SOME IMPORTANT POINTS IN PREPARATION OF AUSTRALIAN MEDICAL COUNCIL EXAM (AMC) AND UK-EXAM MRCP

SOME IMPORTANT POINTS IN PREPARATION OF AUSTRALIAN MEDICAL COUNCIL EXAM (AMC) AND UK-EXAM MRCP

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PUBLIC HEALTH
Levels of Prevention: 1o = actions to decr. incidence of health problems (prenatal care, immunizations)
2o = interventions at early stage of disease to limit development (DM screen, PAP)
3o = interventions to treat problem and prevent further morbidity & mortality

Special Tests Complement & Complement disorders C3, C4, CH50 Rheumatiod - ANA, RF
Lupus - DNA, Anti Smith Antibody
Scleroderma - Scl-70, Anti Centromere
Sjogrens -SSA Anti Ro, Anti LA
Prostate = PSA, Pancreatic = CA 19-9,Ovarian=CA125; Breast = CA15-3 & CA27-29
Testiclar = BHCG, AFP, Thyroid = Calcitonin
10 Biliary Cirrhosis = Anti mitochondrial antibody
Wilson's Disease = Ceroluplasmin Antibody
Liver = Alpha 1 antitrypsin
Thyroid - Antimicrosomal antibody, Thyroglobin antibody
Incidence # new cases / total population
Prevalence # cases at a given time / total pop at that time
Disease Frequency # people w/ disease / population at risk
Case Fatality # who die in a given period/ # people w/ disease

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

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

Mortality Rate # people that die w/ in current population
Std Mortality Rate Adjusted according to age distribution
Attributable Risk exposed rate - unexposed rate
Sensitivity a/a+c; accurate diagnose ; incr. False +
Specificity d/b+d; Prob of neg test in those truly neg; incr. false neg
OMM
Fryettes Laws 1. Side bending then rotation in neutral position
2. Flexion or extension with rotation then side bending
3. Motion free in one direction is restricted in the other

Ribs 1-5 pump handle, 6-10 bucket handle, 11-12 caliper; Elevated = expiration restricted Treat lower ribs 1st; Depressed = inhalation restriction, treat upper ribs 1st

Flexion Test Standing = ilia sacral; Seated = sacroiliac; false neg = tight hamstrings on standing flexion; False positive = tight quads on standing flexion

Sympathetic Innervations Head & Neck = T1-4; Lung T2-5 bilat; Heart T2-5 Left, Stomach T5-9 Left; Duodenum T10 rt; Gall Bladder T9 rt; Liver T5-9 Rt, Pancreas T6-9 bilat, Kidneys, Ovaries, Testes T10-L1 of respective side; Adrenals T10-11, Appendix T11-12 Rt, Bladder L3-4, Uterus L4-5, Rectum & Anus L4-5

Parasympathetic Innervations Eyes=CN III; Nasal sinuses, Eustachian Tube=CN VII; Soft Palate, Salivary Glands=CN IX; Thyroid thru Transverse Colon=CN X (Vagus); Right Colon & Pelvis= Pelvic Splanchnic Nerves S2-4

Somatic Dysfunction An altered or impaired function of related components of the somatic system
Qualities: Texture chg, asymmetry, decr. ROM, tenderness

Treatment Types Direct = engages restricted barrier & pushes thru it, Force takes it from where it is to where it will not go
Indirect = Move away from the barrier, Leaves the structure in the position it was

Direct Technique Used For: Subacute or chronic, no assoc osseous pathology post closure of epiphyseal plate, Short restrictors

Indirect Technique Used For Acute, A lot of pain, a lot of restriction, non closure of epiphysis

HVLA Contraindications
Direct, Passive Absolute = Weak bony structure, spinal cord, nerve compressions, Danger of vascular damage;
Relative: lax ligament, acute inflammation, pregnancy, Calcification of aorta, Recent MI, spondylosis, Ankylosin Spondylitis, Osteoporosis, Chronic Steroid use, Acute disk disease, Extreme scoliosis, Cauda Equina Syndrome, Adv. Degenerative disease, Severe DM, Hx or current malignancy, Agenesis Odontoid process, Vertigo

Counter Strain
Passive Indirect Put joint into position of greatest comfort; Agonist-Antagonist pair; Strain due to rapid stretching followed by protective immediate shortening of agonist along with rapid shortening then lengthening of antagonist
Most comfort of pt (70%) Hold for 90 sec (120 secs for ribs) Reactions to Tx: generalized soreness, treat no more than 6 TP at a time, 3 days between Tx;

Muscle Energy
(Active then passive, direct) Type I = Joint mobilization using direct muscle force
Type II = Muscle lengthening using postisometric relaxation, "Resetting the Gamma Gap or Synaptic Fatigue
Type III = Muscle lengthening using Reciprocal Inhibition
Type IV = Muscle relaxation using Crossed Extensor Reflex - Used w/ sever injury (flexor muscle on one extremity is contracted the flexor on opposite extremity relaxes & extensor contracts)

Natural Body Rhythms Cardiac/Vascular, Ventilatory, Visceral, Cranial Rhythmic Impulse (CRI), Slow Undulating (Breath of life)

Articular Mobility of Cranial Bones Newborn: Base is cartilage for stability, vault is membrane for accommodation Sphenoid motion - influences facial & frontal bones; Occipital Motion - influences temporals (mandible & hyoid) & parietals

Motion of Sacrum between the Ilium Superior transverse axis, Located at S2, Only area of anterior convergence & posterior divergence of the SI joint

Coordination of motion Inhalation = midline flex, paired ext rotate, sacral base post, SBS rises
Exhalation = midline extension, paired int. rotation, sacral base anterior SBS falls
Sacrum & Temporal follow movement of occiput; Facial bones follow motion of sphenoid

Strain Patterns Torsion, Side bending rotation, Vertical Strain, Lateral Strain, Compression

Naming Convention Vert unit, AP, side bending, rotation

Type of Motion C0-C1 (OA) Type I; C1-C2 Rotation; C2-C7 Type II; C7-L5 Type I & II

ACID BASE
pH acedemia < 7.35-7.45 < alkalemia
pCO2 Resp alkalosis < 35 - 45 < Resp acidosis
HCO3 Metabolic Acidosis < 22-26 < Metabolic alkalosis
Anion Gap = (NA) - [(Cl) + (HCO3)]
Primary disorder pCO2 or HCO3 altered same way as pH
Thanks 2 eaziz

POISONING & ACCIDENTS
Burns 1st= only epidermis, red no blister; 2nd = hyperemic, blister; partial thickness; 3rd = full thickness, leathery no pain; 4th = electrical injuries, damage to nerves & bone; entry & exit burn; Fluid resc. If > 20% Parkland formula = 3-4 ml/kg LR x % burn RULE of 9's: head = 9; ant trunk= 18 post trunk = 18, each incr. ext = 9; each decr. ext = 18, Perineum = 1

Common Poisons & Antidotes: Aspirin = Dialysis; Acetaminophen =N-acetylcystine; Digitalis = lidocaine; Methanol & Ethylene Glycol = Ethanol; CO = O2; Narcotics = Narcan, Naloxone; Iron = Deferoxamine; Cu, As, Pb = Penicillamine; Cyanide = Sodium nitrite, or sodium thiosulfate

Types of Fx Open(compound); Simple(closed); Greenstick (incomplete, children usually); Spiral (twisting breakage); Comminuted (multi bone fragments)

Vertebral Fx Most common cause of paraplegia & quadriplegia, Compression Fx seen in elderly due to osteoporosis & DJD

Hip Fx Avascular necrosis of femoral head if blood flow is compromised; Tx: immobilization, bedrest, surgery; Prevention= safety & Ca supplement in women

Skull Fx Signs of Fx: 1.Battle's Sign = discoloration over mastoid bone; 2. Blood draining from ears, 3. Bruising of orbit, CN palsies, CSF leakage from ears & nose

Rib Fx Most common thoracic injury; usually 5-9, local pain worse w/ inspiration

Colles Fx most common wrist fx; breakage & displacement of distal radius, Attempted to break fall on outstretched hand

Elbow Fx <10 yrs old, fall on outstretched hand w/ elbow in full extension; Compression or radial or median nerve or brachial artery; Improper care => Volkman's Ischemic Contracture

Pelvic Fx MVA, 30% blood volume can be lost; Tx as if shock victim

Tibial Fx Compartment syndrome= bleeding into tight compartments=> blood supply compression=>muscle ischemia; 6 Ps = pain, pallor, pulselessness, puffiness, parathesia & paresis (weakness) or paralysis. Surgical opening of compartment

Sprains Tx = RICE => Rest, Ice, Compression, Elevation

Concussion transient loss of consciousness; Coup = bruising under site of injury; Contrecoup = bruising on side contralateral to injury

Blunt Eye Trauma periorbital echymosis, hyphema (bleed into anterior chamber; edema; Blowout Fx = Fx of orbital bone; Aspirin & anticholinergics are contraindicated

Blunt Ear Trauma Auricular Hematoma (cauliflower ear) Tx prompt drainage to prevent dissolution of cartilage

Dog & Cat Bites Pasturella multocida; Tx tetanus & rabies if needed, antibiotics

Snake Bite Splint affected area & transport; In US usually pit vipers

Spider Bite Black Widow: Vomiting, abd pain, shock; Tx Calcium gluconate & methocarbamol; Local bite Tx not needed
Brown Recluse: bite becomes black scab w/ assoc fever, rash, vomiting & jaundice; DIC can occur; Tx: Dexamethasone, dapsone, colchcine & total excision of lesion

Hypovolemic Shock Hemorrhage, Burns, Vomiting, Diarrhea; pale skin, JVD, incr. vasc resistance, incr. pulse Tx: rehydrate, transfusions,

Septic Shock Infection, gangrene, necrosis,CV obstruction; pale/pink skin; flat neck veins, incr. pulse incr. or decr. vascular resistance Tx ventilation, Fluids, antibiotics

Cardiogenic Shock Pale skin, flat neck veins, incr. pulse, incr. vascular resistance; Tx: medication for underlying problem, pacemaker,

Neurogenic Shock Spinal cord injuries, drug OD; Pink skin, flat neck veins, normal => low pulse, low vascular resistance Tx: ventilation, fluids, drainage

PSYCHIATRY
Axis Determination I = clinical psych disorders II personality disorders, III Coexisting medical conditions IV psychosocial stressors, V global assessment of functioning

Schizophrenia Positive Sx: delusions, hallucinations, bizarre behavior; Negative Sx: alteration of affect, ambivalence, apathy, loosening of associations; males=females; industrial nations have incr. prevalence; Misalignment of cells in cortex; incr. ventricle size; decr. activity in frontal cortex on PET scan.
Disorganized: insidious, incoherent, inappropriate affect, social impaired
Catatonic: rigidity, posturing or excitement, negativism
Paranoid: highest functioning type, grandiose, jealous, persecution
Undifferentiated: not defined by other subtypes
Melerill = Retrograde ejaculation, Tx: Respiradol (Best side effect profile), Clozaril (agranulocytosis w/ weekly CBC) prescribed weekly,
Neurolyptic Malignant Syndrome = incr. temp, incr. CPK, rigidity

Schizophrenifrom same sx as schizophrenia but have lasted for less than 6 months

Schizoaffective mood disorder and separate psychotic sx. Must experience 2 weeks of psychotic sx w/o mood impairment for dx to be made; Antidepressants are 1st line tx

Major Depression loss of interest in activities, sleep, wt, concentration, hopelessness, suicidal ideation, nihilism; Seasonal affective, Vegetative (non functioning can be terminal) Dysthymia(chronic low level); Reactive related to environment w/o severity id sx; Masked 1o depression denied or hidden by other sx
Depression & anxiety can occur together & can be treated w/ an antidepressent; Left anterior or rt posterior stroke => incr. possibility of depression; Tx: 1st Tricyclic (Imiprimine); SSRI = side effects; Trazadone=priapism Asendin (Amoxipine) = Extrapyramidal Symptoms

BiPolar Bimodal peak 20's & 30'sCycling mood= highs w/ euphoria, hyperactive, pressured speech, flight of ideas, decr need for sleep, delusions, inflated self esteem, risks, poor judgement; Lows are major depressive episodes tx: lithium

Panic Attacks Sudden, unprovoked onset of fear, impending doom, palpitations, SOB, chest pain, smothering, dizziness. May be associated w/ agoraphobia Tx: with SSRI's

Phobias Persistent and irrational fear of a specific object or activity or situation. Tx like a phobia

Obsessive Compulsive Persistent, unwanted thoughts, impulses or images
repetitive, purposeful intentional behaviors meant to decrease tension caused by the obsessive thoughts; genetic Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI)

PTSD intrusive recollections, daydreams, nightmares, poor concentration, psychic numbing; Tx: don't treat w/ meds unless compulsion component
Studies: Buffalo Creek Disaster, Beverly Hills Nightclub

Dissociative Disorder Amnesia = loss of memory, Fugue = assoc w/ physical flight, Identity Disorder = multiple ego states; Depersonalization = feelings of self estrangement or unreality

Whirndingo Fear of becoming a cannibal

Amok sudden unprovoked outburst of wild rage usually ending in homicide

Coprolalia Feces & filth

Koro penis is shrinking and may disappear

Latah imitate words or actions to which they are exposed

Piblotko Run around in snow naked

White Out Syndrome lack of diverse stimuli in snow clad environment

Narcolepsy REM sleep, sudden onset of daytime sleep and cataplexy; REM sleep is inappropriately present at beginning

Personality Disorders Cluster A = Bizarre = Paranoid, Schizoid (no close relationships, restricted emotions) Schizotypical (schizoid + odd or distorted behavior or cognition)
Cluster B = Over emotional = Antisocial (Disregard for social norms) Borderline, Histrionic, Narcissistic (self centered)
Cluster C = Anxiety & Fear = avoidant, dependent, Obsessive compulsive

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

GASTROENTEROLOGY

Vitamin A Night blindness, conjunctival dryness, corneal keratinization

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

Vitamin K Clotting deficiency with prolonged PT

Thiamine (B1) Beriberi - peripheral neuropathy, Cardiomyopathy - dry or wet (high output failure)
Wernicke-Korsakoff - Alcoholics, confabulation, nystagmus, confusion

Niacin Pellagra - Diarrhea, dermatitis, dementia, death

Pyroxidone (B6) Rare, neuropathy, Cheilosis (swollen cracked bright red lips)

Cobalamin (B12) Macrocytosis, Pernicious Anemia- megaloblastic, neuro chg. ataxia, Schilling test , more in Strict Vegitarian.

Folate Macrocytosis, megaloblastic anemia w/o neuro chgs., common in alcoholics

Vitamin C Scurvy, bleeding gums, Connective Tissue problems, Can manifest 1 yr post defic.

Failure to Thrive Org.= decr. wt gain w/ other disease; Nonorg.=growth failure due to neglect ßstimulation
< 80% wt for Ht

Obesity mild 20-40%, moderate 41-100, severe <101%; age, black women, low income
BMI= body wt (kg)/Ht (mm2) Normal 20-25
Pickwickian Syndrome = obesity, dyspnea, hypovent, CO2 retention, hypoxia

Boerhaave's Syndrome esophageal rupture due to forceful vomit; Gastromediastinal fistula, dyspnea w/o hemetemesis, + Hammonds sign = pneumomediastinum, L lung effusion

Dysphagia Obstructive - solids 1st; Motor -solids = liquids

Infectious Esophagitis Candida (thrush), HSV, CMV, immunocomp, diabetics, Dysphagia & odynophagia

Esophageal Atresia Proximal esophagus, blind pouch

Trachesoph Fistula Congenital defect, distal esoph, coughing & cyanosis when feeding, abd distention

Achalasia Dysphagia for solids & liquids, nocturnal cough, aspiration; Absent peristalsis & tight LES, "Beak" esoph on x-ray, 20-40 yrs old

Esophageal Cancer squamous 90% Dysphagia solids 1st, Cough & hoarse = laryngeal nerve, constricting bands = annular lesion, Risk factors= smoking, alcohol, GERD, Barretts Esoph = adeno CA

Gastritis Antral Creep=fundal tissue replaced by antral mucosa, Not preCA,
Risk Factors = NSAIDS, Alcohol, H.Pylori

PUD Gastric = NSAIDS, eating no help, COPD,blood type A; 25%
Duodenal = H.Pylori, better w/ food, Liver cirrhosis, Blood type O ; 75%

Cullen's Sign Periumbilical cyanosis d/t hemoperitoneum = hemorrhagic pancreatitis, ruptured ectopic, ruptured spleen

Zollinger-Ellison Synd. Gastrinoma ( incr. gastrin); recurrent ulcers, ½ are malignant

Gastric CA Adeno, H.Pylori gastritis, Virchow's Nodes, Types = ulcerating (shallow edges); polyploid (intraluminal late mets); superficial (early CA) ; Linitus Plastica (all layers decr. elasticity) Mets to ovary = Krukenberg Tumor

Diarrhea Osmotic = incr. H2O lumen incr. solutes in bowel; Secretory = electrolytes & H2O secreted not absorbed; Malabsorption; Exudative secretion of blood plasma & mucus (mucosal inflammation); decr. transit time (short bowel); incr. transit (bact. Proliferation)

Ischemic Colitis Vascular compromise (atherosclerotic or embolic); abrupt abd pain after eating, bloody diarrhea, systemic sx.; Barium X-Ray - Thumbprint = pseudo tumor

Irritable Bowel Synd. Dx of exclusion (psych?); Tx: bulk supp, anticholinergics, antidiarrheals, TCA

Colonic Polyps villous>tubular ; sessile>pedunculated for being CA; familial adeno polyps autodom.

Lactose Intolerance Lactase deficiency, bloating & explosive diarrhea after milk; Ages 10-20

Celiac Sprue Gluten sensitivity (wheat, rye, barley); amenorrhea 1st sx girls, Infants = FTT, abnormal stool, bloating, Adults = malabsorption, vit deficiency; X-ray - dilated loops of bowel with thin mucosal folds; most common cause of malbsorption

Tropical Sprue nutritional defic, small bowel mucosal abnormal; Acquired - Caribbean, India, SE Asia; Megaloblastic Anemia, glossitis, diarrhea, wt loss Tx Folic Acid & Tetracycline

Whipple's Disease Infectious; middle aged men; multi-organ; Thickened mucosal folds, Foamy macrophage with rod shaped bacilli that stain w/periodic acid (Schiff's Reagent)

Intestinal Lymphangiectasia Children & young adults; cong or acquired telangiectasia of intramucosal lymphatic
Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/ triglyceride supplement

Toxic Megacolon Dilation > 6cm, Adults preceded by IBD (UC or Crohn's) Kids preceded by Hirschsprungs Ds; Sx: severely ill, incr. temp, abd pain, rebound, leukocytosis; X-ray - intraluminal gas along continuous seg of dilated bowel; Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids, Rectal tube may alleviate but can cause perforation

Inguinal Hernia Indirect = infants, persistent processus vaginalis, protrudes thru ring, lateral Inf Epig.
Direct = Adults, medial to ing ring & inf epig artery, Weakness in Hesselbach's

Ulcerative Colitis Colon & Terminal Ileum w/o skip lesions, w/ rectal bleeding, "lead Pipe" on X-ray (shortened, narrowed, loses haustrations) Tx: Sulfasalazine, steroids, Immunosuppresents; Complications=perf, hemorrhage, Toxic Megacolon, Colon CA

Diverticular Disease Diverticulosis = false diverticulae, pearl sign on xray
Diverticulitis = infection, acute abd pain usually on left, may form fistulas to bladder, vagina or skin, CT w/ water soluble contrast during acute attack

Crohn's Disease Granulomatous colitis; No bloody stools, 1st in terminal ileum, transmural, skip lesions, cobblestoning: Complications=small bowel abscess, obstruction, perianal disease, malabsorption, toxic megacolo, Colon CA. Surgery is not curative

Colon CA Right Sided=napkin ring, anemia Left Sided=Apple core, pencil stools; Genetic; Annual rectal>40, Annual Guaiac >50; Flex Sig q3-5y >50; Rectal CA-hematochezia

Volvulus Rotation of Bowel; Newborns & elderly; Double Bubble; Birds Beak on Barium Enema, Tx: Left Sided = decompression; Rt sided & kids = surgery

Intussusception Telescoping of large bowel into an adjacent section; most common cause of obstruction in kids under 2; Episodic Abd pain 1-2 min. Reflex = early vomit; Obstructive = omit late; Currant Jelly Stool; Small Infants = Pallor, sweating, and vomiting. Leukocytosis with hemoconcentration, BE to reduce x 2 before surgery

Necrotizing Enterocolitis Premature, decr. birth weight, older infants with malnutrition; bilious vomit, abd distention, bloody stool, lethargy; Thrombocytopenia; Small Bowel Distention; pneumatosis (air in bowel wall) TX; NG, TPN, IV antibiotics, surgical Rx necrotic part

Cholera Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic gulfcoast, Asia, Africa, Mid East; Severe dehydration, Metabolic Acidosis, Tx: Tetracycline or Doxycycline

Shigella Dysentery Small bact dose needed, Blood & mucous, Kids worse than adults, Fluid Replacement & Ciprofloxacin

Staph Enteritis Onset 3-6 hrs; "Church Picnic epidemic; N/V/D, HA, fever recovery w/in 24 hrs

Salmonella Enteritis Undercooked Poultry; nausea & cramps => watery &/or bloody diarrhea; No antibiotics prolongs excretion of the organism

Viral Enteritis Norwalk = yr round, Rota (kids) = winter; Coxsackie A1; echo, adeno

Botulism Clostridium Botulinum, neuromuscular; onset 12-36 hrs; N/V/D, cranial nerve palsy, fixed dilated pupils, resp failure, no fever, Wound induced = neuro w/o gi sx
Infants constipation 1st=> cranial nerve sx => cranial nerve Sx => Neuromuscular

Hemorrhagic Colitis E coli 157, cramps, => watery diarrhea => bloody diarrhea Complications= Hemolytic-Uremic Syndrome, thrombotic thrombocytopenic pupura

Pseudomembraneous Colitis Antibiotic induced (clindamycin, ampicillin, cephalosporin) C. Diff; mail -> severe bloody diarrhea; Tx: stop antibiotics, oral metronidazole in severe cases

Acute Pancreatitis Pain radiates to back w/ N/V; Grey Turner's Sign (blue flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase incr. ;
Ranson's Criteria: 3 or more = incr mortality
Admission: >55, gluc>200, LDH >350, AST >250 WBC > 16000
Within 48 hrs: Hct decr. 10%, BUN incr. >5, Ca< 8, PaO2 < 60, Base Def > 4, Fluid Seq>6L

Chronic Pancreatitis ERCP to Dx; Alcoholics, Malabsorption & diabetes are results

Hepatitis Hep A = Fecal oral, shedding before Sx; IG to travelers & contact with HAV infected
Heb B= Blood & STD; HbsAg early if persists = carrier; HbcIGM then HbcIgG for life
HBIG for needle sticks and infants born to + moms; assoc w/ hepatocell CA
Hep C Most common post transfusion hepatitis
Hep D = Co infection with B; Hep E = fecal oral

Cholelithiasis Female, fertile, fat, forty; Ultrasound, RUQ pain after fatty meals, Calcified = preCA

Cholangitis Charcot's Triad = Biliary Colic, Jaundice, Fever; Leukocytosis, incr. Alk Phos

Hepatocellular CA Mets 2x more than primary CA (breast, lung, colon), Budd Chari-thrombosis hep V.
Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins (fungal metabolites)

Benign Hep Adenomas oral contraceptives

Exocrine Pancreatic CA Ductal CA, Courvoiser's Law=palpable nontender GB in a jaundiced patient is a head of Pancreas tumor. Tumor Body or Tail=splenic vein obstruction=> splenomegaly, gastritis, esoph varices

Insulinoma Insulin hypersecretion, hypoglycemic symptoms, Insulin levels still incr. after fasting
Whipple Triad: confirms hypoglycemia as source of Sx 1. Hypoglycemia, 2. Relieved with carb ingestion 3. Sx occur while fasting

VIPoma Makes Vasoactive peptide (VIP); Sx WDHA (watery diarrhea, hypokalemia, achlohydria; unexplained secretory diarrhea; laparoscopy for Dx

Glucagonoma tumor of alpha islet cells; 80% women; 80% malignant; Necrolytic Exfoliating Erythema characteristic exfoliating lesion of the extremities

Pompe's Disease a 1,4 glucosidase deficiency; fatal by age 2

VonGierke's Disease glucose-6-phosphatase def.; big liver & kidneys, growth retardation, electrolyte prob.

McArdles Disease musclephosphorylase is absent, muscle cramps & incr. myoglobin after exercise

Jaundice Prehepatic = hemolysis, gilbert's disease, Crigler Najjar; Hepatic = hepatocellular or cholestatic; Post Hepatic = Biliary obstruction, AST & LDH also incr. ;
incr. unconj prehepatic; incr. conj = intrahepatic cholestasis or post hepatic disease ; incr. all fractions = hepatocellular, hyperbilirubinuria = conj bili water soluble

ETOH Hepatic Disease Fatty liver => ETOH hepatitis => cirrhosis; AST incr. > ALT incr. ; incr. PT; decr. II, VII, IX, X Clot

Cirrhosis necrosis and fibrosis, decr. serum albumin, anemia incr. PT, Not curable or reversible

Esophageal Varices veins that expand to circumvent congested hepatic flow; Tx: vasopressin, balloon tamponade, endoscopic sclerotherapy, transjugular hepatoporto shunt (TIPS

Hepatic Encephalopathy altered consciousness, incr. ammonia incr. glutamine in CSF, EEG abnormal

Ascites Complication of hepatic disease; Paracentesis to examine ascitic fluid values should equal serum if incr. albumin = malignant; incr. LDH > 60% of serum = malig or infective;
incr. WBC = infection

GI Bleeding Upper GI = melaena (black tarry) ; Lower GI = hematochezia (bright red) decr. Lig Trietz

Intestinal Obstruction Vomiting common in small bowel, late in lg bowel, High pitched "tinkling" BS.
X-ray - prox dist = lg bowel; dilated loops of bowel with air fluid levels = sm bowel

Ileus Paralytic obstruction of bowel due to loss of peristalsis

Pyloric Stenosis Projectile vomit in neonates, visible peristaltic wave, String Sign

Meconium Ileus Abnormal thick Meconium with undigested protein, associated with CF

Hirschsprung's Disease No autonomic nerves in colon, Obstipation, late vomit, Megacolon, Toxic Enterocolitis if left untreated, BE proximal dilated & distal narrow, Colostomy

SAMPLE OF RESUME FOR ER-PHYSICIAN

SAMPLE OF RESUME FOR ER-PHYSICIAN


SAMPLE OF RESUME FOR ER-PHYSICIAN

IMPORTANT Algorithms, MUST REMEMBER

HUGE PEDIATRIC BOOKS LIBRARY: FREE DOWNLOAD

Here you can find huge amazing pediatric books.


Neonatal Resuscitation Textbook AAP

http://i2links.com/31910
http://www.boxeg.com/view.php?id=14450




Emergency Care of Children and Young People

http://i2links.com/31911
http://www.boxeg.com/view.php?id=14451


Handbook of Clinical Psychology Children and Adolescents Wiley 2008

http://i2links.com/31912
http://www.boxeg.com/view.php?id=14452



Illustrated Manual of Pediatric Dermatology


http://i2links.com/31913
http://www.boxeg.com/view.php?id=14453


Neonatal Pain


http://i2links.com/31914
http://www.boxeg.com/view.php?id=14454



Pain in Children A practical guide


http://i2links.com/31915

http://www.boxeg.com/view.php?id=14455


Pediatric Endocrinology.
http://i2links.com/31874
http://www.boxeg.com/view.php?id=14419


Case-Based Pediatrics

http://i2links.com/31876
http://www.boxeg.com/view.php?id=14420



Manual of Pediatric Therapeutics




http://i2links.com/31877
http://www.boxeg.com/view.php?id=14421



Nelson Textbook of Pediatrics 16th Edition



http://i2links.com/31878
http://www.boxeg.com/view.php?id=14422


Nelson pediatrics review



http://i2links.com/31879
http://www.boxeg.com/view.php?id=14423



Nelsons PktBk of pediatric Antimicrobial Therapy



http://i2links.com/31880
http://www.boxeg.com/view.php?id=14424




Pediatric Emergency Manual

http://i2links.com/31881
http://www.boxeg.com/view.php?id=14425


Raymond Pediatric Primary Care Ill Child Care


http://i2links.com/31882
http://www.boxeg.com/view.php?id=14426


Raymond Pediatric Primary Care well Child Care


http://i2links.com/31883
http://www.boxeg.com/view.php?id=14427


Basic newborn resuscitation


http://i2links.com/31886
http://www.boxeg.com/view.php?id=14428



PALS Pediatric Advanced Life Support Review


http://i2links.com/31887
http://www.boxeg.com/view.php?id=14429


Clinical Decisions in Pediatric Nephrology

http://i2links.com/31888
http://www.boxeg.com/view.php?id=14430



Hand Book of Pediatric Eye and Systemic Disease


http://i2links.com/31889
http://www.boxeg.com/view.php?id=14431


Hand Book of Pediatric Neuro Ophthalmology

http://i2links.com/31890

http://www.boxeg.com/view.php?id=14432


Hand Book of Pediatric Retinal Disease


http://i2links.com/31891
http://www.boxeg.com/view.php?id=14433


Managing New Born Problems

http://i2links.com/31892
http://www.boxeg.com/view.php?id=14434



Pediatric Musculo Skeletal Disease with an Emphasis on Ultrasound

http://i2links.com/31894
http://www.boxeg.com/view.php?id=14435


Pediatric NeuroSurgery
http://i2links.com/31895
http://www.boxeg.com/view.php?id=14436


Pediatric Bone and Soft Tissue Sarcomas


http://i2links.com/31896
http://www.boxeg.com/view.php?id=14437


Pediatric Critical Care Review

http://i2links.com/31898
http://www.boxeg.com/view.php?id=14438


Pediatric Primary Care

http://i2links.com/31899
http://www.boxeg.com/view.php?id=14439


Pediatric Laparoscopy

http://i2links.com/31900
http://www.boxeg.com/view.php?id=14440


Pediatric Nuclear Medicine and PET

http://i2links.com/31901
http://www.boxeg.com/view.php?id=14441


Pediatric Oncology a Comprehensive Guide
http://i2links.com/31902
http://www.boxeg.com/view.php?id=14442


Pediatric Trauma PathoPhysiology Diagnosis Treatment

http://i2links.com/31903
http://www.boxeg.com/view.php?id=14443



Pediatric Ultrasound

http://i2links.com/31904
http://www.boxeg.com/view.php?id=14444


Pediatric burns

http://i2links.com/31906
http://www.boxeg.com/view.php?id=14445




Pediatric Critical Care Review.

http://i2links.com/31907
http://www.boxeg.com/view.php?id=14438



Clinical Problems in Pediatric Urology Wiley

http://i2links.com/31908
http://www.boxeg.com/view.php?id=14447


Neonatal immunity

http://i2links.com/31909
http://www.boxeg.com/view.php?id=14448