Escolar Documentos
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Cultura Documentos
o Stroke
Ischemic Stroke
Management
o Maintain sufficient cerebral perfusion
Permissive Hypertension – perfusion of penumbra
depends on the mean arterial pressure.
Treat severe hypertension if BP >220/120 mmHg
o CHF
Vasodilators Hydralazine and Isosorbide Dinitrate added if ineffective
with diuretics, beta blockers, and ACE inhibitor (or ARB)
Treathypertension with ACE Inhibitors and Beta Blockers
Treatment
Digoxin
o Sinus Bradycardia
Treatment = Atropine
o Diastolic Dysfunction
Due to LVH as a response to chronic systolic hypertension. Ventricle
becomes stiff and unable to relax or fill adequately, thus limiting its
forward output
o SVT
Treatment: Radiofrequency ablation
o Hypertension
ACE + Arb will lead to higher creatinine levels causing an increased
likelihood that dialysis will become necessary
o Aortic Stenosis
Hemolytic Anemia + Schistocytes
Low haptoglobin and elevated bilirubin
o Kawasaki Disease
o Acyantonic Congenital Heart Defects
o Heart Sounds
Mitral Valve Prolase
o Cyanotic Congenital Heart Defects
HEENT
o Chronic Otitis Media **
Chronic Suppurative Otitis Media
Otitis Media with Effusion (Glue ear)
o Inflammation of the Eyelids
Hordeolum (Stye)
Definition: common acute inflammation of the TEAR GLAND or
EYELASH FOLLICE
Blepharitis
Definition: Chronic and/or recurrent scally inflammation of the
eyelid margins
Chalazion
Definition: Focal granulomatous swelling of the SEBACEOUS
GLANDS
Diagnostics: everting the eyelid may allow for better visualization
of the lesion
Biopsy: for persistent or recurrent chalazion
Treatment:
o Conservative: wait and watch; warm compresses
o Persistent chalazia: Incision and curettage
Persisnte or recurrent chalazion may be a sign of
sebaceous carcinoma (of Meibomian gland!)
o Traumatic Eye Injuries
Closed Globe Contusion (Bruising)
Open Globe Injuries
Ortbial Floor Fracture
Ocular Chemical Burns
o Keratitis
Inflammation of the cornea, a clear and transparent covering over the iris
and pupil
Bacterial Keratitis
Mainly: Staph, Strep, Pseudomonas
Syphilis; Klebsiella
Risk Factors: Contact Len Use
Clinical Features:
o Progressive Pain
o Foreign Body Sensation
o Purulent Discharge
o Photophobia
o Excessive Tearing
o Conjunctival Injection
Diagnostics
o Slit Lamp: Hypopyon (collection of leukocytes at the
bottom of the anterior chamber); Fluorscein staining:
round corneal infiltrate
Treatment
o Topical broad spectrum antibiotics
Cefazolin
Oflaxacin
Ciprofloxacin
Complications
o Irreversible vision loss
o Corneal destruction
Viral Keratitis
Herpes Simplex Keratitis
o Infection due to HSV Type 1 from trigeminal ganglion
o Clinical
Unilateral
Eye Redness
+/- Eye Pain
Foreign Body Sensation
Photophobia
Blurry Vision
o Diagnostics
Fluorescein staining: superficial corneal ulcers
(dendritic ulcers) that resemble the branches of a
tree
o Treatment
Topical trifluridine or ganciclovir
Oral antiviral
Herpes Zoster Keratitis
o Reactive herpes zoster virus (ophthalmic nerve)
o Clinical Features: Prodrome of headache fever
Impaired vision, eye irritation; photophobia; eye
pain
o Diagnosis:
Slit Lamp
1-2 punctate lesions
4-6 days: dendritic lesions on the corneal
surface
Treatment
Oral Acyclovir, Valacyclovir
Acanthamoeba keratitis
Acanthamoeba infection
o Inflammation of the Eyelids
Blepharitis
Treatment: Warm compresses
o Otosclerosis
o Idiopathic Intracranial Hypertension
Etiology – Vitamin A analogs, tetracyclines
Treatment
Adopt a low sodium weight loss diet
Begin acetazolamide (believed to reduce the rate of CSf
production, thereby decreasing intracranial hypertension)
o Laryngitis
Viral infection causing inflammation of the vocal cords lasting less than 3
weeks
Symptoms – loss/muffling of the voice
Treatment – Reassurance
Do not treat children under the age of 2 years of age with OTC
cough and cold medications
o Central Retinal Vein Occlusion (CRVO)
Diagnostics
Fundoscopic Exam - Tortuous an dilated retinal veins
o Esotropia
Light Reflex over the lateral portion of the iris
o Exotropia
Light reflex over the medial iris
o Hypertropia
Light reflex over the inferior iris
Involvement of the superior oblique muscle innervated by CN IV
o Hypotropia
Light reflex over the superior iris
o Conjunctivitis
Viral
Etiology
o Adenovirus
o Herpes Simplex
o Varicella Zoster Virus
Bacterial
o Herpangina
Caused by the Coxsackie A Virus
Multiple 1-mm vesicles on the posterior oropharynx and tonsils
o Meniere’s Disease
Multiple episodes of vertigo lasting for 20-120 minutes accompanied by a
fluctuating hearing loss, tinnitus, and a sense of aural fullness;
Treatment
Lifestyle: Avoid caffeine, alcohol, stress; Low sodium diet
Bed Rest
Medical Therapy
o Vestibular Suppressants (Dimenhydrinate); Antiemetics
o Prophylaxis: Histamine Analog (Betahistine)
o Glaucoma
Acute or chronic destruction of the optic nerve with or without
concomitant increased intraocular pressure
Open Angle Glaucoma
Slowly progressive and asymptomatic but leads to bilateral
peripheral vision loss
Treatment = Non-selective beta blockers (can cause
bradarrhythmias by blocking B1 and orthostatic hypotension by
blocking B2)
Etiology
o Increased IOP; Age >40
Pathophysiology
o Secondary clogging of the trabecular meshwork or
reduced drainage gradual increase in IOP vascular
compression Ischemia to the optic nerve
Clogging Due to inflammatory cells (uveitis); red
blood cells (hemorrhage); retinal detachment
Reduced drainage due to: increased episcleral
venous pressure; damaged trabecular meshwork
after a chemical injury
Diagnostics
o Tonometry: Measures IOP
o Gonioscopy: Eye examination that allows direct
visualization of the anterior chamber and the chamber
angle
o Fundoscopy: Cupping and pallor of optic disc
Therapy
o Conservative: Topical prostaglandins
o Improve drainage: Topical prostaglandins (latanoprost)
o Reduce aqueous humor production: topical beta blockers
(timolol) alpha 2 agonists (apraclonidine)
o Avoid epinephrine in angle closure glaucoma
Acute Angle Closure Glaucoma
Sudden and sharp increase in intraocular pressure caused by an
obstruction of aqueous outflow (most commonly occlusion of the
chamber angle)
Unilateral red, hard, and severely painful eye
Steamy cornea and blurred vision
Etiology: Advanced age; Female gender; Inuit and Asian ethnicity;
Rubeosis iridis; Mydriasis (blocked by the iris) due to drugs
(anticholinergics e.g. atropine; sympathomimetics;
decongestants; darkness stress/fear response
Pathophysiology
Flow of aqueous humor against resistance generates an average
intraocular pressure between 10-21 mmHg
Blocked trabecular meshwork decreased drainage of aqueous
humor from the eye sudden IOP
Primary: chamber angle narrowed due to the peripheral iris
obstructing the trabecular meshwork
Secondary: scarring, lens luxation, or rubeosis iridis
Clinical Features
Unilaterally inflamed, reddened, severely painful eye (hard on
palpation)
Diagnostics:
Rock hard globe on palpation
Gonioscopy (gold standard)
Tonometry: increased IOP
Treatment
First Line:
o Eye drops: Beta blockers (timolol); Alpha 2 agonist
o Systemic: Carbonic anhydrase inhibitor oral or IV
(acetazolamide)
Topical Cholinergics (pilocarpine) added once IOP is <40 mmHg
Analgesics and antiemetics
Definitive surgical treatment
o Once acute attack controlled
o Shunt from posterior to anterior chamber through the
peripheral iris
Neodymium YAG laser iridotomy
o Otitis Malignant Externa
Commonly caused by an infection with pseudomonas aeruginosa;
Connection between diabetes and MOE may be related to increased pH
in diabetic cerumen
Diagnostic: Blood Cultures
Treatment: High Dose IV Ciprofloxacin
Pharmacology
o Renin-Angiotensin-Aldosterone System Inhibitors
Drops in blood pressure reduce renal perfusion.
If the pressure in the renal artery falls by more than 10–15 mm Hg →
proteolytic renin is released from the juxtaglomerular
apparatus → renin converts angiotensinogen to angiotensin I → ACE cleaves C-
terminal peptides on angiotensin I, converting it to angiotensin II → increases the
blood pressure in two ways: (1) vasoconstriction and (2) stimulation of the
release of aldosterone, which increases the retention of water and sodium
Types of RAAS Inhibitors
ACE Inhibitors = Enalapril, Lisinopril, Ramipril, Captopril,
Benazepril
ARBs = Valsartan, Candesartan, Losartan, Irbesartan
Indications:
o Arterial Hypertension
o Diabetes Mellitus
Nephroprotective
Arterial Hypertension
Microalbuminuria (>300 mg/g)
Coronary Heart Disease
o Heart Failure with reduced EF
o History of Myocardial Infarction
o Nondiabetic Associated CKD with Proteinuria
o Scleroderma associated hypertensive crisis
Effects
Side Effects
o ACE Inhibitors = Dry cough due to increase in bradykinin
concentration; angioedema; hyperkalemia; pemphigus
vulgaris
Contraindications
o Absolute
Hypersensitivity
C1 esterase inhibitor deficiency
Pregnancy
Breastfeeding
o Relative
Aortic Stenosis
Renal Dysfunction
Bilateral Renal Artery Stenosis (reduced GFR too
low)
o Chemotherapeutic Agents
Overview - Indications
Alkylating Agents
o Oxazaphosphorines
o Nitrogen Mustards
o Hydrazine
o Plantinum Based Agents
Topoisomerase Inhibitors
o Topoisomerase I Inhibitor
o Topoisomerase II Inhibitor
Mitotic Inhibitors
o Vinca Alkaloids
o Taxanes
Antimetabolies
o Antifolates
o Pyrimidine Antagonists
o Purine Analogs
o Purine Antagonists
o Ribonucleotide Reductase Inhibitors
Other
o Antibiotics
o Enzymes
o Proteasome Inhibitors
o Tyrosine Kinase Inhibitors
Mode of Action
Side Effects
Alkylating Agents
o Oxazaphosphorines
Hemorrhagic Cystitis Mesna (neutralizes
acrolein, a metabolite product)
o Nitrogen Mustards
o Hydrazine
o Platinum Based Agents
Nephrotoxic (prevent with amifostine, free radical
scavenger)
Topoisomerase Inhibitors
o Anthracyclines = Dilated Cardiomyopathy
o Topoisomerase I Inhiitors
o Topoisomerase II Inhibitors
Mitotic Inhibitors
o Vinca Alkaloids
Neurotoxic (Vincristine)
o Taxanes = Pulmonary Fibrosis
Antimetabolies
o Antifolates Folinic acid (Leucovorin) Resuce
o Pyrimidine antagonists = Leucovorin increases effect
o Purine analogs
Toxicity increases with allopurinol and febuxostat
(metabolized by xanthine oxidase)
o Purine Antagonist
o Ribonucleotide Reductase Inhibitor
Antibiotics
o Bleomycin = Pulmonary Fibrosis
o Malignant Hyperthermia
o Diuretics
Thiazide Diuretics
1st line drug for black patients with isolated systolic hypertension
Inhibition of Na/Cl cotransport in the DCT
o Increased reabsorption of calcium
o Increased excretion of sodium, chloride, and potassium
Side Effects
o Hypokalemia and Metabolic Alkalosis
o Hypercalcemia – beneficial in osteoporosis
o Hyperglycemia – Avoid in diabetics
o Hyperlipidemia – Avoid in metabolic
syndrome/hypercholesterolemia
o Hyperuricemia
Potassium Sparing Diuretics
Indications
o Hypertension
o Ascites/Edema due to CHF
o Hyperaldosteronism
o Chloroquine and Hydroxychloroquine
Effects
Anti-malarial: the drugs stabilize the lysosomes of the schizonts
and reach a high concentration in the vacuoles → their alkaline
nature raises the internal pH → bind to heme to form the heme-
chloroquine complex, which is highly toxic to the schizont → the
parasite perishes
Anti-Rheumatoid: these drugs interfere with "antigen processing"
in macrophages and other antigen-presenting cells → decrease
the formation of peptide-MHC protein complexes → down-
regulate the immune response against autoantigenic peptides
Side Effects
Visual Disturbances
o Irreversible retinopathy “Bull’s Eye Maculopathy”
o Blurred Vision
Indicatios
P. malaria, P. ovale, P. falciparum (NOT P VIVAX)
o Pain Management
Types of Pain
Referred Pain
Phantom Limb Pain
Evaluation of Pain
Treatment of Pain
Additional Methods of Pain Management
o Antibiotics
Beta Lactam Antibiotics
Penicillins
Carbapenems
Monobactams
Cephalosporins
o Cefazolin = Recommended prophylactic antibiotic for most
patients undergoing orthopedic procedures
o Third Generation – Ceftriaxone
Glycopeptides (Vancomycin)
Epoxides (Fosfomycin)
Lipopeptides (Daptomycin)
Sulfonamides and Trimethoprim (Cotrimoxazole (TMP/SMX) =
(Trimethoprim + Sulamethoxazole)
Fluoroquinolones
Nitroimidazoles (Metronidazole)
Aminoglycosides (Gentamicin, Amikacin, Tobramycin, Streptomycin,
Neomycin)
Tetracycline
Glycylcyclines (Tigecycline)
Lincosamides (Clindamycin)
Amphenicols (Chloramphenicol)
Oxazolidinones (Linezolid)
Macrolides (Erythromycin, Azithromycin, Clarithromycin)
Adverse Effects
o Increased intestinal motility GI Discomfort
o QT Interval Prolongation Torsades de Pointe
Contraindications
o Pregnancy
Nitrofurans (Nitrofurantoin)
Polymyxins
Antimycobacterial Drugs
Rifamycins
Isoniazid
Pyrazinamide
Ethambutol
Dapsone
Contraindications
Infants = Chloramphenicol
< 8 years = Tetracyclines
< 18 years = Fluoroquinolones
Pregnant Women
o All Trimesters
Tetracyclines
Fluoroquinolones
Erythromycin
Clarithromycin
Streptomcyin
Breastfeeding Women
o Sulfonamides
o Tetracyclines
o Metronidazole
o Fluoroquinolones
o Nitrofurantoin
Renal Failure
o Absolutely Contraindicated: Tetracyclines
o Relatively Contraindicated: Aminoglycosides,
Cephalosporins, Fluoroquinolones
o Opioids
Tramadol
Lowers seizure threshold
Complications
Long term = Hypogonadism
Causes constriction of the sphincter of Oddi
Prevention of constipation: Polyethylene glycol (MiraLax)
o Non-Opioid Analgesics
NSAIDs
Side Effects
o Increased risk of heart attack and stroke WITH THE
EXCEPTION OF ASPIRIN AND NAPROXEN
o Beta Antagonists
Contraindications
Absolute Contraindications
o Symptomatic Bradycardia
o Sick Sinus Syndrome
o Cardiogenic Shock/Hypotension
o Decompensated Heart Failure
o Asthma
o Combination with Calcium Channel Blockers
Relative Contraindications
o Psoriasis
o Raynaud’s Phenomenon
o Pregnancy (Atenolol is ABSOLUTELY CONTRAINDICATED)
o Pharmacokinetics
3A4 Inhibitor
Clarithromycin is a strong 3A4 inhibitor
Other Inhibitors: Antifungals (azoles), Macrolides (Erythromycin,
Clarithromycin), anti-HIV medications, Grapefruit Juice,
Cimetidine
Inducers: Carbamazepine, Rifampicin, St. John’s Wort,
Barbiturates, Several, anti-HIV medications, Griseofulvin
Substrates
o Amlodipine is metabolized by 3A4
o Others: Statins (Except pravastatin), Steroid hormones
(estrogen, glucocorticoids, testosterone),
Immunosuppressives, Macrolides, Carbamazepine,
Haloperidol, Benzodiazepine, Oral Anticoagulants, Calcium
Channel Blockers (Amlodipine)
o Glucocorticoids
Inhibit apoptosis in neutrophils; Promote apoptosis in monocytes,
lymphocytes, and eosinophils
o Statins
Names
Atorvastatin
Simvastatin
Pravastsatin
Lovastatin
Fluvastatin
Pitavastatin
Rosuvastatin
Effects
Competitive inhibition of HMG-CoA Reductase Reduced
intrahepatic cholesterol biosynthesis upregulation of
expression of LDL receptor gene via sterol regulatory element
binding protein (SREBP)
o Decreases LDL; Increased HDL; Decreased Triglycerides
Side Effects
Hepatic: Increased LFTs (CYP3A4 & CYP2C9)
Muscular: Decrease the synthesis of coenzyme Q10 and impair
energy production within muscle which can result in myalgia,
muscle weakness, and increased serum creatine kinase
concentrations due to myositis and/or rhabdomyolysis
o Myalgia – continue as long as CK remains normal
o Statin associated myopathy
Muscle pain and weakness
Increased CK
Progress to rhabdomyolysis: may lead to
myoglobinuria AKI (Increased BUN & Creatinine)
Indications
LDL > 190 mg/dL
Atherosclerotic CVD, stroke, PAD
40-75 with diabetes and LDL levels of 70-18 mg/dL
40-75 with an estimated 10 year ASCVD risk >7.5% and LDL levels
70-189 mg/dL
Contraindications
Hypersensitivity
Active Liver Disease
Muscle Disorder
Pregnancy, Breastfeeding
Interactions
Lipid Lowering Agents
o Fibrates
o Nicotinic Acid
o Both together may cause myopathy
CYP3A4 Inhibitors
o HIV/HCV protease inhibitors
o Macrolides (especially erythromycin and clarithromycin)
o Azole antifungals
o Cyclosporine
Warfarin
o CHF
Digoxin
Cardiac Glycoside Poisoning
o Etiology
Digoxin overdose
Hypokalemia (potassium depleting diuretics)
Renal Failure
Treatment with verapamil, diltiazem, amiodarone,
and/or quinidine (can cause overdose)
Volume depletion
o Clinical Features
Nausea/Vomiting; Diarrhea; Gastrointestinal Pain;
and Anorexia
Blurry vision with a yellow tint and halos;
disorientation; weakness
o Diagnostics:
ECG; PVCs, T wave inversion/flattening; Decreased
QT interval; Increased PR interval
o Laboratory Studies: Serum digoxin concentration;
Hyperkalemia; Creatinine and BUN
o Treatment:
Digoxin specific antibody fragments
Atropine for symptomatic bradycardia; Slowly
normalize serum K+; Magnesium; Class IB
antiarrhythmics;
o Digoxin contraindicated in ventricular fibrillation; must use
coaution in pregnant women
o Oral Anticoagulants
Direct inhibition of thrombin (dabigatran)
Warfarin = reduced activation of the vitamin K dependent clotting factors
2, 7, 9 and 10
Direct Inhibition of Factor Xa (Apixaban and rivaroxaban)
GPIIb/IIIa complex inhibition (Abciximab, Epitifibatide, tirofiban)
Thrombocyte Phosphodiesterase III Inhibitor (Cilostazol and
dipyridamole)
Recombinant tissue plasminogen activator (alteplase, reteplase,
tenecteplase) and streptokinase – increase conversion of plasminogen to
plasmin
Heparin = Induction of conformational change in antithrombin III
o Signal Transduction
Receptors
Intracellular Receptors
Cell Surface Receptors
G Protein Coupled Receptors
o Receptor Type & Connected G proteins
Alpha 1 = Gq; alpha 2 = Gi
Beta1, 2, 3 = Gs
M1, M3 = Gq; M2 = Gi
Histamine H1 = Gq; Gs = H2
Dopamine D1 = Gs; D2 = Gi
Vasopressin V1 = Gq; V2 = Gs
o Gs = Adenylyl Cyclase; Gi = Inhibit adenylyl cyclase; Gq =
phospholipase C
Receptor Tyrosine Kinase
Non-Receptor Tyrosine Kinases
o Nitrates
Agents
Nitroglycerin
Isosorbide Dinitrate
Isosorbide Mononitrate
Sodium Nitroprusside
Effects
Exogenous supply of nitric oxide through nitrate activation of
guanylyl cyclase increased cyclic guanosine monophosphate
(cGMP) Activation of Protein Kinase G
o Peripheral Vasodilation
o Coronary Dilation
Anginal Pain Relief
Side Effects
Circulatory Dysregulation: Hypotension
Nitrate Induced Headache (Vasodilation of the cerebral arteries)
Gastroesophageal Reflux
Development of Tolerance
Cyanide Toxicity
Indications
Angina Pectoris
Hypertensive Crisis
Hypertensive Pulmonary Edema
Chronic Heart Failure
Contraindications
Hypotension
Endocrinology
o Lipid Disorders
o Cushing Syndrome
o Disorders of Sex Development
Congenital Adrenal Hyperplasia
Androgen Insensitivity Syndrome
5-alpha reductase deficiency
Klinefelter Syndrome
Turner Syndrome
Swyer Syndrome
Pure Gonadal Dysgenesis
Aromatase Deficiency
Ovotesticular Disorder of Sex Development
o Hyperprolactinemia
Causes hypogonadotrophic hypogonadism
o Transplantation**
o Primary Hyperaldosteronism
o Acromegaly
o Inborn Errors of Metabolism
o Carcinoid Tumor
VIPoma
Increases relaxation of gastric and intestinal smooth muscles
causing unregulated fluid and electrolyte secretion leading to
secretory tea colored diarrhea along with the resulting
dehydration and hypokalemia
Inhibits gastric acid secretion, increases bone resorption, and
stimulates gluconeogenesis leading to
achlorhydria/hypochlorhydria
o Acute Pancreatitis
Diagnostics
Most useful initial test – Ultrasound
o PCOS
Pathophysiology
Reduced insulin sensitivity
Hyperinsulinemia results in: obesity, epidermal
hyperplasia/hyperpigmentation (acanthosis nigricans); increased
androgen production in ovarian theca cells (increased LH;
Increased androgens; Inhibit production of SHBG in liver)
Clinical Features
Menstrual irregularities; Difficulties conceiving or infertility;
Obesity; Hirsutism; Androgenic alopecia; Acne vulgaris; Acanthosis
nigricans; Premature adrenarche;
Diagnostics
Hyperandrogenism; Oligo- and/or anovulation; Polycystic ovaries
on ultrasound (transvaginal ultrasound)
Increased testosterone; Increased LH (LH:FSH >2:1)
Differential
Pregnancy; Congenital Adrenal Hyperplasia; Cushing’s Disease;
Pituitary Adenoma; Hyperprolactinemia
Treatment –
If treatment for infertility not sought:
o If BMI >25 kg/m^2
First Line = Weight Loss
Second Line = Combined Oral Contraceptive
o If not overweight: combined oral contraceptive therapy
If seeking treatment for infertility
o First Line: Ovulation induction with clomiphene citrate
(inhibits hypothalamic estrogen receptors thereby
blocking the normal negative feedback effect of estrogen
increased pulsatile secretion of GnRH increased FSH
and LH which stimulates ovulation
o Second Line: Ovulation induction with oxogenous
gonadotropins or laparoscopic ovarian drilling
Complications
Cardiovascular Events
Type II Diabetes Mellitus
Endometrial Cancer
Increased miscarriage rate
o Pituitary Adenoma
Can cause hypothyroidism with decreased TSH levels (central
hypothyroidism)
Diagnostics:
Elevated prolactin levels
MRI of the Pitutiary
o Diabetes Mellitus **
Epidemiology
Type 1
o Childhood onset
Type 2
o Adult onset
Etiology
Type 1: Autoimmune beta cell destruction
o Associated with hashimoto thyroiditis, Type A gastritis,
Celiac Disease, Primary Adrenal Insufficiency
Type 2: Hereditary and environmental factors
o Associated with metabolic syndrome
o Risk Factors: Obesity, High calorie diet; High waist to hip
ratio; Physical inactivity; First degree relative with
diabetes; Ethnicity
Classification
Pathophysiology
Clinical Fatures
Diagnostics
Differential Diagnosis
Treatment
Algorithm
Insulin Therapy
Complications
HHS
o Marked hyperglycemia (>600 mg/dL) increases serum
osmolality (>320 mOsm/kg)
o Sodium levels low due to extracellular water shifts from
the hyperosmolarity (hypertonic hyponatremia)
DKA
o Cerebral edema is a risk
Diabetic Nephropathy
Diabetic Retinopathy
Diabetic Neuropathy
Diabetic Foot
Prognosis
Special Patient Groups
o Metabolic Syndrome
Definition
Presence of >3 of the following:
o Insulin Resistance: Fasting Glucose >100 mg/dL
o Elevated BP: >130/85 mmHg
o Elevated Triglycerides: >150 mg/dL
o Low HDL-C
In Men: < 40 mg/dL
In Women: <50 mg/dL
o Abdominal Obesity
> 102 cm (>40 in) in men
> 88 cm (>35 in) in women
Treatment
o First Line: Lifestyle Modifications
Dietary Changes: Calorie Restriction
Physical Activity: minimum of 30 minutes moderate
exercise per day (2.5 hours per week) which
increases insulin sensitivity, lowers blood pressure,
and promotes weight loss
o Medical Therapy:
Treat Hypertension (Ace Inhibitors, Diabetes
Mellitus, and Dyslipidemia (Statin)
o Bariatric Surgery
If BMI >40 with no success with dietary and
lifestyle changes
Complications
o Cardiovascular Disease
o Type II Diabetes
o Non-Alcoholic Steatohepatitis increased risk of
developing liver cirrhosis and hepatocellular carcinoma
o Anti-diabetic Drugs
Biguanides
Mechanism of Action: Enhances effect of insulin
o Reduction in insulin resistance via modification of glucose
metabolic pathways
Inhibits mitochondrial glycerophosphate
dehydrogenase
Decreases hepatic gluconeogenesis and
intestinal glucose absorption
Increases peripheral insulin sensitivity
o Lowers postprandial and fasting blood glucose levels
o Reduces LDL, increases HDL
Indications: Type 2
Clinical Characteristics
o Glycemic efficacy
o Weight Loss of Weight Stabilization
o No risk of hypoglycemia
Important Side Effects
o Metformin Associated Lactic Acidosis
GI Prodromal Syndromes: Nausea, vomiting,
diarrhea, abdominal pain
Severe symptoms: muscle cramps,
hyperventilation, apathy, disorientation, coma
High risk groups: Elderly; Cardiac or Renal
Insufficiency
Diagnostics
ABG: Metabolic Acidosis and Anion Gap
Increased Serum Lactate
o GI Complaints
o Vitamin B12 Deficiency
o Metallic Taste in the Mouth
Contraindications
o Renal Failure (GFR <30 mL/min)
o Severe Liver Failure
o IV Iodinated Contrast Medium
o Pause prior to surgery
o Ketoacidosis
o Heart Failure, Respiratory Failure, Shock, Sepsis
o Alcoholism
Thiazolidinediones (Pioglitazone, Rosiglitazone)
Clinical profile
o Mechanism of Action: Activation of the transcription factor
PPAR (peroxisome proliferator activated receptor of
gamma type) increase transcription of genes involved in
glucose and lipid metabolism increased levels of
adipokines such as adiponectin increased storage of
triglycerides and subsequent reduction of products of lipid
metabolism glucose utilization is increased and hepatic
glucose production reduced
o Clinical Characteristics: Lowers a1c by 1% in 3 months
No risk of hypoglycemia
o Important Side Effects
Fluid Retention and Edema
Weight Gain
Increased risk of heart failure
Increased risk of bone fractures (osteoporosis)
o Contraindications
CHF
Liver Failure
Sulfonylureas (Glyburide, Glipizide)
Clinical Profile
o Mechanism of Action: Block ATP Sensitive potassium
channels of the pancreatic beta cells depolarization of
the cell membrane calcium influx insulin secretion
o Clinical Characteristics: lowers a1c by 1.2% over 3 months
Important Side Effects
o Life Threatening Hypoglycemia
Increased risk in patients with renal failure
Weight Gain
Hematological: Granulocytopenia, Hemolytic
Anemia
Allergic Skin Reactions
Alcohol Intolerance
Contraindications
o Severe Cardiovascular Comorbidity
o Obesity
o Sulfonamide Allergy
o (Beta blockers may mask the warning signs of
hypoglycemia and decrease serum glucose levels even
further
Meglitinides (sulfonylurea analogue – repaglinide, nateglinide)
Mechanism of Action: Enhances insulin secretion similar to
sulfonylureas
Important side effects:
o Life threatening hypoglycemia
o Weight Gain
Contraindications
o Severe Liver Failure
o Severe Renal Failure
Incretin Mimetics (Exenatide, Liraglutide)
Mechanism of Action: Food Intake activation of
enteroendocrine cells in GI tract release GLP-1 GLP-1
degradation via DPP-4 end of GLP-1
o Incretin mimetic drugs bind to GLP-1 receptors and are
resistant to degradation by DPP-4 enzyme insulin
secretion increase, decrease glucagon secretion, slow
gastric emptying (increased feeling of satiety, decreased
weight)
Clinical Characteristics
o Weight Loss
Side Effects
o GI Complaints
o Increased risk of pancreatitis and potentially pancreatic
cancer
Contraindications
o Symptomatic GI motility disorders
o Chronic pancreatitis or family history of pancreatic tumors
Dipeptidyl peptidase 4 inhibitors (Sitagliptin, Saxagliptin)
Mechanism of action: indirectly increase the endogenous incretin
effect by inhibiting the DPP-4 enzyme that breaks down GLP-1
increased insulin secretion, decreased glucagon secretion,
delayed gastric emptying
Important Side Effects
o GI Complaints: Diarrhea, Constipation
o Arthrlagia
o Increased risk of pancreatitis
o Acute Renal Failure
Contraindications
o Liver Failure
SGLT-2 Inhibitors (Dapaglifozin, Empagliflozin, Canagliflozin)
Mechanism of Action: Reversible inhibition of the sodium
dependent glucose co-transporter SGLT-2 in the proximal tubule
of the kidney reduced glucose reabsorption in the kidney
glycosuria and polyuria
Clinical Characteristics: Promotes weight loss, reduces blood
pressure
Important Side Effects:
o Urinary Tract Infections, Genital Infections
o Dehyhdration
o Severe Diabetic Ketoacidosis
Contraindications
o CKD
o Recurrent UTIs
Alpha Glucosidase Inhibitors (Acarbose, Miglitol)
Mechanism of Action: Inhibits alpha glucosidase decrased
intestinal glucose absorption
Clinical Characteristics: No risk of hypoglycemia
Important Side Effects: GI Complaints (Flatulence, Abdominal
Discomfort, Diarrhea)
Contraindications
o IBS
o Malabsorption Conditions
o Sever Renal Failure
o Glucagonoma
Increased fasting glucagon levels
Increases gluconeogenesis and inhibits glycolysis causing hyperglycemia
Necrolytic Migratory Erythema
Paraneoplastic cutaneous reaction
The direct action of glucagon on skin, protein deficiency, and/or a
deficiency of zinc and fatty acids due to chronic diarrhea
o Acute Adrenal Insufficiency
Symptoms: Fatigue and lack of energy, weight loss, hypotension, loss of
appetite, nausea, and vomiting. Dry skin, hyperpigmentation, and
abdominal pain
Diagnostics
Laboratory Findings: Electrolyte disturbances, hyponatremia,
hyperkalemia, hypercalcemia, azotemia, anemia, and eosinophilia
o Diabetes Insipidus
Etiology
Central Diabetes Insipidus
o Primary: Idiopathic
o Secondary: Brain tumors, neurosurgery, TBI, Ppituitary
ischemia
Nephrogenic Diabetes Insipidus
o Medications (lithium, demeclocycline)
o Hypokalemia, Hypercalcemia
o Renal Disease (ADPKD)
o Pregnancy
Clinical Features
Polyuria; Nocturia; Polydipsia; Dehydration
Treatment
Central: Desmopressin
o Alternative: Chlorpropamide (increases ADH release)
Nephrogenic: Thiazide Diuretics; NSAIDs; Amiloride
o Thyroid
Hypothyroid
Can cause an elevated LDL because T4 is required for upregulation
of the LDL receptor on cell surfaces
Antithyroid Drugs
Methimazole – thioamide that interferes with the production of
T3 and T4. Inhibits thyroid peroxidase and the oxidation of iodide.
Graves Disease
Etiology
o B and T lymphocyte mediated autoimmune disorder
o 50% have family history
Pathophysiology
o TSH receptor stimulating IgG immunoglobulin
hyperthyroid
o TRAb stimulate:
Orbital fibroblast hyaluronic acid synthesis and
differentiation of fibroblasts to adipocytes
(opthalmopathy with exophthalmos)
Dermal fibroblasts and deposition of
glycosaminoglycans in connective tissue (pretibial
myxedema)
o Thyroid Cancer
o General Endocrinology
Hypothalamic Neuropeptide Y decreased due to an increase in leptin
serum concentration = decreased appetite
Leptin insensitivity = unopposed appetite Obesity
o Subacute Thyroiditis
Summary
Transient patchy inflammation of the thyroid gland associated
with granuloma formation or lymphocytic infiltration
Subacute granulomatous thyroiditis = Usually occurs after a viral
upper respiratory tract infection
Subacute lymphocytic thyroiditis = postpartum period,
autoimmune diseases, or side effect of drugs
Etiology
DeQuervain Thyroidits
o Viral Infection: Mumps, Coxsackie, Influenza, Echovirus,
Adenovirus, Mycobacterial Infection
Subacute Lymphocytic Thyroiditis
o Drugs: alpha interferon, lithium, amiodarone, interleukin-
2, tyrosine kinase inhibitors
o Autoimmune disease
o Postpartum thyroiditis
Pathophysiology
Inflammation of the thyroid gland associated with a triphasic
response
o Thyrotoxic phase (lasts 4-6 weeks): damage to follicular
cells and release of pre-formed colloid (stored thyroid
hormones)
o Hypothyroid phase (4-6 months): depletion of pre-formed
colloid and impaired synthesis of new thyroid hormones as
a result of damage to follicular cells
o Euthyroid phase: Thyroid function recovers and
pathological changes are no longer visible in the thyroid
gland
Clinical Features
Subacute Granulomatous Thyroiditis
o Possible history of URTI
o Painful, diffuse, firm goiter
o Fever and/or malaise
o Features of hyperthyroidism followed by features of
hypothyroidism
Subacute Lymphocytic Thyroiditis
o Painless, diffuse, firm goiter
o Features of hyperthyroidism followed by features of
hypothyroidism
Diagnostics
o Thyroid Function Test
Thyrotoxic phase: Increased T3 and T4; Increased
thyroglobulin; Decreased TSH
o Confirmatory Test
Increased ESR
Decreased iodine uptake
o Ultrasound: Thyroid with poorly defined hypoechoic
regions and decreased vascularity; cobblestone
appearance
o Histology:
Subacute granulomatous thyroiditis:
Granulomatous inflammation, multinucleated giant
cells
Subacute lymphocytic thyroiditis: Absence of
germinal follicles, lymphocytic infiltration
Treatment
o Thyrotoxic phase:
Beta Blockers
NSAIDs (Granulomatous)
Corticosteroids
Antithyroid drugs should not be administered
o Gastrointestinal
Meckel Diverticulum
Pathophysiology
o Omphalomesenteric duct = connecting yolk sac to the
alimentary tract in the embryo
o Incomplete obliteration of the omphalomesenteric duct
Anatomy
o Meckel diverticulum = true diverticulum
o 2 types of mucosal lining = native ileal mucosa +
heterotopic mucosa
o Blood supply: vitelline artery
Clinical Features
o Asymptomatic
o Symptomatic
Painless lower GI bleeding
Hematochezia
Tarry Stools
Currant Jelly Stools
Diagnostics
o Imagiang
Meckel Scintigraphy Scan (99mTc)
CT Angiography
Alcoholic Liver Disease
Differential Diagnosis
o Non-Alcoholic Steatohepatitis
Colorectal Cancer
Prevention
o Asymptomatic men and women >50 years of age
o Low risk individuals:
Complete colonoscopy = every 10 years if no polyps
or carcinomas detected
Annual fecal occult blood tet (poor sensitivity)
Sigmoidoscopy = every 5 years and FOBT every 3
years
Annual Fecal Imunochemical Testing
CT Colonography every 5 years
o High Risk Individuals
Complete colonscopy 10 YEARS EARLIER thant he
index patient’s age at diagnosis or NO LATER than
40 years of age
o If poly removed:
Hyperplastic polyp < 10 mm in size = 10 years
Low risk adenoma: 1-2 tubular polyps < 10 mm in
size and without intraepithelial neoplasia = 5-10
years
High risk adenoma (3-10 tubular polyps; 1 polyp >
10 mm; 1 villous or tubulovillous polyp; 1 tubular
polyp = 3 years
More than 10 adenomas = <3 years
Lynch Syndrome
Prevention
o Cancer Screening
Annual Colonscopy 2-5 years before earliest case of
tumor in the family
Annual pelvic exam with transvaginal sonography
and endometrial biopsy at 30-35 years of age or 3-
5 years before earliest case of tumor in family
Annual physical exam and urinalysis
o Total Colectomy
Colonic Polyps
Classification
o Low Malignant Potential
Hamartomatous
Juvenile Polyposis Syndrome
Peutz jeghers Syndrome
Cowden Syndrome
Cronkhite Canada Syndrome
Inflammatory Polyps
Ulcerative Colitis
Mucosal Polyps
Submucosal Polyps
o Moderate Malignant Potential
Serrated Polyps
Hyperplasti Polyps
Sessile Serated Polyps
Traditional Serrated Adenoma
o High Malignant Potential
Adenomatous Polyps
Tubular Adenoma
Tubulovillous Adenoma
Villous Adenoma
Subtypes and Variants
o Hereditary Polyposis Syndrome
o Adenomatous Polyposis Syndromes
Familial Adenomatous Polyposis
Prevention:
o Screening begins at 10 years of age =
Rectosigmoidoscopy
o Upper endoscopy begins at 25 years
of age
Primary Biliary Cholangitis
Pathophysiology
o Inflammation and progressive destruction of the small and
medium sized intrahepatic bile ducts (progressive
ductopenia) defective bile duct regeneration chronic
cholestasis secondary hepatocyte damage
Clinical Features
o Fatigue
o Marked generalized pruritis
o Hyperpigmentation
o Hepatomegaly, Dull Lower Margin, RUQ Discomfort
o Splenomegaly
o Maldigestion
o Xanthomas and Xanthelasma
Diagnostics
o Laboratory Tests
Increased Cholestasis (ALP, GGT, Conjugated
Bilirubin)
Transaminases within normal limits
Increased AMA
Increased ANA
Increased IgM
o Liver Biopsy
Pathology
Treatment
o 1st Line = Ursodeoxycholic Acid
o Inguinal Hernia
Indirect Inguinal Hernia
Failure of the processus vaginalis to close
o Pernicious Anemia
Increased risk of developing gastric adenocarcinoma
90% have chronic atrophic gastritis
o Anal Fissures
90% occur at the posterior midline, distal to the pectinate line (dentate
line)
o Inflammatory Bowel Disease
Ulcerative Colitis
Management
o Begin screening colonoscopy 10 years after the initial
diagnosis and continue every 2-5 years
Crohn’s Disease
o PPIs
The use of PPIs + H2 Receptor Antagonist Vitamin B12 Deficiency
o Intestinal Ischemia
Acute Mesenteric Ischemia
Clinical Features
o Periumbilical Pain disproportionate to physical findings
o Diarrhea
o Nausea + Vomiting
o Diverticulitis
Indications for surgery: Generalized peritonitis; Unconfined perforation;
Uncontrolled sepsis; Undrainable abscess; Failure of conservative
management
o Irritable Bowel Syndrome
Treatment: Citalopram
o Nonalcoholic Fatty Liver Disease
Accumulation of fat in hepatocytes
Associated with insulin resistance, central adiposity, increased BMI, HTN,
Dyslipidemia
o Acute Rectal Fissure
Treatment: Internal Sphincterotomy; Botulinum toxin injection
o Zenker Diverticulum
Increased intrapharyngeal pressure on a physiologically weakened area of
the hypopharynx (Killian triangle) causes the local mucosa and submucosa to
bulge through the muscularis propria
Pressure increase is usually due to esophageal dysmotility (e.g., inadequate
relaxation of the upper esophageal sphincter). Pulsion diverticula (due to
increased intraluminal pressure), such as Zenker diverticulum or colonic
diverticula in diverticulosis, are typically false diverticula, whereas traction
diverticula (due to inflammatory processes) are true diverticula.
o Inborn errors of carbohydrate metabolism
Glycogen Storage Disorders
Type I (Von Gierke)
Type II (Pompe)
Type III (Cori)
Type IV (Anderson)
Type V (McArdle)
o Myophosphorylase Deficiency (McArdle’s Disease)
glycogen storage disease that presents with myalgias,
rhabdomyolysis, myoglobinuria, and early fatigue from
exercise due to inability to break down glycogen for use as
energy in muscle tissues
o Second wind phenomenon
Type VI (Hers)
Galactosemia
Most common form is galactose-1-phosphate uridylyltransferase
deficiency which leads to the accumulation of galactose-1-
phospahte and galactitol
Accumulation of galactitol causes infantile cataracts
Symptoms become apparent when the newborn starts feeding
breast milk and/or routine formula
Must avoid food containing lactose (cow and breast milk)
Disorder of Fructose Metabolism
o Rare Neurological Diseases
Adrenoleukodystrophy
X linked neurological disease caused by an impaired peroxisomal
ATP binding cassette transporter protein that leads to an
accumulation of very long chain fatty acids in the adrenal glands,
testes, and white matter, and subsequent neuron demyelination
o Celiac Disease
Associated with Turner Syndrome
MSK
o Collection of Orthopedic Conditions
Popliteal Baker Cyst
Bursitis
Meniscal Cyst
Stress Fracture
Genu Valgum
Genu Varum
Greater Trochanteric Pain Syndrome
Forearm Fractures
o Insertional Tendinopathies
o Dupuytren’s Contracture (Palmar Fibromatosis)
Fibromatosis of the palmar fascia leading to overproliferation of
fibroblasts and formation of collagen nodules/cords
o Reactive Arthritis
o Spinal Stenosis
o Subacromial Bursitis
Subacromial Impingement Syndrome
o Orthopedic Shoulder Examination ***
o Soft Tissue Lesions of the Shoulder
o Patellofemoral Pain Syndrome
Peripatellar pain
Malalignment of the patella and femoral grove with resultant patellar
chondromalacia
o Friedreich Ataxia
8-15 years old
Etiology
Trinucleotide repeat expansion (GAA) in the FXN gene on
chromosome 9 intramitochondrial accumulation of iron and
dysregulation of cellular antioxidant defense oxidative damage
to CNS and CVS cells CNS and CVS degeneration
Clinical Features
Neurological
o Progressive Ataxia
Bilateral lower limbs equally affected
Wide based steppage gait with dysmetria
and frequent falling
Torso and Arms
Action and intention tremors
Choreiform movements
Associated impaired proprioception, vibration
sense, and loss of deep tendon reflexes
o Dysarthria and dysphagia
Skeletal Deformities
o Secondary Scoliosis
o Foot deformity: foot inversion (pes cavus) with hammer
toes
Concentric hypertrophic cardiomyopathy
Diabetes Mellitus
Personality Changes
Diagnostics
Trinucleotide repeat expansion assay
ECG: T wave inversion and ventricular hypertrophy
Echocardiography: symmetric, concentric ventricular hypertrophy
Nerve conduction studies
o Sensory: absent or reduced sensory nerve action
potentials
o Motor: normal until advanced
MRI brain/spinal cord: cervical spine atrophy
Treatment
None
o Paget Disease of Bone
o Septic Arthritis
Etiology
Mechanism of Infection
o Hematogenous Spread
Distant site
Disseminated Infection
o Direct Contamination
Risk Factors
o Prosthetics; Interventions; Immunosuppression; Diabetes
Mellitus; Age; Chronic Skin Infections; IV Drug Use
Causative Organisms
o Most common in adults and children >2 years =
staphylococcus aureus
o Streptococci
o S. epidermidis
o H. influenzae
o N. gonorrhea
o Gram negative rods (E. coli and P. aeruginosa)
o M. tuberculosis; Mycobacteria
o B. burgdorferi
X-Ray of the Femur/Hip then CBC and ESR then ultrasonography (highly
sensitive for effusion)
Treatment
Initial Management
o
o Transient Synovitis
o Polymyositis
Proximal muscle involvement
Elevation of muscle enzymes CK and Aldolase
Treatment = Corticosteroids
o Ankle Injury
Ottawa Ankle Rules
o Necrotizing Fascitis
Group A Streptococcus
Treatment
Mild Infection = Oral Antibiotics (Pencillin V or Cephalosporin or
Dicloxacillin or Clindamycin)
Moderate Infection = IV Antibiotics (Penicillin or Ceftriaxone or
Cefazolin or Clindamycin
Severe Infection = Surgical Debridement + Empiric Antibiotic
Treatment (Vancomycin + Piperacillin/Tazobactam)
o Adehsive Capsulitis
Anterosuperior and Anteroinferior Capsular Ligaments
o Achilles Tendinopathy
o Physical Examination
Muscle Strength
0 = Inability to contract muscle
1 = Contraction without movement
2 = Gravity neutralized
3 = Movement against gravity only
4 = Movement against gravity plus some additional resistance
5 = Movement against substantial resistance
o Lateral Epicondylitis
Degeneration of the extensor carpi radialis muscle tendon
Treatment: Conservative Management
o Patellofemoral Pain Syndrome
Anterior knee pain that is worse with running downhill.
Apprehension when knee extended with pressure over the patella and
patella will sometimes track laterally
Treated with exercises to strengthen the quadriceps and hips and by
using a knee sleeve with a doughnut type cushion that the patella fits into
o Osgood Schlatter
Avascular necrosis from overuse of the quadriceps muscle during periods
of growth
Causes a traction apophysitis at the tibial insetion of the quadriceps
tendon
Inflammation of the patellar ligament at the tibial tuberosity
Clinical: Anterior knee pain that worsens with exercise; Tibial bump may
be felt and can often be seen on X-Ray
o Progressive Muscular Dystrophies
Epidemiology – Only males affected
Age of onset:
o DMD: 2-5 years
o BMD: usually not earlier than 15 years of age
Etiology
DMD and BMD: X Linked Recessive
LGMD: Autosomal Dominant or Autosomal Recessive
Chromosomal defects affect the dystrophin gene on the short arm
of the X chromosome (Xp21)
o Frameshift mutation in DMD
o Point mutation in BMD
Pathophysiology
Dystrophin protein anchors the cytoskeleton of a muscular cell to
the extracellular matrix by connecting cytoskeletal actin filaments
to membrane bound dystroglycan that is in turn connected to the
extracellular laminin
Dystrophin gene mutation and subsequent alterations of the
protein partial or almost complete impairment of the protein
disturbance of numerous cellular signaling pathways
necrosis of affected muscle cells and subsequent replacement
with connective and fat tissue muscle appears larger
(pseudohypertrophy)
Clinical Features
Duchenne Muscular Dystrophy
o Paresis and atrophy starting in the proximal lower limbs
o Weak reflexes
o Waddling gait (bilateral Trendelenburg Sign)
o Gower Maneuver
o Calf Pseudohypertrophy
o Inability to walk by 12 years of age
o Cardiac and respiratory muscle involvement
Dilated cardiomyopathy
Cardiac arrhythmias
Respiratory insufficiency
Becker Muscular Dystrophy
o Slower progression
Diagnostics
Blood tests: Increased creatine kinase
Genetic analysis: detect dystrophin gene mutation
Muscle biopsy
o DMD: Absent dystrophin
o BMD: Reduced dystrophin
Treatment
Medical Therapy
o DMD: Glucocorticoids
o BMD: Glucocorticoids (efficacy is low)
Supportive Therapy
o Physiotherapy; Orthopedic assistive devices; Psychological
Support; Ventilation Support
Prognosis
DMD: 30 years (cardiac or pulmonary death)
BMD: 40-50 years
o Common Peroneal Nerve Injury
High stepping gait, weakness of foot eversion and dorsiflexion, and
decreased sensation in the anterolateral aspect of the leg and dorsum of
the foot
Most common peripheral nerve lesion of the lower extremity
Susceptible to injury during obstetric procedures
Microbiology
o Rabies
Rhabdoviridae
Transmission: Saliva of rabid animal after bite injury
Pathophysiology: migrates from bite wound retrograde along
microtubules using dynein
o Amebiasis
Entamoeba histolytica
o Helminth Infections
Toxocariasis
Enterobiasis
Ascariasis
Trichinellosis
Taeniasis
Hookworm Infections
Strongyloidiasis
Diphyllobothriasis
o Malaria
Epidemiology
Tropical Africa
Tropical and Subtropical regions such as Asia and Latin America
Etiology
Pathogen: Plasmodia
Vector: female Anopheles mosquito
Partial Resistance against Malaria:
o Sickle Cell Trait
o Thalassemia, Hb C
Species
o Plasmodium vivax and Plasmodium ovale (every 2 days
fever)
o Plasmodium malaria (every 3 days)
o Plasmodium falciparum
Pathophysiology
Developmental Stages of Plasmodium in RBCs
o Immature trophozoite: thick, dark purple ring-shaped
inclusions (similar to signet ring cell carcinoma)
With Plasmodium falciparum: fine rings
o Mature trophozoite: ameboid rings
With Plasmodium falciparum: finer rings in comparison
to immature trophozoites
o Immature schizont: irregular round, ameboid, almost filling the
entire erythrocyte
With Plasmodium falciparum: hardly detectable in the
blood
o Mature schizont: conglomerate of 6–24 merozoites (round with
central darkening), which develops from an immature schizont
With Plasmodium falciparum: hardly detectable in the
blood
o Gametocytes
Macrogamete: mature female (sexual) form, visible as a
round structure filling almost the entire erythrocyte
Microgamete: mature male (sexual) form, visible as a
round structure within the erythrocyte. In comparison to
macrogametes, it is smaller and has a brighter nucleus.
Clinical Features
o Incubation: 7-42 days
Relapse in P. ovale or P. vivax
Hypnozoites persist within the liver and cause
reinfection after lying dormant for months or even
years
o Flu Like Symptoms
o High Fever
Tertian Malaria: every 48 hours
Quartan malaria: every 72 hours
Falciparum malaria: irregular fever spikes with no
noticeable rhythm
o Weakness, Paleness, Dizziness
o Increased bleeding risk
o GI; Diarrhea, Abdominal Pain, Nausea, Vomiting
o Liver: Hepatosplenomegaly
o Severe Malaria:
Most commonly from falciparum malaria
Kidneys: hemoglobinuria
Cerebral: hallucinations
Cardiopulmonary: Heart Failure
Diagnostics
o History
o CBC
o Blood Smear
Treatment
o Tertian malaria
P. vivax & ovale = Chloroquine or
hydroxychloroquine + Primaquine
P. vivax = artemether lumefantrine + primaquine
o Quartan Malaria = Chloroquine or Hydroxychloroquine
o Sepsis
Staph Aureus
o Entamoeba histolytica
Cysts or trophozoites ingest phagocytosed erythrocytes
Treatment = paramomycin or diloxanide
o Campylobacter
Treatment – Macrolides (Azithromycin)
o Neisseria gonorrhea
Treatment – Ceftriaxone + Azithromycin
o Community Acquired Pneumonia
Diagnostics:
CURB-65 Score and SaO2
Treatment –
Amoxicillin in children 60 days to 5 years of age for activity against
Streptococcus pneumoniae
Azithromycin for children 5-16 years old because of its activity
against Mycoplasma pneumoniae and Chlamydia pneumoniae
o Sepsis
Management
Respiratory stabilization with oxygen
Fluid resuscitation
Vasopressors (Dopamine and Norepinephrine)
o Croup
Clinical:
Inspiratory stridor, Chest wall retraction, diminished air
movement
Diagnostics:
Steeple Sign
Treatment
Mild croup: Cool mist inhalation, infant in upright position,
Dexamethasone
moderate to severe croup: Nebulized epinephrine
o Tuberculosis
Diagnostics
Interferon gamma release assay –
o Amount of interferon gamma expressed by T cells
o Not influenced by prior BCG vaccination
Management:
Asymptomatic patient with a positive IFN-gamma release assay or
TB skin test, treat if high risk factors for TB using Isoniazid for 9
months
o Asbestosis
Diagnosis:
Elongated, yellow asbestos body
Bilateral infiltrates, Pleural Thickening
o Calcified pleural plaques
o Bilateral ground glass opacities
Increased Alveolar Arterial Gradient
o Ventilation-Perfusion mismatch due to impaired diffusion
of oxygen across the capillary membrane within the alveoli
from inflammation and fibrosis of pleural parenchyma
o Pertussis
Treatment
Macrolides
Post-Exposure Prophylaxis to all close contacts
o Influenza
Complications
Highest risk groups: Children under 2 years old, pregnant women,
adults over 65, morbidly obese (BMI > 40 kg/m^2), and Native or
Alaskan Americans
o Streptococcus
Group A
Treatment: Penicillin
o Rocky Mountain Spotted Fever
Transmission through ticks
Clinical Diagnosis: Fever, hypotension, rash, myalgia, vomiting, and
headache (sometimes severe)
o Sepsis
>38.3 C; WBC >12,000/mm3; Respiratory Rate >20 min;
o Clostridium dificile colitis
Severe = Vancomycin oral 500 mg TID
o Dengue
Clinical Presentation: Retro-orbital pain, fever, malaise, myalgia
Treatment
o Varicella Zoster Virus
Multinucleated giant cells and Cowdry A inclusions via Tzanck test of
shingles lesions
Immunosuppression is a risk factor for reactivation of VZV after a period
of latency in dorsal root ganglia
o Shingles
Complications
Post-herpetic neuralgia
o Treatment
1st line: TCAs
Relative Contraindictions (heart disease,
epilepsy, glaucoma): Glaucoma, Pregabalin
2 Line: Topical capsaicin, opioids, intrathecal
nd
glucocorticoid injections
o Cytomegalovirus (CMV)
Immunocompetent patients >90% asymptomatic; <10% CMV
mononucleosis
Immunocompromised patients: CMV Mononucleosis; CMV Pneumonia;
CMV Retinitis; CMV Esophagitis; Adrenal Insufficiency; CMV Encephalitis
Psychiatry
o Substance-Related and Addictive Disorders
Nicotine Use Disorder
Varenicline
Alcohol Disorder
Minor alcohol withdrawal = tremor, anxiety, nausea, vomiting,
and/or insomnia
Major withdrawal = visual and auditory hallucinations,
diaphoresis, tachycardia, and elevated BP
Delirium Tremens = Delirim
o Anxiety
Anxiety, shortness of breath, paresthesia, and carpopedal spasm =
hyperventilation
o Medications
Anti-depressants
SSRIs
o Duloxetine
Indicated for both depression and chronic pain
Unlikely to cause weight gain
o Parvovirus B19
Associated with Fifth Disease (nonspecific fever, arthropathy, chronic
anemia, and transient aplastic crisis)
Parvovirus Arthritis
Mild febrile illness, maculopapular rash beginning on the perioral
areas of the face several days later and spreading to the
extremities from there. Adopts a lacy and reticular pattern.
Symmetric polyarthritis in the fingers, hands, knees, and ankles
while the rash can be absent
Treatment with analgesics and NSAIDs.
o Prednisone can also be prescribed
OBGYN
o Pregnancy Loss
Etiology
Spontaneous Abortion
o Maternal
o Fetoplacental
o Miscellaneous
Stillbirth
o Maternal
o Fetoplacental
o Miscellaneous
o Pregnancy***
o Childbirth
40 weeks pregnanncy
o Ectopic Pregnancy
o Lichen Planus
o Lichen Sclerosus
o Atrophic Vaginitis
o Chorioamnionitis
Infection of amniotic fluid, fetal membranes, and placenta
Common bacteria: Ureaplasma urealyticum, Mycoplasma hominis,
Gardnerella vaginalis, Bacteroides, Group B Streptococcus, E. Coli
Risk Factors:
Prolonged labor or premature rupture of membranes
Pathological bacterial colonization of vaginal tract
Multiple digital vaginal exams, invasive procedures
Symptoms
Maternal
o Fever (>100 F)
o Tachycardia (>120 /min)
o Uterine tenderness, pelvic pain
o Malodorous and purulent amniotic fluid, vaginal discharge
o Premature Contractions, PROM
Fetal Tachycardia > 160 /min
Diagnostics: Clinical Diagnosis
Maternal Blood Tests
o Leukocytosis >15,000 cells/uL; Elevated CRP
Bacterial Cultures
o Urogenital secretions
o Amniotic fluid
Group B Streptococcus screening: cervicovaginal and rectal swabs
Management
Maternal Antibiotic Therapy
o Vaginal Birth: IV Ampicillin + Gentamicin
o Cesarean Birth: IV Ampicillin and Gentamicin +
Clindamycin
Delivery
o Swift delivery generally indicated to minimize both
maternal and fetal complications
Complications
Maternal
o Uterine atony, postpartum hemorrhage, endometritis
o Septic shock, DIC, venous thrombosis, pulmonary
embolism, death
Fetal/Neonatal
o Fetal death, premature birth
o Asphyxia, Intraventricular hemorrhage, Cerebral palsy
o Neonatal Infection
o Neonatal Infection and Sepsis
o Omphalitis
o Preterm Labor and Birth
Definition:
Preterm Labor: Regular uterine contractions with cervical
effacement, dilation, or both before 37 weeks gestation
Preterm Birth: Live birth between 20 0/7 weeks and 36 6/7 weeks
of gestation
WHO Subcategories
o Extremely Preterm (<28 weeks)
o Very Preterm (28 to < 32 weeks)
o Moderate to Late Preterm (32 to < 37 weeks)
Epidemiology
Complications of preterm birth are leading cause of death in
children < 5 years of age worldwide
Approximately half of patients who deliver prematurely are
diagnosed with preterm labor
Clinical Features
Regular uterine contractions and associated symptoms of labor
Cervical dilation >3 cm, effacement, or both
Premature Rupture of Membranes
Diagnostics
Clinical Diagnosis
Supportive Tests
o Transvaginal Cervical Ultrasound for diagnosis of short
cervix
o Cervicovaginal fetal fibronectin detection test: a positive
test supports diagnosis of preterm labor
Treatment
Single course of antenatal steroids
o Indication: 24-34 weeks gestation with risk of delivery
within next 7 days
o Improves fetal lung maturity and surfactant production
Tocolysis: Administartion of tocolytics to inhibit uterine
contractions and prolong pregnancy
o Recommended for up to 48 hours to enable administration
of antenatal corticosteroids in preterm labor
o First Line: Beta adrenergic agonists, NSAIDs, or Calcium
Channel Blockers
o Second Line: Magnesium Sulfate
o Contraindications
Maternal drug contraindications
Nonreassuring fetal CTG
Intrauterine fetal CTG
Intrauterine fetal demise
Chorioamnionitis
Preterm premature rupture of membranes
Antepartum hemorrhage with hemodynamic
instability
Severe pre-eclampsia or eclampsia
Lethal fetal anomaly
Fetal Neuroprotection: Magnesium sulfate
o Indication: If birth < 32 weeks anticipated
o Decreases risk and severity of neurological diseases
(cerebral palsy)
Antibiotics for Group B Streptococcus prophylaxis is
recommended in preterm labor, preterm premature rupture of
membranes and when GBS infection is evident
Complications
o Neonatal respiratory distress syndrome (RDS)
o Bronchopulmonary dysplasia (BPD)
o Patent ductus arteriosus (PDA)
o Retinopathy of prematurity (ROP)
o Necrotizing enterocolitis (NEC)
o Periventricular leukomalacia (PVL)
o Neurological disorders (e.g.,cerebral palsy, learning
disabilities, developmental delays, ADHD)
o Problems
of homeostasis: apnea, bradycardia, hypothermia
o Infection and sepsis (e.g., pneumonia)
o Anemia of prematurity: impaired ability to produce
adequateerythropoietin (EPO); should be suspected
in premature infants with low hemoglobin
o Intraventricular hemorrhage (IVH)
Risk factors
Birth weight < 1500 g and delivery
before 32 weeks'gestation
Maternal chorioamnionitis
Hypoxia during or after birth
Clinical features
Usually occurs within 5 days ofbirth
Most infants are asymptomatic, but
saltatory (over several days) or, more
rarely, catastrophic (over minutes to hours)
courses are also possible
Lethargy, hypotonia, irregular
respirations, seizures, bulginganterior
fontanelle
Cranial nerve abnormalities (e.g., pupils
react sluggishly to light) and changes
in eyemovement (e.g., roving eye
movements)
Diagnosis
Cranial ultrasound
Since most patients are asymptomatic,
screening ultrasounds are routinely
performed in infants with a birthweight <
1500 g and delivery before 30
weeks gestation.
Prevention
o Avoid modifiable risk factors
o Manage cervical insufficiency
o Vaginal progesterone supplementation
Singleton pregnancy at 16-24 weeks gestation with
a prior singleton preterm birth, regardless of
cervical length and/or cervical cerclage
Women < 24 weeks gestation with a short cervical
length (< 25 mm)
o Benign Breast Conditions
Fibrocystic Changes
Mastitis
Fat Necrosis of the Breast
Benign Breast Neoplasms
Fibroadenoma
Phyllodes Tumor
INtraductal Papilloma
Gynecomastia
o Breast cancer
Overview
Noninvasive (in situ) carcinoma
o Ductal Carcinoma in Situ
o Lobular Carcinoma in Situ
Invasive Carcinomas
o Invasive Ductal Carcinoma
o Invasive Lobular Carcinoma
Inflammatory Breast Cancer
Clinical Features
Subtypes
Paget Disease of the Breast
Inflammatory Breast Cancer
o Congenital TORCH Infections
Toxoplasmosis, Other (Varicella-Zoster, Parvovirus, Listeriosis); Rubella;
Cytomegalovirus; Herpes Simplex Virus
Transplacental transmission occurs following primary infection of a
seronegative mother during pregnancy → maternal IgM
antibodies (which are unable to cross the placenta) form first, and
protective IgG antibodies (which are able to cross the placenta) have not
yet been formed → the infant is not protected from infection via
the placenta!
Congenital Toxoplasmosis
Toxoplasma gondii
Transmission
o Pregnant women
o Fetus
Clinical Features
o First Trimester
Chorioretinitis (form of posterior uveitis)
Diffuse intracranial calcifications
Signs of hydrocephalus
o Second Trimester
Subclinical or Mild Toxoplasmosis
o Sequelae
Epilepsy
Diagnosis
o Fetus: PCR for T. gondii DNA in amniotic fluid
o Newborn:
CT/MRI
T. gondii specific IgM antibodies; PCR for T. gondii
DNA
Ophthalmological Evaluation for Chorioretinitis
Treatment:
o Pregnant Woman: Spiramycin
o Fetal Infection: Pyrimethaminel, Sulfadiazine, and Folinic
Acid
o Newborn Infection: Pyrimethamine, Sulfadiazine, Folinic
Acid
Congenital Syphilis
Pathogen: Treponema pallidum
Transmission:
Clinical Features
o Early Congenital Syphilis (onset prior to 2 years)
Hepatomegaly and Jaundice
Rhinorrhea
Maculopapular Rash on Palms + Soles
Skeletal Abnormalities
o Late Congenital Syphilis (onset after 2 years age)
Facial features: saddle nose, frontal bossing, short
maxilla
Dental findings: Hutchinson teeth and mulberry
molars
Eyes and ears: interstitial keratitis, sensorineural
hearing loss
Skin: Rhagades, Gummas
Skeletal: Saber Shins (Anterior bowing of the tibia);
Painless arthritis in knees and other joints
Neurological: Cranial Nerve Deficits, ID,
Hydrocephalus
Diagnosis
o Newborn
Initial: RPR or VDRL
Confirmatory: Darkfield Microscopy or PCR
o Fetus: Repeated Ultrasound Examinations showing
placentomegaly, hepatomegaly, ascites, and hydrops
fetalis
Treatment: IV Penicillin G for both pregnant and newborns
Prevention: Maternal screening
Congenital and Newborn Listeriosis
Pathogen: Listeria monocytogenes
Transmission
Clinical Features
o Intrauterine transmission to the fetus
Granulomatosis infatiseptica
Severe systemic infection characterized by
disseminated abscesses
Most common findings: respiratory distress
syndrome and skin lesions
Signs of meningitis
o Transmission during birth
Late onset syndrome: Listeria
meningitis/encephalitis
Diagnosis: Culture from blood or CSF samples (pleocytosis)
Treatment: IV Ampicillin and Gentamicin
Prevention: Avoid soft cheese
Congenital and Perinatal Varicella Infection
Pathogen: VZV
Transmission
o Pregnant Women
o Fetus: Vertical transmission during pregnancy or delivery
Clinical Features
o Congenital Varicella Syndrome (1st and 2nd trimester
Hypertrophic scars (cicatricial skin lesions)
Limb Defects (hypoplasia
Ocular Defects (chorioretinitis, cataracts,
microphthalmus)
CNS Defects (Cortical atrophy, seizures, intellectual
disability)
o Neonatal Varicella
Mild Infection (maternal exanthema > 5 days
before birth)
Sever Infection (maternal exanthema < 5 days
before birth); hemorrhagic exanthema,
encephalitis, pneumonia, or congenital varicella
syndrome
Diagnosis
o Newborns: Usually clinical diagnosis based on appearance
of skin lesions
DFA or PCR of fluid collected from bilsters or CSF
Serology
o Fetus: PCR for VZV DNA (fetal blood, amniotic fluid) and
ultrasound to detect fetal abnormalities
Treatment
o Acyclovir
o Postexposure prophylaxis in newborn infants if the mother
displays symptoms of varicella <5 days before delivery
IgG antibodies (varicella zoster immune glbulin or VZIG)
o Hormonal Contraceptives
Effects
Estrogen
o Hypothalamus: Decreased GnRH
o Pituitary: Decreased LH inhibit ovulation, decrease FSH
prevents ovarian folliculogenesis
Progestin
o Inhibits GnRH and LH secretion suppresses ovulation;
inhibits endometrial proliferation; changes cervical mucus
and impairs fallopian tube peristalsis inhibition of
sperm ascension and egg implantation
o Inhibits follicular maturation
Antiprogestin: inhibits or delays ovulation by inhibiting the
progesterone receptor
o The menstrual cycle and menstrual abnormalities
o Cervical Cancer ***
LSIL = repeat pap smear twice at 12 month intervals in patients 21-24
years of age; negative twice patient may return to routine screening
If pap smear shows ASC-H, HSIL, AGC colposcopy should be performed
o Pregnancy Loss
Mifepristone = approved for induction of medical abortion
o Menopause
Definitions
Perimenopause –
Premonapause – 45-55 years of age
Menopause – confirmed after 12 months of amenorrhea; 49-52
years
Post menopause – time period beginning 12 months after last
menstrual period
Pathophysiology
Decreased ovarian function Decreased estrogen and
progesterone levels loss of negative feedback to gonadotropic
hormones increased GnRH levels increased levels of FSH
and LH in blood anovulatory cyclesbecome more and more
frequent progressive follicular depletion
Onset of menopause might be delayed and symptoms might be
milder in obese women
Clinical Features
Irregular Menses
Autonomic Symptoms
o Increased sweating, hot flashes, heat intolerance
o Vertigo; Headache
Mental Symptoms
o Impaired sleep; Depressed mood or mood swings
o Anxiety/Irritability
o Loss of Libido
Atrophic Features
o Breast tenderness and reduced breast size
o Vuvlovaginal atrophy
Atrophy of the vulva, cervix, vagina
Weight Gain and Bloating
Subtypes/Variants
Surgical Menopause
Diagnostics
Decreased estrogen/progesterone
FSH levels can fluctuate widely in perimenopause
Lipid Profile: Increased total cholesterol; Decreased HDL
Treatment
Lifestyle Modifications
o Hot Flashes: Avoid triggers; environmental temperature
regulation
o Atrophic vaginal symptoms: vaginal estrogen creams,
rings, or tablets
o Impaired sleep and/or hot flashes: exercise, acupuncture,
relaxation techniques
o Prevent osteoporosis: Smoking cessation, Adequate
Vitamin D Intake
Hormone Replacement Therapy
o Types
Estrogen Therapy: If hysterectomy
Estrogen + Progestin Therapy: If have uterus
o Risks
Cancer
Unopposed estrogen = endometrial
hyperplasia increased risk of endometrial
cancer
Estrogen plus progestin therapy
increased risk of breast cancer
Cardiovascular Disease: CHD, DVT, PE, Stroke
Gallbladder Disease
Stress Urinary Incontinence
o Contraindications
Vaginal Bleeding
Pregnancy
Breast Cancer/Endometrial Cancer
Chronic Liver Disease
Hyperlipidemia
Recent DVT/Stroke
Coronary Artery Disease
Premature Menopause = before the age of 40
Ovarian Insufficiency
Primary ovarian Insufficiency
Secondary Ovarian Insufficiency
o Function Disorder (ovarian endometriosis, PCOS, cancer of
reproductive organs)
o Genetic syndromes (Turner Syndrome, Swyer Syndrome,
Androgen Insensitivity Syndrome
o Autoimmune Diseases (Autoimmune lymphocytic
oophoritis, Hashimoto’s Thyroiditis)
o Infection: Measles, mumps, TB of genital tract
o Smoking
o Post-oophorectomy
o Radiation/Chemotherapy
o Prolonged GnRH
o Induction of multiple ovulation in infertility
o Secondary amenorrhea
Most common causes = PCOS, Primary Ovarian Failure, Hypothalamic
Amenorrhea, Hyperprolactinemia
o Postpartum Hemorrhage
Definition: Blood loss > 500 mL after vaginal birth; Blood loss > 1000 mL
for cesarean section occurring at any time
Primary PPH: Blood loss within 24 hours
Secondary PPH: Blood loss from 24 hours to 12 weeks postpartum
Etiology
Uterine Atony (most common)
Abnormal placental separation
Maternal injury during birth
Bleeding diathesis
Clinical Features: Anemia; Hypovolemic Shock
Complications: Thromboembolism; Sheehan Syndrome;
Uterine Atony
Definition: Failure of the uterus to effectively contract and retract
after complete or incomplete delivery of the placenta, which can
lead to severe postpartum bleeding from the myometrial vessels
Epi: responsible for ~80% of PPH
Risk Factors: Multiparity, Multiple Pregnancy, Post Term
Pregnancy, Instrumental Delivery, Anatomical Abnormalities,
Large for gestational age newborn (> 4000 g); Poor myometrial
contractions following prolonged or rapid and forceful birth
Clinical Findings: Abnormal vaginal bleeding; Soft, enlarged
(increased fundal height), boggy ascending uterus
Diagnosis: Clinical
Treatment:
o General measures: Monotirong, adequate large bore IV
access (>16 gauge) and an ice pack
Fluid therapy (IV crystalloid solutions)
Oxygenation
o Uterine massage and external compression
Bimanual uterine massage: clenched fist inserted
into the anterior vaginal fornix and exerts pressure
on the anterior wall of the uterus. The other hand
is positioned externally and presses against the
inner fist, located in the uterine body
Tranexamic acid: ASAP to stop fibrinolysis and to
reduce mortality
Uterotonic agents
IV oxytocin
IM Carboprost tromethamine (If no asthma,
prostaglandin analog)
IM Methylergonovine (if no HTN or arterial
disease)
Prostaglandins such as misoprostol
Speculum examination of the vagina and ervix to
evaluate possible sources of extrauterine bleeding
Intracavitary application of prostaglandin
Exclude coagulation
Uterotonics are first line treatment with decreased uterine tone
Methylergonavine should be avoided if hypertensive
o Pre-Eclampsia
Elevated blood pressure and proteinuria after 20 weeks gestation
Management
24 hour urine for quantitative measurement of protein or a spot
urine protein to creatinine ratio, blood pressure monitoring, and
laboratory evaluation (H&H, Platelets, Serum Transaminase,
Creatinine, Albumin, LDH, and Uric Acid)
o Vaccinations
Tdap
Between 27 and 36 weeks gestation to maximize the maternal
antibody response and passive antibody transfer to the infant
o Pre-Eclampsia
Place on magnesium sulfate to prevent seizures and labor should be
induced immediately
o Postmenopausal estrogen plus progesterone
Increases the risk for coronary heart disease, stroke, breast cancer,
gallbladder disease, dementia, and venous thrombosis
Dereased risk of fracture and reduced risk of endometrial cancer
o Painless Postmenopausal Bleeding
Best initial test = transvaginal ultrasonography
o Endometriosis
Diagnosis
Definitive = Laparoscopy
Treatment
Medical Therapy
o Mild to moderate: NSAIDs and Hormonal Contraceptives
o Severe: GnRH Agonists and Estrogen-Progestin OCPs
Surgical Therapy
o First Line: Laparoscopic excision and ablation of
endometrial implants
o Second Line = Hysterectomy w/ or w/o bilateral salpingo-
oophorectomy
o Precocious Puberty
Central vs. Peripheral
Differentiate with GnRH stimulation test
o Increase in LH levels >5 mIU/mL following GnRH
stimulation indicates central precocious puberty
o LH levels <5 mIU/mL indicate peripheral precocious
puberty
o Nausea and Vomiting in Pregnancy
Vitamin B6
Doxylamine
o Antepartum Hemorrhage
Abruptio Placentae
Partial or complete separation of the placenta from the uterus
prior to delivery
Epidemiology: most often in the third trimester
Etiology:
o Vascular: HTN; Pre-eclampsia/eclampsia
o Abdominal Trauma
o Sudden decrease in intrauterine pressure
o Previous abruption
o Maternal Age
o Alcohol and Cigarette Consumption
Clinical Features
o Continuous, dark, vaginal bleeding of sudden onset
o Abdominal pain or back pain; uterine tenderness
o Hypertonic contractions; Premature labor
o Fetal Distress
Decelerations on fetal heart monitor
o Vaginal exam contraindicated!
Diagnostics: Clinical Diagnosis
Treatment:
o General Approach: hemodynamic control; correct
coagulopathy; RhD Prophylaxis in RhD negative mothers
o Specific approach according to severity
Normal fetal findings and hemodynamically stable
Up to 34th week of pregnancy
o Fetal lung maturity induction with
corticosteroids
o If necessary, tocolysis (slows
progression of cervical dilation) with
nifedipine or beta 2 adrenergic
agonist
o Aim for normal delivery
34th to 36th week
o Active Uterine contractions present:
Vaginal Delivery
o No contractions + no signs of fetal
distress + bleeding stopped:
expectant management
After 36th week = deliver!!
Acute symptoms and live fetus = emergency
cesarean section
Acute symptoms + intrauterine fetal death =
vaginal delivery through pharmacological uterine
contraction inducers and opening of the amniotic
sac
Emergency C-section must be performed if
maternal risk due to severe bleeding or
slow progression of birthing process even in
the case of intrauterine fetal death
Complications
o Intrauterine Fetal Death (severe hypoxia)
o Maternal DIC and hypovolemic shock
o Couvelaire uterus
Retroplacental hemorrhage may extend through
the uterus into the peritoneum
Myometreum weakened with possible subsequent
uterine rupture during contractions
Placenta Previa
Definition: presence of the placenta in the lower uterine segment.
May lead to partial or full obstruction of the neck of the uterus
with high risk of hemorrhage (rupture of placental vessels) and
birth complications
Etiology
o Maternal age >35; Multiparity; Short intervals between
pregnancy
o Previous curettage or C-section
o Previous placenta previa
Classification
o Low lying Placenta = lower edge of placenta lies less than 2
cm from the internal cervical os
o Marginal previa = placenta reaches internal cervical os
o Partial previa = placenta partially covers internal cervical
os
o Complete previa = placenta completely covers the internal
cervical os
Clinical Features
o Sudden painless bright red vaginal bleeding
o Usually occurs during the 3rd trimester (before rupture of
the membranes) and stops spontaneously after 1-2 hours
and recurs during birth
Diagnostics
o Transvaginal ultrasound
Treatment
o Approach
<37 weeks gestational age
No active bleeding and no evidence of fetal
distress: expectant
Active bleeding or evidence of fetal distress:
immediate delivery
>37 weeks gestational age: immediate delivery
o Expectant Management
Hospitalization and observation for 48 hours
If gestational age <34 weeks: fetal lung maturity
induction with corticosteroids (betamethasone)
If mild uterine contractions present: tocolysis with
magnesium sulfate
o Route of Delivery
Lower segment cesarean section almost always
preferred
Ideally scheduled at 36-37 weeks gestation
Vaginal birth could cause severe hemorrhage due
to rupture of placental vessels
Vasa Previa
Definition: fetal vessels are located in the membranes near the
internal os of the cervix
Risk Factors: Placental anomalies; placenta previa; multiparity
Clinical Features
o Painless vaginal bleeding after rupture of membranes
o Fetal distress
Diagnostics
o Transabdominal or Transvaginal ultrasound with color
Doppler
Treatment = Emergency Cesarean if signs of fetal distress
o Chancroid = Haemophilus ducreyi
o Chancre = primary syphilis
o Granuloma inguinale
Painless nodules
Klebsiella granulomatis
o Vulvar and Vaginal Cancer
o Screening
High Blood Pressure = >40 years old
Flexible Sigmoidoscopy = every 5 years
Pap smear = every 3 years in women 21-29 years of age
Fecal occult blood test = older than 50 years of age
DEXA = all women > 65 year of age to screen for osteoporosis
Colonoscopy = every 10 years starting at 50 years old
Lipid profile = 45-75 years old with an ASCVD 10 year risk >10%
Blood Glucose Screening = 40-70 years old
HIV = 13-64 years
Mammography = routine mammograms every 2 years in women 50-74
years of age.
o Endometriosis – diarrhea, dyschezia, and hematochezia
o Cervical trauma
Postcoital bleeding
o Childbirth
o Genital Herpes
Painful ulcers on an erythematous base
Bilateral tender inguinal lymphadenopathy
o Ovarian Tumors ***
Epithelial Tumors
Cystadenoma/Cystadenomcarcinoma
o Serous
o Mucinous
Endometrioid Carcinoma
Germ Cell Tumors
Teratoma
o Mature
Dermoid Cyst
Struma Ovarii
o Immature
Dysgerminoma
Yolk Sac Tumor of the Ovary
Non-Gestational Choriocarcinoma
Sex Cord Stromal Tumors of the Ovary
Estrogen Producing
o Granulosa Cell Tumor
o Theca Cell Tumor
Androgen Producing
o Sertoli-Leydig Cell Tumors
Ovarian Fibroma (Meig’s Syndrome)
Metastasis
Krukenberg Tumor
o Fetal Death
Stillbirth = after 20 weeks gestation
Placental abnormalities and obstetric complications were the largest
category
o Breast Conditions
Benign
Fibroadenoma
o Thyroid and Pregnancy
Pregnant woman with Graves Disease, Propylthiouracil is the therapy of
choice during the first trimester.
Propylthiouracil crosses the placenta less readily and is associated
with a lower risk of birth defects when compared with
methimazole. T3 and T4 levels should be checked every 3 weeks
and the dose of the PTU should be decreased once the mother is
euthyroid or only mildy hyperthyroid
Methimazole during first trimester associated with congenital
defects such as aplasia cutis, choanal atresia, esophageal atresia,
and omphalocele
During second and third trimester, methimazole is the preferred
antithyroid drug because PTU associated with a higher risk of
hepatocellular damage and agranulocytosis
o Beta Blockers in Pregnancy
Propranolol and Metoprolol safe during pregnancy
Atenolol associated with an increased risk of fetal growth restriction.
o Child Development and Milestones
the FDA currently recommends that all exclusively breastfed infants receive 400
international units of vitamin Dsupplementation per day. This supplementation
protects against hypocalcemia and rickets, a disease of bone deformities in
children due to a deficiency of vitamin D. Rickets is characterized by impaired
calcification of the bones, delayed closure of the fontanelles, frontal bossing,
prominence of costochondral junctions (“rachitic rosary”), and genu
valgum or genu varum. Children with rickets present with varying degrees
of pain, poor growth, motor delays, and an increased risk of infections.
o Hypertensive Pregnancy Disorders
Before 20 weeks gestation or prior to pregnancy or persisting beyond the
42 postpartum day is known as chronic or pre-existing hypertension
Gestational Hypertension – induced after 20 weeks gestation
Pre-eclampsia
Gestational hypertension with proteinuria, renal insufficiency,
thrombocytopenia, evidence of liver damage, and/or cerebral
edema
HELLP Syndrome = Hemolysis; Elevated Liver Enzymes; Low
Platelets
o Hemolysis (low hemoglobin; elevated LDH)
o Abdominal pain due to stretching of Glisson capsule from
hepatic swelling
o Schistocytes
Eclampsia – severe form of pre-eclampsia with convulsive seizures and/or
coma
Treatment
o Anticonvulsive Therapy
Magnesium Sulfate IV
Antidote: Calcium Gluconate IV
o HPV
16 and 18 responsible for the majority of cervical cancers; Facilitate the
transcription of proteins that alter tumor suppression upon successful
infection of cervical cells.
E2F transcription factors that promote G1 to the S phase transition are normally
inhibited by the retinoblastoma protein (Rb). High-risk types of HPV induce
production of the oncoprotein E7, which binds and inactivates Rb protein, thereby
increasing G1to S phase transition and cell proliferation. High-risk HPV also
induces the production of the oncoprotein E6, which binds and inactivates
the tumor suppressor protein p53.
Oncogenic HPV DNA induces the expression of the E6 protein, which
binds and INACTIVATES p53
o Retinopathy of Prematurity
Supplemental oxygen at birth
Higher arterial oxygen tension in a premature infant inhibits
vascularization of the peripheral retina leading to ischemia and
production of VEGF leading to neovascularization and formation of new
blood vessels that can cause hemorrhages, form fibrovascular
membranes, and ultimately lead to retinal detachment or blindness
o Prenatal Care
Frequency of checkups
Until 28th week of pregnancy = monthly
28th to 36th week = every two weeks
From 36th week to birth = every week
Initial examination (~10 weeks gestation)
Personal and family history
Gynecological examination
Blood pressure
Weight
Laboratory analysis
o CBC
o Hemoglobin (anemia)
o Blood typing (ABO and rhesus)
Rhesus negative mothers receive prophylactic anti-
D immunoglobulins at 28 weeks to prevent
alloimunization
o Urine dipstick protein testing = proteinuria
o Urine culture (asymptomatic bacteriuria)
o Screen for STDs
HIV
Syphillis
Hepatitis B surface antigen
Chlamydia
All patients <25 years of age
>25 years of age with high risk of infection
Rubella and varicella antibody testing
o PAP smear
o Ultrasound assessment of the estimated gestational age
through CROWN RUMP LENGTH
General advice
o Vaccination against seasonal influenza
o Nutritional recommendations
o Tdap vaccine during the 3rd trimester
Subsequent examinations
Weight monitoring
Blood pressure monitoring
First Trimester screening
o Screening of chromosomopathies
Physical examination
o Fundal height and position of the fetus (identified through
the first Leopold’s maneuver)
o Fetal heart monitoring
Laboratory
o Group B Streptococcus screening during 35-37 week
gestation (vaginal and rectal swab for culture and gram
staining)
o Repeat Hb from 24th week of pregnancy
o 50 g one hour oral glucose challenge test at 24-28 weeks
gestation
Positive Screening = 100 g three hour oral glucose
tolerance test (oGTT) to confirm diagnosis
Glucose would increase transport into adpiocytes
via GLUT-4
o Repeat rhesus screening = unsensitized Rh(D) negative
women should receive anti(d) immune globulin
Prenatal Diagnostics
All pregnant women should be offered noninvasive aneuploidy
screening tests (before 20 weeks gestation)
o Testing maternal serum (specific biomarkers and
ultrasound markers )
o Cell free fetal DNA testing
All pregnant women should be given the alternative option to
undergo invasive genetic testing (amniocentesis or CVS)
Non-invasive Screening Test
o First Trimester Combined Screening (11-13 weeks
gestation)
Sonographic nuchal translucency
Subcutaneous area between the skin
and cervical spine of the fetus in the sagittal
section. Nuchal translucency increases when
fluid accumulates in the area.
B-hCG in maternal serum
PAPP-A (pregnancy associated protein A
Conditions Identified
Down Syndrome/Trisomy 21: Increased
hCG, decreased PAPP-A; thickened NT
Trisomy 18: decreased hCG; Decreased
PAPP-A; thickened NT
Trisomy 13: Decreased PAPP-A; Increased
NT
Molar pregnancy: increased hCG
Ectopic Pregnancy: decreased hCG
Neural Tube Defects: Increased hCG
o Quad Screen Test (15-20 weeks gestation)
hCG; AFP; Estriol; Inhibin A
o Triple Screen (15-20 weks gestation)
hCG; AFP; Estriol
Conditions identified
Trisomy 21: elevated B-hCG; decreased AFP
and free estriol; Increased Inhibin A
Trisomy 18: decreased b-hCG; decreased
AFP and decreased free estriol;
Neural Tube Defects: normal B-hCG;
Increased AFP; normal free estriol; normal
Inhibin A
Abdominal Wall Defects
o Normal B-hCG; elevated AFP
o Sequential Integrated Test (10-13 weeks gestation
followed by 15-20 weeks gestation)
First trimester combined test plus quad screen test
o Cell Free fetal DNA testing (cff-DNA)
From 10 weeks gestation onward
Fetal DNA isolated from maternal blood specimen
for genetic testing
Invasive Diagnostic Tests
o Chorionic Villus Sampling (10-13 weeks)
Transcervical or transabdominal
o Amniocentesis (15th week of pregnancy onwards)
o Indications
Early pregnancy
Sonographic appearance of fetal nuchal
edem in 12th to 14th week of pregnancy
Maternal age >35 years
Suspected toxoplasmosis
Late Pregnancy
Determination of bilirubin levels in cases of
rhesus incompatibility
Monitoring of electrolytes in suspected
renal failure
Estimation of lung maturity in imminent
preterm delivery via lecithin-sphingomyelin
ratio
Determination of insulin levels in
gestational diabetes
Drainage of excess amniotic fluid in
polyhydramnios or amniotic fluid
o Neonatal Jaundice
Physiological Jaundice
Always unconjugated hyperbilirubinemia
Pathological Neonatal Jaundice (conjugated or unconjugated jaundice)
Conjugated
o Decreased bilirubin excretion
Intrahepatic cholestasis
Sepsis
Hepatitis A
Hepatitis B
TORCH Infection
Cystic Fibrosis
Extrahepatic Cholestasis
Biliary Atresia
Choledochal Cyst
o Intrahepatic pathology
Infectious Hepatitis
Metabolic Diseases
Dubin-Johnson Syndrome
Rotor Syndrome
Galactosemia
Alpha-1-Antitrypsin
Unconjugated
o Hemolytic
Infection or Sepsis
Hematomas
Hemolytic Disease of Newborn
RBC Structural Defects
Ineffective Erythropoiesis
Glucose-6-Phosphate Dehydrogenase Deficiency
o Nonhemolytic
Hyperbilirubinemia Syndromes
Crigler Najjar Syndrome
Gilbert Syndrome
Glucuronyl Transferase Deficiency
Increased Enterohepatic Circulation
Subtypes and Variants
Breastfeeding Jaundice
o Insufficient breast milk intake lack of calories and
inadequate quantities of bowel movements to remove
bilirubin from body increased enterohepatic circulation
increased reabsorption of bilirubin from the intestines
o Clinical Features – within 1 week of birth
o Treatment: Increase breastfeeding sessions
Breast Milk Jaundice
o Pathophysiology: increased concentrations of b-
glucuronidase in breast milk increased deconjugation
and reabsorption of bilirubin persistence of physiologic
jaundice
o Clinical Features: Onset within 2 weeks after birth
o Treatment: Continued breastfeeding and supplementation
with formula feeds
Phototherapy
Indicated in total serum bilirubin
>15 mg/dL in a 48 hour old term infant; >20 mg/dL in a 96 hour
old infant
Contraindicated in increased direct (conjugated) bilirubin
Geriatic Medicine
o Cachexia = inflammatory response with elevated cytokines + normal appetite in
early stages of starvation
o Starvation = refeeding causes a reversal of changes
Pulmonology
o COPD
Chronic airway inflammation
C: Dyspnea, Productive Cough, Expiratory Wheezing
Diagnostics
<70% FEV1/FVC Ratio
DLCO normal in patients with chronic bronchitis
Chronic low blood oxygen levels may lead to hypoxic pulmonary
vasoconstriction causing an increase in pulmonary arterial
pressure and increased pulmonary vascular resistance and RVH
eventually Right Heart Failure
Management
Continuous oxygen therapy in patients with severe hypoxemia
(oxygen saturation <90% or a PaO2 <60 mmHg)
Exacerbation: Prednisone + Albuterol; Macrolide antibiotic can
also reduce the duration and severity of the exacerbation
o Atelectasis
Etiology
Obsttuctive Atelectasis: airway obstruction (foreign body, mucus
plug, malignancy) nonventilated alveoli reabsorption of gas
in the poststenotic space lung collapse
Non-obstructive Atelectasis
o Compression Atelectasis = external space occupying lesion
that compresses the lung forcefully pushes air out of
the alveoli
o Adhesive atelectasis: surfactant deficiency or dysfunction
increases surface tension of alveoli Instability and
collapse (ARDs or RDS in premature infants)
o Cicatrization atelectasis: parenchymal scarring that leads
to contraction of the lung (Chronic Destructive Lung
Processes such as TB and fibrosis)
o Relaxation atelectasis: loss of contact between parietal
and visceral tissue (pneumothorax, pleural effusion)
o Replacement atelectasis: all alveoli in entire lobe replaced
by tumor (bronchioalveolar cell carcinoma)
Post-Operative Atelectasis – most common post operative
complications (after chest or abdominal surgery) often occurs
within 72 hours of surgery
Rounded atelectasis: folding of the atelectacic lung tissue (with
fibrous bands and adhesions ) to the pleural (asbestosis)
Clinical Features
Small number of affected alveoli Asymptomatic
Large number of affected alveoli acute dyspnea, chest pain,
tachypnea, tachycardia, and cyanosis
Dull percussion note, diminished breath sounds, and decreased
fremitus over the affected lung
Diagnostics
ABG: hypoxemia, potential low PaCO2 and respiratory alkalosis
o Non ventilated alveoli increased physiologic dead space
Chest XR and CT: evidence of lobar collapse
o Direc Signs: displacement of fissures and homogenous
opacification of collapsed lobe
o Indirect Signs:
Elevation of ipsilateral diaphragm
Displacement of the hilum and mediastinal
structures toward the affected side
Loss of volume in the affected side of the chest
Increased lucency and overinflation of the
unaffected lung; silhouetting of the diaphragm or
the heart border
Bronchoscopy (diagnostic and therapeutic)
o May be performed if the etiology is uncertain despite
imaging and mucus plugs can be removed
Treatment
Analgesia
Early mobilization
Deep breathing exercises, directed coughing, and incentive
spirometry
o Pneumonia
Pneumocystis pneumonia
Etiology
o Pathogen: Pneumocystis jirovecii
o Risk Factors:
HIV Infection CD4 < 200 /uL
Primary Immunodeficiency Disorders (SCID)
Malignancy (Leukemia, non-Hogdkin Lymphoma)
Immunosuppressive Treatment
Malnutrition
Diagnostics
o Laboratory Tests:
CD4 count <200 /uL
Elevated Beta-D-glucan
Confirmatory Test: Microscopic identification of P
jirovecii via bronchoalveolar lavage or induced
sputum with methenamine silver staining and
immunofluorescence
Treatment
o High Dose
o Hospitalization based on CURB-65 score (Confusion, Urea
>7, Respiratory Rate >30 min, BP Systolic <90 or Diastolic
<60, Age >65;
<1 = outpatient; >2 Hospitalization; >3 ICU Care
o Pleural Effusion
Diagnostics:
Blunting of the costophrenic angle
o Bronchiolitis
Lower Respiratory Tract Infection in which the bronchioles become
inflamed because of a viral infection (RSV).
Common during winter months in children <2 y/o
Clinical Features
URTI symptoms
Respiratory distress (in infants)
o Tachypnea, prolonged expiration
o Nasal flaring, intercostal retractions
o Cyanosis
Poor feeding in breastfed infants
Auscultatory findings: wheezing, crackles
Clinical Diagnosis
Treatment = Supportive (Hydration, Relief of congestion/obstruction
monitoring)
Hospitalize if:
o Toxic appearance, poor feeding, dehydration, or lethargy
o Marked respiratory distress, oxygen saturation <92%
o Age <12 and/or history of prematurity
o Heart, Lung, or Neurological Condition
o Immunodeficiency
Increased risk of developing asthma
o ARDS
o Chronic Cough
Patients with chronic cough (>3 months) are treated empirically for UACS,
GERD, and asthma.
PFT is the first step in management
Upper Airway Cough Syndrome
Abnormally increased nasal mucus secretion that drips down the back of
the throat and can lead to coughing, a feeling of obstruction in the throat,
and throat clearing. Causes include allergies, cold temperatures, viral or
bacterial infections, dry air, and certain medications.
First-line treatment includes first-generation antihistamines (e.g.,
diphenhydramine).
UACS was previously referred to as post-nasal drip syndrome.
o Obstructive Sleep Apnea
o Obesity Hypoventilation Syndrome
Diurnal alveolar hypoventilation
Resulting daytime hypercapnia and respiratory acidosis with metabolic
compensation (elevated bicarbonate)
o Chronic Pulmonary Aspergillosis
Clinical Presentation: Hemoptysis, Weight Loss, Productive Cough
Diagnostics:
XRay – Monad Sign (Fungus bal in pre-existing lung cavity).
Upper lobe mostly affected because of an increased concentration
of oxygen
o Moving from supine to prone or lateral recumbent
demonstrates mobility of the fungus ball
Laboratory Positive Sputum Culture or Positive Aspergillus IgG
Serology
o Bronchiectasis
Clinical Presentation: chronic cough, dyspnea, hemoptysis, copius
amounts of sputum, crackles
Exacerbated by acute respiratory tract infections
Diagnostics:
XRay: Fibrosis of the bronchial walls = tram track lines and
increased translucency
Confirmed by CT scan
o Acute Tonsillitis
Diagnostics
Gold standard = throat culture for antibiotic sensitivity
o Asthma ***
Can be triggered by viral respiratory infections and is exacerbated by
exercise
Treatment
Beta-2 agonists
Inhaled corticosteroids
Leukotriene pathway modifiers
Omalizumab
o Anti-IgE antibody that binds to serum IgE
o Reduces serum levels of IgE to prevent binding of IgE to
high affinity IgE Receptors (FCERI) on mast cells and
basophils
Methylxanthines
Mast-Cell Stabilizers
o Cancer
Nodules on CXR
CT Scan
o <4 mm Follow up in 12 months
o 4-6 mm 6-12 months
o 6-8 mm 3-6 months
o >8 mm PET scan
Biopsy
o CT guided transthoracic biopsy
o Bronchoscopy with transbronchial biopsy
Squamous Cell Carcinoma of the Lung
Most common type of lung cancer in smokers
Central located cavitary lesions
Associated with paraneoplastic syndromes (Hypercalcemia)
Fatigue, Weight Loss, Hemoptysis
o Cystic Fibrosis
Etiology
Defective CFTR protein (most common is DeltaF508 on
chromosome 7)
Pathophysiology
Mutated CTFR misfolded protein retained protein in RER
unable to reach cell membrane defective chloride channel
inability to transport intracellular chloride ions across the
membrane exocrine glands produce hyperviscous secretions
accumulation of secretions and blockage of exocrine glands
chronic inflammation organ damage
Clinical Features
Gastrointestinal
o Meconium ileus
o FTT
o Pancreatic Disease
Pancreatitis
Exocrine Pancreatic Insufficiency
Foul smelling steatorrhea
Malabsorption
Abdominal Distenion
Diarrhea
ADEK Deficiency
o Liver and Bile Duct Abnormalities
Cholecytolithiasis, Cholestasis
Fatty metamorphosis of the liver eventually
progressing to liver cirrhosis
Biliary cirrhosis with portal hypertension
o Intestinal Obstruction
Abdominal distention
Respiratory
o Obstructive Lung Disease
o Chronic Sinusitis – nasal polps may eventually develop
o Recurrent or chronic productive cough and pulmonary
infections with characteristic microorganisms
Dangerous bacteria (Pseudomonas aeruginosa)
Expiratory wheezing (obstruction), barrel chest,
moist rales (pneumonia), hyperresonance to
percussion
Signs of chronic respiratory insufficiency: digital
clubbing
o Airway hyperreactivity
Sweat Glands
o Salty Tasting Sweat
Musculoskeletal
o Kyphoscoliosis
Urogenital
o Urinary
Nephrolithiasis, Nephrocalcinosis
Frequent UTIs
o Genital
Males
Obstructive azoospermia
Vas deferens may also be absent
Female
Viscous cervical mucus may obstruct
fertilization in females
Diagnostics
General
o Best initial test is the sweat chloride test
Diagnostic Criteria
Neonatal Screening
o Elevated Immunoreactive Trypsinogen (IRT)
Detects elevated levels of IRT in heel-prick blood
o DNA Assay
Laboratory Tests
o Quantitatve Pilocarpine Iontophoresis
Chloride Levels > 60 mmol/L on two or more
occasions are consistent with CF
o DNA Analysis
Prenatal – Via chorionic villus sampling or
amniocentesis
Postnatal/adult analysis
o Nasal Potential Difference Test
Supportive Tests
o Stool: Decreased chymotrypsin and pancreatic elastase
o Chest XR/CT: Hyperinflation
o PFTs: Decreased FEV1:FVC ratio and Increased RV and
TLC
Treatment
Symptomatic Management
o Respiratory
Hypertonic saline nebulization or dornase alpha
(mucolytic agent)
Bronchodilator
Chest Physiotherapy
Chronic Rhinosinusitis = Intranasal glucocorticoids
Mucolytics (N-acetylcysteine)
Chronic Respiratory Insufficiency
Long Term Oxygen Inhalation Therapy
o Diet
Additional Sodium Chloride Intake
High energy diet
Pancreatic enzyme supplements
Oral supplementation of lipophilic vitamins A, D,
E, K
Pulmonary Infections
o Infants
Staphylococcus aureus = IV Vancomycin
o Adults
Pseudomonas aeruginosa = Inhaled tobramycin
Preventative Measures
o Annual influenza vaccine for all CF patients > 6 months
with inactivated influenza vaccine
o Pneumococcal vaccine
o Palivizumab: antibody for RSV for infants < 24 months
Provides passive immunization to RSV infection
Indication: infants at risk for severe bronchiolitis
Complications
Gastrointestinal
o Meconium ileus
Failure to pass the first stool in neonates
CF (90%)
Clinical Findings:
Distal small bowel obstructions
Bilious vomiting
Abdominal Distention
No passing of meconium or stool
Diagnostic
Abdominal X-Ray
o Dilated small bowel loops,
microcolon, Neuhauser Sign
Treatment
Enema with a contrast agent
Respiratory
o Hemoptysis
o Allergic Bronchopulmonary Aspergillosis
o Pulmonary Emphysema
Pneumothorax
Cor Pulmonale
o Interstitial Lung Disease
Excess collagen deposition in the extracellular matrix of the lung
Diffuse thickening of the alveolar walls result in progressive fibrosis of
the lung parenchyma, which in turn causes reduced vital capacity, and the
dyspnea, chronic dry cough, and fatigue
o Pleural Scarring
Pediatrics
o Neonatal Thyrotoxicosis
Usually resolves within 12 weeks when maternal TRAbs disappear
Treatment includes methimazole and beta blocker
Transplacental passage of TSH receptor antibodies
o Vaccinations
o Tetralogy of Fallot
o Puberty
Idiopathic Central Precocious Puberty
Elevated GnRH levels
Treatment = Leuprolide or Buserelin
o Growing Pains
o Legg-Calve-Perthes Disease
o Fever
Most common in any child younger than 29 days should undergo a
complete sepsis workup and be admitted for observation
Most common bacterial organism = Group B Streptococcus and
Escherichia coli
Broad empiric coverage with ampicillin and cefotaxmine
recommended
o RSV Bronchiolitis
Upper respiratory tract infection followed by cough and signs of
respiratory distress (nasal flaring, intercostal retractions, Rhinorrhea,
Cough, Wheezing, Mild Tachypnea, Expiratory wheezes)
Treatment = Hydration and Supplemental Oxygenation
Nebulized hypertonic saline
o Acute Otitis Media
Treatment = Amoxicillin/Clavulanate
Prophylactic antibiotics not recommended
o Atopic Dermatitis
Clinical Features
Infantile AD
o Eczema: over the cheeks, face, head, and extensor
surfaces of the extremities that usually spares the diaper
area (begin as cradle cap)
o Dennie-Morgan Fold : increased folds below the eye
Childhood AD
o Eczema: Flexural creases (antecubital and popliteal
fossae), skin folds, extensor surfaces of hands
o Lichenified lesions (thickening of the skin with accentuated
skin markings
Adult AD
o Lichenified lesions and pruritis of flexor surfaces of the
extremities
o Also:
Nummular eczema (coin shaped lesion)
st
Treatment = 1 line is topical corticosteroids
o Croup
Swelling of the larynx causing a barking cough
Treatment = Epinephrine then Oral dexamethasone
o Whooping Cough
Catarrhal stage = Viral URI
Paroxysmal stage = severe coughing spells that occur in paroxysms
followed by the inspiratory whoop
Post-tussive emesis
Nasopharyngeal culture and PCR
Dermatology
o Impetigo
Etiology:
Staphylococcus aureus: Bullous and nonbullous impetigo
Strep pyogenes (GAS)
Clinical Features
Nonbullous impetigo
o Lesions: Papules Small vesicles surrounded by erythema
pustules that rupture oozing secretion that dries
honey colored crusts heal without scarring
Negative nikolsky sign
o Localization: Face, especially around the nose and mouth
Bullous impetigo
Ecthyma
Systemic Signs
o Staphylococcal Scalded Skin Syndrome
Etiology
Staphylococcus aureus strains that produce exfoliative toxins
o Toxins A and B cleave desmoglein 1 in the granular layer of
the epidermis, thereby disrupting keratinocyte
attachments
o Vitiligo
Autoimmune destruction of melanocytes
o Psoriasis
Epidemiology: Age of onset 20-40 years old
Etiology: Polygenetic
Infectious (B-hemolytic streptococci, staph, HIV); Mechanical
Irritation; Drugs (Beta Blockers, Chloroquine, Lithium, Interferon)
Pathophysiology
Increased proliferation of keratinocytes
o Acanthosis: thickening of epidermis
o Parakeratosis: retention of nucleated keratinocytes in
stratum corneum
T Cells
Clinical Features
Course: Relapsing with symptom free intervals
Well-demarcated, erythematous lesions and silvery white scaling
plaques
o Mainly on scalp, back, elbows, and knees (Extensor
surfaces)
o Pruritis
Involvement of nails
o Nail pitting
o Oil drop sign
o Brittle nails
o Onycholysis
Subtypes
o Psoriatic Arthritis
Definition: Inflammation of joints
Clinical Features
Oligoarthritis
Enthesitis (where tendons attach to bone)
Tenosynovitis
Dactylitis (sausage digit)
Diagnostics
Evidence of psoriasis
Psoriatic nail dystrophy
Negative rheumatoid factor
Dactylitis
Radiologic Signs
o Pencil in Cup Deformity
o Asymmetric Paravertebral
Ossification
Treatment
NSAIDs
Moderate to Severe: DMARDs
Physical Therapy
o Cutaneous Variants
Plaque Psoriasis: symmetrically distributed, thick,
scaly, erythematous lesions
Guttate psoriasis: size of drops of water; mainly in
children and adolescents after streptococcal
infection (URTI)
Erythrodermic psoriasis: generalized erythematous
lesion with diffuse scaling; lead to fever and
dehydration
Ivnerse psoriasis: may affect skin folds and flexural
creases of large joints
Diagnostics
o Koebner Phenomenon – skin injury lead to skin lesions
typical of underlying condition
o Auspitz Sign = small pinpoint bleeding when scales scraped
off
o Skin Biopsy
Parakeratosis
Munro microabscesses
Acanthosis
Spongiotic Dermatitis
o Laboratory Tests
Elevated ESR & CRP
Treatment
o Mild to Moderate:
First Line: Moisturizers & Topical Medications
Steroids; Vitamin D Derivatives
(Calcipotriene); Tar Preparations; Retinoids;
Vitamin A Derivatives
o Moderate to Severe
Topical Medications
Systemic Agents (Methotrexate, Retinoid,
Cyclosporine), Phototherapy
o Severe Psoriasis
Topical + Systemic Treatment
Phototherapy
Antiproliferative effects and anti-
inflammatory effects
UVB
PUVA (Psoralen + UVA)
o Photodermatoses
Zinc Oxide
o Scabies
Treatment: Permethrin
Binds to voltage gated sodium channels to delay repolarization of
neuron cell membranes which causes paralysis and death of the
mite
o Contact Dermatitis
Type IV Hypersensitivity Reaction
Diagnosis = Patch Test
Treatment
Mild to Moderate = Topical corticosteroid, oatmeal bath, soothing
lotion, wet ressing, topical antihistamine
Severe = Systemic corticosteroids, Systemic Antihistamines
o Pityriasis Rosea
Differential Diagnosis = Drug Eruptions, Secondary Syphilis, Guttate
Psoriasis, Erythema MIgrans
o Lichen Simplex Chronicus
Treatment
Moisturizers and/or calamine lotion
Topical glucocorticoids, calcineurin inhibitors, capsaicin,
antihistamines
Systemic H1 Antihistamines
o Benign Skin Lesions
Vascular Skin Tumors
Cherry Hemangioma
o Epidemiology: Increases with Age
o Pathophysiology: Proliferation of dilated mature capillaries
o Clinical Features: Bright cherry red, dome shaped papules
or macules
Strawberry Angioma = benign vascular tumor of
infancy/childhood
Pyogenic Granuloma
o Definition: Benign vascular tumor
o Etiology: Associated with trauma and pregnancy
o Clinical Features: soft, round, bright red tumor that bleeds
easily
o Diagnostics: Clinical
o Treatment: Surgical Excision
Hypertrophic Scars
Definition: High fibroblast proliferation and collagen production as
excessive skin tissue response to penetrating trauma; Does not
grow beyond the boundaries of the original lesion
Etiology: Imbalance in wound healing processes
Clinical Features: Raised scar tissue; Pruritis
Diagnosis: Clinical
Treatment
o Medical Therapy
1st Line: Intralesional Steroid Injection
o Surgery: Cryotherapy; Laser; Surgical Excision; Light
Therapy
Keloid Scars
Caused by high fibroblast proliferation collagen production as
excessive skin tissue response to typically small skin injuries
GROWS BEYOND THE BOUNDARIES OF THE ORIGINAL LESION
Does not regress spontaneously
Recurs after resection
Etiology: Imbalance in wound healing
Clinical Features: Scar tissues of varying consistency that may be
brownish-red in color; Pruritis; Localization: earlobes, face, neck
Diagnostics: Clinical appearance of lesion
Treatment: Same as for hypertrophic scars
Warts
Definition: Hyperkeratosis and hyperplasia of epidermis
commonly caused by human papillomavirus
Epidemiology: children and young adults
Clinical Features
o Common Warts (Verruca vulgaris)
Localized to elbows, knees, fingers, palsm
Appearance: skin colored or whitish, rough, scaly
papules or plaques (cauliflower like appearance)
o Flat Warts (Verruca Plana)
Localized to face, back of hands, legs
Appearance: Flesh colored, smooth papules, flat
surface
o Plantar Wart (verruca Plantaris)
Localized to soles of the feet
Appearance: Flesh colored, hyperkeratotic surface
o Treatment: Salicylic Acid; 5-FU; Topical Retinoic Acid;
Cryotherapy or Surgical Excision
Seborrheic Keratosis
Histology: Immature keratinocytes with small keratin filled cysts
(horn cysts)
Clinical Features: Multiple darkly pigmented papules/plaques,
sharply demarcated and soft
o Greasy, wax like stuck on appearance
o May be irritated by external trauma or spontaneously
o Localization: Trunk, back of hands, face, and neck
Diagnosis:
Treatment: Not necessary
Dermatofibroma
Definition: Fibroblast proliferation resulting in small, fibrous
benign dermal growth
Clinical Features: Asymptomatic; Slowly growing skin colored or
brownish nodules of ~3-10 mm diameter
Localization: lower extremities
Diagnostics: Dimple Sign
Nevus
Lipoma
Melasma
Acanthosis Nigricans
Solar Lentigo
o Cancerous Lesions
Basal Cell Carcinoma
o Acne Rosacea
Treatment = Doxycycline
o Tinea Capitis
Treatment = Oral griseofulvin
o Intertrigo
Skin inflammation caused by skin on skin friction. Facilitated by moisture
trapped in deep skinfolds where air circulation is limited
Treatment: keep skin clean and dry, evaluate for infection
o Tinea versicolor
Commonly caused by increased growth of Malssezia globose
Abnormal pigmentation involving the trunk, back, and/or abdomen
following a history of travel to a humid and warm place such as the
Caribbean
Lesions become more apparent after UV exposure or tanning because the
surrounding skin gets darker, which provides greater contrast to the
lesions
KOH Preparation
o Epidermoid Cyst
Firm, mobile, slow-growing nodule arising from the epidermis
o Autoimmune Blistering Diseases
Pemphigus Vulgaris
Autoimmune blistering caused by autoantibodies against
desmosomal adhesion proteins including desmoglein 3 and
desmoglein 1
Medicatinos such as captopril, glyburide, thiol containing drugs
(penicillamine) and phenol containing drugs (cephalosporins,
rifampicin, phenobarbital, aspirin) can induce the formation of
these autoantibodies
Desmosomal adhesion proteins enable keratinocyte adherence,
damage to these proteins causes intraepidermal bullae formation
and positive Nikolsky sign
Occur first on mucous membranes and an become confluent or
erode to form painful ulcers
o Collection of Dermatological Disorders
Sebaceous and Epidermoid Cysts
Cat Scratch Disease
Millaria
Nummular Eczema
Livedo reticularis
Xeroderma pigmentosum
Pseudofolliculitis barbae
Most common in black males
Pathophysiology
o Extrafollicular penetration: hair enters interfollicular
epidermis after it exits the follicular orifice
o Transfollicular penetration: hair penetrates the dermis
before exiting the follicular orifice
Clinical Findings
o Firm, hyperpigmented, tender, pruritic papules and
pustules on hair growing areas
Treatment
o Cessation of shaving; alternative hair removal techniques
o Adjunctive: Topica (retinoids, corticosteroids,
antimicrobials)
Albinism
Rheumatology
o Rheumatoid Arthritis ***
Presentation
Affects wrists and other extremity joints that have a high ratio of
synovium to articular cartilage
Diagnostics
Anti-CCP antibody (highly specific marker)
IgM Autoantibodies targeting Fc region of IgG
Imaging
o Early: Soft Tissue swelling
o Late: Joint Space Narrowing, Erosions of Cartilage and
Bone;
Treatment
Acute Inflammatory Therapy
o Indication: Acute Attack
o Glucocorticoids
o NSAIDs and COX-2 Inhibitors
Long Term
o Methotrexate
Folic Acid given 24-48 hours after to minimize side
effects
o Biologic Therapy
TNF-alpha inhibitors (adalimumab, infliximab,
etanercept)
Complications
Atlanto-axial Subluxation
o Pain/Stiffness of the Neck
o Cervical Radiculopathy
o Diagnostic: Extension/Flexion X-rays of the Cervical Spine
o Ankylosing Spondylitis
Etiology
90-95% HLA-B27
Clinical Features
Articular symptoms
o Back and Neck Pain
Morning stiffness that improves with activity
o Limited mobility of the spine (especially forward lumbar
flexion)
o Inflammatory enthesitis
Extra-Articular Manifestations
o Most common: Unilateral anterior uveitis
o GI Symptoms
o Prostatitis
o Fatigue
o Restrictive Pulmonary Disease
Diagnostics
Differential Diagnosis
Treatment
NSAIDs
TNF-Alpha Inhibitors (Etanercept)
Complications
Uveitis
o Presentation = Painful red eye with conjunctival injection,
photophobia, and sluggishly reacting pupil
o Treatment = Topical corticosteroids
o Sarcoidosis
Epidemiology: Bimodal Distribution
Pathophysiology: T Cell Dysfunction and increased B Cell Activity;
Formation of non-caseating granulomas commonly within the lungs and
lymphatic system
Clinical Features
Acute Sarcoidosis
o High fever, malaise, lack of appetite, weight loss
o Pulmonary dyspnea, cough, chest pain
o Extrapulmonary: Arthritis, anterior uveitis, erythema
nodosum
Chronic Sarcoidosis
o Pulmonary (Most Common)
Dry cough, exertional dyspnea
o Extrapulmonary
Common
Peripheral Lymph Nodes
Iridocyclitis
Skin:
o Lupus pernio
o Scar Sarcoidosis
o Other Manifestations: MSK, Bone Lesion, Nervous, Heart,
Liver, Kidney, Spleen (GRUELING – granulomas, arthritis,
uveitis, erythema nodosum, lymphadenopathy, interstitial
fibrosis, engative TB, gammaglobulinemia
o Granulomatosis with Polyangitis
c-ANCA
o Drug Induced Lupus
SHIPP Hydralazine; Procainamide
o Gout
Etiology
Deposition of urate crystals in the joints
Hyperuricemia predisposes to gout (end product of purine
metabolism that is renally excreted)
o Insufficient excretion or increased production leads to
hyperuricemia
Primary Hyperuricemia
Idiopathic extracellular supersaturation of uric acid
Secondary Hyperuricemia
Decreased uric acid excretion
o Medications (pyrazinamide, aspirin, loop diuretics,
thiazides, niacin)
o Chronic Renal Insufficiency; Lead nephropathy
o Ketoacidosis (starvation, Diabetes mellitus, lactic acidosis)
Increased uric acid production
o High cell turnover (Tumor Lysis Syndrome, Hemolytic
Anemia, Psoriasis, Myeloproliferative Neoplasms)
o Enzyme defects (Lesch Nyhan, PRPP Synthetase
overactivity, von Gierke Disease
o High Protein Diet
o Obesity
Combined decreased excretion and overproduction (high alcohol
consumption)
Pathophysiology
Uric acid has poor water solubility
Clinical Features
Asymptomatic Stage
Acute Gouty Arthritis
o Usually monoarticular
Acute severe pain with overlying erythemia,
decreased ROM, swelling, and warmth
More likely to occur at night, typically waking the
patient
Joint may present with desquamation of the
overlying skin
o Location: Peripheral small joints in the lower extremities
Podagra (MTP inflammation)
Gonagra (knee)
Chiragra (finger joints, especially the thumb)
Intercritical Stage
Chronic Gouty Arthritis
o Progressive joint destruction
o Tophi formation
Multiple painless hard nodules with possible joint
deformities
Bone tophi – urate crystal deposition in bones
Soft tissue tophi – urate crystal deposition in the
pinna of the external ear, subcutis, tendon sheaths,
or synovial bursas
Diagnostics
Arthrocentesis
o Needle shaped negatively birefringent monosodium urate
crystals
o WBC >2000 /uL with >50% neutrophils
Laboratory Tests
o Elevated serum uric acid
o Typical in acute attacks: Increased WBC and ESR
Imaging
o Ultrasound – Double contour sign (hyperechoic
monosodium urate crystals)
o MRI – Excellent to detect tophi formation
o CT – bone erosions
o XRay – Chronic gout only – punched out lytic bone lesions
Treatment
Acute Gout Attack
o NSAIDs (Indomethacin, Naproxen, Ibuprofen)
Aspirin contraindicated because it inhibits uric acid
excretion, thereby delaying the cessation of
symptoms
o Colchicine
Inhibition of microtubule polymerization – inhibits
phagocytosis of urate crystals, leukocyte activation
and micragion, and cell chemotaxis
Use in patients who cannot tolerate NSAIDs (CKS or
GI Ulcers) or glucocorticoids
Side effects: Diarrhea, Nephrotoxicity, and
Myelosuppression
o Oral Glucocorticoids
Indications: No response or contraindication to
NSAIDs and Colchicine
o Proton Pump Inhibits should be given to patients being
treated with both NSAIDs and Glucocorticoids to avoid
gastrointestinal ulcers
o Intra-articular corticosteroid
Indications: single joint involvement
Chronic Gout
o General Measures: Weight Loss, Purine Restricted Diet,
Reduce Alcohol Consumption; High fluid intake; Consume
dairy products, Vitamin C, and Coffee
o Medical Therapy
Indications
Recurrent Gout (more than 2 gout attacks
per year)
Uric Acid Nephropathy
Tophi Development
Serum Uric Acid >9 mg/dL
General Approach
Delay initiation of urate lowering
medications until ~2 weeks after an acute
attack has resolved
Urate lowering medications may trigger or
prolong an acute gout attack
st
1 Line Treatment: Xanthine Oxidase Inhibitors
(Allopurinol)
Mechanism of Action: Reversible inhibitor
of xanthine oxidase hypoxanthine and
xanthine will not be degraded into uric acid
Side Effects: Skin Reaction; TEN; SJS
Indications: Chronic Gout and/or
hyperuricemia >9 mg/dL; Hyperuricemia
Prophylaxis (TLS)
Contraindications: Acute Gout Attack
Previous hypersensitivity; Kidney Disease
(Dose adjustment)
Interactions: Increased bone marrow
toxicity with purine analog (6-
mercaptopurine and azathioprine)
nd
2 Line Treatment (Benzbromarone, Probenecid,
Lesinurad)
Mechanism of Action: Inhibition of Uric Acid
Reabsorption along renal tubules --.
Increased renal elimination
Notable side effects: Urolithiasis; GI
symptoms; Rash
Indication: In combination with allopurinol
Contraindications: Acute Gout Attack;
Kidney Disease
Recombinant Uricase (Rasburicase)
Mechanism of Action: Catalyzes the
breakdown of uric acid to allantoin (water
soluble)
Side Effects: Infusion Reactions
(premedications administered as
prophylaxis e.g. hydrocortisone and
antihistamine)
Indications: Rapid relief desired; No benefit
from 1st and 2nd line
Contraindications: Acute Gout Attack; G6PD
Deficiency (causes hemolytic crisis due to
production of hydrogen peroxide)
Allopurinol + Azathioprine leads to INCREASED
BONE MARROW TOXICITY
During first 2 weeks of an acute gout attack,
treatment with allopurinol should not be initiated
or altered can lead to urate crystal mobilization
which worsens the symptoms!
Complications
o Nephrolithiasis: Uric Acid Stones
o Uric Acid Neprhopathy
Chronic Tubulointerstitial Nephropathy with
Monosodium urate crystal deposition in the stroma
of the kidney Inflammatory process
Clinical Presentation: Hypertension; Renal Failure
(rare)
Acute Uric Acid Nephropathy: Possible in TLS
o Pseudogout
Paroxysmal joint inflammation due to calcium pyrophosphate crystal
deposition (calcium pyrophosphate dehydrate)
Epidemiology (Adults >50 y/o)
Etiology: mostly idiopathic
Secondary form: joint trauma, familial chondrocalcinosis,
hyperparathyroidism, hemochromatosis, gout,
hypophosphatemia
Clinical presentation
Often asymptomatic
Acute (pseudogout attack): monoarthritis (rarely oligoarthritis),
mostly affecting the knees and other large joints (hips, wrists, and
ankles)
Diagnostics
Arthrocentesis:
o Polarized light microscopy: detection of rhomboid shaped,
positively birefringent CPPD crystals
o Synovial fluid: 10,000 – 50,000 WBCs/ uL with >90%
neutrophils
X-Ray Findings: Cartilage calcification of the affected joint
(chondrocalcinosis)
o Fibrocartilage (meniscus, annulus fibrosus of IV disc) and
hyaline cartilage (joint cartilage)
Test for hypercalcemia
Treatment
Asymptomatic: No treatment
Symptomatic Treatment
o Best initial treatment: NSAIDs
o Alternative: Colchicine or Intra-articular Corticosteroids
Arthroscopic Lavage
Possible Joint Replacement
o Inflammatory Myopathies
Etiology
Polymyositis: cell mediated cytotoxicity against unidentified
skeletal muscle antigens, chiefly affecting the endomysium
Dermatomyositis: idiopathic or paraneoplastic antibody-mediated
vasculopathy associated with malignancy (NHL; Lung, Stomach,
Colorectal, Ovarian)
Clinical Features
Proximal Muscle Weakness
o Pelvic and Shoulder Girlde muscles most common
o Difficulty combing hair, standing up, climbing stairs
o Dysphagia
Muscle Tenderness
Cutaneous Manifestations of Dermatomyositis
o Gottron Papules
Extensor surface of the hands
o Heliotrope rash: erythematous rash on the upper eyelids
o Midfacial erythema
o Photosensitive poikiloderma
Shawl sign
V Sign
Cutaneous Manifestations of Inclusion Body Myositis
o Asymmetric muscle involvement of both proximal and
distal muscle groups
Diagnostics
PM Diagnostic Criteria
o Proximal Muscle Involvement
o Positive laboratory findings
o EMG suggestive of inflammatory myopathy
Laboratory Test
o Increased muscle enzymes
Increased CK and Aldolase
Elevated Enzymes: Myoglobin, LDH, AST, ALT
o Inflammatory Markers: Increased ESR, CRP, Leukocytosis
o Antibodies
ANA
MSA: Anti-Mi-2; Anti-Jo-1
Other
o EMG
o Imaging
o Muscle Biopsy
PM: Cell Mediated Inflammation, Intrafascicular
Infiltration of Cytotoxic CD8+ T cells
DM: Antibody Mediated Inflammation involving
parafascicular and perivascular infiltration with
plasmacytoid dendritic cells and B lymphocytes
Inclusion Body Myositis: Endomysial Inflammation
+ Intramuscular Vacuoles
Infectious Disease
o HIV ***
Prophylaxis
CD4 <200 = Trimethoprim Sulfamethoxazole for Pneumocystis
pneumonia
CD4 <100 = Toxoplasma gondii
CD4 <50 = Mycobacterium avium intracellulare complex
Neurosurgery
o CSF Rhinorrhea
Leakage of CSF from the anterior nares
o Meningioma
Neurology
o Neurocutaneous Syndromes (Phakomatosis – neuro-oculo-cutaneous syndromes
= derived from ectoderm)
Autosomal Dominant or Spontaneous
Neurofibromatosis Type I
o Melanocyte Dysfunction
Café au lait spots
Lisch Nodules
Axillary and inguinal Freckling (Hyperpigmentation)
o Multiple Neurofibromas
Soft Painless Nodules
Seizure when CNS involved
o Scoliosis
o Bone Involvement
o Optic Gliomas
o Associated with Pheochromocytoma and Wilms Tumor
Neurofibromatosis Type II
o Bilateral Vestibular Schwannomas (acoustic neuromas)
ipsilateral tinnitus, hearing loss, vertigo
o Multiple cerebral and spinal tumors
o Meningioma
Pheochromocytoma
o Contraindications
Selective beta blockers, Metoprolol
Tuberous Sclerosis
o Intellectual Disability
o Infantile Spasms or Seizures
o Skin Manifestations
Adenoma sebaceum
Ash leaf spots
Shagreen patch
o Small Benign Tumor
Brain tumors
Hamartoma
Giant Cell Astrocytoma
Cardiac rhabdomyoma
Renal cysts of renal angiomyolipoma
Ungual fibroma
Von Hippel-Lindau Disease
o Hemangioblastomas
o Bilateral Renal Cell Carcinoma
o Pheochromocytoma
Autosomal Recessive: Ataxia Telangiectasia
Progressive cerebellar ataxia
Telangiectasias on the face and conjunctivae
Decreased immunocompetence
Febrile Seizures
Definition: Seizures associated with fever (>100.4 F) in absence of
CNS infection, metabolic abnormalities, or history of afebrile
seizures
Epidemiology: Peak incidence common between 6 months and 5
years of age
Clinical Features
o Simple Febrile Seizure
Generalized, usually tonic-clonic seizures
Symmetrical
Duration: <15 minutes; Maximum of one seizure
within 24 hours
Age: 6 months to 5 years
Post-Ictal Phase
Quick return to normal
Confusion and drowsiness may be present
for a short period of time
Prolonged drowsiness or deviated eyes may
be a sign of other etiology
o Complex Febrile Seizure
Focal onset
Pronounced on one side of the body
Transient hemiparesis and speech impairment
Duration: > 15 minutes; > 1 seizure within 24 hours
Diagnostics
o Simple febrile seizures do not require specific diagnostic
workup
o Focus on identifying the cause of fever
o Complex febrile seizures always require specific
investigative tests (EEG and imaging)
o Determine cause of fever
Physical Exam
UA and Urine Cultures
Blood Tests (CBC w/ diff, CRP, Electrolytes, Blood
Glucose)
Imaging to locate source of infection (U/S, X-Ray)
Toxicology if suspected
o Additional diagnostic steps: for complex febrile seizures
and/or abnormal neurological exam
Lumbar puncture Exclude meningitis and/or
herpes encephalitis
EEG
Imaging
Treatment
o Uncomplicated seizures resolve after a few minutes
spontaneously
o Abortive Therapy
Treatment of Choice: IV Lorazepam
Repeat medication after 5 minutes
o Reassure caregivers and provide information
o After a febrile seizure, initiate antipyretic therapy (NSAIDs
and acetaminophen) at an early stage (temperatures from
100.4 F) as they restore the central thermoregulatory
setpoint back to normal by reducing the synthesis of
prostaglandin E2
Non-inherited: Sturge Weber Syndrome
Port wine stain
Vascular malformation of chroic and CNS
o Early onset glaucoma
o Epilepsy or epileptic spasms in infancy
o Intellectual Disability
o Myotonic Syndromes
Epidemiology: Myotonic Dystrophy Type I: Congenital, Juvenile, or Adult;
Myotonic Dystrophy Type II: Usually Adult Onset
Clinical Features
Myotonic Dystrophy
o Meningitis
o Leukocoria “Cat’s eye pupil”
All patients with leukocoria should undergo prompt fundoscopic
examination to rule out retinoblastoma
White mass in the retina on fundoscopy
o Retinoblastoma
Clinical Features
Leukocoria (white fundal reflex
Strabismus
Painful, red eye
Loss of vision
Retinal Detachment (later stage)
Diagnostics
Fundus examination: grayish white, vascularized retinal tumor
Molecular genetic testing of leukocytes for mutations in the RB1
gene recommended for all patients with retinoblastomas
Differential Diagnosis
Leukocoria is considered a retinoblastoma until proven otherwise;
a fundus examination of an infant presenting with leukocoria
should be conducted as quickly as possible
Treatment
Low Risk Retinoblastoma:
o Cryotherapy; Photocoagulation; Brachytherapy
High Risk Retinoblastoma: Chemotherapy
If eye not salvageable
o Enucleation
o Adjuvant systemic chemotherapy
Increased risk for osteosarcoma
o Parkinson’s Disease
Treatment
First Line = Pramipexole or Ropinirole
o Trigeminal Neuralgia
Treatment
Conservative Therapy
o Drug of Choice: Carbamazepine
Surgical Treatment: Microvascular Decompression or Ablative
Therapy
o Cerebellar Syndromes
Etiology
Acute
o Infarction, TIA
o Head Trauma, Edema, Hemorrhage
o Infections
Adult: VZV, EBV, Lyme, Tertiary Syphilis, Malaria
Children: VZV, Coxsackievirus, Parvo B19, HHV-6,
HAV, Enterovirus, Measles, Mumps, Lyme Disease
o Medications, toxins, poisons: Barbiturates,
benzodiazepines, heavy metals, chemotherapy
Subacute/Chronic
o Alcoholism
o Intracranial tumors
o Vitamin Deficiency: Vitamin B12, Vitamin B1 (Wernicke)
o Paraneoplastic Cerebellar Degeneration
o Genetic: Spinocerebellar Ataxia, Friedrich Ataxia, Ataxia
Telangiectasia
o Multiple Sclerosis
o Wilson Disease
Clinical Features
Cerebellar Ataxia
o Gait Ataxia: Abnormal wide based, and unsteady gait;
irregular, uncoorindated movements of the limbs
Romberg Test: Unable
Unterberger: Positive
o Truncal Ataxia: Inability to sit upright and/or stand without
support
Dysmetria and tremor (postural, action, intention tremor)
o Finger to Nose Test: Patient unable to touch tip of nose
with index finger
o Heel Knee Shin: inability to slide heel of one foot down the
shin of the opposite leg; heel will deviate to alternate sides
Dysdiadochokinesia
o Inability to perform rapidly alternating agonistic-
antagonistic movements
o Rapid alternating movement test: unable to rapidly screw
in an imaginary light bulb simultaneously with both hands
Rebound phenomenon
o Patient bends arm at elbow resisting examiner’s pull on
the forearm. Sudden release of arm by examiner results in
overshooting movement
o Indicates impaired coordination between muscular
agonists and antagonists
Pronator Drift: Stretch supinated arms out in front of them at
shoulder level; arm ipsilateral to the lesion will pronate and drift
upwards
Dysarthria (Scanning speech): Words are broken down into
separate syllables
Oculomotor dysfunction, including nystagmus
Acute cerebellar hemorrhage: occipital headache, neck stiffness,
vomiting, nystagmus, gait ataxia
Muscular hypotonia
Vertigo
Diagnostics
Neuroimaging (CT/MRI)
Laboratory Testing: CBC, Electrolytes, B12, B1
Genetic Testing
∂P
o Headache
Cluster Headache
Prevention = Verapamil
Vasoconstriction of cranial blood vessels in response to high
oxygen concentration and hypocapnea
Abortive Therapy
o Oxygen
o Sumatriptan
Migraine
Epidemiology
o Peak incidence 30-40 years old
Etiology
o Potential triggers = emotional stress; weather changes;
food and beverages; poor sleeping habits
Pathophysiology
o Not fully understood
o Vascular dysregulation (vasodilation and vasospasms);
Dysregulation of pain sensitization in trigeminal system
o Cortical spreading depression
Clinical Features
o Recurrent attacks and may occur with aurua
o Prodrome (24-48 hours before)
Excessive yawning; Difficulties writing or reading
o Aura
Visual disturbances
PHotopsia, Central Scotoma, Flashing Lights,
Fortification spectra (star like zig zags)
Paresis
Impaired sensibility, paresthesia
Dizziness
Aphasia
o Headache
Typically unilateral
4-24 hours, rarely lating over 72 hours
Progression of pulsating, throbbing, or pounding
pain
Accompanied by photophobia, phonophobia, and
nausea/vomiting
o Prodrome
Exhaustion/Euphoria
Muscle weakness
Anorexia or Food Cravings
Diagnostics
o With aura >2 attacks; without aura >5 attacks
o Physical exam to exclude red flag symptoms
o Neuroimaging should be used in unusual clinical
presentation
Treatment
o Abortive Therapy
Limit stimuli
Mild to moderate = NSAIDs
Severe = Triptans (sumatriptan) or ergotamine
Sumatriptan
o 5-HT1 receptor agonist
(vasoconstriction of dilated cranial
and basilar arteries)
o Indicated in migraine and cluster
headaches
o Contraindicated in coronary artery
disease, peripheral artery disease,
HTN, and pregnancy/breastfeeding
Initial therapy if nausea/vomiting = antiemetics
(prochlorperazine, chlorpromazine)
o Prophylactic Therapy
Non-pharmacological = lifestyle (exercise, avoid
triggers)
Pharmacological
Indications = frequent attacks >3/month;
Long lasting (>12-24 hours); Abortive theray
fails
Agents =
o Beta blockers (metoprolol,
propranolol, bisoprolol)
o Tricyclic antidepressants
(amitriptyline)
o Anticonvulsants (topiramate or
valproate)
o Calcium channel blockers
(conflicting study results)
o Syncope
Aortic Stenosis
Vasovagal
Orthostatic
o Stroke ***
May be ischemic or hemorrhagic
Transient Ischemic Attack – Temporary, focal cerebral ischemia result in
brief neurologic deficits lasting <24 hours
Stroke = acute neurologic condition caused by an acute cerebrovascular
event
Ischemic = cerebral infarction due to insufficient cerebral blood flow
(more common)
Etiology
o Large artery atherosclerosis (secondary to HTN0
o Embolic stroke
Cardiac emboli (A Fib)
Infectious emboli
Ahteroemboli
Paradoxical embolism (R->L cardiac shunt)
o Small Vessel Occlusion
Lipohyalinotic thickening of the small vessels –
occlusion of small, penetrating arteries that
originate directly from large vessels
o Other causes
Watershed
Coagulopathies
Hemorrhagic = Due to hemorrhage (Intracerebral or subarachnoid)
Intracerebral = within the brain parenchyma
o Hypertension
o Cerebral Amyloid Angiopathy – deposition of beta amyloid
in vessel walls result in focal damage with formation of
microaneurysms and elevated risk of rupture
o Ruptured AVM
Subarachnoid = into the subarachnoid space
o Ruptured aneurysm (usually in circle of Willis)
Round saccular aneurysm at major branches in
large arteries
Clinical Features
Sudden onset of focal neurologic deficits and nonspecific
symptoms
SAH = worst headache of my life, neck stiffness, pupils not
reactive to light
By vessel
o MCA
Contralateral sensory loss and paralysis in the
arms, lower half of the face, and lower limbs
Gaze deviates TOWARD the side of infarction
Contralateral homonymous hemianopia without
macular sparing
Aphasia
o ACA
Contralateral paralysis in lower limbs >> upper
limbs
o PCA
Visual field defects (Contralateral homonymous
hemianopia with macular sparing)
Contralateral hemisensory loss (thalamic
involvement)
Memory deficits
o Penetrating Arteries (Lacunar syndromes)
o Vertebrobasilar
Vertebrobasilar Insufficiency
Ipsilateral cranial nerve deficits
Vertigo, drop attacks, tinnitus, Gait ataxia
Brainstem
Wallenberg (Lateral medullary syndrome)
Medial medullary syndrome
Weber Syndrome
Millard Gubler Syndrome
Foville Syndrome
o Extracranial Arteries
Internal Carotid Artery
Ipsilateral amaurosis fugax
Common carotid artery
Horner’s Syndrome
Vertebral Artery
Wallenberg Syndrome
By affected region
o Pure motor stroke
Most common type of lacunar stroke (Posterior
limb or the angle of the internal capsule)
Contralateral hemiparesis
o Pure sensory stroke
Thalamus
Contralateral numbness and paresthesia of the
face, arm, leg
o Sensoriomotor stroke
THalamocapsular area
Hemiparesis and ipsilateral sensory impairment
o Ataxic hemiparesis
Corona radiate or the posterior limb of the internal
capsule
o Dysarthria clumsy hand syndrome
Base of the pons
Dysarthria, dysphagia, contralateral facial and hand
weakness
o Hemiballismus
Subthalamic nucleus
Contralateral involuntary large and fierce flinging
of the arm or leg
Others
o Putamenal Stroke
Contralateral hemiplegia, hemisensory loss and
gaze palsy, ipsilateral deviation of the eyes, stupor,
and coma
o Cerebellar Stroke
Cerebellar signs (ataxia, nystagmus, slurred speech)
NO hemiparesis
o Thalamic Stroke
Contralateral hemiparesis and hemisensory loss
Miotic and unreactive pupils, upgaze palsy with
gaze deviation away from the side of the lesion
(wrong way eyes)
o Pontine stroke
Decreased level of consciousness or coma,
quadriplegia, ocular bobbing, facial palsy,
dysarthria
Lateral pontine Syndrome
Infarction of the lateral pons
Descending tracts –
corticospinal tract (contralateral
hemiparesis)
Lateral spinothalamic tract – contralateral
loss of pain and temperature sensations
Cerebellar tracts – ipsilateral limb and gait
ataxia
Cranial nerve nuclei
Facial nerve nuclei
Descending sympathetic tract
o Ipsilateral Horner’s Syndrome
Initial Evaluation
o Clinical assessment and history
Identify risk factors
Signs of the affect vessel or region
Onset of symptoms
o Rule out other causes of neurologic deficits
o Rule out atrial fibrillation via ECG
o Laboratory studies (CBC, Coagulation studies, Electrolytes,
Serum troponin)
Neuroimaging
o Noncontrast cranial CT detects acute hemorrhage
Cannot reliably identify early ischemia
Ischemia
Acute Ischemia (6-12 hours after)
o Hyperdense occluded vessels
o Parenchymal hypodensity
o Effacement of the sulci and loss of
corticomedullary differentiation
12-24 hours after = hypodense
Days after = hyperdense
Hemorrhage
Hyperacute = Hypodense lesion
Acute
o Hyperdense lesion
o Hpodense perifocal edema
o Possible midline shift
o MRI
Diffusion weighted imaging identifies ischemia
earlier than CT (3-30 minutes after onset)
Ischemia
T1 = Hypointense
T2 = Hyperintense
Hemorrhage
Hyperacute
o T1 = Hypointense
o T2 = Hyperintense
Acute = Hypointense
o Other studies
o CT, MRA
o Digital Subtraction Angiography
o Transcranial Doppler Sonography
Lumbar Puncture
o Definitive diagnostic test for SAH
o Yellowish (Xanthochromia) or red discoloration
o Increased RBCs, Increased WBCs, Increased protein
Histologic changes in infarcted region
o 12-24 hours = red neurons (eosinophilic cytoplasm +
pyknotic nucleus)
o 1-3 days after = neutrophils = liquefactive necrosis
o 3-5 days = macrophages (microglia)
o 5-15 days = reactive gliosis (astrocytes) + vascular
proliferation
o >15 days = Glial scarring
Treatment
o Acute stabilization/resuscitation and intensive care
moitoring
Maintain sufficient oxygen supply
Maintain blood glucose levels within 140-180
mg/dL
o Control elevated ICP and/or cerebral edema; monitor for
signs of brain herniation
Head elevation to 30 degrees
Hyperventilation
Administer IV mannitol
NO GLUCOCORTICOIDs
o Maintain cerebral perfusion
Antihypertensive treatment
Ischemic Stroke = PERMISSIVE HYPERTENSION;
Treat severe hypertension when >220/120 mmHg
Hemorrhagic stroke = Maintain blood pressure
<160 mmHg
NITRATES SHOULD BE AVOIDED MAY INCREASE
INTRACRANIAL PRESSURE
o Cardiac monitoring for at least 24 hours
o Ischemic Stroke Treatment
Intravenous rTPA
Inclusion criteria = within 3 hours of
symptom onset; >18 years old
Exclusion criteria
o Pre-existing conditions
Previous intracranial
hemorrhage
Head trauma or stroke within
the past 3 months
Recent intracranial or
intraspinal surgery
Intracranial neoplasm
o Current Conditions
Intracranial bleeding
Active internal bleeding
Hypertension >185/110
mmHg
Anticoagulation (prolonged
PTT or INR >1.7)
Low platelet count
Intra-arterial thrombolysis
Intra-arterial administration of tPA close to
the vessel occlusion within 6 hours of
symptom onset
Mechanical thrombectomy
Indicated in patients with proximal large
artery occlusion in the anterior cerebral
circulation
Antiplatelet therapy
ALL ischemic stroke patients
Contraindicated for 24 hours after
thrombolytic therapy
Drug of Choice = Aspirin
o Hemorrhagic Stroke Treatment
Intracerebral Hemorrhage
Reverse anticoagulation
Cranitomy and Clot evacuation
o Indications
Signs of brain herniation
Brainstem compression
Obstructive hydrocephalus
Hemorrhage extension >3 cm
(patients with hemorrhage in
basal ganglia or internal
capsule should generally not
undergo surgical clot
removal)
Subarachnoid Hemorrhage
Reverse Anticoagulation
Prevent vasospasm (ischemic stroke) with
IV calcium channel blocker (nimodipine)
Neurosurgery = surgical clipping or
endovascular coiling
Epilepsy
Childhood Absence Epilepsy
o Characteristics
5-10 seconds up to 100x per day
Brief unresponsiveness without convulsions
Amnestic during seizures; Appear to be staring or
daydreaming with lip smacking, eye fluttering, or
head nodding
No postictal phase
o EEG = 3 hz spikes and waves in all regions of the brain
o Treatment:
1st line: Ethosuximide
Inhibition of the low threshold T-type Ca2+
channels in the thalamus that are thought
to be responsible for the rhythmic 3 Hz
discharge seen
2 line: Sodium valproate
nd
o AIHA
Circulating antibodies (positive direct Coombs test) consistent with
autoimmune hemolytic anemia
Diagnostics = nucleated RBCs and polychromasia (indicates release of
immature RBCs into the circulation as a result of elevated erythropoietic
activity
o Paroxysmal Nocturnal Hemoglobinuria
Clinical Presentation: Fatigue, abdominal pain, jaundice, and dark urine in
the morning
Pancytopenia, evidence of intravascular hemolysis (unconjugated
hyperbilirubinemia, elevated LDH, low haptoglobin) and red urine
without RBCs in the sediment (consistent with hemoglobinuria)
Decreased CD55 and CD59 in the RBC membrane
At risk for venous thrombosis
Treatment with oral prednisone
o Factor V Leiden (mutation of coagulation factor V)
Does not allow activated Protein C (potent anticoagulant) to inhibit the
coagulation cascade leading to a procoagulant state by activation of
prothrombin into thrombin.
o Waldenstrom macroglobulinemia
Indolent type of non-Hodgkin lymphoma caused by an abnormal
production of IgM antibodies by monoclonal plasma cells.
Presents in old age with impaired platelet function (nosebleeds), anemia
(Hb < 13.5 g/dL), and mild thrombocytopenia, progressive neuropathy
(pain and numbness in feet), and hyperviscosity syndrome (vision and
hearing loss)
Increased ESR, LDH, and ALP can be seen
o Hemolysis
Extravascular hemolysis
Elevated LDH; Haptoglobin level normal; No hemoglobinuria
Intravascular hemolysis
Exertional hemoglobinuria
o Mechanical destruction of RBCs in the feet during
strenuous exercise;
o Reticulocytosis; Elevated LDH; Decreased haptoglobin;
Hemoglobinuria
o G6PD Deficiency
Impaired production of NADPH
Impaired regeneration of reduced glutathione (antioxidant that protects
the erythrocyte membrane from oxidative damage)
Vulnerable to oxidative stress caused by primaquine or antibiotics such as
sulfamethoxazole and dapsone
Offers resistance against Plasmodium infection
o Polycythemia Vera
Mutation in JAK2 gene leads to uncontrolled EPO Independent
proliferation of the myeloid cell lines, resulting in increased blood cell
mass
Increased red blood cell mass suppresses secretion of EPO by the kidneys,
resulting in low EPO levels
Individuals with PV usually have normal arterial O2 saturation and a
slightly increased or normal plasma volume
o Von Willebrand Disease
Deficiency in von Willebrand Factor
Hinders the ability of platelets to adhere to subendothelial collagen and
inhibits platelet activation which leads to a prolonged bleeding time
o Myeloproliferative Neoplasms
Overview = All show varying degrees of JAK2 mutations (valine
phenylalanine)
Primary Myelofibrosis
Bone marrow fibrosis, extramedullary hematopoiesis, and
splenomegaly
Peak incidence between 60-70 years
Clinical Features
o Weakness, fatigue, weight loss
o Splenomegaly: LUQ pain
o Thrombocytosis and Leukocytosis
o Pancytopenic Phase (Late Phase)
Erythrocytopenia anemia
Thromboytopenia petechial bleeding
Leukopenia increased susceptibility to infections
Diagnosis
o Elevated LAP, LDH, and Uric Acid
o Peripheral Blood Smear: Dacrocytes
o Bone Marrow Aspiration: Punctio Sicca
Treatment
o Curative: Allogenic Stem Cell Transplant
o Supportive
Hyperproliferative Phase:
Prevent thromboembolisms: antiplatelet
drug
Control cell count: hydroxyurea, interferon
alpha, cladribine
Pancytopenic Phase
JAK2 Inhibitior: Ruxolitinib
Periodic Transfusions
Low Dose Thaldiomide + Glucocorticoids
Essential Thrombocytopenia
Clinical Features
o Thromboembolic events
o Increased risk of fetal loss
o Vasomotor symptoms (headache, visual disturbances,
acral paresthesias)
o Acute gouty arthritis
o Petechial Bleeding
Diagnostics
o Thrombocytosis (>600,000 /uL)
o Increased LDH and Uric Acid
o Bone Marrow Aspiration: Hyperplasia of Megakaryocytes
Differential Diagnosis
o Reactive Thrombocytosis
Etiology: Inflammation, Infection; Malignancy; Iron
Deficiency
Treatment: Prevent thromboembolisms: Low dose
aspirin; Reduce thrombocyte count: hydroxyurea
or interferon alpha
Chronic Eosinophilic Leukemia
Description: Leukemia with monoclonal proliferation of
eosinophilic granulocytes that causes peripheral eosinophilia and
tissue damage
Clinical Features
o Hepatosplenomegaly
o Anemia and/or coagulation disorders
Diagnosis
o CBC: Elevated eosinophilic granulocytes
o Peripheral blood smear and bone marrow aspiration:
monoclonal blast cells or cytogenetically abnormal
eosinophils
o Migratory thrombophlebitis
Secondary to an occult malignancy, classically pancreatic cancer
Trousseau Syndrome (months to years before a malignant process
detected)
Diarrhea (steatorrhea secondary to exocrine pancreatic insufficiency) and
poor appetite and a long smoking history
Abdominal CT is the most specific and sensitive diagnostic test for
detecting underlying visceral cancer
o Hemophilia
Hemophilic arthropathy
Iron deposition causes increased synovial inflammation and
recurrent synovitis eventually leading to erosion and loss of
cartilage, joint space narrowing, and permanent joint destruction
o Malabsorption Syndrome
Inadequate breakdown and absorption of fats and fat soluble vitamins
ADEK, leading to deficiency of II, VII, IX, and X.
o Inherited hyperbilirbinemia
Indirect
Gilbert’s Syndrome
o Common, inherited hyperbilirubinemia that causes mild
excess (<3 mg/dL) of indirect bilirubin (unconjugated
hyperbilirubinemia), scleral icterus, and fatigue
o Commonly after a period of stress and/or fasting
G6PD deficiency
o Recent primaquine usage
o Blood smear with Heinz bodies
Crigler Najjar Syndrome
o Type I – affected neonates demonstrate exceptionally high
levels of indirect bilirubin and often require liver
transplantation
o Type II – more mild, intermittent periods of jaundice
o Phenobarbital is prescribed to induce the production of
the underlying, partially deficienct UDP
glucuronosyltransferase enzyme
Direct
Rotor Syndrome
o Increased urinary coproporphyrin and normal liver
histology
o Aplastic Anemia
Hyperplasia of adipocytes in bone marrow
Causees
Medications (carbamazepine, NSAIDs)
Radiation
Viruses (Parvovirus B19)
Inherited (Fanconi anemia)
Preleukemia
o Sickle Cell Anemia **
Transient Aplastic Crisis = reticulocytopenia
Treatment
Hydroxyurea
Family Medicine
o Screening
Low Dose CT in adults 55-80 y/o with a 30 pack year smoking history and
currently smoke or have quit within the past 15 years
Genetics
o Fragile X Syndrome
Mitral Valve Prolapse (Mitral Regurgitation) in ½ of Fragile X patients
Toxicology
o Metal Toxicity
Lead Toxicity
Cognitive Deficits
Behavioral Problems
Fatigue
Constipation
Abdominal Pain
Gingival Hyperpigmentation
Microcytic, Hypochromic Anemia
o Poisoning