, surgery
• (HSV) + get serum gastrin levels to r/o Z-E

• Tx PPIs → if ulcer persists for 6 wks, EGD w/ bx
• to r/o gastric cancer → if ulcer persists for 18
• wks, surgery (wedge resection or distal
• gastrectomy)

Other
Etiology: NSAIDs and H. pylori
(MCC); EtOH, uremia, burns
(Curling), smoking, stress, head
injury (Cushing)
Zollinger-Ellison syndrome:
gastrinoma → ↑gastrin →
parietal cell stimulation → ↑HCl
→ ulcer formation

• Dx CXR (pneumoperitoneum)
• Tx emergent surgical repair
• Dx barium swallow
• Tx NPO/IVF/NG tube
• Dx EGD
• Tx PPIs (slow) or surgical repair (rapid)
• Dx EGD w/ bx
• Tx d/c NSAIDs, triple therapy for H. pylori
• Dx EGD w/ bx
• Tx d/c NSAIDs, triple therapy for H. pylori

Complications: PUD, gastric
adenocarcinoma or lymphoma

• Dx EGD w/ bx, then CT scan for staging
• Tx surgical resection

Krukenberg tumor: ovarian mets
(bx shows “signet ring” cells)
Blumer shelf: rectal mets
SMJ node: periumbilical LN mets
Virchow node: left supraclavicular LN mets
Irish node: left axillary LN mets

Linitis plastica: “leather bottle”
stomach due to full thickness
infiltration and fibrosis, poor px

Risk factors: type A blood,
Japanese (smoked foods)
Gastric lymphoma

presents as epigastric abd pain,
weight loss, early satiety, etc.

• Dx EGD w/ bx
• Tx radiation (partial thickness) or surgical
• resection (full thickness)

MEDICINE × GI
GI BLEEDING

Dz
UGIB

LGIB

ESOPHAGEAL DZ

Dz
Esophageal cancer

Achalasia

Diffuse esophageal spasm

Hiatal hernia

Mallory-Weiss syndrome
Boerhaave syndrome

Plummer-Vinson syndrome

Schatzki ring

Esophageal divertula

Presentation
GI bleed proximal to Ligament
of Treitz → hematemesis,
melena, hematochezia (if rapid)

GI bleed distal to Ligament of
Treitz → hematochezia, melena
(if slow)

Presentation
dysphagia of solids > liquids +
weight loss ± odynophagia (if
severe)
SCC: found in upper 2/3, due to
smoking and EtOH abuse
Adenocarcinoma: found in
lower 1/3, due to GERD/Barrett’s
hypertonic and nonrelaxing LES
w/ poorly relaxing esophagus
→ dysphagia of liquids > solids
uncoordinated esophageal
peristalsis → dysphagia +
angina-like chest pain
Type 1 HH: sliding hernia, can
present as GERD or reflux
esophagitis
Type 2 HH: paraesophageal
hernia, high risk of incarceration
and strangulation
Type 3 HH: both type 1+2
retching → laceration of lower
esophagus → UGIB
retching → perforation of lower
esophagus → epigastric pain,
fever, pneumomediastinum
iron deficiency → anemia,
upper esophageal webs
(dysphagia), koilonychia
ingestion of acids, alkali, bleach,
or detergents → lower
esophageal webs → usually asx,
dysphagia if severe
Zenker diverticulum: lack of
cricopharyngeal relaxation →
diverticulum at upper
esophagus → food gets stuck
→ halitosis + dysphagia
Traction diverticulum: TB or
cancer → LN-opathy → traction
→ diverticulum at middle
esophagus
Epiphrenic diverticulum:
esophageal motility d/o →
diverticulum at lower
esophagus

Management
• Dx NG tube aspirate/lavage…
• • +blood/±bile is UGIB
• • –blood/+bile is LGIB
• • –blood/–bile is indeterminate
• UGIB → Dx/Tx EGD
• LGIB → Dx colonoscopy
• bleeding won’t stop → Dx tagged RBCs or
• angiography to localize site of bleeding
• “hemodynamic instability despite
• transfusion”, loss of 4-6 units in 24 hrs, or 8-10
• units in 48 hrs → Tx ex lap
• unstable pt w/ massive BRBPR, no imaging to
• help localize site → Tx total colectomy

Management
• Dx esophagoscopy w/ bx, then staging via
• endoscopic U/S + CT scan

Other
Etiology: PUD (#1), NSAID use
(#2), esophageal varices (#3)
UGIB in ICU pt: stress ulcer
UGIB in alcoholics: esophageal
varices, Mallory-Weiss tear,
Boerhaave syndrome
UGIB s/p aortic graft: aortoenteric fistula (small herald bleed
followed by massive UGIB)
Etiology: diverticulosis (#1), AVM
(#1), colon cancer (#3)
LGIB in kids: Meckel diverticulum

Other

• upper 1/3 → Tx chemo + radiation
• middle 1/3 → Tx chemo + radiation, then
• esophagectomy
• lower 1/3 → Tx esophagectomy + proximal
• gastrectomy
• Dx screen w/ barium swallow (bird’s beak),
• confirm w/ manometry (↑LES pressure)
• Tx botox vs. Heller myotomy
• Dx screen w/ barium swallow (corkscrew),
• confirm w/ manometry (uncoordinated)
• Tx nifedipine, nitrates
• Tx PPIs vs. lap Nissen

• Tx surgical repair

• Tx surgical repair
• Dx upper GI endoscopy
• Tx observation (bleeding stops on its own)
• Dx barium swallow
• Tx emergent surgical repair

Etiology: alcoholics (MCC),
hyperemesis gravidarum, etc.
Etiology: alcoholics (MCC),
hyperemesis gravidarum, etc.

• Tx esophageal dilatation + PO iron supplement

• dysphagia → Tx esophageal dilatation
• full-thickness necrosis → Tx esophagectomy

• Dx barium swallow
• Tx cricopharyngeal myotomy

• Dx barium swallow
• Tx observation

• Dx barium swallow
• Tx esophagomyotomy

Complications: esophageal
stricture or cancer

MEDICINE × GI
SI DZ

IBD

Dz
SBO

Presentation
colicky abd pain, n/v,
obstipation or constipation

Paralytic ileus

lack of peristalsis

Celiac sprue

gluten hypersensitivity → villi
atrophy w/ dietary wheat →
malabsorption, diarrhea, weight
loss, bloating

Management
• Dx KUB (dilated loops w/ air-fluid levels)
• Tx NPO/IVF/NG tube, observation
• adhesions → Tx LOA + resect dead gut
• hernias → Tx herniorrhaphy + resect dead gut
• Dx KUB (uniform gas in SI, colon, rectum)
• Tx NPO/IVF/NG tube, observation

• Dx anti-gliadin or anti-endomysial ab
• Tx avoid wheat/gluten in diet

Other
Etiology: adhesions from prior
abd surgery (MCC), hernias (#2)
Complications: septic shock,
gangrene, peritonitis, bowel
perforation
Etiology: s/p abd surgery, meds
(e.g. narcotics, anticholinergics),
spinal cord injury, shock, hypokalemia, peritonitis
Dermatitis herpetiformis: skin
lesions found in celiac sprue

IBD: Crohn’s disease and ulcerative colitis
Dz
Crohn disease

Ulcerative colitis

Presentation
flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss

flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss

Pouchitis: fever, bloody
diarrhea, and dyschezia s/p ileal
pouch formation in a UC pt
Toxic megacolon: huge flare →
paralyzes the colon → fever,
bloody diarrhea, abd distention
in a UC pt

Management
• Dx KUB (terminal ileum string sign), flex sig,
• tissue bx (transmural, noncaseating
• granulomas, creeping fat)
• Tx steroids + 5-ASA (sulfsalazine)
• perianal Crohn → Tx metronidazole
• rectal Crohn → Tx subtotal colectomy
• Dx KUB (lead pipe sign), flex sig, tissue bx
• (mucosa only, crypt abscesses, pseudopolyps)
• Tx steroids + 5-ASA (sulfsalazine)
• severe dysplasia → Tx total proctocolectomy
• Tx metronidazole

• Dx KUB (dilated colon)
• Tx NPO/IVF/NG tube, IV steroids, abx

Other
Location: “mouth to anus” w/
skip lesions, terminal ileum is MC
site
Complications: erythema
nodosum, SBO, fissures/fistulae

Location: colorectal only,
continuous lesions
Complications: CRC, pyoderma
gangrenosum, sclerosing
cholangitis, cholangiocarcinoma,
pouchitis, toxic megacolon

MEDICINE × HEPATOBILIARY/PANCREATIC
LIVER DZ

Dz
Cirrhosis

Wilson disease
(hepatolenticular degeneration)

Hemochromatosis (“bronze
diabetes”)

Hepatic adenoma

Cavernous hemangioma
Focal nodular hyperplasia (FNH)

Presentation
fibrosis → disruption of liver
architecture → portal HTN +
impaired biosynthetic function
→ multiple complications
Varices: portal HTN → dilated
veins in butt (hemorrhoids), gut
(esophageal varices), and caput
(caput medusae)

Ascites: portal HTN + hypoalbuminemia → fluid
accumulation in abd cavity
Hepatic encephalopathy: ↓NH4
metabolism → ↑NH4 → CNS
toxicity → ∆MS, asterixis,
rigidity, hyperreflexia, fetor
hepaticus
Hepatorenal syndrome: endstage liver dz → renal vx vasoconstriction → progressive
renal failure (despite normal
kidneys)
Spontaneous bacterial
peritonitis (SBP): infx of ascitic
fluid → abd pain, fever, n/v,
rebound tenderness
Hyperestrinism: ↓estrogen
metabolism → ↑estrogen →
spider angiomas, palmar
erythema, gynecomastia,
testicular atrophy
Coagulopathy: ↓clotting factor
synthesis → ↑risk of bleeding
AR ∆ceruloplasmin → copper
accumulation in liver (cirrhosis),
corneas (Kayser-Fleischer rings),
brain (movement d/o), RBCs
(schistocytes)
↑iron → accumulation in liver
(cirrhosis), heart (restrictive
CM), joints (arthritis), skin
(bronze suntan), pancreas (DM)
usually asx, can present as
hypovolemic shock and
distended abdomen if ruptured
usually asx, MC benign liver
tumor
usually asx

Hepatocellular carcinoma (HCC)

vague RUQ pain and mass +
s/sx of chronic liver dz (portal
HTN, ascites, jaundice)

Nonalcoholic steatohepatitis
(NASH)
Gilbert syndrome

fatty liver in a nonalcoholic pt,
usually asx
AD ∆UDP-glucuronyltransferase
→ usually asx, but can present
w/ mild jaundice after fasting
injury to liver or biliary tract →
blood drains into duodenum via
CBD → UGIB, jaundice, RUQ
pain
Polycystic liver: ADPKD →
simple cyst in liver and kidneys
Hydatid cysts: Echinococcus
granulosus (dog tapeworm) →
multilocular cyst w/ calcified
walls
multiple types, all present as
fever, RUQ pain, jaundice

Hemobilia

Liver cysts

Liver abscess

Budd-Chiari syndrome

occlusion of hepatic vein
outflow → hepatic congestion +
portal HTN → hepatomegaly,
RUQ pain, ascites, jaundice

Management
• Dx liver bx

• PPx β-blockers
• bleeding esophageal varices → Tx band the
• varices, correct coagulopathy, IV octreotide to
• lower portal pressure → if bleeding continues,
• repeat banding → if bleeding continues, TIPS
• or gastric balloon tamponade
• Dx PE (shifting dullness, fluid wave) +
• paracentesis (to determine cause)
• Tx salt restriction + loop diuretic
• Tx lactulose (prevents NH4 absorption) +
• neomycin (kills GI flora that make NH4) + low
• protein diet

Other
Etiology: alcohol (MCC), HBV and
HCV (2nd), other causes
Child’s classification: stratifies
risk of surgery in pts w/ liver
failure; measure 3 labs (albumin,
bilirubin, PT) and 3 clinical
findings (encephalopathy,
ascites, nutrition)

• Tx liver txp

• Dx paracentesis (↑WBC)
• Tx IV abx + repeat paracentesis in 2-3 days

---

• Dx ↑PT/PTT
• Tx FFP transfusion (vit K won’t work)
• Dx ↓ceruloplasmin, ↑AST/ALT, liver bx
• Tx D-penicillamine (copper chelating agent) +
• zinc (copper uptake competition)

• Dx ↑ferritin, ↓TIBC, liver bx
• Tx repeated phlebotomies

• Dx CT scan or U/S
• Tx d/c OCP, if it persists → Tx resection due to
• possibility of rupture
• Dx CT scan or U/S
• Tx reassurance
• Dx CT scan (central stellate scar or sunburst
• pattern)
• Tx reassurance
• Dx CT scan, ↑αFP
• Tx resection w/ negative margins (as long as
• there’s no mets)

1° hemochromatosis: AR dz that
↑GI iron absorption
2° hemochromatosis: ↑iron 2/2
multiple transfusions or chronic
hemolytic anemia
Etiology: associated with OCP
and anabolic steroid use
Etiology: VAT – vinyl chloride,
aflatoxin, thorotrast

Etiology: cirrhosis (MCC), A1AT
deficiency, hemochromatosis,
Wilson dz, smoking, chemical
carcinogens

• Dx mild ↑ALT/AST
• Tx controversial
• Tx reassurance

• Dx arteriogram (gold std); EGD shows
• bleeding from ampulla of Vater
• Tx supportive care, stop bleeding if severe

Etiology: trauma (MCC), surgery
(CBD exploration), tumors, infx

• Tx reassurance
• Tx inject hypertonic saline inside cyst and
• carefully excise it + post-op mebendazole

• multiple/small bacterial abscesses → Tx IV abx
• single/large bacterial abscess → Tx perc drain
• amebic abscess (in Mexicans) → Tx Flagyl
• Tx TIPS as a “bridge to liver txp”

Etiology: polycythemia vera
(MCC), OCPs (#2)

MEDICINE × HEPATOBILIARY/PANCREATIC
LFTS

↑AST/ALT (ALT>AST): chronic viral hepatitis (virALT)
↑AST/ALT (AST>ALT): acute alcoholic hepatitis (toAST)
↑↑AST/ALT: acute viral hepatitis
↑↑↑AST/ALT: severe hepatic necrosis
AΦ
↑AΦ + GGT nl: pregnancy or bone dz (e.g. Paget’s)
↑AΦ + ↑GGT: biliary obstruction

albumin

AST
bilirubin
ALT

↑bilirubin (conjugated <20%): hemolytic jaundice
↑bilirubin (conjugated 20-50%): hepatocellular jaundice (viral or alcoholic hepatitis)
↑bilirubin (conjugated >50%): obstructive jaundice (cancer, choledocholithiasis)
↓albumin: chronic liver dz, nephrotic syndrome, malnutrition, inflammatory states

BILIARY DZ

Dz
Gallstone dz

Presentation
cholelithiasis
fatty meal
passes
biliary colic
into CBD
lodge/infx
acute cholecystitis

Management
• Dx RUQ U/S (HIDA scan if inconclusive) + get
• ERCP for choledocholithiasis/acute cholangitis

choledocholithiasis
lodge/infx
acute cholangitis
lodge
gallstone pancreatitis

Acalculous cholecystitis

GB adenocarcinoma

1° sclerosing cholangitis (PSC)

1° biliary cirrhosis (PBC)

Cholangiocarcinoma

Choledochal cysts
Biliary stricture

Biliary dyskinesia

Cholelithiasis: presence of
stones in GB, usually asx
Biliary colic: cholelithiasis →
RUQ pain after fatty meals ± n/v
Acute cholecystitis: impacted
stone in cystic duct → infx →
RUQ pain, n/v, Murphy’s sign
Choledocholithiasis: presence
of stones in CBD
Gallstone pancreatitis:
impacted stone in pancreatic
duct → reflux of pancreatic
enzymes → midepigastric pain
Acute cholangitis: impacted
stone in CBD → infx → Charcot
triad → Reynold pentad
acute cholecystitis (RUQ pain,
n/v, Murphy’s sign) w/o stones
in the cystic duct, usually found
in ICU pts
presents as a mass in GB fossa

thickening of bile duct walls →
narrowed lumens → gradual
jaundice and pruritus → liver
failure, cirrhosis, portal HTN
AMA → destruction of intra-hepatic bile ducts → gradual
jaundice and pruritus → liver
failure, cirrhosis, portal HTN
tumor of bile ducts → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)

cystic dilation of biliary tree →
RUQ mass/pain, jaundice, fever
iatrogenic injury → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
motor dysfxn of sphincter of
Oddi → recurrent biliary colic
w/o stones

Other
Boas sign: referred right scapular
pain of biliary colic
Charcot triad: RUQ pain, fever,
jaundice
Reynold pentad: Charcot triad +
∆MS, hypotension
Gallstone ileus: gallstone enters
bowel through cholecystenteric
fistula → gets stuck in terminal
ileum → SBO

• Tx reassurance
• Tx elective lap chole
• Tx NPO, IVF, abx → lap chole within 24 hrs

• Tx NPO, IVF, ±abx → ERCP to remove stone
• if amylase returns to normal → Tx lap chole
• if amylase elevated → ERCP to remove stone

• Tx NPO, IVF, abx → ERCP to decompress CBD
• → finally lap chole
• Tx NPO, IVF, abx → lap chole within 24 hrs;
• perc drain w/ cholecystostomy if nonsurgical
• candidate
• Dx CT scan
• Tx radical cholecystectomy (GB + hilar LN +
• liver resection w/ negative margins)
• Dx ERCP (beading of bile ducts)
• Tx cholestyramine (helps w/ pruritus), liver txp
• (definitive)

Porcelain GB: dystrophic
calcification of GB has 50% risk of
adenocarcinoma, take it out
Etiology: idiopathic, but highly
associated w/ UC

• Dx screen w/ AMA (anti-mitochondrial ab),
• confirm w/ liver bx
• Tx ursodeoxycholic acid

2° biliary cirrhosis: progressive
cirrhosis 2/2 biliary obstruction,
sclerosing cholangitis, cystic
fibrosis, or biliary atresia
Etiology: PSC (MCC US),
Chlonorchis sinensis (MCC China)
Klatskin tumor: tumor of
proximal 1/3 of CBD, poor px
since it’s not resectable

• Dx ERCP
• Tx Whipple if resectable

• Dx ERCP
• Tx resection
• Dx ERCP
• Tx endoscopic stent (1st line), surgical bypass
• Dx HIDA scan (fill up GB w/ contrast and give
• CCK to determine ejection fraction)
• Tx lap chole

Complications: 2° biliary cirrhosis,
acute cholangitis, liver abscess

MEDICINE × HEPATOBILIARY/PANCREATIC
PANCREATIC DZ

Dz
Acute pancreatitis

Chronic pancreatitis

Pancreatic cancer

Presentation
stabbing epigastric pain boring
through to the back

Management
• Dx screen w/ ↑lipase, confirm w/ CT scan
• Tx NPO/IVF/pain meds

Hemorrhagic pancreatitis:
presents as MSOF, ARDS, hemodynamic instability, signs of
ecchymoses (Grey-Turner, Fox,
Cullen signs)
Pancreatic abscess: presents as
abd pain and early satiety 2 wks
s/p acute pancreatitis
Pseudocyst: presents as abd
pain and early satiety 5 wks s/p
acute pancreatitis
chronic epigastric pain,
steatorrhea, diabetes mellitus

• Dx CT scan
• Tx admit to ICU for close monitoring

dull abd pain + s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)

• Dx CT scan
• Tx perc drain + IV abx
• Dx CT scan
• Tx observation (<5 cm), perc drain (>5 cm)
• Dx stool elastase test
• Tx insulin + pancreatic enzyme replacement,
• IVF/NPO/pain meds for acute attacks
• Dx CT scan
• cancer in head → Tx Whipple
• cancer in body or tail → Tx distal
• pancreatectomy
• mets or local invasion → palliative care
• f/u tumor markers CA 19-9, CEA

Other
Etiology: I GET SMASHED –
idiopathic, gallstones (#1), EtOH
(#2), trauma, steroids, mumps,
autoimmune, scorpion sting,
hypertriglyceridemia (#3),
hypercalcemia, ERCP, drugs
Grey-Turner sign: flank
ecchymoses
Cullen sign: periumbilical
ecchymoses
Fox sign: ecchymoses of inguinal
ligament
Etiology: alcoholism (MCC
adults), cystic fibrosis (MCC kids)
Trousseau phenomenon:
migratory SVT in 10% of
pancreatic cancer pts
Courvoisier sign: palpable GB
w/o pain in 30% of cancer pts

MEDICINE × ENDOCRINE
THYROID DZ

Dz
Thyroglossal duct cyst
Hyperthyroidism

Thyroid storm

Hypothyroidism

Myxedema coma

Thyroid nodules

Presentation
remnant of thyroglossal duct →
mobile midline neck mass
Graves disease (diffuse toxic
goiter): autoimmune dz due to
TSI (anti-TSH) → hyperthyroid
sx, exophthalmos, thyroid
bruits, pretibial myxedema
Plummer disease (toxic
multinodular goiter): multiple
hyperfunctioning areas in
thyroid → hyperthyroid sx
Toxic adenoma: single hyperfunctioning nodule → hyperthyroid sx
precipitating factor (stress,
infx) → hyperthyroidism
exacerbation → marked fever,
tachycardia, agitation, GI sx
Hashimoto thyroiditis:
autoimmune dz w/ lymphocytic
infiltration → hypothyroid sx
De Quervain thyroiditis: painful
granulomatous inflammation
following viral URI → hypothyroid sx
Acute thyroiditis: painful,
swollen, tender thyroid mass
due to Staph/Strep infx → hypothyroid sx
Riedel thyroiditis: firm, painless
thyroid → hypothyroid sx
precipitating factor (stress,
infx) → hypothyroidism
exacerbation → marked
hypothermia, ∆MS, respiratory
depression
thyroid nodule found on
physical exam

Management
• Tx Sistrunk operation (take out cyst, trunk, and
• medial portion of hyoid bone)
• Dx ↓TSH, ↑free T4
• Tx PTU (pregnant), methimazole (not
• pregnant), oral radioiodine (can become
• hypothyroid), subtotal thyroidectomy
• (permanent)
• Dx ↓TSH, ↑free T4 + patchy uptake on T3 scan
• Tx oral radioiodine (<2 cm), subtotal
• thyroidectomy (>2 cm)

Other

Hyperthyroidism in elderly:
presents as weakness, weight
loss, atrial fibrillation

• Dx ↓TSH, ↑free T4 + hot nodule on T3 scan
• Tx oral radioiodine (<2 cm), lobectomy (>2 cm)
• Tx β-blockers + antithyroid drugs

Px: 20% mortality rate

• Dx ↑TSH, ↓/nl free T4
• Tx Synthroid

Hashimoto abs: anti-TSH, antimicrosomal, anti-thyroglobulin,
anti-peroxidase (TPO)

• Dx ↑TSH, ↓/nl free T4
• Tx NSAIDs + observation (will self-resolve)

• Dx ↑TSH, ↓/nl free T4
• Tx I+D

• Dx ↑TSH, ↓/nl free T4
• Tx Synthroid vs. surgery
• Tx IV thyroxine + hydrocortisone + supportive
• care

Dx TSH (normal)

MC type: benign colloid nodule
Malignancy signs: solid nodules,
cold nodules (lack of radioiodine
uptake), size >1.5 cm

Dx FNA
benign

indeterminate

malignant

Dx thyroid scan
hot

Thyroid cancer

thyroid nodule or mass found
on physical exam; 80% papillary,
15% follicular, 4% medullary, 1%
anaplastic
Papillary cancer: lymphatic
spread, “Psamomma bodies w/
Orphan Annie nuclei”, best px
Follicular cancer: hematogenous spread, endemic to
iodine-deficient areas
Medullary cancer: lymphatic
and hematogenous spread,
amyloid deposits
Anaplastic cancer: rare, worst
px
Hürthle cell cancer: aggressive ,
lymphatic-spreading variant of
follicular cancer

cold

observation
Tx surgery
• Dx FNA (for all types except follicular, must
• see capsular invasion for adenoma/carcinoma)

• Tx total thyroidectomy w/ central LN excision
• → modified radical neck dissection if +LN
• f/u thyroglobulin levels
• Tx hemilobectomy + frozen bx → total
• thyroidectomy if bx shows carcinoma
• f/u thyroglobulin levels
• Tx total thyroidectomy w/ central LN excision
• → modified radical neck dissection if +LN
• f/u calcitonin levels + 24-hr urinary VMA
• (MEN2 syndrome also has pheos)
• Tx palliative care
• Tx total thyroidectomy w/ central LN excision
• → modified radical neck dissection if +LN
• f/u thyroglobulin levels

Risk factors: Post-radiation
(Papillary), MEN2 syndrome
(Medullary)
Px: MACIS system – Metastasis,
Age (<45), Completeness of
resection, Invasion, Size (>2 cm)
Surgery complications: recurrent
laryngeal nerve (hoarseness),
superior laryngeal nerve (soft,
deep voice), parathyroid glands
(hypocalcemia)

MEDICINE × ENDOCRINE
PARATHYROID DZ

Hypocalcemia sx: neuromuscular irritability (tingling, tetany), prolonged QT, arrhythmias
Hypercalcemia sx: stones (kidney)
bones (bone pain, osteitis fibrosa cystica)
groans (peptic ulcers, pancreatitis)
psychic overtones (depression, anxiety, ∆MS)
Dz
Hypoparathyroidism

Presentation
head/neck surgery → accidental
PTH-ectomy → hypocalcemia sx

Management
• Dx ↓PTH, ↓Ca, ↑P
• Tx vit D + calcium replacement

Pseudohypoparathyroidism

end-organ resistance to PTH →
hypocalcemia sx

• Dx ↑PTH, ↓Ca, ↑P
• Tx vit D + calcium replacement

1° HPTH

90% adenoma, 9% hyperplasia,
1% carcinoma → hypercalcemia
sx

2° HPTH

renal failure → ↓1α-hydroxylase
→ ↓vit D → ↓Ca →
compensatory ↑PTH
2° HPTH pts get renal txp but
parathyroid glands still
hypersecretory despite ↑Ca
Ca >15

• Dx ↑PTH, ↑Ca, ↓P + Cl:P ratio >33:1
• Tx surgery (adenoma → take it out,
• hyperplasia → 3½ gland removal, carcinoma
• → en bloc resection of parathyroid and ipsi
• thyroid lobe)
• Dx ↑↑PTH, ↓Ca, ↑P
• Tx vit D + calcium replacement, low P diet

3° HPTH

Hypercalcemic crisis

PITUITARY DZ

Other
Chvostek sign: tapping on Cheek
causes muscle contractions
Trousseau sign: inflating BP cuff
causes carpal muscle spasms
DiGeorge syndrome: thyroid +
parathyroid hypoplasia
Knuckle-knuckle-dimple-dimple
sign: hand morphology seen w/
pseudohypoparathyroidism

• Dx ↑PTH, ↑Ca, ↓P
• Tx observation for 1 year, then 3½ gland
• excision if still problematic
• Tx “flush and drain” (NS then Lasix), then
• surgery for parathyroid carcinoma

Polyuria/polydipsia DDx: DM, DI, diuretic use, primary polydipsia (Ψ d/o)
Dz
Pituitary adenoma

Craniopharyngioma

Diabetes insipidus (DI)

SIADH

Presentation
tumor of anterior pituitary
gland → bitemporal hemianopsia (◐◑) + hyperpituitary
or hypopituitary sx
Prolactinoma: ↑PRL →
galactorrhea, amenorrhea,
infertility, ↓libido
Acromegaly: ↑GH →
overgrowth of brow, jaw,
hands, and feet; MCC death is
CV disease
Pituitary Cushing: ↑ACTH →
truncal obesity, abd striae,
buffalo hump, hyperglycemia,
osteoporosis, HTN, immunosuppression
Hypopituitarism: ↓FSH/LH,
↓ACTH, ↓TSH, ↓PRL, ↓GH
embryological remnant of
Rathke pouch → bitemporal
hemianopsia (◐◑), headache,
papilledema, ∆MS
polyuria, polydipsia

Central DI: ↓ADH secretion from
posterior pituitary
Nephrogenic DI: normal ADH
but kidneys don’t respond
↑ADH secretion from posterior
pituitary → volume expansion,
hyponatremia (coma/sz/death if
acute, asx if chronic)

Management
• Dx MRI

Other

• Dx ↑PRL + β-HCG/TSH (r/o 2° causes)
• Tx bromocriptine or cabergoline (<1 cm),
• transsphenoid hypophysectomy (≥1 cm)
• Dx oral glucose test
• Tx transsphenoid hypophysectomy +
• octreotide (suppress GH)
• Dx ↑ACTH + dexa suppression test (pituitary
• Cushing is suppressable)
• Tx transsphenoid hypophysectomy

• Dx hormone levels
• Tx hormone replacement
• Dx MRI (supracellar calcified cysts)
• Tx transsphenoid hypophysectomy

• Dx water deprivation test (normal pts increase
• urine osm >280, central DI <280 but normalize
• w/ ADH, nephrogenic DI <280 and don’t
• normalize w/ ADH)
• Tx DDAVP
• Tx HCTZ
• Dx Na <135, plasma osm <270
• Tx water restriction

Central pontine myelinolysis:
rapid correction of hyponatremia
will cause demyelination and
locked-in syndrome, so replace
Na at a max of 0.5/hr

MEDICINE × ENDOCRINE
ADRENAL DZ

Dz
Cushing syndrome

Presentation
↑cortisol → truncal obesity, abd
striae, buffalo hump,
hyperglycemia, osteoporosis,
HTN, immunosuppression

Management

Other
Cushing syndrome

Dx ACTH, cortisol,
dexamethasone suppression test
↑ACTH, ↑cortisol

↓ACTH, ↑cortisol
adrenal Cushing
(Dx abd CT)

>50% suppression

Pheochromocytoma

1° hyperaldosteronism (Conn
syndrome)
Adrenal insufficiency

Congenital adrenal hyperplasia

Incidentaloma

PANCREATIC DZ

Dz
Insulinoma

Gastrinoma (ZE syndrome)

Glucagonoma

Somatostatinoma
VIPoma

MEN SYNDROME

Dz
MEN 1 (Wermer syndrome)

MEN 2A (Sipple syndrome)

MEN 2B

Pituitary Cushing: ↑ACTH
secretion from pituitary gland
Adrenal Cushing: ↑cortisol
secretion from adrenal gland
Ectopic Cushing: ↑ACTH
secretion from SCLC
(paraneoplastic syndrome)
Iatrogenic Cushing: MCC
0verall, d/t exogenous steroids
episodic catecholamine excess
→ 5 Ps – Pressure (BP), Pain
(HA), Perspiration, Palpitations,
Pallor
67% adenoma, 33% hyperplasia
→ ↑aldosterone → ↑Na (HTN),
↓K, ↓H (metabolic alkalosis)
↓cortisol/↓aldosterone →
hypoglycemia, HTN, fatigue,
hyperpigmentation, weight
loss, abd pain
1° adrenal insufficiency
(Addison disease): autoimmune
(MC US), TB (MC 3rd world),
Waterhouse-Friderichsen
syndrome (N. meningitidis)
2° adrenal insufficiency: due to
abrupt cessation of steroid use
(MCC overall)
congenital deficiency of 21αhydroxylase (MC) or 11βhydroxylase → hirsutism,
virilization, ↓Na/↑K/↑H
adrenal tumor found
incidentally on CT scan

Presentation
↑insulin → Whipple’s triad
(hypoglycemia, worse w/
fasting, better w/ glucose)
↑gastrin → ↑gastric acid
secretion → ulcers

↑glucagon → new-onset
diabetes + necrolytic migratory
erythema
↑SST → triad of gallstones,
diabetes, steatorrhea
↑VIP → “rice water” diarrhea

Presentation
pituitary adenoma, pancreatic
endocrinoma (MC gastrinoma),
parathyroid hyperplasia
parathyroid hyperplasia,
pheochromocytoma, thyroid
medullary cancer
pheochromocytoma, thyroid
medullary cancer, mucosal
neuromas, Marfanoid habitus

<50% suppression

pituitary Cushing
ectopic Cushing
(Dx head MRI)
(Dx chest/abd CT)
• Tx transsphenoid hypophysectomy
• Tx adrenalectomy
• Tx underlying cause

• Tx taper steroids slowly
• Dx 24 hr urinary VMA/metanephrines
• Tx α-blockers (phenoxybenzamine) then
• β-blockers then adrenalectomy

Rule of 10’s: 10% malignant, 10%
bilateral, 10% extraadrenal, 10%
calcify, 10% kids, 10% familial
(MEN2A/2B)

• Dx abd CT scan
• Tx adrenalectomy (adenoma), spironolactone
• (hyperplasia)
• Dx ↓cortisol + ACTH levels (↑ACTH if primary,
• ↓ACTH if secondary)

• Tx glucocorticoid (prednisone) +
• mineralocorticoid (fludrocortisone)

• Tx glucocorticoid (prednisone) only

• Dx ↑17-OHP
• Tx glucocorticoid (prednisone) +
• mineralocorticoid (fludrocortisone)
• <5 cm → leave alone
• >5 cm → Tx resection + check other organs
• since adrenals are common site of metastasis

Management
• Dx ↑C-peptide levels or monitored fasting (to
• see if they’re “faking it”)
• Tx resection
• Dx gastrin levels (<200 absent, >500 present);
• if 200-500, get secretin stimulation test
• (paradoxical ↑gastrin w/ secretin)
• Tx resection
• Dx glucose challenge test
• Tx resection

Other

Gastrinoma triangle: neck of
pancreas, cystic duct, junction
b/t 2nd and 3rd part of duodenum

• Tx resection
• Tx resection

Management
• Tx excise parathyroid first (since hyper
• calcemia can cause ↑gastrin), then gastrinoma,
• then pituitary adenoma (w/ cabergoline)
• Tx excise pheo first (life-threatening)

Other

• Tx excise pheo first (life-threatening)

Etiology: AD ret proto-oncogene

Etiology: AD ret proto-oncogene

MEDICINE × ENDOCRINE
DIABETES MELLITUS

Dz
Impaired glucose tolerance
T1DM

T2DM

Presentation
asx
autoimmune destruction of βcells → lack of insulin → pt
usually presents in acute DKA
obesity → ↑FFA release →
↑insulin resistance → ↑glucose
→ classic sx (polyuria, polydipsia, polyphagia) + blurry
vision, weight loss, recurrent
vaginal yeast infx

Management
• Dx fasting glc 110-126
• Tx insulin, 0.5-1 u/kg (2/3 morning, 1/3 evening)
• inpatient → Tx SSI

Other

• Dx fasting glc >126, random glc >200 w/ sx, or
• HbA1C >6.5%

Ideal levels: HbA1c <7%, fasting
glc <130, post-prandial glc <180,
BP <130/80, LDL <100

T2DM
fasting glc <240
lifestyle changes
(still high)
Tx metformin or
sulfonylurea
(still high)
add another PO drug

DM complications

DKA

HHNS

Hypoglycemia

Macrovascular complications:
nonenzymatic glycosylation
(NEG) → atherosclerosis →
CAD, MI, PVD, stroke/TIA, etc.
Diabetic nephropathy: NEG of
basement membrane → loss of
negative charge → microalbuminuria → proteinuria →
CKD → ESRD
Diabetic retinopathy: NEG of
retinal vx → either background
or proliferative retinopathy
Diabetic neuropathy: NEG of
peripheral nerves → damage →
“stocking/glove” burning pain,
numbness, tingling
Diabetic foot: peripheral
neuropathy + PVD (ischemia) →
repetitive injuries → ulcers and
nonhealing
T1DM exacerbation → ↓insulin
→ hyperglycemia + ketosis →
osmotic diuresis, dehydration,
fruity breath, Kussmaul
respiration, etc.
T2DM exacerbation → ↓insulin
→ hyperglycemia → hyperosmolarity, osmotic diuresis,
severe dehydration
↓glc → ↑epinephrine
(sympathetic sx), CNS
dysfunction at 40-50 (HA,
weakness, drowsiness, coma)

fasting glc >240

Insulin dosage: “basal bolus” –
long-acting Lantus + short-acting
Novolog w/ meals

Tx insulin
(still high)

Outpatient mgmt: q day – glucose
q visit – BP, foot chk
q 3 mo – HbA1c
q 6 mo – neuropathy chk
q yr – microalbuminuria,
BUN/Cr, lipids, eye chk
• PPx reduction of risk factors (BP, lipids,
• smoking, diet, exercise)

Microalbuminuria: 20-200
μg/min or 30-300 mg/day

• PPx annual microalbuminuria screening
• Tx ACE inhibitors

• PPx annual ophtho referral
• Tx photocoagulation
• neuropathy → Tx amitriptyline (1st line),
• gabapentin or duloxetine (2nd line)
• gastroparesis → Tx metoclopramide
• PPx regular foot check
• Tx wound care, amputation (last resort)

• Dx ↑glc, ↑ketones, metabolic acidosis
• Tx insulin + IVF (NS) + potassium (paradoxical)

• Dx ↑glc, ↑osmolarity, no acidosis or ketosis
• Tx insulin + IVF (NS)

• Dx ↓glc
• Dx C-peptide, insulin levels, anti-insulin ab, and
• sulfonylurea levels (look for underlying cause)
• Tx underlying cause + sugary foods or IV D50W

Etiology: insulin overdose (MCC),
factitious hypoglycemia (low Cpeptide levels), insulinoma, etc.

MEDICINE × NEURO
STROKE

Stroke types: ischemic (85%), hemorrhagic (15%)
Stroke in young pt: cocaine abuse
Carotid bruit: either internal carotid artery stenosis, or referred heart murmur
Dz
Subclavian steal syndrome

Transient ischemic attack (TIA)

Ischemic stroke

Hemorrhagic stroke

HEAD TRAUMA

Presentation
asx at rest, but arm claudication
and CNS sx with exercise due to
stenotic subclavian artery (can
present like a TIA)
focal neuro sx <24 hrs (usually
<1 hr)
Carotid TIA: abrupt
contralateral sx
Vertebrobasilar TIA: ipsilateral
CN palsy, contralateral
hemiplegia
Drop attacks: brief paralytic
spells resulting in pt dropping
to knees w/o LOC
Transient global amnesia: TIA in
temporal lobes or thalamus →
rapid retrograde memory loss +
confusion but preservation of
self-identity
Amaurosis fugax: TIA in retinal
artery → temporary unilateral
loss of vision
focal neuro sx >24 hours
ACA syndrome: contralateral
leg hemiparesis, incontinence
MCA syndrome: contralateral
face/arm hemiparesis
PCA syndrome: homonymous
hemianopia
Vertebrobasilar syndrome:
ipsilateral CN palsy,
contralateral hemiplegia
Cerebellar infarction:
headache, nausea, vomiting,
vertigo, nystagmus
Lacunar syndromes: pure
motor or sensory stroke, clumsy
hand-dysarthria syndrome
ICH: bleeding into brain
parenchyma → focal neuro sx +
sudden headache + vomiting
SAH: rupture of berry aneurysm
→ bleeding into subarachnoid
space → “worst headache of my
life”

Management
• Dx arteriogram
• Tx bypass surgery

Other

• CV risk factor analysis, since risk of stroke is
• much higher in the near future
• anterior circle TIAs → Dx carotid duplex;
• consult surg for CEA if ≥70% stenosis

• Dx head CT w/o contrast (dark areas)
• Tx TPA <3 hrs, aspirin ≥3 hrs or TPA c/i
• AFib-related stroke → Tx heparin/warfarin
• lacunar strokes → Tx control HTN
• anterior circle strokes → Dx carotid duplex;
• consult surg for CEA if ≥70% stenosis

• Dx head CT w/o contrast (white areas)
• Tx intubate and hyperventilate, slowly lower
• BP, control ↑ICP w/ mannitol, admit to ICU
• Dx head CT w/o contrast (white areas),
• do an LP if not sure (blood, xanthrochromia)
• Tx bed rest in dark/quiet room, analgesics for
• headache, nifedipine for vasospasm ppx,
• consult neurosurg to clip berry aneurysm

Risk factors: HTN (#1), old age
(#2), CAD, CHF, acute MI, AFib,
diabetes, male sex, Black race,
smoking, alcohol, OCPs
Etiology: embolic stroke (AFib,
endocarditis), thrombotic stroke
(atherosclerosis), lacunar stroke
(HTN)

Risk factors: HTN (#1)

Basal skull fx: raccoon eyes, hemotympanum, otorrhea, rhinorrhea, ecchymosis behind the ear (Battle sign)
Coup-contrecoup injury: injury at site of impact + opposite point of impact
Diffuse axonal injury: global damage to entire brain during impact → severe neuro dysfxn, coma
Dz
EDH

SDH

Concussion

Presentation
temporal bone fx → tear in
middle meningeal artery →
bleeding into epidural space →
LOC w/ lucid interval
tear in bridging veins → venous
bleed into subdural space →
∆MS, headache, cortical dysfxn,
possible herniation if acute
brief LOC following blunt head
trauma w/ confusion, dizziness,
impaired concentration, etc.

Management
• Dx head CT (convex lens hematoma)
• Tx emergent craniotomy

Other

• Dx head CT (crescent moon hematoma)
• Tx craniotomy (acute), reassurance (chronic)

Risk factors: shrunken brain
states (alcoholics, elderly)
SDH in kids: consider child abuse

• no tx available

MEDICINE × NEURO
MOVEMENT D/O

Movement d/o in young pt: consider Wilson disease
Dz
Parkinson disease (PD)

Presentation
loss of dopaminergic neurons
→ early PD presents as TRAP –
pill-rolling Tremor, cogwheel
Rigidity, Akinesia, Postural
instability; late PD presents as
Alzheimer-like dementia

Management
• early PD → Tx Sinemet (carbidopa + levodopa)
• late PD → Tx subthalamic nucleus deep brain
• stimulation

Huntington chorea

AD CAG trinucleotide repeats on
chromosome 4 → ↓GABA →
chorea, apathy, depression,
dementia w/ onset at 35-50 y/o

• Dx MRI (caudate atrophy), DNA testing
• no tx available

Other
PD brain: neuronal death in
substantia nigra, senile plaques,
Lewy bodies
Shy-Drager syndrome: PD +
autonomic insufficiency
Progressive supranuclear palsy
(PSP): PD w/o ophthalmoplegia
or tremors

Anticipation: longer CAG repeats
correlates with earlier age of
onset
Essential tremor

Ataxia

Tourette syndrome

AD tremor w/ intentional
activity but not at rest,
improved w/ EtOH use
gait instability, loss of balance,
impaired limb coordination
Acquired ataxia: ataxia 2/2
EtOH, B12/thiamine deficiency,
cerebellar dz, demyelinating dz,
or 3° syphilis
Friedreich ataxia: ataxia w/
staggering gait, nystagmus, pes
cavus and hammer toes
Ataxia-telangiectasia:
Friedreich ataxia +
telangiectasias
most severe tic disorder w/
multiple daily motor/vocal tics,
onset before 18 y/o; associated
w/ OCD and ADHD

• Tx β-blockers

• Tx underlying cause

• Tx clonidine or pimozide (Haldol if severe)

Coprolalia: involuntary swearing,
pathognomonic but rare in
Tourette syndrome

MEDICINE × NEURO
DEMENTIA

Normal aging vs. dementia: no impairment of daily functioning w/ normal aging
Delirium vs. dementia:
Delirium
Dementia
Definition

Onset
Duration
Px
Amnesia
Alert
Oriented
Dx

waxing-andwaning change in
pt’s level of
consciousness
acute
3 days – 2 wks
reversible
immediate and
recent memory
no
no
abnormal EEG

impairment in
memory and
other cognitive
functions
chronic
months – yrs
irreversible
recent and
remote memory
yes
sometimes
abnormal MRI

Dementia: progressive and irreversible impairment in memory and other cognitive functions w/o change in level of consciousness
Causes of dementia: Alzheimer (#1), vascular (#2), Lewy body (#3), others
Dz
Pseudodementia
Secondary dementia

Alzheimer disease (AD)

Vascular dementia

Lewy body dementia

Pick disease (frontotemporal
dementia)

HIV-associated dementia

Creutzfeldt-Jakob disease

Normal pressure hydrocephalus

Presentation
severe depression that can
present like dementia in elderly
dementia 2/2 hypothyroidism,
B12/folate deficiency, thiamine
deficiency, neurosyphilis, or
medication use
↓ACh → gradual progressive
decline in memory and other
cognitive functions

Management
• Tx SSRIs

accumulation of multiple small
infarcts → stepwise loss of
function + focal neurological sx
Lewy body and neurite
accumulations in the basal
ganglia → dementia, waxingand-waning parkinsonism,
visual hallucinations, sensitivity
to antipsychotics
profound changes in
personality and social conduct,
disinhibition, hyperorality,
hypersexuality; good memory
and language though
neutropenia → infection →
rapid decline in memory,
cognition, behavior, motor
skills; depression and social
withdrawal also common
abnormal prion accumulation
→ rapidly progressive
dementia, myoclonus (muscle
spasms), personality changes
3 Ws – Wet (urinary
incontinence), Wobbly (gait
apraxia), Wacky (dementia)

• Dx MMSE (<25), head CT (multiple small
• lacunar infarcts)
• no tx available
• Dx MMSE (<25), clinical judgment
• manage like Alzheimer disease

Other

• Tx underlying cause

• Dx MMSE (<25), head CT (diffuse atrophy w/
• enlarged ventricles, flat sulci)
• r/o secondary causes
• Tx AChE-inhibitors for mild/moderate AD
• (tacrine, donepezil), NMDA antagonist for
• severe AD (memantine)

• Dx MMSE (<25), head CT (marked atrophy of
• frontal and temporal lobes)
• no tx available

• Tx HAART

• Dx EEG (generalized sharp waves), confirm w/
• postmortem brain bx (spongiform change)

• Dx MRI (large ventricles)
• Tx CSF shunt

Amyloid cascade hypothesis:
high risk genes (presenilin I,
presenilin II, APP, apoE4) can
predispose to Aβ-amyloidosis
Alzheimer × Down syndrome:
trisomy 21 → triple apoE4
expression → inevitable by 40
y/o

MEDICINE × NEURO
ALTERED MS

ICP: normally 5-15; ICP >20 → bilateral fixed/dilated pupils → herniation → death
Cushing triad: triad of vital signs in ICP – ↑BP, ↓HR, irregular RR
Glasgow coma scale: GCS score = E+M+V / 15
Abnl pupillary light reflex: mass lesions, pupil drugs, hypoxia, eye drops
Bilateral fixed/dilated pupils: severe anoxia
Unilateral fixed/dilated pupil: herniation w/ CN III compression
Pinpoint pupils: narcotics, ICH (in pons)
Dz
Delirium

Coma

“Locked in” syndrome

Brain herniation

Presentation
waxing-and-waning change in
level of consciousness; can also
have visual hallucinations, short
attention span, and impaired
recent memory
Sundowning: worsening of
delirium at night
damage to RAS or bilateral
hemispheres → depressed LOC,
unresponsive to any stimuli
damage to ventral pons →
coma-like state but pt is fully
conscious and can control
blinking, vertical eye movement
edema or mass lesion → ↑ICP
→ brain tissue moves past
anatomic barriers

Management
• Dx MMSE (<25)
• r/o life-threatening causes, then ID and Tx
• underlying cause

Other
Etiology: AEIOU TIPSS – Alcohol
and drug toxicity or withdrawal,
Electrolyte imbalance,
Iatrogenic, Oxygen hypoxia,
Uremia/hepatic encephalopathy,
Trauma, Infection, Poison,
Seizures, Stroke

• Dx GCS (≤8)
• r/o life-threatening causes, then ID and Tx
• underlying cause
---

• Dx head CT
• Tx intubate, lower ICP, consult neurosurg

CN III: ipsilateral “blown pupil”
PCA: contralateral
homonymous hemianopia
Crus cerebri: ipsilateral paresis
Brainstem: Duret hemorrhages,
death

DEMYELINATING DZ

CNS NEOPLASMS

Brain death

irreversible absence of brain
function despite adequate
oxygenation/ventilation, no
brainstem reflexes

• Dx EEG (no activity)
• d/c life support

Dz
Multiple sclerosis

Presentation
selective CNS demyelination →
optic neuritis, intranuclear
ophthalmoplegia (crazy eyes),
transient sensory deficits, etc.

Management
• Dx MRI (multiple white plaques), LP w/ CSF
analysis (oligoclonal bands)
• Tx IFN-β (prevent relapses), high-dose steroids
(for acute attacks)

Guillain-Barré syndrome

rapid PNS demyelination →
ascending weakness/paralysis,
possible respiratory arrest

• Dx CSF (↑protein), EMG (↓nerve conduction)
• Tx IVIG vs. plasmapheresis

Other

Ring-enhancing lesions: MALT – metastases, abcesses, lymphoma, toxo
Brain cancer sx: mass effect → headache, seizures, focal neuro sx
MC brain cancers: metastases (overall), astrocytoma (adults), infratentorial tumors (kids)
Dz
GBM

Astrocytoma
Oligodendroglioma
Meningioma
Acoustic schwannoma
CNS metastases
Primary CNS lymphoma
Meningeal carcinomatosis

Buzzwords
can cross corpus callosum
(butterfly glioma), pseudopalisading necrosis, GFAP+
Rosenthal fibers, GFAP+
“fried egg” cells, chicken-wire
capillary pattern
Psamomma bodies, attached to
dura
S-100+, CN VIII
multiple ring-enhancing lesions
AIDS/immunosuppression
cancer that metastasizes to
meninges via bloodstream →
focal neuro sx, meningitis,
hydrocephalus

Management
• Dx MRI
• Tx resection (if resectable), radiation
• (astrocytomas, oligodendrogliomas,
• lymphoma, metastases)

Other

Bilateral schwannoma: NF type 2
Mets source: lung > breast > skin
> kidney > colon
• Dx LP w/ CSF analysis (malignant cells)
• Tx intrathecal chemotherapy

MEDICINE × NEURO
NEUROMUSCULAR DZ

Dz
Myasthenia gravis

Presentation
anti-nAChR → gradually
progressive muscle weakness
(initial sx is ptosis, diplopia,
blurry vision) that get worse w/
repetitive muscle use

Lambert-Eaton myasthenic
syndrome (LEMS)

SCLC → anti-VGCC → gradually
progressive muscle weakness
that get better w/ repetitive
muscle use
XR ∆dystrophin → muscle cells
die off → ascending weakness
w/ Gowers maneuver, calf
pseudohypertrophy, death by
15 y/o
XR ∆dystrophin → same as
DMD, but later onset and less
severe sx

Duchenne muscular dystrophy

Becker muscular dystrophy

NEUROCUTANEOUS
SYNDROMES

Dz
Neurofibromatosis type I
(von Recklinghausen disease)
Neurofibromatosis type II
Tuberous sclerosis

Sturge-Weber syndrome
Von Hippel-Lindau disease

SPINAL CORD DZ

Presentation
AD ∆NF1 → café-au-lait spots,
Lisch nodules (iris hamartomas),
CNS tumors, pheo
AD ∆NF2 → bilateral acoustic
neuromas, juvenile cataracts
AD ∆TSC1/2 → CNS/retinal
hamartomas, sebaceous
adenomas, hypopigmented
“ash leaf spots”, Shagreen
patches, renal angiomyolipoma, cardiac rhabdomyoma
facial “port-wine stain” w/
ipsilateral brain AVM
AD ∆VHL → hemangioblastomas, bilateral RCC,
pheochromocytomas

Management
• Dx ↑anti-nAChR (best), edrophonium test,
• EMG (decreased response w/ repetitive
• stimulation), chest CT to look for thymoma
• Tx pyridostigmine, plasmapheresis (if severe),
• thymectomy (if thymoma)

Other

• myasthenic crisis → emergent ventilation
• Dx ↑anti-VGCC
• Tx underlying cause

• Dx ↑CPK, DNA testing
• no tx available

• Dx ↑CPK, DNA testing
• no tx available

Management
• NF pt w/ HTN → Dx urinary metanephrines

Other

-----

-----

CS tract: descending motor signals, crosses at medulla
DCML tract: ascending touch and proprioception, crosses at medulla
ALS tract: ascending pain and temperature, crosses in spinal cord
Dz
Syringomyelia

Presentation
central cavitation of cervical
cord → bilateral “cape-like”
loss of ALS, ipsilateral CS

Management
• Dx MRI
• Tx syringosubarachnoid shunt

Brown-Sequard syndrome

stab wound → spinal cord
hemisection → ipsilateral loss
of DCML and CS, contralateral
loss of ALS

---

Transverse myelitis

viral infx → loss of function of
entire spinal cord at a single
level → bilateral loss of
CS/DCML/ALS below level of
lesion + sphincter dysfunction
polio infx (fecal-oral) →
bilateral lower motor neuron
loss of function → asymmetric
muscle weakness w/ normal
sensation

• Dx MRI
• Tx high-dose steroids

Poliomyelitis

• PPx vaccination

Other

MEDICINE × NEURO
OTHER CNS DZ

Syncope vs. seizures: prolonged LOC or bowel/bladder incontinence indicates seizures
Dz
Vertigo

Presentation
“spinning of the room”, five
types (BLAME) – BPPV,
Labyrinthitis, Acoustic
neuroma, Meniere disease,
EtOH/drug-induced
Cardiac syncope: sudden LOC
w/o prodromal sx; d/t massive
MI, arrhythmias, or obstruction
(e.g. aortic stenosis)
Vasovagal syncope: paradoxical
PSNS activity during intense
emotion → LOC w/ premonitory
sx (pallor, sweating, nausea)
Orthostatic hypotension: delay
in peripheral venoconstriction
→ LOC w/ sudden or prolonged
standing
Simple partial sz: transient
unilateral movements w/o LOC
Complex partial sz: transient
automatisms w/ LOC →
postictal confusion
Grand-mal sz: sudden LOC →
rigidity (tonic phase) →
musculature jerking (clonic
phase) → postictal confusion
Absence sz: “staring into
space” for a few seconds

Management
• Tx underlying cause + meclizine for nausea

Amyotrophic lateral sclerosis
(Lou Gehrig disease)

upper and lower motor neuron
lesions → progressive muscle
weakness → death in 5-10 yrs

• Dx EMG (fasciculations, fibrillations), nerve
• conduction studies (↓conduction velocity)
• Tx supportive care + riluzole (glutamate• antagonist that delays death by 3-5 months)

Aphasia

Wernicke aphasia: superior
temporal gyrus lesion → fluent
w/ impaired comprehension
Broca aphasia: inferior frontal
gyrus lesion → nonfluent w/
intact comprehension
Conduction aphasia: both gyri
lesion → nonfluent w/ impaired
comprehension
Global aphasia: arcuate
fasciculus lesion → can’t repeat
“no ifs, ands, or buts”
weakness or paralysis of facial
muscles innervated by CN VII

• usually resolves on its own

Etiology: stroke (#1), trauma,
tumors, Alzheimer dz

• usually resolves on its own
• Tx steroids if ≥10 days, ACV if shingles,
• doxycycline if Lyme disease

Etiology: trauma, Lyme disease,
tumors, Guillan-Barre syndrome,
shingles

Syncope

Seizures

Bell palsy

Trigeminal neuralgia (tic
douloureux)

Bilateral Bell: Lyme disease or
Guillain-Barre syndrome
severe, recurrent pain attacks in
trigeminal distribution

Other

• first step is to r/o cardiac causes (get EKG,
• CV-focused physical)
• cardiac syncope → Tx underlying cause
• vasovagal syncope → Dx tilt-table study,
• Tx β-blockers + disopyramide
• orthostatic hypotension → Dx orthostatics,
• Tx fluid/sodium intake

• first time → Dx labs (renal panel, glucose) +
• EEG + MRI (r/o mass lesions)
• epileptic → check anticonvulsant levels
• partial sz → Tx phenytoin or CBZ
• grand-mal sz → Tx phenytoin or CBZ
• absence sz → Tx ethosuximide

• Tx CBZ

Etiology: 4 Is + 4 Ms – Infx,
Ischemia (stroke/TIA), ↑ICP,
Intoxication, Metabolic and
electrolytes, Mass lesions,
Missing drugs (anticonvulsants,
sedatives/EtOH), Misc
Pseudoseizure: looks like sz but
no EEG changes
Secondary generalization:
partial sz → generalized sz
Status epilepticus: brain is stuck
in a state of persistent seizure

MEDICINE × MSK
BUZZWORDS

HLA-B27: PAIR – psoriatic arthritis, ankylosing spondylitis, IBD, Reiter syndrome
HLA-DR2: SLE
HLA-DR3: SLE, Sjögren syndrome
HLA-DR4: Rheumatoid 4rthritis, mixed CT disease
C-ANCA: Wegener granulomatosis
P-ANCA: Churg-Strauss syndrome, microscopic polyangiitis
Anti-basement membrane: Goodpasture syndrome
Anti-CCP: rheumatoid arthritis
Anti-centromere: CREST syndrome
Anti-desmosome: pemphigus vulgaris
Anti-dsDNA: SLE
Anti-endomysial: celiac sprue
Anti-Fc IgG (RF): SLE, RA, many others
Anti-gliadin: celiac sprue
Anti-hemidesmosome: bullous pemphigoid
Anti-histone: drug-induced lupus
Anti-Jo-1: polymyositis/dermatomyositis
Anti-microsomal: Hashimoto thyroiditis
Anti-mitochondrial (AMA): primary biliary cirrhosis
Anti-nAChR: myasthenia gravis
Anti-nuclear (ANA): SLE, RA, many others
Anti-peroxidase: Hashimoto thyroiditis
Anti-Scl-70 (anti-topoisomerase): scleroderma (diffuse)
Anti-Sm: SLE
Anti-smooth muscle: autoimmune hepatitis
Anti-SSA/SSB (anti-Ro/La): Sjögren syndrome
Anti-thyroglobulin: Hashimoto thyroiditis
Anti-TSH (TSI): Graves disease
Anti-U1-RNP: mixed CT disease
Anti-VGCC: Lambert-Eaton myasthenic syndrome

CONNECTIVE TISSUE DZ

Dz
SLE

Drug-induced lupus

Neonatal lupus

APA syndrome

Raynaud disease
Scleroderma (diffuse)
Scleroderma (CREST syndrome)

Sjögren syndrome

Mixed CT disease

Presentation
type 3 HS → flare-and-remission
pattern of I’M DAMN SHARP –
↑IgG
Malar rash
Discoid rash
ANA
Mucositis (throat ulcers)
Neurologic d/o
Serositis (pleuritis, pericarditis)
Hematologic d/o
Arthritis
Renal d/o (“wire loops”)
Photosensitivity
drugs → type 3 HS → SLE-like
presentation but no kidney or
CNS involvement
maternal ag-ab cross placenta
→ lupus sx; anti-SSA attacks
fetal heart → 3° AV block
hypercoagulability in SLE or
other collagen-vascular dz →
high-risk for venous (DVT, PE)
and arterial clots (stroke, MI),
recurrent abortions
digital vasospasm → fingertips
go from blue-to-white-to-red
severe, widespread fibrosis of
skin (sclerodactyly) and viscera
Calcinosis of fingers, Raynaud
phenomenon, Esophageal
dysmotility, Sclerodactyly (only
face and fingers), and
Telangiectasias (over fingers)
autoimmune attack of salivary
and lacrimal glands → dry eyes,
dry mouth, arthritis
“overlap syndrome” of SLE,
RA, scleroderma, polymyositis

Management
• Dx screen w/ ANA, confirm w/ anti-dsDNA,
• anti-Sm, or ↓C3-C5
• Tx low-dose aspirin, corticosteroids for flares,
• cyclophosphamide for lupus nephritis

Other
MC pts: Af-American women

• Dx anti-histone
• Tx d/c meds

Etiology: HIPP – Hydralazine,
INH, Procainamide, Phenytoin

• Tx close management during prenatal care

• Dx lupus anticoagulant or anticardiolipin ab
• Tx anticoagulation (warfarin)

• Tx underlying disorder, keep hands warm,
• Ca-blockers if severe
• Dx anti-Scl-70 (anti-topoisomerase)
• Tx palliative care
• Dx anti-Centromere
• Tx palliative care

• Dx anti-SSA/SSB (anti-Ro/La)
• Tx pilocarpine, artifical tears, oral hygiene
• Dx anti-U1-RNP
• Tx predominant dz

MEDICINE × MSK
ARTHRITIS

Dz
Osteoarthritis

Rheumatoid arthritis

Gout

Pseudogout (CPPD)

MYOSITIS

Dermatomyositis

Inclusion body myositis
Polymyalgia rheumatica

Fibromyalgia

SPONDYLOARTHROPATHY

Joints: weight-bearing joints
(hips, knees, spine), PIP+DIP
(Heberden, Bouchard)
type 3 HS → symmetric
polyarthritis w/ morning
stiffness, rheumatoid nodules
Joints: wrists (ulnar deviation),
MCP+PIP (Boutonniere, swan
neck, Z-thumb deformities)
cold, stress, EtOH, red meat →
hyperuricemia → MSU deposits
in joints → sudden-onset
monoarthritis (e.g. podagra),
chronic tophi

Management
• Dx X-ray (joint space narrowing, osteophytes
• aka bone spurs, sclerosis, subchondral cysts)
• Tx weight loss + physical therapy (1st line),
• acetaminophen/NSAIDs (2nd line), steroid
• injections (3rd line), joint replacement (4th line)

Other
Risk factors: old age, obesity,
joint overuse, trauma

• Dx ↑RF, ↑anti-CCP , X-ray (joint space
• narrowing, bony erosions)
• Tx NSAIDs or low-dose steroids (for pain);
• MTX, hydroxychloroquine, TNFα-blockers

Felty syndrome: RA +
neutropenia + splenomegaly
Juvenile RA: RA before 18 y/o

• Dx arthrocentesis (needle-shaped, negatively
• birefringent yellow crystals)
• Tx indomethacin > colchicine (acute attacks),
• probenecid or allopurinol (chronic ppx)

Etiology: ↓uric acid excretion
(90%), ↑uric acid production (10%)

calcium pyrophosphate
deposits in joints → suddenonset monoarthritis

• Dx arthrocentesis (rhomboid-shaped, weakly
• positively birefringent blue crystals)
• Tx indomethacin > colchicine (acute attacks) +
• Tx underlying cause

Presentation
hip and shoulder muscle
weakness ± pain
hip and shoulder muscle
weakness ± pain, skin rashes
(heliotrope rash, Gottron
papules, V sign, shawl sign)
symmetrical proximal and distal
muscle weakness
hip and shoulder muscle pain
w/o weakness, profound
morning stiffness
widespread muscle pain and
stiffness associated w/ trigger
points

Management
• Dx ↑CK, anti-Jo-1, muscle bx
• Tx steroids
• Dx ↑CK, anti-Jo-1, muscle bx
• Tx steroids

Lesch-Nyhan syndrome: AR
∆HGPRT → gout, self-mutilation,
yellow sand in diapers

-myositis: weakness, may have pain
-myalgia: pain, no weakness
Dz
Polymyositis

SERONEGATIVE

Presentation
wear-and-tear of joints →
degeneration of cartilage →
deep, dull joint pain, worse w/
activity and improved w/ rest

Other

Complications: ovarian cancer

• Dx slightly ↑CK, muscle bx
• Tx steroids
• Dx ↑ESR (CK is normal)
• Tx steroids

Complications: aortic aneurysms,
temporal arteritis

• Dx PE (multiple trigger points)
• Tx SSRIs, CBT

Complications: depression,
anxiety, axis II diagnoses

Seronegative spondyloarthropathies: PAIR – Psoriatic arthritis, Ankylosing spondylitis, IBD, Reiter syndrome
Common features: inflammatory oligoarthritis, negative RF, HLA-B27 association
Dz
Ankylosing spondylitis

Reiter syndrome (reactive
arthritis)

Psoriatic arthritis

Presentation
bilateral sacroiliitis + gradualonset upward fusion of spine +
enthesitis (pain at tendon
attachment sites)
triad of anterior uveitis,
urethritis, arthritis (“can’t see,
can’t pee, can’t climb a tree”)
following a bacterial GI infx
(Salmonella, Shigella, Campy,
Chlamydia, Yersinia)
asymmetric polyarthritis in 10%
of psoriasis pts, usually fingers

Management
• Dx X-ray (bamboo spine)
• Tx NSAIDs + physical therapy

Other
Complications: restrictive lung
dz, cauda equina syndrome,
spine fx w/ spinal cord damage,
osteoporosis, spondylodiscitis

• Dx joint aspiration (r/o infx arthritis)
• Tx NSAIDs

• Dx X-ray (pencil-in-cup deformity)
• Tx NSAIDs

Complications: dactylitis
(sausage fingers)

MEDICINE × MSK
VASCULITIS

Small vessel vasculitis: type 3 HS, “palpable purpura”
Muscular artery vasculitis: claudication/infarction
Elastic artery vasculitis: granulomatous dz, pulselessness
Dz
Temporal arteritis (giant cell
arteritis)
Takayasu arteritis
Polyarteritis nodosa

Buerger disease
(thromboangiitis obliterans)
Behçet syndrome
Churg-Strauss syndrome
Wegener granulomatosis

Hypersensitivity vasculitis

Presentation
elderly pt w/ unilateral
headache, jaw claudication,
visual changes
young Asian woman w/ absent
pulses and asymmetrical BP
vasculitis of renal and visceral
vx → abd pain (bowel angina),
fatigue, joint pain, renal failure;
associated w/ HBV infx
smokers w/ gangrene and
autoamputation of fingers/toes
recurrent oral and genital
ulcers, arthritis, uveitis, CNS sx
triad of asthma + eosinophilia +
granulomatous vasculitis
triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract, and
necrotizing glomerulonephritis
→ hematuria + hemoptysis
drug-induced type 3 HS →
palpable purpura

Management
• Dx ↑ESR
• Tx emergent high-dose steroids (can become
• blind if you wait too long)
• Dx arteriogram
• Tx steroids, angioplasty for stenosed vx
• Dx tissue bx, ↑P-ANCA
• Tx steroids

• Tx smoking cessation
• Dx tissue bx
• Tx steroids
• Dx tissue bx, ↑P-ANCA
• Tx steroids
• Dx tissue bx (necrotizing granulomas),
• ↑C-ANCA
• Tx cyclophosphamide

• Dx tissue bx
• Tx steroids, d/c meds

Other
Complications: polymyalgia
rheumatica, blindness, aortic
aneurysms

MEDICINE × RENAL
URINALYSIS

↑protein: proteinuria >150 mg/day, nephrotic syndrome >3.5 g/day
↑albumin: microalbuminuria is earliest sign of diabetic nephropathy
↑glucose: diabetes
↑RBC: microscopic hematuria >3 RBC/HPF, gross hematuria visible to naked eye
↑ketones: DKA or starvation
↑nitrites: indicates bacteria in urine
↑LE: indicates WBC in urine
↑eosinophils: acute interstitial nephritis
RBC casts: glomerulonephritis, ischemia, or malignant HTN
WBC casts: pyelonephritis, tubulointerstitial dz, or txp rejection
Granular casts: acute tubular necrosis (ATN)
Broad waxy casts: CRF w/ dilated ducts
Fatty casts: nephrotic syndrome
Hyaline casts: nonspecific

RENAL FAILURE

BUN: normally reabsorbed, can’t be reabsorbed if kidney is damaged
Azotemia: ↑BUN
Uremia: ↑BUN w/ sx (usually BUN >60)
Cr: freely filtered and not reabsorbed, measure of GFR
Acute renal failure: rapid decline in renal fxn → ↑BUN, ↑creatinine
Oliguric phase: UOP <500 mL/day, lasts 10-14 days
Diuretic phase: UOP >500 mL/day, due to diuresis of retained fluids/electrolytes
Recovery phase: recovery of tubular function

Etiology

Urine osm
Urine Na+
FENa
BUN/Cr

Prerenal ARF
↓renal blood flow →
↓GFR (hypotension,
CHF, etc.)
>500
<10
<1%
>20:1

Intrinsic ARF
damage to renal
parenchyma (ATN,
toxins, glomerulonephritis, etc.)
<350
>20
>2%
<15:1

Postrenal ARF
bilateral urinary tract
obstruction (stones,
BPH, cancer, etc.)
<350
>40
>4%
>15:1

Ischemic ATN: ↓renal blood flow → proximal/distal tubules don’t enough O2 for Na/K pump → cell death → ARF
Nephrotoxic ATN: toxin-mediated damage to proximal tubules → cell death → ARF (e.g. IV dye, gentamycin, Hb/Mb)
Chronic renal failure: irreversible, progressive reduction in GFR
Etiology: DM (#1), HTN (#2), chronic glomerulonephritis (#3)
Stages: stage 1 GFR 90-100
stage 2 GFR 60-89
stage 3 GFR 30-59
stage 4 GFR 15-29
stage 5 GFR <15 or dialysis (aka ESRD)
ARF/CRF complications: ↓GFR → electrolyte retention → ↑Na, ↑K, ↑H → HTN, CHF
uremia → n/v, pericarditis, asterixis, encephalopathy, platelet dysfxn
↓EPO → normocytic anemia
↓vit D → renal osteodystrophy, 2° HPTH, calciphylaxis

DIALYSIS

Dialysis: artifical removal of electrolytes/toxins from blood
Dialysate: articifial solution that resembles human plasma
Indications: AEIOU – Acidosis (severe metabolic acidosis)
Electrolytes (severe hyperkalemia)
Intoxication (methanol, ethylene glycol, lithium, aspirin)
Overload (severe hypervolemia)
Uremia (severe uremia, pericarditis, BUN >150)
Limitations: doesn’t help w/ kidney synthetic functions (e.g. EPO, vitamin D)

Method

Frequency
Advantages
Disadvantages

Hemodialysis
blood from AV fistula pumped
through dialyzer, filtrated, then
sent back into pt body
MWF or TuThSa
 faster/more efficienct
 can be initiated quickly
 risk of removing too much
 fluid or electrolytes
 requires vascular access
 “first-use syndrome” –
 chest and back pain, rare
 anaphylaxis w/ new machine

Peritoneal dialysis
high-glucose dialysate infused into
peritoneal cavity, then drained from
abdomen
q 4-8 hrs
 mimics normal kidney fxn
 self-dialysis
 risk of hyperglycemia
 risk of peritonitis
 increased abdominal girth

MEDICINE × RENAL
PROTEINURIA AND
HEMATURIA

Dz
Proteinuria

Hematuria

Presentation
>150 mg protein/24 hr

Microscopic hematuria:
>3 RBC/HPF
Gross hematuria: visible to
naked eye

Nephritic vs. nephrOtic syndrome:
Etiology
Sx

Glomeruli
Casts

GLOMERULAR DZ

Management
• Dx screen w/ dipstick and UA, then get 24 hr
• urine collection
• asx/transient → reassurance
• asx/persistent → Dx check BP and examine
• urine sediment; Tx underlying cause
• sx → Tx underlying cause + ACE inhibitors
• Dx screen w/ dipstick and UA, then get
• imaging of upper/lower urinary tracts
• Tx underlying cause

Nephritic syndrome
glomerular
inflammation
- hematuria
- oliguria
- HTN
- azotemia
- proteinuria (<3.5 g)
hypercellular
RBC casts

Other

Etiology: glomerular dz
Etiology: postrenal causes
(trauma, stones, cancer)

NephrOtic syndrome
loss of GBM negative
charge
- proteinuria (>3.5 g)
- edema
- hypoalbuminemia
- hyperlipidemia
- hypercoagulability
normo-/hypocellular
fatty casts

Nephritic syndrome × chronic pain: analgesic nephropathy
Nephritic syndrome × hemoptysis: Goodpasture, Wegener
Nephritic syndrome × s/p strep throat: post-strep GN
NephrOtic syndrome × deafness/blindness: Alport syndrome
NephrOtic syndrome × kids: minimal change dz
NephrOtic syndrome × HBV: MGN
NephrOtic syndrome × HCV: MPGN
NephrOtic syndrome × HIV: FSGS
NephrOtic syndrome × Hodgkin lymphoma: minimal change dz
Dz
Minimal change dz
FSGS
Membranous glomerulonephritis (MGN)
IgA nephropathy (Berger’s dz)

Alport syndrome

Diabetic nephropathy

Presentation
nephrOtic syndrome in kids
following a viral infx
nephrOtic syndrome in adults
and HIV+ pts, steroid-resistant
nephrOtic syndrome in adults;
associated w/ drugs, infx, SLE,
and solid tumors
nephritic syndrome following
URI or gastroenteritis;
associated w/ Henoch-Schonlein
(palpable) purpura in kids
XR ∆type 4 collagen → split
GBM (nephritic and nephrOtic
syndromes), deafness, ocular
and nerve disorders
nephrOtic syndrome in DM pts

HTN nephropathy
Lupus nephropathy

nephrOtic syndrome in HTN pts
ag-ab deposits → nephritic
syndrome in SLE pts

Membranoproliferative
glomerulonephritis (MPGN)
Poststreptococcal GN

nephrOtic syndrome in HCV+
pts
coke-colored urine and
periorbital edema in a kid w/
strep throat or cellulitis
anti-GBM → attacks glomeruli
and alveoli → hematuria +
hemoptysis

Goodpasture syndrome

Management
• Dx EM (foot process effacement)
• Tx steroids
• Dx LM (segmental sclerosis)
• Dx LM (diffuse GBM thickening), EM (“spike
• and dome” appearance)
• Dx LM (mesangial deposits), IF (IgA stain)

• Dx family hx

• Dx microalbuminuria, LM (mesangial
• expansion, Kimmelsteil-Wilson nodules)
• Tx ACE inhibitors
• Tx underlying HTN
• Dx LM (“wire loops”), EM (subendothelial
• deposits), IF (“full house”)
• Tx underlying SLE
• Dx EM (“tram tracks” or “dense deposits”)
• Dx ↑ASO, LM (“lumpy-bumpy” appearance)
• Tx reassurance
• Dx LM (crescent shaped), IF (linear staining)

Other

MEDICINE × RENAL
TUBULOINTERSTITIAL DZ

Dz
Acute interstitial nephritis (AIN)
Chronic interstitial nephritis

Renal papillary necrosis

Renal tubular acidosis (RTA)

Hartnup syndrome

Fanconi syndrome

RENAL CYSTIC DZ

Dz
Adult polycystic kidney dz
(ADPKD)

Medullary sponge kidney

Simple renal cysts

RENAL VASCULAR DZ

Dz
RA stenosis (renovascular HTN)

RV thrombosis

Hypertensive nephrosclerosis

Sickle cell nephropathy

Presentation
drug allergy → acute renal
railure, rash, fever, eosinophilia
slowly progressive nephritis →
asx, but can lead to progressive
scarring, renal failure, and ESRD
damage to renal papillae →
necrosis → slough off and
cause ureteral obstruction

Management
• Dx UA (eosinophuria)
• Tx d/c meds
---

Other
Etiology: gentamycin, IV dye,
Hb/Mb

• Dx excretory urogram
• Tx underlying cause

Etiology: analgesic nephropathy
(chronic NSAID/Tylenol use),
diabetic nephropathy, sickle cell,
obstruction, txp rejection

Type 1 (distal) RTA: collecting
duct can’t excrete H+ →
metabolic acidosis, hypo-K,
nephrolithiasis, alkaline urine
Type 2 (proximal) RTA:
proximal tubule can’t reabsorb
HCO3- → metabolic acidosis,
hypo-K, hypophosphatemic
rickets, alkaline urine
Type 3 RTA: type 1 + type 2
Type 4 (hyper-K) RTA: either
hypoaldosteronism or lack of
response to aldosterone →
metabolic acidosis, hyper-K,
acidic urine
AR ∆neutral amino acid
transporter → ↓neutral amino
acids → ↓tryptophan for niacin
synthesis → pellagra (3 Ds –
diarrhea, dermatitis, dementia)
proximal tubule dysfxn →
defective transport of glucose,
amino acids, HCO3-, phosphate
→ glucosuria, aminoaciduria,
type 2 RTA, hypophosphatemic
rickets, etc.

• Tx IV HCO3-

Presentation
AD ∆APKD1/2 → multiple, large
bilateral cysts that can destroy
renal parenchyma → renal
failure, HTN, berry aneurysms,
liver cysts
cystic dilation of collecting
ducts → resembles sponge in
medulla → hematuria,
recurrent UTIs, kidney stones
benign incidental finding

Management
• Dx renal U/S (multiple large cysts)
• no tx available

Presentation
RA stenosis → ↓renal blood
flow → kidney thinks you’re
hypotensive → RAA system →
HTN, abdominal bruits, ↓renal
function
intrinsic clot or extrinsic
compression → ↓renal blood
outflow → flank pain, HTN,
hematuria, proteinuria
Benign nephrosclerosis: hyaline
arteriolosclerosis in chronic
HTN
Malignant nephrosclerosis:
hyperplastic (“onion skin”)
arteriolosclerosis in rapidly
progressive HTN
recurrent sickling → papillary
infarction → eventual papillary
necrosis, renal failure, UTIs

Management
• Dx renal arteriogram (if pt is in renal failure,
• use MRA instead since dye is nephrotoxic)
• Tx angioplasty

• Tx underlying cause

--• Tx fludrocortisone

• Tx niacin replacement

• Tx electrolyte replacement

Other

• Dx IV pyelo (sponge-like calyx)
• no tx available

• leave it alone

• Dx renal venography
• Tx underlying cause

• Tx BP control, sodium nitroprusside for
• malignant HTN

• Tx ACE inhibitors (w/ hydroxyurea for SCD)

Other
Etiology: fibromuscular dysplasia
(young women), atherosclerosis
(old men)

MEDICINE × RENAL
STONES/OBSTRUCTIONS

Dz
Nephrolithiasis (kidney stones)

Urinary tract obstruction

GU NEOPLASMS

OTHER GU DZ

Presentation
colicky flank pain ± radiation to
groin, hematuria, n/v
Calcium stones: most common
type, 2/2 hypercalciuria or
hyperoxaluria
Uric acid stones: radiolUcent
(rest are all radioopaque), 2/2
gout or tumor lysis syndrome
Struvite stones: 2/2 urease+
bugs (P. mirabilis), can form
large staghorn caliculi
Cystine stones: 2/2 cystinuria
colicky flank pain ± radiation to
groin (if acute), asx (if chronic)

Dz
Prostate cancer

Presentation
usually asx, “elderly man w/ low
back pain” if invasive

Renal cell carcinoma (RCC)

Bladder cancer

abdominal mass, flank pain,
hematuria, and paraneoplastic
syndromes (PAPER – PTH-rP,
ACTH, prolactin, EPO, renin)
painless hematuria

Testicular cancer

firm, painless testicular mass

Penile cancer

exophytic penile mass in a
noncircumcised dirty old man

Dz
Testicular torsion

Presentation
twisting of spermatic cord →
severe testicular pain + “high
riding testicle w/ horizontal lie”
presents like testicular torsion,
but w/ fever, pyuria, and cord is
also tender

Epididymitis

Management
• Dx KUB
• Tx analgesics + fluids (<0.5 cm), shockwave
• lithotripsy (0.5 – 2 cm), percutaneous
• nephrolithotomy (≥2 cm)
• recurrent calcium stones → PPx HCTZ
• uric acid stones → PPx allopurinol, Tx
• potassium citrate
• cystine stones → Dx urinary sodium nitro• prusside test, Tx acetazolamide

Other
Hematuria + pyuria: stone w/
concomitant UTI
Kidney stone diet: high fluids
(#1), low sodium, low protein,
high calcium (counterintuitive),
low oxalate

• Dx renal U/S (shows dilation), then IV pyelo
• Tx underlying cause

MC location: ureteropelvic jxn
Complications: renal
insufficiency, hydronephrosis

Management
• Dx screen w/ PSA (≥10) or DRE (firm nodule);
• confirm w/ U/S-guided needle bx
• Tx radical prostatectomy (local), radiation +
• flutamide + leuprolide (invasive)
• Dx abdominal CT
• Tx radical nephrectomy

Other
Cancers that rarely metastasize:
prostate, esophageal, skin
(nonmelanoma), oropharyngeal

• Dx IV pyelo + cystoscopy w/ bx
• Tx resection + close f/u for high recurrence

Risk factors: Pee SAC – pain killer
abuse, smoking (#1), aniline dyes,
cyclophosphamide
Bladder SCC: Schistosoma
haematobium

• Dx transillumination (doesn’t light up),
• testicular U/S (solid mass)
• Tx radical orchiectomy, then CT chest/A/P for
• staging, then radiation (if seminoma),
• retroperitoneal LN-ectomy (if nonseminoma)
• f/u αFP + βHCG levels
• Dx skin bx
• Tx local excision

Management
• Tx emergent surgical detorsion, then
• orchipexy (don’t waste time on dx tests)
• Dx U/S to r/o torsion
• Tx abx

Risk factors: smoking (#1),
obesity
Bilateral RCC: von Hippel-Lindau

Etiology: HPV-16/18 infx

Other
Cremasteric reflex: stroking of
inner thigh causes elevation of
testicle; absent w/ torsion
Etiology: GC or CT in young men,
E. coli in kids and elderly

Cystine Uric acid
crystal crystal

Cystine crystals

(think gout or TLS)

Uric acid crystals

(think Proteus mirabilis)

Struvite crystal

Oval calcium
oxalate crystals

Calcium oxalate crystals

RBCs

Budding yeast

(think CRF w/ dilated ducts)

Broad waxy cast
Granular casts

Normal RBC
Ghost RBC
Crenated RBC Normal RBC

(think nephritic syndrome)

RBC casts
(think acute pyelonephritis)

WBC casts

PMNs

Subepi Humps

Granular CapillaryIgG/C3

EM

IF

Light

Nephritic Dz
PostInfx

MSG Deposits

Granular MSG IgA

IgA Neprho

MSG
HyperCellular
-ity

Subepi

Full House:

Class
III/IV

SLE Class II

Subendo

“Wire Loops”

Crescents + Fibrin

Normal

Linear Capillary IgG/C3

Anti-GBM

EM

IF

Light

Normal

Normal

Minimal Change

Nephrotic Dz

Foot process
effacement

Normal

Segmental Sclerosis

FSGS

Granular
Capillary
IgG

Pseudolinear
Capillary IgG

Art. Hyalinosis

Diabetic Neph

Nodular MSG
Expansion

Spikes&Holes
in BM

Subepi Deposits

Thick Cap
walls

MembranousNeph

Thick GBM

Nodulesl

MEDICINE × FEN
FLUIDS

60-40-20 rule: 60% of body weight is water, 40% is ICF, 20% is ECF (5% plasma, 15% ISF)
Starling forces: hydrostatic pressure drives fluid into ISF, oncotic pressure sucks it back out
Blood osmolarity: 2×Na + BUN/2.8 + gluc/18; normally 285-300 mOsm/L
Urine osmolarity: 70-1200 mOsm/L, controlled by ADH
Urine output: normally 0.5-1.0 mL/kg/hr
IV fluids: NS, LR, D5½NS, D5W
NS: good for dehydrated pts
LR: good for trauma pts
D5½NS: standard maintenance fluid
D5W: good for hypernatremic pts
100-50-20 rule: maintenance fluids for 24 hrs (100 mL/kg for first 10 kg, then 50 for next 10 kg, then 20 for each kg over)
4-2-1 rule: maintenance fluids for 1 hr (4 mL/kg for first 10 kg, then 2 for next 10 kg, then 1 for each kg over)

ELECTROLYTES

ADH: causes water reabsorption (V2, aquaporins) and vasoconstriction (V1)
Aldosterone: causes ↑Na, ↓K, ↓H
PTH: causes ↑Ca, ↓P, ↑vit D
Calcitonin: causes ↓Ca, ↓P
Vit D: causes ↑Ca, ↑P
Imbalance
Hypernatremia

Etiology
water loss due to 6 Ds – Diuresis,
Dehydration, Diabetes insipidus,
Docs (iatrogenic), Diarrhea,
Diseases
SIADH (MCC)

Presentation
thirst and signs of volume depletion
(slow) or ∆MS (rapid)

Management
• Tx PO fluids > IV fluids (correct gradually due
• to risk of cerebral edema)

confusion, coma, convulsions

Hyperkalemia

renal failure, K-sparing diuretics,
release from dead tissue (crush
injury, ischemic bowel, etc.)

nausea/vomiting, intestinal colic,
weakness

Hypokalemia

diarrhea, vomiting, diuretics

Hypercalcemia

hyperparathyroidism (MCC
outpt), cancer (MCC inpt)

Hypocalcemia

hypoparathyroidism (MCC)

weakness, muscle cramps, ileus,
digoxin toxicity (K and dig compete for
same Na/K receptors on heart)
stones (kidney), bones (bone pain,
osteitis fibrosa cystica), groans (PUD,
pancreatitis), psychic overtones
(depression, anxiety, ∆MS)
neuromuscular irritability (tingling,
tetany), arrhythmias, Chvostek and
Trousseau signs

• Tx water restriction + NS (correct gradually
• due to risk of central pontine myelinolysis)
• first, confirm w/ repeat blood draw
• Dx EKG (peaked T waves, sine waves)
• Tx C BIG K DIE – calcium gluconate, bicarb
• insulin-glucose, kayexalate, dialysis (if severe)
• Dx EKG (scooped T waves)
• Tx KCl (<10 mEq/hr)

Hyponatremia

Hypermagnesemia
Hypomagnesemia
Hyperphosphatemia
Hypophosphatemia

ACID-BASE

renal failure (MCC)
alcoholism (MCC), DKA
renal failure (MCC)
alcoholism (MCC), DKA

Acid-base algorithm:
CO2 <40
CO2 >40

pH <7.4
met acidosis*
resp acidosis

delirium, ↓DTRs, cardiac arrest
refractory hypo-K
kidney stones, metastatic calcifications
rickets, osteomalacia

• Dx EKG (short QT)
• Tx “flush and drain” (NS + furosemide),
• bisphosphonates if mild
• confirm w/ corrected Ca = [measured Ca +
• 0.8 x (4 – albumin)]
• Dx EKG (prolonged QT)
• Tx vit D + calcium replacement
• Tx IV calcium gluconate + NS + furosemide
• Tx mag replacement
• Tx antacids (binds phosphate in GI tract)
• Tx phos replacement

pH >7.4
resp alkalosis
met alkalosis

*if met acidosis, calculate anion gap (Na+ – (Cl- + HCO3-)), nl 8-12

Respiratory acidosis
Respiratory alkalosis
Anion-gap metabolic acidosis

Non anion-gap metabolic acidosis
Metabolic alkalosis

Causes
hypoventilation
hyperventilation 2/2 pain, fever,
sepsis, or early ARDS
MUDPILES – Methanol, Uremia,
DKA, Paraldehyde, Iron, INH,
Lactic acidosis, Ethylene glycol,
Salicylates
diarrhea, glue sniffing, RTA,
hyperchloremia
vomiting, diuretics, antacids,
hyperaldosteronism

Management
Tx mechanical ventilation
Tx underlying cause
Tx underlying cause

Tx underlying cause
Tx chloride or potassium replacement

pH changes: CO2 ↑10 → pH ↓0.08
HCO3 ↑10 → pH ↑0.15
Post-ictal AGMA: will resolve on its own in 60-90 minutes, recheck labs then
Aspirin overdose: tinnitus, fever, hyperventilation → respiratory alkalosis (early), metabolic acidosis (late)
Iron overdose: AGMA, shock, abdominal pain, UGIB

MEDICINE × HEM/ONC
TRANSFUSION

PRBCs: Hb +1, Hct +3; indicated if Hb ≤7 or acute bleed
Platelets: platelets +10,000
FFP: contains clotting factors 1-12; ↓PT, ↓PTT
Cryoprecipitate: contains factors 1+8 only; ↓PTT
Whole blood: contains everything, rarely used

RBC PANEL

MCV: RBC size, normally 80-100
Ferritin: iron levels in blood
TIBC: transferrin levels (protein that binds ferritin); serum ferritin has a negative feedback on TIBC levels
RDW: variability in RBC size; characteristic ↓RDW in thalassemias
RI: measure of immature RBCs; <2% indicates impaired bone marrow function
LDH: enzyme of anaerobyic glycolysis; ↑ w/ intravascular hemolysis or tissue hypoxia
Haptoglobin: enzyme in blood that binds free Hb; ↓ w/ intravascular hemolysis
Schistocytes + helmet cells: indicates hemolytic anemia
Coombs test: detects antibody or complement on RBCs

ANEMIA

Anemia?
microcytic
(MCV <80)

normocytic
(MCV 80-100)

macrocytic
(MCV >100)

IDA (↑TIBC)
ACD (↓TIBC)
thalassemias (↓RDW)
sideroblastic anemia

folate deficiency
B12 deficiency
reticulocytosis

calculate reticulocyte index
(retic count × hct/45)
impaired erythropoiesis
(RI <2%)
acute hemorrhage
acute IDA or ACD
aplastic anemia
anemia of CRF (↓EPO)

normal erythropoiesis
(RI >2%)
intrinsic RBC defects

extrinsic RBC defects

membrane defects (PNH, spherocytosis)
abnormal hemoglobin (sickle cell)
deficient enzymes (G6PD, PK)

AIHA
prosthetic valves
MAHA
chronic hemorrhage

Anemia sx: conjunctival pallor, headache, fatigue; ↑HR/↓BP if severe
Pseudoanemia: ↓Hb/↓Hct/↓WBC/↓plt secondary to dilution (e.g. fluid overload)
Dz
Iron-deficiency anemia (IDA)

Presentation
(typical anemia sx)

Management
• Dx RBC panel (MCV <80, ↓Fe, ↑TIBC, ↑RDW)
• Tx underlying cause + PO iron supplements

Anemia of chronic disease
(ACD)
β-thalassemia

(typical anemia sx)

• Dx RBC panel (MCV <80, ↑Fe, ↓TIBC, ↑RDW)
• Tx underlying cause
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis
• Tx reassurance
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis (↑HbF)
• Tx frequent transfusions
---

β-thal minor: heterozygous
∆β-chain → mild anemia sx
β-thal major: homozygous
∆β-chain → severe anemia sx

α-thalassemia

Sideroblastic anemia

Aplastic anemia

Folate deficiency

Vit B12 deficiency

Silent carrier: 1-2 α-chain
deletion → asx
HbH disease: 3 α-chain deletion
→ severe anemia sx
Barts disease: 1-2 α-chain
deletion → fetal hydrops
biochemical abnormalities →
iron gets stuck in mitochondria
→ can’t make Hb → anemia sx
bone marrow failure →
pancytopenia (anemia, neutropenia, thrombocytopenia) →
anemia sx + ↑infx + petechiae
↓folate → ↓methionine (RBC)
→ anemia sx, glossitis
↓vit B12 → ↓methionine (RBC) +
impaired FA synthesis (myelin)
→ anemia sx, glossitis,
peripheral neuropathy

Other
Etiology: Meckel diverticulum
(MCC kids), menorrhagia (MCC
women), peptic ulcers (MCC
men), colon cancer (MCC elderly)
Etiology: cancer, chronic infx,
systemic inflammation, trauma

• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis (↑HbH)
• Tx frequent transfusions
• Dx post-mortem autopsy
• Dx blood smear (ringed sideroblasts)
• Tx underlying cause, vit B6 supplements

Etiology: lead poisoning, vit B6
deficiency, INH or EtOH use

• Dx CBC (↓RBC, ↓WBC, ↓plt); confirm w/ bone
• marrow bx
• Tx transfusions, bone marrow txp

Fanconi anemia: aplastic anemia
+ short stature, hypopigmented
areas, eye/ear deformities

• Dx RBC panel (MCV >100), hypersegmented
• neutrophils, ↓folate
• Tx underlying cause, folate supplements
• Dx RBC panel (MCV >100), hypersegmented
• neutrophils, ↓vit B12; DDx w/ Schilling test
• Tx underlying cause, vit B12 injections

Folate source: leafy vegetables
Etiology: “tea and toast” diet,
alcoholics, phenytoin or MTX use
Vit B12 source: meats
Etiology: pernicious anemia (lack
of IF), s/p gastrectomy, strict
vegans, terminal ileal dz (Crohn),
D. latum fish tapeworm

MEDICINE × HEM/ONC
HEMOLYTIC ANEMIA

Intravascular hemolysis: ABO-mismatched blood → hemolysis within blood stream → immediate fever/chills, nausea, vomiting, chest and flank pain,
dyspnea → risk of hypovolemic shock, DIC, renal failure
Extravascular hemolysis: minor antigen-mismatched blood (e.g. Kell) → delayed hemolysis within spleen → mild fever, jaundice, anemia
Dz
Sickle cell disease

Hereditary spherocytosis

G6PD deficiency

Autoimmune hemolytic anemia
(AIHA)

Paroxysmal nocturnal
hemoglobinuria (PNH)

PLATELET D/O

Platelet range: >750
>450
150-450
<150
<70
<20
<5

Presentation
AR ∆HbE6V (β-chain) → sickling
of RBCs w/ ↓O2 conditions →
small vessel occlusion → extravascular hemolysis, painful
vasoocclusive crises,
autosplenic infarction
AR ∆spectrin → spherical RBCs
get stuck in spleen →
extravascular hemolysis
XR ∆G6PD → ↓glutathione for
handling oxidant stressors →
intravascular hemolysis, back
pain, hemoglobinuria in men
Warm AIHA: IgG against RBC →
chronic, extravascular
hemolysis
Cold AIHA: IgM against RBC →
acute, intravascular hemolysis
triggered by cold
acquired ∆DAF → lack of
complement inactivation on
RBCs → hemolytic anemia +
hepatic vein thromboses

Management
• Dx blood smear (sickled RBCs), confirm w/ Hb
• electrophoresis
• Tx avoid crises + hydroxyurea (↑HbF) + early
• SHiN vaccination

• Dx osmotic fragility test
• Tx splenectomy
• Dx blood smear (Heinz bodies, bite cells)
• Tx avoid precipitants

• Dx Coombs test (coating w/ IgG is warm,
• complement is cold)
• Tx steroids (warm), avoid cold exposure (cold)

Other
Sickle cell trait: painless
hematuria in young black male
Splenic sequestration crisis:
sudden, rapid pooling of blood
into spleen → splenomegaly,
hypovolemic shock, death
Aplastic crisis: spherocytosis +
parvovirus B19 infx, prevent w/
folic acid supplements
Etiology: sulfa drugs, antimalarials, infx, fava beans

AIHA × lymphoma: CLL is a
trigger for both warm/cold AIHA
AIHA × PNA: Mycoplasma
pneumoniae is a trigger for cold
AIHA

• Dx ↑urine hemosiderin
• Tx steroids, bone marrow txp

↑risk of clots
thrombocytosis by definition
normal
thrombocytopenia by definition
↑risk of bleeding during surgery/trauma
petechiae
major spontaneous bleeding

Thrombocytopenia sx w/ normal plt count: aspirin or NSAID use
Dz
Thrombocytopenia
Heparin-induced
thrombocytopenia (HIT)

Idiopathic thrombocytopenic
purpura (ITP)
Thrombotic thrombocytopenic
purpura (TTP)

Bernard-Soulier syndrome
Glanzmann thrombasthenia

Presentation
plt <150,000; most common sx
is petechiae
HIT type 1: heparin directly
causes platelet aggregation,
within 0-2 days
HIT type 2: heparin induces
auto-antibodies against platelet
factor 4, after 3-12 days
auto-antibodies against
gpIIb/IIIa → platelet clearance
→ petechiae, ecchymoses, etc.
HUS: tons of clots form in small
vx (e.g. renal vx) → microangiopathic hemolytic anemia +
thrombocytopenia + renal
failure
TTP: HUS + fever + ∆MS
AR ∆gpIb → platelets can’t
adhere to subendothelium
AR ∆gpIIb/IIIa → platelets can’t
aggregate

Management
• Tx underlying cause, plt transfusion (severe)

Other
Asx thrombocytopenia: consider
HIV testing

• Tx reassurance

• Tx d/c heparin

• Dx plt <20, ↑megakaryocytes
• Tx steroids, plt transfusion then splenectomy
• (severe)
• Dx CBC (↓plt, ↓RBC) + blood smear
• (schistocytes)
• Tx emergent plasmapheresis

-----

HUS × diarrhea: EHEC (O157:H7)

MEDICINE × HEM/ONC
COAGULATION

PTT: measures intrinsic pathway (12→→1)
PT/INR: measures extrinsic pathway (7→→1)
Thrombin time: measures fibrinogen levels (2→1)
Bleeding time: measures platelet function
Shortest T½: factor 7

ANTICOAGULATION

Heparin: potentiates AT-III to inhibit factors 2/10 → ↑PTT
Heparin side-effects: bleeding, HIT, osteoporosis
Heparin reversal: protamine sulfate
LMWH: longer T½, less side-effects, but more $$$
Warfarin: blocks vitamin K from activating factors 2/7/9/10/C/S → ↑PT/INR
Warfarin side-effects: bleeding, skin necroses (d/t protein C/S), teratogen
Warfarin reversal: vit K if mild, FFP if severe
tPA: activates plasmin to break down existing clots
tPA side-effects: severe bleeding (c/i in active bleed, recent surg, prior ICH)
tPA reversal: aminocaproid acid
Therapeutic INR: 2-3 normally, 2.5-3.5 for prosthetic valves

COAGULATION D/O

Dz
von Willebrand disease (vWD)

Management
• Dx ↓/∆/no vWF, ↑bleeding time
• Tx DDAVP (types 1-2), factor 8 concentrate
• (refractory type 2, type 3)

Other

Hemophilia A (classic
hemophilia)

Presentation
vWD type 1: AD ↓vWF →
bleeding diathesis
vWD type 2: AD ∆vWF →
bleeding diathesis
vWD type 3: AD lack of vWF →
severe bleeding diathesis
XR ∆factor 8 → hemarthroses,
hematomas, and ICH in men

• Dx ↑PTT, ↓factor 8
• Tx factor 8 concentrate; analgesia + RICE (for
• acute hemarthroses)

Hemophilia A vs. factor 8
inhibitor: mix pt’s plasma w/
normal plasma; if PTT fails to
normalize, then factor 8 inhibitor

Hemophilia B (Christmas
disease)

XR ∆factor 9 → hemarthroses,
hematomas, and ICH in men

Disseminated intravascular
coagulation (DIC)

abnl activation of clotting
factors → microthrombi all over
blood stream → run out of
factors → bleed out → die
↓vit K → can’t γ-carboxylate
factors 2/7/9/10/C/S → bleeding
diathesis

• Dx ↑PTT, ↓factor 9
• Tx factor 9 concentrate; analgesia + RICE (for
• acute hemarthroses)
• Dx ↑PT/↑PTT, ↑D-dimer, ↓fibrinogen, ↓plt,
• blood smear (schistocytes)
• Tx underlying cause, supportive measures

Vit K deficiency

Coagulopathy of liver disease
AT-III deficiency

Factor V leiden

liver can’t make coagulation
factors → bleeding diathesis
can’t break down factors 2-12 →
hypercoagulability that doesn’t
respond to heparin
protein C can’t block factor 5 →
hypercoagulability

• Dx ↑PT/↑PTT, everything else is nl
• Tx vit K supplements, FFP if severe

• Dx ↑PT/↑PTT, ↓fibrinogen, everything else is nl
• Tx FFP
---

---

Etiology: G– septic shock (MCC),
obstetric complications, cancer,
massive burns, rattlesnakes, etc.
Vit K source: leafy vegetables,
intestinal flora
Etiology: critically ill pts that are
NPO and on broad-spectrum abx
(MCC), fat malabsorption,
warfarin overdose, neonates

MEDICINE × HEM/ONC
PLASMA CELL D/O

Dz
Multiple myeloma

Monocolonal gammopathy of
undetermined significance
(MGUS)
Waldenstrom
macroglobulinemia

Presentation
monoclonal plasma cell
proliferation → makes lots of
monoclonal IgG and eats up
bone marrow space → CRAB –
hyperCalcemia, Renal failure,
Anemia, Bone lesions/fx
(asx, precursor of myeloma)

monoclonal IgM plasma cell
proliferation → ↑IgM →
hyperviscosity (IgM is big),
anemia, splenomegaly, LNopathy

Management
• Dx SPEP (monoclonal spike), urinalysis (Bence
• Jones protein), X-ray (punched out lytic bone
• lesions), blood smear (rouleaux formation)
• Tx chemo/radiation only if symptomatic

Other
MCCOD: recurrent lung or
urinary tract infx (↓normal IgG)

• Dx SPEP (monoclonal spike), urinalysis (Bence
• Jones protein)
• Tx close f/u
• Dx SPEP (monoclonal spike), urinalysis (Bence
• Jones protein), ↑IgM, no bone lesions
• no tx exists

Px: <20% convert to myeloma in
10-15 yrs

- painful
- small (<2 cm)
- rapid onset
- mobile
- normal site

- Reed-Sternberg cells (CD15+/CD30+)
- localized, single group of nodes with contiguous spread
- “B” symptoms – fever, night sweats, weight loss
- prognosis: stage of disease and HL subtype are most important factors

Hodgkin’s lymphoma

- multiple, peripheral nodes with noncontiguous spread
- fewer constitutional “B” symptoms
- associated with HIV/immunosuppression

Non-Hodgkin’s lymphoma

- painless
- large (>2 cm)
- insidious onset
- fixed (fibrotic)
- unusual site

LYMPHOMA vs. REACTIVE HYPERPLASIA

Is the lymph node swollen due to malignancy
or is it an inflammatory process?

T-cell NHL (10-15%)

B-cell NHL (80-85%)

LYMPHOMA

rare
RS > lymphocytes

6%
RS << lymphocytes

25%
RS = lymphocytes

65-75%
RS << lymphocytes

high grade

high grade

low grade

low grade

middle grade

high grade

high grade

- older males with disseminated disease
- poor prognosis

Lymphocyte-depleted HL

- “popcorn cells”
- infrequent classic RS cells
- excellent prognosis

Lymphocyte-predominant HL

V
- male-dominant
- numerous RS cells, EBV association

Mixed cellularity HL

V = viral association

- female-dominant
- supraclavicular nodes + anterior mediastinal nodes

Nodular sclerosing HL

- skin lesions with Pautrier’s microabscesses
- CD4+ T-cell neoplasm
- Sezary syndrome is leukemic phase of mycosis fungoides

Mycosis fungoides

V
- adults with aggressive cutaneous lesions
- HTLV-1 association

Adult T-cell lymphoma

- H. pylori (stomach), Sjogren’s syndrome (salivary glands)

MALT/extranodal lymphoma

- t(14;18)
- overexpression of BCL-2 anti-apoptosis gene

Follicular lymphoma

- t(11;14)
- poor prognosis, CD5+

Mantle cell lymphoma

- most common adult NHL
- 20% are T-cell origin (counterintuitive)

Diffuse large B-cell lymphoma

V
- t(8;14)
- EBV association, common childhood NHL
- “starry sky” appearanceW
- jaw lesion in endemic form in Africa
- pelvis/abdomen in sporadic form

Burkitt’s lymphoma

ALL
AML/CML
CLL

Pre-leukemia

Leukemia

0-14
15-60
60+

(extremely important)

AGE BRACKETS

- <5% blasts
- accumulation of mature cells

Chronic leukemias

- >20% blasts
- accumulation of immature cells

Acute leukemias

- bone marrow proliferation of myeloid lineages
- associated with specific TK abnormalities

Chronic lymphoid neoplasms

myeloid lineage

myeloid lineage

B-cells

B-cells

MKC lineage
w/ fibroblasts

MKC lineage

RBC lineage

myeloid
lineage

B-cells (90%), T-cells (10%)

Myeloproliferative neoplasms

LEUKEMIA

subtypes

- gum infiltration

Acute monocytic leukemia

- t(15;17), defect in retinoic acid
- Tx retinoic acid, possible DIC

Acute promyelocytic leukemia

- severe anemia in elderly
- 30% develop AML
- ringed sideroblasts

Myelodysplastic syndrome

- positive TRAP stain
- splenomegaly
- Tx with purine nucleosides

Hairy cell leukemia

- B-cell neoplasm, ↓γ-globulins
- MCC generalized lymphadenopathy >60 y/o
- smudge cells

CLL

- marrow fibrosis (dry bone marrow aspirate)
- extramedullary hematopoiesis → splenomegaly
- tear drop RBCs

Primary myelofibrosis

- abnormal appearing platelets

Essential thrombocythemia

- ↑plasma volume, ↑RBC mass, normal SaO2, ↓EPO
- 4 H’s: hyperviscosity, hypervolemia, histaminemia, hyperuricema

Polycythemia vera

- age: 30-60 y/o
- Philadelphia chromosome t(9;22) or Bcr-Abl gene
- ↓LAP score

CML

- age: <15 y/o
- pre-B cells (90%); CALLA+/TdT+
- CNS and testicle involvement
- t(12;21) offers good prognosis

ALL

- age: median onset ~60 y/o
- Auer rods in myeloblasts

AML

MEDICINE × ID
RESPIRATORY INFX

Dz
Pneumonia

Lung abscess

Tuberculosis

Influenza

Bug(s)
Typical CAP: Strep pneumo
(#1), H. influenzae (#2),
aerobic GNR
Atypical CAP: Mycoplasma
(#1), Chlamydia, Legionella
Nosocomial PNA: Staph
aureus (#1), Pseudomonas,
aerobic GNR
PNA × alcoholics: Klebsiella
PNA × immigrants: TB
PNA × nursing home:
nosocomial pathogens
PNA × AIDS: Pneumocystis
carinii (PCP), TB
oral anaerobes (Prevotella,
Peptostreptococcus, Fusobacterium, Bacteroides)
M. tuberculosis

influenza virus

Presentation
Typical CAP: sudden-onset fever/chills,
productive cough, pleuritic chest pain
Atypical CAP: insidious-onset sore throat,
headache, nonproductive cough, dyspnea
Complications: pleural effusions,
empyema, acute respiratory failure

Management
• Dx CXR (consolidations)
• suspect TB → acid-fast stain
• suspect Legionella → urinary ag
• HIV+ → silver stain (fungi, PCP)
• admit if 2/5 of CURB-65 – Confusion, Uremia,
• RR ≥30, BP <90/60, age ≥65
• outpatient → Tx azithromycin (<60 y/o),
• ceftriaxone (≥60 y/o)
• inpatient → Tx azithromycin + either
• ceftriaxone or fluoroquinolone
• PPx annual flu vaccine, Pneumovax if ≥65 y/o

aspiration → cough w/ foul-smelling
sputum, SOB, fever/chills
1° TB: granulomatous inflammation in lower
lobes → infx contained → usually asx
2° TB: reactivation in upper lobes →
fever/chills, night sweats, weight loss,
cough w/ hemoptysis
Miliary TB: hematogenous “miliary seed”
spread of TB → sx depend on organs
Pott disease: TB in vertebral body → bone
pain, risk for pathological fx
rapid-onset fever/chills, malaise, headache,
sore throat, nonproductive cough

• Dx CXR (cavitation w/ air-fluid levels, most
• commonly in right lower lobe)
• Tx IV abx
• Dx screen w/ tuberculin skin test (≥15 mm,
• ≥10 mm if high-risk, ≥5 mm if HIV+ or CXR+);
• confirm w/ CXR (cavitation in upper lobe)
• active TB → Tx SPIRE (streptomycin,
• pyrazinamide, INH, rifampin, ethambutol) for
• 2 months, then INH + rifampin for 4 months
• latent TB → Tx INH only
• Tx supportive care + oseltamivir if ≤48 hrs

2° bacterial infx: pt gets better from flu,
then sick again d/t bacterial colonization

CNS INFX

Dz
Meningitis

Encephalitis

Brain abscess

Bug(s)
Meningitis × neonates: GBS >
E. coli > Listeria
Meningitis × kids: MC > Strep
pneumo > H. influenzae
Meningitis × adults: Strep
pneumo > MC > H. influenzae
Meningitis × elderly: Strep
pneumo > MC > Listeria

viruses (HSV-1 in temporal
lobe, arbovirus, enterovirus),
toxoplasmosis, aspergillosis
Staph, Strep, anaerobes

Presentation
triad of fever, nuchal rigidity, ∆MS
Kerning sign: inability to fully extend knees
when lying supine w/ hips flexed
Brudzinski sign: flexion of head causes
flexion of hips/knees when lying supine
Disseminated meningococcal infx:
meningitis, purpura fulminans, bilateral
adrenal hemorrhage (W-F syndrome)
∆MS, focal neuro sx, s/sx of meningitis

mass effect → headache, ∆MS, seizures,
nausea/vomiting, focal neuro sx

Management
• Dx head CT to check for ↑ICP, then lumbar
• puncture + CSF analysis
• Tx IV abx

• Dx head CT to check for ↑ICP, then lumbar
• puncture + CSF PCR
• Tx admit + ACV (for HSV), GCV (for CMV)
• Dx head CT or MRI
• Tx IV abx, surgical drainage, ±steroids

Abscess × AIDS: toxo, fungi
Abscess × DKA: zygomycosis

GU INFX

Dz
Asymptomatic
bacteruria
Lower UTI (cystitis)

Bug(s)
E. coli (#1), Staph saprophyticus (#2), Enterococcus
(#3), other GNB
"

Upper UTI
(pyelonephritis)

"

Prostatitis

E. coli (kids/elderly), STDs
(young adults)

Presentation
(asx)

dysuria, ±hematuria, frequency/urgency,
suprapubic tenderness
Risk factors: diabetes, females (shorter
urethra), sexual intercourse, Foley catheter
(same as above) + fever/chills, flank pain,
CVA tenderness
Risk factors: (same as above) + VUR
Acute prostatitis: fever/chills, dysuria,
frequency, urgency, low back pain
Chronic prostatitis: usually asx

Management
• Dx UA/UCx (≥105 CFU w/o squamous cells)
• Tx only if pregnant (nitrofurantoin) or before
• urologic surgery, otherwise reassurance
• Dx UA/UCx (≥105 CFU w/o squamous cells)
• Tx Bactrim or Cipro, nitrofurantoin if pregnant,
• low-dose Bactrim ppx if recurrent

• Dx UA/UCx (≥105 CFU w/o squamous cells,
• WBC casts)
• uncomplicated → Tx Bactrim or Cipro
• complicated → Tx admit + IV amp/gent
• Dx DRE (boggy tender prostate) + UA/UCx
• Tx Bactrim or Cipro
• Dx prostatic secretion analysis (↑WBC)
• Tx long-term Cipro

MEDICINE × ID
GI INFX

Dz
Viral hepatitis

Bug(s)
HAV (fecal-oral)

Presentation
jaundice, dark-colored urine, RUQ pain, n/v

HBV (parenteral or sexual)

Buzzwords: Asx (usually), daycare, travel
jaundice, dark-colored urine, RUQ pain, n/v
Buzzwords: polyarteritis nodosa, MGN

Botulism

Intra-abdominal abscess
Diarrhea

SKIN/SOFT TISSUE INFX

Dz
Cellulitis

Erysipelas
Necrotizing fasciitis
(“gas gangrene”)
Lymphadenitis

HCV (parenteral)

jaundice, dark-colored urine, RUQ pain, n/v

HDV (parenteral or sexual)

Buzzwords: Cryoglobulinemia, Chronic infx,
Cirrhosis, Carcinoma, Carriers, IVDA, MPGN
jaundice, dark-colored urine, RUQ pain, n/v

HEV (fecal-oral)

Buzzwords: Deadly, HBV co-infection
jaundice, dark-colored urine, RUQ pain, n/v

Clostridium botulinum
preformed exotoxin (from
canned food or wound infx)
polymicrobial

Buzzwords: cruise ships, fatal in pregnancy
symmetric, descending flaccid paralysis

fever/chills, abd pain, mass

Management
• Dx HAV IgM = acute infx
• Dx HAV IgG = previous infx or immunity
• Tx supportive care
• Dx HBsAg = acute/chronic infx
• Dx HBsAb = previous infx or immunity
• Dx HBeAg = infectivity
• Dx HBcAb IgM = window period
• Tx IFN-α
• Dx HCV RNA
• Tx IFN-α + ribavarin, liver txp if severe

• Dx HDV Ab
• Tx IFN-α
• Dx HEV Ab
• Tx supportive care
• Dx toxin assay
• Tx admit + antitoxin
• Dx CT scan (cavitation w/ air-fluid levels)
• Tx I&D + IV abx
acute diarrhea

Diarrhea × n/v: viral gastroenteritis or food poisoning
Diarrhea × fever/blood:
Shigella, Salmonella, Campy,
EHEC
Diarrhea × mayonnaise:
Staph aureus (<6 hrs),
Salmonella
Diarrhea × raw chicken:
Salmonella, Shigella
Diarrhea × raw seafood:
Vibrio, Salmonella, hep A
Diarrhea × abx: C. diff
Diarrhea × travel: ETEC
Diarrhea × daycare: rotavirus,
Shigella, Giardia
Diarrhea × AIDS:
Cryptosporidium

---

Bug(s)
skin flora (Strep pyogenes,
Staph aureus)

Presentation
infx of skin and subcutaneous tissue →
erythema, warmth, pain, swelling

Management
• Tx Keflex or Bactrim, consult ophtho if orbital
• involvement

“fiery red”, painful skin lesion on face or
extremities
infx of deeper fascia → extreme fever and
pain, evident tissue necrosis, crepitus
infx of LN → tender LN w/ local cellulitis

• Tx PCN or erythromycin

blocks GABA and glycine release → trismus
(lockjaw), opisthotonos (spastic back),
risus sardonicus (spastic smile)
fever, rash, desquamation of palms/soles;
associated w/ menstruation and tampons

• Tx tetanus antitoxin (TIG) in one site, Td
• immunization in a different site

Cellulitis × fight bite:
Eikenella
Strep pyogenes

Tetanus

Strep pyogenes, Clostridium
perfringens
skin flora (Strep pyogenes,
Staph aureus)
Clostridium tetani exotoxin

Toxic shock syndrome

Staph aureus TSST-1 exotoxin

H+P
not complicated

complicated
(blood, fever, n/v)

Tx symptomatic relief
(rehydrate, ±loperamide) Dx fecal leukocytes
–WBC

+WBC
stool cx,
C. diff toxin

• bacteria → Tx ciprofloxacin x5 days
• C. diff → Tx Flagyl or PO vancomycin

• Tx rapid surgical exploration + debridement,
• broad-spectrum IV abx
• Tx Keflex or Bactrim, warm compresses

• Tx admit + stabilize + IV nafcillin (prevents
• recurrence, not current toxin-mediated illness)

MEDICINE × ID
STDS

BONE/JOINT INFX

Dz
Chlamydia

Bug(s)
Chlamydia trachomatis

Gonorrhea

Neisseria gonorrhoeae

Vaginal candidiasis

Candida albicans

Syphilis

Treponema pallidum

Chancroid

Haemophilus ducreyi

HSV

HSV-1/2

Presentation
Women: cervicitis, PID, TOA, usually asx
Men: urethritis
Women: cervicitis, PID, TOA, usually asx
Men: urethritis
Disseminated gonoccocal infx: migratory
polyarthritis, endocarditis, skin rash
Fitz-Hugh-Curtis syndrome: perihepatitis
causing RUQ pain, ↑LFTs, “violin string”
adhesions
thick, white curd-like discharge, itching,
satellite lesions, no odor
1° syphilis: painless chancre + inguinal LNopathy
2° syphilis: palmar/plantar rash, fever,
condyloma lata, generalized LN-opathy
3° syphilis: neurosyphilis (tabes dorsalis),
CV syphilis (luetic heart), gummas
Jarisch-Herxheimer rxn: acute febrile rxn
s/p syphilis tx (MC w/ 2° syphilis), due to
dead spirochetes → endotoxin release
painful chancre + inguinal LN-opathy
recurrent, painful oral (HSV-1) or genital
(HSV-2) vesicles that can rupture

LGV

Chlamydia trachomatis, L1-L3
serotypes

Condyloma acuminata

HPV-6/11

Herpetic whitlow: painful, paronychia-like
lesions in fingers of healthcare workers
1° LGV: transient, painless ulcer
2° LGV: painful LN-opathy
3° LGV: anogenital syndrome (proctocolitis,
rectal strictures, rectovaginal fistulae,
genital elephantiasis)
genital warts

Bacterial vaginosis

Gardnerella vaginalis

thin homogenous discharge, fishy odor

Trichomoniasis

Trichomonas vaginalis

HIV/AIDS

HIV-1/2 (sexual, parenteral,
vertical, or breastmilk)

Pediculosis pubis
(“crabs”)

Phthirus pubis

green-gray frothy discharge, odor,
strawberry cervix (petechiae)
Primary infx: presents as mono-like
syndrome ± truncal maculopapular rash
Asx stage: CD4+ >500, asx
Sx stage: CD4+ 200-500, mild sx
(generalized LN-opathy, fungal infx, night
sweats, weight loss, diarrhea)
AIDS: CD4+ <200, or presence of AIDS OI
severe itching, irritation, vesicles, burrows

Dz
Osteomyelitis

Bug(s)
Staph aureus (#1), coag-neg
Staph epidermidis (#2), others

Presentation
hematogenous or direct spread → infx of
bone → bone pain w/ local inflammation

Infx arthritis

OM × IV catheter: Staph
aureus
OM × prosthetic joint: coagneg Staph epidermidis
OM × diabetic foot:
polymicrobial
OM × nosocomial:
Pseudomonas
OM × IVDA: Pseudomonas
OM × sickle cell: Salmonella
OM × vertebra: TB (Pott dz)
OM × cat/dog bite: Pasturella
multocida
Staph aureus (#1), others
Arthritis × sexually-active
young adults: N. gonorrhoeae
Arthritis × IVDA:
Pseudomonas
Arthritis × sickle cell:
Salmonella

Management
• Dx Chlamydia NAAT
• Tx azithromycin ± ceftriaxone
• Dx discharge Gram stain (G– diplococci)
• Tx ceftriaxone ± azithromycin

• Dx KOH prep (budding yeast + pseudohyphae)
• Tx fluconazole (Diflucan) or miconazole cream
• Dx screen w/ RPR-VDRL, confirm w/ FTA-ABS;
• or definitive dx w/ Darkfield microscopy
• Tx Benzathine PCN G (1°/2°), IV PCN G (3°)

• Dx Gram stain (“school of fish” appearance)
• Tx azithromycin or ceftriaxone
• Dx Tzanck smear (multinucleated giant cells)
• or viral cx
• Tx ACV/VACV + palliative care

• Dx complement fixation
• Tx doxycycline

• Dx PE
• Tx removal
• Dx wet prep (clue cells)
• Tx metronidazole
• Dx wet prep (mobile trichomonads)
• Tx metronidazole
• Dx screen w/ HIV ELISA, confirm w/ WB
• Tx HAART (2 NRTIs + 1 NNRTI or PI)

• Dx hair under microscope
• Tx permethrin shampoo

Management
• Dx needle aspiration + cx (best), MRI
• Tx admit + IV abx + debride dead bone
• f/u serial ESR/CRP to monitor response to tx

hematogenous or direct spread → infx of
joints → swollen, painful joint w/ ↓↓ROM

• Dx joint aspiration + analysis
• Tx admit + IV abx, drain if shoulder or knee

MEDICINE × ID
ZOONOSES AND
ARTHROPOD-BORNE INFX

FUNGAL INFX

Dz
Lyme disease

Bug(s)
Borrelia burgdorferi via Ixodes
tick vector

Rocky Mountain
spotted fever
Malaria

Rabies

Rickettsia rickettsii via tick
vector
Plasmodium falciparum (24h),
P. vivax and ovale (48h),
P. malariae (72h) via
Anopheles mosquito vector
rabies virus via animal host

Dz
Candidiasis

Bug(s)
Candida albicans

Management
• Dx screen w/ ELISA, confirm w/ WB
• Tx doxycycline

pain at bite location → fever, malaise →
agitation, photophobia, hydrophobia
(foaming) → paralysis, coma → death

• Dx viral cx, Negri bodies on Purkinje cell bx
• Tx emergent passive + active immunization

Presentation
Vaginal candidiasis: thick, white curd-like
discharge, itching, satellite lesions, no odor
Thrush: thick, white plaques in oral mucosa
Cutaneous candidiasis: erythematous,
eroded patches w/ satellite lesions

Management
• Dx KOH prep (budding yeast + pseudohyphae)
• Tx fluconazole or miconazole cream (vaginal),
• nystatin powder (cutaneous), nystatin “swish
• and-swallow” (thrush)

Risk factors: DM, abx use, immunosuppression, HIV/AIDS
ABPA: asthma + pulmonary infiltrates +
Aspergillus allergy
Aspergilloma: prior lung cavitation, filled
up w/ Aspergillus ball → chronic cough ±
hemoptysis
Invasive aspergillosis: acute-onset fever,
cough, respiratory distress, hemoptysis
meningitis/encephalitis in HIV+ pts

• Tx doxycycline
• Dx blood smear w/ Giemsa stain
• Tx chloroquine (mefloquine if resistant) ±
• primaquine for P. vivax/ovale hypnozoites

• Dx CXR (air-crescent sign for aspergilloma)
• Tx avoidance (ABPA), lung lobectomy
• (aspergilloma), IV ampho B (invasive
• aspergillosis)

Aspergillosis

Aspergillus fumigatus

Cryptococcosis

Blastomycosis

Cryptococcus neoformans via
pigeon droppings
Histoplasma capsulatum via
bat/bird droppings in caves
Blastomyces dermatitidis

Coccidioidomycosis

Coccidioides immitis

Sporotrichosis (“rose
gardener disease”)

Sporothrix schenkii via rose
thorn prick

Dz
Giardiasis

Bug(s)
Giardia lamblii

Amebiasis

Entamoeba histolytica

Cryptosporidiosis

Cryptosporidium parvum

Presentation
bloating, flatulence, foul-smelling fatty
diarrhea
flask-shaped ulcers in ascending colon →
bloody diarrhea; “anchovy paste” abscess
in liver → RUQ pain
mild diarrhea, severe diarrhea in HIV+ pts

Ascariasis

Ascaris lumbricoides

usually asx, can cause bowel obstruction

Hookworm

Ancylostoma duodenale (old),
Necator americanus (new)
Enterobius vermicularis

hooks onto bowel walls and sucks blood →
iron-deficiency anemia
perianal pruritus, worse at night

Tapeworm

Taenia saginata (beef),
Taenia solium (pork),
Diphyllobothrium latum (fish)

usually asx, D. latum eats vitamin B12 →
macrocytic anemia

Schistosomiasis

S. haematobium

S. mansoni/japonicum cause fibrosis of liver
and spleen; S. haematobium causes bladder
infx → dysuria, bladder SCC

• Dx stool/urine sample
• Tx praziquantel

Presentation
erythema around an IV cath left in for too
long (>3 days)
fever/chills, sore throat, malaise, myalgias,
severe cervical LN-opathy after making out
w/ someone

Management
• Dx remove and send tip for cx
• Tx IV abx
• Dx Monospot (heterophile agglutination) test
• Tx supportive care + avoid contact sports to
• prevent splenic rupture

Histoplasmosis

PARASITIC INFX

Presentation
Stage 1: erythema chronicum migrans
(target-shaped lesion)
Stage 2: bilateral Bell palsy + AV block
Stage 3: chronic arthritis
triad of HA + fever + rash (vasculitis that
starts on extremities and comes inward)
cyclic fever/chills, headache, anemia,
splenomegaly

Pinworm

S. mansoni

usually asx, mild respiratory sx
inflammatory lung dz, granulomatous
nodules in skin and bone
usually asx, mild respiratory sx after
earthquakes in SW US
local ulcer + ascending LN-opathy

• Dx LP + India ink stain (thick capsules)
• Tx IV ampho B + flucytosine
• Dx bx (macrophage-filled spores)
• Tx itraconazole
• Dx bx (Broad Based Buds)
• Tx itraconazole
• Dx bx (huge spherule w/ endospores)
• Tx itraconazole
• Dx bx (cigar-shaped yeasts)
• Tx itraconazole or potassium iodide

Management
• Dx stool sample
• Tx metronidazole
• Dx stool sample
• Tx metronidazole (for diarrhea and abscess)
• Dx acid-fast stain
• (no tx exists)
• Dx stool sample
• Tx mebendazole
• Dx stool sample
• Tx mebendazole
• Dx Scotch tape test
• Tx mebendazole
• Dx stool sample
• Tx praziquantel

S. japonicum

OTHER INFX

Dz
Catheter-related sepsis
Mononucleosis

Bug(s)
Staph aureus (#1), coag-neg
Staph epidermidis (#2)
EBV (#1), CMV (#2)

MEDICINE × SKIN
COMMON SKIN DZ

Dz
Acne vulgaris

Rosacea
Seborrheic dermatitis

Contact dermatitis

Pityriasis rosea

Erythema nodosum

Lichen planus
Bullous pemphigoid

Pemphigus vulgaris

INFX SKIN DZ

Dz
Warts

Molluscum contagiosum

Shingles (zoster)

Dermatophytes

Scabies

Presentation
obstruction of sebaceous
follicles → proliferation of P.
acnes → noninflammatory
comedones (pimples) →
inflammatory acne
red forehead, nose, cheeks w/o
underlying comedones
usually asx; can present as scaly
patches on scalp (dandruff),
hairline, behind ears, eyebrows,
armpits, groin area
skin rash w/ vesicles and oozing
(acute) or crusted, thickened
skin (chronic)
Irritant contact dermatitis:
physical or chemical insult to
skin → rash shortly after
exposure
Allergic contact dermatitis:
reexposure to allergen → rash
hours-to-days after exposure
herald patches (ringworm-like),
then generalized “Christmas
tree” rash
painful, red, subcutaneous
nodules over shins

4 Ps – pruritic, purple, polygonal
papules
anti-hemidesmosome ab →
tense blisters on skin but not
oral mucosa
anti-desmosome ab → tense
blisters on skin and oral mucosa
w/ acantholysis

Presentation
HPV infx → epithelial growth →
fleshy asx mass, plantar warts
can be painful on walking
Common wart: verruca vulgaris
found on elbows, knees, palms,
and fingers
Flat wart: verruca plana found
on chin/face, dorsum of hands,
and legs
Plantar wart: verruca plantaris
found on sole of foot
Anogenital wart: condyloma
acuminatum found on genital
areas
poxvirus infx → highly
contagious domed papules w/
umbilicated center
reactivation of latent VZV
(chicken pox) infx → pain and
rash in dermatomal distribution

Tinea capitis: found on scalp of
kids w/ itching and hair loss
Tinea corporis: ringworm,
found on body/trunk
Tinea unguium: onychomycosis,
found on finger- and toenails
Tinea pedis: athlete’s foot,
found on webbing of toes
Tinea cruris: jock itch, found in
groin and inner thighs
Sarcoptes scabiei skin mite →
tunnel in epidermis → burrows
and severe pruritus

Management
• Tx clean skin (1st line), topical benzoyl
• peroxide, retinoids, or abx (2nd line), systemic
• abx (3rd line), isotretinoin (last line/teratogen)

• Tx topical metronidazole (1st line), systemic
• abx (2nd line), isotretinoin (last line)
• Tx sunlight + dandruff shampoo (1st line),
• topical ketoconazole (2nd line), topical steroids
• (last line)
• Dx patch test if unsure
• Tx cold compresses, topical steroids, systemic
• steroids (severe)
• PPx avoid allergen

Other
Risk factors: male sex, puberty,
Cushing syndrome, oily skin,
androgens, meds
Steroid acne: not associated w/
underlying comedones
Rhinophyma: large, bulbous,
greasy nose in men

Etiology: ACD is delayed (type 4)
HS to poison ivy, oak, sumac,
iodine, nickel, rubber, cosmetics

• Tx reassurance

• Dx CXR (for TB, sarcoidosis), VDRL, CBC, ESR,
• skin cx/bx to look for underlying cause
• Tx underlying cause + symptomatic relief (bed
• rest, leg elevation, NSAIDs, heat pads)
• Tx systemic steroids

Etiology: Strep, sarcoidosis, IBD,
fungal infx, syphilis, TB,
pregnancy, meds, idiopathic

• Tx systemic steroids

• Tx systemic steroids

Management
• Tx removal (cryotherapy, salicylic acid,
• podophyllin, surgical or laser excision)

Other

• Tx removal (cryotherapy, podophyllin, surgical
• or laser excision)
• Tx ACV + analgesics
• PPx shingles vaccine for elderly

• Dx scrape lesions + KOH prep
• Tx PO griseofulvin for tinea capitis and
• onychomycosis, topical antifungals for others

• Dx scrape lesions + microscopy
• Tx permethrin cream for pt and close contacts

MC sites: thorax and trigeminal
nerve distribution
Complications: postherpetic
neuralgia, uveitis, dissemination,
meningoencephalitis, deafness

MEDICINE × SKIN
SKIN CANCERS

Dz
Actinic (solar) keratosis

Presentation
small, rough, scaly lesions on
face of fair-skinned people;
precursor to SCC
raised waxy lesion or nonhealing ulcer in upper face,
doesn’t spread
non-healing ulcer in lower
face, spreads to LN

Management
• Tx removal (cryotherapy, surgical scraping,
• or topical 5-FU)

Melanoma

ABCDE – asymmetric, border
irregularity, colors, diameter >6
mm, elevated; highly metastatic

• Tx excisional bx w/ 1 cm margins + search for
• mets

Dz
Decubitis ulcers (pressure
sores)

Presentation
prolonged pressure → tissue
ischemia and necrosis → ulcers

Management
• Tx local wound care, surgical debridement,
• BID wet-to-dry for deeper ulcers
• PPx turn and reposition q 2 hrs

Psoriasis

Stage 1: skin intact
Stage 2: partial-thickness skin
loss
Stage 3: full-thickness skin loss
Stage 4: full-thickness skin loss
that extends into underlying
muscle, bone, joints, tendons
abnormal proliferation of skin
cells → silvery, scaling plaques
w/ Auspitz sign (bleeding upon
removal)
“pasted on” dark, oily plaques
common in older pts
irregular depigmentation of
skin, most commonly on face

BCC

SCC

OTHER SKIN DZ

Seborrheic keratosis
Vitiligo

ALLERGIC REACTIONS

Other

• Tx excisional bx w/ 1 mm margins

• Tx excisional bx w/ 1 cm margins + LN excision

Risk factors: sunlight exposure,
draining fistulas, arsenic, HPV
Keratoacanthoma: variant of SCC
that grows rapidly and dies off
spontaneously
Marjolin’s ulcer: SCC arising from
a chronic wound
Growth phases: initially grows
radially, then vertically; px
related to depth of invasion
Dysplastic nevus: atypical mole,
precursor to melanoma
Spitz nevus: well-circumscribed,
raised lesion confused w/
melanoma

Other
MC sites: sacrum, greater
tuberosity, ischial tuberosity
Risk factors: immobilization,
dementia, peripheral vascular dz
Complications: secondary
bacterial infx (cellulitis, osteomyelitis, nec fasc, gangrene)

• mild → Tx topical steroids, calcipotriene
• severe → Tx MTX, infliximab, cyclosporine A

• Tx removal (cryotherapy, surgical excision)
• only for cosmetic reasons
• Tx topical steroids or photochemotherapy

Type 1 HS: allergen exposure → IgE-mediated mast cell degranulation → HA release, atopic/anaphylactic
Type 2 HS: IgG or IgM against cell surface, cytotoxic
Type 3 HS: ab-ag complex deposition → complement activation → cell damage
Type 4 HS: T-cell mediated activation of macrophages, delayed-type
Dz
Urticaria (hives)

Presentation
type 1 HS → edematous wheals
(hives) that cause intense
pain/pruritus
severe urticaria + target lesions
(“bulls-eye lesions”)
severe erythema multiforme +
mucus membrane involvement
severe Stevens-Johnson
syndrome
fluid extravasation into
subcutaneous tissue → painful
swelling of eyelids, lips, tongue,
genitalia, hands, or feet
types 1-4 HS → skin eruptions
(MC), lung, kidney, hematologic
complications, anaphylaxis

Management
• Tx remove offending agent, symptomatic
• relief (anthistamines)

Other

• Tx remove offending agent, symptomatic
• relief (anthistamines)
• Tx remove offending agent, admit to ICU

Etiology: sulfa drugs (MCC),
other drugs, HSV infx
Etiology: sulfa drugs (MCC),
other drugs
Etiology: sulfa drugs (MCC),
other drugs
Etiology: ACE inhibitors (MCC)
Hereditary angioedema: C1esterase inhibitor deficiency

Food allergy

type 1 HS → skin eruptions
(MC), GI sx, anaphylaxis

• Tx remove offending agent, symptomatic
• relief (anthistamines)
• anaphylaxis → Tx epinephrine

Insect sting allergy

Nonallergic rxn: localized
swelling, pain, pruritis, redness
Allergic rxn: looks like cellulitis
severe type 1 HS → skin
eruptions followed by airway
obstruction, then shock

• nonallergic → Tx ice pack
• allergic → Tx ice pack + antihistamines
• anaphylaxis → Tx epinephrine
• Tx ABCs, epinephrine, antihistamines, steroids

Erythema multiforme
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Angioedema

Drug allergy

Anaphylaxis

• Tx remove offending agent, admit to ICU
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• laryngeal edema → Tx epinephrine
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• anaphylaxis → Tx epinephrine

Adverse drug reaction: broad
category including drug allergy,
side-effects, drug interactions,
toxicity, etc.
Adverse food reaction: broad
category including food allergy,
food poisoning, metabolic
conditions, malabsorption, etc.
Etiology: Hymenoptera spp.
(wasps, yellow jackets, honeybees, hornets)

MEDICINE × OUTPATIENT
CARDIOVASCULAR DZ

Dz/CC
HTN

Presentation
asx, but can present w/ end-organ
complications...

Management
Dx BP cuff
H+P
lifestyle modifications

Heart: LVH, MI, CHF
Eyes: retinopathy, papilledema
Kidney: CKD
Brain: stroke, TIA
Arteries: PVD, aortic dissection

not at goal BP
stage 1

Tx HCTZ

stage 2

compelling
indications

Tx HCTZ + Tx specific drug
ACEI/ARB/BB/CB
not at goal BP

optimize dose or add drug
• if diabetic, stroke → Tx ACE inhibitor
• if CAD, CHF → Tx β-blocker
• if pregnant → Tx Ca-blocker
• if refractory → check for compliance

HLD

• H+P: ask about CP, SOB, HA, side-effects;
• labs (renal panel, fasting lipids)
• Lifestyle modifications: weight loss,
• DASH eating plan, sodium restriction,
• aerobic exercise, moderate alcohol use
• Goal BP: <140/90, <130/80 if CKD or DM
Dx fasting lipid panel

asx, but can present w/ end-organ
complications…

initial evaluation +
lifestyle modifications

Atherosclerosis: MI, CAD, stroke,
PVD, AAA
↑LDL: xanthelasma, xanthoma
↑TG: acute pancreatitis

not at goal lipids
LDL >130 (if high risk)
LDL >160 (if med risk)
LDL >190 (if low risk)
Tx statins

TG >500

Tx niacin

not at goal lipids
optimize dose or add drug
• Initial evaluation: look for 2° causes + labs
• (TSH, LFTs, renal, fasting glucose)
• Lifestyle modifications: diet + exercise
• Goal lipids: <130, <100 if CHD or DM

Hyperlipidemia drugs:
Statins

LDL
↓↓↓

HDL
↑

TG
↓

Niacin

↓

↑↑

↓↓

Bile acid resins (colestipol,
cholestyramine)
Fibrates (gemfibrozil)

↓↓

↑

↑

↓

↑

↓↓↓

Side-effects
hepatotoxicity, rhabdomyolysis (check
CK, LFTs)
flushing, hyperglycemia,
hyperuricemia (check CK, LFTs)
GI distress, poorly tolerated
hepatotoxicity, rhabdomyolysis,
cholesterol gallstones (check CK, LFTs)

Other
Pre-HTN: 120-139/80-89
Stage 1 HTN: ≥140/90
Stage 2 HTN: ≥160/100
HTN urgency: ≥220/120
HTN emergency: ≥220/120 + endorgan damage
1° (essential) HTN: 95%, no
underlying cause
2° HTN: 5%, due to renovascular
dz (MCC), OCPs (MCC young
women) or other meds,
stimulants, endocrine dz, etc.

MEDICINE × OUTPATIENT
HEADACHE

1° HA types: tension, cluster, migraines
2° HA causes: VOMIT – Vascular (SAH, SDH, EDH, ICH, temporal arteritis)
Other (malignant HTN, psedomotor cerebri, post-LP, pheo)
Meds (nitrates, alcohol withdrawal, analgesic withdrawal)
Infx (meningitis, encephalitis, abscess, sinusitis, shingles, fever)
Tumor
Severe HA w/ HTN: get noncontrast head CT to r/o ICH, then get LP
Dz/CC
Tension HA

Cluster HA

Migraine HA
Rebound analgesic HA

UPPER RESPIRATORY DZ

Presentation
tight band-like pain encircling
entire head + tightness in
posterior neck muscles
unilateral, episodic “burning,
searing, or stabbing pain”
behind eye + ipsi tearing, flush,
or nasal discharge in men
unilateral, throbbing HA ± n/v,
phono-/photophobia in women
“migraine” after discontinuing
long-term analgesic use

Management
• Tx NSAIDs or Tylenol if mild/moderate,
• sumatriptan (Imitrex) if severe

Other
Etiology: unknown

• Tx sumatriptan + O2 for acute attacks,
• use verapamil for ppx

Etiology: unknown

• Tx sumatriptan for acute attacks,
• use TCA or propranolol for ppx
• Tx wean pt from analgesics (do not give pt
• more narcotics)

Etiology: stress → ↓5-HT →
vasospasm → headache

Viral vs. bacterial URI: common sx – fever, cough
viral only – rhinorrhea, myalgia, headache
bacterial only – yellow sputum
“Double sickening”: cold that gets better for a few days then gets worse, consider 2° bacterial infx
Dz/CC
Cough

Acute bronchitis
“Common cold” (viral
rhinosinusitis)

Presentation
---

cough (dry or productive),
±fever, ±shortness of breath
dry cough, sore throat, malaise,
rhinorrhea, nasal congestion

Sinusitis

nasal stuffiness, purulent
discharge, cough, sinus pain or
pressure (maxillary sinuses may
resemble dental pain)

Laryngitis

hoarseness, sore throat, ±other
viral URI sx
---

Sore throat

Management
• suspect pulmonary dz → Dx CXR
• suspect infx → Dx CBC
• suspect asthma → Dx PFT
• Tx underlying cause (if known) + symptomatic
• relief (codeine syrup, hydration, expectorants)
• smoker → Tx cessation
• postnasal drip → Tx antihistamine +
• decongestant
• suspect PNA → Dx CXR
• Tx symptomatic relief (codeine syrup)
• Tx symptomatic relief (codeine syrup,
• hydration, expectorants, analgesics)
• PPx hand washing
• Dx (think viral if <7-10 days, bacterial if
• >7-10 days)
• viral → Tx decongestant (pseudoephedrine)
• bacterial → Tx decongestant + amoxicillin; if
• not improved after 2 wks, Tx penicillinase
• resistant abx ± ENT consult
• Tx voice rest
• Dx rapid strep test, throat cx
• suspect mono → Dx Monospot test
• Tx symptomatic relief (salt water gargling,
• throat lozenges, analgesics)
• strep throat → Tx PCN x10 days

Other
Acute cough: <3 wks, MCC
viruses
Chronic cough: >3 wks, due to
smoking, postnasal drip, GERD,
or asthma

Etiology: MCC viruses
Etiology: MCC viruses, through
hand-to-hand transmission
Complications: 2° bacterial infx
Etiology: viruses, Strep pneumo,
H. flu, Moraxella catarrhalis
Complications: mucocele,
polyps, infx spread (cellulitis,
osteomyelitis, abscess)
Etiology: MCC viruses
Etiology: MCC viruses, bacterial
tonsillitis, strep throat, mono

MEDICINE × OUTPATIENT
GASTROINTESTINAL DZ

Dz/CC
Dyspepsia

GERD

Diarrhea

Presentation
spectrum of epigastric sx
(pain/discomfort, heartburn,
bloating, indigestion)

heartburn, regurgitation,
waterbrash (sour taste), cough,
dysphagia

---

Management
• suspect severe GI dz → Dx endoscopy +
• urease breath test
• suspect MI → Dx EKG + cardiac enzymes
• Tx underlying cause, make lifestyle changes,
• antacids for acid reflux
• H. pylori → Tx triple or quadruple therapy
• Tx PPIs → if it persists >6 wks, Dx EGD w/ bx
• to see what’s going on
• Esophagitis: multiple nonulcerating erosions;
• mild Tx → PPIs, severe → lap Nissen
• Barrett esophagus: intestinal metaplasia of
• esophageal epithelium; no dysplasia → Tx
• PPIs, low-grade dysplasia → Tx lap Nissen +
• annual surveillance, high-grade dysplasia →
• Tx esophagectomy
acute diarrhea
H+P
not complicated

complicated
(blood, fever, n/v)

Tx symptomatic relief
(rehydrate, ±loperamide) Dx fecal leukocytes
–WBC

+WBC
stool cx,
C. diff toxin

• bacteria → Tx ciprofloxacin x5 days
• C. diff → Tx Flagyl or PO vancomycin

Constipation

IBS

Nausea/vomiting

Hemorrhoids

---

altered bowel habits (diarrhea,
constipation, or both) that
improve w/ defecation + chronic
abdominal pain
---

dilated perianal veins; can
present as BRBPR or painful
thrombosis

• suspect 2° cause → Dx TSH, renal panel
• suspect CRC → Dx CBC, FOBT
• suspect obstruction → Dx KUB
• Tx underlying cause, make lifestyle changes
• (exercise, fluids, high-fiber diet)
• obstruction → surg consult
• Dx CBC and FOBT to r/o organic causes
• constipation → Tx fiber, lubiprostone (2nd line)
• diarrhea → Tx loperamide
• Dx (ask food intake, meds, recent abdominal
• surgery, define vomitus)
• suspect 2° cause → Dx CBC, renal panel, LFTs
• women → Dx β-HCG
• suspect obstruction → Dx KUB
• Tx underlying cause, symptomatic relief
• (promethazine or prochlorperazine)
• severe dehydration → Tx admit + IVF (½NS+K)
• Tx symptomatic relief (high-fiber diet, stool
• softeners, sitz baths, steroid suppository)
• severe → Tx hemorroidectomy or rubber
• band ligation (internal only)

Other
Etiology: 90% due to GI causes
(PUD, GERD, gastritis, nonulcer
dyspepsia); must r/o acute MI

Etiology: ↓LES tone →
retrograde flow of stomach
contents into esophagus
Complications: erosive
esophagitis, peptic strictures,
esophageal ulcers, Barrett
esophagus, recurrent PNA w/
lipid-laden macrophages

Acute diarrhea: <2 wks, due to
viruses (MCC), bacteria, or meds
Chronic diarrhea: >4 wks, IBS
(MCC), lots of causes
Diarrhea × n/v: viral gastroenteritis or food poisoning
Diarrhea × fever/blood: Shigella,
Salmonella, Campy, EHEC
Diarrhea × mayonnaise: Staph
aureus (<6 hrs), Salmonella
Diarrhea × raw chicken:
Salmonella, Shigella
Diarrhea × raw seafood: Vibrio,
Salmonella, hep A
Diarrhea × abx: C. diff
Diarrhea × travel: ETEC
Diarrhea × daycare: rotavirus,
Shigella, Giardia
Diarrhea × AIDS:
Cryptosporidium
Diarrhea × appendicitis-like pain:
Yersinina enterocolitica
Diarrhea × mycotic aneurysm:
Salmonella
Diarrhea × PNA × hyponatremia:
Legionella
Electrolyte imbalance:
hypokalemic metabolic acidosis
Etiology: diet (lack of fiber),
meds, IBS, obstruction, etc.
Complications: hemorrhoids,
rectal prolapse, anal fissures,
fecal impaction

Etiology: unknown, but more
common in women and high
prevalence of Ψ d/o
Etiology: viral gastroenteritis or
food poisoning (MCC), lots of
causes
Complications: dental caries,
aspiration pneumonitis, MalloryWeiss or Boerhaave syndrome
Electrolyte imbalance:
hypokalemic, hypochloremic
metabolic alkalosis
Internal hemorrhoids: above the
dentate line, painless but can
prolapse
External hemorrhoids: below
the dentate line, painful

MEDICINE × OUTPATIENT
MUSCULOSKELETAL DZ

Dz/CC
Low back pain

Ankle sprain

Tendinitis

Bursitis

Carpal tunnel syndrome

Osteoarthritis (OA)

Osteoporosis

Presentation
Lumbar strain: dull LBP after
physical activity
Herniated disc: sciatic-type LBP
radiating to butt/thigh, worse w/
sitting or leaning forward
Degenerative disc dz: chronic
LBP, worse w/ activity
Cauda equina syndrome: bilat
sciatica + bowel/bladder sx,
neuro sx
Vertebral osteomyelitis: LBP +
fever, tender to palpation
Malignancy: LBP + night pain,
h/o cancer, weight loss, failure
to improve
Spinal stenosis: LBP worse w/
activity, better w/ sitting or
leaning forward
Compression fx: well-localized
LBP, worse w/ activity
Spondylolisthesis: LBP worse w/
hyperextension
tenderness directly over injured
ligament (ATFL or CFL)

Supraspinatus tendinitis: aka
impingement syndrome, dull
pain over lateral deltoid w/ arm
aBduction
Lateral epicondylitis: aka tennis
elbow, pain at lateral elbow w/
supination or pronation
Medial epicondylitis: aka
golfer’s elbow, pain at medial
elbow w/ wrist flexion
De Quervain dz: pain at radial
wrist w/ thumb gripping
Olecranon bursitis: swelling
“bag of fluid” and pain at point
of elbow
Trochanteric bursitis: greater
trochanter painful on palpation
carpal tunnel tightness →
median nerve compression →
pain, numbness, tingling over
median nerve distribution;
usually worse at night

wear-and-tear of joints →
degeneration of cartilage →
deep, dull joint pain, worse w/
activity and improved w/ rest

decreased bone mass (≤2.5 std
deviations) → asx, but can
present w/ complications

Management

Other
LBP
H+P

no red flags
Tx rest + NSAIDs

red flags
(night pain, pain at rest,
fever, neuro sx, trauma,
bowel/bladder sx, IVDA)
focused work-up

• suspect radiculopathy → Dx straight leg raise
• suspect compression fx, tumor mets, or
• osteomyelitis → Dx X-ray
• suspect cauda equina → Dx emergent MRI +
• consult neurosurg

• Dx ankle X-ray only if Ottawa rules are met
• (can’t walk 4 steps, bony tenderness over
• either malleolus, navicular bone, or base of 5th
• metatarsal)
• Tx RICE + physical therapy
• Tx steroid injections, surgical acromioplasty

• Tx forearm splint, physical therapy

• Tx forearm splint, physical therapy

• Dx Finkelstein test (clench thumb under other
• fingers then ulnar deviate wrist)
• Tx thumb spica splint + NSAIDs
• Tx reassurance

• Tx NSAIDs, steroid injections
• Dx screen w/ Tinel’s sign (tapping median
• nerve causes tingling), Phalen’s test (palmar
• flexion for 1 min causes tingling)
• Dx confirm w/ EMG
• Tx wrist splints (1st line), steroid injections (2nd
• line), surgical carpal tunnel release (3rd line)
• Dx X-ray (look for joint space narrowing,
• osteophytes aka bone spurs, sclerosis, and
• subchondral cysts)
• Tx glucosamine-chondroitin supplements
• Tx weight loss + physical therapy (1st line),
• acetaminophen or NSAIDs (2nd line), steroid
• injections (3rd line), joint replacement (4th line)
• screen women ≥65 w/ DEXA scan q 2 yrs
• Dx DEXA scan
• Tx calcium + vitamin D + weight-bearing
• exercise (1st line), bisphosphonates or HRT

MC joints: hips, knees, spine
Risk factors: old age, obesity,
joint overuse, trauma
HeberDen nodes: OA at DIP
Bouchard nodes: OA at PIP
Risk factors: postmenopause,
old age, steroid or heparin use
Complications: vertebral body
compression fx (→ kyphosis),
Colles fx (distal radius), hip fx

MEDICINE × OUTPATIENT
EYE DZ

Dz/CC
Age-related macular
degeneration (ARMD)

Presentation
degeneration of macula → loss
of central vision, scotoma

Glaucoma

Wet ARMD: sudden onset
Dry ARMD: gradual onset
↑intraocular pressure → optic
nerve damage → loss of
peripheral vision, blindness

Cataracts

Red eye

Conjunctivitis

Amaurosis fugax

SLEEP D/O

Dz/CC
Sleep apnea

Narcolepsy

Insomnia

Open-angle: gradual onset,
usually asx for years
Closed-angle: sudden onset w/
severe eye pain, tearing, n/v
opacification of lens → gradual
loss of visual acuity

Conjunctivitis: (see below)
Subconjunctival hematoma:
blood vx rupture → blotchy red
spot in eye
Keratoconjunctivitis sicca: dry
eyes
Blepharitis: eyelid inflammation,
due to Staph aureus
Scleritis:inflammation of sclera
→ eye pain, blurry vision
Uveitis/iritis: inflammation of iris
→ circumcorneal injection, eye
pain, blurry vision
HSV keratitis: presents similar to
conjunctivitis but fluorescein
stain shows dendritic ulcer

Viral conjunctivitis: adenovirus
infx → swollen, red eye w/
watery discharge
Bacterial conjunctivitis: Strep
pneumo infx → rapid-onset red
eye w/ mucopurulent discharge
Hyperacute conjunctivitis: N.
gonorrhoeae infx → rapid-onset
red eye w/ copious purulent
discharge
Allergic conjunctivitis: bilateral
red eye w/ itching, tearing, other
upper respiratory sx
internal carotid artery plaque →
embolize to retinal artery →
suddent, transient monocular
loss of vision

Presentation
neck obesity or structural
abnormalities → intermittent
airflow obstruction → episodic
apenic/hypoxic periods →
snoring + fragmented sleep →
daytime sleepiness, brain
damage, HTN/pulmonary HTN
REM sleep disregulation →
excessive daytime sleepiness,
cataplexy, sleep paralysis,
hypnogogic/hypnopompic
hallucinations
---

Management
• Dx ophthalmoscope shows drusen (yellow• white deposits under pigmented epithelium)
• no effective tx exists, but ranibizumab →
• ↓rate of vision loss due to wet ARMD

Other

• Dx ophthalmoscope to check CN II damage,
• visual field testing, tonometry to measure IOP
• open angle → Tx topical β-blockers, α
• agonists, acetazolamide, or prostaglandins
• closed angle → Tx pilocarpine drops +
• emergent iridectomy
• Dx ophthalmoscope
• Tx surgery

Etiology: old age (MCC),
smoking, diabetes, etc.
“Second sight”: pts w/ cataracts
become increasingly nearsighted and no longer need
reading glasses

red eye
H+P
no red flags

red flags
(severe eye pain, flashes,
Tx cause
floaters, trauma, recent
eye surgery, orbital cellulitis,
corneal ulcer/opacification)
consult ophtho

• subconjunctival hematoma → reassurance
• keratoconjunctivitis sicca → Tx artificial tears
• blepharitis → Tx warm compress
• scleritis → consult ophtho (Tx steroids)
• uveitis/iritis → consult ophtho
• HSV keratitis → Tx topical ACV
• viral → Tx cold compress
• bacterial → Tx topical Cipro
• hyperacute → Tx topical + PO ceftriaxone
• allergic → Tx topical antihistamines

• Dx ophthalmoscope shows Hollenhorst plaque
• Dx carotid U/S and cardiac work-up (lipid
• panel, EKG)
• Tx resolves spontaneously

Management
• Dx polysomnography
• mild-moderate → Tx weight loss
• severe → Tx CPAP, surgery (last resort)

• Tx methylphenidate (Ritalin), modafinil

• Tx underlying cause, short-term symptomatic
• relief (Ambien, Lunesta, Sonata)

Other

MEDICINE × OUTPATIENT
OTHER PROBLEMS

Dz/CC
Hearing loss

Presentation
Conductive hearing loss: lesion
in external or middle ear →
decreased perception of lowvolume sounds
Sensorineural hearing loss:
lesion in CN VIII or CNS →
decreased perception of lowand high-volume sounds w/
tinnitus
Stress incontinence: urine
leakage w/ exertion or straining

Management
• Dx whisper test, audiogram, Weber/Rinne test
• suspect CNS lesion → Dx MRI

• Tx anticholinergics (oxybutinin), TCAs
• (imipramine)

Fatigue

Urge incontinence: urine
leakage d/t involuntary bladder
contractions (detrusor hyperactivity)
Overflow incontinence: urine
leakage d/t urinary retention
and overdistention
Bypass incontinence: urine
leakage d/t fistula following
pelvic surgery or pelvic radiation
Functional incontinence: urine
leakage d/t physical or psych
issues; common in nursing home
or gero pts
---

Erectile dysfunction (ED)

Chronic fatigue syndrome
(CFS): profound fatigue for >6
months, not due to medical or
psych d/o
can’t get it up

Alcoholism

---

Urinary incontinence

• cerumen impaction → Tx Debrox eardrops
• conductive → Tx underlying cause
• sensorineural → Tx underlying cause, consider
• cochlear implants

• Tx surgery to stabilize hypermobile urethra
• (best), Kegel exercises, pessaries

• Tx intermittent self-cath

Etiology: vesicovaginal, urethrovaginal, ureterovaginal fistulas

• Tx underlying cause

Etiology: physical impairment,
dementia or delirium,
medications

• Dx CBC (anemia), TSH, fasting glucose, renal
• panel, UA, LFTs to r/o organic causes
• Tx underlying cause
• CFS → Tx CBT ± SSRIs

Etiology: depression (MCC), lots
of other causes

• Tx sildenafil (nitrates c/i)

Etiology: penile vasculature
atherosclerosis (MCC), meds
(anti-HTN), alcohol abuse, etc.
Wernicke encephalopathy:
acute thiamine deficiency →
reversible Confusion,
Ophthalmoplegia (CN VI palsy),
Ataxia, Thought disturbances

• Dx CAGE screening (cut down, annoyed by
• criticism, guilt, eye opener)
• Dx labs show ↑LFTs (AST:ALT >2, ↑GGT, ↑CDT),
• ↑MCV (folate deficiency)

Smoking

---

• Tx varenciline (Chantix) and buproprion
• (Zyban) are partial nicotinic agonists; nicotine
• patch or gum

Dz
HTN
HLD

Population
adults ≥18
adults ≥18

Colorectal cancer

adults ≥50

Prostate cancer
Breast cancer

--women ≥20

Cervical cancer

women 21-65

STDs

sexually active women <25,
other high-risk women
women ≥65
adults ≥18
adults ≥18
adults ≥18

Screening test
measure BP
fasting lipid panel q 5 yrs (more frequently if
increased risk of CAD)
annual FOBT + either colonoscopy q 10 yrs or
flex sigmoidoscopy q 5 yrs
not recommended
monthly self-exam + physician exam q 3 yrs until
40, then q yr + mammogram q 1-2 yrs ≥40
Pap smear q 2 yrs 21-29, q 3 yrs >30 after 3
negative Paps (don’t need s/p hysterectomy)
cervical sampling + RPR-VDRL ± HIV ELISA

Osteoporosis
Smoking
Alcohol
Depression
Diabetic retinopathy
Hearing loss
Atherosclerosis complications
(PVD, stroke, CAD)

diabetic pts
adults ≥65
adults ≥65

Etiology: chronic ↑ abdominal
pressure, pelvic relaxation, old
age (↓estrogen → loss of
mucosal coaptation)
Etiology: idiopathic (MCC), UTIs,
bladder stones or cancer,
urethral diverticula, foreign
bodies
Etiology: medications,
neurologic disease

• Dx methylene blue or indigo carmine dye
• Tx surgery to repair fistula

• Tx AA referral
• Tx disulfiram (Antabuse) blocks aldehyde
• dehydrogenase → aversive reaction;
• naltrexone blocks opioid-R → ↓cravings;
• acamprosate → ↑GABA/↓glu → ↓cravings

HEALTH MAINTENANCE

Other
Etiology: cerumen impaction
(MCC conductive), presbycusis
(MCC sensorineural), lots of
other causes

DEXA scan q 2 yrs
screen + counsel
screen + counsel
screen + counsel if clinic has adequate
mechanisms for dx, tx, and f/u
referral to ophtho for annual fundoscopic exam
hearing test
assess risk factors

Korsakoff psychosis: chronic
thiamine deficiency →
irreversible Retrograde and
Anterograde amnesia,
Confabulations
Complications: CV dz (CAD, MI,
stroke, PVD), COPD, cancers,
osteoporosis, Buerger dz, etc.

PEDIATRICS

Pediatrics – Shelf notes

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GENERAL PEDS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––


★ Developmental milestones

Fine motor
---

Speech
cooing

Social
recognizes parents, social smile

6 mo
1 yr

Gross motor
holds head up, rolls
front-to-back
sits up
walks

raking grasp
throws object, 3 blocks

babbling
10 words

2 yr

climbs stairs

turns pages, 6 blocks

3 yr

rides tricycle

draws circle, 9 blocks

4 yr

hops on one foot

draws cross

40 words, 2-word sentences,
50% understandable
900 words, 3-word sentences,
75% understandable
counts to ten, tells stories,
100% understandable

stranger anxiety
comes when called, imitates
actions, object permanence
parallel play

3 mo





cooperative play, imaginary
friends


Speech delay: deafness, autism, child abuse
Vaccinations: only contraindication across all vaccines is a severe allergic response

DTaP contraindications: severe allergic response, encephalopathy within 7 days

Adverse response to DTaP: give DT instead, since rxn is due to pertussis component

Foot drop s/p injection: needle injection in lower/inner gluteal quadrant → iatrogenic damage to sciatic nerve
Orthopedic issues

Clavicle fx: presents w/ clavicular crepitus or callus, ↑risk w/ LGA infants and breech deliveries; Tx reassurance > figure-of-8 splint

Supracondylar fx: MC fx in kids, due to trauma to humerus; Tx ortho c/s + check radial pulse since brachial artery can be injured

Toddler fx: nondisplaced spiral fx of distal tibia in infants; Tx splint immobilization

Nursemaid elbow: pulling on hand → subluxation of radial head from annular ligament → kid holds arm in a pronated position; Tx manual
reduction via supinating motion

Radial epiphyseal separation: falling out outstretched arm → separation of radius at epiphyseal plate

Genu varum (bowlegs): observe in kids <2 y/o, called Blount disease in kids >2 y/o and requires ortho c/s

Genu valgus (knock-knees): observation okay

Metatarsus adductus: congenital foot deformity, forefoot pointing inwards
Presentation
Management
Type I metatarsus adductus
overcorrects into position w/ passive and active movements
Tx reassurance
Type II metatarsus adductus
corrects into position w/ passive and active movements
Tx orthosis or corrective shoes
Type III metatarsus adductus
doesn’t correct into position w/ passive or active movements
Tx surgical correction




group play

Clubfoot: congenital foot deformity, inward and downward-pointing feet, ↑risk of associated spina bifida; Tx stretching + manipulation +
serial casts (<3 mo), surgery (>3 mo)

★ Legg-Calve-Perthes disease: avascular necrosis of femoral head, presents as painless limp in a boy <10 y/o, requires ortho c/s

★ Slipped capital femoral epiphysis: painful limp in a fat boy; Dx X-ray, requires ortho c/s

★ Osgood-Schlatter disease: overuse injury of quads and patellar tendon → traction apophysitis of tibial tuberosity → localized
pain/swelling; Tx RICE + NSAIDs

Congenital hip dysplasia: presents as uneven gluteal folds and “snapping hips” during physical exam in a newborn; Dx U/S (not calcified
enough for X-ray), Tx splinting

Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg for 3
days), Tx admit + IV abx

Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx drainage + IV nafcillin

Osteogenesis imperfecta: AD ∆type 1 collagen → abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss;
often mistaken as child abuse

Osteosarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows Codman’s triangle and “sunburst appearance”, Tx ortho c/s for
surgery

Ewing sarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows “onion skin” appearance, Tx ortho c/s for surgery

Growing pains: deep aching pain in leg muscles w/o any “red flags” (fever, swelling, systemic sx); Tx reassurance

Patellofemoral syndrome: chronic anterior knee pain, worse w/ exercise or prolonged sitting; Tx strengthening exercises
★ Skin rashes
Presentation
Management
Eczema (atopic dermatitis)
chronic pruritic rash on cheeks, behind ears,
Tx moisturizers (calamine or eucerin
extensor surfaces, flexural areas
lotion) + topical steroids
Urticaria
allergic reaction → pruritic “wheal and flare”
Tx antihistamines + PO steroids + avoid
rash
allergen
Chickenpox (varicella)
VZV infx → “dew drops on a rose petal”
Tx antihistamines, ACV if onset <24 hrs
vesicular rash in an ill child
Staphylococcal scalded skin syndrome
Staph aureus exfoliatoxins A/B → fever +
Tx abx + local skin care
(SSSS)
severe, painful rash that develop into bullae,
rupture, and eventually desquamate
Pityriasis rosea
single oval herald patch (resembles
Tx reassurance
ringworm), followed by diffuse “Christmas
tree” pattern rash on back 5-10 days later
Lichen planus
Purple Polygonal Pruritic Papules (rare in
Tx PO steroids
children)
Contact dermatitis
skin rash w/ vesicles and oozing (acute) or
Tx antihistamines + topical steroids +

Pediatrics – Shelf notes

Psoriasis
Henoch-Schonlein (anaphylactoid)
purpura

Scabies
Impetigo
Porphyria cutanea tarda







crusted, thickened skin (chronic) in an
exposure pattern (e.g. linear for poison ivy,
localized for nickel)
thick silvery scales that bleed upon removal
(Auspitz sign)
IgA-mediated small vessel vasculitis →
“palpable purpura” on buttocks and legs,
renal disease (IgA mesangial expansion),
ileocecal edema → colicky abdominal pain +
↑risk for intussusception
Sarcoptes scabeii infx under skin → pruritic
bullae and pustules (not burrows like adults)
Staph aureus infx → vesicles/pustules on face
and extremities w/ classic “golden crust”
∆uroporphobilinogen decarboxylase →
photosensitivity to UV light, tea-colored urine,
recurrent attacks of abdominal pain

avoid exposure

Tx topical steroids + calcipotriene (mild),
MTX/infliximab/cyclosporine A (severe)
Tx steroids vs. symptomatic relief, will
self-resolve

Tx permethrin cream (lindane causes
seizures in kids/elderly)
Tx topical mupirocin > PO erythromycin
---

Behavioral issues

★ Enuresis: involuntary urination >5 y/o; Dx UA to r/o UTI, Tx bed-wetting alarm > desmopressin > imipramine

★ Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows dilated/stoolfilled colon, Tx bowel catharsis + miralax

Breath-holding spells: child holds breath and passes out, due to pain or being upset; Tx avoid reinforcing behavior

Night terrors: child wakes up screaming/agitated, but falls back asleep and remembers nothing in the morning

Nightmares: child wakes up scared and crying, remembers incident

Learned behavior: child wakes up scared and crying, in order to gain sympathy and sleep in mommy’s bed; Tx avoid reinforcing behavior

Somnambulism: sleepwalking, don’t wake up the child

Somniloquy: sleeptalking, benign

Conduct disorder: Capriciousness, Oppressive, Nonconfrontational, Deceitful, Unlawful, Carefree, Temper issues; <18 y/o

Antisocial personality disorder: conduct disorder >18 y/o

★ ADHD: short attention span, impulsivity, hyperactivity for >6 months in 2+ settings (e.g. home and school); ↑risk of aggression; Dx
Vanderbilt scale, Tx dextroamphetamine or methylphenidate

Mental retardation (MR/DD): IQ <70; MCC overall is fetal alcohol syndrome, MC genetic cause is Down syndrome, MC inherited cause is
Fragile X syndrome
Abnormal physical exam findings

Head lice: due to Pediculosis capitis; Tx permethrin shampoo (lindane causes seizures in kids/elderly)

Traction alopecia: linear hair-loss in kids who tie their hair too tightly

Alopecia areata: hair stops growing suddenly → small patches of complete hair loss w/ “exclamation point” stubs

Asymmetric red reflex: retinoblastoma (AD ∆Rb on chromosome 13), juvenile cataracts (galactosemia, congenital rubella syndrome,
neurofibromatosis II, myotonic muscular dystrophy)

Cherry-red macula: Tay-Sachs disease (AR ∆hexosaminidase A) w/o HSM, Niemann-Pick disease (AR ∆sphingomyelinase) w/ HSM

Strabismus: cross-eyes; Tx ophtho c/s to patch the good eye (uncorrected strabismus can lead to ambylopia)

Blue sclerae: osteogenesis imperfecta

Pinpoint pupils: opioids (Tx naloxone), organophosphates (Tx atropine + pralidoxime)

Cholesteatoma: small whitish debris-containing sac on TM, ↑risk w/ recurrent otitis media; Tx ENT c/s for surgical removal

Nasal polyps: cystic fibrosis, triad asthma (aspirin-sensitive)

Strawberry tongue: Kawasaki disease, scarlet fever, toxic shock syndrome

Primary teeth eruption: central incisors (at ~6 mo), lateral incisors, first molars, canines

Permanent teeth eruption: central incisors (at ~6 yr), lateral incisors, canines, first molars, second molars, third molars

Tooth decay: prolonged use of bottles → high sugar concentration → extensive tooth decay of all but mandibular front teeth

Tooth avulsion: facial trauma → knocked out teeth; Tx transport teeth in mouth or milk/saline, then replant permanent teeth within 30 min
(earlier is better)

Retained primary teeth: Job syndrome (hyper-IgE)

Single central incisor: GH deficiency

Thyroid nodule: Dx TSH levels, if euthyroid then get FNA

Café-au-lait spots: neurofibromatosis I, McCune-Albright syndrome

Knuckle-knuckle-dimple-knuckle sign: brachydactyly of 4th digit = Turner syndrome

Knuckle-knuckle-dimple-dimple sign: brachydactyly of 4th/5th digits = pseudohypoparathyroidism

Erythema nodosum: painful red nodules on shins; MCC in kids is Strep pyogenes (not sarcoidosis like adults)

Pes cavus: high-arched foot associated w/ Friedreich ataxia, Charcot-Marie-Tooth disease

Micropenis: GH deficiency

★ Child abuse: suspect w/ retinal hemorrhages, subdural hematoma, multiple healed fx, posterior rib fx, metaphyseal corner (“bucket
handle”) fx, long-bone spiral fx (except distal tibia), cigarette burns, stocking-and-glove scalding water injury, or genital trauma/STDs; first
r/o medical causes, then do a complete physical exam, then get whole-body X-rays, then call CPS if necessary

Neonatal HIV: suspect w/ thrush, generalized LAD, hepatomegaly, and FTT; Dx HIV PCR (not ELISA since mom’s ab can cause false-positive),
requires Bactrim ppx for PCP pneumonia
Environmental exposure

Dog/cat bite: Tx copious irrigation, make sure tetanus is up-to-date, allow healing by 2° intention, PPx Augmentin for Pasturella cellulitis

Human bite + cellulitis: due to Eikenella or other oral anaerobes; Tx admit + debridement + IV abx, leave open to heal by secondary intention

Pediatrics – Shelf notes



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




Black widow bite: neurotoxin → severe abdominal cramps, acute abdomen, n/v; Tx IV calcium gluconate + muscle relaxants
Brown recluse bite: necrotoxin → local skin ulceration; Tx excise ulcer + skin graft
Heat stroke: T>105 after playing in the sun, #1 risk factor is dehydration, ↑risk of rhabdomyolysis → renal ATN; Tx emergent cold water bath +
IV fluids
Frostnip: cold exposure → small/firm/cold/white blisters on exposed skin; Tx rewarming
Frostbite: cold exposure → dead tissue → numb/white extremities followed by erythema and pain on reexposure to heat
Chilblain: cold exposure → small, ulcerated lesion on ears and fingertips; Tx reassurance
Cold panniculitis: cold exposure → destruction of fat cells; “popsicle panniculitis” found on lips/cheeks of kids during summertime
Hypothermia: cold exposure → T<95, lethargic, tired, uncoordinated, bradycardia; Tx gradual rewarming
Trench foot: prolonged cold/moisture exposure → foot becomes cold, clammy, numb, pale, swollen

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NEWBORN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

















APGAR score: score of 0-10 taken at 1 and 5 minutes; score of 0-3 requires resuscitation
0
1
Appearance
all blue/pale
mixed blue/pale and pink
Pulse
0
<100
Grimace
no response to stimulation
grimace
Activity
limp
some flexion of limbs
Respirations
0
slow/irregular

2
all pink
>100
active cough
active flexion of limbs
regular

Primitive reflexes: originate from brainstem and vestibular (CN VIII) nuclei

Moro reflex: limb flexion when extending head

Grasp reflex: grasps at finger when placed in baby’s palm

Rooting reflex: turns face towards cheek stimulation

Placing reflex: steps up when stimulating dorsum of feet

Tonic neck reflex: turning neck causes arm extension (ipsi) and flexion (contra)

Babinski reflex: fanning of toes when scratching dorsum of feet

Parachute reflex: startled arm extension when dropping baby
★ Neonatal skin rashes

Milia: benign, tiny white bumps on nose

Salmon patch (nevus flammeus): benign, splotchy red rash on forehead, eyelids, or back of neck; more prominent with exercise or emotion

Pustular melanosis: benign, little pustules that leave a hyperpigmented spot when ruptured

Erythema toxicum: benign, yellow-white papules w/ surrounding erythema, fluid exam shows eosinophils

Mongolian spots: benign, bluish macules on back and buttocks

Seborrheic dermatitis: greasy scaly rash, usually on scalp in newborns (“cradle cap”), can result in dandruff; Tx sunlight + mild shampoo

Sebaceous nevus: raised, yellow-orange hairless lesion on scalp; Tx resection before adolescence (can undergo malignant degeneration)

Neonatal acne: pimples on healthy newborn due to maternal hormones; Tx reassurance (mild), topical benzoyl peroxide or tretinoin (severe)

Strawberry hemangioma: small reddish capillary malformations

Incontinentia pigmenti: XR, inflammatory bullae that evolve into hyperpigmented lesions, lethal in males
★ SIDS: sudden-death in infants w/o underlying cause; prevent by putting infant on “back to sleep”, don’t smoke around your kid
Breastfeeding contraindications: HIV, HSV on breast, active TB, chemotherapy, galactosemia, PKU, lithium, EtOH, iodine
LP contraindications: elevated ICP w/o open fontanelle, severe cardiorespiratory distress, puncture site cellulitis, severe coagulopathy
Circumcision contraindications: hypospadias (foreskin used to repair defect)
Oligohydramnios: renal problems → ↓amniotic fluid → pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet)
Polyhydramnios: GI obstruction or maternal diabetes → ↑amniotic fluid
Twin-twin transfusion syndrome (TTTS): abnormal vascular flow between mono-di twins → donor twin oligohydramnios/anemia, recipient twin
polyhydramnios/polycythemia; Dx hct difference >15
Coombs test: indicated for neonatal jaundice in type-O or Rh- moms

★ ABO hemolytic disease: type-O mom w/ type-A/B baby develops anti-A/B IgG → crosses placenta and attacks fetal RBCs → causes fetal
hydrops; ↑risk of late-onset high output CHF; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions

★ Rh hemolytic disease (erythroblastosis fetalis): Rh- mom w/ 2nd Rh+ baby develops anti-D IgG → crosses placenta and attacks fetal RBCs
→ causes fetal hydrops; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions
Neonatal care

Neonatal shots: HBV vaccine, vitamin K

★ Choanal atresia: non-canalized nasal passages → difficulty breathing while feeding but normal when crying; Dx nasal catheter or checking
for fog under nares, Tx nasal tubes

★ Meconium aspiration: suspect w/ meconium staining, low Apgar scores, respiratory distress, can result in systemic hypoxia and
pulmonary hypertension; Tx intubation + tracheal suction + O2 mask

★ Transient tachypnea of the newborn (TTN): tachypnea, grunting, possible cyanosis in a c/s infant due to retained fetal lung fluid; Dx CXR
shows pulmonary vascular markings, Tx 100% O2 (will resolve in 3 days)

TTN vs. RDS: TTN improves w/ O2, RDS persists despite O2

Neonatal bloody stool: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal

Neonatal hypothermia: ↑risk of hypoglycemia; Tx place under a warmer

Neonatal hypoglycemia: increase feedings if glucose <40, start IV if <20

AGA: Appropriate for Gestational Age, 10th–90th percentile

SGA: Small for Gestational Age, <10th percentile; ↑risk of congenital malformations, hypoglycemia (low glycogen/fat stores), future growth
retardation

Pediatrics – Shelf notes












LGA: Large for Gestational Age, >90th percentile; ↑risk of shoulder dystocia, type 2 DM, future obesity
Hyperviscosity syndrome: fetal hypoxia → reactive polycythemia (hct >65%) → sludging/clotting of blood in lungs (respiratory distress),
brain (seizures, tremors), kidney (renal vein thrombosis), GI (necrotizing enterocolitis); Tx partial exchange transfusion

Narcosis: lethargic/limp neonate in mom that got intrapartum opioids for pain control; Tx NICU admit + naloxone

Diaphragmatic hernia: bowels herniate into chest cavity → respiratory distress in a newborn; first put in a orogastric tube, then Dx CXR
shows bowels in chest cavity, Tx surgical repair (high morbidity/mortality)

★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction

★ Duodenal atresia: presents as bilious vomiting and polyhydramnios, ↑risk w/ Down syndrome; Dx KUB shows “double bubble”
appearance, Tx surgical repair

★ Intestinal atresia: aka “apple peel” atresia; presents like duodenal atresia, due to vascular accidents in utero; Dx KUB shows “triple bubble”
appearance, Tx surgical repair

Cleft lip/cleft palate: complications include recurrent OM, hearing loss → speech defects; Tx surgical repair (CL in 2-3 months, CP in 6 mo)

Pierre-Robin sequence: micrognathia → posteriorly displaced tongue (glossoptosis) → cleft palate + airway obstruction

Neonatal hypothyroidism : thyroid dysgenesis → lack of T4/T3 synthesis → subtle, nonspecific sx (constipation → distended abdomen →
umbilical hernia, bradycardia, hypothermia, large fontanelles, etc.); Dx ↑TSH, Tx Synthroid

Neonatal thyrotoxicosis: maternal TSI crosses placenta → hyperthyroidism → tachycardia, tachypnea, irritability, diarrhea, vomiting, CHF,
etc.; Dx ↓TSH, Tx propylthiouracil (PTU) for 2-4 months until mom’s ab disappear

★ Neural tube defects: anencephaly, spina bifida occulta (“tuft of hair”), meningocele, myelomeningocele; Dx ↑AFP, PPx folate
supplements before 4th week of gestation

Thumb polydactyly: rare, requires full genetic work-up

Pinky polydactyly: Tx surgical removal, also get echo for white (but not black) kids since white kids have cardiac issues as well

Neonatal tetanus: tetanus toxin (found in dirt) infects umbilical stump → rigidity, trismus, opisthotonus, risus sardonicus

Neonatal thrush: acquired from mom’s vag, does not indicate immunodeficiency; Tx nystatin swish-n-spit

AVM of great vein of Galen: presents w/ cranial bruits + high-output CHF
Colic: unexplained crying for >3 hrs in an infant <3 months, Tx swaddle infant to calm him/her
Premature infants: increased risk of necrotizing enterocolitis, intraventricular hemorrhage, neonatal RDS

★ Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis
intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated

Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Tx VP shunt

★ Neonatal RDS: prematurity or infant of diabetic mother → lack of surfactant → respiratory distress in a newborn; Dx L:SM ratio <2, PPx 48
hrs of maternal steroids, Tx surfactant + O2 therapy + CPAP

Retinopathy of prematurity: disorganized growth of retinal blood vx in premies → scarring and retinal detachment; ↑risk w/ both hypoxia
and oxygen toxicity

Harlequin syndrome: transient erythema on dependent half of body, more common in premies
Cerebral palsy: cerebral anoxia in utero → brain damage → non-progressive impairment of motor function (hypotonia, hyperactive DTRs, learning
disabilities, low APGAR at birth)
★ TORCHES
Presentation
Management
Congenital toxoplasmosis
chorioretinitis + hydrocephalus + intracranial
Tx pyrimethamine + sulfadiazine
calcifications
Congenital rubella syndrome
cataracts + deafness + PDA
Tx supportive care
Congenital CMV
usually asx, MC sequelae is sensorineural
--hearing loss
CMV inclusion disease
“blueberry muffin” rash, HSM/jaundice,
Tx IV GCV + supportive care
thrombocytopenia, periventricular calcifications
Neonatal HSV
vesicular rash, HSV pneumonitis, temporal lobe
Tx IV ACV + vidarabine if disseminated/systemic
encephalitis (focal seizures)
Neonatal HIV
suspect w/ thrush, generalized LAD,
Dx HIV PCR (not ELISA since mom’s ab can cause
hepatomegaly, and FTT
false-positive), requires Bactrim ppx for PCP
pneumonia, give IV ZDV to all neonates of
infected mothers
Early congenital syphilis
maculopapular peeling rash, snuffles (rhinitis w/
Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTAserous, purulent, or bloody discharge), HSM,
ABS, Tx PCN + supportive care
jaundice, generalized LAD
Late congenital syphilis
deafness, saber shins, mulberry molars,
Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTAHutchinson teeth, saddle nose
ABS, Tx PCN + supportive care
Congenital varicella syndrome
limb hypoplasia, clear vesicles → cutaneous
Tx VZIG if mom has chickenpox from 5 days prior
scars, chorioretinitis, cortical atrophy
to 2 days after delivery, otherwise reassurance
Neonatal head trauma

★ Caput succedaneum: soft-tissue swelling of scalp where baby was delivered, crosses midline

★ Cephalohematoma: bleeding between periosteum and skull → “squishy” feel to scalp that doesn’t cross midline

Subgaleal hemorrhage: bleeding under galeal aponeurosis → “squishy” feel to rapidly expanding scalp that crosses midline; Tx NICU admit
for possible hemorrhagic shock

Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Dx head CT, Tx VP shunt

Epidural hematoma: head trauma to temporal bone → torn middle meningeal artery → LOC w/ “lucid interval” → uncal herniation → death;
Dx head CT shows convex lens, Tx emergent craniotomy

Subdural hematoma: “shaken baby syndrome”

Pediatrics – Shelf notes

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– FEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––







Length: 1× at birth → 1.5× in 1 yr → 2× in 5 yrs
Weight: 1× at birth → 0.9× in 1 wk (ECF diuresis) → 1× in 2 wks → 2× in 6 mo → 3× in 1 yr

Adiposity rebound: period of growth where BMI increases faster than height, average 5 yrs
Vision: 20/200 at birth → 20/40 at 6 mo → 20/20 at 4 yr
★ Failure to thrive: growth <5th percentile in 2+ of the following – height, weight, head circumference; most commonly due to nonorganic causes; Dx
bone age (left wrist X-ray), Tx underlying cause

Constitutional growth delay: bone age < real age, tracks along low percentile on growth chart, good prognosis

Familial short stature: bone age = real age, usually have short parents, poor prognosis

Pathologic short stature: craniopharyngioma, hypothyroidism, GH deficiency, Turner syndrome, renal tubular acidosis
★ Vitamins
Deficiency
Toxicity
Vitamin A: used to treat cystic acne,
night blindness, dry skin
increased CSF pressure (headache, blurry
measles, and AML (M3 type)
vision), dry skin, teratogenic; found in
animal liver consumption
Vitamin B1 (thiamine): given to kids
dry beriberi (peripheral neuropathy), wet
--before IV D5 to prevent iatrogenic
beriberi (CHF), Wernicke-Korsakoff (ataxia,
Wernicke-Korsakoff
amnesia, confabulations, etc.)
Vitamin B2 (riboflavin)
cheilosis (dried cracks along corners of lips),
--corneal vascularization
Vitamin B3 (niacin)
pellagra (diarrhea, dermatitis, dementia)
flushing, pruritus (Tx NSAIDs)
Vitamin B6 (pyridoxine)
peripheral neuropathy, seizures,
--sideroblastic anemia; found in INH usage
Vitamin B7 (biotin)
seborrheic dermatitis, enteritis, alopecia;
--found in kids who eat raw eggs (avidin binds
biotin) and biotinidase deficiency
Vitamin B9 (folate): given to sickle cell
megaloblastic anemia w/o neuro sx, neural
--kids to help hematopoiesis
tube defects; found in babies fed goat’s milk
Vitamin B12 (cobalamin)
megaloblastic anemia w/ neuro sx; found in
--strict vegan diets and pernicious anemia
Vitamin C
scurvy (bleeding gums)
uric acid stones
Vitamin D: given to breast-fed kids who
rickets (bowed legs, rachitic rosary)
metastatic calcifications, kidney stones
don’t get enough sunlight
Vitamin E
hemolytic anemia
hemorrhagic diathesis
Vitamin K: all infants get vitamin K shot
hemorrhagic diathesis
--at birth











ADEK deficiency: malabsorption syndromes (cystic fibrosis, celiac sprue, tropical sprue, Whipple disease, abetalipoproteinemia, pancreatic
insufficiency, lactose intolerance, etc.)
★ Goat milk: ↓folate → megaloblastic anemia
★ Cow milk: ↓iron → microcytic anemia ± pica, fatigue, pallor; Tx PO iron supplements
★ Breast milk: ↓vitamin D → nutritional rickets
Zinc deficiency: acrodermatitis enteropathica (erythematous desquamating rash on hands/feet, scalp, buttocks, mouth)
Selenium deficiency: CHF
Kwashiorkor: protein malnutrition → FTT, anemia, edema, apathy, fatty liver
Marasmus: overall lack of calories → FTT, subcutaneous fat loss, muscle atrophy, premature aged look
Fluids/electrolytes

Serum osmolarity: 2×Na + BUN/2.8 + glucose/18

Maintenance fluids: D5½NS+20KCl using 100/50/20 rule for daily fluids, 4/2/1 rule for hourly fluids

Resuscitation fluids: 20 mL/kg bolus of NS or LR

★ Vomiting: hypokalemic, hypochloremic, metabolic alkalosis

★ Diarrhea: hypokalemic, metabolic acidosis

Dehydration: diarrhea or vomiting → lethargy, ↑HR, ↓BP, delayed capillary refill; Tx PO fluids (mild), 20 mL/kg bolus of NS/LR (severe)

Parkland formula: fluid resuscitation for burn victims; give LR at 4 mL/kg × %BSA, ½ over first 8 hrs then ½ over the next 16 hrs

Hyponatremia + pancytopenia: consider RMSF

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– DRUGS/POISONS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

★ Poisons
Presentation
Management
Acetaminophen
n/v, malaise, liver damage (↑LFTs)
wait 4 hrs then get acet levels, determine
need for N-acetylcysteine at that time (no
harm in waiting up to 8 hrs before giving
antidote)
Aspirin, oil of wintergreen
triad of fever, tinnitus, tachypnea → causes
Tx sodium bicarb vs. hemodialysis
mixed respiratory alkalosis + AGMA
Caustic agents, drain cleaner, lye
esophageal erosion, possible perforation
Dx endoscopy to determine extent of
damage, Tx controversial (call poison
control)
Cyanide
headache → agitation/confusion → seizures
Tx nitrites + hydroxocobalamin +
and metabolic acidosis
thiosulfate
Hydrocarbons
usually asx, may have transient gagging and
Dx CXR to r/o aspiration pneumonitis,

Pediatrics – Shelf notes

Iron
Lead

Methanol, ethylene glycol

Opioids
Organophosphates

Phenothiazine, metoclopramide
Shellfish
TCAs
Warfarin


admit + observe for 24 hrs
Dx iron levels, Tx deferoxamine
Dx blood lead >10 μg/dL, Tx CaEDTA +
dimercaprol + dimercaptosuccinic acid

Tx EtOH vs. fomipezole (4-MP)

Tx naloxone
Tx atropine + pralidoxime (2-PAM)

Tx diphenhydramine
Tx supportive care, may need mechanical
ventilation
Tx sodium bicarb or Fab antibody
fragments
Dx ↑PT/↑PTT, Tx vitamin K + FFP if severe

Teratogens: worst when exposed within first 8 weeks of gestation
Effect
ACE inhibitors
renal dysgenesis
Alcohol
fetal alcohol syndrome (MR, abnormal facies, smooth philtrum, IUGR, congenital heart defects)
Alkylating agents
adactyly
AmiNOglycosides
Nephrotoxicity, Ototoxicity
Cocaine
fetal addiction, IUGR, placental abruption
DES
vaginal clear-cell adenocarcinoma
Folate antagonists
NTDs
Iodide
Lithium
Maternal diabetes
Retinoic acid
Smoking
Tetracyclines
Thalidomide
Valproic acid
Warfarin
X-rays, CT scans



coughing
upper GI bleed, abd pain, metabolic acidosis,
shock
LEAD – Lead lines (basophilic stippling),
Encephalopathy, Anemia and Abdominal pain,
wrist Drop, foot Drop; MC source is paint in
old homes (before 1950)
AMS and AGMA after drinking “homemade
alcohol”, methanol has optic disc hyperemia,
EG has renal failure (oxalic acid crystals)
miosis, bradypnea, bradycardia, hypotension
“kid playing in garden shed found
salivating/unconscious”, blocks ACh-esterase
→ muscarinic sx (LUSHPADS BBB)
extrapyramidal sx (e.g. torticollis,
opisthotonus, dysphagia)
perioral parasthesias/numbness, generalized
weakness, paralysis
AMS, hypotension, anticholinergic effects
(dilated pupils, etc), widened QRS complex
hemorrhagic diathesis

goiter, hypothyroidism
Ebstein anomaly
fetal macrosomia (risk of shoulder dystocia), caudal regression syndrome (anal atresia to sirenomelia), CV
defects
CNS defects, hydrocephalus, microtia/anotia, micrognathia, athymia
preterm labor, IUGR, ADHD
tooth discoloration
phocomelia (hands attached to shoulders)
blocks folate absorption → NTDs; best management for anticonvulsants is monotherapy at lowest effective
dose w/ careful monitoring
bone deformities, fetal bleeding, abortion
multiple anomalies

Common side-effects
Corticosteroids
Cyclophosphamide
Diphenhydramine
Doxorubicin (Adriamycin)
Erythromycin
HCTZ
Inhaled corticosteroids
Local epinephrine
Nitrates
NSAIDs
Pseudoephedrine
Sodium nitroprusside
Topical benzocaine (Orajel)
Vincristine

Side-effects
infection, HTN, hyperglycemia, cataracts, osteoporosis, truncal obesity w/ abdominal striae, etc.
hemorrhagic cystitis (Tx mesna)
drowsiness
dilated cardiomyopathy
↑risk of pyloric stenosis in <1 mo
hyperGLUC – hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia
thrush
vasoconstriction (contraindicated in end-organ supply)
methemoglobinemia (Tx IV methylene blue)
platelet dysfxn, renal impairment, peptic ulcers
sympathetic stimulation (tachycardia, hypertension, etc.)
cyanide poisoning
methemoglobinemia (Tx IV methylene blue)
peripheral neuropathy

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GENETICS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––



Triplet expansion syndromes: Fragile X, DMD, Huntington chorea, Friedreich ataxia
★ Genetic syndromes
Mutation
Presentation
Patau syndrome
trisomy 13
MR, cleft lip/Palate, holoProsencephaly, Polydactyly, rocker-bottom
feet, death by 1 y/o
Edward syndrome
trisomy 18
MR, VSD, micrognathia, clenched hands, rocker-bottom feet, death
by 1 y/o
Down syndrome
trisomy 21 (95%),
MR, flat facies, epicanthal folds, simian crease, AVSD (endocardial
Robertsonian
cushion defect), GI issues (Hirschsprung dz, duodenal atresia),
translocation (5%)
↑↑incidence of ALL, Alzheimer by 40 y/o; high-risk in women >35 y/o
[note: Down syndrome + UMN sx = atlantoaxial instability]

Pediatrics – Shelf notes

Fragile X syndrome

XR ∆FMR1 (CGG
trinucleotide repeats)

Williams syndrome

7q– (includes elastin)

Cri-du-chat syndrome

5p–

DiGeorge/velocardiofacial
syndromes

22q11–

Klinefelter syndrome

47, XXY

47, XYY males
Turner syndrome

47, XYY
45, XO

Noonan syndrome

---

VACTERL syndrome

---

AngelMan syndrome

Maternal 15q11–

Prader-Willi syndrome

Paternal 15q11–

Cornelia de Lange syndrome
Marfan syndrome

--AD ∆fibrillin (15q)

Ehlers-Danlos syndrome

AD ∆type 3 collagen

Beckwith-Wiedemann syndrome

---

Holt-Oram syndrome

AD ∆TBX5

Jeune syndrome (asphyxiating
thoracic dysplasia)
Crouzon syndrome
Neurofibromatosis I (von
Recklinghausen disease)

---

Neurofibromatosis II
Tuberous sclerosis

AD ∆NF2
AD ∆TSC

Sturge-Weber syndrome

---

PHACES syndrome

---

Von Hippel-Lindau syndrome
Alport syndrome
Waardenburg syndrome

AD ∆VHL
XR ∆type 4 collagen
AD or associated w/
advanced paternal age
AD ∆FGFR3 or
associated w/ advanced
paternal age
---

--AD ∆NF1

Achondroplasia

Frohlich syndrome (adiposogenital
dystrophy)
Laurence-Moon-Biedl syndrome

---

Kartagener syndrome

∆dynein → immotile
cilia
AR ∆frataxin (GAA
triplet repeats)

Friedreich ataxia



DSM-V – Discontinued chromosomal staining, Shows anticipation,
Males-only, MR, Macrognathia, Macroorchidism, Mitral valve
prolapse
MR, elfin facies, extreme friendliness, English skills, hypercalcemia,
CV defects (supravalvular aortic stenosis)
MR, high-pitched “mewing” cry, microcephaly, epicanthal folds, CV
defects
CATCH-22 – Cleft palate, Abnormal facies, Thymic aplasia (no T-cells),
CV defects, Hypocalcemia (no PTH), 22q11–; Dx intradermal Candida
test, requires irradiated transfusions (prevent GVHD)
female traits on a male (e.g. long legs, small balls, gyno, high-pitched
voice, etc.)
aggressive, antisocial behavior
CLOWNS – Coarcted aorta, Lymphedema (knuckle-knuckle-dimpleknuckle), Ovarian dysgenesis, Webbed neck (cystic hygroma), Nipples
spread (shield chest), Short stature; Tx GH replacement + ppx
bilateral gonadectomy
phenotypically similar to Turner syndrome but AD (males = females),
associated w/ pulmonic stenosis rather than aortic coarctation
Verbetral defects, Anal atresia, CV defect, TE fistula, Esophageal
atresia, Renal/Radial defects, Limb defects
“happy puppet syndrome” – MR, ataxia, flailing arms, outbursts of
laughter
MR, hypotonia, hyperphagia/obesity, hypogonadism, “almond eyes”;
Tx GH replacement + dietary caloric restriction
MR, bushy eyebrows + hirsutism, limb defects, self-injurious behavior
elongated body habitus, MVP, aortic aneurysms, aortic dissection,
lens subluxation [note: Marfan + clotting sx = homocystinuria]
thin fragile skin, joint hypermotility/dislocations, MVP, aortic
aneurysms, aortic dissection
generalized overgrowth, large tongue, neonatal hypoglycemia,
certain cancers (Wilms tumor, hepatoblastoma (Dx ↑AFP))
upper limb abnormalities (hypoplastic thumb, hypoplastic radii,
missing pectoralis major) + cardiac abnormalities (Heart-Arm
syndrome)
long/narrow thorax → hypoplastic lungs, fibrotic liver, death due to
pulmonary causes
craniosynostosis, wide-eyes w/ proptosis, “beak nose”
café-au-lait spots, Lisch nodules (iris hamartomas), optic gliomas, CNS
tumors, pheos [note: NFI + HTN = Dx 24 hr urinary metanephrines to
r/o pheo]
bilateral acoustic neuromas, juvenile cataracts
CNS/retinal hamartomas, sebaceous adenomas, hypopigmented “ash
leaf” spots, Shagreen patches, renal angiomyolipomas, cardiac
rhabdomyomas
facial “port-wine stain” w/ ipsilateral AVM (Dx head CT shows
“gyriform calcifications”)
Sturge-Weber syndrome + other commonly-associated defects;
Posterior fossa tumors, Hemangiomas on face, Arterial abnormalities,
Coarctation of aorta, Eye abnormalities, Sternal defects
bilateral RCC, hemangioblastomas, pheos
nephritic syndrome (hematuria), deafness, ocular defects
wide-eyes, broad nasal bridge, medial hyperplasia of eyebrows, white
forelock (think Rogue), heterochromia, deafness
short limbs but normal-sized torso (think Mini-me)

hypothalamic tumor → hyperactive feeding center (childhood
obesity) + ↓GnRH secretion (secondary hypogonadism); similar to
Prader-Willi syndrome
obesity + MR, hypogonadism, polydactyly, retinitis pigmentosa →
night blindness
situs inversus (right-sided heart), recurrent pulmonary infx, infertility
staggering gait + frequent falls, kyphoscoliosis, pes cavus, hammer
toes; MCC death is hypertrophic cardiomyopathy

★ Inborn errors of metabolism: suspect w/ neonatal vomiting + metabolic acidosis, unusual odor of urine/sweat, HSM, MR, hyperammonemia, FHx of

early infant death, seizures
PKU

Mutation
AR ∆phenylalanine
hydroxylase

Presentation
MR, mousy body odor, blue eyes,
blond hair

Maple syrup urine disease
(MSUD)

AR ∆branched-chain
amino acid

inability to digest isoleucine, leucine,
valine (“I LoVe maple syrup”) →

Management
Dx Guthrie test, Tx dietary
↓phe/↑tyr, can relax dietary
restrictions over time but must
reinstate during pregnancy to
prevent maternal PKU
Tx dietary ↓ile/↓leu/↓val

Pediatrics – Shelf notes

Galactosemia

Hereditary fructose
intolerance

AR ∆aldolase B

Biotinidase deficiency

AR ∆biotinidase

Tyrosinemia

AR ∆fumarylacetoacetate hydrolase
AR ∆glucose-6phosphatase

Von Gierke disease



decarboxylase
AR ∆gal-1P
uridyltransferase

Pompe disease

AR ∆acid maltase

A1AT deficiency

AR ∆α1-antitrypsin

Mitochondrial diseases

---

Lysosomal storage diseases

---

Hurler syndrome

AR ∆α-L-iduronidase

OTC deficiency

XR ∆ornithine
transcarmbamylase

Alkaptonuria

AR ∆homogentisate
oxidase

Homocystinuria

AR ∆cystathionine βsynthase

Lesch-Nyhan syndrome

XR ∆HGPRT

Medium-chain acyl-CoA
deficiency (MCADD)

AR ∆fatty acid oxidase

PKU-like sx w/ sweet-smelling urine
inability to digest galactose →
Tx dietary ↓lactose/↓galactose
profound illness following first
milk/formula feedings, ↑risk of E. coli
sepsis
inability to digest fructose →
Tx dietary ↓sucrose/↓fructose
profound illness following first fruit
juice feedings
inability to synthesize biotin (vitamin
Tx biotin supplements
B7) → seborrheic dermatitis,
enteritis, alopecia
inability to digest tyrosine → failure
Tx nitisinone (enzyme that helps
to thrive, hepatomegaly, liver failure
bypass metabolite accumulation)
inability to run glycolysis → FTT,
--hypoglycemia, hepatomegaly, lactic
acidosis, characteristic appearance
(short w/ fat cheeks, thin arms, big
abdomen)
inability to run glycolysis → FTT,
--hypoglycemia, cardiomegaly
inability to export enzyme → builds
--up in liver (cirrhosis) + can’t break
down proteolytic enzymes in lungs
(early-onset panacinar emphysema)
maternal inheritance w/
--heteroplasmy, affects permanent
cells (heart, skeletal muscle, brain);
diseases include MERFF, MELAS,
LHON, and Kearns-Sayre syndrome
inability to digest cellular debris →
Dx urinary mucopolysaccharides, Tx
systemic effects of mucopolybone marrow txp + enzyme
saccharide accumulation (coarse
replacement therapy
facial features, HSM, joint
contractures, MR, etc.)
Fabry disease: XR ∆β-galactosidase, “bathing trunk” angiokeratomas
Gaucher disease: AR ∆β-glucosidase, “Erlenmeyer-flask” appearance of long
bones, “wrinkled paper” cells
Metachromatic leukodystrophy: AR ∆arylsulfatase A
Niemann-pick disease: AR ∆sphingomyelinase, “cherry-red macula” w/ HSM
Tay-Sachs disease: AR ∆hexosaminidase A, “cherry-red macula” w/o HSM,
exaggerated startle response (hyperacusis)
Sandhoff disease: AR ∆hexosaminidase A+B
inability to digest glycosaminoDx urinary dermatan sulfate and
glycans → coarse facial features
heparan sulfate
(“gargoyle-like”), HSM, progressive
developmental delay, death
inability to digest amino acids in
Tx arginine, benzoic acid, or
urea cycle → profound illness
phenylacetate to get rid of
following first protein feedings
ammonia; dialysis if unresponsive
accumulation of homogentisate in
--urine and joints → urine that turns
brown/black on air exposure, adultonset arthritis
HOMOCysteine – Hypercoagulable,
Tx vitamin B6 + cysteine
Optic lens dislocation, MR,
Marfanoid habitus, Osteoporosis,
Cysteine becomes essential in diet
impaired purine metabolism → MR,
--hyperuricemia, gout, self-mutilation
can’t break down FA for energy →
Tx L-carnitine + avoid prolonged
hypoketotic hypoglycemia w/o
fasting
acidosis

Collagen defects

Osteogenesis imperfecta: AD ∆type 1 collagen → abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss;
often mistaken as child abuse

Ehlers-Danlos syndrome: AD ∆type 3 collagen → thin stretchy skin, joint hypermotility/dislocations, MVP, aortic aneurysms, aortic dissection

Alport syndrome: XR ∆type 4 collagen → nephritic syndrome (hematuria), deafness, ocular defects

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CARDIOVASCULAR ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––





Antibiotic ppx for dental procedures: give amoxicillin only if prior endocarditis, prosthetic valve, heart txp, or severe or repaired congenital heart
defects (do not give for innocent childhood murmurs)
Cyanosis: normal if peripheral (doesn’t involve mucus membranes), diagnostic for R-to-L shunt if central (involves mucus membranes)
Benign murmurs: asymptomatic, <grade II, normal S2, no clicks, normal pulses
Pathologic murmurs: symptomatic, >grade III, diastolic or continuous

Pediatrics – Shelf notes



★ Congenital heart defects: 1% incidence, 2-6% w/ one sibling, 20-30% w/ two siblings










L-to-R shunts: late-onset cyanosis due to Eisenmenger syndrome; includes VSD, ASD, PDA

ASD: presents w/ fixed-split S2 + exercise intolerance

Thrombocytopenia-absent radius syndrome (TAR): thrombocytopenia + bilateral absent radii + ASD

VSD: MC CHD overall, presents w/ holosystolic blowing murmur at LLSB, louder is better, most resolve spontaneously

PDA: presents w/ continuous machinery-like murmur + bounding pulses; Tx keep Patent w/ PGE1 and closed w/ indomethacin,
surgical closure if >1 mo (won’t close spontaneously)

Eisenmenger syndrome: pulmonary hypertension reverses L-to-R shunts into R-to-L shunts

R-to-L shunts: early-onset cyanosis; includes ToF, TGV, TAPVR, Tricuspid atresia

Tetralogy of Fallot: PROVe – Pulmonic stenosis (determines Prognosis), RVH, Overriding aorta, VSD; presents as cyanotic “tet
spells” and clubbing in a kid who squats for relief; Dx CXR shows “boot-shaped heart”, Tx shunt placement

Transposition of the great vessels: presents w/ life-threatening cyanosis in a newborn + single loud S2 without murmur; Dx CXR
shows “egg on a string” w/ RVH, Tx emergent PGE1 then cath lab for atrial septostomy

TAPVR: presents w/ cyanosis + dyspnea; Dx CXR shows “diffuse reticular pattern” from pulmonary edema

Tricuspid atresia: lack of tricuspid valve + hypoplastic RV → cyanosis + LVH; Tx emergent PGE1 to keep PDA open and consult
surgery

Aortic coarctation: suspect w/ weak femoral pulse or treatment-resistant HTN at young age, consider Turner syndrome in short women; Dx
CXR shows rib-notching and “figure 3” aorta, Tx balloon angioplasty

Ebstein anomaly: RA hypertrophy + atrialized RV + tricuspid valve dilatation; associated w/ antenatal lithium use

Mitral valve prolapse: AD; presents w/ mid-systolic click and late-systolic rumble, does not require abx ppx for dental procedures
Carotid artery dissection: trauma to head/neck/soft palate → dissection of internal carotid artery → stroke-like presentation, may have delayed onset
relative to traumatic incident; Dx MRI, Tx observation vs. anticoagulation vs. surgical repair
Cardiac diseases

Myocarditis: coxsackie B virus infx → inflammation of myocardium results in systolic dysfxn → fever + lethargy + CHF sx

Dilated cardiomyopathy (DCM): ventricular dilatation → systolic dysfunction → CHF sx (dyspnea, orthopnea, PND); Tx diuretics + inotropes,
heart txp if severe

Hypertrophic cardiomyopathy (HCM): AD ∆β-myosin heavy chain → exertional dyspnea, angina, syncope, “sudden death in a young athlete”,
systolic murmur enhanced by ↓preload; Dx echo + family hx, Tx β-blockers vs. myomectomy vs. pacemaker

Restrictive cardiomyopathy (RCM): endocardial fibroelastosis is MCC in kids

★ Rheumatic fever: strep throat → anti-M ab → type 2 hypersensitivity → carditis, arthritis (MC), erythema marginatum, chorea,
subcutaneous nodules; Dx ASO titer, Tx amoxicillin + PO steroids

★ Kawasaki disease: CRASH and BURN – Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet swelling, fever >5 days; Tx IVIG +
high-dose aspirin (watch out for Reye syndrome)

Postpericardiotomy syndrome: pericardial effusion w/ possible tamponade s/p cardiac surgery; presents w/ Beck triad (hypOtension, JVD,
muffled heart sounds)
Arrhythmias

Premature atrial beats: premature, abnormally-shaped P wave, benign

Premature ventricular beats: premature, wide QRS complex, benign

Supraventricular tachycardia (SVT): MC symptomatic arrhythmia in kids; re-entrant mechanism → HR >200 → sx of low cardiac output
(dyspnea, pallor, syncope); Tx vagal maneuvers (carotid massage) or IV adenosine

WPW syndrome: presence of atrioventricular accessory tract → SVT + “delta wave” on EKG; Tx radiofrequency ablation

Congenital heart block: maternal SLE → anti-Ro/SSA attacks fetal heart conduction → complete (3°) heart block

Prolonged QT syndrome: prolonged QT interval → uncoordinated repolarization → torsades de pointes (Tx IV mag) → death

Prolonged QT + deafness: Jervell-Lange-Nielsen syndrome

Widened QRS + ingestion: TCAs (imipramine, amitriptyline, etc.); Tx sodium bicarb
★ Neurocardiogenic syncope: presents as 6 Ps – syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or
light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– RESPIRATORY ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––






Acute respiratory failure: hypoxemia (PO2 <50) or hypercapnea (PCO2 >60) → cyanosis, tachypnea, grunting, nasal flaring, chest retractions; Tx ABCs,
then adequate oxygenation (may require intubation), then address underlying cause
Wheezing: asthma (MCC), bronchiolitis, cystic fibrosis, foreign body aspiration, tracheomalacia
★ Asthma: reversible airway obstruction → wheezing, cough, chest tightness, dyspnea; normal PCO2 is a bad sign (retaining CO2 despite
hyperventilation); Dx reversible FEV1/FVC <70%

Asthma + thrush: due to inhaled corticosteroids; Tx rinse mouth after inhaler use

Asthma + hypokalemia: β2-agonists can cause potassium to go into cells

Triad asthma: asthma + aspirin sensitivity (↑LT) + nasal polyps

Churg-Strauss syndrome: asthma + eosinophilia + vasculitis
Frequency
Tx
Mild intermittent asthma
<2 times/wk
prn SABA (albuterol)
Mild persistent asthma
2+ times/wk
add low-dose inhaled steroids
Moderate persistent asthma
daily + nighttime sx 1/wk
add LABA (salmeterol)
Severe persistent asthma
continuous + frequent nighttime sx
add high-dose inhaled steroids
Asthma exacerbation
--albuterol nebulizer + PO steroid burst
Status asthmaticus
unresponsive to meds
admit + intubate
Foreign body aspiration: sudden-onset respiratory distress + focal wheezing, can have recurrent PNA in same lobe; Dx/Tx rigid bronchoscopy

Pediatrics – Shelf notes











Respiratory infx

★ Croup: parainfluenza infx → barking cough, low-grade fever, respiratory distress; Dx AP neck X-ray shows “steeple sign”, Tx PO steroids +
O2 therapy > racemic epinephrine > intubation

Bacterial tracheitis: rare complication of croup (superinfection), presents w/ biphasic stridor, spiking fever, respiratory distress;
Tx emergency intubation + IV abx

★ Epiglottitis: H. flu infx of epiglottis → sore throat, fever, inspiratory stridor, drooling, “sitting on a table leaning forward”; Dx lateral neck
X-ray shows “thumbprint sign”, Tx emergency intubation + IV abx

★ Bronchiolitis: RSV infx during wintertime → bronchiolar inflammation → wheezing, URI sx, respiratory distress, ↑risk of developing
asthma; Tx supportive care w/ monitoring of O2 and hydration status (ribavarin if severe, pavilizumab ppx for high-risk infants)

Typical PNA: Strep pneumo (MCC) infx → acute-onset fever, chest pain, productive cough; Dx CXR shows lobar consolidation, Tx ceftriaxone
or respiratory fluoroquinolones

Atypical PNA: Mycoplasma (MCC), Legionella, or Chlamydia infx → inflammation of lung interstitium → presents w/ fever, malaise,
nonproductive cough; Dx CXR shows interstitial infiltrates, Tx azithromycin

Empyema: Strep/Staph infx of pleural space → respiratory distress; Dx CXR shows unilateral “white out” of lung, Tx vancomycin + chest tube
drainage

Tuberculosis: Mycobaterium tuberculosis infx → cough/hemoptysis, fever, weight loss; Dx Tb skin test (>15 mm w/o risk factors, >10 mm w/
risk factors, >5 mm w/ immunosppression or known contacts) → if positive, get CXR

Latent TB: negative CXR, Tx INH x 9 months

Active TB: positive CXR, Tx RIPE (Pyrazinamide + INH + Rifampin + Ethambutol) x 6 months

TB meningitis: Dx CSF shows lymphocytosis + low glucose; Tx RIPE + steroids

★ Retropharyngeal abscess: Staph/Strep or oral anaerobe infx of posterior pharyngeal wall → fever, sore throat, “muffled voice”, drooling;
Dx lateral neck X-ray shows bulging mass, Tx emergent I+D

★ Peritonsillar abscess: Staph/Strep or oral anaerobe infx → fever, sore throat, “hot potato voice”, deviated uvula; Tx emergent I+D

★ Pertussis: Bordetella pertussis via respiratory droplets → “whooping cough” (short bursts of cough followed by loud inspiratory sound);
Dx CBC (lymphocytosis), confirm w/ nasopharyngeal swab if necessary, Tx azithromycin for pt + all close contacts (regardless of
immunization status)

Subcutaneous emphysema 2/2 cough: get CXR to r/o PTX
Respiratory malformations

Bronchopulmonary dysplasia: inadequate repair of acute lung injury in premies → arrested lung development → chronic respiratory sx,
need for O2 beyond 1 month; Dx abnormal CXR (nonspecific), Tx long-term supplemental O2

Congenital cystic adenomatoid malformation (CCAM): improper development of bronchioles → cystic mass in lungs → asx if small,
respiratory distress w/ mediastinal shift if large; Dx chest U/S, Tx surgical excision

Laryngomalacia: soft, small, underdeveloped larynx → inspiratory stridor in neonates; Dx fiberoptic bronchoscopy, Tx reassurance (will
resolve w/ growth), feed child only while upright and keep him upright for 30 min afterwards

★ Vascular rings: congenital abnormalities of aortic arch or branches → rings around airway can compromise ventilation → inspiratory
stridor relieved w/ opisthotonic position (“crowing” respiration); Tx surgery

★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
Neonatal apnea: breath-holding spells >20 seconds (<20 seconds is normal) w/ possible cyanosis or bradycardia, due to immature respiratory center
(central) or airway obstruction

Apparent life-threatening event (ALTE): apnea + color change (cyanosis, pallor), change in muscle tone (limpness), choking/gagging

Central apnea: Tx underlying cause, theophylline or caffeine can help

Obstructive sleep apnea: Dx polysomnography, Tx underlying cause (tonsillectomy/adenoidectomy, weight loss, CPAP)
Idiopathic pulmonary hemosiderosis: unknown etiology → bleeding into lungs → recurrent PNA w/ hemoptysis, rapid clearing of CXR findings, irondeficiency anemia; Dx BAL shows hemosiderin-laden macrophages, Tx steroids
Tension PTX: PTX + building pressure → mediastinal shift, hypOtension, JVD, absent unilateral breath sounds, hyperresonant to percussion; Tx emergent
needle thoracostomy + chest tube
★ ABG analysis
Dx
Causes
Management
Respiratory acidosis
pH <7.4, CO2 >40
hypoventilation
increase ventilation
Respiratory alkalosis
pH >7.4, CO2 <40
hyperventilation 2/2 pain, fever,
Tx underlying cause
ARDS, sepsis
NAGMA
pH <7.4, CO2 <40, AG 8diarrhea, glue sniffing, RTA,
Tx underlying cause
12
hyperchloremia
AGMA
pH <7.4, CO2 <40, AG >12
MUDPILES
Tx underlying cause
Metabolic alkalosis
pH >7.4, CO2 >40
vomiting, antacids,
Tx underlying cause
hyperaldosteronism


Anion gap: [Na – (Cl + HCO3)], normally 8-12

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GI/HEPATOBILIARY ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––



Cyclical vomiting: idiopathic, recurrent self-limited episodes of n/v in children, no abdominal pain or constipation/diarrhea; Tx antiemetics
Upper GI: proximal to Ligament of Treitz

Infant GERD: common complaint, presents w/ regurgitation of recently ingested food; Dx esophageal pH probe (gold standard but rarely
necessary), Tx thickened feeds + reassurance (will resolve by 1-2 y/o)

Eosinophilic esophagitis: allergic response to food in esophagus → GERD-like sx unresponsive to PPIs; Dx EGD + bx shows eosinophils in
esophagus, Tx PO steroids

★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction

Bleeding esophageal varices: Tx octreotide, PPx β-blockers

Pediatrics – Shelf notes

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Mallory-Weiss syndrome: forceful emesis → small mucosal tears in esophagus → streaks of blood in vomitus; Tx reassurance
Boerhaave syndrome: forceful emesis → esophageal rupture → severe retrosternal pain + acute distress; Tx surgical repair
Caustic ingestion: alkali are worse than acids; Dx endoscopy to determine extent of damage, Tx controversial (call poison control)
Foreign body ingestion: Tx emergent removal of disc batteries stuck in esophagus, other materials can be watched
★ Pyloric stenosis: presents w/ non-bilious projectile vomiting in first-born boys; Dx palpable epigastric olive + abdominal U/S, Tx
pyloromyotomy

PUD: presents w/ gnawing epigastric pain (can persist at night) + occult GI bleed; Dx EGD, Tx PPIs
Lower GI: distal to Ligament of Treitz

Milk protein intolerance: neonate w/ bloody diarrhea + eosinophils in stool

★ Volvulus (malrotation): incomplete rotation of GI tract during development → bilious vomiting, abdominal pain/distention; Dx barium
enema shows malposition of the cecum, Tx emergent surgical correction (↑risk of short gut)

★ Meconium ileus: pathognomonic for CF, presents in newborn w/ bilious vomiting, abdominal pain/distention; Dx KUB shows dilated
megacolon but barium enema shows microcolon from disuse, Tx gastrograffin enema

★ Acute appendicitis: lymphoid hyperplasia or fecalith impaction → obstructed appendix w/ bacterial overgrowth → presents w/ fever,
anorexia, n/v, diffuse abdominal pain that localizes to RLQ; Dx ↑WBC + CT scan or U/S, Tx appendectomy

Mesenteric adenitis: Yersinia enterocolitica infx → appendicitis-like presentation, associated w/ chitterlings and daycare centers

★ Intussusception: presents w/ colicky abdominal pain that lasts 1 min then resolves + “currant jelly” stools, RUQ “sausage-like mass” on
abdominal exam; Dx/Tx air contrast enema

★ Hirschsprung disease: neural crest cells fail to migrate → lack of nerves in distal colon → chronic constipation since birth; Dx screen w/
barium enema, confirm w/ rectal bx, Tx surgical pull-through

★ Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis
intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated

Anal atresia: Tx surgical repair (low pouch), colostomy then delayed repair (high pouch)

Congenital inguinal hernia: patent processus vaginalis → indirect inguinal hernia → incarcerated bowel is common; Tx elective
herniorrhaphy prior to d/c

★ Meckel diverticulum: MCC painless LGIB in a child; Dx technetium uptake for ectopic gastric mucosa, Tx surgery if symptomatic

Neonatal GI bleed: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal

Functional constipation: infrequent large/hard stools + normal physical exam; Dx KUB shows stool-filled megacolon, Tx reassurance +
dietary counseling

★ Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows stool-filled
megacolon, Tx bowel catharsis + miralax

Toddler diarrhea: chronic explosive diarrhea in an infant w/ normal physical exam; Tx reassurance
Malabsorption syndromes: present w/ steatorrhea + vitamin ADEK deficiency

★ Cystic fibrosis: AR ∆CFTR (∆F508) → thick mucus → recurrent Pseudomonas pneumonia, bronchiectasis, infertility, chronic pancreatitis →
malabsorption/steatorrhea + type 1 diabetes, meconium ileus (uncommon but pathognomonic), focal biliary cirrhosis, nasal polyps; Dx sweat
chloride test x2 (>60), Tx pancreatic enzymes + vitamins ADEK + chest physiotherapy + mucolytics (N-acetylcysteine)

Lactose intolerance: lactase (disaccharidase) deficiency at brush border → lactose provides osmotic gradient for water + acts as GI flora
nutrient → bloating, flatulence, diarrhea; Dx hydrogen breath test, Tx dietary ↓lactose

Celiac disease: AR ∆MTTP (microsomal TG transfer protein) → gluten hypersensitivity → chronic non-bloody diarrhea ± dermatitis
herpetiformis; Dx anti-gliadin or anti-endomysial ab, Tx dietary ↓wheat/↓gluten

Abetalipoproteinemia: celiac disease-like presentation but normal GI bx; Tx ADEK supplements + low-fat diet

★ Inflammatory bowel disease (IBD): presents w/ flare-and-remission pattern of crampy abdominal pain, bloody diarrhea, and weight loss
Crohn disease
Ulcerative colitis
Location
“mouth to anus” w/ skip lesions, rectal sparing
colorectal, continuous lesion
Morphology
transmural inflammation, cobblestoning,
mucosal inflammation, crypt abscesses and
noncaseating granulomas
pseudopolyps
Complications
strictures, fistulas, SBO
toxic megacolon, colorectal cancer
Dx
+calprotectin, +ASCA, KUB shows terminal ileal
+calprotectin, +p-ANCA, KUB shows “lead pipe sign”
“string sign”
Tx
steroids + 5-ASA
steroids + 5-ASA + annual colonoscopy
Neonatal hyperbilirubinemia

★ Physiologic hyperbilirubinemia: appears after day 2, direct bilirubin <1, total bilirubin <12

★ Pathologic hyperbilirubinemia: suspect w/ jaundice on day 1, direct bilirubin >2, total bilirubin >20 (risk of kernicterus), rate of rise >5/day;
MCC neonatal hepatitis and biliary atresia

Biliary atresia: lack of CBD → progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan, Tx hepatoportoenterostomy
(Kasai procedure)

Choledochal cyst: cyst in CBD → biliary tree obstruction → progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan,
Tx surgery

★ Breast-feeding jaundice: ↓feeding → dehydration → retained meconium → ↑enterohepatic circulation of bilirubin; Tx ↑feeding frequency

Breast-milk jaundice: d/t glucuronidase and indirect bilirubin in breast milk

Dubin-Johnson syndrome: neonatal direct hyperbilirubinemia + ↑LFTs + “black liver”

Rotor syndrome: neonatal direct hyperbilirubinemia + ↑LFTs + no black liver
Hepatobiliary/pancreatic

Acute cholecystitis: inflammation of gallbladder → Charcot triad (RUQ pain, n/v, fever); Dx RUQ U/S, Tx NPO/IVF/abx then lap chole within
24 hrs

Pediatrics – Shelf notes

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Acute pancreatitis: I GET SMASHHED (recall acronym) → inflammation of pancreas → stabbing epigastric pain boring through to the back,
exacerbated w/ eating; Dx screen w/ ↑amylase/↑lipase, confirm w/ abdominal U/S, Tx NPO/IVF/pain meds
Viral hepatitis: presents w/ jaundice, RUQ pain, n/v, dark-colored urine
Buzzwords
Management
HAV (fecal-oral)
asymptomatic, daycare, travel
Dx HAV IgM (acute), HAV IgG (immune or previous
infx); Tx supportive care
HBV (parenteral, sexual)
polyarteritis nodosa, MGN
Dx HBsAg (acute), HBsAb (immune or previous
infx), HBcAb IgM (window), HBeAg (infectious); Tx
IFN-α
HCV (parenteral, sexual)
cryoglobulinemia, chronic infx, carriers,
Dx HCV RNA (acute or chronic); Tx IFN-α + ribavarin
cirrhosis, carcinoma, IVDA, MPGN
HDV (parenteral, sexual)
deadly, defective, HBV co-infection
Dx HDV Ab; Tx IFN-α
HEV (fecal-oral)
cruise ships, fatal in pregnancy
Dx HEV Ab; Tx supportive care
A1AT deficiency: AR ∆α1-antitrypsin → inability to export enzyme → builds up in liver (cirrhosis) and can’t break down proteolytic enzymes in
lungs (early-onset panacinar emphysema)
Wilson disease (hepatolenticular degeneration): AR ∆ATP7B (copper-transporting ATP-ase) → copper overload → cirrhosis + movement
disorder + hemolytic anemia + Kayser-Fleischer corneal rings; Dx ↑LFTs/↓ceruloplasmin/↓total copper/↑free copper, Tx D-penicillamine
Reye syndrome: viral infx + ASA = fatty liver/liver failure, vomiting, AMS, 40% mortality rate (due to cerebral edema → herniation)
Gilbert syndrome: AD ∆UGT-glucuronyltransferase → mild jaundice following stress or starvation; benign

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– RENAL/GU ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
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Renal
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Nephrotic syndrome: loss of negative charge on GBM → proteinuria → edema, hypoalbuminemia, hyperlipidemia; Dx UA shows fatty casts

Asymptomatic proteinuria: repeat dipstick, then quantify w/ 24 hr urine, then refer to nephro if still positive

Nephritic syndrome: inflammation of glomeruli → hematuria, oliguria, HTN, azotemia; Dx UA shows RBC casts

Asymptomatic hematuria: repeat UA, then get renal imaging if still positive

★ Minimal change disease: nephrotic syndrome in kids following a viral URI, MCCOD is spontaneous bacterial peritonitis; Tx steroids, saltrestriction + diuretics during flares

★ WAGR syndrome: ∆WT1 on chromosome 11 → Wilms tumor (kidney), Aniridia, GU anomalies, mental Retardation, hemihypertrophy

★ Neuroblastoma: N-myc amplification → proliferation of neural crest cells in adrenal gland → abdominal mass/pain + opsoclonus-myoclonus
syndrome (muscle jerks + eyelid jerks) ± bone mets (pancytopenia); Dx urinary ↑HVA/↑VMA

Goodpasture syndrome: anti-GBM antibodies attack pulmonary and renal basement membranes → hemoptysis + hematuria; Dx renal bx +
linear-staining immunofluorescence

Fanconi syndrome: proximal tubule dysfunction → defective resorption of amino acids, bicarb, glucose, phosphate → polydipsia, polyuria,
glucosuria, aminoaciduria, type 2 RTA, hypophosphatemic rickets, etc.

Type 1 RTA: “distal RTA”, collecting duct can’t excrete H+ → metabolic acidosis + urinary alkalosis, hypo-K

Type 2 RTA: “proximal RTA”, proximal tubule can’t resorb bicarb → metabolic acidosis + urinary alkalosis, hypo-K

Type 3 RTA: (does not exist)

Type 4 RTA: “hyperkalemic RTA”, ↓aldosterone or ∆aldosterone-R → metabolic acidosis + urinary acidosis, hyper-K

Low implantation of ureter: asx in boys, “wet w/ urine all the time” in girls b/c ureter drips into vagina instead of bladder; Dx IV pyelo, Tx
surgical correction

★ Posterior urethral valve: presents w/ oliguria + lower abdominal mass (distended bladder) in a neonate; first catheterize to empty bladder,
then Dx VCUG, Tx resection

Myoglobinuria: rhabdomyolysis (heat, niacin, etc.) → myoglobin in urine → ↑risk of renal failure; Dx ↑CPK, UA shows heme but no RBC

Alport syndrome: XR ∆type 4 collagen → nephritic syndrome (hematuria), deafness, ocular defects

★ Enuresis: involuntary urination >5 y/o; Tx bed-wetting alarm > desmopressin > imipramine

Idiopathic hypercalciuria: persistent excretion of calcium irritates urinary tract → dysuria, ↑risk of kidney stones, microscopic hematuria w/
recurrent episodes of gross hematuria

Kidney stones: presents w/ flank pain radiating to groin + hematuria; Dx U/S or CT scan, Tx hydration (<½ cm), shockwave lithotripsy (½–2
cm), surgery (>2 cm)
Dialysis indications: AEIOU – Acidosis (severe metabolic acidosis), Electrolytes (severe hyperkalemia), Intoxication, Overload (severe hypervolemia),
Uremia (BUN >150, pericarditis)
Kidney infx

Lower UTI (acute cystitis): presents w/ dysuria, frequency/urgency; ↑risk in uncircumcised males; Dx UA/UCx, Tx Bactrim > Cipro

Upper UTI (acute pyelonephritis): presents w/ dysuria, frequency/urgency, flank pain, fever/chills; Dx UA/UCx, Tx ceftriaxone

VCUG: indicated to r/o VUR in all males w/ UTIs, girls <5 y/o, or girls >5 w/ 2+ UTIs

★ Vesicoureteral reflux (VUR): ureters implanted into wrong site on bladder → no mechanism for preventing retrograde urine reflux →
recurrent UTIs at young age; Dx VCUG, Tx long-term abx until kid grows out of it (low grade), surgical reimplantation of ureter (high grade)

Chronic pyelonephritis: VUR → recurrent upper UTI → kidney scarring w/ “blunted calyces” on IV pyelo

Nephronia: halfway between pyelonephritis (dysuria, frequency/urgency, flank pain, fever/chills) and renal abscess; Dx CT scan shows
“distinct tissue” in kidney, Tx long-term IV abx

★ Poststreptococcal GN: GAS infx (strep throat, impetigo, cellulitis) → ag-ab complexes deposit in GBM → nephritic syndrome sx
(hematuria, HTN, oliguria, azotemia, edema); Dx ↑ASO titers, Tx supportive care
Male GU

Inconspicuous penis: normal in fat boys, retract foreskin and measure → refer to urology if <2.5 std dev

Micropenis: GH deficiency

Phimosis: inability to retract foreskin, Tx reassurance (normal for <3 y/o), urology consult (>3 y/o)

Pediatrics – Shelf notes

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Paraphimosis: inability to relocate foreskin after retraction; Tx urology consult
★ Hypospadias: urethral opening on ventral penis, ↑risk of UTIs; Tx urology consult, do not circumcise
Epispadias: urethral opening on dorsal penis; Tx urology consult
Urethritis: GC or CT infx → dysuria, frequency/urgency, urethral discharge; Dx GC/CT tests, Tx azithromycin + ceftriaxone
★ Testicular torsion: twisting of spermatic cord → severe testicular pain and “high riding testicle w/ horizontal lie”, lacks cremasteric reflex;
first consult surgery, then Dx U/S to r/o epididymitis (similar presentation), Tx emergent surgical detorsion (<6 hrs) + orchiopexy
★ Epididymitis: presents like testicular torsion but w/ fever and pyuria; Dx U/S, Tx abx (usually for GC/CT)
Varicocele: incompetent valves in spermatic vein → dilation of pampiniform plexus → “bag of worms” appearance when standing up but
disappears lying down; Tx reassurance (kids), surgical correction (adults w/ infertility issues)
Hydrocele: accumulation of fluid in tunica vaginalis → dilated, fluid-filled sac around testicle; Dx transillumination shines through (vs.
testicular cancers). Tx reassurance (small), surgical correction (large)

Hydrocele vs. scrotal edema: scrotal edema feels like a big scrotum, hydrocele feels like a big nut
Cryptorchidism: undescended testis → high risk for testicular torsion and seminoma; Dx U/S of inguinal canal, Tx orchipexy if undescended
by 1 y/o (to avoid sterility and cancer)
★ Potter sequence: bilateral renal agenesis (or other renal abnormalities) → inability to secrete amniotic fluid in utero → oligohydramnios
w/ amnion nodosum (granules on amnion) → pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet)
★ Prune belly syndrome: congenital malformation in males that consists of lax abdominal wall → marked distention, dilated urinary tract →
Potter sequence, bilateral cryptorchidism

Female GU

Labial adhesions: benign fusion of labia minora; Tx estrogen cream

Labial adhesions + electrolyte imbalances: congenital adrenal hyperplasia

★ Infant menstruation: maternal estrogen withdrawal → endometrial sloughing → sticky gray discharge (may be blood-tinged) in a 2-week
girl; Tx reassurance (normal phenomenon)

★ “Bubble-bath” vaginitis: vaginal irritation in little girls due to chemicals from bubble baths; Tx d/c bubble baths, wear cotton underwear,
wipe front-to-back after potty

Polycystic ovarian syndrome (PCOS): ↑LH, ↓FSH, ↑E/T → anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss ±
metformin

Pelvic inflammatory disease (PID): polymicrobial infx of upper female genital tract (endometritis, salpingitis, peritonitis) → nonspecific
lower abdominal pain → ↑risk for infertility, ectopic pregnancy, pelvic adhesions, abscesses; Dx STD tests + “cervical motion tenderness”, Tx
ceftriaxone + doxycycline

PID + pelvic mass: tubo-ovarian abscess; Dx transvaginal U/S, Tx I+D
Umbilical cord

Delayed cord separation: leukocyte adhesion deficiency; Dx flow cytometry (∆CD11b)

Umbilical granuloma: red nodule on separated umbilical cord; Tx topical silver nitrate

★ Omphalocele: intestines protrude into umbilical cord w/ peritoneal covering, ↑risk of associated cardiac defects; first sterile wrapping,
then Dx echo to r/o cardiac defects, then Tx closure if small, silo if large

★ Gastroschisis: intestines tear through abdominal wall w/o peritoneal covering; first sterile wrapping, then Tx closure if small, silo if large

★ Umbilical hernia: associated w/ neonatal hypothyroidism, Beckwith-Wiedemann syndrome; Tx reassurance (<2 cm), surgical repair (>2 cm
or persistent into kindergarten)

Patent urachus: failure of urachus to obliterate → urination from umbilical cord

Vitelline fistula: failure of vitelline duct to obliterate → meconium from umbilical cord
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NEURO/MSK ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

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Muscular dystrophy

Duchenne muscular dystrophy (DMD): XR ∆dystrophin → muscle cells die off → ascending weakness w/ Gowers maneuver, calf
pseudohypertrophy, death by 15 y/o; Dx ↑CPK + muscle bx, no tx available

Becker muscular dystrophy (BMD): XR ∆dystrophin → milder form of DMD

Myotonic muscular dystrophy: AD; delayed muscle relaxation (can’t release handshake) + distal muscle wasting (older kids), neonatal
respiratory distress (newborn), cataracts, ptosis, baldness, hypogonadism; Dx ↑CPK + muscle bx, no tx available

Charcot-Marie-Tooth disease: intrinsic foot muscle atrophy (pes cavus), then intrinsic hand muscle atrophy
Muscle weakness/paralysis

Myasthenia gravis: anti-nAChR → gradually progressive muscle weakness (initial sx is ptosis, diplopia, blurry vision) that get worse w/
repetitive use; Dx edrophonium test + get chest CT to r/o thymoma, Tx pyridostigmine

Acute disseminated encephalomyelitis (ADEM): autoimmune demyelination after viral infx → multiple sclerosis-like sx but in kids <10 y/o; Dx
MRI shows white matter demyelination, Tx high-dose corticosteroids

Acute infantile hemiplegia: trauma, infx, hypercoagulable state, arteritis, or metabolic d/o → MCA stroke in infant → abrupt onset
hemiplegia

★ Guillain-Barre syndrome: rapidly ascending paralysis after viral infx (or other infx), ↑risk of respiratory arrest (Tx mechanical ventilation);
Dx CSF shows ↑protein, Tx IVIG or plasmapheresis

Bell palsy: facial nerve palsy 2 weeks after viral infx; Tx eyedrops (to prevent keratitis), will resolve on its own

Bilateral Bell palsy: 2° Lyme disease, Guillain-Barre syndrome

★ Phrenic nerve palsy: presents w/ respiratory distress and unilateral decreased breath sounds in neonate (phrenic nerve innervates
hemidiaphragm); Dx chest U/S or fluoroscopy shows “seesaw diaphragm”

★ Erb-Duchenne palsy: C5/C6 palsy after difficult delivery → “waiter’s tip” posture

★ Klumpke palsy: C7-T1 palsy after difficult delivery → total hand paralysis + ipsilateral Horner syndrome

Werdnig-Hoffman disease (SMA type 1): ∆SMN gene (protects neuroblasts from atrophy) → progressive degeneration of CNS motor
neurons → respiratory distress + tongue fasciculations in newborn; Tx supportive care

Pediatrics – Shelf notes

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Seizures
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Simple partial seizure: automatisms
Complex partial seizure: automatisms + LOC + postictal confusion
Absence (petit mal) seizure: “brief staring spells”; Dx EEG shows 3-Hz spike-and-wave pattern, Tx valproic acid > ethosuximide
Tonic-clonic (grand mal) seizure: LOC + rigidity (tonic phase) + muscular jerking (clonic phase) + postictal confusion
Pseudoseizure: seizure-like activity w/o EEG changes, usually don’t have bowel/bladder incontinence or self-injury; Tx psych consult
Febrile seizure: brief seizure in febrile child usually 2/2 bacterial or viral infx, doesn’t require extensive work-up, #1 risk factor is rate of temp
change; Tx underlying cause, phenobarbital if necessary

Phenytoin toxicity: gingival hyperplasia; Tx good dental hygiene

Todd paralysis: focal weakness for 1-2 days following grand-mal seizure
Malignant hyperthermia: AD ∆ryanodine receptor → T>104 + muscle rigidity + rhabdomyolysis following anesthesia; Dx caffeine contracture test, Tx
dantrolene sodium, 100% O2, cooling blankets
★ Craniosynostosis: premature fusion of skull sutures → abnormal head shape + impaired brain development, 80% sporadic, 20% genetic (e.g. Crouzon
syndrome); Tx surgical correction

Apert syndrome: AD, craniosynostosis + syndactyly of fingers/toes

Crouzon syndrome: craniosynostosis + wide-eyes w/ proptosis, “beak nose”

Scaphocephaly: isolated craniosynostosis of sagittal suture → long, narrow skull
Headaches

Migraine headache: bifrontal headache w/o aura, or diffuse “throbbing” headache, atypical presentation in kids (no nausea/vomiting,
photophobia, phonophobia)

Tension headache: bilateral, tight “squeezing” pain + posterior neck muscle stiffness

Cluster headache: unilateral, episodic “burning, stabbing” pain behind eye + ipsilateral tearing, flush, rhinorrhea

Factitious headache: recurrent headache on Mon-Fri mornings

★ Pseudotumor cerebri: fat girl w/ pulsatile headache/tinnitus, high risk of blindness; first get imaging to r/o mass lesion (can have empty
sella), then get LP w/ opening pressure to r/o infx causes, Tx acetazolamide vs. serial LPs
Brain abscess: headache + focal neuro sx + fever, ↑risk w/ congenital heart defects; Dx head CT/MRI, Tx surgery + IV abx (unifocal), IV abx (multifocal)
Brain tumor: headache + focal neuro sx + subacute onset; infratentorial more common <10 y/o, supratentorial more common >10 y/o

★ Craniopharyngioma: embryological remnant of Rathke pouch in sella turcica → headache, bitemporal hemianopsia, papilledema; Dx MRI
shows suprasellar calcified cysts, Tx transsphenoid hypophysectomy

Pinealoma: brain tumor at rostral midbrain → vertical gaze paralysis (Parinaud syndrome) + eyelid retraction (Collier sign) + ↑ICP sx

Retinoblastoma: AD ∆Rb on chromosome 13 → retinoblastoma (MCC leukocoria in kids) + ↑risk of osteosarcoma later in life
Cushing triad: brain mass lesion → ↑ICP → ↓HR, ↑BP, irregular RR
Epidural hematoma: head trauma to temporal bone → torn middle meningeal artery → LOC w/ lucid interval → uncal herniation → death; Dx head CT
shows convex lens, Tx emergent craniotomy
Infantile botulism: ingestion of C. botulinum bacteria (not toxin) in raw honey → bacteria releases toxin in GI tract → constipation (initial sx) then
gradual flaccid paralysis; Tx BabyBIG (botulinum immunoglobulin) + ventilator support
Dandy-Walker syndrome: enlargement of 4th ventricle (hydrocephalus) + agenesis of cerebellar vermis
Acute cerebellar ataxia: autoimmune attack on cerebellum after a viral infx → cerebellar sx (ataxia, nystagmus, dysarthria); Dx of exclusion
Rasmussen encephalitis: autoimmune attack on brain → rapid degeneration, initially presents w/ frequent and worsening seizures; Dx MRI, Tx
hemispherectomy
Pervasive developmental disorders

★ Autism: characterized by problems w/ social interaction, communication skills, and repetitive/stereotyped patterns of behavior and
activity before 3 y/o; must get hearing test to r/o deafness

Asperger syndrome: mild autism w/ normal language skills and cognitive development

Rett syndrome: ∆MECP in girls → normal development for 5 months, then ↓rate of head growth + loss of purposeful hand movements, then
ataxia, ↓language skills, “hand wringing”

Childhood disintegrative disorder: normal development for >2 years, then loss of previously acquired skills

★ Learning disability: significant discrepancy between IQ and ability in one of the following – math, reading, or writing
★ Neurocardiogenic syncope: presents as 6 Ps – syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or
light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration
Transient tic disorder of childhood: nonrhythmic, spasmodic, involuntary behaviors (e.g. blinking, throat clearing) that last <1 yr; Tx reassurance
Tourette syndrome: severe tic disorder w/ multiple daily motor/vocal tics, may have echolalia or coprolalia (rare), ↑association w/ OCD and ADHD; Tx
haloperidol > α2-agonists (clonidine, guanfacine)

–––––––––––––––––––––––––––––––––––––––––––––––––––––––– INFECTIOUS DISEASES ––––––––––––––––––––––––––––––––––––––––––––––––––––––––




★ Ophthalmia neonatorum

Chemical conjunctivitis

Timing
day 0-1

Management
Tx reassurance

Gonococcal conjunctivitis
Chlamydia conjunctivitis

day 2-5
day 5-14

Tx topical erythromycin + IV ceftriaxone
Tx PO erythromycin

Features
not seen anymore since silver nitrate
drops are rarely used
can cause corneal ulceration
can cause chlamydial pneumonia
(“staccato cough” + eosinophilia)

STDs
Chlamydia

Bugs
Chlamydia trachomatis

Presentation
urethritis in men; cervicitis, PID, TOA, often
asx in women

Management
Dx Chlamydia NAAT, Tx
azithromycin (+ ceftriaxone)

Pediatrics – Shelf notes

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

Gonorrhea

Neisseria gonorrhoeae

urethritis in men; cervicitis, PID, TOA, often
asx in women
thick, white curd-like discharge, severe
itching, satellite lesions

Vaginal candidiasis

Candida albicans

Syphilis

Treponema pallidum

Chancroid

Haemophilus ducreyi

Herpes simplex

HSV-1/2

Lymphogranuloma
venereum

Chlamydia trachomatis,
L1-L3 serotypes

Condyloma acuminata
Bacterial vaginosis

HPV-6/11
Gardnerella vaginalis

Trichomoniasis

Trichomonas vaginalis

green-gray frothy discharge, odor,
strawberry cervix

HIV/AIDS

HIV-1/2

Crabs (pediculosis pubis)

Phthirus pubis

1° – mono-like syndrome w/ maculopapular
rash
asx stage – CD4 >500, asx
sx stage – CD4 200-500, general LAD,
fungal infx, night sweats, weight loss,
diarrhea
AIDS – CD4 <200 or opportunistic infx
severe itching, irritation, burrows, vesicles

1° – painless chancre + LAD
2° – palmar/plantar rash, condyloma lata,
general LAD
3° – neurosyphilis + CV syphilis (luetic heart)
+ gummas
painful chancre + LAD
recurrent, painful oral or genital vesicles
that can rupture
1° – transient, painless ulcer
2° – painful LAD
3° – anogenital syndrome (proctocolitis,
rectal strictures, rectovaginal fistulas,
genital elephantiasis)
genital warts
thin homogenous discharge w/ fishy odor

Dx discharge Gram stain, Tx
ceftriaxone (+ azithromycin)
Dx KOH prep shows
pseudohyphae, Tx diflucan vs.
miconazole cream
Dx screen w/ RPR-VDRL,
confirm w/ FTA-ABS, definitive
dx w/ Darkfield microscopy; Tx
benzathine PCN G
Dx discharge Gram stain, Tx
azithromycin or ceftriaxone
Dx Tzanck smear, Tx ACV/VACV
within 48 hrs
Dx complement fixation, Tx
doxycycline

Tx removal
Dx wet prep (clue cells), Tx
metronidazole
Dx wet prep (motile
trichomonads), Tx
metronidazole
Dx screen w/ ELISA, confirm w/
WB, HIV PCR in infants; Tx
HAART (2 NRTIs + 1 NNRTI or
PI)

Dx hair under microscope, Tx
permethrin shampoo

Rule-out sepsis: T >100.4 in any neonate (<28 days) gets admitted and the full work-up (UA/UCx, CSF, blood cx, CXR, etc.), MCC viral infx; Tx amp+gent
until cx negative
Bacteria

Neonatal PNA: MCC GBS; presents as respiratory distress, fever/hypothermia, leukocytosis/leukopenia w/ left-shift; Dx CXR, Tx ampicillin +
gentamicin

Neonatal meningitis: MCC GBS; presents as fever, irritability, AMS, ±bulging fontanelle, and may not have meningeal signs; Tx ABCs then LP
then ceftriaxone + vancomycin (different from adults, where you’d get CT then LP)

Meningitis + subdural effusions: common, benign finding

Listeria meningitis: due to maternal ingestion of lunch meats or unpasteurized dairy products

Meningococcal meningitis: Tx penicillin

Acute bacterial sinusitis: Strep pneumo > H. flu > Moraxella catarrhalis superinfx of viral URI → sinus tenderness, nasal congestion/discharge,
headache, low-grade fever; Tx amoxicillin

Otitis media: Strep pneumo > H. flu > Moraxella catarrhalis; Tx amoxicillin

Otitis externa: Tx cipro drops

Diphtheria: due to Corynebacterium diphtheriae; presents as mild sore throat that leads to pseudomembranous pharyngitis, LAD with “bull
neck” appearance, possible respiratory compromise

Shigellosis: watery/bloody diarrhea, fever, tonic-clonic seizures can precede GI sx (Ekiri syndrome); Dx stool cx, Tx IV fluids + ceftriaxone

★ Strep throat: GAS infx of pharynx → sore throat, fever, tonsillar exudates, palatal petechiae; Dx rapid strep test, Tx amoxicillin

★ Scarlet fever: due to GAS exotoxin; presents w/ sore throat, fever, strawberry tongue, “sandpaper rash” w/ possible
desquamation of palms/soles; Dx ASO titers or rapid strep test, Tx amoxicillin

Arcanobacterium haemolyticum: strep throat/scarlet fever-like presentation but throat cx grows out Arcanobacterium instead

★ Toxic shock syndrome: due to S. aureus TSST, often found in tampons; presents w/ septic shock, diffuse maculopapular rash
(desquamation of palms/soles is late finding), strawberry tongue; Tx admit + stabilize + IV nafcillin (prevents recurrence)

Staph food poisoning: ingestion of preformed S. aureus enterotoxin → diarrhea, vomiting, abdominal cramps within 6 hrs

★ Meningococcemia: meningitis, purpura fulminans (“petechiae becoming purpura in front of your eyes”), death by bilateral adrenal
hemorrhage (W-F syndrome); Dx blood cx x3, Tx IV abx, PPx Rifampin for Roommates

Leptospirosis: due to Leptospira interrogans; presents as fever/chills, sore throat, myalgias, headache, cervical LAD, scleral injection,
photophobia, and can lead to meningitis (but most infx are subclinical)

Weil disease: leptospirosis + renal failure + liver failure

Infx endocarditis: usually due to Strep/Staph; presents as FROM JANE – Fever, Roth spots, Osler nodes, Murmurs, Janeway lesions, Anemia,
Nailbed hemorrhage, Embolic phenomena; Dx blood cx x3, Tx IV abx

Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg), Tx
admit + IV abx

Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx admit + drainage + IV abx

Dacryocystitis: infx of medial canthus of eye; Tx warm compresses + abx drops

Orbital cellulitis: cellulitis around eye, requires emergent ophtho c/s

Pediatrics – Shelf notes

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Fungi
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Viruses

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

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Orbital vs. preseptal cellulitis: consider preseptal w/ eyelid discoloration; consider orbital w/ proptosis, limited eye movement,
pain w/ movement, or loss of vision
RMSF: due to Rickettsia rickettsii from Dermacentor ticks; causes fever/chills and rash that starts on hands/feet and moves inward, can result
in pancytopenia + hyponatremia; Tx doxycycline (regardless of age)
Lyme disease: due to Borrelia burgdorferi from Ixodes ticks; 1° Lyme = erythema chronicum migrans, 2° Lyme = bilateral Bell palsy + AV block,
3° Lyme = chronic arthritis; Tx amoxicillin (<9 y/o), doxycycline (>9 y/o)

Lyme disease + hemolytic anemia: due to Babesia microtii also from Ixodes ticks; Dx RBC smear, Tx clindamycin + quinine
Tularemia: “rabbit fever” due to Francisella tularensis; MC presentation is ulceroglandular syndrome (nonhealing ulcer + ascending LAD); Tx
streptomycin
Pseudomonas: G– oxidase+ rod; commonly found in burns, tennis shoe puncture wounds, swimming pools, hot tubs, cystic fibrosis
Peptic ulcer disease: presents as dyspepsia and upper GI bleed; Dx EGD+bx or H. pylori breath test, Tx “triple therapy” (2 abx + 1 PPI)
★ HUS: due to EHEC O157:H7; presents w/ bloody diarrhea and possible renal failure (MCCOD) after eating undercooked hamburgers; Dx
stool cx on MacConkey (sorbitol) agar, Tx TPN + peritoneal dialysis (do not use abx)
Lymphadenitis: Staph aureus infx → swollen, tender, erythematous LN; Tx dicloxacillin
Cat scratch disease: Bartonella henselae infx from cats (flea vector) → Parinaud oculoglandular syndrome (nonpainful conjunctivitis +
preauricular LAD); Tx azithromycin
Typhoid fever: Salmonella typhi infx → fever, diarrhea, HSM, abdominal pain w/ “rose spot” rash; Dx ↑fecal leukocytes + stool cx
Campylobacter gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; ↑risk of Guillain-Barre syndrome
Yersinia gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; ↑risk of mesenteric adenitis (appendicitis-like presentation);
associated w/ chitterlings and daycare centers
Pseudomembranous colitis: broad-spectrum abx use → C. difficile proliferates in colon → profuse watery diarrhea; Dx stool toxins, Tx
metronidazole > PO vancomycin

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Parasites
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Sporotrichosis: “rose gardner disease” due to Sporothrix schenckii; presents as nonhealing ulcer + ascending LAD; Tx potassium iodide
★ Tinea capitis: due to Trichophyton tonsurans; presents as boggy scalp lesion w/ hair loss; Dx KOH prep, Tx PO griseofulvin
Cryptosporidiosis: chronic diarrhea in HIV+ pts
PCP pneumonia: opportunistic infx that indicates T-cell deficiency (AIDS, SCID, DiGeorge, etc.); Dx BAL, PPx azithromycin, Tx Bactrim
Viral meningitis: due to enterovirus infx (echo, coxsackie); Dx CSF shows ↑lymphocytes + normal glucose, Tx supportive care
★ Bronchiolitis: due to RSV; presents w/ wheezing, URI sx, respiratory distress; Tx supportive care (ribavarin if severe, pavilizumab ppx for
high-risk infants)
★ Erythema infectiosum (fifth disease): due to Parvovirus B19; presents w/ fever, URI sx, “slapped cheek” and lacy rash on extremities, can
cause aplastic anemia in SCD or spherocytosis, hydrops fetalis in pregnant women (rare)
Hand-foot-mouth disease: due to Coxsackie A16; presents w/ sores/blisters on hand, feet, mouth, genitalia; Tx supportive care
Mononucleosis: due to EBV; presents w/ fever/chills, sore throat, myalgia, cervical LAD, HSM after making out w/ someone; Dx Monospot
(heterophile agglutination) test, Tx avoid contact sports
★ “Amoxicillin rash”: rash s/p amoxicillin in a misdiagnosed “strep throat” is pathognomonic for EBV infx
Mumps: parotitis, orchitis, meningitis, pancreatitis
Rabies: commonly found in bats, skunks, raccoons, foxes, coyotes; give reassurance if pet is sterile, kill animal for bx if unknown, give postexposure ppx for any bat exposure
★ Rubeola (measles): cough, coryza (head cold), conjunctivitis, Koplik spots, then diffuse maculopapular rash; Tx vitamin A
★ Rubella: diffuse maculopapular rash (starts on face and migrates down) w/ low-grade fever, marked LAD, sore throat, ±arthralgias
★ Roseola: due to HHV-6; high-grade fever for 3 days, then diffuse maculopapular rash
Varicella (chickenpox): due to VZV; “dew drops on a rose petal” vesicular rash in an ill child
Viral gastroenteritis: rotavirus infx → fever, vomiting, severe watery diarrhea during the wintertime; Tx supportive care
Herpes keratoconjunctivitis: HSV infx → vesicular lesions on skin + dendritic corneal ulcers, ↑risk of blindness
Cutaneous larva migrans: due to Toxocara canis/cati; presents as itchy lesion on bottom of foot after playing around barefoot; Tx ivermectin
Visceral larva migrans: due to Toxocara canis/cati; presents w/ fever + HSM + eosinophilia; Tx ivermectin
Malaria: due to Plasmodium spp; presents w/ cyclic fever/chills and hemolytic anemia; Dx Giemsa stain of blood smear, Tx mefloquine (+
primaquine for hypnozoites)
Pinworm: due to Enterobius vermicularis; causes perianal pruritus worse at night; Dx scotch tape test, Tx mebendazole
Ascariasis: due to Ascaris lumbricoides; presents w/ eosinophilia + intestinal obstruction
Trichinellosis: found in undercooked pork; triad of periorbital edema, myositis, eosinophilia; may have nonspecific splinter hemorrhages
Giardiasis: due to Giardia lamblii; presents w/ fever, foul-smelling fatty stools, abdominal pain; Tx metronidazole

––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALLERGY/IMMUNOLOGY –––––––––––––––––––––––––––––––––––––––––––––––––––––––





Allergy

Urticaria (hives): pruritic “wheal and flare” rash; Tx PO benadryl + avoid exposure

Erythema multiforme: urticaria + target lesions, <10% BSA (body surface area)

Stevens-Johnson syndrome: EM + mucosal involvement, 10-30% BSA

Toxic epidermal necrolysis: severe SJS, >30% BSA

DRESS syndrome (drug rash, eosinophilia, systemic sx): EM w/ eosinophilia + systemic sx, usually due to anticonvulsants
Maternal ab: IgG via placenta (lasts 3-6 months), IgA via breast milk
★ Immunology

Chronic granulmatous disease: XR ∆NADPH oxidase → phagocytic defect → recurrent abscesses; Dx nitroblue tetrazolium (NBT) test

Pediatrics – Shelf notes

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Wiskott-Aldrich syndrome: XR, TIE – thrombocytopenia (petechiae), recurrent infx, eczema; Dx CBC (↓plt), ↓IgM, ↑IgA, ↑IgE
Bruton agammaglobulinemia: XR B-cell defect → lack of all Ig types → recurrent bacterial infx (OM, PNA, etc.) after 6 months since mom’s
Ig confers passive immunity; Dx ↓serum Ig levels, Tx repeated IVIG
T-cell defect: likely DiGeorge syndrome (CATCH-22); Dx intradermal Candida test
Combined variable immunodeficiency: acquired B-cell defect (>10 y/o) → lack of all Ig types but normal B-cell levels; ↑risk of lymphomas
SCID (“bubble boy disease”): XR or AR ∆adenosine deaminase → lymphocytes can’t make DNA to proliferate (both B- and T-cells) → severe
infx → death at young age; Tx bone marrow txp
Job syndrome: FATED – coarse Facies, Abscesses, retained primary Teeth, ↑↑IgE, Derm issues (eczema)
Asplenia: recurrent encapsulated bacterial infx (SHiN – Strep pneumo, H. influenza, Neisseria), common in SCD kids; Dx CBC w/ smear (HowellJolly bodies)
Hereditary angioedema: AD ∆C1 esterase inhibitor → random activation of complement pathway → recurrent episodes of edema w/ positive
family hx
IgA deficiency: recurrent respiratory infx + diarrhea + anaphylatic transfusion rxns (reacts to donor serum IgA); Dx ↓IgA
Complement deficiency: C5-C9 deficiency predisposes to recurrent Neisseria infx; Dx CH50 test

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– HEM-ONC ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
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Juvenile rheumatoid arthritis (Still disease): RF (anti-IgG Fc domain) → type 3 HS; Tx NSAIDs > MTX > PO steroids

Polyarticular JRA: >5 joints

Pauciarticular JRA: 0-4 joints, can present w/ anterior uveitis (iridocyclitis); Dx slit-lamp eye exam, Tx PO/OU steroids

Systemic JRA: systemic sx prior to arthritis, rheumatoid rash, high spiking fevers
Juvenile dermatomyositis: presents w/ progressive muscle weakness, skin rash, fatigue; Dx ↑CPK
Neonatal lupus: skin lesions (maternal ab-ag complexes cross placenta) + 3° heart block (anti-SSA attacks fetal heart conduction)
Systemic lupus erythematosus (SLE): type 3 HS → flare-and-remission pattern of I’M DAMN SHARP – ↑IgG, Malar rash, Discoid rash, ANA, Mucositis
(throat ulcers), Neuro sx, Serositis (pleuritis/pericarditis), Hematologic d/o, Arthritis, Renal d/o (wire loops), Photosensitivity; Dx screen w/ ANA, confirm
w/ anti-dsDNA or anti-Smith, Tx low-dose aspirin
ITP: autoantibodies against gpIIb/IIIa → platelet sequestration in spleen → petechiae, purpura; Dx ↓plt/↑MKC, Tx RhoGAM (if Rh+), IVIG (if Rh-), steroids
(2nd line), splenectomy (if severe)
★ Anemia

Fanconi anemia: AR ∆DNA repair genes → aplastic anemia + short stature, hypopigmented areas, eye/ear deformities; Tx androgens +
hematopoietic drugs (EPO, neupogen, etc.)

Anemia of prematurity: MCC anemia in premature and SGA infants; Dx CBC shows profound anemia w/ ↓reticulocytes, Tx iron supplements

Transient erythroblastopenia of childhood: RBC aplasia in children following a viral infx; Dx CBC shows profound anemia w/ no reticulocytes,
Tx supportive care (lasts 1-2 months, may need pRBCs)

Blackfan-Diamond anemia: macrocytic RBC aplasia + short stature, webbed neck, cleft lip, shield chest, triphalangeal thumbs

Sickle cell anemia: Dx Hb electrophoresis shows ↑HbF, Tx folate supplements (for effective hematopoiesis) + hydroxyurea (↑HbF)

Sickle cell + sepsis: Strep pneumo

Sickle cell + osteomyelitis: Salmonella

Sickle cell + aplastic crisis: Parvo B19

Dactylitis: sickle cell anemia → vaso-occlusion → vascular necrosis of metacarpals/metatarsals → acute onset painful swelling of
hands and feet

Acute chest syndrome: PNA-like presentation; Dx CXR shows infiltrate, Tx azithromycin + ceftriaxone

Sickle cell trait: MC sx is painless gross hematuria; Dx Hb electrophoresis shows HbS of 35-40%
Thalassemias
Mechanism/presentation
Management
β-thalassemia minor
heterozygous ∆β-chain → mild anemia sx
Dx screen w/ CBC (microcytic anemia + ↓RDW),
confirm w/ ↑HbA2; Tx reassurance
β-thalassemia major
homozygous ∆β-chain → severe anemia sx
Dx screen w/ CBC (microcytic anemia + ↓RDW),
confirm w/ ↑HbF; Tx frequent transfusions
Silent carrier
1-2 α-chain deletion → asx
--HbH disease
3 α-chain deletion → severe anemia sx
Dx screen w/ CBC (microcytic anemia + ↓RDW),
confirm w/ ↑HbH; Tx frequent transfusions
Barts disease
4 α-chain deletion → fetal hydrops
Dx post-mortem autopsy
Kasabach-Merritt phenomenon: large vascular anomalies (kaposiform hemangioendothelioma, tufted angioma) sequester RBCs, platelets, and clotting
factors → anemia, thrombocytopenia, coagulopathy; Tx steroids + IFN-α
G6PD deficiency: XR ∆G6PD in African-American boys → RBCs can’t make enough NADPH to deal w/ oxidative stress (fava beans, sulfa drugs,
antimalarials, infx) → hemolytic anemia following exposure to oxidative stress
★ ALL: MC cancer in kids <15 y/o; pre-B-cell proliferation (CALLA+/TdT+) → infiltration of reticuloendothelial system (LAD, splenomegaly) and bone
marrow (pancytopenia); Dx bone marrow bx shows >25% lymphoblasts, Tx chemotherapy

ALL prognosis: good px w/ age 1-10, hyperdiploidy, WBC <50, and TEL/AML1 on t(12;21); poor px w/ Philadelphia chromosome on t(9;22)
Hodgkin lymphoma: B-cell proliferation into Reed-Sternberg cells → B-type sx (fever, weight loss, night sweats); Dx CXR to look for mediastinal mass
then LN bx, Tx chemotherapy
Langerhans cell histiocytosis: Langerhans cell proliferation → eosinophilic granuloma → painful, solitary lytic bone lesion (MC site is skull)
Hereditary spherocytosis: AR ∆spectrin → hemolytic anemia + jaundice in newborn; Dx CBC shows spherocytes + abnormal osmotic fragility test, Tx
splenectomy
Disseminated intravascular coagulation (DIC): systemic insult (MCC septic shock) → widespread microcoagulation → run out of clotting factors →
bleeding out; Dx ↑PT/INR + ↑PTT + ↑D-dimer + ↓platelets, Tx underlying cause
Von Willebrand disease: AD ∆vWF → MCC hemorrhagic diathesis; Dx vWF levels + activity (ristocetin cofactor activity), Tx DDAVP

Pediatrics – Shelf notes

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Tumor lysis syndrome: lysis of cancer cells → hyperkalemia + hyperuricemia + renal failure; Dx renal panel + ↑uric acid, Tx allopurinol
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ENDOCRINE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

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Sick euthyroid syndrome: ↑bodily stress (trauma, starvation, etc.) → ↑cortisol blocks TSH → ↓T4/T3, normal TSH, ↑rT3 (deiodinase 3 activated by stress)
Adrenal

Pheochromocytoma: episodic ↑catecholamine → 5 Ps – Pressure (BP), Pain (HA), Perspiration, Palpitations, Pallor; Dx 24 hr urinary
metanephrines, Tx α-blockers (phenoxybenzamine) then β-blockers then adrenalectomy

Cushing syndrome: ↑cortisol → truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, immunosuppression; Dx
ACTH/cortisol levels + dexamethasone suppression test (pituitary Cushing can be suppressed), Tx underlying cause

Hyperaldosteronism: ↑aldosterone → ↑Na, ↓K, ↓H (HTN, metabolic alkalosis)

Addison syndrome: ↓cortisol/↓aldosterone → fatigue, hypoglycemia, HTN, hyperpigmentation, weight loss; Tx prednisone + fludrocortisone
replacement

★ Congenital adrenal hyperplasia: ∆21α-hydroxylase → ↓aldosterone/↓sex hormones → ↓Na, ↑K, ↑H (metabolic acidosis), hirsutism,
virilization; Dx ↑17-OHP, Tx hydrocortisone + fludrocortisone replacement

Central DI: ↓ADH → can’t resorb water → polyuria, polydipsia, hemoconcentration (↑Na, ↑K); Tx DDAVP

Nephrogenic DI: end-organ resistance to ADH → polyuria, polydipsia, hemoconcentration (↑Na, ↑K); Tx HCTZ

SIADH: ↑ADH → fluid overload → hemodilution (↓Na, ↓K); Tx water restriction
Pancreatic

HbA1C: reflects 2-3 months of glucose control, normal <6.5%

DM type 2: presents as polyuria (bedwetting), polydipsia, polyphagia, acanthosis nigricans; Dx fasting glucose >126 x2, random >200 w/ sx,
or HbA1C >6.5%
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Factitious hypoglycemia: mom’s giving baby insulin → hypoglycemia + hyperinsulinemia + low C-peptide levels (high C-peptide reflects
insulinoma); Munchhausen by proxy is a form of child abuse
Parathyroid

Hypercalcemia sx: stones (kidney, GB), bones (pain, osteitis fibrosa cystica), groans (PUD, pancreatitis), psychic overtones
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Hypocalcemia sx: neuromuscular irritability (tingling, tetany), prolonged QT, arrhythmias

Hypercalcemia s/p fracture: due to extensive bone resorption; Dx urine calcium:creatinine ratio >0.2, Tx hydration, calcitonin if severe

Nutritional rickets: dietary ↓vitamin D → normal Ca, ↓P → decreased bone mineralization; increased risk in exclusively breast-fed babies, lack
of vitamin D supplements, African-Americans, limited sun exposure

X-linked hypophosphatemic rickets: XD ∆PHEX (renal phosphate resorption gene) → ↑urinary P, ↓serum P → decreased bone mineralization
resistant to vitamin D supplements

Pseudohypoparathyroidism: renal tubules unresponsive to PTH → ↓Ca, ↑P, ↑PTH → hypOcalcemia sx + 4th/5th finger bradydactyly (knuckleknuckle-dimple-dimple sign)

Hypoparathyroidism: lack of PTH → ↓Ca, ↑P, ↓PTH → hypOcalcemia sx

1° hyperparathyroidism: excessive PTH → ↑Ca, ↓P, ↑PTH → hypercalcemia sx

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ADOLESCENT ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
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HEADSSS assessment: Home, Education, Activities, Drugs, Sex, Suicide, Safety
Eating disorders

Anorexia nervosa: fear of being fat → <85% ideal body weight, secondary amenorrhea, lanugo, hypothermia, osteoporosis, arrhythmias; Tx
TID sandwiches

Bulimia nervosa: binge-eating + behaviors intended to counteract weight gain (purging, diuretics, exercise, fasting), sialadenosis, dental
caries, Russell’s sign (dorsal knuckle callouses); Tx SSRIs + CBT

Anorexia vs. bulimia: both can have purging behavior, but anorexia has <85% ideal body weight

Refeeding syndrome: increased nutrition in starving pt → ↑synthesis of glycogen, fat, proteins uses up electrolytes (especially ↓K and
↓phosphate)
Sports contraindications: bleeding d/o (hemophilia), single eye, single kidney, unexplained syncope, infectious mononucleosis (to prevent splenic
rupture)
Sports concussions
Sx
Management
Grade 1 (mild)
no LOC, confusion <15 min
can return to play
Grade 2 (moderate)
no LOC, confusion >15 min
must sit out for a week, go to hospital if >1 hr
Grade 3 (severe)
LOC
go to hospital
★ Tanner (SMR) staging

Tanner 1
Tanner 2
Tanner 3
Tanner 4
Tanner 5

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Males
kid
scrotal darkening, thin long pubic hair
dark curly pubic hair
adult pubic hair but w/o full coverage, peak growth velocity
adult

Females
kid
breast buds
breast elevation, peak growth velocity
areolar mound (look 4 big nipples)
adult

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Late-onset congenital adrenal hyperplasia: 21-hydroxylase deficiency → excess of sex steroids → precocious puberty in boys

McCune-Albright syndrome: precocious puberty in girls + café-au-lait spots + polyostotic fibrous dysplasia (bone zits that cause multiple fx)
Teenage pregnancy: complications include poor maternal weight gain, premature delivery, low birth weight, ↑risk of pre-eclampsia
★ Substance abuse: suspect w/ declining school performance, poor hygiene, exaggerated mood swings, hanging w/ the wrong crowd, frequent hostile
reactions

Pediatrics – Shelf notes

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Cocaine: euphoria, tachycardia, hypertension, nosebleeds, heart attacks, strokes
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Marijuana: euphoria, paranoia, injected eyes, munchies

Anabolic steroids: muscles, hirsutism, acne, gynecomastia, testicular atrophy, roid rage; consider in football players

MDMA (Ecstasy): euphoria, stimulant, “sense of closeness with others”, death by hyperthermia or dehydration; consider in clubs/raves

Inhalants: brain damage, arrhythmias, death
Suicide: women attempt more but men are more successful; Tx admit + get full psych eval
Sleeping late w/ puberty: due to melatonin phase-delay in sleep-wake cycle
★ Acne vulgaris: not associated with food or caffeine intake; Tx topical benzoyl peroxide (1st line), topical retinoids or abx (2nd line), PO abx (3rd line),
isotretinoin (last line, teratogenic)
Dysfunctional uterine bleeding: abnormal menses w/o identifiable cause; Dx of exclusion, Tx OCPs to normalize cycle

★ = high-yield topics (review these before the shelf)