CARDIOVASCULAR
Contraindications to BP meds Asthma/COPD = Bblockers, DM = Thiazides & Bblockers, Cardiac Failure = Bblockers & Ca Channel Blockers; Pregnancy = Thiazides & ACE
Rheumatic Fever post strep infection, migratory arthritis, endocardits, subcutaneous nodules on extensor surface, chorea, erythema marginatum, incr. Sed, WBC & ASO
ASD L=>R; Wide split & fixed S2; patent foramen ovale
VSD L=>R; pansystolic murmur left sternal border, thrill; most common defect; Eisenmenger's Syndrome = shunt direction reversed due to incr. pulm vasc resistance
Patent Ductus Arterio L=> R; Continuous machinery murmur; Indomethacin inject may close
Tetralogy of Fallot VSD, RVH, Pulmonic Stenosis, Overriding Aorta
Pulmonic Stenosis R=>L, Early systolic click, High pitched systolic ejection murmur, soft or absent S2
Coarction of the Aorta HTN arms but not legs, murmur heard on back, X-ray scalloping of ribs,
Bacterial Endocarditis Acute: S.aureus, Group A strep, N Gonh., Sub acute: Strep Viridans; New heart murmurs, petechia over incr. half of body, Splinter hemorrhages on fingernails, Osler's Nodules (nodules on fingertips) Roth's Spots (retinal hemorrhages)
Noninfective Endocarditis Libman Sacks Disease associated with SLE
Aortic Aneurysm Abdominal = pulsatile mass on exam, atherosclerosis, smoking HTN >4 cm = surgery Thoracic =Marfan's & syphilis >7c = surgery; Dissecting =split between medial & adventitial layers "ripping in chest" Normal EKG vs abnormal in MI
Peripheral Vascular Disease Weak pulses, Atrophic skin, Little Hair growth, Nonhealing ulcers, intermittent claudication 5P's = pallor, pain, pulseless, parathesia, paralysis
Raynaud's Phenomenon Pallor, cyanosis, erythema of fingers, most are idiopathic, others related to collagen vascular disease Tx vasodialators
Heart Dysfunction Diastolic = difficulty filling ventricles; Systolic = problem ejecting blood from ventricle
Polyarteritis Nodosa inflamed medium arteries->ischemia in tissues; men 3x> women, usually 40-50; Dx confirmed by biopsy or angiography showing aneurysm of medium arteries
Giant Cell Arteritis Temporal Arteritis; women >50; severe temporal or occipital HA, Amaurosis Fugax (temp blindness 1 eye) Temporal artery swollen & tender, Dx confirmed by biopsy
Cor Pulmonale COPD most common cause; Dyspnea & syncope on exertion, S/Sx Rt heart failure
Mitral Stenosis Mitral facies = red rash on cheekbones, Loud S1 and opening snap after S2; Right heart failure TX with diuretics; LAH=>Pulm HTN=>RVH Bblockers & Ca Channel Blockers to decr. HR & preload; Progressive Dyspnea
Mitral Regurge Midsystolic click; Harsh blowing holosystolic murmur; MVP; LAH & LVH; wide S2 that widens more with inspiration; Bblockers for Sx Valve replacement
Aortic Stenosis Triad = Angina, Syncope & Dyspnea on exertion; Cong bicuspid valve, weak long pulse, LVH T wave invesions; Left sided failure; Bblockers decr. HR & incr. coronary flow
Aortic Regurge Decrescendo murmur, widened pulse pressure, "Water Hammer Pulse" (rapid up & down stroke); "Pistol Shot over femoral Artery; 2o Austin Flint murmur= diastolic murmur as blood goes thru AV to hit MV. Kids = cong VSD w/ MVP
Supraventricular Tachycardia Sudden attacks due to reentry rhythm, P on T on EKG; #1 AV Nodal Reentry #2 Wolff Parkinson White = reentry thru accessory muscle bundle, can cause V fib in a Pt with Afib; Torsades De Point is drug induced
Left Sided Failure Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, LVH
Right Sided Failure Most common cause is Left sided failure; Neck vein distention, Liver big, Edema
MI ST elevation, T wave inversion; CPK-MB 12 - 40 hr for peak; LDH peaks 3-6 days
Congestive Cardiomyopathy Alcohol = chronic; Infection Coxsackie B or Trypanosoma cruzi (Chagas Disease)
Hypertrophic Cardiomyopathy Cong or acquired VH with normal afterload; incr. venous pressure, JVD, ascites, edema, edema, pleural effusion, S4 on exam
Chronic Pericardtis Causes right sided failure; Kussmaul's Sign ( incr. neck vein distention on exertion) Dyspnea on exertion and Orthopnea; pulsus paradoxus; Surg removal of pericardium is curative.
Pericardial Effusion Friction rub, distant heart sounds, "water bottle" on x-ray; acute pericarditis = exudate; neoplasm or fibrosis =transudate; symmetrically enlarged cardiac silhouette
Cardiac Tamponade Pulsus paradoxus, Kussmauls Absent; pericardial fluid compresses heart, Becks Triad = Hypotension, (ß decr. pulse pressure), JVD, Muffled heart signs
Heart Murmurs AI: precordium, early diastolic, >S2, + heave; AS: 2nd R ICS & radiates to carotids, harsh, < S2; Diastolic = r/o malignancy, check BP both arms; MR: Apex radiates to axilla, + heave, assoc w/ sever anterior MI, endocarditis prophylaxisis; MS: Apex, late diastolic, opening snap after S2; MVP: Apex, blowing, holosystolic, incr. w/ valsalva;
PR: 2nd L ICS, pulm HTN, clubbing, PE; PS: harsh; TR: 4th L ICS, incr. loud w/ inspiration; bounding JVD, pulsatile liver; VSD: loud holoystolic, assoc w/ Down's
RESPIRATORY
Peritonsillar Abscess uvula away; Head tilted toward, Trismus (can't open mouth)Strep or Bacteroides
Epiglottitis H.flu type B, Insp. Stridor, Dysphagia with drooling, Thumbprint sign on xray
Larengitracheitis Croup; Paraflu #1, RSV, Flu, barking cough, stridor hoarse, r/o epiglottitis
Acute Bronchitis non smokers = M. pneumonia; smokers=S.pneumonia & H.flu
Bronchiolitis Circumoral cyanosis (blue around mouth) RSV; kids < 2
Strep Pneumonia Red-brown sputum, lobar pneumonia, most common adult community acquired
Pneumovax vaccine = >65, immunocompromised, chronic disease
H.Flu Pneumonia COPD, children, slow onset with URI sx 1st, patchy bronchial infiltration on xray
Viral Pneumonia Most common cause in kids, flu like prodrome, patchy infiltrates; WBC not incr. a lot
Klebsiella Pneumonia Alcoholics, aspiration, Currant Jelly Sputum, Encapsulated gram neg rod
Staph Pneumonia Salmon colored sputum, Nosocomial, pneumatoceles on xray are pathognomic
Mycoplasma Pneumonia atypical no cell wall to stain, young adults in close contact; xray worse than pt looks
Pseudomonas Pneum. hospital acquired, CF, immunocompromised
Legionella Pneumonia atypical, CNS & GI sx; confusion & ataxia, aerosolized water (air conditioning)
TB fever, night sweats, wt loss, bloody sputum, Miliary = disseminated; Acid fast stain, PPD>10mm nonimmunocompromised; ppd>5mm AIDS; Extrapulmonary manifestations= meningitis, pericarditis, bone invasion (Pott's Disease)
Bronchiectasis chronic destructive; dilation of bronchial tree, cough with incr. incr. incr. sputum, dyspnea, hemoptysis, Xray = incr. bronchial markings, "honeycombing"
Emphysema Destroyed alveolar walls, Risks: smoking, alpha 1 antitrypsin deficiency;
PFTS: ß decr. FEV1; decr. VC, FEV1/FVC < 60% normal
Blue Bloaters Bronchitis>Emphysema; cough w/ mucous 3mos/yr x 2y; cyanosis, pulm HTN
Pink Puffers Emphysema >Bronchitis; gradual dyspnea not hypoxic, underweight
Cystic Fibrosis auto recessive, COPD, Pancreatic insufficiency; meconium illeus, incr. sweat chloride
Sarcoidosis non caseating granulomatous, increased Calcium, ground glass, bilateral hilar & paratracheal adenopathy is pathognomic
Asbestosis Increased risk of lung CA & mesothelioma, gradual dyspnea, nonproductive cough; no wheeze; diffuse linear opacities on xray
Silicosis increased risk of TB, SiO2 inhalation; metal mining; multiple small nodules & calcification of hilar lymph nodes
Resp Failure ABG=> PO2 50-60 mmHg; PCO2 >45 mmHg
Laryngeal CA squamous cell, smoking & alcohol, hoarsness for several weeks
Lung CA squamous>adeno>small(oat) cell; Squamous = hilar; Adeno = peripheral; Horner's Syndrome=invasion of the cervical symp. Ganglion= miosis, ptosis, anhydrosis
Pancoast tumor = Horners + pain in arm or shoulder on affected side
Asthma PFTs decr. FEV1; ABG resp alkalosis, decr. CO2; If CO2 incr. or normal resp failure imminet
Massive Hemoptysis >600 ml blood in 24 hrs; trauma; PE, aortic aneurysm, heart failure
Pneumothorax Spontaneous = 15-35 y/o males; Tension = pressure in pleural spaces; displaces heart & lungs (mediastinal shift) = surgical emergency
ARDS acute lung injury with non-cardiogenic pulm edema, ABG =acute resp alkalosis (ßO2 & ßCO2; Xray =pulm edema with normal cardiac silhouette, Positive pressure or PEEP ventilatory support
Pleural Effusions decr. tactile fremitus; dull; egophony (incr resonance; chg voice to high pitched)
Transudates: <3g protein, Plasma/serum protein<0.5; Plasma/serum LDH <0.6 caused by CHF, cirrhosis, nephrotic syndrome
Exudates:Reverse labs; neoplasms & infections; incr. triglycerides = chylous effusion; Pus = empyema (s. Aureus); Meiggs syndrome = pleural eff, ascites pelvic tumors)
Pulmonary Edema Pink, frothy sputum, Kerley B lines on xray; Incr cardiac silhouette if cardiac origin
Pulmonary Embolism DVT (iliac & femoral) V/Q useful, angiography is god std for dx
RDS <37 wks gestation, Lung maturity: L/S ratio >2, + PG; Beclomethasone hastens maturity; artificial surfactant for kid
Pulm HTN Primary = dx of exclusion; secondary valvular heart disease, L=>R shunt, chronic ateletasis (localized collapse of alveoli)
ENDOCRINOLOGY
Hypothyroid Weight gain, Lethargy, Coarse hair & dry skin, irregular menses, cold intolerance, myxedema; Acquired = Hashimoto's; Congenital = cretinism, severe I deficiency = hoarse cry; resp distress, cyanosis, poor feeding, decr bone growth, ßT4 incr. TSH
Wolff Chaikoff effect = inhibition of thyroid hormone release due to high doses of I during thyroid scan
Hyperthyroid 1. GRAVES: most common, autoimmune, antibodies bind to TSH receptors; incr thyroid hormone, pretibial myxedema, Incr radio I uptake
2. SUBACUTE THYROIDITIS: tender, enlarged, Decr Radio I uptake, Sed Rate up, maybe followed by period of hypothyroid
3. SILENT LYMPHOCYTIC THYRODITIS: transient, postpartum, no pain or fever, Radio I uptake decr, lymphocytic infiltration, Tx Bblockers
4. TOXIC ADENOMA: multinodular goiter; nodules function autonomously, Excess T3 & T4; Scan shows a few hot spots with cold background
5. THYROTOXICOSIS FACTITIA: exogenous thyroid hormone, no goiter
6. PLUMMERS : multinodular goiter, nodules become autonomous and secrete thyroxine
Sick Euthyroid acutely ill patients; T3&T4 decr due to chgs in hormone metabolism; TSH not decreased => not truly hypothyroid
Thyroid CA Papillary = most common, best prognosis, Follicular = older, hematogenous spread to bone, lung, brain, liver; Anaplastic = worse prognosis, local invasion, hoarse & dysphagia; Medullary= Calcitonin producing Cells, MEN Type II(parafollicularC cells)
Diabetes Dx: elevated random glucose sx, fasting BS > 140 x 2 days; Oral challenge >200 after 2 hrs; Type I: alpha islet cells, HLADR3, HLADR4, HLADQ, ketoacidosis
Type II: insulin resistance; no HLA association, endogenous production enough so no ketoacidosis but do get hyperosmolar coma(dehydrated, glucose 600-2000
Parathyroid Hormone incr. Ca mobilization from bones, incr. Vit D production decr. phos reabsorption in distal tubules = decr. serum phos.
Hypoparathyroidism ßPTH, ßCa, incr. Phos, Tingling, tetany, Chvostek's sign (tap on face & get muscle spasm) ; Trousseau's Sign (BP cuff up 3min => carpal tunnel sx; decr. Mg in alcoholics can lead to decr. Ca due to ßPTH secretions
Hyperparathyroid Bones, stones, abd. Groans and psychic moans; 1o = excess PTH; 80% benign adenoma; 2o due to decr. serum Ca=> vit D defic, renal tube prob and Ca loss
Diabetes Insipidus Lack of ADH, polyuria and polydypsia
Kallman's Syndrome Male, anosmic, small testicles, azospermic d/t head trauma; decr. FSH & LH, no GNRH
SIADH Excess ADH, Tumor, trauma, pulm disease, drugs; Hypoatremia, Conc. urine;
Acromegaly Excess GH; bone & tissue enlargement; glucose intolerance, osteoarthritis
Addison's Disease Decreased cortisol (aldosterone) Wt loss, fatigue, skin pigmentation, eosinophilia; Decr aldosterone, decr Na, incr K; Give ACTH if cortisol doesn't increase Dx made
Cushing's Syndrome Incr cortisol, Buffalo hump, moon facies, central obesity, Osteoporosis, #1 Cushing disease due to pit. Adenoma, #2 Ectopic- ACTH from lung tumor, #3 Adrenal Cortical tumor- incr. cortisol, ACTH suppressible, cortisol not #4 Chronic glucocorticoid Tx
Waterhouse Friedrickson Syndrome hemorrhagic infarct of adrenals, assoc w/ meningococcemia
Pheochromocytoma Episodic HTN, Dx by urinary catecholamines
Familial Hypercholesterolemia Autosomal dominant, Xanthomas (lipid on tendons) Xanthelasmas (lipids on eyelids) MI's in 40's, Homozygous usually has incr. total cholesterol
Familial Hypertriglyceridemia Trig incr. , LDL normal, Autosomal dominant, Pancreatitis, milky serum
Familial Combined Hyperlipidemia Auto dominant, incr. trig and cholesterol; no xanthomas
Familial Dysbetalipo-proteinemia rare, problem with lipoproetin catabolism; palmar or tuberous xanthomas, incr. risk periph vasc disease & CAD, Abn VLDL, cholesterol & triglycerides
MEN I Parathyroid , pituitary & Pancreatic tumors
MEN II Pheochromocytoma, Parathyroid & medullary thyroid tumors
Hemochromatosis Auto recessive, incr. GI absorption of Fe; Excessive Fe, incr. Ferritin, incr. Transferrin saturation, cirrhosis, diabetes, bronze skin
Wilson's Disease Auto recessive, excessive Cu accumulation, ataxia & dementia, Kayser Fleisher rings on cornea
Hyperaldosteronism Aldosterone works on distal renal tubule to facilitate incr. Na retention and incr. K loss
excretion due to decr. Na, decr. BP (renin angio), incr. K
1o Conn's Syndrome = adrenal hyperplasia, adrenal adenoma Tx: spironolactone
2o incr. renin angiotensin system activity => decr. BP
GENTOURINARY
Neurogenic Bladder Bladder control requires: intact sensation(full) motor function (start void) Cerebral control (timing)
Atonic, distended with overflow= acute spinal cord injury or sensory impaired
Motor defect = sense full bladder but can't start emptying
Autonomous = spinal cord injuries after acute; bladder fills & empties reflexively
Hydronephrosis dilation of renal pelvis, incr. pressure in urinary system w/ or w/o ureter dilation
Fanconi's Syndrome renal tubule defect; Urinary excretion of glucose, phos, AA; Tx: Vitamin D
Pyelonephritis & Pyelitis Pyelonephritis = dilation of renal parenchyma, pyelitis = dilation of renal pelvis; E. coli; Different from cystitis since there are WBC casts not just WBC's
Cystitis WBC in spun sample, E. coli, freq, urge, dysuria & suprapubic pain
Bladder Ca transitional cell CA; Risk factors = smoking, schistosomiasis, aniline dyes
Renal Artery Stenosis Cause of 2o HTN; Fibromuscular dysplasia (young women) Atherosclerosis (older)
Urolithiasis incr. Ca = Calcium stones; Struvite Stones = post UTI w/ urea splitting bact (proteus or pseudo) when urine basic MgNH4PO4 (struvite) stones ppt.
Uremic Syndrome Symptomatic renal failure = GFR< 20 ml/min; CNS chgs, asterixis (flapping tremor) pericarditis, N/V, yellow-brown skin (uremic frost) Normochromic, normocytic anemia due to decr. erythropoietin; incr. Phos & decr. Ca = renal osteodystrophy
Glomerulonephritis Hematuria, proteinuria, RBC casts: Post strep = give Antibiotics only if still strep +, steroids no help; Goodpastures- autoimmune, high dose steroids, uremia 3-9 mos.
Nephrotic Syndrome Proteinuria > 3g/day, Edema, hypoalbuminemia & hyperlipidemia (milky serum); minimal chg disease in kids; idiopathic Glomerulonephritis in adults
Acute Tubular Necrosis most common cause of acute renal failure; ischemia or toxins; resolves in several weeks may need dialysis
Polycystic Kidney Disease Auto dominant; multiple bilateral renal cysts; gross hematuria, proteinuria, pyuria, HTN, UTI's; asymptomatic until adult; 15% have associated subarachnoid hemorrhage
Alport's Syndrome X-linked, Type IV collage, deafness & renal failure in males
Wilm's Tumor nephroblastoma, kids < 4yrs commonly, hematuria, abd mass; resection & chemo
Renal CA adenocarcinoma; Triad: hematuria, abd mass & flank pain
Chronic Renal Failure >90% glomeruli destroyed; uremia incr. K, ßNa incr. phos, ßCa = renal osteodystrophy
Hypernatremia > 155 mEq/L; due to dehydration, CNS depression (neuronal shrinkage); Diabetes Insipidus= decr ADH = lots of dilute urine = dehydration = urine output incr.
Hyponatremia <135 mEq/L; pseudo if lipids are incr. incr. incr. high to displace polar Na; Osmotic = diabetes incr. Na 1.6 for 100 mg/dl glucose value is above 140.; SIADH, Central Pontine Myelinosis if corrected to fast
Hyperkalemia > 5.5 mEq/L; muscle weakness, cardiac arrhythmia, met acidosis, oliguria, K sparring diuretics
Hypokalaemia <3.5 mEq/L; muscle weakness, cardiac arrhythmias, resp failure, GI or renal loss
Urethritis GC (gram - rodds in WBC, + thayer martin culture); nonGC = chlamydial; coinfection, Ceftrixone for GC, Doxycycline for Chlamydia
Epididymitis Induration & tenderness of spermatic cord; support relieves pain
Torsion of the Testes adolescents, swelling & tenderness, superior displacement, support does not relieve pain, Emergent SURGERY
Hydrocele Painless lump, can be transilluminated; congenital process vaginalis remains in communication w/ abdomen = indirect inguinal hernias
Varicocele "bag of worms", assoc w/ infertility
Seminoma Painless lump; does not transilluminate, most common testicular neoplasm in men < 30; Undescended testes at greater risk even after surgical correction
Prostatitis Nonbacterial > bacterial (GI organisms); recurrent UTIs; Rectal - warm, tender, boggy prostate; Tx TMP/SMX
BPH Enlarged rubbery prostate on rectal; Urinary retention, a blockers; TURP, transrectal US more sensitive for Dx; PSA can be falsely elevated
Prostate Ca Firm, nodular irregular prostate, Bone mets; Alk Phos and PSA are incr.
Bacters Syndrome pre-auricular skin tag and kidney agenesis
INFECTIOUS DISEASES & IMMUNOLOGY
Fever most common cause immed post op = atelectasis; 3-5 days postop = infection; > 2 wks post op = PE or thrombophlebitis
Fever of Unknown Origin > 100F for > 3 weeks despite active search for cause for > 1 week; need to get CBC w/diff, blood cultures; kids = usually infection; adults = infectious, neoplasm, autoimmune
Inflamation Rubor, Tumor, Calor, Dolor
Types of Immunity Active Acquired= direct exposure - infection or vaccination; Passive Acquired = temporary, serum Ab given (IG, breast milk)
Bacteremia bacteria in blood but asymptomatic
Septicemia bacteria in blood with symptoms
Immunizations in Kids HEP B = mom + HbsAG = HBIG & 1st Hep B vaccine at birth
DTP = contraindications => progressive neuro disorder, Hx encephalopathy w/ in 7 days of previous dose; Pertussis not given if > 7 y/o or if currently have pertussis
H FLU = not in kids > 5
POLIO = IPV if immunocompromised
MMR = not effective before age 1; don't give if less than 3 months since transfussion or IG use; ok for HIV +; suppresses TB - give Tine(PPD) & MMR at same time or 4-6 weeks apart.
Adult Immunizations TETANUS = booster q10y, No Hx immunization 2 td 1-2 mos apart then booster at 6-12 mos then on normal 10 y cycle
FLU = chronic resp problems, metabolic diseases, adults > 65; can cause false positive HIV test
HIV/AIDS RNA retro, CD4 cells, Dx based on concurrent related diseases &/or CD4 , 200 cells/mm3; Flu-like illness, antibodies 1 - 6 months after infection
AIDS related infections CMV, HSV, VZV, EBV, TB, mycoplasma avium-intracellular, candida coccidioides, histoplasmosis, cryptococcus, Pneumocystic carnii (protozoa) Toxoplasmosis, cryptosporidiosis, Giardiasis
DeGeorge's Syndrome Thymic aplasia, Absent T cells, congenital heart disease, craniofacial abnormalities
Wiskcott- Aldrich Syndrome X linked, no antibodies against encapsulated bacteria, eczema, decr. platelets,
Chronic Granulamatous Disease Autosomal recessive, defect in phagocytic enzymes, recurrent bacterial & fungal infections
Chediak-Higashi Syndrome Autosomal recessive, recurrent strep & staph infections
Bruton's Disease x-liked, agammaglobulinemia, N B cells or antibodies
Ataxia Telangectasia Auto recessive, lymphopenia & IgA deficiency; gait abnormal, telangiectasia
Severe Combined Immunodeficiency Deficits of B & T cells, IgA deficiency, recurrent infections esp resp & GI, IG administration contraindicated
HEMATOLOGY & ONCOLOGY
Microcytic Anemia MCV < 80; IRON DEFICIENCY = decr. ferritin; CHRONIC DISEASE decr. Fe, decr. Transferrin, incr. Ferritin; LEAD POISONING; THALASSEMIA
Normocytic Anemia MCV 80 - 100; Hemolysis, Chronic disease, Bone marrow suppression (drugs, leukemia) (aplastic)
Macrocytic Anemia MCV > 100; FOLATE DEF. = most common cause, decr. folate normal B12;
B12 DEFICIENCY: B12 absorbed when linked with IF from parietal cells, neuro sx,
Alpha Thalassemia Acanthocytes (rounded projections from cells); Poikilocytosis (variable size); target cells, Very low MCV but mild anemia, Hemoglobin H = a chain missing; Asians, Dx by Hb electrophoresis,
Beta Thalassemia Peripheral Smear = basophillic stippling, nucleated RBC, anisocytosis (chgs in size) Mediterranean & African heritage; Minor = heterozygous, Major = homozygous
Sickle Cell Anemia sickled cells, decr. Hct & incr. reticulocyte count, electrophoresis HbS + HbA neg. Salmonella osteomyelitis, S. pneumonia sepsis.
Hemophilia X linked factor VIII (A) or IX (B) deficiency; Prolonged PTT, Joint & soft tissue bleeding; Tx cryoprecipitate & FFP
Von Willebrand's Disease autosomal dominant deficiency of VIII & vWF, epistaxis, menorrhagia, bruising, increased PTT & bleeding time
Eosinophilia Allergic Drug Reaction; NAACP = neoplasm, asthma/allergies, Addison's disease, connective tissue disorders, parasites
Thrombotic Thrombocytopenic Pupura adults > kids, women > men; platelets consumed in clotting reactions, Fluctuating neurologic defects, decr. platelets, decr. HCT, incr. retic count, incr. incr. incr. LDH, acute onset not autoimmune
Idiopathic Thrombocytopenic Pupura kids > adults, autoimmune destruction of platelets, Purpurea & Petechia , Platelets<10000, Epistaxis, menorrhagia
Hemolytic Uremic Syndrome Usually caused by E. coli toxin, RBC fragments on smear, RBC destruction => acute renal failure, 2o thrombocytopenia, abd pain & diarrhea after a flu or URI prodrome; platelets derc, LDH greatly increased
Hodgkin's Lymphoma Painless cervical lymphadenopathy, Reed Sternberg cells (multinucleated reticular cells), 80% survival
Burkitt's Lymphoma B cell lymphoma, Associated with Epstein-Barr virus, children & young adults
Hereditary Spherocytosis dominant deficit in RBC membrane proteins, damaged cells get trapped in spleen. Spherical RBC & reticulocytosis on smear. Coombs neg.
G-6-PDase Deficiency X linked hemoglobin accumulates in RBC (Heinz bodies) hemolysis occurs after ingestion of oxidant
Agranulocytosis neutrophils = decr production or incr destruction
DIC wide spread activation of coagulation cascade. decr. platelets, fragmented RBC, incr. PT & PTT ; decr. fibrinogen, Pregnancy, malignancy, infections, massive trauma
Acute Lymphocytic Leukemia 80% childhood leukemia, peak age 3 - 7; usually B cell origin; incr. lymphoblasts, few other cells on bone marrow biopsy
Acute Myelocytic Leukemia affects myeloid cells (N,B,E,erythrocytes, megakarocytes) adults > kids; DIC possible, gram neg and fungal infections, Auer Rods (red staining intracellular inclusions.
Chronic Myelocytic Leukemia Philadelphia Chromosome (acquired translocation chromosome 9 & 22), tumor cells are more mature, Dx in middle aged, WBC > 150000; incr. uric acid, incr. B12 (B12 carrier protein produced by WBC); leukocyte alkaline phos decr or absent, RBC normal
Blast crisis transforms it to acute leukemia
Chronic Lymphocytic Leukemia Disorder of mature B cells (rarely T); B cells don't differentiate into plasma cells, men > women; usually > 50; No Blast Crisis
Hairy Cell Leukemia B cell transformed into tumor cell with fine hair like projections; pancytopenia, red pulp of spleen infiltrated
Multiple Myeloma Plasma cell proliferation and monoclonal IG; men = women; peak 50 - 60, 1 - 3 year survival; xrays show osteolytic bone lesions, Increased urine protein (Bence Jones)
Waldenstrom's Macroglobulinemia single B cell line = monoclonal IM over production; decr. RBC with normal WBC & platelets; Rouleau Formation = RBC pile up forming cylinders
Mycosis Fungoides Clonal proliferation of CD4 T cells; infiltrates dermis & epidermis, thickened & nodular skin lesions
Polycythemia Vera overproduction of all 3 cell lines; RBC > 1,000,000, Hct > 60%; men & women peak age 60; Bone biopsy- hypercellular with absent Fe stores; R/O spurious polycythemia = incr. RBC due to dehydration; R/O 2o polycythemia = RBC mass incr. due to decr. oxygenation.
Eaton Lambert 90% assoc w/ small cell CA, decr. presynaptic Ca release = proximal muscle weakness; hyporeflexia, dysautonomia, function incr. w/ stimulation; weakest in AM (opposite MG) Tx Tubocurare
DERMATOLOGY
Seborrheic Dermatitis Red skin with greasy scales, worse in winter & when under stress, Se or Tar soap
Psoriasis HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled plaques w/ sharp demarcations, Pitted fingernails
Pilonidal Cyst Hair lined tract in sacral area = "Jeep Seat"
Actinic Keratoses Firm, yellow scale, Due to sun exposure, can lead to squamous cell CA
Skin CA Basal Cell > Squamous; Basal Cell = pearly papule w/ dilated blood vessels and central depression; Squamous Cell: Red papule w/ crusted surface, later nodular and ulcerated, rarely mets; Assoc w/ sun exposure
Malignant Melanoma Change in size, shape or color of a mole, Usually superficial spreading, Mets incr. as invasion goes deeper than 0.76 mm; itchy & ulcerated
Contact Dermatitis 1o = irritant contact - direct injury, all w/ contact affected, Occurs w/ 1st exposure
Allergic = type IV hypersensitivity, T cell medicated, Never 1st exposure
Carbuncle Abscess of skin caused by several boils coming together
Dermatopytoses TINEA CORPORIS: ring worm of body (round lesion w/ raised borders, spreads peripherally w/ central clearing) TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot; TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm of scalp;
NEVI PIGMENTED: (Benign) sun exposed areas in children & adolescents
DYSPLASTIC: 2-12 mm, more irregular, unexposed areas, Multiple dysplastic Nevi = familial incr. risk of melanoma
Hemangiomas NEVUS FLAMMEUS: Port wine stain - flat, purple, does not fade
CAPILLARY: strawberry mark, raised, bright red, regress spontaneously by age 5
CAVERNOUS: Raised red or purple, enlarged vascular spaces
MUSCULOSKELETAL & CONNECTIVE TISSUE
Osteoarthritis incr. morning stiffness, bone spurs, osteophytes, DIP = heberdon's nodes, PIP = Bouchard's nodes, also affects hips, knees, spine
Rheumatoid Arthritis Symmetric, PIP & MCP joints NOT DIP, Subcutaneous nodules, 70% +RF
Gout Affects big toe (Podagra), pinna of ear; Negatively birefringent crystals; Sodium urate; Colchicine or NASIDS for acute attacks
Pseudo Gout Calcium pyrophosphate dihydrate; Knee most affected; Positively birefringent
Phocomelia Hands & feet attached to trunk, Thalidomide
Slipped Capital Femoral Epiphysis Overweight Teens; stiffness=>weakness=>pain radiating down anteromed thigh to knee, ext rot of leg; avascular necrosis
Lyme Disease Borrelia burgdorfi, Ixodes tick, arthralgias, Rash w/ central clearing = erythema chronicum migrans, CNS chgs 1 month after exposure
Osteoporosis decr. mass of bone; hip & wrist fx most common; decr. estrogen, Ca & Phos normal; Risk factors = post menopause, Caucasian, Asian, smoking, alcohol, corticosteroids, Cushings, hyperparathyroid, hyperthyroid; Etidronate - inhibits osteoclast activity, used for men & women who can't take estrogen
Systemic Lupus Erythematosus Malar (butterfly) rash, arthralgias (raynauds), ANA sensitive; Anti dsDNA specific; Neuro = HA, psychosis, seizures, aseptic meningitis; Check for hemolytic anemia w/ Coombs; Renal = incr. BUN incr. Cr, + protein = immune complex glomerulonephritis
Polymyositis & Dermatomyositis inflammation of skeletal muscles; violet discoloration of eyelids (heliotrope rash), elevated muscle enzymes (CPK, SGOT, SGPT, LDH) symetric proximal muscle weakness; hips & shoulders 1st
Ankylosing Spondylitis "Bamboo shoots" = vertebral squaring w/ bony outgrowths, paraspinal lig. Calcifications on xray; sacroiliac involvement is diagnostic; HLA-B27; incr. ESR
Shoulder Hand Syndrome Pain, stiffness, swelling in hand and shoulder; Occurs 1 month after MI or other acute disease
Bone Mets from Primary breast, lung, prostate, kidney, thyroid
Paget's Disease Osteolytic => osteoblastic; Frontal "bosing" (enlarged skull with rounded forehead) bow legs and shortened spine; incr. alk phos, Ca & phosphorus levels normal; "Cotton Wool" appearance on skull xray; high output cardiac failure
Congenital Hip Femoral head partially or completely dislocated from acetabulum; BARLOWS: dislocates hip when abducted and decr. pressure; ORTOLANI'S: reduces dislocation by abduction and flexion
Osteochondritis Inflammation of bone & cartilage; Osgood Schlaters - teens, tibial tubercle, pain& swelling at the insertion of the patellar tendon
Osteomyelitis Bone infection; Local or hemtogenous spread; Prepuberty infection is in metaphysis; Salmonella - sicklers; S. aureus; pseudomonas; incr. ESR; incr. WBC; Radionucleotide bone scan w/ in 72 hrs; 4-6 wks organism specific antibiotics
Septic Arthritis S, aureus = most common; N. Gon most common sexually active; synovial fluid = incr. WBC and + culture; Ceftriaxone NG infection; Nafcillin for others
Degenerative Disk Nucleus Pulposa herniates post or postlat.; Lumbosacral = sciatics = L3L4; + pain on straight leg raise;
CaudaEquina Syndrome Lg midline post. Hemorrhage compressing C.E. Urinary and bowel incontinence; bilateral leg weakness
Polymyalgia Rheumatica older women; assoc w/ temporal arteritis; Morning stiffness; swelling 1-2 joints; no weakness; incr. ESR; neg. Rheum factor; steroid response immediate
Fibromyalgia "Trigger Points" reduce pain, IBS, depression, anxiety
Osteosarcoma teenage boys, distal femur & proximal tibia; mets to lungs
Eosinophillic Granuloma 20-40; granuloma w/ histiocytes, eosinophilic infiltrate & fibrosis; multifocal = poor prognosis
NEUROLOGY
Blindness visual acuity 20/400 with best possible correction
Open Angle Glaucoma Increased intraocular pressure, gradual, bilateral vision loss => tunnel vision, elderly, diabetics, African Americans, familial; halos around lights, cuping of ocular disc, Beta Adrenergic blockers to treat; decr. amt aqueous humor produces
Closed Angle Glaucoma Rapid rise in pressure due to blockage of aqueous drainage in the eye; Severe pain, blurred vision, halos, Nausea, Abd pain; Reddened eye, upper lid edema, steamy cornea, dilated non-reactive pupil; mannitol, oral glycerin or carbonic anhydrase in acute attack, Beta adrenergic blockers for prevention
Diabetic Retinopathy Black spots, "cobwebs", flashing lights; cotton wool spots (infarct of vessel wall) neovascularization, hard yellow exudates
Cataracts Painless clouding of lens; Age most common cause, Assoc. W/ smoking & alcohol; Absent red reflex.
Senile Macular Degeneration Main cause of vision loss in the elderly; Atrophic degeneration or Leakage of Retinal Vessels , gradual loss of VA, Decr central vision, hemorrhagic or pigmented regions in the macula; Neovascular Membranes (Bruch's membrane)
Conjunctivitis Acute inflammation, Adenovirus, a lot of discharge, no blurring, purulent if bacteria
Uveitis Inflammation of the uveal tract (iris, ciliary body & choriod layer), haziness, floating spots; Photophobia & redness = iridocyclitis; "salt & pepper fundus = syphillis
Central Retinal Occlusion sudden painless loss of sight in one eye, Pale fundus, cherry red spot fovea & boxcar appearance of veins
Central Vein Occlusion unilateral loss of sight that is more gradual, Swelling of optic disc, cotton wool spots & tortuous dilated veins
Retinoblastoma Childhood malignancy of immature retina, associated with other malignancies later in life, "white reflex or "cat's eye.
Hearing Loss Rinne's Test: hold against mastoid process then adjacent to pinna, norm = pinna louder, if not maybe conductive loss; Weber Test: Midline of forehead, unilateral conductive loss = louder in affected ear; unilateral sensorineural = louder in unaffected ear
Presbycusis normal loss of hearing associated with age, sensorineural
Mastoiditis Usually following otitis media, Redness & swelling w/ fever & pain; X ray = destroyed mastoid air cells & fluid in the air pockets, IV antibiotics
Meniere's Disease Severe vertigo w/ N/V, hearing loss, tinnitus worse during attack of vertigo
Acoustic Neuroma Vestibular Schwannoma; tumor of CN VIII; Hearing loss, dizziness, tinnitus;
Migraine 2x women : men; Age of onset 10 - 30; gone by age 50; family Hx; stress, bright lights, menstruation, fatigue, tyramine, monosodium glutamate, nitrites; Aura prior to onset; visual, scintillating scotomas (small areas of visual loss) , dull throbbing, unilateral; N/V, photo & sound sensitivity;
Cluster Headache Men age 20-50; alcohol & vasodilators; severe, nonthrobbing, unilateral, recur same time each day for weeks, Horners syndrome & periorbital pain; Tx: ergot & lidocaine
Tension Headache cause unknown, most common type; bilateral, occipital, constant; muscles tight
Tumor Associated Headaches progressive, increasing, dull, nonthrobbing, worse w/ postural chgs, exertion. Disrupt sleep, assoc w/ N/V
Trigeminal Neuralgia Tic douloureux; severe, "lightening" pain in V1 & V2 distribution of CN V; Trigger Pts
Tx: carbamazepine & phenytoin; Surgical decompression of CN V
Partial Seizures Simple = focal sx, conscious, Jacksonian = simple muscle twitch that spreads progressively; 2o generalization = simple becomes grand mal; Complex Partial = automatism, olfactory hallucinations, fear, deja vu, loss of contact w/ environment; postictal confussion
Generalized Seizures Absence = petit mal; brief, freq. Loss of consciousness w/o loss of muscle tone, rapid eye blinks, no aura, no postictal
Grand Mal= tonic clonic, preceded by GI upset or mood chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax & contract of muscles, unconscious, then confussion & postictal
Status Epilepticus continuous seizures w/o regained consciousness, grand mal progress or withdrawal of anticonvulsants; Complications = high fever, circulatory collapse, brain damage; Diazapam until controlled, Treat potential causes (glucose, thiamine, narcan)
TIA sudden, brief, emboli or arterial stenosis, Risks: obesity, smoking, DM, hyperlipidemia, Carotid artery= unilateral, contralateral hemiparesis & parathesia w/ ipsilateral blindness; Aphasia if dominant hemisphere involved, Vertebrobasillar = brainstem dysfunction => vertigo, confusion, blindness, diplopia, weakness, parathesia of extremities
Aneurysm localized vessel dilation, Berry Aneurysm = circle of Willis assoc w/ polycystic kidney disease & coarction of aorta
Subarachnoid Hemorrhage between pia & arachoid; usually rupture of a cerebral artery aneurysm or AV malformation; Worst HA, syncope, nuchal rigidity, vomiting, nonfocal abnormalities, decr consciousness, CT first if neg then lumbar puncture mandatory.
Intracerebral Hemorrhage Chronic HTN or local thrombus 2o to ischemia; Supratentorial: transtentorial herniation, w/ brainstem compression & midbrain bleeding, hemiparesis; Cerebellar : acute hydrocephalus due to CFS flow blockage; Acute onset HA w/ progressive neurological chgs.
Stroke Middle Cerebral: most often, contralateral limb weakness, sensory loss, homonymous hemianopsia, dominant hemisphere = aphasia, nondominant = sensory neglect & apraxia
Posterior Cerebral: contralateral homonymous hemianopsia & sensory loss, thalamic pain, hemiballistic movement disorder
Vertebrobasilar artery: fatal, unilateral occlusion = ipsilateral CN abnormalities, contralateral weakness; Complete occlusion = opthalmoplegia, defective pupil constriction, bilateral weakness, paralysis, decreased consciousness, dysphagia & dysarthria; completed = neuro stable; Evolution = progressive signs over 1-2 days
CT positive 48 - 72 hrs after onset.
Cavernous Sinus Thrombosis CN palsies, fever, exophthalmos, papilledema, HA, decr. consciousness, occasional seizures; IV antibiotics immediately
Acute Subdural Hematoma rapid bleed between arachnoid & dural layers; Tearing of bridging veins, Sx slower to progress, Signs of transtentorial herniation w/ deepening coma, progression from decorticate to decerebrate posture, mid position or fixed & dilated pupils, spastic hemiplegia w/ incr. DTR. LP is contraindicated because may lead to herniation
Chronic Subdural Hematoma Delayed formation of a subdural clot, Sx weeks after head injury, Elderly & alcoholics; Progressive daily HA, fluctuating consciousness & mild hemeparesis
Epidural Hematoma Between dura & skull, less common than subdural, injury to arteries (middle meningeal); Rapid brain compression, permanent neurological problems or death; Brief lucid period after head injury; progressive neuro signs
Concussion Injury due to blunt trauma; short loss of consciousness w/ intact brainstem function; post traumatic confussion syndrome w/ transient retrograde or anterograde amnesia; HA, vertigo, mild cognitive dysfunction
Toxic Vestibulopathies Alcohol: positional vertigo & nystagmus w/ in 2 hrs of ingestion
Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 1-2 wks after ending tx
Salicylates: reversible vertigo, tinnitus, sensorineural hearing loss
Quinine & Quinidine: cinchonism (color vision defects, tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain & sweating
Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing loss, sensory neuropathy
Toxic Neuropathies Lead: multi motor neuropathy; acute encephalopathy in children
Organophosphates: delayed motor neuropathies, cholinergic crisis
Arsenic and Thallium: acute onset symetrical sensorimotor polyneuropathy
Isoniazid: Reversible sensory polyneuropathy reversible w/ concurrent pyridoxine Gold: symetrical polyneuropathy
Bacterial Meningitis 1st month life = group B strep & E. coli; Older kids = H. flu; Adults = S. pneumonia
N. meningiditis at any age = 50% have petechial rash
Brudzinski sign = neck flexion when supine causes involuntary hip & knee flexion
Kernig's Sign: extension of knee in pt w/ flexed hip is painful
CSF: decr. glucose, incr. neutrophils, incr. protein, incr. opening pressure; Tx: ampicillin & cefotaxime = infants; 3rd generation cephlosporin in kids > 3mos and adults
Aseptic Meningitis nonbacterial meningeal irritation; CSF = incr. lymphocytes, normal glucose, neg gram stain & bacterial cultures, mild incr. protein, normal opening pressure; supportive Tx
Fungal/TB Meningitis CSF: incr. lymphocytes, decr. glucose, incr. protein, incr. opening pressure; AIDS = cryptococcal meningitis
Encephalitis Inflammation of brain tissue; Viral etiology = CSF lymphocytes, normal glucose & negative bacterial cultures; Acylcovir x10 days
Reye's Syndrome follows viral infection; fatty infiltrate of organs; Usually kids; Salicylates can induce
Sudden onset of encephalopathy, severe vomiting, & liver dysfunction; liver biopsy w/ fatty infiltrates confirms Dx.
Neurosyphillis Argyll Robertson Pupil (small, reacts to light but not accommodation); Psych disorders, Tabes Dorsalis; Tx: Procaine Penn G x 21 days; Examine CSF q 3-6 months until normal x 2 yrs.
Rabies Dogs worldwide; wild animals in US, Sx: malaise, fever, restlessness 1st. Sx progress to extreme excitement w/ painful laryngeal & pharyngeal spasms, Tx: Passive IG and active vaccine
Polio Fecal-oral; aseptic meningitis, paralysis w/o loss of sensation; Asymmetric paralysis during a febrile illness suggests it; Tx is palliative; OPV for all except immunocompromised who get IPV
Primary Neoplasms Glioblastoma Multiforme: most common in adults, high mortality; Meningioma: most common benign tumor in adults; Cerebellar Astrocytoma & Medulloblastoma: most common in kids
Huntington's Disease Autosomal dominant, Age 30-50; subtle dementia, irritability, antisocial, chorea, death 10-15 yrs after onset, atrophy of caudate nucleus & cerebral cortex, Tx D2-receptor antagonists (haloperidol)
Parkinsonism Idiopathic - loss of dopaminergic cells in substantia nigra; Pin rolling temor, masklike facies, lack of arm swing when walking, cogwheel rigidity, difficulty initiating movement, small shuffling steps w/ increasing speed (festinating gait). Tx: Levadopa (dopamine precursor), Amantadine, bromocriptine (dopaminergic agonists), Benzotropine (anticholinergic)
ALS
(Lou Gehrig's Disease) Progressive loss of anterior horn cell function; Initially = LMN dysfuntion w/ hand & foot weakness & atrophy; asymmetric progression, No sensory abnormalities; Later= UMN dysfunction w/ muscle spasticity, incr. DTR, extensor plantar reflexes
Tay Sachs Disease Autosomal recessive; Eastern Europe jews & french Canadians; Absence of Hexosaminidase A, can't metabolizes lipid gangliosides, build up in brain; Progressive dev. delay, paralysis, blindness, dementia; death by age 4
Multiple Sclerosis Progressive demyelinating, women>men; Peak onset 20 - 40; Gradual & variable CNS sx suggest dx; CSF = mild incr. proteins, mild lymphocytes , oligoclonal bands, MRI = multi plaques in white matter
Guillain-Barre Syndrome polyneuropathy after mild viral illness, inoculation or surgery; Most common acquired demyelinating disorder; progressive bilateral weakness of legs, proximal weakness, abnormal DTR, instability of temp & BP; CSF = incr. protein w/ normal pressure, glucose & cell numbers; Plasmaphresis speeds recovery; Corticosteroids are contraindicated
Cerebral Palsy CNS damage before age 5; Risks: Prematurity, IUGR, inutero complcations, neonatal jaundice, birth trauma, asphyxia, spastic syndrome, incr. DTR, incr. tone, weakness, toe walking, scissors gait
Myasthenia Gravis autoimmune, antibodies against acetylcholine receptors at neuromuscular junctions, incr. women, age 20 - 40; Ptosis, diplopia, dysarthria, enhanced muscle fatigue, thymoma on chest x-ray; Tx exogenous anticholinesterase (edrophonium or neostigmine); Thymectomy in pts < 60; steroids or azathioprine if unresponsive to tx
Muscular Dystrophy Duchenne most common type; X linked recessive, mutation in dystrophin gene; CK incr. before onset of sx; By age 5 toe walking, waddling gait, can't run; Prox legs 1st then prox arms; Pseudohypertrophy of calves = fat infiltrates in muscles;
Coma dysfunction both cerebral hemispheres or RAS; Acute onset = subarachnoid hemorrhage or brainstem infarct; progressive min-> hours = Intracerebral hemorrhage; days => weeks = chronic subdural hematoma, tumor or abscess; No laterialization following delirium = metabolic; Pupil size: dilated nonreactive = at or below midbrain, pinpoint = pontine; opiod OD, Constriction intact w or w/o extraoccular impairment = metabolic; Localizing response to pain = superficial coma; Decorticate (flex @ elbow, ext leg) = thalamic lesion of compression; Decerebrate (elbow & leg extension) = midbrain; No response to pain = pontine or medullary
Gait Abnormality Cerebellar lesions = truncal ataxia, broad based, unsteady, irregular; can't turn
Corticospinal = affected leg circumducts as it steps forward, scissors if bilateral
Extrapyramidal = festinating gait, flexed posture, small rapid steps, no arm swing
Motor System = Footdrop - anterior tibial; Calf muscle - can't toe walk; Pelvic muscle - waddling gait.
Arnold Chiari Syndrome Cong. Protrusion of medulla thru foramen magnum; unusual sensory & motor chgs, Onset ~ 40
Cold Calorics Test vestibular system, Slow deviation toward ear w/ cold water = brainstem intact, fast nystagmus away = contralateral cortex intact; COWS = cold opposite Warm same for fast component
GYNECOLOGY
Trichomonas Vaginitis Yellow green discharge, Strawberry patches, Motile flagellated, Tx: Metronidazole
Gardenerella Vaginitis KOH whiff test = fish; Clue cells, most common symptomatic infection; Metronidazole
Condyloma Acuminata Warts, HPV 6, 11, Not assoc w/ cervical cancer
PID Cervical motion tenderness, Purulent discharge, assoc w/ ectopic pregnancy & infertility; Leukocytosis, neutrophilia, incr. ESR
Candida cottage cheese, red vulva; Pseudohypahe & spores on wet mount, DM, antibiotics, OC, pregnancy
UTI E coli, Dysuria, frequency, urgency; Tx: TMP-SMX, Bactrim, Septra
Toxic Shock Syndrome Staph aureus exotoxin, rash, high fever, hypotensive shock
Chancroid H. Ducreyi, tropical & sub tropical climates, gram neg; Tx Emycin or Ceftriaxne
Chlamydia Trachomatis Intracellular, columnar epithelium, mucopurulent, Immunofluoresent discharge, Tx: Doxycycline (Emycine if pregnant)
Herpes Genitalis HSV II clear sores , multinucleated giant cells w/ intracell inclusions; Tzanck smear
Molluscum Contagiosum umbilicated nodule, remove & cauterize
Endometriosis Ectopic endometrium tissue, Dysmenorrhea, Dyspareunia, infertility
Paget's Disease of Breast Intraductal Ca in main excretory ducts; crusting erosion of nipples w/ or w/o discharge
Polycystic Ovarian Disease incr. LH, decr. or normal FSH; hirsutism, obesity, menstrual irregularities, infertility
Menopause Avg age =51; incr. FSH & LH; Hot flashes, Atrophic vaginal epithelium
Urinary Incontinence Stress = incr. intra abd pressure, leak small amts of urine; Kegel exercises, estrogen
Urge = detrussor instability; lg amts of urine leaked immediately after urge to void
1o Amenorrhea Absence age 16 w/ 2o sex development or absence by age 14 w/o 2o characteristics
Anatomic Abnormalities; Ovary Failure ( incr. FSH & LH, decr. estradiol) (XO, turners, no ovary); Pituitary = Prolactinoma presents w/ galactorrhea (Bromocriptine to Tx), Hypothalamic = decr. FSH & LH, (anorexia, incr. exercise, stress); XY karotype
2o Amenorrhea Absence for 6 mos if prev normal; absence for 12 months if prev oligomenorrhea; r/o pregnancy; Galactorrhea = prolactinoma; Hirsutism = polycystic ovarian; Tx: 1st = progestin challenge (bleed w/ in 2 wks) if no bleed measure FSH levels
1o Dysmenorrhea correlates w/ 1st day of menses, cyclic, begins in adolescence, low back & abd pain, N/V/D, fatigue, HA
2o Dysmenorrhea acquired, Sx don't correlate w/ 1st day of cycle, Endometriosis most common cause
Asherman's Syndrome intrauterine adhesions after D&C; destruction of endometrium => amenorrhea
Fibroademoma Age 19 -29, stromal fibrosis; nontender, estrogen sensitive, regress w/ menopause
Fibrocystic Breast Disease Age 29 - 39, may have green nipple discharge; tender w/ ovulation, regress w/ pregnancy,
Breast Disease Age 39-49 malignant = intraductal Ca (bloody nipple discharge); Papillary #1 cause of nipple discharge; Sclerosing Adenitis
Breast Ca Upper outer quadrant, Mets = bone, liver, lung, brain; Risks: Family Hx, menarche < 12, 1st pregnancy > 35; late menopause, null parity, obesity, other breast, radiation, reserpine
PAP Smear Atypia = inflamm, infection HPV (16 & 18); Mild Dysplasia = lowgrade epithelial lesion; Mod/Severe=high grade intraepithelial;
Carcinoma in situ incr. nuclear/cytoplasm, dense chromatin, crowding, incr. mitosis; Koilocytes = HPV, pyknotic nucleus, perinuclear halo; Risks: early sex, multi partners, smoking, decr. social class, HPV; Culposcopy = white epithelium, mosiacism, punctation, atypical vessels
Cervical CA 90% squamous cell; s/sx: Early = postcoital bleeding, intermenstral bleed, Late= backache, leg pain, edema, hematuria Tx: Ia=TAH, iB & IIA = rad hysto & pelvic lymph nodes, IIB -IVA = Radiation - Brachytherapy => Radium, Cesium
Endometrium CA most common gyn malignancy; Risks: obesity, DM, HTN, anovulation, early menses, later menopause, nullparous, unopposed estrogen; Dx : abnormal menses, post menopausal bleeding; EMB, D&C; Histologic= grade 1-3 based on differentiation;
AdenoCA=70%; Adenocanthoma=benign squamous, best prog; adenosquamous= malig squam, poor prog; Papillary Serous = acts like ovarian CA, Clear Cell = poorest prog, older, DES, least common Tx; TAH/BSO, perioneal wash, pelvic & aortic nodes, Adjuvant Rad if + nodes, cervical +, > ½ myometrium, higrade
Ovarian CA Abd./pelvic mass, ascites, early satiety, CA125, CEA, CA19-9, 75% w/ stage 3; Path types = Serous (psammoma bodies), Mucinous, Endometroid, Clear Cell (hobnail bodies) Brenner; Staging: 1A= 1 ovary, 1B = both ovaries; 1C= + wash, tumor rupture; IIA = fall tubes/uterus, IIB other pelvic structures, IIB + wash rupture w/ spread; IIIA gros in pelvis, micro to diaphragm or omentum, IIIB Intra abd < 2 cm, IIIC: intra abd > 2cm, pelvic/aortic nodes, inguinal nodes; IV = distant spread, pleural effusion w/ malig cells, liver/spleen mets; Tx: debulk tumor surgery, Chemo = cisplatin/cytotoxin, taxol; Radiation (bowel obstruction);
Teratomas immature (neuro epithelial); mature (dermoid)=95% of all teratomas, hemolytic anemia; LDH elev, CA125
Dysgerminomas most common malignant, 15% bilateral, radiosensitive
Endodermal Sinus Tumor Schiller Duvall Body, AFP
Embryonal CA HCG, AFP, CA125
Choriocarcinoma HCG
Sexcord-Stromal Tuors Granulosa: 50% post menopause, incr. estrogen, Call-Exner bodies
Sertoli-Leydig: most often virilizing; Gonado Blastoma: gonadal dysgenesis
Krukenburg Tumor: Ovarian mets from GI & breast; Signet ring cells
Vulvar CA TNM staging, squamous cell, Vulvar pruritus; Pagets= adenoca of vulva, 20% assoc w/ breast, GI, cervical CA
Gestational Trophoblastic - Benign: Complete Mole = 46 XX, paternal, no embryonic tissue; Incomplete = 69 XXY triploid, paternal, no fetal/ embryonic tissue
Malignant: Invasive= molar villi; Choriocarcinoma = no villi, any pregnancy; Placental Site = non molar gestations
S/Sx: size > dates, hyperemesis, hyperthyroid, large theca lutein cyst
F/U = CBC. Liver function, BUN, CR, TSH, HCG, US, CXR; TX = D&C
Weekly HCG' until 3 values that are non detectable then 1/mo x 1yr, BCP x 1 yr
Ca in Pregnancy Melanoma = worsened by preg, can met to placenta or fetus
Breast CA = most common CA in pregnancy
Chemotherapy Cyclophosphamide (Cytoxan) = ovarian, hem, cystits, alopecia, decr. bone marrow, N/V
Cisplatinum = ovaian, renal toxic, ototoxic, bone marrow ß, N/V
Adrimycin (Doxyrubicin)= endomet, ovarian; cardiotoxic (heart failure)
Bleomycin= cervical, germ cell, Pulmonary fibrosis
Vincristine= cervical germ cell; neurotoxic
Methotrexate = GTN, germ cell, hepatic & renal toxic, decr. bone marrow
OBSTETRICS
Hydantiform Mole Preeclampsia 1st TM, Very high Beta HCG, Snowstorm on US
Ectopic Pregnancy Beta HCG rises slowly, Amenorrhea, spotting, pain, Empty gestational sac on ultrasound, Ampulla of fallopian tube is most common site
Gestational Age Nagel's = Add 7 days to FDLMP subtract 3 months; fundal ht in cm after 13 weeks
Amniocentesis Adv maternal age, abn AFP - incr. Spina bifida, decr. Down's, detect lung maturity, early 2nd trimester
CVS Adv. Maternal age, late 1st trimester
Non stress Test > 2 fetal movements accompanied by incr. FHR of 15 bpm for at least 15 sec w/ in 20 min period
Contraction Stress Test Negative = 3 contractions in 10 min, lasting 40 sec w/o late decelerations
Positive = consistent & late decelerations
Biophysical Profile Nonstress test, fetal breathing, movement, adeq, amniotic fluid, limb extension
Fetal HR normal 120-160, Brady = mild 100-120, < 100 severe; Tachy = mild 161-180; severe > 180
Decelerations Early = shape is mirror of contraction, head compression
Variable = shape varies, cord compression
Late = starts as contraction peaks, recovery after contraction is terminated, uteroplacental insufficiency
Placental Previa Partial - partially over os; Complete= covers OS, Marginal = at edge of OS, Complete Previa is indication for C section
Placental Abruption Premature separation of a normally implanted placenta, vag bleed, uterine tenderness, back pain, hypertonic uterus, fetal distress
Preeclampsia HTN w/ proteinuria & edema after 20 wks gestation
Eclampsia Preeclampsia + seizures
Gestational Diabetes 1 hr > 140 then do 3 hr; 3hr test = fast > 120, 1 hr > 190; 2 hr > 165, 3 hr > 145; Macrosomia, RSD, Cong abnormalities
Types of Pelvises Gynecoid = round inlet, nonprominent spines, wide subpubic angle
Anthropoid = heart shaped inlet, decr. transverse and incr. AP diameters, decr. subpubic angle
Android= triangular inlet, decr. subpubic angle, prominent spines
Platypoid= incr. transverse and decr. AP diameters
Leopold's Maneuvers fundal palpation, sides of uterus from feet of mother, lower part of uterus, sides of uterus from head of mother
Stages of Labor 1. Onset contract => full dilation 2. Full dilation to delivery of head 3. Delivery of fetus to delivery of placenta 4. Delivery of placenta to 1 hr later
Cardinal Movements Engagement, descent, flexion, int rotation, extension, ext rotation, expulsion
Post Partum Hemorrhage Uterine Atony (most common); Placental Accreta: Accreta = superficial invasion into myometrium, Increta = deeper, Percreta = invasion to serosa of uterus; Undiagnosed lacerations, Coag defect; Retained placental fragments
Apgar Scoring Heart Rate, Resp. Effort, Muscle Tone, Reflex Irritability, Color
Shoulder Dystocia Maternal obesity, diabetes mellitus, postterm pregnancy
Cesarean Section Indications Health of mom or baby endangered by labor, Dystocia precludes vag delivery, Emergent situation, Herpes, Prev C section if contributing factor still exists, Malpresentation of fetus
Premature Rupture of Membranes Pooling of fluid in vagina, + nitrazine test, + ferning test, risk of endometritis
Polyhydraminos Duodenal Atresia, Tracheoesophageal fistula, Anencephaly
Oligohydraminos Renal Agenesis, Pulmonary hypoplasia
PEDIATRICS
Fetal Alcohol Syndrome IUGR, Microcephaly, Short palpebral fissures & philtrum, Cardiac Abnormalities, SGA, mental retardation, microencephaly
Fetal Narcotic Exposure Hypertonicity, Sweating, Stuffy Nose
Fetal Cocaine Exposure Limb reduction malformations, Intestinal Atresia, Jittery, tremors
Grey Baby Syndrome chloramphenicol use, decr. metabolism due to immature liver, CV collapse, maybe fatal
Erythroblastosis Fetalis Rh neg mom Rh + baby; Subsequent Rh + babies are at risk; Give RhoGam - binds to fetal RBC, prevents Antibodies from being made
Beckwith Weiderman neonatal hypoglycemia d/t hyperinsulinemia, macroglossia, giantism, omphalocele, kidney anomalies, facial nevus flammus, poor prognosis
Apt Test Determine cause of neonatal rectal bleed; differentiates adult vs fetal hemoglobin
Dubin Johnson Chronic idiopathic jaundice
Erb Duchenne C5-C6, flail arm (int rotation & abduction) due to traction on head during delivery; If c4 involved - paralytic diaphragm also present
Henoch Schoenlein Pupura kids, allergic vasculitis, non-blanching petechiae or pupura on lower extremities only, arthralgias, abd pain, hematuria, proteinuria, coag & platelets are WNL; Immune mediated after virus or strep
Kawasaki's look sick w/ fever > 5d, truncal rash, incr. cervical nodes, URI sx, "glove" desquamation on palms, feet, lips; Assoc w/ coronary artery aneurysm; TX: High dose asa, IV gammaglobin, Steroids contraindicated
4 out of 5 =bulbar conjunctivitis, erythematous mouth, lips & tongue; polymorphous erythematous rash, induration of hands & feet w/ erythema, solitary unilateral cervical lymph node < 1.5 cm; Thrombocytosis after 10th dy is common
Kleinfeltters XXY, most common hypogonadal syndrome; + BARR body, small firm testicle, azospermia, incr. FSH
Meckel's Diverticulum 2 ft from ileocoecal valve, 2 in long, 2& population, 2 tissue types (gastric or pancreatic) sx before 2 yrs old
Newborn Blood 85 cc/kg, Hgb 14 - 22 gms/dl HCT 44-64%; incr. alk phos than adults & is incr. until adolescent growth spurt
TORCH Toxoplasmosis, syphillis, rubella, CMV, herpes
CMV maybe asymptomatic or deafness, blindness, jaundice, petechia, fever, seizure, mental retardation, IUGR; Transplacental passage of virus
Cong. Rubella IUGR, cataracts, glaucoma, microphthalmia uveitis, retinitis
Kernicterus unbound bili crosses blood brain barrier resulting in neuro problems or death
Prolonged Hyperbili Bili > 10 at 10 days of life
Photo therapy can be used as long as direct isn't > 1 mg%
Hemorrhagic Disease of Newborn Deficiency of vitamin K dependent factors (2-7-9-10)
Intrauterine Shunts placental, ductus venousus , foramen ovale, ductus arteriosus Ductus venosus = ligamentum venosus; Ductus Arteriosus = Ligamentum Arteriosus
Growth & Development 1st teeth - 6-9 mos; Neuromuscular development in cephalocaudid direction; 4 wks regard face, smile 4-6 wks, social laugh 4-5 mos; 15 mos stack 2 blocks; 18 mos stack 3 blocks; walk up stairs 20 mos ; w/ alt feet 3 yrs;
Drawing = circle 2.5-3; cross 3-4; Square 4-5; Triangle 5; Diamond 6 yr
Wt Gain = BW by 10d; 15 lbs 1st yr, 6-7 lb 2nd yr
Length = 10 in 1st yr, 5 in 2nd yr; < 2in / yr is abnormal
Head Circumference: 0-35; 3-40, 9-45, 3-50, 9-55 cm
# Alveoli increase as lungs grow; # nephrons don't increase after term
ADHD 3x more male than female; inattentiveness, impulsivity, hyperactivity
SIDS Peak 2-4 mos, declines after 6 mos; 60:40 male:female;
Risk Factors: < 20yrs old, poverty, smoking
Apnea of prematurity in infants < 34 wks gestation; Tx: tactile stimulation, decr environmental temp, incr O2, transfuse to get Hct to 45%; CPAP, theophylline, last resort = mech vent
Special Human IG hepatitis B, Rabies, Tetanus, Varicella Zoster, CMV
CHF in Peds cardiomegaly, tachypnea, hepatomegaly
Noncyanotic Cong Heart Disease ASD, VSD, AV septal defect, PDA, coarction of aorta, aortic stenosis, MVP
Cyanotic Heart Disease Tetralogy of fallot, pulm Atresia w/ VSD, tricuspid Atresia, hypoplastic left heart, transposition of great vessels, anomalous pul venous return, truncus arteriosus
Rheumatic Fever carditis, polyartheritis, sydenham chorea, erythema marginatum, subcutaneous nodules; Mitral insuffucuency most common valvular residual = Carey Coombs murmur
Acute Myocarditis Coxsackie B #1, Coxsackie A, CMV, mumps, herpes, adenovirus
Otitis Media Moraxella Catarrhalis #1 cause of bacterial in infants < 18 mos
Epiglotitis prior to vaccine H. flu most common cause; peak ages 3-8 ys
Resp Infections < 5 Viral pneumonia = RSV, Bacterial pneumonia = strep; Lower resp infection = mycoplasma pneumonia ( Eaton Agent, 1o atypical pneumonia or walking pneumonia); Croup = rhino, RSV #2;
Pyelonephritis poor feeding, irritability, and seizure ; r/o sepsis
Hemorrhagic Cystitis Adenovirus
Neurogenic Diabetes Insipidus x linked recessive, renal ADH receptors; Sx polyuria, polydipsia, FTT; r/o psychogenic polydipsia; Due to hypofunctioning hypothalamus or posterior pituitary w/ ADH deficiency
Rashes Measles (rubeola); Face then body; Cough, Coryza, Conjunctivitis, Koplik's spots
Scarlet Fever = red skin folds (Pastia sign), strawberry tongue, sandy exanthum on trunk => flexor surfaces
German Measles (Rubella)
Filatov Dukes Disease (4th. No longer used)
Erythema Infectiosus (5th disease) parvo B19, slapped cheek; circumoral pallor => lacy reticular rash
Roseola infantum (herpes 6)High fever then after fever get rash 1st on trunk then face
Rash on face 1st = measles, 5ths, Rubella
Rash on Trunk 1st = Scarletina, Roseolla, Chickenpox
Rashes on Palms & Soles = Erythema Multiforme (Stevens Johnson); Hand Foot & Mouth (Coxsackie A19; Kawasaki, Rocky Mt Spotted Fever, 2o syphillis, TEN, Dermatomyositis
Infectious Mono EBV, Dx by positive heterophile test (Paul Brunnel Ab); hepatosplenomegaly
Conjunctivitis Neonatal infectious = Chlamydia trachomatis,minimal discharge, congestion & edema 7-14 days after birth
Rocky Mountain Spotted Fever Rickettsia rickettsii, high fever, peripheral rash, Atlantic seaboard, wood & dog ticks
Cat Scratch Disease R. Henselae; regional lymphadenitis; Chemical = silver nitrate
PKU blonde hair, MRDD, seizures, eczemoid rash
Galactosemia Auto recessive, n/v/d, jaundice, hepatomegally, cirrhosis & cataracts if untreated
Homocysteinuria tall thin stature w/ MRDD sublaxation, lens, genu valgum (knock knee), pectus carinatum
Lesch Nyhan Purine metabolism; normal until 6-8 mos; loss of motor milestones; incr. spasticity, self mutilation without loss of sensory feeling; Urine has orange uric acid crystals
Self mutilation w/ loss of sensory = familial dysautonomia
Hurler's Syndrome mucopolysaceharidosis, grotesque coarse features, skeletal anomalies, dead by age 10
Glycogen Storage Disease Von Gierke, Pompe, Forbes
Tay Sachs Lipid Storage, Jewish , defic of hexosaminidase A; normal at birth then loss of motor milestones & hypotonia at 6 mos, Death by age 2; Cherry red macula
ALL most common malig of childhood, peak at age 4; thrombocytopenia, anemia, elevated uric acid & LDH; Dx by bone marrow biopsy showing infiltration of leukemia blast cells; CXR = mediastinal mass or widening, 2o ary to lymphadenopathy
Brain Tumors most common solid tumor of childhood; < 2 intratentorial tumors > 2 supreatntorial tumors
Morning vomiting = posterior fossa ependymoma
Astrocytoma most common brain tumor
Hodgkins Lymphoma Reed Sternberg Cells; Painless cervical lymphadenopathy
Neuroblastoma Neural crest of sympathetic ganglia or adrenal medulla; 50% before age 2; 90% before age 5; and mass that crosses the midline
Nephroblastoma asymptomatic abd mass; HTN, Ages 2-5; Aniridia (loss of iris) hemihypertrophy Also called Wilm's Tumor
Rhabdosarcoma Most common soft tissue sarcoma; < 10yrs old; nasal, aural, anus or vaginal area
Ewing Sarcoma diaphyses
Osteosarcoma Metaphyses, #1 site distal femur
Retinoblastoma Neuroectodermal malignancy , most occur before age 5; Leukocoria (white pupil reflex)
G6PDase Defic most common red cell enzyme deficiency that causes hemolytic anemia; usually asymptomatic until exposed to stress, infection or certain foods; Cause of hyperbilirubinem
