Disclaimer
This material is for educational purposes only.
It is not to be used to make medical decisions.
Medical decisions should be made only with the
guidance of a licensed medical professional.
While efforts have been made to ensure
the accuracy of the content within,
the accuracy is not guaranteed.
Blackbook
Approaches to Medical Presentations
Eleventh Edition (2018)
Produced by The Cumming School of Medicine, University of Calgary
Blackbook: Approaches to Medical Presentations
Eleventh Edition (2018)
Chief Editors Faculty Editor
Kea Archibold Dr. Sylvain Coderre
Sunny Fong
Lucas Streith Editorial Board
Dr. Henry Mandin
Consulting Editors Dr. Kevin McLaughlin
Alec Campbell Dr. Brett Poulin
Jinghui Hu
Taryn Ludwig
Incoming Editors
Rebecca Phillips
Ainna Preet Randhawa
Vaneet Randhawa
i
Eleventh Edition (2018). First Printing.
Copyright © 2007-2018. Faculty of Medicine, University of Calgary. All Rights Reserved.
First Edition 2007 (Reprint 2008) Seventh Edition 2014
Second Edition 2009 (Reprints 2009, 2010) Eighth Edition 2015
Third Edition 2010 Ninth Edition 2016
Fourth Edition 2011 Tenth Edition 2017
ISBN Pending Assignment Eleventh Edition 2018
This material is covered by the following Creative Commons License:
Creative Commons Attribution-NonCommercial 4.0 International License.
This material is for educational purposes only. It is not to be used to make medical decisions.
Medical decisions should be made only with the guidance of a licensed medical professional.
While efforts have been made to ensure accuracy of the content within, the accuracy is not
guaranteed.
ii
The Black Book Project may be contacted at: Design
Undergraduate Medical Education Michael Cheshire
Faculty of Medicine
University of Calgary Illustrations
Health Sciences Centre Gray’s Anatomy (Public Domain)
3330 Hospital Drive N.W. Vecteezy.com
Calgary, Alberta, Canada T2N 4H1
blackbk@ucalgary.ca
Medical presentation schemes conceived by Henry Mandin.
The Calgary Black Book Project founded by Brett Poulin.
Printed in Calgary, Alberta, Canada.
iii
iv
A Message from the Editors
Welcome to the eleventh edition of the Blackbook! This evolving project is the result of
collaboration between medical students and faculty at the University of Calgary. The Blackbook
schemes have been incorporated into medical education at the University of Calgary for several
years, and more recently at several other institutions across Canada and the United States. We are
proud that health care institutions across North America find it to be a useful tool.
For the first time in the Blackbook’s history, we are offering this resource as a free online PDF.
It is our hope that these schemes will assist learners in structuring their clinical reasoning and
will promote discussions about approaches to many different presentations. As the Blackbook
continues to grow and develop, we are always interested in collaboration with users. If you have
feedback or suggestions to improve the Blackbook, please direct these communications to:
blackbk@ucalgary.ca. Thank-you for your interest in the Blackbook, we hope you will find it a
useful addition to your clinical repertoire.
Kea Archibold, Sunny Fong and Lucas Streith
v
vi
Introduction to Schemes
The material presented in this book is intended to assist learners in organizing their knowledge
into information packets, which are more effective for the resolution of the patient problems they
will encounter. There are three major factors that influence learning and the retrieval of medical
knowledge from memory: meaning, encoding specificity (the context and sequence for learning),
and practice on the task of remembering. Of the three, the strongest influence is the degree of
meaning that can be imposed on information. To achieve success, experts organize and “chunk”
information into meaningful configurations, thereby reducing the memory load.
These meaningful configurations or systematically arranged networks of connected facts are
termed schemata. As new information becomes available, it is integrated into schemes already
in existence, thus permitting learning to take place. Knowledge organized into schemes (basic
science and clinical information integrated into meaningful networks of concepts and facts) is
useful for both information storage and retrieval. To become excellent in diagnosis, it is necessary
to practice retrieving from memory information necessary for problem resolution, thus facilitating
an organized approach to problem solving (scheme-driven problem solving).
vii
The domain of medicine can be broken down to 121 (+/- 5) clinical presentations, which represent
a common or important way in which a patient, group of patients, community or population
presents to a physician, and expects the physician to recommend a method for managing the
situation. For a given clinical presentation, the number of possible diagnoses may be sufficiently
large that it is not possible to consider them all at once, or even remember all the possibilities.
By classifying diagnoses into schemes, for each clinical presentation, the myriad of possible
diagnoses become more manageable ‘groups’ of diagnoses. This thus becomes a very powerful
tool for both organization of knowledge memory (its primary role at the undergraduate medical
education stage), as well as subsequent medical problem solving.
There is no single right way to approach any given clinical presentation. Each of the schemes
provided represents one approach that proved useful and meaningful to one experienced,
expert author. A modified, personalized scheme may be better than someone else’s scheme, and
certainly better than having no scheme at all. It is important to keep in mind, before creating a
scheme, the five fundamentals of scheme creation that were used to develop this book.
If a scheme is to be useful, the answers to the next five questions should be positive:
viii
1. Is it simple and easy to remember? (Does it reduce memory load by “chunking” information
into categories and subcategories?)
2. Does it provide an organizational structure that is easy to alter?
3. Does the organizing principle of the scheme enhance the meaning of the information?
4. Does the organizing principle of the scheme mirror encoding specificity (both context and
process specificity)?
5. Does the scheme aid in problem solving? (E.g. does it differentiate between large categories
initially, and subsequently progressively smaller ones until a single diagnosis is reached?)
By adhering to these principles, the schemes presented in this book, or any modifications to them
done by the reader, will enhance knowledge storage and long term retrieval from memory, while
making the medical problem-solving task a more accurate and enjoyable endeavour.
Dr. Henry Mandin
Dr. Sylvain Coderre
ix
Table of Contents
A Message from the Editors�������������������� v Shock�����������������������������������������������������������������������������������������13
Syncope�����������������������������������������������������������������������������������14
Introduction to Schemes������������������������vii Systolic Murmur Benign & Stenotic��������������������15
Systolic Murmur Valvular & Other������������������������16
Cardiovascular 1 Diastolic Murmur���������������������������������������������������������������17
Abnormal Rhythm (1)�������������������������������������������������������� 3
Abnormal Rhythm (2)������������������������������������������������������� 4 Respiratory 19
Chest Discomfort Cardiovascular��������������������������� 5 Pulmonary Function Tests Interpretation�������21
Chest Discomfort Pulmonary / Medistinal�����6 Acid-Base Disorder Pulmonary�����������������������������22
Chest Discomfort Other������������������������������������������������� 7 Chest Discomfort Cardiovascular������������������������ 23
Hypertension��������������������������������������������������������������������������8 Chest Discomfort Pulmonary��������������������������������� 24
Hypertension in Pregnancy�����������������������������������������9 Chest Discomfort Other���������������������������������������������� 25
Left-Sided Heart Failure����������������������������������������������10 Chest Trauma Complications���������������������������������� 26
Isolated Right-Sided Heart Failure������������������������11 Cough Chronic������������������������������������������������������������������� 27
Pulse Abnormalities��������������������������������������������������������12 Cough, Dyspnea & Fever������������������������������������������� 28
x
Dyspnea Acute������������������������������������������������������������������ 29 Anemia with Elevated MCV�������������������������������������� 43
Dyspnea Chronic Cardiac������������������������������������������30 Anemia with Normal MCV����������������������������������������� 44
Dyspnea Chronic Pulmonary / Other����������������31 Anemia with Low MCV������������������������������������������������� 45
Excessive Daytime Sleepiness������������������������������ 32 Approach to Bleeding / Bruising Platelets &
Hemoptysis�������������������������������������������������������������������������� 33 Vascular System��������������������������������������������������������46
Hypoxemia���������������������������������������������������������������������������� 34 Approach to Bleeding / Bruising Coagulation
Lung Nodule����������������������������������������������������������������������� 35 Proteins����������������������������������������������������������������������������� 47
Mediastinal Mass��������������������������������������������������������������36 Approach to Prolonged PT (INR), Prolonged
Pleural Effusion������������������������������������������������������������������ 37 PTT���������������������������������������������������������������������������������������48
Pulmonary Hypertension�������������������������������������������38 Prolonged PT (INR), Normal PTT��������������������������49
Prolonged PTT, Normal PT (INR) Bleeding
Hematologic 39 Tendency�������������������������������������������������������������������������50
Overall Approach to Anemia������������������������������������41 Prolonged PTT, Normal PT (INR) No Bleeding
Approach to Anemia Mean Corpuscular Tendency��������������������������������������������������������������������������51
Volume������������������������������������������������������������������������������ 42 Approach to Splenomegaly������������������������������������� 52
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Fever in the Immunocompromised Host������� 53 Abdominal Mass��������������������������������������������������������������� 72
Lymphadenopathy Diffuse��������������������������������������� 54 Abdominal Pain (Adult) Acute - Diffuse����������� 73
Lymphadenopathy Localized��������������������������������� 55 Abdominal Pain (Adult) Acute - Localized�����74
Neutrophilia��������������������������������������������������������������������������56 Abdominal Pain (Adult) Chronic - Constant� 75
Neutropenia Decreased Neutrophils Only��� 57 Abdominal Pain (Adult) Chronic - Crampy /
Neutropenia Bicytopenia / Pancytopenia����58 Fleeting�����������������������������������������������������������������������������76
Polycythemia����������������������������������������������������������������������59 Abdominal Pain (Adult) Chronic - Post-
Suspected Deep Vein Thrombosis (DVT)������60 Prandial����������������������������������������������������������������������������� 77
Suspected Pulmonary Embolism (PE)��������������61 Anorectal Pain��������������������������������������������������������������������78
Thrombocyopenia�����������������������������������������������������������62 Acute Diarrhea�������������������������������������������������������������������79
Thrombocytosis����������������������������������������������������������������63 Chronic Diarrhea Small Bowel�������������������������������80
Hemolysis������������������������������������������������������������������������������64 Chronic Diarrhea Steatorrhea & Large Bowel
��������������������������������������������������������������������������������������������������81
Gastrointestinal 65 Constipation (Adult) Altered Bowel Function
Abdominal Distention���������������������������������������������������69 & Idiopathic��������������������������������������������������������������������82
Abdominal Distention Ascites��������������������������������70 Constipation (Adult) Secondary Causes���������83
Abdominal Distention Other Causes������������������71 Constipation (Pediatric) ����������������������������������������������84
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Dysphagia������������������������������������������������������������������������������85 Renal 99
Elevated Liver Enzymes���������������������������������������������86 Acute Kidney Injury������������������������������������������������������ 101
Hepatomegaly�������������������������������������������������������������������87 Chronic Kidney Disease��������������������������������������������102
Jaundice���������������������������������������������������������������������������������88 Dysuria�����������������������������������������������������������������������������������103
Liver Mass������������������������������������������������������������������������������89 Generalized Edema������������������������������������������������������104
Mouth Disorders (Adult & Elderly) ���������������������90 Hematuria����������������������������������������������������������������������������105
Nausea & Vomiting Gastrointestinal Disease Hyperkalemia Intercellular Shift������������������������ 106
��������������������������������������������������������������������������������������������������91
Hyperkalemia Reduced Excretion��������������������107
Nausea & Vomiting Other Systemic Disease
Hypokalemia�������������������������������������������������������������������� 108
������������������������������������������������������������������������������������������������� 92
Hypernatremia���������������������������������������������������������������� 109
Stool Incontinence����������������������������������������������������������93
Hyponatremia������������������������������������������������������������������� 110
Upper Gastronintestinal Bleed (Hematemesis
Hypertension���������������������������������������������������������������������� 111
/ Melena)�������������������������������������������������������������������������94
Increased Urinary Frequency��������������������������������112
Lower Gastrointestinal Bleed����������������������������������95
Nephrolithiasis������������������������������������������������������������������113
Weight Gain��������������������������������������������������������������������������96
Polyuria�����������������������������������������������������������������������������������114
Weight Loss������������������������������������������������������������������������� 97
Proteinuria����������������������������������������������������������������������������115
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Renal Mass Solid������������������������������������������������������������ 116 Adrenal Mass Malignant�������������������������������������������133
Renal Mass Cystic�����������������������������������������������������������117 Amenorrhea�����������������������������������������������������������������������134
Scrotal Mass����������������������������������������������������������������������� 118 Breast Discharge������������������������������������������������������������135
Suspected Acid-Base Disturbance������������������ 119 Gynecomastia Increased Estrogen &
Metabolic Acidosis Elevated Anion Gap������120 Increased HCG����������������������������������������������������������136
Metabolic Acidosis Normal Anion Gap�����������121 Gynecomastia Increased LH & Decreased
Metabolic Alkalosis ����������������������������������������������������� 122 Testosterone���������������������������������������������������������������137
Urinary Incontinence���������������������������������������������������123 Hirsutism������������������������������������������������������������������������������138
Urinary Tract Obstruction�����������������������������������������124 Hirsutism & Virilization Androgen Excess����139
Hirsutism & Virilization Hypertrichosis�����������140
Endocrinology 125 Hypercalcemia Low PTH����������������������������������������� 141
Abnormal Lipid Profile Combined & Hypercalcemia Normal / High PTH����������������142
Decreased HDL��������������������������������������������������������129 Hypocalcemia High Phosphate��������������������������143
Abnormal Lipid Profile Increased LDL & Hypocalcemia Low Phosphate���������������������������144
Increased Triglycerides���������������������������������������130 Hypocalcemia High / Low PTH��������������������������145
Abnormal Serum TSH�������������������������������������������������131 Hyperglycemia����������������������������������������������������������������146
Adrenal Mass Benign��������������������������������������������������132 Hypoglycemia������������������������������������������������������������������147
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Hyperphosphatemia����������������������������������������������������148 Back Pain������������������������������������������������������������������������������167
Hypophosphatemia�����������������������������������������������������149 Cognitive Impairment������������������������������������������������ 168
Hyperthyroidism�������������������������������������������������������������150 Dysarthria���������������������������������������������������������������������������� 169
Hypothyroidism����������������������������������������������������������������151 Falls in the Elderly���������������������������������������������������������170
Hyperuricemia�����������������������������������������������������������������152 Gait Disturbance��������������������������������������������������������������171
Male Sexual Dysfunction�����������������������������������������153 Headache Primary�������������������������������������������������������� 172
Sellar / Pituitary Mass������������������������������������������������154 Headache Secondary, without Red Flag
Sellar / Pituitary Mass Size�������������������������������������155 Symptoms��������������������������������������������������������������������� 173
Short Stature����������������������������������������������������������������������156 Hemiplegia������������������������������������������������������������������������� 174
Tall Stature��������������������������������������������������������������������������157 Mechanisms of Pain����������������������������������������������������� 175
Weight Gain / Obesity�����������������������������������������������158 Movement Disorder Hyperkinetic���������������������176
Movement Disorder Tremor����������������������������������� 177
Neurologic 159 Movement Disorder Bradykinetic����������������������178
Altered Level of Consciousness Approach163 Peripheral Weakness��������������������������������������������������179
Altered Level of Consciousness GCS ≤ 7�����164 Peripheral Weakness Sensory Changes����� 180
Aphasia Fluent�����������������������������������������������������������������165 Spell / Seizure Epileptic Seizure����������������������� 181
Aphasia Non-Fluent���������������������������������������������������� 166 Spell / Seizure Secondary Organic�����������������182
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Spell / Seizure Other��������������������������������������������������183 Amenorrhea Secondary������������������������������������������ 199
Stroke Intracerebral Hemorrhage���������������������184 Antenatal Care����������������������������������������������������������������200
Stroke Ischemia���������������������������������������������������������������185 Bleeding in Pregnancy < 20 Weeks�����������������201
Stroke Subarachnoid Hemorrhage����������������� 186 Bleeding in Pregnancy 2nd & 3rd Trimester
Syncope��������������������������������������������������������������������������������187 ���������������������������������������������������������������������������������������������� 202
Dizziness������������������������������������������������������������������������������ 188 Breast Disorder��������������������������������������������������������������� 203
Vertigo����������������������������������������������������������������������������������� 189 Growth Discrepancy Small for Gestational
Age / Intrauterine Growth Restriction����204
Obstetrical & Gynecological 191 Growth Discrepancy Large for Gestational
Intrapartum Abnormal Fetal HR Tracing Age������������������������������������������������������������������������������������205
Variability & Decelerations�������������������������������193 Infertility (Female)���������������������������������������������������������206
Intrapartum Abnormal Fetal HR Tracing Infertility (Male)��������������������������������������������������������������� 207
Baseline��������������������������������������������������������������������������194 Intrapartum Factors that May Affect Fetal
Abnormal Genital Bleeding������������������������������������195 Oxygenation���������������������������������������������������������������208
Acute Pelvic Pain���������������������������������������������������������� 196 Pelvic Mass������������������������������������������������������������������������209
Chronic Pelvic Pain�������������������������������������������������������197 Ovarian Mass���������������������������������������������������������������������210
Amenorrhea Primary�������������������������������������������������� 198 Pelvic Organ Prolapse�������������������������������������������������211
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Post-Partum Hemorrhage�������������������������������������� 212 Morphology of Skin Lesions Primary Skin
Recurrent Pregnancy Loss������������������������������������� 213 Lesions����������������������������������������������������������������������������227
Vaginal Discharge����������������������������������������������������������214 Morphology of Skin Lesions Secondary Skin
Lesions��������������������������������������������������������������������������� 228
Dermatologic 215 Mucous Membrane Disorder Oral Cavity��� 229
Burns���������������������������������������������������������������������������������������219 Nail Disorders Primary Dermatologic Disease
Dermatoses in Pregnancy Physiologic ���������������������������������������������������������������������������������������������� 230
Changes������������������������������������������������������������������������ 220 Nail Disorders Systemic Disease����������������������� 231
Dematoses in Pregnancy Specific Skin Nail Disorders Systemic Disease - Clubbing
Conditions��������������������������������������������������������������������� 221 �����������������������������������������������������������������������������������������������232
Disorders of Pigmentations Pruritus No Primary Skin Lesion�������������������������233
Hyperpigmentation�����������������������������������������������222 Pruritus Primary Skin Lesion��������������������������������� 234
Disorders of Pigmentations Skin Rash Eczematous���������������������������������������������� 235
Hypopigmentation�������������������������������������������������223 Skin Rash Papulosquamous��������������������������������� 236
Genital Lesion�������������������������������������������������������������������224 Skin Rash Pustular���������������������������������������������������������237
Hair Loss (Alopecia) Diffuse�����������������������������������225 Skin Rash Reactive������������������������������������������������������� 238
Hair Loss (Alopecia) Localized���������������������������� 226 Skin Rash Vesiculobullous������������������������������������� 239
xvii
Skin Ulcer by Etiology�����������������������������������������������240 Pathologic Fractures�������������������������������������������������� 256
Skin Ulcer by Location Genitals��������������������������241 Soft Tissue���������������������������������������������������������������������������257
Skin Ulcer by Location Head & Neck��������������242 Fracture Healing������������������������������������������������������������ 258
Skin Ulcer by Location Lower Legs / Feet243 Osteoporosis BMD Testing������������������������������������ 259
Skin Ulcer by Location Oral Ulcers������������������ 244 Tumour����������������������������������������������������������������������������������260
Skin Ulcer by Location Trunk / Sacral Region Mytomes Segmental Innervation of Muscles
���������������������������������������������������������������������������������������������� 245 �����������������������������������������������������������������������������������������������261
Vascular Lesions������������������������������������������������������������ 246 Guide to Spinal Cord Injury������������������������������������ 262
Musculoskeletal 247 Psychiatric 263
Acute Joint Pain Vitamin CD��������������������������������� 249 Anxiety Disorders Associated with Panic���� 265
Chronic Joint Pain���������������������������������������������������������250 Anxiety Disorders Recurrent Anxious
Bone Lesion�����������������������������������������������������������������������251 Thoughts ���������������������������������������������������������������������266
Deformity / Limp�����������������������������������������������������������252 Trauma & Stressor Related Disorders����������� 267
Infectious Joint Pain���������������������������������������������������� 253 Obsessive-Compulsive & Related Disorders
Inflammatory Joint Pain�������������������������������������������� 254 ����������������������������������������������������������������������������������������������268
Vascular Joint Pain������������������������������������������������������� 255 Personality Disorder����������������������������������������������������269
xviii
Mood Disorders Depressed Mood������������������ 270 Ophthalmologic 287
Mood Disorders Elevated Mood������������������������ 271 Cross Section of the Eye & Acronyms�����������289
Psychotic Disorders ����������������������������������������������������272 Approach to an Eye Exam��������������������������������������290
Somatoform Disorders�����������������������������������������������273 Acute Vision Loss Bilateral��������������������������������������291
Acute Vision Loss Unilateral��������������������������������� 292
Otolaryngologic 275 Chronic Vision Loss Anatomic����������������������������� 293
Hearing Loss Conductive����������������������������������������277 Amblyopia�������������������������������������������������������������������������� 294
Hearing Loss Sensorineural���������������������������������� 278 Diplopia�������������������������������������������������������������������������������� 295
Hoarseness Acute�������������������������������������������������������� 279 Pupillary Abnormalities Isocoria������������������������296
Hoarseness Non-Acute��������������������������������������������280 Pupillary Abnormalities Anisocoria������������������ 297
Neck Mass���������������������������������������������������������������������������281 Red Eye Atraumatic�����������������������������������������������������298
Otaligia���������������������������������������������������������������������������������� 282 Red Eye Traumatic�������������������������������������������������������299
Smell Dysfunction�������������������������������������������������������� 283 Strabismus Ocular Misalignment���������������������300
Tinnitus Objective��������������������������������������������������������� 284 Neuro-Ophthalmology Visual Field Defects
Tinnitus Subjective������������������������������������������������������ 285 �����������������������������������������������������������������������������������������������301
xix
Pediatric 303 Constipation (Pediatric)��������������������������������������������� 321
Developmental Delay������������������������������������������������ 307 Mouth Disorder (Pediatric)��������������������������������������322
School Difficulties���������������������������������������������������������308 Depressed / Lethargic Newborn����������������������323
Small for Gestational Age���������������������������������������309 Cyanosis in the Newborn Non-Respiratory
Large for Gestational Age����������������������������������������310 ���������������������������������������������������������������������������������������������� 324
Congenital Anomalies�������������������������������������������������311 Cyanosis in the Newborn Respiratory����������� 325
Preterm Infant Complications������������������������������ 312 Pediatric Dyspnea�������������������������������������������������������� 326
Failure to Thrive Adequte Calorie Noisy Breathing Pediatric Wheezing��������������327
Consumption��������������������������������������������������������������313 Noisy Breathing Pediatric Stridor���������������������� 328
Failure to Thrive Inadequte Calorie Pediatric Cough Acute���������������������������������������������� 329
Consumption��������������������������������������������������������������314 Pediatric Cough Chronic�����������������������������������������330
Hypotonic Infant (Floppy Newborn)����������������315 Respiratory Distress in the Newborn��������������331
Acute Abdominal Pain������������������������������������������������316 Sudden Unexpected Death in Infancy����������332
Pediatric Vomiting Gastrointestinal Causes317 Enuresis�������������������������������������������������������������������������������� 333
Pediatric Vomiting System Causes�������������������318 Acute Life Threatening Event������������������������������ 334
Neonatal Jaundice��������������������������������������������������������319 Pediatric Fractures������������������������������������������������������� 335
Pediatric Diarrhea��������������������������������������������������������� 320 Salter Harris Physeal Injury Classification��� 336
xx
Pediatric Seizure Unprovoked�����������������������������337
Pediatric Seizure Provoked����������������������������������� 338
Pediatric Seizure Spells������������������������������������������� 339
Pediatric Mood & Anxiety Disorder������������������340
General Presentations 341
Fatigue����������������������������������������������������������������������������������� 343
Acute Fever����������������������������������������������������������������������� 344
Fever of Unknown Origin / Chronic Fever� 345
Hypothermia���������������������������������������������������������������������346
Sore Throat / Rhinorrhea�����������������������������������������347
Historical Executive Student Editors�� 349
Scheme Creators���������������������������������� 350
Abbreviations ������������������������������������ 351
xxi
Cardiovascular
Abnormal Rhythm (1)����������������������������������������������������������3
Abnormal Rhythm (2)���������������������������������������������������������4
Chest Discomfort Cardiovascular�����������������������������5
Chest Discomfort Pulmonary / Medistinal������ 6
Chest Discomfort Other���������������������������������������������������7
Hypertension��������������������������������������������������������������������������� 8
Hypertension in Pregnancy������������������������������������������ 9
Left-Sided Heart Failure�����������������������������������������������10
Isolated Right-Sided Heart Failure�������������������������11
Pulse Abnormalities��������������������������������������������������������� 12
Cardiovascular
Shock������������������������������������������������������������������������������������������ 13
Syncope������������������������������������������������������������������������������������ 14
Systolic Murmur Benign & Stenotic��������������������� 15
Systolic Murmur Valvular & Other�������������������������16
Diastolic Murmur���������������������������������������������������������������� 17
1
Historical Editors Student Editors
Katie Lin Azy Golian
Payam Pournazari Harsimranjit Singh
Marc Chretien Shaye Lafferty
Tyrone Harrison
Hamza Jalal Faculty Editor
Geoff Lampard Dr. Sarah Weeks
Luke Rannelli
Connal Robertson-More
Jeff Shrum
Cardiovascular
Sarah Surette
Lian Szabo
Kathy Truong
Vishal Varshney
2
Abnormal Rhythm (1)
ABNORMAL RHYTHM 1
Types
of
Arrhythmia
Bradyarrhythmia
Tachyarrhythmia
Abnormal
Beats
(<60
bpm) (>100
bpm)
• Sinus
Bradycardia • Premature
atrial
contraction
• Sick
Sinus
Syndrome • Premature
ventricular
contraction
• SA
Block
• AV
Block
(1st/2nd /3rd degree)
• Junctional
Escape
Rhythm
• Ventricular
Escape
Rhythm
Narrow QRS (<120 msec) Wide QRS (>120 msec)
SVT VT or SVT with aberrancy
Cardiovascular
Regular
Rhythm
SVT Irregular
Rhythm
SVT Regular
Rhythm Irregular
Rhythm
(constant
R-‐R
Interval) (variable
R-‐R
interval) (constant
R-‐R
Interval) (variable
R-‐R
interval)
• Sinus
Tachycardia • AFib • Monomorphic
VT • Polymorphic
VT
(including
• Monofocal
Ectopic
Atrial
• AFlutter
with
Variable
AV
• Regular
rhythm
SVT
with
Tosades
de
Pointes
if
in
a
Tachycardia Conduction
conduction
aberrancy setting
of
long
QT)
• Aflutter • Multifocal
Atrial
• Irregular
rhythm
SVT
with
• AVNRT
Tachycardia conduction
aberrancy
3 • AVRT
(ie.
WPW)
Abnormal Rhythm (2)
ABNORMAL RHYTHM 2
Causes
of
Arrhythmia
May present as: palpitations, dizziness,
syncope, chest discomfort
Cardiac Non-‐Cardiac
Electrical
Conduction
Structural
Abnormalities
• Valve
disease • Ectopic
foci
• Cardiomyopathy • Accessory
pathway
• Scar
tissue
(previous
MI)
Cardiovascular
High
Output
State Metabolic Drugs Psychiatric
• Anemia • Hypoglycemia • Alcohol • Panic
Attack
• Fever/infection • Thyrotoxicosis • Caffeine • Generalized
Anxiety
• Pregnancy • Pheochromocytoma • Sympathomimetics Disorder
•Anticholinergics
•Cocaine 4
Chest Discomfort
CHEST DISCOMFORT: Cardiovascular
Cardiovascular
Chest Discomfort Chest Discomfort
Cardiovascular Pulmonary/Mediastinal
Cardiovascular Pulmonary/Mediastinal Other
Outflow Obstruction Ischemic
Cardiovascular
Outflow Obstruction Ischemic Non-‐Ischemic
• Aortic Stenosis • Myocardial Infarction* •A
• Stable/Unstable Angina* •D
• Aortic Stenosis • Myocardial Infarction* • Aortic Dissection*
•P
• Stable/Unstable Angina* • Dilating Aneurysm*
•M
• Pericarditis
• Myocarditis
5 * Denotes acutely life-threatening causes
Chest Discomfort
CHEST DISCOMFORT: Pulmonary/Mediastinal
Pulmonary / Medistinal
Chest Discomfort
Chest
Discomfort
cular Pulmonary/Mediastinal Other
Cardiovascular Pulmonary/Mediastinal Other
Chest Wall/Pleura Parenchymal
Cardiovascular
Vascular Chest
Wall/Pleura
Parenchymal
• Pneumothorax* • Pneumonia with pleurisy*
• Pleural Effusion • Tuberculosis*
• Pulmonary
Embolism*
• Pleuritis/Serositis • Pneumothorax* • Pneumonia
with
pleurisy*
• Neoplasm*
(chest
pain
often
not
• Pleural
Effusion • Tuberculosis*
• Sarcoidosis
present) • Pleuritis/Serositis • Neoplasm*
• Pulmonary
Hypertension • Sarcoidosis
* Denotes acutely life-threatening causes 6
Chest Discomfort
CHEST DISCOMFORT: Other
Other
Chest Discomfort Chest Discomfort
Cardiovascular Cardiovascular
Pulmonary/Mediastinal Pulmonary/Mediastinal
Other
Gastrointestinal Musculoskeletal
Gastrointestinal Musculoskeletal Neurologic/Psychiatric
Cardiovascular
• Gastro-Esophageal Reflux • Costochondritis
• Gastro-‐Esophageal Reflux • Costochondritis
Disease • Anxiety/Panic
• Muscular Injury
Disease • Muscular Injury
• Biliary Disease • Herpes
• Trauma Simplex Virus/Post-‐
• Biliary Disease • Trauma
• Peptic Ulcer Disease Herpetic Neuralgia
• Peptic Ulcer Disease • Pancreatitis* • Somatoform Disorder
• Pancreatitis* • Esophageal Spasm • Spinal Radiculopathy
• Esophageal Spasm • Esophageal Perforation*
7 • Esophageal Perforation*
* Denotes acutely life-threatening causes
* Denotes acutely life-‐threatening causes
Hypertension
HYPERTENSION
HYPERTENSION
HYPERTENSION
Hypertension
Hypertension
Hypertension
Primary
Primary
Primary
(Essential)
(Essential)
(Essential)
(95%) (95%)
(95%) Secondary
Secondary
Secondary
(5%)
(5%)(5%) Mislabelled
Mislabelled
Mislabelled
Onset
abge
etween
2a0
5ge
20
5a0.
nd
50. age
Onset
o<r
a
ge
5<0
o
r
2years.
0
>
o5r
0
>y
ears.
50
years. Repeatedly
normal
blood
Onset
Onset
between
between
20
aage
nd
0. and
Onset
Onset
<
2a0
ge
>2
0
Repeatedly
Repeatedly
normal
normal
blood
bplood
ressure
wphen
ressure
pressure
when
when
Positive
family
history. No
family
history.
Hypertensive
urgency.
taken
aork
t
home,
woork
or
wau
hen
using
Positive
Positive
family
fhamily
istory. history. No
family
No
fhamily
istory.
history.
Hypertensive
Hypertensive
urgency.
urgency.
taken
taken
at
home,
at
hw
ome,
owr
ork
when
r
w
using
hen
n
sing
an
an
No
No
features
of
features
No
features
of
shecondary
secondary
of
secondary
ypertension. hypertension.
hypertension. Resistant
hResistant
Resistant
ypertension. hypertension. hypertension. ambulatory
monitor.
ambulatory
ambulatory
monitor. monitor.
• Long-‐ • Long-‐
• Long-‐
standing standing
standing • White-‐c•oat
• White-‐White-‐
H coat
coat
ypertensionHypertension
Hypertension
• Uncontrolled
• Uncontrolled
• Uncontrolled • HMasked
• Masked
• Masked
ypertension Hypertension
Hypertension
• Drug
•
• Drug
Drug
Withdrawal W
Withdrawalithdrawal
Exogenous Renal Renal
Renal Mechanical
Mechanical
Mechanical Endocrine
Endocrine
Endocrine
Exogenous
Exogenous
• Corticosteroids
• Corticosteroids
• Corticosteroids • Renal
p•arenchymal
Renal
• Renal
parenchymal
parenchymal
• Aortic
c•oarctation
Aortic
• Aortic
coarctation
coarctation • Glucocorticoid
• Glucocorticoid
• Glucocorticoid
excess
excess
excess
(Cushing
(Cushing
(Cushing
• Oral
Contraceptive
disease
disease
disease
•Obstructive
•Obstructive
•Obstructive
Sleep
Sleep
Sleep
• Oral
• COral
ontraceptive
Pills PillsPills
Contraceptive
•CKD Apnea syndrome
syndrome
syndrome
or
doisease)
or
disease) r
disease)
• Cocaine •CKD•CKD ApneaApnea •Catecholamine
excess
Cardiovascular
• Cocaine
• Cocaine •Catecholamine
•Catecholamine
excess
excess
• Black
•
• Black
Black
licorice l icorice
licorice •AKI •AKI•AKI (pheochromocytoma)
(pheochromocytoma)
(pheochromocytoma)
• Medications •Glomerulonephritis
•Glomerulonephritis
•Glomerulonephritis •Mineralocorticoid
excess
• Medications
• Medications • Renovascular
disease
•Mineralocorticoid
•Mineralocorticoid
excess
excess
• Renovascular
• Renovascular
disease
disease
(primary
(primary
(primary
aldosteronism)
aldosteronism)
aldosteronism)
(unilateral
(unilateral
(unilateral
nd
abnd
and
bailateral
bilateral
ilateral
•Hyperthyroidism
(mainly
renal
a rtery
s tenosis) •Hyperthyroidism
•Hyperthyroidism
(mainly
(mainly
renal
renal
artery
artery
stenosis)stenosis) systolic
hsystolic
systolic
ypertension)hypertension)
hypertension)
Definition
oDefinition
Definition
f
hypertension: of
hypertension:
of
hypertension: Hypertensive
Hypertensive
Hypertensive
Urgency:
BU
P
rgency:
Urgency:
BP
uB
usually
>P
usually
sually
180/110mmHg
>180/110mmHg
>180/110mmHg
or
or
or
•Hypothyroidism
•Hypothyroidism
•Hypothyroidism
(mainly
(mainly
(mainly
Systolic
BP
Systolic
Systolic
P
≥
B1P
≥
1B40mmHg
≥
1o40mmHg
40mmHg
r
Diastolic
oB
r
P
Diastolic
or
Diastolic
≥
9B0mmHgP
≥
B9P
0mmHg≥
90mmHg asymptomatic
asymptomatic
asymptomatic
Diastolic
Diastolic
Diastolic
BP
BP
>130mmHg
>130mmHg
BP
>130mmHg
with
wtoarget
with
target
ith
target
rgan
organ
organ
diastolic
diastolic
diastolic
hypertension) hypertension)
hypertension)
Isolated
Isolated
Isolated
systolic
systolic
s ystolic
hypertension
h ypertension
hypertension
in
in
the
ien
lderly:
t he
the
elderly:
e lderly:
≥
160mmHg ≥
1 60mmHg
≥
160mmHgdamage
damage
usually
damage
u sually
present
usually
p resent
but
not
present
b ut
acutely
but
n ot
a
changing
not
acutely
cutely
changing c hanging •Hyperparathyroidism
•Hyperparathyroidism
•Hyperparathyroidism
Diabetes
mDiabetes
Diabetes
ellitus
≥
m
mellitus
ellitus
130/80mmHg ≥
130/80mmHg
≥
130/80mmHg Hypertensive
Hypertensive
Emergency:
Hypertensive
Emergency:
BP
uB
BP
usually
Emergency:
>P
usually
220/140mmHg
sually
>220/140mmHg
>220/140mmHg
•Pregnancy
(Gestational
Note:
Note:
Note:
In
children,
In
the
children,
In
children,
the
dtefinition
definition
he
odf
efinition
hypertension
of
hypertension
of
hypertension
is
is
is
with
ewith
with
volving
evolving
target
evolving
target
toarget
rgan
organ
odrgan
amage damage damage •Pregnancy
•Pregnancy
(Gestational
(Gestational
different
(either
systolic
or
diastolic
BP
>95%ile),
but
the
hypertension) hypertension)
hypertension)
different
different
approach
(either
(either
iapproach
approach
systolic
systolic
or
diastolic
is
stame.
s
the
iss
ame.
the
or
diastolic
he
same.
BP
>95%ile),
but
the
BP
>95%ile),
but
the
8
Hypertension in Pregnancy
HYPERTENSION IN PREGNANCY
HYPERTENSION IN PREGNANCY Clinical
Pearl:
BP
should
always
be
Hypertension
in
PregnancyClinical
Pearl:
Bmeasured
in
a
sitting
position
for
a
HYPERTENSION IN PREGNANCY
Hypertension
in
Pregnancy
P
should
aplways
pregnant
atient.be
DBP
≥
90mmHg,
based
on
two
measurements measured
in
a
sitting
position
for
a
pregnant
patient.
DBP
≥
90mmHg,
based
on
two
measurements Clinical
Pearl:
BP
should
always
be
Hypertension
in
Pregnancy measured
in
a
sitting
position
for
a
pregnant
patient.
DBP
≥
90mmHg,
based
on
two
measurements
Pre-‐existing Hypertension Gestational Hypertension
Pre-‐existing Hypertension
Before Pregnancy OR Gestational Hypertension
Previously normotensive,
<20 weeks gestational age >20 weeks gestational age
Before Pregnancy OR Previously normotensive,
Pre-‐existing
<20 weeks gestational age Hypertension Gestational
>20 weeks gestational age Hypertension
Before Pregnancy OR Previously normotensive,
<20 weeks gestational age >20 weeks gestational age
No Proteinuria Proteinuria (≥0.3g/24hr urine) No Proteinuria Proteinuria (≥0.3g/24hr urine)
Pre-‐Eclampsia +
No Proteinuria Proteinuria (OR one or umrine)
≥0.3g/24hr ore Adverse
No Proteinuria• Gestational Proteinuria (OR one or umrine)
≥0.3g/24hr ore Adverse
Seizures/Coma
Pre-‐Eclampsia +
OR one or more AConditions*
dverse • Gestational
HypertensionOR one or more A Conditions*
dverse
No Proteinuria Proteinuria (≥0.3g/24hr urine) No ProteinuriaConditions*Proteinuria Seizures/Coma
(≥0.3g/24hr urine) • Eclampsia
Conditions* Hypertension
• Pre-‐existing Hypertension with • Gestational H ypertension w ith Pre-‐Eclampsia +
Chronic Pre-‐EOR one or more Adverse
clampsia • Gestational Pre-‐EOR one or more A
clampsia
• Gestational Hypertension with
• dverse
Eclampsia
Seizures/Coma
• Pre-‐existing Hypertension with
Chronic Hypertension Conditions* Hypertension
Pre-‐Eclampsia
Conditions*
Pre-‐Eclampsia • Eclampsia
Cardiovascular
Hypertension
• Primary • Pre-‐existing
Hypertension
with
• Gestational
Hypertension
with
Chronic
• Secondary Pre-‐Eclampsia Maternal Pre-‐Eclampsia Fetal
• Primary
• Secondary
Hypertension
Maternal
•Persistent
or
•Pulmonary
Edema
Fetal
• Primary new/unusual
headache
*Adverse
•Persistent
or
• Visual
disturbances • Suspected
placental
•Oligohydramnios
• Secondary •Pulmonary
Maternal
Edema
abruption Fetal
•Intrauterine
growth
restriction
new/unusual
h• eadache
*Adverse Conditions:
Persistent
• Suspected
placental
•Oligohydramnios
• Visual
disturbances • Elevated
serum
•Absent/reversed
end-‐diastolic
flow
in
the
(SOGC,
2008) abdominal/RUQ
r
pain
•Persistent
oabruption •Intrauterine
growth
restriction
creatinine/AST/ALT/LDH umbilical
artery
Conditions: • Persistent
• Severe
nausea
new/unusual
o r
• Elevated
headache serum
•Pulmonary
• Platelet
Edema
•Absent/reversed
<100x109/L end-‐diastolic
•Intrauterine
flow
fetal
deathin
the
(SOGC,
2008) abdominal/RUQ
*Adverse pain
vomiting • Suspected
placental
•Oligohydramnios
• Visual
disturbances
creatinine/AST/ALT/LDH
• Serum
albumin
umbilical
<20g/L artery •Intrauterine
growth
restriction
• Severe
nausea
or
pain/dyspnea
• Chest
abruption
Conditions:
vomiting
• Persistent
• Platelet
<100x109/L
• Elevated
s
•Intrauterine
fetal
death
erum
•Absent/reversed
end-‐diastolic
flow
in
the
9 •(SOGC,
• Severe
Chest
p2ain/dyspnea
008)
hypertension
• Serum
abdominal/RUQ
• Severe
nausea
or
albumin
<20g/L
pain
creatinine/AST/ALT/LDH umbilical
artery
• Severe
hypertension • Platelet
<100x109/L •Intrauterine
fetal
death
vomiting
• Serum
albumin
<20g/L
Left-Sided Heart Failure
LEFT-SIDED HEART FAILURE
LEFT-SIDED HEART FAILURE
Left-‐Sided Heart Failure
SV = Stroke Volume
EDV = End-‐Diastolic Volume
ESV = End-‐Systolic Volume
SV = Stroke Volume
Left-‐Sided Heart Failure EDV = End-‐Diastolic Volume
ESV = End-‐Systolic Volume
Ejection Fraction = SV
= EDV -‐ ESV
EDV EDV
Valvular Disease
= EDV -‐ ESV
Ejection Fraction = SV
(Preserved Diastolic/Systolic EDV EDV Myocardial
Function) Valvular Disease
• Mitral Stenosis (Preserved D iastolic/Systolic Myocardial
• Mitral Regurgitation Function)
• Aortic Stenosis • Mitral Stenosis Systolic Dysfunction Diastolic Dysfunction
• Aortic Regurgitation • Mitral Regurgitation (Reduced Ejection Fraction) (Preserved Ejection Fraction)
• Aortic Stenosis Systolic Dysfunction Diastolic Dysfunction
• Aortic Regurgitation (Reduced Ejection Fraction) (Preserved Ejection Fraction)
Impaired Contractility Increased Afterload Impaired Diastolic Filling
• Uncontrolled
Severe
Impaired
Contractility Increased
Afterload • Transient
Myocardial
Ischemia
Impaired
Diastolic
Filling
Hypertension
• Left
Ventricular
Hypertrophy
Cardiovascular
• Aortic
Stenosis
(Severe)
• Uncontrolled
Severe
• Restrictive
Cardiomyopathy
• Transient
Myocardial
Ischemia
Hypertension
• Pericardial
Constriction• Left
Ventricular
Hypertrophy
• Aortic
Stenosis
(Severe) • Restrictive
Cardiomyopathy
Coronary
Artery
Chronic
Volume
Dilated
• Pericardial
Constriction
Disease Overload Cardiomyopathies
Coronary
Artery
Chronic
Volume
Dilated
• Myocardial
Infarction • Mitral
Regurgitation • Infiltrative
• Transient
Myocardial
•Disease
Aortic
Regurgitation Overload
• Infectious Cardiomyopathies
Ischemia • Myocardial
Infarction •R
• Mitral
Toxic
(alcohol,
egurgitation • Infiltrative
• Transient
Myocardial
cocaine)
Ischemia
• Aortic
Regurgitation
• Genetic
• Infectious
• Toxic
(alcohol,
9 10
cocaine)
Isolated Right-Sided Heart Failure
ISOLATED RIGHT-SIDED HEART FAILURE
URE Note:
all
left-‐sided
heart
failure
can
also
lead
Isolated
Right-‐Sided
Heart
to
right-‐sided
heart
failure
Note:
all
left-‐sided
heart
failure
can
also
lead
Failure (the
most
common
cause
of
right
heart
art
to
right-‐sided
heart
failure failure
is
left
heart
failure)
(the
most
common
cause
of
right
heart
failure
is
left
heart
failure)
Cardiac Pulmonary
Pulmonary
Rule out Left-‐Sided
Heart Failure
(Most Common)
Cardiovascular
Myocardium Valves Pericardium Parenchyma Vasculature
• Right
Ventricle
• Pulmonary
Stenosis
• Constrictive
Pericarditis • Chronic
Obstructive
• Pulmonary
Embolism
Parenchyma
Infarction Vasculature
• Tricuspid
Regurgitation • Pericardial
Tamponade
Pulmonary
Disease
• Primary
Pulmonary
• Restrictive
• Diffuse
Lung
Disease Arterial
Hypertension
Cardiomyopathy• Pulmonary
Embolism
• Chronic
Obstructive
• Acute
Respiratory
• Pulmonary
Veno-‐
Pulmonary
Disease
• Primary
Pulmonary
Distress
Syndrome Occlusive
Disease
• Diffuse
Lung
Disease Arterial
Hypertension • Chronic
Lung
• Acute
Respiratory
• Pulmonary
Veno-‐ Infection
11
Distress
Syndrome Occlusive
Disease
• Bronchiectasis
• Chronic
Lung
Pulse Abnormalities
PULSE ABNORMALITIES
Pulse Abnormalities
Pulsus Alternans Pulsus Paradoxus
Unequal/Delayed Variation in pulse amplitude Exaggerated inspiratory drop in
with alternate beats arterial pressure >10mmHg
• Obstructive arterial disease
(ie. Atherosclerosis) • Left heart failure • Cardiac tamponade
• Aortic dissection • AECOPD/ Acute Exacerbation
• Aortic aneurysm of Asthma
• Aortic coarctation • Hypovolemic shock
• Takayasu disease • Constrictive Pericarditis
• Normal variant • Restrictive Cardiomyopathy
Cardiovascular
Aortic
Stenosis Water
Hammer
Pulse
Rapid
upstroke
followed
by
rapid
collapse
• Anacrotic
• Pulsus
parvus
(small
amplitude) • Aortic
regurgitation
• Pulsus
tardus
(delayed/slow
• High
output
states
(ie.
upstroke) Anemia,
hypoglycemia,
thyrotoxicosis,
)
12
Shock
SHOCK
Shock
Warm Extremities Cold Extremities
High JVP Low JVP
Obstructive Shock Hypovolemic Shock
Distributive Shock Cardiogenic Shock
Cardiovascular
Normal/Decreased (Rule out Decompensated
Low JVP Bibasilar Lung Crackles
Breath Sounds Distributive Shock)
• Sepsis • Myocardial Ischemia or • Pulmonary Embolism • Hemorrhage
• Anaphylaxis Infarction • Tension Pneumothorax • Dehydration
• Burns • Left-‐sided Valvular Disease • Cardiac Tamponade • Vomiting
• Neurogenic • Arrhythmia • Diarrhea
• Cardiomyopathy (ie. HOCM) • Interstitial Fluid
Redistribution
13
Syncope
SYNCOPE
Rule
out
Syncope Seizure
Neurocardiogenic Cardiac Respiratory Other
• Vasovagal • Pulmonary Embolism • Hypoglycemia
• Orthostatic Hypotension • Hypoxia • Anemia
• Autonomic Neuropathy • Hypercapnia • Medications (CCB, βB,
• Situational (micturition, CO = SV x HR Nitrates, Diuretics)
coughing, defecation) • TIA
• Psychiatric
• Intoxication
• Migraine
Stroke Volume Heart Rate/Rhythm
Cardiovascular
Contractility Afterload Preload Tachyarrhythmia Bradyarrhythmia
• MI • Mitral/Aortic • Blood • VT/VFib • Sick Sinus Syndrome (SA
• DCM Stenosis Loss/Hypotension • AFib/AFlutter Node)
• HCM (LVOT) • Mitral Stenosis • AVNRT/AVRT • 2nd/3rd degree AV Block
• Cardiac Tamponade • Pacemaker Malfunction
• Constrictive • Tachy-‐Brady Syndrome
Pericarditis 14
Systolic Murmur
Benign & Stenotic
SYSTOLIC MURMUR: Benign & Stenotic
Systolic Murmur
Benign/Flow/
Stenosis Incompetent
Valve Other
Hyperdynamic
• Pregnancy
• Fever
• Anemia
Supravalvular Subvalvular Valvular
• Aortic Coarctation • Hypertrophic Obstructive
• Supravalvular Aortic Cardiomyopathy
Cardiovascular
Stenosis (rings, webs) • Subvalvular Aortic Stenosis
(rings, webs)
Pulmonary
Aortic
Stenosis*
Stenosis*
• Uni-‐/Bicuspid
S1 S2 • Degenerative
(Tricuspid)
•Aortic
Stenosis/ • Rheumatic
Heart
15 Pulmonary
Stenosis
Disease
Systolic Murmur
Valvular & Other
SYSTOLIC MURMUR: Valvular & Other
Systolic Murmur
Benign/Flow/
Stenotic Incompetent
Valve Other
Hyperdynamic
• Ventricular
Septal
Defect
Mitral Regurgitation* Tricuspid Regurgitation*
Papillary Muscle Dilation of Right
Leaflet/Annulus Chordae Tendinae Leaflet
Dysfunction Ventricle/Annulus
• Prolapse* • Rupture • Ischemia • Dilated • Prolapse*
Cardiovascular
• Dilated
cardiomyopathy • Endocarditis • Infarct cardiomyopathy
• Endocarditis
• Endocarditis • Rheumatic
Fever • Rupture • MI • Rheumatic
Fever
• Hypertrophic
• Trauma • Pulmonary
• Ebstein’s
Anomaly
Cardiomyopathy Hypertension • Carcinoid
• Rheumatic
Fever
• Marfan’s
Disease
S1 S2 S1 OS S2
•Mitral
Regurgitation/ *
Mitral
Valve
Prolapse
(OS
– 16
Tricuspid
Regurgitation
opening
snap) 15
Diastolic Murmur
DIASTOLIC MURMUR
Diastolic Murmur
Early Diastolic Mid-‐Diastolic Late Diastolic
• Aortic Regurgitation* • Mitral Stenosis* • Mitral Stenosis*
• Pulmonary Regurgitation • Tricuspid Stenosis* • Tricuspid Stenosis*
(Graham-‐Steell Murmur)* • Severe Aortic • Myxoma
Regurgitation (Austin Flint
Cardiovascular
Murmur)
• Atrial
Myxoma
Prolapse
S1 S2 S1 S2 OS S1
•Aortic
Regurgitation/ *
Mitral
Stenosis/Tricuspid
Stenosis
Pulmonary
Regurgitation
17 (OS
– opening
snap)
Respiratory
Pulmonary Function Tests Interpretation�������21 Lung Nodule����������������������������������������������������������������������� 35
Acid-Base Disorder Pulmonary���������������������������� 22 Mediastinal Mass��������������������������������������������������������������36
Chest Discomfort Cardiovascular������������������������ 23 Pleural Effusion������������������������������������������������������������������ 37
Chest Discomfort Pulmonary��������������������������������� 24 Pulmonary Hypertension�������������������������������������������38
Chest Discomfort Other���������������������������������������������� 25
Chest Trauma Complications����������������������������������26
Cough Chronic������������������������������������������������������������������� 27
Cough, Dyspnea & Fever�������������������������������������������28
Dyspnea Acute������������������������������������������������������������������ 29
Dyspnea Chronic Cardiac������������������������������������������30
Dyspnea Chronic Pulmonary / Other����������������31
Respiratory
Excessive Daytime Sleepiness������������������������������ 32
Hemoptysis�������������������������������������������������������������������������� 33
Hypoxemia���������������������������������������������������������������������������� 34
19
Historical Editors Student Editors
Calvin Loewen Amanda Comeau
Yan Yu Shaye Lafferty
Marc Chretien
Vanessa Millar Faculty Editor
Geoff Lampard Dr. Naushad Hirani
Shaina Lee Dr. Daniel Miller
Reena Pabari
Katrina Rodrigues
Eric Sy
Lian Szabo
Respiratory
Ying Wang
20
Pulmonary Function Tests
Interpretation
Respiratory
21
Acid-Base Disorder
Pulmonary
ACID-BASE DISORDER
Acid-‐Base
Disorder
pH < 7.35 pH 7.35-‐7.45 > pH < 7.45
Acidemia Normal pH Alkalemia
• Mixed Acid-‐Base Disorder
Respiratory Acidosis Metabolic Alkalosis Respiratory Alkalosis
Metabolic Acidosis
See “Metabolic• Decrease
Alkalosis”EABV
on page 122 • Hypokalemia*
Elevated High
Anion
Normal
Anion
Gap Chronic Acute Chronic Acute
Anion Gap Gap
See “Metabolic• Methanol See “Metabolic • Diarrhea Hypovennlaaon • COPD Hypovennlaaon • Asthma* Hypervennlaaon • Pregnancy Hypervennlaaon• Hypoxia
• Uremia Acidosis Normal
Acidosis Elevated • RTA present for • Interstitial
Disease
present for • Neuromuscular
present for • Psychogenic present for • Salicylates
Anion Gap” on • DKA Anion Gap” on • Interstitial
N ephritis
hours to days minutes to hours• Obstruction
hours to days • Sepsis
minutes to hours
page 120 • Paraldehydepage 121 • Pulmonary
• Isoniazid Embolism*
Respiratory
• Lactic
Acid
• Ethylene
Glycol *
Denotes
acutely
life-‐threatening
causes
• Salicylates Appropriate
Compensation: Ratio
(CO2:HCO3-‐)
Metabolic
Acidosis 12:10
Metabolic
Acidosis
– Mixed
Metabolic
Disorder: Metabolic
Alkalosis 7:10
Anion
Gap
Normal Normal
AG
Acidosis
Alone Acute
Respiratory
Acidosis 10:1
ΔAnion
Gap
=
ΔHCO3-‐ High
AG
Acidosis
Alone Chronic
Respiratory
Acidosis 10:3
ΔAnion
Gap
<
ΔHCO3-‐ Mixed
AG
Acidosis
+
Normal
AG Acute
Respiratory
Alkalosis 10:2
ΔAnion
Gap
>
ΔHCO3-‐ Mixed
High
AG
Acidosis
+
Metabolic
Alkalosis Chronic
Respiratory
Alkalosis 10:4
22
Chest Discomfort
Cardiovascular
Pulmonary
Respiratory
Aorrc Disseccon*
23 * Potentially acutely life-threatening
Chest Discomfort
Pulmonary
Pulmonary
Pleural Processes Processes that can
affect the Pleura
• Pneumothorax (Tension*) • Pneumonia*
• Pleuriis/Serosiis • Pulmonary Embolism*
Respiratory
• Pleural Effusion • Malignancy
• Malignant Mesothelioma • Sarcoidosis
• Acute Chest Syndrome
* Potentially acutely life-threatening 24
Chest Discomfort
Other
Respiratory
25
Chest Trauma Complications
Chest Trauma
Complicaaons
Esophageal Injury
Respiratory
* Potentially acutely life-threatening 26
Cough
Chronic
LLN)
Bronchiectasis
Respiratory
Rhinosinusiis/ Upper
Airway Cough Syndrome Reflux-Associated Cough
Psychogenic Cough
Vocal Cord Dysfunccon
Aspiraaon
27
Cough, Dyspnea & Fever
Viral Pneumonia
Bacterial Pneumonia
Tuberculosis
Respiratory
Fungal Pneumonia Pulmonary Vasculiis
Granulomatosis with polyangiiis
(Immuno-compromised host)
Seppc Emboli
* Potentially acutely life-threatening 28
Dyspnea
Acute
Respiratory
29
Dyspnea Chronic
Cardiac
Respiratory
* Potentially acutely life-threatening 30
Dyspnea Chronic
Pulmonary / Other
Airway Obstruccon Abnormal Parenchyma Pleural Abnormaliies Chest Wall
Abnormaliies
Pleural Effusions Neuromuscular Weakness
Pleural Thickening/Masses Kyphoscoliosis
Abdominal Distennon
Respiratory
ILD
CHF
COP
Neoplasm
31
Excessive Daytime Sleepiness
Differennate Faague from Sleepiness
Respiratory
32
Hemoptysis
Hematemesis
Epistaxis
Bronchiis Pulmonary Vasculiis
Respiratory
Pulmonary Vasculiis
Granulomatosis with polyangiiis
33 /microscopic polyangiiis
Hypoxemia
Normal < (Age/4) + 4
Normal < (Age/4) + 4
Pulmonary
Arterial
Hypertension
Obesity Hypovennlaaon
Syndrome
Respiratory
Neuromascular Weakness
Pleural Abnormaliies
Obesity Hypovennlaaon Chest Wall Abnormaliies
Syndrome
Neuromascular Weakness
Pleural Abnormaliies Severe Pneumonia
Chest Wall Abnormaliies Atelectasis
* Potentially acutely life-threatening 34
Lung Nodule
Respiratory
Metastases Granulomatosis with
polyangiiis (GPA)/microscopic
polyangiiis (MPA)
35 * Potentially acutely life-threatening
Mediastinal Mass
Mediastinal Mass
Anterior Middle Posterior
• Thyroid • Aneurysm • Neurogenic Tumour
• Thymoma • Lymphadenopathy • Esophageal Lesion
• Teratoma • Cystic (Bronchial, Pericardial, • Diaphragmatic Hernia
• “Terrible” Lymphoma Esophageal)
Respiratory
36
Pleural Effusion
Thoracic
Thoracic Ultrasound should be used to
perform
perform Diagnossc Thoracentesis
Use Light’s
Use Light’s Criteria
Criteria
Increased Hydrostaac
Hydrostaac Decreased
DecreasedOncooc
Oncooc
Pressure Pressure
Pressure
Congessve Heart Cirrhosis
Cirrhosis
Failure Nephrooc
NephroocSyndrome
Syndrome
Renal Failure with
with
Hypervolemia
(Early) Pulmonary
Respiratory
Pulmonary
Embolus
SerumLDH
Serum LDHUpper
Upper Limit
Limit of
of Normal
Normal
37 * Potentially acutely life-threatening
Pulmonary Hypertension
Associated with:
- Conneccve Tissue Disease Sleep-Disordered Breathing
- Portal Hypertension
- Congenital Heart Disease
- HIV
Miscellaneous
Hematologic Disorders
Metabolic Disorders
Respiratory
38
Hematologic
Overall Approach to Anemia������������������������������������41 Prolonged PTT, Normal PT (INR) No Bleeding
Approach to Anemia Mean Corpuscular Tendency��������������������������������������������������������������������������51
Volume������������������������������������������������������������������������������ 42 Approach to Splenomegaly������������������������������������� 52
Anemia with Elevated MCV�������������������������������������� 43 Fever in the Immunocompromised Host������� 53
Anemia with Normal MCV����������������������������������������� 44 Lymphadenopathy Diffuse��������������������������������������� 54
Anemia with Low MCV������������������������������������������������� 45 Lymphadenopathy Localized��������������������������������� 55
Approach to Bleeding / Bruising Platelets & Neutrophilia��������������������������������������������������������������������������56
Vascular System��������������������������������������������������������46 Neutropenia Decreased Neutrophils Only��� 57
Approach to Bleeding / Bruising Coagulation Neutropenia Bicytopenia / Pancytopenia����58
Proteins����������������������������������������������������������������������������� 47 Polycythemia����������������������������������������������������������������������59
Approach to Prolonged PT (INR), Prolonged Suspected Deep Vein Thrombosis (DVT)������60
Hematologic
PTT���������������������������������������������������������������������������������������48 Suspected Pulmonary Embolism (PE)��������������61
Prolonged PT (INR), Normal PTT��������������������������49 Thrombocyopenia�����������������������������������������������������������62
Prolonged PTT, Normal PT (INR) Bleeding Thrombocytosis����������������������������������������������������������������63
Tendency�������������������������������������������������������������������������50 Hemolysis������������������������������������������������������������������������������64
39
Historical Editors Lian Szabo
Soreya Dhanji Evan Woldrum
Jen Corrigan Ying Wang
Jennifer Mikhayel
Yang (Steven) Liu Student Editors
Megan Barber Andrea Letourneau
Lorie Kwong Victoria David
Khaled Ahmed
Aravind Ganesh Faculty Editor
Jesse Heyland Dr. Lynn Savoie
Tyrone Harrison
Hematologic
Nancy Nixon
Nahbeel Premji
Connal Robertson-More
40
Overall Approach to Anemia
Hematologic
41
Approach to Anemia
Mean Corpuscular Volume
Hematologic
42
Anemia with Elevated MCV
Hematologic
43
Anemia with Normal MCV
Hematologic
44
Anemia with Low MCV
Hematologic
45
Approach to Bleeding / Bruising
Platelets & Vascular System
Hematologic
46
Approach to Bleeding / Bruising
APPROACH
TO
BLEEDING/BRUISING:
Coagulation
Proteins
Coagulation Proteins
Bleeding/Bruising
Platelets Vascular System Coagulation Proteins
Congenital Acquired
• Factor VIII Deficiency • Anticoagulation (Iatrogenic)
• Factor IX Deficiency • Liver Disease
• Von Willebrand’s Disease • Vitamin K Deficiency
Hematologic
• Other deficiencies • Disseminated Intravascular
LCoagulation
47
Approach to Prolonged PT (INR), Prolonged PTT
Hematologic
48
Prolonged PT (INR), Normal PTT
PROLONGED
PT
(INR),
NORMAL
PTT
Normal PTT/Long PT
Sufficient Vitamin K Insufficient Vitamin K
• Congenital Clotting Factor
Deficiency – Extrinsic Factor
(Factor VII Deficiency)
Vitamin K Deficiency Vitamin K Antagonist
• Coumadin (Warfarin) use
Hematologic
Child/Adult Newborn
• Antibiotics
and
Poor
Nutrition • Hemorrhagic
Disease
of
the
• Fat
Malabsorption Newborn
49
Prolonged PTT, Normal PT (INR)
Bleeding Tendency
Hematologic
50
Prolonged PTT, Normal PT (INR)
No Bleeding Tendency
Hematologic
51
Approach to Splenomegaly
Hematologic
52
Fever in the Immunocompromised Host
Hematologic
53
Lymphadenopathy
Diffuse
LYMPHADENOPATHY:
Diffuse
Diffuse Lymphadenopathy
Reactive Neoplastic
Monoclonal
Reed-‐
Systemic
Infectious Other Leukemia Lymphocytes
Sternberg
Cells
Inflammatory
on
Biopsy on
Biopsy
• Systemic Lupus •EBV • Acne • Non-‐Hodgkin’s • Hodgkin’s
Erythematosus •CMV • Allergy Lymphoma Lymphoma
• Sarcoidosis •HIV • Insect Bites
Hematologic
• Rheumatoid
•Tuberculosis • Young
age
Arthritis • Hepatitis
• Pseudotumor History
of
Asymptomatic,
Bleeding,
Infection,
Age
>
50
Fatigue
• Acute
Lymphoblastic
• Chronic
Lymphocytic
Leukemia
Leukemia
(CBC
with
(Pancytopenia,
WBC
Lymphocytes)
differential
includes
54
Blasts)
Lymphadenopathy
Localized
Hematologic
55
Neutrophilia
Hematologic
56
Neutropenia
Decreased Neutrophils Only
NEUTROPENIA:
Decreased
Neutrophils
Only
Neutropenia
Bicytopenia/Pancytopenia
Isolated
Neutrophil
Decrease (Neutrophils
and
Other
Cell
Lines
Decreased)
Decreased Marrow Increased Increased
Congenital Idiopathic
Production Chronic Consumption Destruction
Septicemia
• Gram Positive • Systemic Lupus
Bacteria Erythematosus
• Gram Negative • Rheumatoid Arthritis
Bacteria
Medications Viral Infection
Hematologic
• Anticonvulsants • Epstein-‐Barr Virus
• Antibiotics • Cytomegalovirus
• Antithyroid • Childhood viruses
• Antihypertensive • HIV
• Antirheumatic • Influenza
• Antistroke
• Antipsychotic
57 • Antineoplastic
Neutropenia
Bicytopenia / Pancytopenia
NEUTROPENIA: Bicytopenia/Pancytopenia
Neutropenia
Bicytopenia/Pancytopenia
Isolated
Neutrophil
Decrease (Neutrophils
and
Other
Cell
Lines
Decreased)
Decreased Production Sequestration
• Splenomegaly
Hematologic
Marrow
Infiltration Stem
cell
damage
or
suppression Nutritional
deficiency
• Hematologic and non-‐hematologic • Chemotherapy • B12/folate/combined deficiencies
malignancies • Radiation
• Infection • Drugs
• Primary Myelofibrosis • Toxins
• Aplastic Anemia
• Myelodysplasia
58
Polycythemia
Hematologic
59
Suspected Deep Vein Thrombosis (DVT)
Hematologic
60
Suspected Pulmonary Embolism (PE)
SUSPECTED PULMONARY EMBOLISM (PE)
Suspected PE
Calculate Clinical Probability
Score
Low: ≤ 4 Points High: > 4 Points
Negative Positive CT-‐PA or
D-‐Dimer D-‐Dimer Compression U/S
STOP
Well’s Criteria for PE Negative Non-‐ Positive
Clinical Signs and Symptoms of DVT (3.0)
CT-‐PE Diagnostic CT-‐PA
(leg swelling and pain with palpation of the deep veins) TREAT
Alternative
diagnosis
less
likely
than
PE
(3.0) Low
Clinical
High
Clinical
Compression
U/S
Suspicion Suspicion
Heart
rate
>100bpm
(1.5)
STOP
Immobilization or surgery in last 4 weeks (1.5) Positive Negative
Hematologic
Previous DVT or PE (1.5) TREAT • Repeat U/S in 1
Week
Hemoptysis (1.0)
Malignancy (ongoing or previous 6 months) (1.0)
Wells
P.S,
et
al.
(2000).
Derivation
of
a
simple
clinical
model
to
categorize
patients
probability
of
pulmonary
embolism:
increasing
the
models
utility
with
the
SimpliRED
D-‐dimer.
Thromb
Haemost
2003;
83:
416-‐20.
Writing
Group
for
the
Christopher
Study
Investigators.
(2006).
Effectiveness
of
managing
suspected
pulmonary
embolism
using
an
algorithm
combining
clinical
probability,
D-‐Dimer
testing,
and
computer
tomography.
61 JAMA;295:
172-‐179.
Thrombocyopenia
Hematologic
62
Thrombocytosis
THROMBOCYTOSIS
Thrombocytosis
Reactive Spurious Autonomous
• Artifact (redo CBC) • Essential thrombocytosis
• Polycythemia Vera
• Chronic Myelogenous Leukemia
• Primary Myelofibrosis
Non
malignant
Infectious Inflammatory Tissue
Damage hematologic
Other
Hematologic
conditions
• Acute
or
Chronic • IBD • Post-‐op
surgery • Rebound
effect
• Post-‐splenectomy
or
• Rheumatic
• Trauma following
hyposplenic
states
disorders • Burns treatment
of
ITP • Non-‐hematologic
• Celiac
disease • Rebound
effect
malignancy
following
ETOH
• Iron
deficiency
induced
anemia
thrombocytopenia
63
Hemolysis
Hemolysis
Hemolysis
Extravascular Intravascular
Spleen
and
RES-‐ Hemolysis
within
mediated
hemolysis circulation
Extrinsic to Intrinsic to Complement-‐ Mechanical
Infections
RBC RBC Mediated Shearing
• Malaria • Cold AIHA • MAHA (TTP, DIC,
• Babesiosis • PCH HUS)
Immune-‐ • C. perfringens • PNH • Prosthetic heart
Mediated • Drug-‐induced valves
Hematologic
immune-‐complex
• Atriovenous
• Warm
AIHA hemolytic
anemia malformations
• Cold
AIHA • Acute
HTR
• Alloimmune
delayed
HTR Abnormal
Hgb &
Membrane
RBC
Enzyme
• Drug-‐induced
Hgb Defects Defects Defects
AIHA • G6PD
deficiency
• Thalassemia • Hereditary
• Sickle
cell spherocytosis • PK
deficiency
• Unstable
Hgb • Hereditary
elliptocytosis 64
Gastrointestinal
Abdominal Distention���������������������������������������������������69 Chronic Diarrhea Steatorrhea & Large Bowel
Abdominal Distention Ascites��������������������������������70 ��������������������������������������������������������������������������������������������������81
Abdominal Distention Other Causes������������������71 Constipation (Adult) Altered Bowel Function
Abdominal Mass��������������������������������������������������������������� 72 & Idiopathic��������������������������������������������������������������������82
Abdominal Pain (Adult) Acute - Diffuse����������� 73 Constipation (Adult) Secondary Causes���������83
Abdominal Pain (Adult) Acute - Localized�����74 Constipation (Pediatric) ����������������������������������������������84
Abdominal Pain (Adult) Chronic - Constant� 75 Dysphagia������������������������������������������������������������������������������85
Abdominal Pain (Adult) Chronic - Crampy / Elevated Liver Enzymes���������������������������������������������86
Fleeting�����������������������������������������������������������������������������76 Hepatomegaly�������������������������������������������������������������������87
Abdominal Pain (Adult) Chronic - Post- Jaundice���������������������������������������������������������������������������������88
Gastrointestinal
Prandial����������������������������������������������������������������������������� 77 Liver Mass������������������������������������������������������������������������������89
Anorectal Pain��������������������������������������������������������������������78 Mouth Disorders (Adult & Elderly) ���������������������90
Acute Diarrhea�������������������������������������������������������������������79 Nausea & Vomiting Gastrointestinal Disease
Chronic Diarrhea Small Bowel�������������������������������80 ��������������������������������������������������������������������������������������������������91
65
Nausea & Vomiting Other Systemic
Disease�������������������������������������������������������������������92
Stool Incontinence�����������������������������������������������93
Upper Gastronintestinal Bleed
(Hematemesis / Melena)�������������������������94
Lower Gastrointestinal Bleed�����������������������95
Weight Gain���������������������������������������������������������������96
Weight Loss�������������������������������������������������������������� 97
Gastrointestinal
66
Historical Editors Shabaz Syed
Dr. Chris Andrews Ying Wang
Khaled Ahmed
Jennifer Amyotte Student Editors
Stacy Cormack Scott Assen
Beata Komierowski Jonathan Seto
James Lee Jacob Charette
Shaina Lee
Matt Linton Faculty Editor
Michael Prystajecky Dr. Sylvain Coderre
Gastrointestinal
Daniel Shafran Dr. Kelly Burak
Robbie Sidhu
Mia Steiner
67
68
Gastrointestinal
Abdominal Distention
Gastrointestinal
69
Abdominal Distention
Ascites
ABDOMINAL
DISTENTION:
Ascites
Abdominal Distention
Ascites Bowel Dilatation Other Causes
High Albumin Gradient (SAAG)* Low Albumin Gradient (SAAG)*
>11 g /L serum-‐fluid albumin <11 g /L serum-‐albumin gradient
Gastrointestinal
Portal
Hypertension Cardiac Peritoneal Other
Causes
• Cirrhosis • Congestive Heart Failure • Carcinomatosis • Pancreatitis
• Alcoholic Hepatitis • Constrictive Pericarditis • Infection (Neutrophils > • Serositis
• Portal vein thrombus 250/cc) • Nephrotic Syndrome
• Budd-‐Chiari Syndrome
Clinical
pearl:
“rule
of
97”:
SAAG
97%
accurate.
If
high
SAAG,
97%
of
time
it
is
cirrhosis/portal
hypertension.
If
low
SAAG,
97%
time
carcinomatosis
(and
cytology
97%
sensitive)
*Serum
Ascites
Albumin
Gradient
(SAAG)
=
[Serum
albumin]
– [Peritoneal
fluid
albumin] 70
Abdominal Distention
ABDOMINAL
Other Causes DISTENTION:
Other
Causes
Abdominal Distention
Ascites Bowel Dilatation Other Causes
Pelvic Mass Feces/Flatus Organomegaly
• Pregnancy • Constipation • Hepatomegaly
• Fibroids • Irritable Bowel Syndrome • Splenomegaly
• Ovarian Mass • Carbohydrate Malabsorption • Hydronephrosis
Gastrointestinal
• Bladder Mass • Diet (Lactose Intolerance) • Renal Cysts
• Malignancy • Chronic Obstruction • Aortic Aneurysm
• Obesity
6 Fs of Abdominal Distention
• Fluid
• Feces
• Flatus
• Fetus
• Fibroids and benign masses
71 • Fatal tumour
Abdominal Mass
ABDOMINAL MASS
Abdominal Mass
Exclude pregnancy/hernia/abdominal wall mass
Organomegaly Neoplastic Other Causes
• Liver • Gastrointestinal Tumours (e.g. Colonic,
• Spleen Gastric, Pancreatic)
• Kidneys (e.g. Cysts, Cystic Renal Cell • Gynecologic Tumors (e.g. Ovarian,
Carcinoma, Hydronephrosis) Uterine)
• Lymphoma/Sarcoma
Gastrointestinal
Feces Pulsatile Pseudoneoplastic
• Vascular (Abdominal Aortic • Pancreatic Pseudocyst
Aneurysm)
72
Abdominal Pain (Adult)
Acute - Diffuse
ABDOMINAL PAIN (ADULT): Acute -‐ Diffuse
Acute Abdominal Pain
(<72 hours)
Look For Surgical Abdomen
Upper Quadrant: R/O Cardiac, Pulmonary, Renal, Musculoskeletal Causes
Lower Quadrant: R/O Genitourinary Causes
Diffuse Localized
Peritonitic Non-‐Peritonitic
Gastrointestinal
• Pancreatitis • Gastroenteritis
• Bowel
Obstruction • Irritable
Bowel
Syndrome
• Viscus
Perforation • Constipation
• Intraperitoneal
Hemorrhage • Metabolic
Disease
(e.g.
Diabetic
(ruptured
AAA) Ketoacidosis)
• Mesenteric
Ischemia
• Mesenteric
Thrombus
• Sickle
Cell
Anemia
• Musculoskeletal
73 • Trauma
• Peptic
Ulcer
Disease
Abdominal Pain (Adult)
Acute - Localized
Gastrointestinal
74
Abdominal Pain (Adult)
ABDOMINAL
PAIN
(ADULT):
Chronic
-‐ Constant
Chronic - Constant
Chronic Abdominal Pain
Recurrent abdominal pain? Consider tumor
Upper Quadrant/Epigastric? Consider cardiac causes
Lower quadrant? Consider genitourinary causes
Constant Cramping/Fleeting Post-‐Prandial
Upper Quadrant Lower Quadrant Any Location/Diffuse
Gastrointestinal
• Gastroesophageal Reflux Disease • Crohn’s Disease • Ascites
• Peptic Ulcer Disease • Gynecologic (e.g. Tumor, Endometriosis) • Muscle Wall
•Chronic Pancreatitis • Neuropathic pain
• Pancreatic Tumor • Somatization
• Gastric Cancer
• Liver Distention (e.g. Hepatomegaly,
Tumor, Fat)
• Splenic (e.g. Abscess, Splenomegaly) –
very rare
75
Abdominal Pain (Adult)
ABDOMINAL PAIN (ADULT): Chronic – Crampy/Fleeting
Chronic - Crampy / Fleeting
Chronic Abdominal Pain
Recurrent abdominal pain? Consider tumor
Upper Quadrant/Epigastric? Consider cardiac causes
Lower quadrant? Consider genitourinary causes
Constant Cramping/Fleeting Post-‐Prandial
Upper Quadrant Lower Quadrant Any Location/Diffuse
Gastrointestinal
• Biliary
Colic/Cholelithiasis • Bloating
(e.g.
Celiac
Disease,
Lactose
• Bowel
Obstruction
(e.g.
Adhesions,
• Choledocholithiasis Intolerance) Crohn’s,
Volvulus,
Neoplasm,
Hernia)
• Sphincter
of
Oddi
Dysfunction • Renal
colic • Irritable
Bowel
Syndrome
• Renal
Colic • Irritable
Bowel
Syndrome
76
Abdominal Pain (Adult)
ABDOMINAL
PAIN
(ADULT):
Chronic
– Post-‐Prandial
Chronic - Post-Prandial
Chronic Abdominal Pain
Recurrent abdominal pain? Consider tumor
Upper Quadrant/Epigastric? Consider cardiac causes
Lower quadrant? Consider genitourinary causes
Constant Cramping/Fleeting Post-‐Prandial
Upper Quadrant Lower Quadrant Any Location/Diffuse
Gastrointestinal
• Biliary Colic/Cholelithiasis • Obstructing Colon Cancer • Bowel Obstruction (e.g. Adhesions,
• Gastroesophageal Reflux Disease Crohn’s, Volvulus, Neoplasm, Hernia)
• Peptic Ulcer Disease/Dyspepsia • Mesenteric Angina
• Gastric Cancer
• Chronic Pancreatitis
• Obstructing Colon Cancer
77
Anorectal Pain
ANORECTAL
PAIN
Anorectal Pain
Exclude: Poor Hygiene, Dietary,
Anal Trauma
Internal Lesion Diagnosis of Exclusion External Lesion
• Proctalgia
Gastrointestinal
Proctitis Other Dermatologic Anorectal
Disease
• Inflammation • Malignancy • Dermatitis • Fissure
• Infection (Including Sexually • Solitary Rectal Ulcer • Psoriasis • Fistula/Abscess (Crohn’s)
Transmitted) • Hemorrhoid
78
Acute Diarrhea
ACUTE
DIARRHEA
Acute
Diarrhea
> 2-‐3 loose stools/day, >175-‐235 g /day; > 48
hours, <14 days
Infectious Ischemic Inflammatory Dietary
Nausea/Vomiting
Diarrhea
Predominant Non-‐Bloody Bloody
Predominant
• Bacillus
cereus • Crohn’s
Ileitis • Ulcerative
Colitis
•Staphylococcus
aureus • Crohn’s
Colitis • Crohn’s
Colitis
Gastrointestinal
Bloody/Pain/Small
Watery/Large
Volume **C.
difficile
is
under
“large
bowel”
but
presents
Volume/Urgency with
non-‐bloody
diarrhea
usually.
(Small
Bowel)
(Large
Bowel)
• Viral • Bacterial
(e.g.
E.
coli,
C.
Ischemic
colitis
is
a
self-‐limiting
illness
in
most
(due
• Bacterial
(e.g.
C.
perfringens,
difficile,
Salmonella,
to
vascular
network
from
SMA,
IMA,
iliacs)
whereas
V.
cholerae,
E.
coli,
Salmonella,
Campylobacter,
Shigella) small
bowel
ischemia
is
an
abdominal
catastrophe
Yersinia) • Parasitic
(e.g.
E.
histolytica) (only
one
supply,
SMA).
• Parasitic
(e.g.
Giardia)
• Drugs
(Antibiotics,
Laxatives,
Antacids)
79 • Toxins
Chronic Diarrhea
Small Bowel
CHRONIC
DIARRHEA:
Small
Bowel
Chronic Diarrhea
>3 Loose Stools/Day, > 14 days
Exclude Chronic Inflammation
Large
Bowel
Steatorrhea Small
Bowel
Small
Volume/Bloody/Painful/
Oily/Foul/Hard
to
Flush Large
Volume/Watery
Tenesmus/Urgency
Secretory Disordered Motility Osmotic
• Irritable Bowel Syndrome (diagnosis of • Magnesium, Phosphate, Sulfate
exclusion)
• Carbohydrate Malabsorption
• Diabetic Neuropathy
• Lactose Intolerance
• Hyperthyroidism
Gastrointestinal
Mucosal Tumors
• Crohn’s Disease (Screen with CBC,
albumin, ESR, endoscopy)
• Celiac Disease (screen with TTG)
• Chronic Inflammation Mucosal Neoplastic
• Whipple’s Disease
• Gastrinoma • Adenocarcinoma
• Carcinoid Syndrome • Lymphoma
• Mastocystosis
80
Chronic Diarrhea
Steatorrhea & Large Bowel
CHRONIC DIARRHEA: Steatorrhea & Large Bowel
Chronic Diarrhea
>3 Loose Stools/Day, > 14 days
Exclude Chronic Inflammation
Large
Bowel
Steatorrhea Small
Bowel
Small
Volume/Bloody/Painful/
Oily/Foul/Hard
to
Flush Large
Volume/Watery
Tenesmus/Urgency
Maldigestive Malabsorptive Motility Inflammatory Secretory
• Pancreatic • Irritable Bowel Syndrome • Inflammatory Bowel • Villous Adenoma
Gastrointestinal
Insufficiency • Hyperthyroid Disease • Colon Cancer
• Radiation Colitis • Microscopic Colitis
• Ischemic Colitis
Primary
Secondary
Malabsorption Malabsorption
• Celiac
Disease • Bacterial
Overgrowth
• Mucosal
Disease • Liver
Cholestasis
• Ileal
Crohn’s
Disease • Mesenteric
Ischemia
81 • Short
Bowel/
Resection
Constipation (Adult)
Altered Bowel Function & Idiopathic
CONSTIPATION
(ADULT):
Altered
Bowel
Function
&
Idiopathic
Constipation
Infrequency (< 3 bowel movements/week)?
Sensation of Blockage or incomplete evacuation? Straining?
Altered Bowel Function Severe Idiopathic Secondary Causes
Diet/Lifestyle Medications Colonic Inertia Outlet Delay Irritable Bowel
• Neurally Active
Gastrointestinal
• Fibre • Pelvic
Floor
• Calories Medications
(e.g.
Dyssyngergia
• Fluid Opiates,
Anti-‐
• Exercise Hypertensives)
• Psychosocial • Cation
Related
(e.g.
Iron,
Aluminum,
Calcium,
Potassium)
• Anticholinergic
(e.g.
Antispasmodics,
Antidepressants,
Antipsychotics)
82
Constipation (Adult)
Secondary Causes
CONSTIPATION
(ADULT):
Secondary
Causes
Constipation
Infrequency (< 3 bowel movements/week)?
Sensation of Blockage or incomplete evacuation? Straining?
Altered Bowel Function Severe Idiopathic Secondary Causes
Neurogenic Non-‐Neurogenic
Gastrointestinal
Peripheral Central Metabolic Colorectal Disease
• Hirschsprung’s Disease • Multiple Sclerosis • Hypothyroidism • Colon Cancer
• Autonomic Neuropathy • Parkinson’s Disease • Hypokalemia • Colonic Stricture
• Pseudo-‐obstruction • Spinal Cord/Sacral/Cauda • Hypercalcemia (Inflammatory Bowel Disease
Equina Injury and Diverticular Disease)
83
Constipation (Pediatric)
CONSTIPATION (PEDIATRIC)
Constipation
Infrequent Bowel Movements? Hard, Small
stools? Painful evacuation? Encopresis?
Neonate/Infant Older Child
Gastrointestinal
Dietary/Functional Neurologic Dietary/Functional Anatomic Neurologic
• Insufficient
Volume/
• Hirschsprung’s
Disease • Insufficient
Bulk/Fluid • Bowel
Obstruction • Hirschsprung’s
Disease
Bulk • Imperforate
Anus • Withholding • Pseudo-‐obstruction • Spinal
Cord
Lesions
• Anal
Atresia • Painful
(e.g.
Fissures) • Myotonia
Congenita
• Intestinal
Stenosis • Guillain-‐Barré
Syndrome
• Intestinal
Atresia
84
Dysphagia
DYSPHAGIA
Dysphagia
If heartburn present: Consider GERD
Oropharyngeal
Dysphagia
Esophageal
Dysphagia
Immediate
Difficulty
Delayed
Difficulty
Difficulty
initiating
swallowing?
Food
sticks
seconds
later/
Further
down?
Choking?
Nasal
Regurgitation?
Motor Disorder Mechanical
Neuromuscular/Toxi
Structural Functional Solids and/or Obstruction
c/Metabolic
Liquids Solids only
• Tumors • Myasthenia Gravis
• Zenker’s Diverticulum • CNS Tumors
• Foreign Body • Cerebrovascular
Accident
Gastrointestinal
• Multiple
Sclerosis
• Amyotrophic
Lateral
Sclerosis
• Polymyositis
Intermittent Progressive Intermittent Progressive
Symptoms Symptoms Symptoms Symptoms
• Esophageal Spasm • Scleroderma • Schatzki Ring • Reflux Stricture
• Achalasia • Esophageal Web • Esophageal Cancer
85 • Diabetic Neuropathy • Eosinophilic Esophagitis
Elevated Liver Enzymes
ELEVATED LIVER ENZYMES
ELEVATED LIVER ENZYMES
ELEVATED LLIVER
ELEVATED IVER ENZYMES
NZYMES Elevated Liver Enzymes
ELEVATED LIVER EENZYMES
Elevated Liver Enzymes
Elevated Liver Enzymes
Elevated LLiver
Elevated
Hepatocellular iver EEnzymes
nzymes
Cholestatic (does not always cause
Hepatocellular ALT or AST > ALP Jaundice) ALP > ALT or AST
Cholestatic (does not always cause
ALT or AST > ALP
Hepatocellular Jaundice)
Cholestatic ( A LP
does n >
ot A LT
a o
lways r A ST
cause
Hepatocellular
Hepatocellular Cholestatic
Cholestatic (does
(does nnot
ot always
lways
aUS cause
ause
Severe ALT ALT or AST > AModerate
ALT oor r AAST
ST >> A ALP
LP
LP MildJaundice) ALP > A LT AcST
–or Normal Bile US – Dilated Bile
Jaundice) AALP
Jaundice) LP >> A ALT
LT oor r AAST
ST
Severe ALT > 15x ULN Moderate ALT 5–15x ULN Mild ALT < 5x ULN US – Normal Bile Ducts US – Dilated Bile Ducts
ALT Severe
> 1• 5x ULN
Viral ALT 5–15x
Moderate ULN ALT <Mild 5x •UNAFLD
LN Ducts• PBC
US – Normal Bile Ducts• Common
US – Dilated Bile Bile Duct
• Viral
Severe
Severe
ALT > 1• 5x ULN
Drugs/Toxins
Moderate
Moderate
ALT 5–15x • Drugs ULN ALT Mild
Mild
< 5x •UAlcohol LN •US
US
PBC ––Normal
Normal
Ducts•BPSC Bile
ile US ––Dilated
US Dilated
Ducts BBile
ile
Stone
• Viral
ALT >> 1 15x
5x U LN • ALT
Viral • NAFLD
ALT < 5 x U LN Ducts • Alcoholic hepatitis • Common DuctsBile D uct
ALT U LN
• Ischemia ALT
5 5 –15x
–15x UU LN LN ALT < 5 x U LN
• Viral • PSC
• PBC Ducts Ducts • Biliary stricture
•• Drugs/Toxins
Viral • Drugs • AIH •• NAFLD Alcohol • Drugs Stone
• Common Bile Duct
• ••• Viral
Viral
Ischemia • Autoimmune •••Viral Viral
• Wilson’s • •NAFLD
••NAFLD Viral
Alcohol
• Hemochromatosis • •PBC
••PBC Alcoholic
PSC hepatitis
• •Common
Common
•Stone BBile •uct
PSC
ile DDuct
Biliary stricture
Drugs/Toxins • AIH
• Viral Drugs • Drugs • •PSC
••PSCDrugs • TPN
Biliary stricture• Worms/flukes
• ••• Drugs/Toxins
Drugs/Toxins
Autoimmune • Wilson’s • Hemochromatosis
• • •
Alcohol Alcohol
Hemochromatosis Alcoholic hepatitis Stone
Stone•• PSC
Ischemia • •Drugs
••Drugs
Wilson’s
AIH • Viral • • Alcoholic
TPN h • Sepsis
epatitis
• Pregnancy • •AIH • AIH • Alcoholic
• Drugs h epatitis stricture• Cholangiocarcinoma
• ••• Ischemia
Ischemia
Wilson’s • •Viral
••ViralDrugs •••Biliary
Worms/flukes
• Infiltrative• Biliary
PSC stricture
Autoimmune Wilson’s • NAFLD
••AIH
Hemochromatosis Hemochromatosis
• •Drugs
• A1AT deficiency ••Drugs
Sepsis
TPN
• ••• Autoimmune
Autoimmune
Pregnancy
Wilson’s • AFLP • •Wilson’s
••Wilson’s
NAFLD • Others
Hemochromatosis
• •Hemochromatosis
••Hemochromatosis
AIH
Drugs • •PSC
• Sarcoid Worms/flukes• Pancreatic cancer
••PSC
Cholangiocarcinoma
• Wilson’s • •TPN••TPN
Infiltrative
Sepsis • Others
• •• Wilson’s
Wilson’s
• AFLP
Pregnancy • HELLP • •Hemochromatosis
••Hemochromatosis
Others • •Drugs
••Drugs
A1AT
AIH deficiency • •Worms/flukes
•Worms/flukes
• Pancreatic cancer
Cholangiocarcinoma
NAFLD • •Sepsis
•Sepsis • Sarcoid
Infiltrative • Amyloid
• • Pregnancy
Pregnancy
•• HELLP • •NAFLD • •AIH ••AIH
Wilson’s • Others
A1AT deficiency • •Cholangiocarcinoma
••Cholangiocarcinoma
Others
Pancreatic cancer
AFLP •NAFLD
Others •Infiltrative
•isease Infiltrative
•• Amyloid
Sarcoid • Malignancy
• ••AFLP
AFLP
HELLP •
• OthersOthers • • •
A1AT
• A1AT
Others
d
Wilson’sd
eficiency•
eficiency Cholestatic d • • Pancreatic
Pancreatic
• Others c c ancer
ancer
Gastrointestinal
• •Sarcoid
••Sarcoid
Malignancy
Amyloid • Infection
• •HELLP
HELLP • •Wilson’s
••Wilson’s
Cholestatic
Others disease • •OthersOthers
• •Amyloid
••Amyloid
Infection
Malignancy • Cirrhosis
(any)
• •Others •Others
Cholestatic
disease • • •Malignancy
•Malignancy
Cirrhosis
(any)
Infection •Congenital
• •Cholestatic
Cholestatic
ddisease
isease
• •Infection
•Congenital
• Cirrhosis
Infection
(any) •Biliary
Atresia
• •Cirrhosis
Cirrhosis
•Congenital (any)Atresia•Alagille Syndrome
•Biliary
(any)
•Congenital
•Congenital •Alagille
•Biliary
ASyndrome
tresia•Progressive
Familial
•Biliary
•Biliary
•Alagille AAtresia
tresia
•Progressive
Familial
Syndrome Intracholestasis
•Alagille
•Alagille Syndrome
Intracholestasis
Syndrome
Dx
ALF
if ETOH
hepatitis
NAFLD •Progressive
Familial
Dx
by
biopsy ERCP
for
dx
Dx
ALF
if ETOH
hepatitis
•Progressive
•Progressive
Familial
Familial
ERCP
for
dx
↑INR
and
hepatic
usually
cholestatic,
NAFLD10%
populationDx
Intracholestasis bIntracholestasis
y
biopsy
Intracholestasis ± MRI/MRCP and
therapy
↑INR
and
Dx
hepatic
ALF
if usually
ETOH
chholestatic,
epatitis
±Dx
MRI/MRCP
by
biopsy and
therapy ERCP
for
dx
Dx
aAA
Dx
LF
encephalopathy
LF
ihfiepatic
f ETOH
ETOH
hh epatitis
and
usually 10%
NAFLDpopulation
NAFLD
ERCP
for
ddxx
encephalopathy
↑INR
nd
and
usually
cepatitis
uholestatic,
sually NAFLD
10%
population
Dx
Dx
bby
y
bbiopsy
± MRI/MRCP iopsy ERCP
and
tfherapy
or
↑INR
↑INR
aand
nd
hhepatic
epatic
usually
usually
ccholestatic,
holestatic,
ALT
<
300 10%
10%
ppopulation
opulation ±±MRI/MRCP
MRI/MRCP and
ttherapy
and
herapy
encephalopathy
encephalopathy
encephalopathy
ALT
and
and
and
u<sually
uusually
ALT
<sually
300
300
86
ALT
<<
3
300
ALT
00
Hepatomegaly
HEPATOMEGALY
Hepatomegaly
Rule out concurrent splenomegaly and jaundice
Infiltrative Congestive Infectious Inflammatory
• Right Heart Failure • Hepatitis A, B, C • Alcoholic Hepatitis
• Budd-‐Chiari Syndrome • Mononucleosis • Autoimmune Hepatitis
• Constrictive Pericarditis • Tuberculosis • Drug Induced Hepatitis
• Bacterial Cholangitis • Sarcoidosis
• Abscess • Histiocytosis X
Gastrointestinal
• Schistosomiasis • Primary Sclerosing
Cholangitis
• Primary Biliary Cirrhosis
Malignant Non-‐Malignant
• Primary Carcinoma • Fatty Liver
• Metastases • Cysts
• Lymphoma • Hemochromatosis
• Leukemia • Wilson’s Disease
• Polycythemia • Amyloidosis
87 • Multiple Myeloma • Myelofibrosis
Jaundice
JAUNDICE
Jaundice
Post-‐Hepatic
Pre-‐Hepatic Hepatic
Usually
has
Duct
Dilatation
on
Unconjugated
Hyperbilirubinemia Conjugated
Hyperbilirubinemia
Ultrasound
• Hepatocellular
• Cholestatic
• Dubin Johnson
See Elevated Liver Enzymes scheme
Gastrointestinal
Increased
Decreased
Hepatic
Decreased
Biliary
Duct
Intraductal
Production Uptake Conjugation Compression Obstruction
• Hemolysis • Sepsis • Gilbert’s
Syndrome • Malignancy • Gallstones
• Ineffective
• Drugs
(e.g.
Rifampin) • Crigler-‐Najjar
• Metastases • Biliary
Stricture
Erythropoiesis Syndromes
(I
and
II) • Pancreatitis • Cholangiocarcinoma
• Hematoma • Primary
Sclerosing
Cholangitis
88
Liver Mass
LIVER
MASS
Liver Mass
Cystic Solid
Benign Malignant Benign Malignant
• Cystadenocarcinoma
Simple Complex
•Cyst
•Polycystic
Liver
Gastrointestinal
Disease
•Caroli’s
Primary
Secondary
Proliferative Infectious Proliferative Infectious
Malignancy Malignancy
•Cystadenoma •Hydatid
Cyst • Hemangioma • Abscess • Hepatocellular
• Metastases
• Focal
Nodular
Carcinoma (e.g.
Lung,
Colon,
Hyperplasia • Cholangiocarcinoma Breast)
89 • Adenoma
Mouth Disorders (Adult & Elderly)
Gastrointestinal
Granulomatosis with
polyangiiis (GPA)/microscopic
polyangiiis (MPA)
90
Nausea & Vomiting
NAUSEA
AND
Gastrointestinal VOMITING:
Gastrointestinal
Disease
Disease
Nausea and Vomiting
Gastrointestinal Disease Other Systemic Disease
Upper Gastrointestinal Hepatobiliary Lower Gastrointestinal
• Acute
Hepatitis
• Acute
Cholecystitis
• Cholelithiasis
• Choledocholithiasis
• Acute
Pancreatitis
Gastrointestinal
Acute Chronic Acute Chronic
• Infectious Gastroenteritis • Gastroesophageal Reflux • Infectious Gastroenteritis
• Inflammatory Bowel Disease
• Gastric/Duodenal Disease • Small/Large Bowel
• Colonic Neoplasm
Obstruction • Peptic Ulcer Disease Obstruction
• Gastric Volvulus • Gastroparesis • Acute Appendicitis
• Mesenteric Ischemia
91 • Acute Diverticulitis
Nausea & Vomiting
NAUSEA AND VOMITING: Other Systemic Disease Other Systemic Disease
Nausea and Vomiting
Gastrointestinal Disease Other Systemic Disease
Endocrine/Metabolic Other Drugs/Toxins Central Nervous System
• Pregnancy • Chemotherapy
• Sepsis
(e.g.
Pyelonephritis,
• Diabetes/
DKA • Antibiotics
Pneumonia)
• Uremia • Ethanol
• Radiation
Sickness
• Hypercalcemia • Carbon
Monoxide
• Acute
Myocardial
Infarction
• Addison’s
Disease • Heavy
Metal
• Nicotine
Gastrointestinal
• Thyroid
Disease
Vestibular
High
Intracranial
Pressure Psychiatric
(Inner
Ear)
• Hemorrhage • Ear
Infection • Self-‐Induced
(Bulimia)
• Meningitis • Motion
Sickness • Cyclic
Vomiting
• Infarction • Vestibular
Migraine • Psychogenic
• Malignancy • Ménière’s
Disease
• Head
Trauma 92
Stool Incontinence
STOOL
INCONTINENCE
Stool Incontinence
Intact Pelvic Floor Affected Pelvic Floor
Congenital
Anorectal
Trauma/Surgery Nerve/Sphincter
Damage
Malformation
• Surgery:
Anorectal,
Prostate,
• Vaginal
Delivery
Bowel • Rectal
Prolapse
• Pelvic
Fracture • Severe
Hemorrhoid
• Pelvic
Inflammation
Gastrointestinal
Stress and Emotional
Chronic Constipation Neurological Conditions Diarrheal Conditions
Problems
• Stool Impaction with • Age-‐Related (e.g. Dementia, • Inflammatory Bowel Disease
overflow Strokes) • Irritable Bowel Syndrome
• Encopresis • Neuropathy (e.g. Diabetes, • Chronic Laxative Use
Congenital Megacolon,
Hirschsprung’s Disease)
• Multiple Sclerosis
• Tumors/Trauma (e.g. Brain,
93 Spinal Cord, Cauda Equina)
Upper Gastronintestinal Bleed
UPPER GASTROINTESTINAL BLEED
(Hematemesis / Melena)
(HEMATEMESIS/MELENA)
Acute Hematemesis/Melena
Blood in vomitus?/black, tarry stools
If Melena, 5-‐10% colorectal/small bowel.
Exclude bleeding disorder.
Peptic Ulcer Disease Portal Hypertension
Other
(55%) (15%)
• Gastro-‐esophageal varices
Gastric Acid Non-‐Steroidal Anti-‐ Stress
Helicobacter Pylori
Gastrointestinal
Hypersecretion Inflammatory
Drugs (ICU
Setting)
• Zollinger-‐Ellison
Syndrome
Retching?
Esophagitis/
Mallory
Weiss
Tear Tumors
Gastritis
• Benign
• Malignancy 94
Lower Gastrointestinal Bleed
LOWER
GASTROINTESTINAL
BLEED
Lower Gastrointestinal Bleed
Occult (Stool + Occult
Overt Bleeding
blood and/or iron
deficiency anemia)
In Patient Out Patient
• Colorectal
cancer
• Angiodysplasia
(colon
or
Gastrointestinal
small bowel) • RULE OUT BRISK Upper GI
• Perianal Disease
• Occult UGI bleeding (ulcer, bleed, Diverticular bleed,
• Acute colitis (ischemia, (most common)
esophagitis, gastritis, • Inflammatory Bowel
cancer) infectious, inflammatory),
• Small bowel source (e.g. Disease
• Other: small bowel tumors, • Colorectal Cancer
asymptomatic IBD Meckel's, tumor),
• Angiodysplasia
95
Weight Gain
WEIGHT GAIN
Weight Gain
Increased Intake Decreased Expenditure
• Dietary • Sedentary Lifestyle
• Social/Behavioural • Smoking Cessation
• Iatrogenic
Neurogenic/Genetic Hypothalamic/Pituitary Gonadic Other Causes
Gastrointestinal
• Depression • Cushing’s
Disease
• Hypothalamic
Syndrome • Polycystic
Ovarian
Syndrome
• Dementia • Hypothyroidism
• Growth
Hormone
Deficiency • Hypogonadism
96
Weight Loss
WEIGHT
LOSS
Weight Loss
Decreased Intake Malabsorption Increased Expenditure
• GI
illness
(upper
and
lower) • Small
Bowel
Disease
(e.g.
Crohn’s
• Increased
Protein/Energy
Requirements
• Psychiatric
(Depression,
eating
disorders)
Disease,
Celiac
Disease) (e.g.
Post-‐Surgical,
Infections,
Trauma,
• Poverty • Pancreatic
Insufficiency Burns)
•Abuse • Cholestatic
Liver
Disease • Cancer
• Dementia • Protein-‐losing
Enteropathy
(e.g.
• Hyperthyroidism
• Anorexia
as
an
Adverse
Drug
Effect Inflammatory
Bowel
Disease) • Chronic
Cardiac/Respiratory
distress
(e.g.
COPD)
Gastrointestinal
• Chronic Renal Failure
• Adrenal Insufficiency
• Poorly Controlled Diabetes Mellitus
• HIV
97
Renal
Acute Kidney Injury������������������������������������������������������ 101 Proteinuria����������������������������������������������������������������������������115
Chronic Kidney Disease��������������������������������������������102 Renal Mass Solid������������������������������������������������������������ 116
Dysuria�����������������������������������������������������������������������������������103 Renal Mass Cystic�����������������������������������������������������������117
Generalized Edema������������������������������������������������������104 Scrotal Mass����������������������������������������������������������������������� 118
Hematuria����������������������������������������������������������������������������105 Suspected Acid-Base Disturbance������������������ 119
Hyperkalemia Intercellular Shift������������������������ 106 Metabolic Acidosis Elevated Anion Gap������120
Hyperkalemia Reduced Excretion��������������������107 Metabolic Acidosis Normal Anion Gap�����������121
Hypokalemia�������������������������������������������������������������������� 108 Metabolic Alkalosis ����������������������������������������������������� 122
Hypernatremia���������������������������������������������������������������� 109 Urinary Incontinence��������������������������������������������������� 123
Hyponatremia������������������������������������������������������������������� 110 Urinary Tract Obstruction�����������������������������������������124
Hypertension���������������������������������������������������������������������� 111
Increased Urinary Frequency��������������������������������112
Nephrolithiasis������������������������������������������������������������������113
Renal
Polyuria�����������������������������������������������������������������������������������114
99
Historical Editors Student Editors
Dr. Andrew Wade Colin Roscher (Co-editor)
Dr. Sophia Chou Mark Elliot (Co-editor)
Dave Campbell
Derrick Chan Faculty Editor
Marc Chretien Dr. Kevin McLaughlin
Mollie Ferris
Kody Johnson
Becky Kennedy
Vera Krejcik
Keith Lawson
Vanessa Millar
Eric Sy
Renal
Maria Wu
100
Acute Kidney Injury
(
FeNa = 100 × (Serum Creaanine × Urine Na)
(Serum Na × Urine Creaanine) )
(
FeNa = 100 × (Serum Creaanine × Urine Na)
(Serum Na × Urine Creaanine) )
Renal
(Granulomatosis with
101 polyangiiis /microscopic
polyangiiis)
Chronic Kidney Disease
CHRONIC KIDNEY DISEASE
Chronic Kidney Disease
Decreased kidney function (eGFR < 60ml/min/1.73m2)
persistent over at least 3 months
Pre-‐Renal Renal Post-‐Renal
(Evidence of Renovascular disease) (Abnormal urinalysis: proteinuria/pyuria) (Obstruction/hydronephrosis on U/S)
• Atheroemboli • Reflux nephropathy
• Renal artery stenosis • Benign prostatic hyperplasia
• Drugs • Constipation
• Chronic hypoperfusion • Prostate cancer
Interstitial
Tubular Vascular Glomerular
(Sterile
pyuria,
WBC
casts,
(Family
history,
ultrasound) (Other
small
vessel
disease) (Proteinuria)
eosinophiluria)
• Polycystic kidney disease • Atherosclerosis • Diabetes • Drugs (NSAIDs, analgesics)
• Medullary cystic disease • Hypertension • Infections (chronic
• Nephronophthisis pyelonephritis)
Renal
• Immune
(sarcoid,
Sjögren)
• Multiple
myeloma
• Hyperoxaluria
• Hypercalcemia
• Hyperphosphatemia 102
Dysuria
DYSURIA
Dysuria
Pyuria No
Pyuria
Leukocytes
on
No
Leukocytes
on
Dipstick/Microscopy Dipstick/Microscopy
Bacteriuria
&
No
Bacteriuria
&
No
Hematuria
Hematuria Urethritis Vaginitis Non-‐Pathogenic
Dipstick
positive
for
nitrites
Dipstick
negative
for
(if
infected
with
nitrites.
enterobacteria).
• Gonococcal • Candida • Candida • Estrogen deficiency
• Non-‐Gonococcal (e.g. • Herpes Simplex Virus • Gardnerella • Interstitial cystitis
Chlamydia, Trichomonas) • Neoplasm • Radiation cystitis
Renal
Upper Urinary Tract Lower Urinary Tract
Infection/Pyelonephritis Infection/Cystitis
WBC Casts WBC Clumps
103
Generalized Edema
GENERALIZED
EDEMA
Generalized
Edema
Increased
blood
pressure
Overfill
Underfill
(Increased
renal
sodium
(Urine
Na
<
20meq/L)
retention,
Urine
Na
>
40meq/L)
• NSAIDs
• AKI/CKD
• Nephrotic
Syndrome
Signs
of
left
ventricular
failure
Congestive Heart Failure
Altered Startling Forces
“forward failure”
(Absolute decrease in EABV)
(Relative decrease in EABV)
Low serum albumin due to
Severely ill (e.g. in ICU)
loss or impaired synthesis
Increased Interstitial Increased Capillary Decreased Capillary Increased Capillary
Oncotic Pressure Hydrostatic Pressure Oncotic Pressure Permeability
Renal
• Myxedema
(Hypothyroid) • Right
heart
failure • Nephrotic
syndrome • Inflammation
• Constrictive
pericarditis • Cirrhosis • Sepsis
• Portal
hypertension • Acute
Respiratory
Distress
• Pregnancy Syndrome
• Allergies
• Burns/Trauma 104
Hematuria
Renal
(Granulomatosis with
polyangiiis/microscopic
105 polyangiiis)
Hyperkalemia
Intercellular Shift
HYPERKALEMIA:
Transcellular
Shift
HYPERKALEMIA:
Transcellular
Shift TTKG
=
(KUrine x
OsmSerum)/(KSerum x
OsmUrine)
Hyperkalemia TTKG
=
(KUrine x
OsmSerum)/(KSerum x
OsmUrine)
Hyperkalemia
Exclude
pseudohyperkalemia
Serum
Potassium
>
5.5
mmol/L Leukocytosis,
thrombocytosis,
Exclude
pseudohyperkalemia
hemolysis
Serum
Potassium
>
5.5
mmol/L Leukocytosis,
thrombocytosis,
hemolysis
Transcellular
Shift
Increased
Intake
Reduced
Excretion Appropriate
renal
excretion
(IV
potassium
with
reduced
excretion)
(GFR,
TTKG,
distal
flow
adequate)
Transcellular
Shift
Increased
Intake
Reduced
Excretion Appropriate
renal
excretion
(IV
potassium
with
reduced
excretion)
(GFR,
TTKG,
distal
flow
adequate)
Increased Release Decreased Entry
Increased Serum Osmoles, Increased Decreased Na+-‐H+ Exchanger
Urate, Phosphate, Creatinine Kinase Decreased Na+-‐K+-‐ATPase
Renal
Increased
Release
• Non-‐Anion
Gap
Metabolic
Acidosis
Decreased
Entry
• Insulin
Deficiency/Resistance
Increased
Serum
Osmoles,
Increased
• Hyperosmolarity • β2 antagonism Decreased
Na+-‐H+ Exchanger
• Cell
Urate,
Phosphate,
Creatinine
Kinase • α1 agonism Decreased
Na -‐K -‐ATPase
+ +
Lysis
(e.g.
Tumor
Lysis
Syndrome,
rhabdomyolysis) • Digoxin
• Non-‐Anion
Gap
Metabolic
Acidosis • Insulin
Deficiency/Resistance 106
• Hyperosmolarity • β2 antagonism
Hyperkalemia
HYPERKALEMIA:
Reduced
Excretion
Reduced Excretion Hyperkalemia
HYPERKALEMIA:
Reduced
Excretion
Exclude
pseudohyperkalemia
Hyperkalemia
Serum
potassium
>
5.5
mmol/L Leukocytosis,
thrombocytosis,
hemolysis
Exclude
pseudohyperkalemia
Serum
potassium
>
5.5
m
Increased
mol/L
Intake Leukocytosis,
thrombocytosis,
Reduced
Excretion Transcellular
Shift
(IV
potassium
with
reduced
excretion) hemolysis
Increased
Intake
Reduced
Excretion Transcellular
Shift
(IV
potassium
with
reduced
excretion)
Principal Cell Problem Reduced flow through Decreased Glomerular
TTKG < 7 distal nephron Filtration Rate
TTKG > 7, Urine Na < 20meq/L Increased Creatinine
• Low EABV (e.g., CHF, cirrhosis, • Chronic renal failure
hypotension)
Reduced flow through • AKI
Decreased Glomerular
Principal Cell Problem
TTKG < 7 distal nephron Filtration Rate
TTKG > 7, Urine Na < 20meq/L Increased Creatinine
High Renin High
• Low R(enin
EABV e.g., CHF, cirrhosis, Low Renin • Chronic renal failure
High Aldosterone hypotension)
Low Aldosterone Low Aldosterone • AKI
• ENaC blockers • ACEi/ARB • Diabetic nephropathy
•High
AIN/CIN • Adrenal insufficiency • β2 antagonism
Renin •High Renin • Low Renin
Renal
• Obstruction Heparin NSAIDs
High Aldosterone Low Aldosterone Low Aldosterone
• ENaC blockers • ACEi/ARB • Diabetic nephropathy TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine)
• AIN/CIN • Adrenal insufficiency • β2 antagonism
107 • Obstruction • Heparin • NSAIDs
Hypokalemia
HYPOKALEMIA
Hypokalemia
Serum Potassium <3.5 mmol/L
Decreased
intake
Increased
Loss Transcellular
shift
(rare
cause
in
isolation)
• Insulin
• β2 agonists
• alkalemia
Renal
Loss GI
loss • Refeeding
syndrome
Urine
loss
>20mmol/d Urine
loss
<20mmol/d • Rapid
hematopoiesis
• Diarrhea • Hypothermia
• Vomiting • Thyrotoxic
periodic
High
distal
[K] High
distal
flow • NG
suction paralysis/familial
TTKG
>
4 TTKG
<
4 hypokalemic
periodic
• Laxatives
•Polyuria paralysis
Volume
Status
Assessment
Normal
or
EABV
contracted
expanded
EABV
Renal
• Loop
diuretics/
Bartter’s
syndrome
• Thiazide
diuretics/
High
renin Low
renin Low
renin
Gittelman’s
syndrome High
aldosterone High
aldosterone Low
aldosterone
• Magnesium
depletion •Renal
artery
stenosis •Hyperaldosteronism •Licorice
intake
•Liddle’s
syndrome 108
Hypernatremia
HYPERNATREMIA
Hypernatremia
Excess
free
water
loss
Serum Sodium >145 mmol/L
High Urine Volume
Low Urine Volume
>3L/24 hours
<3L/24 hours
Renal water loss
High Urine Osmolality Low Urine Osmolality Hypodipsia
Non-‐renal losses
> 300 mmol/kg < 300 mmol/kg Decreased intake of water
• Hypertonic saline •Diabetes Insipidus • Decreased level of
administration consciousness
• Osmotic diuresis • No access to water
(see Polyuria scheme)
e.g., mannitol, glucosuria
GI loss Insensible loss
Renal
• Watery Diarrhea • Burns
• ICU patients
• Fever
• Inadequate intake for
exercise-‐related loss
109 • Hyperventilation
Hyponatremia
HYPONATREMIA
HYPONATREMIA Hyponatremia
Hyponatremia
Artifactual Serum
Sodium
<135
mmol/L
Hypo-‐osmolar
plasma
Posm
<
280
Hypo-‐
mmol/kgosmolar
plasma
Artifactual Serum
Sodium
<135
mmol/L
Posm
<
280
mmol/kg
Normal
Posm High
Posm Impaired
H20
Excretion Intact
H20
Excretion
Normal
Posm
280-‐295mmol/kg >295mmol/kg High
Posm
• Reduced
GFR Impaired
H20
Excretion Intact
H20
Excretion
280-‐295mmol/kg >295mmol/kg
•Hypertriglyceridemia • Hyperglycemia* • Diuretics • Reduced
GFR
• Paraproteinemia • Mannitol • Hyperglycemia*
•Hypertriglyceridemia • Diuretics
• Paraproteinemia • Mannitol
Hyper-‐osmolar
urine Hypo-‐osmolar
urine
Uosm
>
100
Hyper-‐osmolar
mmol/kg urine Hypo-‐
Uosm
<
100
m osmolar
urine
mol/kg
ADH
expression
Uosm
>
100
mmol/kg ADH
suppression
Uosm
<
100
mmol/kg
ADH
expression • Primary
polydipsia ADH
suppression
• Insufficient
o•smole
intake
Primary
polydipsia
• Insufficient
osmole
intake
Syndrome
of
Inappropriate
ADH Reduced
EABV
Syndrome
Euvolemic;
no
physiologic
of
Inappropriate
stimulus
to
ADH ADH Reduced
EABV
Urine
[Na+]
<
20mmol/L
Euvolemic;
no
physiologic
stimulus
to
ADH Urine
[Na+]
<
20mmol/L
• Pain/Post-‐op
• Neurologic
trauma
• Pain/Post-‐op True
hypovolemia With
edema Hormonal
changes
• Drugs • Neurologic
trauma
• Pulmonary
p•athology True
hypovolemia With
edema Hormonal
changes
Drugs • Bleeding • Congestive
heart
failure • Hypothyroidism
Renal
• Malignancy • Pulmonary
pathology • GI
losses • Bleeding • Cirrhosis • Adrenal
• Congestive
heart
failureinsufficiency
• Hypothyroidism
• Malignancy • Renal
losses
• GI
losses • Nephrotic
syndrome• Cirrhosis • Pregnancy • Adrenal
insufficiency
(especially
• Renal
losses
• Reduced
GFR• Nephrotic
syndrome • Pregnancy
thiazide
diuretics)
(especially
AKI/CRF • Reduced
GFR
*serum
sodium
correction
in
hyperglycemia: thiazide
d iuretics) AKI/CRF
[Na+]corrected =
[*serum
Na+]
+
(s0.3
*
(
[glucose]
odium
– 5))
correction
in
hyperglycemia: 110
[Na+]corrected =
[Na+]
+
(0.3
*
(
[glucose]
– 5))
Hypertension
HYPERTENSION Hypertension Consider secondary HTN
HYPERTENSION BP > 140/90 (>130/80 for DM)
Hypertension •Onset <20yo, >50yo secondary HTN
Consider
Hypertensive urgency BP >o 1r 40/90 (>130/80
emergency (any for
visit) DM) •No FHx
Hypertension with end-‐organ damage or DM (visit 2) •Hypertensive urgency
•Onset <20yo, >50yo
Diagnosis based Hypertensive
on repeat clinic visits, oAr mbulatory •Refractory hypertension
•No FHx
urgency emergency b(lood
any visit)
pressure monitor, Self/Home pressure monitoring (visit (multi-‐drug resistance)
•Hypertensive urgency
Hypertension with end-‐organ damage or D3M
+)(visit 2)
Diagnosis based on repeat clinic visits, Ambulatory blood •Refractory hypertension
pressure monitor, Self/Home pressure monitoring (visit 3+) (multi-‐drug resistance)
Essential (Primary) Hypertension Secondary Hypertension
Essential (Primary) Hypertension Secondary Hypertension
Cardiac Output Systemic Vascular Resistance
(Volume dependent) (Vasoconstrictive)
Cardiac Output Systemic Vascular Resistance
(Volume dependent) (Vasoconstrictive)
Renal Parenchymal Mineralocorticoid
Vasoconstrictors Anatomic Causes Metabolic Causes
Diseases Excess
Renal Parenchymal Mineralocorticoid
• Glomerulonephritis • Conn’s syndrome • Sympathetic nVasoconstrictors Anatomic Causes
ervous system • Aortic coarctation Metabolic Causes
• Hyperthyroidism
Diseases • NSAIDs Excess (ie. cocaine, • Hypercalcemia
• Nephritic syndrome • Unilateral RAS
Renal
• AKI/CKD • Glomerulonephritis • Licorice • Conn’s
syndrome pheochromocytoma) • Sympathetic
nervous
system
• Aortic
coarctation • Pheochromocytoma
• Hyperthyroidism
• Liddle’s
syndrome
• Nephritic
syndrome • NSAIDs • Steroids
((ie.
Cushing’s,
exogenous
cocaine,
• Unilateral
RAS • Hypercalcemia
• AKI/CKD • Bilateral
RAS
• Licorice steroids) pheochromocytoma) • Pheochromocytoma
• Liddle’s
syndrome• Renin-‐Angiotensin
• Steroids
s(timulation
Cushing’s,
exogenous
• Bilateral
RAS (OCP) steroids)
111 • Alcohol
a•buse/
Renin-‐
•Unilateral
(OCP)
RAS
wAithdrawal
ngiotensin
stimulation
• Alcohol abuse/ withdrawal
Increased Urinary Frequency
INCREASED URINARY FREQUENCY
Increased Urinary Frequency
Non-‐increased urine volume (<2mL/min)
Rule out polyuria
Intrinsic to Urinary Tract Extrinsic to Urinary Tract
• Vulvovaginitis
• Bladder
compression/Pregnancy
Urinary Tract Infection Urinary Obstruction Small volume bladder Detrusor Hyperactivity
Renal
(See
Dysuria
scheme) • Benign
prostatic
hyperplasia • Overactive
Bladder
• Prostatitis •Diabetes
• Prostate
cancer • MS
• Nephrolithiasis • Irritant
drugs:
Diuretics,
caffeine,
alcohol 112
Nephrolithiasis
NEPHROLITHIASIS
Nephrolithiasis
Radio-‐opaque Radiolucent
Calcium-‐containing Non-‐calcium
90%
of
stones 10%
of
stones
Hard Stones Soft Stones Cysteine Stones
Calcium oxalate/phosphate Struvite Stones Non Calcium containing, Uric Acid Stones
80% of stones 10% of stones but opaque
• Urinary tract infection • Cystinuria • Hyperuricosuria
• High protein intake
Stones
with
Hypercalciuria Hyperoxaluria Anatomical
problem
decreased
solubility
Renal
• Increased
PTH • Enteric
overproduction • Low
urine
volume • Medullary
sponge
kidney
• High
salt
intake • Low
calcium
intake • Hypocitraturia
• High
protein
intake • Dietary • RTA
type
I
113 • Ethylene
glycol
ingestion • High
protein
intake
Polyuria
POLYURIA
Polyuria
Urine Output > 3L/day
Increased Urine Volume (>2ml/min)
Osmotic Diuresis Water Diuresis
Urine Osmolality > Serum Osmolality Urine Osmolality < Serum Osmolality
• Hyperglycemia (uncontrolled Diabetes Mellitus)
• Mannitol administration
• Increased urea concentration (e.g. Recovery
from Acute Renal Failure, increased protein
feeds, Hypercatabolism [Burns, Steroids], GI
Bleed) Hypotonic Urine Following
• NaCl administration Hypertonic Urine Following
Water Deprivation Test
Water Deprivation Test
Excessive Loss
• Primary polydipsia
Give DDAVP
Renal
Uosm
unchanged
or
Uosm
Increased
by
>50%
Proper
kidney
response
increased
by
<50%
Unresponsive
Kidney
• Central
Diabetes
Insipidus
• Nephrogenic
Diabetes
Insipidus
114
Proteinuria
Renal
Granulomatosis with
polyangiiis (GPA)/microscopic
polyangiiis (MPA)
115
RENAL
MASS:
Solid Renal Mass
Solid
Renal Mass
Solid Cystic
Benign
<3
cm
in
size Suspicious
Presence
of
fat
on
CT >3
cm
in
size
• Angiomyolipoma (hamartoma) • Renal Cell Carcinoma
• Oncocytoma • Wilm’s tumor (nephroblastoma)
• Tuberous Sclerosis • Metastatic spread to kidneys
Renal
116
Renal Mass
RENAL
Cystic
MASS:
Cystic
Renal Mass
Solid Cystic
Benign Suspicious
Anechoic
on
ultrasound Septated/Loculated
on
ultrasound
Well-‐demarcated
on
ultrasound/CT Irregular
border
on
ultrasound/CT
Non-‐enhancing
with
CT
contrast Enhancing
with
CT
contrast
Polycystic
Simple
Cysts
Multiple
bilateral
cysts Abscess
No
family
history
of
ADPKD
Positive
family
history Carcinoma
Normal
sized
kidneys Fever
and
leukocytosis
No
signs
of
infection
Renal
Enlarged kidneys Positive Gallium scan
No cysts in other organs
Cysts in other organs
• Polycystic Kidney Disease • Renal Cell Carcinoma
• Tuberous Sclerosis
117 • Von Hippel-‐Lindau Syndrome
Scrotal Mass
SCROTAL
MASS
Scrotal
Mass
Painful Painless
Gradual Onset Does Not Trans-‐
Sudden Onset If with Dysuria see Dysuria Trans-‐illuminates
illuminate
scheme
• Testicular Torsion • Acute Epididymitis
• Torsion of the Testicular Appendix • Epididymo-‐orchitis
• Trauma
• Incarcerated Hernia
Tumor
Renal
Varicocele
Epididymal Spermatic
Cord Hydrocele Solid
=
Tumor
until
Soft/”Bag
of
Worms”
proven
otherwise
• Epididymal
Cyst • Communicating
hydrocele • Communicating/non-‐ • Germ
cell
• Spermatocele • Indirect
hernia communicating Seminoma,
Teratoma,
Mixed
• Traumatic/Reactive • Non-‐germ
cell 118
Leydig,
Sertoli
Suspected Acid-Base Disturbance
ASE DISORDER
Acid-‐Base
Disorder
H < 7.35 pH 7.35-‐7.45 pH < 7.45
cidemia Normal pH Alkalemia
• Mixed Acid-‐Base Disorder
Respiratory Acidosis Metabolic Alkalosis Respiratory Alkalosis
idosis
• Decrease EABV
• Hypokalemia*
Normal Anion Gap Chronic Acute Chronic Acute
• Diarrhea • COPD • Asthma* • Pregnancy • Hypoxia
• RTA • Interstitial Disease • Neuromuscular • Psychogenic • Salicylates
• Interstitial Nephritis • Obstruction • Sepsis
• Pulmonary
Embolism*
* Denotes acutely life-‐threatening causes
Renal
Appropriate Compensation: Ratio (CO2:HCO3-‐)
Metabolic Acidosis 12:10
osis – Mixed Metabolic Disorder: Metabolic Alkalosis 7:10
mal Normal AG Acidosis Alone Acute Respiratory Acidosis 10:1
ΔHCO3-‐ High AG Acidosis Alone Chronic Respiratory Acidosis 10:3
ΔHCO3-‐ Mixed AG Acidosis + Normal AG Acute Respiratory Alkalosis 10:2
ΔHCO3-‐ Mixed High AG Acidosis + Metabolic Alkalosis Chronic Respiratory Alkalosis 10:4
119
Metabolic Acidosis
Elevated Anion Gap
METABOLIC ACIDOSIS: Elevated Anion Gap
Metabolic Acidosis
Need
to
correct
anion
gap
for
albumin:
For
every
drop
of
10
for
albumin
(from
40)
add
2.5
to
the
anion
gap
Elevated Anion Gap (>12) Normal Anion Gap (≤12)
(Gain of H+) (loss of HCO3)
Elevated
serum
creatinine
Decreased NH4 production
Excess acid addition
and anion secretion
• AKI/CKD
Positive serum Elevated Positive serum Elevated
salicylate level serum lactate ketones osmolar gap
Renal
Toxic
alcohol
Salicylate
poisoning Lactic
acidosis Ketosis Other
ingestion
ingestion
• Shock • Diabetic
ketoacidosis • Ethylene/Propylene
• Paraldehyde,
Iron,
• Drugs • Starvation/alcoholic
glycol Isoniazid,
Toluene,
Cyanide
• Inborn
errors ketosis • Methanol 120
Metabolic Acidosis
Normal Anion Gap
METABOLIC
ACIDOSIS:
Normal
Anion
Gap
Metabolic
Acidosis
METABOLIC
ACIDOSIS:
Normal
Anion
Gap
Need
to
correct
anion
gap
for
albumin:
For
every
drop
Metabolic
of
10
for
albumin
(from
40)
add
Acidosis
2.5
to
the
anion
gap
Need
to
correct
anion
gap
for
albumin:
For
every
drop
Elevated
Anion
Gap
(>14) of
10
for
albumin
(from
40)
add
2.5
to
the
anion
gap Normal
Anion
Gap
(≤14)
(Acid
Gain) (Loss
of
Bicarbonate)
History of diarrhea?
Elevated Anion Gap (>14) Normal Anion Gap (≤14)
(Acid
GI GTain)
ract Loss (Loss of Bicarbonate)
(Negative urine net charge)
Renal Loss
History of diarrhea?
• Diarrhea
• Fistula
GI Tract Loss
(Negative urine net charge) Direct Loss Renal Loss
Indirect Loss
• Diarrhea Negative U net charge Positive U net charge
• Fistula High FEHCO3
• RTA Type II
• Carbonic Direct
anhydrase
Lossinhibitor Indirect Loss
TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine) Negative U net charge Positive U net charge
Renal
Urine net charge = UNa + UK -‐ UCl High FEHCO3
• RTA Type II
Principal Cell
• Carbonic anhydrase inhibitor α-‐ Intercalated Cell
TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine)
Problem Problem
Low TTKG High TTKG
Urine net charge = UNa + UK -‐ UCl
121 • RTA Type IV • RTA Type I
Principal Cell α-‐ Intercalated Cell
Metabolic Alkalosis
METABOLIC
ALKALOSIS
Transient
Sustained Metabolic Rule • IV Bicarbonate
• Acute correction of hypercapnia
Alkalosis Out
Volume Status Assessment Renal Failure with
Ingestion
• Milk-‐Alkali syndrome
Expanded Effective Arterial Contracted Effective Arterial • Bicarbonate ingestion
Blood Volume Blood Volume
No signs of volume depletion Signs of volume depletion
Gastrointestinal Loss Renal Loss
Low U Cl-‐ High U Cl-‐
Lower Non-‐reabsorbed Impaired tubular
Gastric
Bowel anions transport
• Vomiting • Villous adenoma • Penicillins • Diuretics (loop/thiazide)
• NG suction • Laxative abuse • Hypomagnesemia
• Chloridorrhea • Barrter’s/Gitelman’s
Renal
High
Renin
Low
Renin Low
Renin
High
Aldosterone High
Aldosterone Low
Aldosterone
• Malignant
Hypertension • Aldosterone-‐secreting
mass • Licorice
• Renovascular
Hypertension • Adrenal
hyperplasia • Liddle’s
Syndrome
• Renin-‐Secreting
Tumor • Glucocorticoid
remediable
aldosteronism • Enzyme
deficiency 122
Urinary Incontinence
URINARY
INCONTINENCE
Urinary
Incontinence
Transient Established
Easily
reversible
cause Not
easily
reversible
cause
• Delirium/confusional
states
• Infection
(UTI)
• Atrophic
urethritis/vaginitis
• Pharmaceuticals
• Psychological/psychiatric
• Excessive
urine
output
• Restricted
mobility
• Stool
impaction
Stress Incontinence Urge Incontinence
Overflow Incontinence
Failure of urethral sphincter to remain Detrusor overactivity
Distended bladder with high post-‐void
closed Abrupt urgency
residual volume
Small Volume Moderate to large leakage of urine
Continuous small volume leakage
Precipitated by stress maneuvers Precipitated by cold temperature &
+/-‐ Precipitated by stress maneuvers
More common in multiparous women running water
Renal
Impaired Detrusor Contraction
Signs of autonomic neuropathy or spinal Bladder Outlet Obstruction
cord disease, cauda equina syndrome,
123 anticholinergic medications
Urinary Tract Obstruction
URINARY TRACT OBSTRUCTION
Urinary Tract Obstruction
Upper Tract Lower Tract
Bladder NOT distended on ultrasound Distended bladder on ultrasound
Hematuria, flank pain, +/-‐ N/V Urgency, frequency, hesitancy, nocturia
CT KUB
Intraluminal Extraluminal Intramural Bladder Outflow Tract
• Retroperitoneal Fibrosis • Ureteropelvic junction • Carcinoma (until • BPH
• Cancer obstruction proven otherwise) • Prostate cancer
• Bladder stone • Urethral stricture
• Thrombus (frank • Posterior Urethral
hematuria) valves
Mass Stone
Renal
• Urothelial
cell
• Calcium
oxalate
carcinoma • Calcium
phosphate
• Squamous
cell
• Uric
acid
[radiolucent
on
x-‐ray]
carcinoma • Struvite
• Cysteine 124
Endocrinology
Abnormal Lipid Profile Combined & Hirsutism & Virilization Androgen Excess����139
Decreased HDL��������������������������������������������������������129 Hirsutism & Virilization Hypertrichosis�����������140
Abnormal Lipid Profile Increased LDL & Hypercalcemia Low PTH������������������������������������������141
Increased Triglycerides���������������������������������������130 Hypercalcemia Normal / High PTH����������������142
Abnormal Serum TSH�������������������������������������������������131 Hypocalcemia High Phosphate��������������������������143
Adrenal Mass Benign�������������������������������������������������� 132 Hypocalcemia Low Phosphate���������������������������144
Adrenal Mass Malignant�������������������������������������������133 Hypocalcemia High / Low PTH��������������������������145
Amenorrhea�����������������������������������������������������������������������134 Hyperglycemia����������������������������������������������������������������146
Breast Discharge������������������������������������������������������������135 Hypoglycemia������������������������������������������������������������������147
Gynecomastia Increased Estrogen & Hyperphosphatemia����������������������������������������������������148
Endocrinology
Increased HCG����������������������������������������������������������136 Hypophosphatemia�����������������������������������������������������149
Gynecomastia Increased LH & Decreased Hyperthyroidism�������������������������������������������������������������150
Testosterone��������������������������������������������������������������� 137 Hypothyroidism����������������������������������������������������������������151
Hirsutism������������������������������������������������������������������������������138 Hyperuricemia�����������������������������������������������������������������152
125
Male Sexual Dysfunction��������������������������������153
Sellar / Pituitary Mass���������������������������������������154
Sellar / Pituitary Mass Size����������������������������155
Short Stature������������������������������������������������������������ 156
Tall Stature�����������������������������������������������������������������157
Weight Gain / Obesity������������������������������������� 158
Endocrinology
126
Historical Editors Student Editors
Dr. Andrew Wade Parul Khanna (Co-editor)
Dr. Sophia Chou Patricia Wong (Co-editor)
Dave Campbell Soreya Dhanji
Derrick Chan
Marc Chretien Faculty Editor
Mollie Ferris Dr. Kevin McLaughlin
Kody Johnson
Becky Kennedy
Vera Krejcik
Endocrinology
Keith Lawson
Vanessa Millar
Eric Sy
Maria Wu
127
128
Endocrinology
Abnormal Lipid Profile
Combined & Decreased HDL
Endocrinology
129
Abnormal Lipid Profile
Increased LDL & Increased Triglycerides
Endocrinology
130
Abnormal Serum TSH
*
**
Endocrinology
*Refer to Hyperthyroidism (1) on page 150
131 **Refer to Hyperthyroidism (2) on page 151
Adrenal Mass
Benign
ADRENAL MASS: Benign
Benign Adrenal Mass
Most common neoplasm is Benign Non-‐Functioning Adenoma
No
Signs
of
Signs
of
Hormone
Excess
Hormone
Excess
Positive 24-‐ Hour
Estrogen Aldosterone
Androgen Glucocorticoid Metanephrines Silent/Non-‐
Hyperplasia Excess Excess + Nor-‐
Excess Feminization, Excess Functioning
Often Bilateral Hypertension +/-‐ Metanephrines
Virilization/ Hirsutism Early Puberty, Cushingoid Features
Hypokalemia/Alkalosis Mass
Heavy Menses
•Congenital •Estrogen •Glucocorticoid •Aldosterone •Pheochromocytoma
Adrenal Releasing Releasing Releasing (Paroxysmal
Hyperplasia Adenoma (High Adenoma Adenoma (High Hypertension,
•ACTH Plasma E2 + (Positive Dexa-‐ Aldosterone: Headache,
Dependent Clinical Picture) methasone Renin Ratio) Diaphoresis,
Endocrinology
•ACTH
Suppression
Test) Palpitations,
Anxiety)
Independent
•Macronodular
Hyperplasia Rule
of
10’s
For
High
DHEAS Normal
DHEAS Pheochromocytoma: Normal
DHEAS Other
10%
are
Malignant
•Androgen
•Other
Source
10%
are
Bilateral
•Non-‐functioning
•Cyst
Releasing
(e.g.
Polycystic
10%
are
Extra-‐Adrenal Adenoma •Pseudocyst
Adenoma Ovarian
10%
are
Familial •Lipoma •Hematoma
Syndrome,
10%
are
not
Associated
•Myelolipoma •Infection
Congenital
•Ganglioneuroma (TB,
Fungal)
with
Hypertension
Adrenal
Hyperplasia) Amyloidosis
132
Adrenal Mass
ADRENAL MASS: Malignant
Malignant
ADRENAL MASS: Malignant
Malignant
Malignant
Adrenal
Adrenal
Mass
Mass
Suggestive
of
Malignancy:
Inhomogenous
Density,
Delay
in
CT
Contrast
Washout
(<50%
in
10
mSuggestive
of
Malignancy:
inutes),
Irregular
Inhomogenous
Shape,
Diameter
>4cm,
CDalcification,
ensity,
Delay
in
CHT
>20
Contrast
ounsfeld
UW ashout
nits
on
CT,
Vascularity
of
Mass,
(<50%
in
10
minutes),
Irregular
Shape,
Diameter
Hypointense
to
>Liver
4cm,
Calcification,
on
>20
T1
Weighted
Hounsfeld
MRI
– DO
NOT
Units
Biopsy on
CT,
Vascularity
of
Mass,
Hypointense
to
Liver
on
T1
Weighted
MRI
– DO
NOT
Biopsy
No
Signs
of
Signs
of
Hormone
Excess No
Signs
of
Signs
of
Hormone
Excess Hormone
Excess
Hormone
Excess
Positive
24-‐Hour
Aldosterone
Positive
Estrogen
Excess
Androgen
Estrogen
Glucocorticoid
Aldosterone
24-‐Hour
Silent/Non-‐
Androgen
Excess Glucocorticoid
Excess Metanephrines
Metanephrines
Silent/Non-‐
Excess Feminization,
Excess Excess +
Nor-‐ Functioning
Excess Feminization,
Early
Puberty,
Excess Hypertension
+/-‐ +
Nor-‐ Functioning
Virilization/
Hirsutism Early
Heavy
Puberty,
Cushingoid
F eatures Hypertension
+ /-‐ Metanephrines Mass
Virilization/
Hirsutism
Heavy
Menses
Menses Cushingoid
Features Hypokalemia/Alkalosis Metanephrines
Hypokalemia/Alkalosis Mass
•Estrogen
•Glucocorticoid
•Aldosterone
•Pheo-‐ •Lymphoma
•Estrogen
•Glucocorticoid
•Aldosterone
•Pheo-‐ •Lymphoma
Releasing
Releasing
Releasing
chromocytoma
Metastases
(Often
Releasing
Releasing
Releasing
chromocytoma
Metastases
(Often
Carcinoma
(High
Carcinoma
Carcinoma
(High
(Paroxysmal
Bilateral)
Adrenal
Carcinoma
Bilateral)
Adrenal
Endocrinology
Carcinoma (High (Positive Carcinoma (High (Paroxysmal Carcinoma
Plasma E + (Positive Aldosterone: Renin Hypertension, Carcinoma
Plasma E2 + 2 Dexamethasone Aldosterone: Renin Hypertension,
Clinical Picture) Dexamethasone Ratio) Headache,
Clinical Picture) Suppression Test) Ratio) Headache,
Diaphoresis,
Suppression Test) Diaphoresis,
Palpitations,
High DHEAS Normal Normal DHEAS Palpitations, Rule of 10’s For
High DHEAS DHEAS Anxiety) Rule oPheochromocytoma:
f 10’s For
Anxiety)
Pheochromocytoma:
•Androgen Releasing •Other Source (e.g. 10% are Malignant
•Androgen Releasing
Carcinoma (e.g. •Other Source (Oe.g.
Polycystic varian 10% a10%
re Maalignant
re Bilateral
Carcinoma (e.g.
Adrenocortical Polycystic Ovarian
Syndrome, 10% a10%
re Bilateral
Adrenocortical Syndrome, are Extra-‐Adrenal
Carcinoma) Congenital Adrenal 10% a10%
re Extra-‐
are FAamilial
drenal
Carcinoma) Congenital A drenal
133 Hyperplasia)
Hyperplasia)
10% a10%
re Familial
10% awith
are not Associated
re not A ssociated
Hypertension
with Hypertension
Amenorrhea
AMENORRHEA
AMENORRHEA Amenorrhea
Amenorrhea
Rule Out Pregnancy
Rule Out Pregnancy
Low/Normal FSH Elevated FSH
Low/Normal FSH Elevated FSH
•Premature
Ovarian Failure
•Premature
Bleed With Progestin Hypothalamic-‐ No Bleed With Ovarian F•Menopause
ailure
Bleed With Progestin
Challenge Hypothalamic-‐
Pituitary Axis No B leed With Challenge
Progestin •Menopause •Spontaneous
ChallengeOvarian
•Polycystic Pituitary Axis Progestin Challenge
•Hypothyroidism •Spontaneous
•Polycystic
Syndrome Ovarian •Hypothyroidism
•Hyperthyroidism
Syndrome •Hyperthyroidism
•Diabetes Mellitus
•Diabetes Mellitus Androgen Use
•Exogenous
•Exogenous Androgen
•Congenital Use
Structural
•Congenital Structural
Abnormalities
Abnormalities
Organic Cause Failed Progestin
High Prolactin Failed Progestin
Endocrinology
High
Prolactin Organic
Cause Challenge
Challenge
•Hyperprolactinemia •Congenital
GnRH
Deficiency •Functional
•Hyperprolactinemia •Congenital
GnRH
Deficiency •Functional
•Infiltrative
or
Inflammatory
•Hypothalamic
•Infiltrative
or
Inflammatory
•Hypothalamic
Lesion Lesion •Amenorrhea
•Amenorrhea
(e.g. (e.g.
•Tumors •Tumors •Weight
•Weight
Loss,
Eating
Loss,
Eating
•Infarction
•Infarction Disorders,
Disorders,
Exercise,
Exercise,
•Empty
•Empty
ella
Syndrome Stress,
PStress,
Sella
SSyndrome Prolonged
rolonged
•Apoplexy
•Apoplexy Illness) Illness)
If
bleed
If
bleed
with
w ith
progestin
progestin
challenge
challenge
=
estrogenized
=
estrogenized
If
no
If
bnleed
o
bleed
with
w ith
progestin
progestin
challenge
challenge
=
non-‐=e
non-‐estrogenized
strogenized 134
Breast Discharge
BREAST DISCHARGE
Breast Discharge
True Galactorrhea Other Breast
(on microscopy) Discharge
•Neoplasm (usually blood)
•Other Internal Breast
Discharge
Abnormal TSH/ Normal TSH/
Prolactin Prolactin
•Idiopathic
Endocrinology
High Prolactin + High Prolactin + Autonomous High Prolactin +
Normal TSH Normal/ Low TSH Production High TSH
•Microprolactinoma •Pituitary Macroadenoma •Renal Cancer or Failure •Primary Hypothyroidism
•Steroid Hormone Intake •Dopamine Inhibition •Lactotroph Adenoma
•Chronic Renal Failure •Pituitary Stalk •Bronchogenic Tumor
•Stress (e.g. Pregnancy, Compression/Lesion •Contraceptive
Breast Stimulation, Pill/Patch/Ring
135 Trauma/Surgery)
Gynecomastia
Increased Estrogen & Increased HCG
Endocrinology
136
Gynecomastia
Increased LH & Decreased Testosterone
Endocrinology
137
Hirsutism
138
Endocrinology
Hirsutism & Virilization
Androgen Excess
Endocrinology
139
Hirsutism & Virilization
Hypertrichosis
Endocrinology
140
Hypercalcemia
Low PTH
Endocrinology
141
Hypercalcemia
Normal / High PTH
Endocrinology
142
Hypocalcemia
High Phosphate
Endocrinology
143
Hypocalcemia
Low Phosphate
Endocrinology
144
Hypocalcemia
High / Low PTH
Endocrinology
145
Hyperglycemia
Endocrinology
146
HYPOGLYCEMIA
HYPOGLYCEMIA
Hypoglycemia
Hypoglycemia
Hypoglycemia
(<
4
m(<
mol/L)4
mmol/L)
Fasting Hypoglycemia Post-‐Post-‐Prandial
Prandial Other Causes
Fasting Hypoglycemia (Reactive)
(Reactive)
Other Causes
•Excess
•Excess
InsulinInsulin •Alimentary
•Alimentary
(e.g.
(e.g.
in
the
isn
etting
the
setting
of
of
•Critical
•Critical
Illness
Illness
(e.g.
H(epatic
e.g.
Hepatic
Failure,
Failure,
•Medications
•Medications
(e.g.
Insulin
(e.g.
Insulin
Gastric
Gastric
Surgery)
Surgery) Renal
Renal
Failure,
Failure,
Cardiac
Cardiac
Failure) Failure)
Secretagogues,
Secretagogues,
β-‐Adrenergic
β-‐Adrenergic
•Congenital
•Congenital
Enzyme
Enzyme
Deficiencies Deficiencies •Sepsis•Sepsis
Antagonists,
Antagonists,
Quinine,
Quinine,
Salicylates,
Salicylates,
•Idiopathic
•Idiopathic •Hypopituitarism
•Hypopituitarism
Pentamidine)
Pentamidine) •Adrenal
•Adrenal
Insufficiency
Insufficiency
•Alcohol
•Alcohol •Hyperinsulinemic
•Hyperinsulinemic
States
S(tates
e.g.
(e.g.
Glucagon,
Glucagon,
Catecholamine
Catecholamine
Deficiency,
Deficiency,
Endocrinology
Insulinoma)
Insulinoma)
•Malnutrition/Anorexia
•Malnutrition/Anorexia
Nervosa Nervosa
Signs/Symptoms
Signs/Symptoms
of
Hypoglycemia:
of
Hypoglycemia:
Neurogenic:
Neurogenic:
irritability,
irritability,
tremor,
tremor,
anxiety,
anxiety,
palpitations,
palpitations,
tachycardia,
tachycardia,
sweating,
sweating,
pallor,
ppallor,
paresthesias
aresthesias
147 Neuroglycopenia:
Neuroglycopenia:
confusion,
confusion,
lethargy,
lethargy,
abnormal
abnormal
behaviour,
behaviour,
amnesia,
amnesia,
weakness,
weakness,
blurred
blurred
vision,
vsision,
eizures seizures
HYPERPHOSPHATEMIA
Hyperphosphatemia
Hyperphosphatemia
(>
1.46
mmol/L)
Increased
Intake/
Decreased
Excretion Absorption Pseudo-‐
Transcellular
Shift
FEPO4 <
20% Normally
in
Context
of
Impaired
hyperphosphatemia
Renal
Function
•Rhabdomyolysis •Renal Disease •Hypervitaminosis D •Multiple Myeloma
•Tumor Lysis •Hypoparathyroidism •Phosphate Supplementation Hyperbilirubinemia
•Metabolic or Respiratory •Pseudo-‐hypoparathyroidism •Phosphate Containing •Hemolysis
Acidosis •Acromegaly Enemas/Laxatives •Hyperlipidemia
•Insulin Deficiency •Bisphosphonate Therapy •Tumor Lysis
Endocrinology
148
HYPOPHOSPHATEMIA
Hypophosphatemia
Hypophosphatemia
(<
0.8
mmol/L)
Transcellular Shift Increased Excretion Decreased Intake
•Recovery From DKA
•Refeeding Syndrome
•Acute Respiratory Alkalosis Dietary deficiency Malabsorption
•Hypokalemia
•Hypomagnesemia GI Renal •Anorexia •Aluminum/Magnesium
•Burns FePO4 > 5% •Chronic Alcoholism Containing Antacids
•Hyperparathyroidism •Inflammatory Bowel Disease
•Small bowel diarrhea
Endocrinology
•Vitamin D Deficiency/Resistance •Steatorrhea
•Enteric Fistula
•Hypophosphatemic Rickets •Chronic Diarrhea
•Oncogenic Osteomalacia
•Fanconi Syndrome
•Osmotic Diuresis
•Acute Volume Expansion
•Acetazolamide and Thiazide
Diuretics
149
Hyperthyroidism
HYPERTHYROIDISM
Hyperthyroidism
High/Normal Low Radioiodine
Radioiodine Uptake Uptake
Autoimmune Autonomous Subacute Exogenous/Ectopic
TSH/HCG Excess
Thyroid Disease Thyroid Tissue Thyroiditis Hormone
•Grave’s Disease •Toxic Adenoma •TSH-‐Secreting Pituitary •Granulomatous •Excessive Thyroid Drug
Endocrinology
•Positive
anti-‐TSH
•Toxic
Multinodular
Adenoma •Lymphocytic •Struma
Ovarii
Receptor
Antibody Goiter •Gestational
Trophoblastic
•Postpartum
Neoplasm •Amiodarone
•Radiation
150
Hypothyroidism
HYPOTHYROIDISM
Hypothyroidism
Central Primary Thyroid Hormone
Iatrogenic
Hypothyroidism Hypothyroidism Resistance
•Isolated TSH
Deficiency
•Panhypopituitarism
Chronic Transient
•Subacute
Lymphocytic/
Granulomatous
•Thyroiditis
•Post-‐Partum
Thyroiditis
•Subtotal
Thyroidectomy
Endocrinology
Congenital Thyroid Central
Infiltrative Disease Agenesis/ Degenesis
Medications
Hypothyroidism
•Fibrous Thyroiditis •Severe Iodine •Thionamides •Hashimoto’s Thyroiditis
•Hemosiderosis Deficiency •Lithium
•Amiodarone
151 •Interferon
Hyperuricemia
HYPERURICEMIA
Hyperuricemia
Hyperuricemia
Primary Secondary
Over-‐production Under-‐excretion Over-‐production Under-‐excretion
• Increased turnover • Lower uric acid
of nucleotides clearance
• Starvation
Lymphoproliferative
Hemolytic
Others Endocrine Renal Drug-‐Induced
Disorders Anemia
• Acute
lymphoblastic
• See
hemolysis
scheme • Psoriasis • Hyperparathyroidism • Chronic
renal
failure • Antiuricosuric drugs
Endocrinology
leukemia
(ALL) • Chemotherapy • Diabetic
acidosis • Sarcoidosis • ACE
inhibitors
• Acute
myeloid
• Drug-‐induced • Hypercalcemia • Cyclosporine
leukemia
(AML) • High
purine
diet • Diuretics
• Chronic
myeloid
• Organic
acids
leukemia
(CML) • Ethambutol
• Alcohol
152
Male Sexual Dysfunction
MALE SEXUAL DYSFUNCTION
Sexual
Dysfunction
Establish
Dysfunction
in
Context: Partner
Showing
Less
Desire
is
not
Necessarily
Impaired
Global
Dysfunction
is
likely
Organic
Cause
Situational
Impairment
Most
Likely
Psychological
Erectile Dysfunction Desire
Reduced/Absent
Psychological Physiological Pharmacological Physiological Pharmacological Psychological
•Performance Anxiety •Anti-‐hypertensives •Hypo-‐ •Anti-‐depressants •Mood Disorders
•Lack of Sensate •Anti-‐depressants testosteronism •Narcotics •Anxiety Disorders
•Focus •Diuretics •Prolactinemia •Anti-‐psychotics •Guilt
•Mood Disorder •Benzodiazepines •Hyper-‐estrogenism •Anti-‐androgens •Stress
•Anxiety Disorder •Alcohol •Hypothyroidism •Alcohol •Interpersonal Issues (e.g.
•Stress •Sympathomimetic •Hyperthyroidism •Benzodiazepines Lack of trust in partner)
•Guilt Drugs (e.g. Cocaine, •Chronic Pain •Hallucinogens •Psychosis/Delusions
•Interpersonal Issues Amphetamines) •Previous psycho-‐social
Endocrinology
trauma
•(e.g.
Abuse)
Chronic Disease Neurological Physiological Pelvis Other
•Diabetes •Stroke •Hypo-‐ •Trauma •Hypertension
•Cardiovascular •Spinal Cord Injury testosteronism •Pelvic Surgery •Dyspareunia
Disease •Multiple Sclerosis •Prolactinemia •Prostate Surgery •Dialysis
•Peyronie’s •Dementia •Hypothyroidism •Priapism
•Connective Tissue •Polyneuropathy •Hyperthyroidism •Infection
153 Disease •Bicycling
Sellar / Pituitary Mass
SELLAR/PITUITARY MASS
Sellar/Pituitary Mass
Adenoma Non-‐Adenomatous Inflammatory
Hyperplasia
Primarily Anterior Pituitary
•Physiological (e.g. •Infectious
Pregnancy) •Autoimmune
•Compensation (e.g. •Giant Cell Granuloma
Hypothyroidism) •Langerhan’s Cell
•Stimulatory (e.g. Ectopic •Histiocytosis
GNRH, CRH) •Sarcoidosis
Endocrinology
Non-‐
Secreting Vascular Hamartoma Neoplasm Metastatic
Functioning
•Prolactin •Oncocytoma •Aneurysm •Craniopharyngioma
•GH •Null
Cell
•Infarction •Meningioma
•ACTH Adenoma •Cyst
•TSH •Glioma
•LH/FSH •Ependymoma
•Mixed
154
SELLAR/PITUITARY MASS: Size
Sellar / Pituitary Mass
Size
Sellar/Pituitary Mass
Small Large Other
(<1cm) (>1cm)
•Hypersecretion •Hypersecretion
Endocrinology
•Hyposectretion
155
Short Stature
SHORT STATURE
Short
Stature
<3rd Percentile
Detailed
History,
Physical
Exam,
and
Mid-‐Parental
Target
Height
Pathological/Abnormal Normal Variant
Normal Puberty Delayed Puberty
Disproportionate Proportionate Onset (BA=CA) Onset (BA<CA)
•Skeletal Dysplasias •Familial Short Stature •Constitutional Short
•(e.g. Achondroplasia) Stature (Late Bloomer)
•Rickets
No Dysmorphic
Dysmorphic Features
Features
•Trisomy 21
•Noonan Syndrome
•Prader-‐Willi Syndrome
•Russell-‐Silver Syndrome
•Turner Syndrome
Endocrinology
Deprivation Endrocrine Treatment Chronic
Disease Other
•Primary
Malnutrition •Cushing’s
Disease •Glucocorticoids •GI
(e.g.
Celiac,
IBD) •Intrauterine
Growth
•Psychosocial •GH
Deficiency •Radiation •Renal
(e.g.
CRF) Retardation
•Deprivation •IGF-‐1
Deficiency
(e.g.
•Chemotherapy •Infection
(e.g.
Chronic
•Bulimia
Nervosa
Laron
Dwarfism) •Bone
Marrow
UTI) •Anorexia
Nervosa
•Hypothyroidism Transplant •Cardiopulmonary
(e.g.
•CNS
Tumors
(e.g.
•Congenital
Adrenal
Cystic
Fibrosis,
CHF) Craniopharyngioma)
Hyperplasia •Inborn
Metabolism
Error
•Panhypopituitarism •Immunologic
•Hematologic
156
Tall Stature
TALL STATURE
Tall
Stature
> 97th Percentile
Detailed History, Physical Exam, and Mid-‐Parental Target Height
No Other Obvious Other Obvious
Abnormalities/Stigmata Abnormalities/Stigmata
Normal Growth Accelerated Growth Disproportionate Proportionate
(BA=CA) (BA>CA)
•Familial Tall Stature •Klinefelter’s Syndrome •Bechwith-‐Weidmann
•XYY Syndrome (XXY) Syndrome (Normalizing
•Soto’s Syndrome/ Cerebral growth after birth)
Gigantism •Weaver Syndrome
Non-‐Obese BMI Obese BMI •XYY Syndrome
•Marfan’s Syndrome
•Exogenous Obesity •Homocystinuria •Neurofibromatosis 1
•Sex Steroid Deficiency/ •Hyperthyroidism
Resistance (Untreated/Severe)
Normal Puberty •Acromegaly (Rare in
Early Puberty Onset
Endocrinology
Onset Children)
•GH
Excess
•Hyperthyroidism
Precocious Puberty Constitutional
•Adrenal Tumor •Constitutional Tall Stature
•Ovarian Tumor (Early Bloomer)
•Testotoxicosis
•Congenital Adrenal
157 Hyperplasia
Weight Gain / Obesity
WEIGHT GAIN/OBESITY
Weight Gain/Obesity
Energy Related Secondary
(Primary)
Decreased
Increased
Intake Neuroendocrine Genetic
Expenditure
•Sedentary
Lifestyle •Polycystic
Ovarian
•Autosomal
Dominant
•Smoking
Cessation Syndrome •Autosomal
Recessive
•Hypothyroid •X-‐Linked
•Cushing’s
Syndrome •Chromosomal
•Hypogonadism Abnormality
•GH
Deficiency
Endocrinology
•Hypothalamic
Obesity
Dietary Social/Behavioural Iatrogenic
•Progressive •Socioeconomic •Drugs/Hormones
•Polyphagia •Ethnicity •Tube Feeding
•High-‐Fat Diet •Psychological Hypothalamic Surgery
158
Neurologic
Altered Level of Consciousness Approach163 Movement Disorder Hyperkinetic���������������������176
Altered Level of Consciousness GCS ≤ 7�����164 Movement Disorder Tremor����������������������������������� 177
Aphasia Fluent�����������������������������������������������������������������165 Movement Disorder Bradykinetic����������������������178
Aphasia Non-Fluent���������������������������������������������������� 166 Peripheral Weakness��������������������������������������������������179
Back Pain������������������������������������������������������������������������������167 Peripheral Weakness Sensory Changes����� 180
Cognitive Impairment������������������������������������������������ 168 Spell / Seizure Epileptic Seizure����������������������� 181
Dysarthria���������������������������������������������������������������������������� 169 Spell / Seizure Secondary Organic�����������������182
Falls in the Elderly���������������������������������������������������������170 Spell / Seizure Other��������������������������������������������������183
Gait Disturbance��������������������������������������������������������������171 Stroke Intracerebral Hemorrhage���������������������184
Headache Primary�������������������������������������������������������� 172 Stroke Ischemia���������������������������������������������������������������185
Headache Secondary, without Red Flag Stroke Subarachnoid Hemorrhage����������������� 186
Neurologic
Symptoms��������������������������������������������������������������������� 173 Syncope��������������������������������������������������������������������������������187
Hemiplegia������������������������������������������������������������������������� 174 Dizziness������������������������������������������������������������������������������ 188
Mechanisms of Pain����������������������������������������������������� 175 Vertigo����������������������������������������������������������������������������������� 189
159
160
Neurologic
Historical Editors Student Editors
Dr. Darren Burback Kaitlin Chivers-Wilson Jared McCormick
Dr. Brian Klassen Lindsay Connolly Dilip Koshy
Dr. Gary Klein Nichelle Desilets Aleksandra Ivanovic
Dr. Dawn Pearson Jonathan Dykeman
Dr. Oksana Suchowersky Vikram Lekhi Faculty Editor
Erin Butler Chris Ma Dr. Kevin Busche
Aaron Wong Sandeep Saran
Sophie Flor-Henry Jeff Shrum
Ted Hoyda Siddhartha Srivastava
Andrew Jun Stephanie Yang
Neurologic
Khaled Ahmed
Anastasia Aristarkhova
John Booth
161
162
Neurologic
Altered Level of Consciousness
ALTERED
ApproachLEVEL
OF
CONSCIOUSNESS:
Approach
Altered Level of Consciousness
Glasgow Coma Scale Score:
12-‐15 = Investigate
8-‐12 = Urgent Investigation
≤ 7 = Resuscitate + Investigate
Rapidly Deteriorating = Resuscitate + Investigate
Clinical Exam Blood Work Imaging
Metabolic No Metabolic Structural Non-‐
Focal Non-‐Focal
Abnormality Abnormality Abnormality Structural
• Trauma • Refer to • Hypoxia • Postictal • Epidural • Post-‐Ictal
Neurologic
• Stroke Blood Work • Hypercapnea • Concussion Hemorrhage • Concussion
• Tumor and Imaging • Hyper/HypoNa • Meningitis • Subdural • Encephalitis
• Hemorrhage Sections • Hyper/HypoCa • Encephalitis Hemorrhage
• See Imaging • Hyper/HypoK • Intracranial
Section • Sepsis Hemorrhage
• Ischemia
163 • Tumor
Altered Level of Consciousness
GCS ≤ 7
ALTERED
ALTERED LEVEL LEVEL OF CONSCIOUSNESS:
OF CONSCIOUSNESS: GCS ≤ 7 GCS ≤ 7
Altered LOC GCS Altered
≤ 7 LOC GCS ≤ 7
Coma Coma Other Other
• Locked-‐in
• Locked-‐in
Syndrome
Syndrome
Brain Involvement Brain Involvement •Stupor
•Stupor
•Persistent
•Persistent
Vegetative State
Focal Diffuse
Lesions Lesions Diffuse Lesions Vegetative State
Focal Lesions
Hemispheric Hemispheric
Brain
Stem Brain
Stem
Vascular Vascular
Infection Infection
Other Systemic
Systemic
Involvement
OtherInvolvement
• Hemorrhage • Hemorrhage • Hypertensive
• Meningitis • Trauma/
• Hemorrhage • Hemorrhage • Hypertensive
• Meningitis • Trauma/
• Traumatic • Traumatic encephalopathy • Encephalitis Concussion
• Traumatic • Traumatic encephalopathy • Encephalitis Concussion
• Ischemia/
• Ischemia/
• Vasculitis • Post-‐ictal
• Ischemia/
• Ischemia/
• Vasculitis • Post-‐ictal
Infarction Infarction • TTP
Infarction Infarction • TTP
• Neoplastic
• Neoplastic
• DIC
• Neoplastic
• Neoplastic
• DIC
Abscess Abscess • Hypoxemia
Excesses Excesses
Deficiencies Deficiencies
Drugs/Toxins Drugs/Toxin
Abscess Abscess • Hypoxemia
• Skull
fracture • Herniation • Multiple
• Skull
fracture • Herniation • Multiple
• Liver/Renal
Failure • Hypoxemia • Alcohols
Neurologic
• Subdural
• Brain
stem
• Liver/Renal
emboli Failure • Hypoxemia • Alcohols
• Subdural
• Brain
stem
emboli • Carbon
Dioxide
• Hypoglycemia • Barbituates
hematoma Lesion • Carbon
Dioxide
• Hypoglycemia • Barbituates
hematoma Lesion Narcosis • B12/Thiamine
• Tranquilizers
• Intracranial
Narcosis • B12/Thiamine
• Tranquilizers
• Intracranial
• Metabolic
Acidosis deficiency • Other
Bleeding • Metabolic
Acidosis deficiency • Other
Bleeding • Hypernatremia • Hyponatremia
• Hypernatremia • Hyponatremia
• Hypercalcemia • Hypocalcemia
*NB
– must
be
• Hypercalcemia • Hypocalcemia
*NB
– must
be
• Hypermagnesemia • Hypomagnesemia
direct
or
indirect
• Hypermagnesemia • Hypomagnesemia
direct
or
indirect
• Hyperthermia • Hypothermia
bi-‐hemispheric
• Hyperthermia • Hypothermia
bi-‐hemispheric
involvement
involvement • Thyroid
Storm
• Thyroid
Storm
• Myxedema
Coma
• Myxedema
Coma 164
Aphasia
APHASIA:
Fluent
Fluent
Aphasia
Fluent Non-‐Fluent
Grammatically
correct,
but
Agrammatic,
hesitant,
but
nonsensical,
tangential.
Phonemic
&
semantic
paraphasias
substantive
communication
Impaired Repetition Intact Repetition
Neurologic
Impaired Intact Impaired Intact
Comprehension Comprehension Comprehension Comprehension
• Wernicke’s Aphasia • Conduction Aphasia • Transcortical Sensory • Anomic Aphasia
Aphasia
165
Aphasia
APHASIA: Non-‐Fluent Non-Fluent
Aphasia
Fluent Non-‐Fluent
Grammatically
correct,
but
Agrammatic,
hesitant,
but
nonsensical,
tangential.
Phonemic
&
semantic
paraphasias
substantive
communication
Impaired Repetition Intact Repetition
Neurologic
Impaired
Intact
Impaired
Intact
Comprehension Comprehension Comprehension Comprehension
• Global
Aphasia • Broca’s
Aphasia • Mixed
Transcortical
• Transcortical
Motor
Aphasia Aphasia
166
Back Pain
BACK
PAIN Red
Flags:
bowel
or
bladder
dysfunction,
saddle
paresthesia,
constitutional
symptoms,
parasthesis,
age
>50,
<18,
IV
drug
Back
Pain
BACK
PAIN use,
neuromotor deficits,
nocturnal
Red
pain,
ohr
igh
Flags:
bowel
energy
bladder
trauma,
past
dysfunction,
history
saddle
of
neoplasm
paresthesia,
constitutional
symptoms,
Always
assess
for
red
flags. parasthesis,
age
>50,
<18,
IV
drug
If
no
red
fBack
Painafter
6
weeks
lags,
assess
use,
neuromotor deficits,
nocturnal
pain,
high
energy
trauma,
past
history
of
neoplasm
Always assess for red flags.
If no red flags, assess after 6 weeks
Acute/Subacute + Chronic/Acute After 6
Red Flags weeks + No Red Flags
< 6 weeks > 6 weeks
Acute/Subacute + Chronic/Acute After 6
Red Flags Cauda Equina weeks + No Red Flags
Fracture Tumor/Infection
< 6 weeks Syndrome > 6 weeks
Neurologic
Fracture Unresolved Radicular Cauda Equina
Tumor/Infection Spondyloarthropathies
Symptoms Syndrome Myelopathic or Osteoarthritis
167
Unresolved
Radicular
Spondyloarthropathies
Cognitive Impairment
COGNITIVE
IMPAIRMENT
Cognitive
Impairment
Affecting Multiple Decline in Instrumental
Dementia
Domains Activities of Daily Living
• Depression • Amnestic Mild Cognitive
• Delirium Impairment
• Non-‐Amnestic Mild Cognitive
Impairment
Subcortical Dementia Cortical Dementia
Early
Extrapyramidal
Treatable
Cause Rapidly
Progressive
Features
• Normal
Pressure
• Parkinson’s
Disease
with
• Creutzfeldt-‐Jakob
Hydrocephalus Dementia Disease
• Chronic
Meningitis • Huntington’s
Disease • Paraneoplastic
disorder
• Chronic
Drug
Abuse
Neurologic
• Tumor
• Subdural
Hematoma
• B12
deficiency
• Hypothyroidism
Early
Language
Abrupt
Onset,
Early
Early
Impairment
• Hypoglycemia and
Behavioral
Stepwise
Extrapyramidal
of
Recent
Memory
Dysfunction Progression Features
• Fronto-‐temporal
• Vascular
Dementia • Alzheimer’s
• Dementia
with
Lewy
Dementia Dementia Bodies 168
Dysarthria
DYSARTHRIA
Dysarthria
Lower Motor Neuron Upper Motor Neuron Extra-‐Pyramidal
Slow, Low Volume, Breathy Speech Slow, strangulated, harsh voice Ataxic (Cerebellar) Rapid, Low Volume, Monotone
Tongue and Facial Atrophy Positive jaw jerk, hyperactive gag Irregular Rhythm and Pitch
Speech
Fasciculations reflex. Emotional lability
•Motor
Neuron
Disease •Bilateral
Lacunar
Internal
•Spinal-‐Cerebellar
Ataxia •Parkinson’s
Disease
•Lesions
of
Cranial
Nerves
Capsule
Strokes •Multiple
Sclerosis
VII,
IX,
X,
XII •Multiple
Sclerosis •Alcohol
•Myasthenia
Gravis •Amyotrophic
Lateral
•Tumour
•Muscular
Dystrophy Sclerosis •Paraneoplastic
Disorder
Neurologic
169
Falls in the Elderly
FALLS
IN
THE
ELDERLY
Fall
Normally is a combination of multiple factors
Intrinsic Factors Extrinsic Factors
Presyncope/ Sensory Neurological Performance Musculo-‐
Syncope Impairments Psychiatric Measures skeletal
• Cardiac • Vision • Stroke • Weakness • Arthritis
• Non-‐Cardiac • Vestibular • Parkinsonism • Decreased
• Neuropathy • Cognition Balance
• Proprioception • Depression • Gait
• Other Abnormalities
Neurologic
Drugs Environment
• Polypharmacy
• Rugs
– esp.
>4
• Stairs
medications • Lighting
• Psychotropics
170
Gait Disturbance
GAIT
DISTURBANCE
Gait
Disturbance
Movement Disorder Hereditary Sporadic
See Movement Disorder • Vascular
schemes • Infection
• Toxic
• Nutrition
• Metabolic
• Inflammation
• Neoplasm
• Degenerative
Sensory Ataxia Cerebellar Ataxia
• Vestibular
• Visual
• Proprioceptive Progressive/ Catalytic Deficiency
Degenerative (Childhood)
Neurologic
X-‐Linked/
Dominant Recessive Intermittent Chronic
Progressive
Mitochondrial
• Fragile
X • Spinocerebellar
Ataxia • Friedrich’s
Ataxia • Hyperammonemia • Tay-‐Sachs
Disease
• Telangiectasia • Aminoaciduria • Niemann-‐Pick
Disease
• Pyruvate/Lactic
Acid
171
Headache
Primary
HEADACHE:
Primary
Headache
Primary Secondary
Usually
episodic Usually
constant
No pattern Other In Clusters
• Primary Cough Headache
• Primary Exertional
Headache
• Primary Stabbing Headache
Neurologic
Autonomic
Cephalgias Other
Last
for
minutes
to
hours.
Unilateral Bilateral Separated
by
hours.
Last
for
seconds,
separated
by
minutes
to
hours
Sudden
onset.
• Migraine • Tension/Stress Headache • Cluster Headache • Trigeminal Neuralgia
(Throbbing/Pulsating) (Tightening, Band-‐Like, (Orbital, Sharp, Autonomic (Shooting, stabbing)
Dull) Dysfunction)
• Hemicranial Continua 172
Headache
HEADACHE: Secondary, without Red Flag Symptoms
Secondary, without Red Flag Symptoms
Headache
Primary Secondary
Usually
episodic Usually
constant
With Red Flag
Symptoms No Red Flag
Systemic symptoms, focal Symptoms
neurological signs, sudden
onset, old age, progressive
signs of increased
intracranial pressure
Chronic
Neurologic
Acute
Drugs
• Sinusitis • Analgesic Induced
• Dental Abscess Headache
• Glaucoma • Substance Withdrawal
• Traumatic Brain Injury
• Acute Mountain Sickness
173
Hemiplegia
HEMIPLEGIA
Upper Motor Neuron Weakness
Tone: Spastic with clasp-‐knife resistance
Reflexes: Hyperactive +/-‐ Clonus
Pathological Reflexes: Babinski/Hoffman
Contralateral/Sub-‐
Cerebral
Hemisphere
Cortical Unilateral
Spinal
Cord
(Contralateral
motor
Brain
Stem
(Corona
radiata,
Lesions
Above
~C5
cortex)
Internal
Capsule)
• Aphasia • May
be
without
sensory
• Diplopia • Brown-‐Sequard
• Apraxia loss • Dysarthria Syndrome
(sensory
loss
to
• Agnosia • May
be
combined
with
• Dysphagia pain
and
temperature
• Agraphia contralateral
sensory
loss • Ptosis contralateral
to
weakness,
• Acalculia • Decreased
Level
of
vibration
and
• Alexia Consciousness proprioception
loss
Neurologic
• Anomia • Cranial
Nerve
Palsies ipsilateral
to
weakness)
• Anosognosia • ‘Crossed’
Sensory
• Asterognosia Findings:
ipsilateral
facial
• Seizures and
contralateral
• Personality
Changes extremity
findings
•Cognition/Confusion,
Dementia
• +/-‐ Sensory
Loss
174
Mechanisms of Pain
MECHANISMS OF PAIN
Pain
Neuropathic
Nociceptive Mixed
Burning,
shooting,
gnawing,
Tissue
Damage Nociceptive/Neuropathic
aching,
lancinating
Visceral
(From
organ/cavity
lining) Central
Nervous
Peripheral
Nervous
Somatic
Poorly
localized,
crampy,
System System
diffuse,
deep
sensation
• Post-‐Herpetic
Neuralgia
• Neuroma
• Neuropathy
Neurologic
Deep Superficial
Deafferentation
Less
well-‐localized,
dull,
Well-‐localized,
sharp,
Sympathetic
Loss
of
sensory
input
longer
duration short
duration
• Phantom Limb • Complex regional pain
• Post-‐stroke syndrome
175 • Spinal injury
MOVEMENT DISORDER: Hyperkinetic Movement Disorder
Hyperkinetic
Movement Disorder
Hyperkinetic
Examples
listed
not
exhaustive
for
all
Tremor Bradykinetic
causes
Tics Dystonia Stereotypies Myoclonus Chorea Athetosis Ballism
• Tourette’s • Generalized • Epilepsy • Huntington’s
Syndrome dystonia • Toxic/ Disease
• Attention • Writer’s cramp metabolic
Deficit • Blepharospasm
Hyperactivity • Cervical
Disorder Dystonia
Neurologic
• Obsessive
Compulsive
Disorder
176
Movement
MOVEMENT
Disorder
DISORDER:
Tremor
Tremor
Movement Disorder
Hyperkinetic Tremor Bradykinetic
Action Tremor Postural Tremor
Resting Tremor
Occurs During Voluntary Occurs While Held
Occurs at Rest
Muscle Movement Motionless Against Gravity
• Cerebellar Disease (e.g. • Parkinson’s Disease • Enhanced Physiologic
spinocerebellar ataxia, • Midbrain Tremor Change
Vitamin E deficiency, • Wilson’s Disease • Essential tremor
stroke, multiple sclerosis) • Progressive supranuclear • Dystonia
palsy • Metabolic Etiology
Neurologic
• Multiple System Atrophy (Thyroid, Liver, Kidney)
• Drug-‐Induced • Drugs (Lithium,
Parkinsonism Amiodarone, Valproate)
177
MOVEMENT
DISORDER:
Bradykinetic Movement Disorder
Bradykinetic
Movement Disorder
Hyperkinetic Tremor Bradykinetic
Parkinson’s Disease Drug-‐Induced Progressive Multiple System
(TRAP) Parkinsonism Supranuclear Palsy Atrophy
• Resting Tremor • Neuroleptics Characteristics: Characteristics:
• Cogwheel Rigidity • Haloperidol • Vertical Gaze Palsy • Bradykinesia
• Akinesia/Bradykinesia • Metoclopramide • Axial rigidity > limb • +/-‐ tremor
• Postural Instability • Prochlorperazine rigidity • Cerebellar signs
• Amiodarone • +/-‐ Tremor • Postural Hypotension
Neurologic
• Verapamil • Bradykinesia
• Falling
backwards
178
Peripheral Weakness
PERIPHERAL
WEAKNESS
Weakness
Objective Weakness No Objective Weakness
• Cardio-‐pulmonary disease
Upper Motor Neuron Lower Motor Neuron • Anemia
Upper and Lower • Chronic Infection
Increased tone and reflexes Decreased tone and reflexes
Babinski Reflex No Babinski reflex
Motor Neuron • Malignancy
• Amyotrophic Lateral • Depression
Sclerosis • Deconditioning
• Cervical myelo-‐ • Arthritis
• Fibromyalgia
Sensory Changes No Sensory Changes radiculopathy
• Syrinx • Endocrine Disease
See Peripheral Weakness:
Sensory Changes scheme
Motor Neuron and Motor Myopathy
Neuromuscular Junction
Neurologic
Neuropathy Fatigability, Variability, Oculomotor
Proximal muscle involvement,
Atrophy, Fasciculations, Hyperreflexia elevated CK
• Lead toxicity • Myasthenia Gravis • Polymyositis
• Progressive muscular atrophy • Lambert-‐Eaton Myasthenic • Duchenne Muscular Dystrophy
• Hodgkin’s lymphoma Syndrome • Statin Toxicity
• Polio • Botulism • Dermatomyositis
• Multifocal Motor Neuropathy • Congenital • Viral infection
179 • Spinal Muscular Atrophy
Peripheral Weakness
Sensory Changes
Neurologic
180
Spell / Seizure
Epileptic Seizure
SPELL/SEIZURE:
Epileptic
Seizure
SPELL/SEIZURE:
Epileptic
Seizure
Spell/Seizure
Spell/Seizure
Unprovoked
Recurrence
Provoked
Recurrence
Epileptic
Seizure Non-‐epileptic
organic
seizure/other
Unprovoked
Recurrence
Provoked
Recurrence
Epileptic
Seizure Non-‐epileptic
organic
seizure/other
Focal Seizure1 Unclassified Generalized
Focal Seizure1 Unclassified Generalized
Non-‐Dyscognitive1 Dyscognitive 2
Non-‐Dyscognitive 1
Dyscognitive2
Features
of
Non-‐Convulsive Convulsive
Non-‐Convulsive Convulsive
Features
of
• Aura • Aura
• Motor • Motor • Absence • Absence • Myoclonic • Myoclonic
Neurologic
• Autonomic • Autonomic • Atonic • Atonic • Clonic • Clonic
• Tonic • Tonic
Evolving to Bilateral
Evolving to Bilateral • Tonic-‐Clonic
• Tonic-‐Clonic
Convulsive
Convulsive Seizure 3,4 Seizure3,4
1 Previously 1named
Previously named Simple Partial Seizure
Simple Partial Seizure
2 Previously named Complex Partial Seizure
2 Previously 3named Complex Partial Seizure
Previously named Secondary Generalized Tonic-‐Clonic Seizure
3 Previously 4named Secondary
A focal seizure may Generalized Tonic-‐tC
evolve so rapidly o lonic Seizure
a bilateral convulsive
181 4 A focal seizure seizure
may etvolve
hat no sio rapidly
nitial to a bilateral
distinguishing convulsive
features are apparent.
seizure that no initial distinguishing features are apparent.
Spell / Seizure
Secondary Organic
SPELL/SEIZURE: Secondary Organic
Spell/Seizure
Unprovoked
Recurrence
Provoked
Recurrence
(Secondary)
(Primary) Non-‐epileptic
organic
seizure/other
Epileptic
Seizure
Other Secondary Organic
Febrile Infection Metabolic Vascular Degenerative Structural Pregnancy
Neurologic
• Sepsis • Hypoglycemia • Intracerebral
• Dementia • Congenital
• Eclampsia
• Encephalitis • Hyperglycemia hemorrhage abnormality
• Meningitis • Hypocalcemia • Subarachnoid
• Neoplasm
• Hyponatremia hemorrhage • Arteriovenous
• Uremia • Subdural
malformation
• Alcohol/drug
hemorrhage
withdrawal • Epidural
• Drug
overdose hemorrhage
182
• Liver
Failure • Ischemic
Spell / Seizure
Other
SPELL/SEIZURE:
Other
Spell/Seizure
Unprovoked
Recurrence
Provoked
Recurrence
(Secondary)
(Primary) Non-‐epileptic
organic
seizure/other
Epileptic
Seizure
Other Secondary Organic
Neurological Cardiovascular Psychogenic
• Migraine/Auras • Syncope • Panic Disorder
Neurologic
• Movement disorders • Conversion Disorder
(Dystonia, Dyskinesia, • Pseudoseizures
Chorea)
183
STROKE:
Intracerebral
Hemorrhage
Stroke
Intracerebral Hemorrhage
Stroke
Intracerebral Hemorrhage Ischemia Subarachnoid Hemorrhage
Hypertension Vessel Disease Other
• Essential Hypertension • Amyloid Angiopathy • Trauma
(Aneurysm) • Vascular Malformation • Bleeding diathesis
• Drugs (Cocaine, • Aneurysm • Hemorrhage into tumors
Amphetamines) • Vasculitis • Hemorrhage into infarct
Neurologic
184
Stroke
Ischemia
STROKE:
Ischemia
Stroke
Intracerebral Hemorrhage Ischemia Subarachnoid Hemorrhage
Thrombosis
Atherosclerosis,
Arterial
Embolus Systemic
Hypoperfusion
Dissection,
Fibromuscular
Dysplasia
Large Small Ascending Pump Cardiac Output
Unknown Heart
Vessel Vessel Aorta Failure Reduction
• Lacunar • Left Ventricle •Cardiac arrest • Myocardial
Neurologic
• Left Atrium • Arrhythmias infarction
• Valvular • Pulmonary
• Atrial embolus
fibrillation • Pericardial
• Bacterial effusion
endocarditis • Shock
• Myocardial
185 infarction
STROKE: Subarachnoid Hemorrhage Stroke
Subarachnoid Hemorrhage
Stroke
Intracerebral Hemorrhage Ischemia Subarachnoid Hemorrhage
Vessel Disease Other
• Aneurysm • Bleeding Diathesis
• Vascular Malformation • Trauma
• Drug Use
Neurologic
186
Syncope
SYNCOPE
Syncope
Cardiac Non-‐Cardiac
Arrhythmia Outflow Obstruction Vasovagal/Autonomic Orthostatic
• Tachyarrhythmia • Aortic Stenosis • Dehydration
• Bradyarrhythmia • Hypertrophic Obstructive • Hypovolemia
• Supraventricular Cardiomyopathy • Medications
Tachycardia • Pulmonary Embolus
• Sick-‐Sinus Syndrome • Other
• Second/Third Degree
Atrioventricular Block Central Peripheral/Situational
• Emotional • Bladder Emptying
• Pain
• Reduced Effective Arterial
Neurologic
Blood
Volume
• Carotid
Sinus
Syncope
• Tussive
• Defecation
187
Dizziness
VERTIGO/DIZZINESS:
Dizziness
Vertigo/Dizziness
True Vertigo Dizziness
Illusion of Rotary Movement Lightheaded, unsteady, disoriented
Organic Disease Psychiatric Disease
• Presyncope/Vasodepressor
• Depression
Syncope • Anxiety
• Cardiac
Arrhythmia • Panic
Disorder
Neurologic
• Orthostatic
Hypotension • Phobic
Dizziness
• Hyperventilation • Somatization
• Anemia
• Peripheral
neuropathy
• Visual
Impairment
• Musculoskeletal
Problem
• Drugs 188
Vertigo
VERTIGO/DIZZINESS:
Vertigo
Vertigo/Dizziness
True Vertigo Dizziness
Illusion of Rotary Movement Lightheaded, unsteady, disoriented
Central Vestibular Dysfunction Peripheral Vestibular Dysfunction
Imbalance, neurologic symptoms/signs, Nausea and vomiting, auditory symptoms,
bidirectional nystagmus unidirectonal nystagmus
• Benign Paroxysmal Positional Vertigo
• Labrynthitis/Vestibular Neuronitis
Space-‐ • Menière’s Disease
Infection Trauma Occupying Vascular • Acoustic Neuroma
Lesion • Ototoxicity (usually imbalance and
oscillopsia)
• Meningitis • Cerebellar • Infratentorial • Vertebrobasilar
• Otitis Media
• Cerebellar/ Contusion Tumors Insufficiency
• Temporal Bone Fracture
• Cerebellopontine • Basilar Artery
Neurologic
Brainstem
Abscess Angle
Tumors Migraine
• Glomus
Tumors • Transient
Ischemic
Attack
Inflammatory Intoxication • Cerebellar/
Brainstem
Infarction
• Multiple
• Barbiturates • Cerebellar
189 sclerosis • Ethanol Hemorrhage
Obstetrical & Gynecological
Intrapartum Abnormal Fetal HR Tracing Growth Discrepancy Small for Gestational
Variability & Decelerations�������������������������������193 Age / Intrauterine Growth Restriction����204
Intrapartum Abnormal Fetal HR Tracing Growth Discrepancy Large for Gestational
Baseline��������������������������������������������������������������������������194 Age������������������������������������������������������������������������������������205
Abnormal Genital Bleeding������������������������������������195 Infertility (Female)���������������������������������������������������������206
Acute Pelvic Pain���������������������������������������������������������� 196 Infertility (Male)��������������������������������������������������������������� 207
Chronic Pelvic Pain�������������������������������������������������������197 Intrapartum Factors that May Affect Fetal
Amenorrhea Primary�������������������������������������������������� 198 Oxygenation���������������������������������������������������������������208
Amenorrhea Secondary������������������������������������������ 199 Pelvic Mass������������������������������������������������������������������������209
Antenatal Care����������������������������������������������������������������200 Ovarian Mass���������������������������������������������������������������������210
Bleeding in Pregnancy < 20 Weeks�����������������201 Pelvic Organ Prolapse�������������������������������������������������211
Obstetrical
Bleeding in Pregnancy 2nd & 3rd Trimester Post-Partum Hemorrhage�������������������������������������� 212
���������������������������������������������������������������������������������������������� 202 Recurrent Pregnancy Loss������������������������������������� 213
Breast Disorder��������������������������������������������������������������� 203 Vaginal Discharge����������������������������������������������������������214
191
Historical Editors Student Editors
Dr. Heather Baxter Neha Chadha (Co-editor)
Dr. Dorothy Igras Angela Deane (Co-editor)
Dr. Clinton Chow
Dr. Calvin Greene Faculty Editor
Dr. Magali Robert Dr. Ronald Cusano
Dr. Maire Duggan
Dr. Barbara Walley
Vera Krejcik
Shaina Lee
Mia Steiner
Obstetrical
Maria Wu
Danny Chao
Neha Sarna
192
Intrapartum Abnormal Fetal HR Tracing
Variability & Decelerations
INTRAPARTUM
ABNORMAL FETAL
HEART
RATE
TRACING:
Variability
&
Decelerations
Abnormal
Fetal
Heart
Rate
Tracing
Abnormal Variability Baseline Abnormality Decelerations
Minimal/Absent
Absent
Marked
Variability Sinusoidal
Pattern
Variability ≥
25
bpm Accelerations
≤
5
bpm
• Fetal
sleep • Mild
hypoxia • Severe
fetal
anemia
• Hypoxic
acidemia
• Prematurity (Hgb
<
70) • Fetal
abnormality
• Medications
• Tissue
hypoxia
in
fetal
(analgesia,
sedatives) brain
stem
• Hypoxic
acidemia
•Congenital
anomalies
Obstetrical
Early decelerations Variable decelerations Late decelerations Prolonged deceleration
• Fetal head compression • Cord compression • Uteroplacental insufficiency • Hypertonic uterus
(mirror contractions) • Fetal acidemia if complicated • Maternal hypotension • Unresolving umbilical cord
variable decelerations • Reduced maternal arterial compression
oxygen saturation • Maternal hypotension
• Hypertonic uterus • Maternal seizure
193 • Fetal acidemia • Rapid fetal descent
Intrapartum Abnormal Fetal HR Tracing
INTRAPARTUM ABNORMAL FETAL HEART RATE TRACING: BaselineBaseline
Abnormal Fetal Heart Rate Tracing
Abnormal Variability Baseline Abnormality Decelerations
Bradycardia Tachycardia
<
110
bpm >
160
bpm
Maternal Fetal Maternal Fetal
Obstetrical
• Hypotension • Umbilical
cord
occlusion • Fever • Infection
• Drug
response • Fetal
hypoxia/acidosis • Infection • Prolonged
fetal
activity
or
• Maternal
position • Vagal
stimulation
(e.g.
• Dehydration stimulation
• Connective
tissue
disease
chronic
head
compression) • Hyperthyroidism • Chronic
hypoxemia
with
congenital
heart
block
• Fetal
cardiac
conduction
or
• Endogenous
adrenaline
or
• Cardiac
abnormalities
(e.g.
SLE) structural
defect anxiety • Congenital
anomalies
• Drug
response • Anemia
• Anemia 194
Abnormal Genital Bleeding
ABNORMAL
GENITAL
BLEEDING
Abnormal Genital Bleeding
Pregnant Non Pregnant
See Bleeding in Pregnancy
Scheme
Gynecologic Non-‐Gynecologic
• Medical (e.g. coagulopathy, liver disease,
renal disease)
• Drugs
Uterus
Obstetrical
• Anovulatory
• Atrophy
Cervix Vagina Vulva
• Fibroid
• Polyp • Polyp • Atrophy • Vulvar
dystrophy
• Exogenous
estrogen • Ectropion • Vulvovaginitis • Vulvar
Atrophy
• Neoplasm • Dysplasia • Neoplasm • Vulvovaginitis
• Infection • Neoplasm • Infection • Neoplasm
• Endometrial
Hyperplasia • Infection • Trauma • Infection
195 • Trauma • Trauma
Acute Pelvic Pain
ACUTE
PELVIC
PAIN
ACUTE
PELVIC
PAIN
Acute
Pelvic
Pain
Acute Pelvic Pain
Gynecologic Non-‐Gynecologic
Gynecologic Non-‐Gynecologic
• Genitourinary
(Infection,
Stone)
• Gastrointestinal
(Appendicitis,
Gastroenteritis,
• Genitourinary
(Infection,
Stone)IBD)
Diverticulitis,
• Gastrointestinal
(Appendicitis,
Gastroenteritis,
•
Diverticulitis,
IBD)
Musculoskeletal
• Musculoskeletal
Pregnant
Pregnant Non-‐Pregnant
Non-‐Pregnant
Extrauterine
Extrauterine Intrauterine
Intrauterine Uterus Uterus Ovary Ovary
Fallopian
Tube Fallopian
Tube
Obstetrical
• Ectopic
pregnancy**
• Ectopic
• Placental
pregnancy** • aPlacental
• Fibroid
bruption**abruption** • Fibroid • Tubo-‐ovarian
abscess** • Tubo-‐ovarian
abscess**• Tubo-‐ovarian
abscess**
• Tubo-‐ovarian
abscess**
• Spontaneous
abortion • Endometriosis • Torsion** • Pelvic
inflammatory
• Labour
• Spontaneous
a bortion
• Adenomyosis
• Endometriosis • Torsion**disease
• Pelvic
inflammatory
• Ovarian
cyst
• Labour
•Molar
pregnancy • Pyometrium • Adenomyosis • Endometriosis • Ovarian
•Torsion
cyst disease
•Molar
pregnancy• Hematometra • Pyometrium• Ovulation
pain • Endometriosis • Endometriosis •Torsion
• Congenital
A•nomaly
Hematometra • Ovulation
pain
• Hydrosalpinx • Endometriosis
• Dysmenorrhea • Congenital
Anomaly • Hydrosalpinx
**Obstetrical
Emergencies • Dysmenorrhea 196
**Obstetrical
Emergencies
Chronic Pelvic Pain
CHRONIC
PELVIC
PAIN
Chronic Pelvic Pain
> 6 months in duration
Gynecologic Non-‐Gynecologic Co-‐morbidities
• Endometriosis • Somatization
• Chronic
pelvic
inflammatory
disease • Sexual/physical/psychological
abuse
• Dysmenorrhea • Depression/anxiety
• Adenomyosis • Abdominal
wall
pain
• Ovarian
cyst
• Adhesions
Obstetrical
Gastrointestinal Genitourinary Musculoskeletal
• Irritable bowel syndrome • Interstitial cystitis • Pelvic floor myalgia
• Inflammatory bowel disease • Urinary retention • Myofascial pain (trigger points)
• Constipation • Neoplasm • Injury
197 • Neoplasm
Amenorrhea
Primary
AMENORRHEA: Primary
Amenorrhea
Primary Secondary
No
onset
of
menarche
by
age
16
with
secondary
sexual
characteristics
Absence
of
menses
for
3
cycles
or
6
months
Or,
No
onset
of
menarche
by
age
14
without
secondary
sexual
characteristics
Ovarian Etiology Central Congenital Outflow
High FSH Receptor Abnormalities Low FSH
Low Estrogen and Enzyme Deficiencies Low Estrogen Tract Anomalies
• Imperforate hymen
• 46, XX Gonadal Dysgenesis • Androgen insensitivity
• Transverse vaginal septum
(e.g. Fragile X, Balanced • 5-‐α Reductase deficiency
• Vaginal agenesis (Mayer-‐
Translocations, Turner’s • 17-‐ α Hydroxylase deficiency
Rokitansky-‐Küster-‐Hauser
mosaic) • Vanishing Testes Syndrome
syndrome)
• 46, XY Gonadal Dysgenesis • Absent Testes Determining
• Cervical stenosis
(e.g. Swyer’s Syndrome) Factor
• 45, XO Turner syndrome
• Savage syndrome (ovarian
resistance)
Obstetrical
• Premature
Ovarian
Failure
Hypothalamic Pituitary
(Autoimmune,
Iatrogenic)
• Functional
(e.g.
eating
• Surgery
disorder,
weight
loss,
stress,
• Irradiation
excessive
exercise,
illness)
• Tumor,
Infiltration
• Congenital
GnRH
deficiency
• Hyperprolactinemia
(Kallmann
syndrome) • Hypothyroidism
• Constitutional
delay
of
puberty 198
Amenorrhea
Secondary
AMENORRHEA:
Secondary
Amenorrhea
Secondary
Primary Absence
of
menses
for
more
than
3
cycles
or
6
No
onset
of
menarche
by
age
16 months
in
women
who
were
previously
menstruating
Rule out pregnancy (β-‐hCG)
Hypothalamic Outflow Tract
Ovarian Negative progesterone challenge, Pituitary
Low FSH, Low estrogen Obstruction
• Functional (e.g. eating disorder, • Asherman’s syndrome
weight loss, stress, excessive • Cervical stenosis
exercise, illness)
• Infiltrative lesions (e.g. lymphoma,
Langerhans cell histiocytosis, High Prolactin Other
sarcoidosis)
Obstetrical
• Pituitary
Adenoma
• Sheehan’s
Syndrome
• Prolactinoma
• Radiation
Normal
FSH High
FSH • Chest
wall
irritation
• Infection
• Hypothalamic-‐Pituitary
Stalk
• Polycystic
ovarian
syndrome
• Infiltrative
Lesions;
• Menopause Damage
(e.g.
Tumors,
trauma,
(positive
progesterone
hemochromatosis
• Premature
ovarian
failure
compression)
challenge,
normal
prolactin,
(<35
years
old,
e.g.
• Hypothyroidism
chaotic
menstruation
history) autoimmune,
chromosomal,
199 iatrogenic)
Antenatal Care
ANTENATAL
CARE
Antenatal
Care
At
Every
Visit
Weight,
Blood
pressure,
Psychosocial
screening,
Counseling
re.
Indications
to
go
to
hospital
First Trimester Second Trimester Third Trimester
(0-‐12 weeks) (12-‐28 weeks) (28-‐40 weeks)
• Detailed
history
and
physical
exam • Fetal
heart
rate
tones
(starting
at
12
• Fetal
surveillance
• Estimated
date
of
delivery weeks) • Fetal
movement
counts
(>6
• Dating
ultrasound • Prenatal
genetic
screening movements
in
2
hours)
• Prenatal
labs
(CBC,
ABO/Rh
type
&
• First
trimester
screen
(nuchal
• Symphysis
fundal
height
screen,
Antibody
screen,
HBsAg,
Syphilis
translucency,
β-‐hCG
,
PAPP-‐A;
11-‐14
•Leopold
maneuvers
serology,
Rubella
IgG,
Varicella,
HIV) weeks) • Group
B
Streptococcus
screen
(35-‐37
• Chlamydia/Gonorrhea
screen • Maternal
serum
screen
(AFP,
uE3,
β-‐ weeks)
• Urine
culture
&
sensitivity hCG;
15-‐22
weeks) • ± Ultrasound
for
growth,
presentation,
• ± Prenatal
diagnosis biophysical
profile
• Chorionic
villus
sampling
(11-‐13
• ± Non-‐stress
test
Obstetrical
weeks)
• Amniocentesis
(15-‐17
weeks)
• Detailed
18-‐20
week
Ultrasound
(dating,
number
of
fetuses,
placental
location,
anatomic
survey)
• Gestational
diabetic
screen
(50g
oral
glucose
challenge;
24-‐28
weeks)
• Rh
antibody
screen
and
Rh
200
immunoglobulin
if
indicated
(28
weeks)
Bleeding in Pregnancy
< 20 Weeks
BLEEDING IN PREGNANCY: <20 Weeks
Bleeding in Pregnancy
Hemodynamically Unstable – Do ABCDEs
< 20 Weeks Second / Third Trimester
Bleeding from the Os Not Bleeding from the Os
• Cervical polyp/Ectropion
• Cervical/Vaginal neoplasm
• Vaginal laceration
• Infection
Cervix Open Cervix Closed
Passing Not Passing IUP on No IUP on
Tissue and Clots Tissue and Clots Transvaginal U/S Transvaginal U/S
• Complete abortion • Missed abortion
• Incomplete abortion • Inevitable abortion Ectopic No Ectopic
Obstetrical
• Ectopic pregnancy • Cervical insufficiency
Pregnancy on U/S Pregnancy on U/S
β-‐hCG < 1500 β -‐hCG > 1500
Ectopic likely
β-‐hCG doubled in 72h β-‐hCG not doubled in 72h
Viable pregnancy – monitor for Ectopic pregnancy or
201 ectopic or IUP (implantation bleed) failed pregnancy
Bleeding in Pregnancy
2nd & 3rd Trimester
BLEEDING IN PREGNANCY: 2nd and 3rd Trimesters
Bleeding in Pregnancy
Hemodynamically Unstable – Do ABCDEs
< 20 Weeks Second / Third Trimester
Do NOT perform digital examination
until the placental location is known
Bleeding from the Os Not Bleeding from the Os
• Cervical polyp/Ectropion
• Cervical/Vaginal neoplasm
• Vaginal laceration
Obstetrical
• Infection
Painful Painless
• Placental
abruption • Placenta
previa
• Uterine
rupture • Vasa
previa
• Labour
(bloody
show) 202
Breast Disorder
BREAST
DISORDERS
Breast Disorders
Breast Infection Breast Mass Gynecomastia
Non
Lactational Malignant Benign Physiologic Pathologic
Lactational
• Mastitis • Subareolar
• Newborn • Drugs
• Abscess abscess • Adolescence • Decreased
• Acute
mastitis • Aging testosterone
• Increased
estrogen
• Idiopathic
Obstetrical
Non-‐Invasive Invasive Nodular Benign
• Ductal carcinoma • Ductal carcinoma • Fibrocystic change • Gross cyst
in situ • Lobular carcinoma • Galactocele
• Lobular carcinoma • Tubular carcinoma • Fibroadenoma
in situ • Medullary carcinoma
• Papillary carcinoma
203 • Mucinous carcinoma
Growth Discrepancy
GROWTH DISCREPANCY: SSmall
mall for
For Gestational
Gestational Age A ge/
/ Intrauterine Growth Restriction
Intrauterine Growth Restriction
Growth Discrepancy
Large for Gestational Age Small for Gestational Age
(Growth > 90th percentile for GA) (Growth < 10th percentile for GA)
Maternal Factors Fetal Factors Placental Factors
Chromosomal
TORCH
Infections Multiple
Gestation
Abnormalities
• Trisomy
13,
18,
21
• Turner
syndrome,
45X
Placental Ischemia/ Placental Confined Placental
Placental Abruption
Infarction Malformations Mosaicism (Rare)
• Placenta previa • Vasa previa
• Chronic insufficiency
Obstetrical
Decreased
Maternal
Maternal
Lifestyle Iatrogenic
Uteroplacental
Flow Hypoxemia
• Gestational
hypertension/
• Malnutrition • Pulmonary
diseases • Folic
acid
antagonists
Pre-‐eclampsia • Smoking • Chronic
anemia • Anticonvulsants
• Renal
insufficiency • Alcohol • High
altitude
• Diabetes
mellitus • Drugs
• Autoimmune
disorders 204
Growth Discrepancy
Large for Gestational Age
GROWTH
DISCREPANCY:
Large
for
Gestational
Age
Growth Discrepancy
Large for Gestational Age Small for Gestational Age
(Growth > 90th percentile for GA) (Growth < 10th percentile for GA)
Maternal Factors Fetal factors
• Multiparity • Male infant
• Previous history of large for gestational • Prolonged gestation (>41 weeks)
age fetus • Genetic disorder (e.g. Sotos syndrome,
• Aboriginal, Hispanic, and Caucasian races Beckwith-‐Wiedemann syndrome,
• Maternal co-‐morbidities (e.g. diabetes, Weaver’s syndrome)
obesity)
• Excessive weight gain over course of
pregnancy (>40 lbs)
FETAL COMPLICATIONS
Obstetrical
MATERNAL COMPLICATIONS • Shoulder dystocia
• Prolonged labour • Birth injury (brachial plexus injury,
• Operative vaginal delivery clavicular fracture)
• Caesarean section • Cerebral palsy secondary to hypoxia
• Genital tract lacerations • Hypoglycemia
• Post-‐partum hemorrhage • Polycythemia
• Uterine rupture • Perinatal asphyxia
• Hyperbilirubinemia
205
Infertility (Female)
INFERTILITY:
Female
Infertility
Failure to conceive following > 1 year of
Unprotected sexual intercourse
Male (35%) Unexplained (15%) Female (50%)
Uterus Fallopian Tube Ovary
Ovulation confirmation: mid-‐luteal serum progesterone
HSG or SHG or hysteroscopy HSG or SHG or laparoscopy
Ovarian reserve: Day 3 FSH +/-‐ Estradiol
• Fibroids/polyps • Pelvic inflammatory disease
• Asherman’s syndrome • Endometriosis
• Congenital anomalies • Adhesions
• Adenomyosis • Previous tubal pregnancy
• Unfavourable cervical mucous • Congenital Anomalies
• Cervical stenosis
Decreased FSH Normal FSH Increased FSH
Obstetrical
• Polycystic
ovarian
syndrome • Premature
ovarian
failure
• Obesity • Premenopausal
changes
• Turner’s
syndrome
Hypothalamic Hypopituitarism
• Weight
loss/malnutrition • Hypothyroidism
• Excessive
exercise • Hyperprolactinemia
• Stress/psychosis • Tumors
(e.g.
Prolactinoma)
• Systemic
disease 206
Infertility (Male)
INFERTILITY:
Male
Infertility
Failure to conceive following > 1 year of unprotected sexual intercourse
Male (35%) Unexplained (15%) Female (50%)
Sperm Production Sperm Motility
(Non-‐obstructive azoospermia) Sperm Transport Sexual Dysfunction
Abnormal semen analysis
Low testosterone
• Antibodies from infection • Vasectomy
• Cystic fibrosis gene mutation
• Post-‐infectious obstruction See Sexual Dysfunction
• Ejaculatory duct cysts (e.g. Scheme
prostate)
• Kartagener syndrome
Obstetrical
Pre-‐Testicular Testicular
(Hypogonadotrophic
hypogonadism) (Sperm
production
problem)
Low
FSH/LH High
FSH/LH
• Kallmann
syndrome • Genetic
abnormality
(e.g.
Klinefelter’s)
• Suppression
of
gonadotropins
(e.g.
• Cryptorchidism
hyperprolactinemia,
hypothyroidism, • Varicocele
drugs,
tumor,
infection,
trauma) • Mumps
orchitis
207 • Anabolic
steroids • Radiation,
Infection,
drugs,
trauma,
torsion
Intrapartum
Factors that May Affect Fetal Oxygenation
INTRAPARTUM
Factors
that
may
affect
fetal
oxygenation
Factors affecting fetal
oxygenation
Uteroplacental
Maternal
Factors Fetal
Factors
Factors
Excessive Uterine Uteroplacental Decreased Fetal O2
Cord Compression
Activity Dysfunction Carrying Capacity
• Hyperstimulation • Placental abruption • Oligohydramnios • Fetal anemia
• Placental abruption • Placental infarction • Cord prolapse • Carboxyhemoglobin
• Chorioamnionitis • Cord entanglement • Intrauterine growth
• Post-‐dates pregnancy restriction
• Prematurity
• Fetal sepsis
Obstetrical
Decreased
Maternal
Decreased
Maternal
O2 Decreased
Uterine
Maternal
Medical
Arterial
O2 Tension Carrying
Capacity Blood
Flow Conditions
• Smoking • Maternal
anemia • Hypotension • Fever
• Hypoventilation • Carboxyhemoglobin • Anesthesia • Vasculopathy
(SLE,
Type
1
• Respiratory
disease • Maternal
positioning diabetes
mellitus,
HTN)
• Seizure • Hyperthyroidism
• Trauma • Antiphospholipid
syndrome 208
Pelvic Mass
PELVIC
MASS
Pelvic Mass
Do Pelvic U/S
Gynecologic Non-‐Gynecologic
Gastrointestinal Genitourinary
• Appendiceal
abscess • Distended
bladder
• Diverticular
abscess • Bladder
cancer
• Diverticulosis • Pelvic
kidney
• Rectal/Colon
cancer • Peritoneal
Cyst
Non-‐Pregnant Pregnant
Obstetrical
Uterus Fallopian Tube Ovary Uterus Fallopian Tube Ovary
• Fibroid • Tubo-‐ovarian • Intrauterine • Tubal ectopic • Ovarian ectopic
• Adenomyosis abscess pregnancy pregnancy pregnancy
• Neoplasm • Paratubal cyst See Ovarian
• Pyometra • Neoplasm Mass scheme
• Hematometra • Pyosalpinx
209 • Hydrosalpinx
Ovarian Mass
OVARIAN MASS
Ovarian Mass
Benign Neoplasms Hyperplastic Functional Malignant Neoplasms
• Polycystic ovary • Follicular cyst
• Endometrioid cyst • Corpus lutein cyst
• Theca lutein cyst
Epithelial Germ Cell Sex Cord Stromal
• Serous cystadenoma • Mature teratoma (may be • Fibroma
• Mucinous cystadenoma cystic) • Thecoma
• Gonadoblastoma (can • Granulosa cell tumor
become malignant)
Obstetrical
Epithelial Germ
Cell Sex
Cord
Stromal Metastases
• Serous cystadenocarcinoma • Dysgerminoma • Granulosa cell tumor • Krukenberg tumor
• Mucinous • Immature teratoma • Sertoli Cell (gastrointestinal metastasis)
cystadenocarcinoma • Yolk Sac • Sertoli -‐ Leydig • Breast
• Endometrioid
• Clear Cell 210
Pelvic Organ Prolapse
PELVIC ORGAN PROLAPSE
Pelvic Organ Prolapse
Herniation of one or more pelvic organs
Risk factors: genetics, multiparity, operative vaginal delivery,
obesity, increasing age, estrogen deficiency,
pelvic floor neurogenic damage (i.e. surgical),
strenuous activity (i.e. weight bearing)
Uterus Vaginal Apex Bladder
Slow urinary stream, stress Bowel/Rectum
Sensation of object “falling out of Pelvic pressure, urinary retention,
incontinence, bladder neck Defecatory symptoms
vagina,” possible lower back pain stress incontinence
hypermobility
• Uterine prolapse • Vaginal vault prolapse • Cystocele (anterior prolapse) • Enterocele
• Cervical prolapse • Cystourethrocele • Rectocele (posterior
prolapse)
Obstetrical
211
Post-Partum Hemorrhage
POST-‐PARTUM
HEMORRHAGE
Post-‐Partum Hemorrhage
Blood Loss: >500mL post vaginal delivery
OR >1000mL post Caesarean section
Uterine Atony (70%) Trauma (20%) Remnant Tissue (10%) Thrombin (1%)
• Uterine
fatigue
(e.g.
• Perineal
laceration
(e.g.
• Retained
blood
clots
• Thrombocytopenia
prolonged/induced
labor,
episiotomy) • Retained
cotyledon
or
• Idiopathic
thrombocytopenic
rapid
labor,
grand
multiparity) • Vaginal
laceration/
succenturiate
lobe purpura
(ITP)
•Overdistension
of
uterus
(e.g.
hematoma
• Abnormal
placentation
• Thrombotic
multiple
gestation,
• Cervical
laceration
(e.g.
(placenta
accreta,
increta,
or
thrombocytopenic
purpura
polyhydramnios,
fetal
forceps/vacuum
delivery) percreta) (TTP)
Obstetrical
macrosomia) • Uterine
rupture • HELLP
syndrome
• Bladder
distension • Uterine
inversion • Disseminated
intravascular
• Uterine
infection
(e.g.
coagulation
(DIC)
chorioamnionitis) • Anti-‐coagulation
agents
(e.g.
• Functional/anatomic
heparin)
distortion
of
uterus • Pre-‐existing
coagulopathy
• Drugs
– Uterine
relaxants
(e.g.
von
Willebrand’s
disease,
(e.g.
nifedipine,
magnesium
Hemophilia
A)
sulfate,
NSAIDs) 212
Recurrent Pregnancy Loss
RECURRENT
PREGNANCY
LOSS
Recurrent Pregnancy Loss
≥ 3 consecutive spontaneous abortions
Maternal Fetal
• Genetic
abnormalities
Environmental Medical Anatomic
• Toxin (organic solvents, mercury, lead)
• Smoking
• Alcohol
Cervix Uterus
• Drugs
• Ionizing radiation • Cervical • Fibroids
insufficiency • Congenital
Obstetrical
anomaly
• Polyps
• Asherman’s
Other Autoimmune Endocrine Genetic syndrome
• Maternal
infection • Antiphospholipid
• Diabetes
mellitus • Maternal
age
• Thrombophilia syndrome • Hypo/hyperthyroidism • Maternal/paternal
• Lupus
anticoagulant • PCOS chromosomal
213 • Luteal
phase
deficiency abnormality
Vaginal Discharge
VAGINAL
DISCHARGE
Vaginal Discharge
Infectious Inflammatory Neoplastic
• Endometrium
• Cervix
• Vulva
Systemic Local • Vagina
• Crohn’s disease • Chemical irritant
• Collagen vascular • Douching
disease • Atrophic vaginitis
• Dermatologic • Foreign body
• Lichen planus
Obstetrical
Sexually
Toxic
Shock
Transmitted
Vulvovaginitis
Infection Syndrome
• Chlamydia
• Vulvovaginal
trachomatis candidiasis
• Neisseria
gonorrhoeae • Bacterial
vaginosis 214
• Trichomonas
vaginalis
Dermatologic
Burns���������������������������������������������������������������������������������������219 Morphology of Skin Lesions Secondary Skin
Dermatoses in Pregnancy Physiologic Lesions��������������������������������������������������������������������������� 228
Changes������������������������������������������������������������������������ 220 Mucous Membrane Disorder Oral Cavity��� 229
Dematoses in Pregnancy Specific Skin Nail Disorders Primary Dermatologic Disease
Conditions��������������������������������������������������������������������� 221 ���������������������������������������������������������������������������������������������� 230
Disorders of Pigmentations Nail Disorders Systemic Disease����������������������� 231
Hyperpigmentation�����������������������������������������������222 Nail Disorders Systemic Disease - Clubbing
Disorders of Pigmentations �����������������������������������������������������������������������������������������������232
Hypopigmentation�������������������������������������������������223 Pruritus No Primary Skin Lesion�������������������������233
Genital Lesion�������������������������������������������������������������������224 Pruritus Primary Skin Lesion��������������������������������� 234
Dermatologic
Hair Loss (Alopecia) Diffuse�����������������������������������225 Skin Rash Eczematous���������������������������������������������� 235
Hair Loss (Alopecia) Localized���������������������������� 226 Skin Rash Papulosquamous��������������������������������� 236
Morphology of Skin Lesions Primary Skin Skin Rash Pustular���������������������������������������������������������237
Lesions����������������������������������������������������������������������������227 Skin Rash Reactive������������������������������������������������������� 238
215
Skin Rash Vesiculobullous��������������������������� 239
Skin Ulcer by Etiology������������������������������������� 240
Skin Ulcer by Location Genitals���������������� 241
Skin Ulcer by Location Head & Neck����242
Skin Ulcer by Location Lower Legs /
Feet��������������������������������������������������������������������������243
Skin Ulcer by Location Oral Ulcers���������244
Skin Ulcer by Location Trunk / Sacral
Region��������������������������������������������������������������������245
Vascular Lesions�������������������������������������������������� 246
Dermatologic
216
Historical Editors Student Editors
Danny Guo Noelle Wong (Co-editor)
Rachel Lim Heena Singh (Co-editor)
Dave Campbell
Joanna Debosz Faculty Editor
Safiya Karim Dr. Laurie Parsons
Beata Komierowski
Natalia Liston
Arjun Rash
Jennifer Rodrigues
Dermatologic
Sarah Surette
Yang Zhan
217
218
Dermatologic
URNS
Burns
BURNS
Burns
Burns
Physical Agents Chemical Agents
Physical Agents Chemical Age
• Thermal Burn • Acid
• Cold Burn • Alkali • Thermal Burn • Acid
• Alkali
• Electrical Burn • Oxidants (Bleaches,
• Cold pBeroxides,
urn
• Electrical Burn • Oxidants (Bleaches, perox
• Sun Burn chromates, manganates)
• Sun Burn chromates, manganates)
• Vesicants (sulfur and nitrogen, mustards, • Vesicants (sulfur and nitro
Dermatologic
arsenicals, phosgene oxime
arsenicals, phosgene oxime) • Others (white phosphorus
• Others (white phosphorus, metals, persulfates, sodium azide)
persulfates, sodium azide)
Parkland formula for fluid resuscitation:
219 4cc x Weight (kg) x %TBSA burn
Dermatoses in Pregnancy
Physiologic Changes
DERMATOSES IN PREGNANCY: Physiologic Changes
Dermatoses in Pregnancy
Physiologic Skin Changes Specific Skin Conditions
Pigmented Other Vascular
• Striae Distensae (striae gravidarum)
• Distal Onycholysis
• Subungual Keratosis
• Hyperhidrosis
• Miliaria
• Dyshidrotic Eczema
• Hirsutism (face, limbs, and back)
Dermatologic
Mucous
Face Abdomen Hormone
induced Skin
Membranes
• Melasma • Linea
Nigra • Hyperpigmentation
of
• Palmar
erythema • Chadwick’s
sign
(bluish
areolae,
axillae
&
• Spider
Nevi discoloration
of
genitalia • Cherry
Hemangioma
cervix/vagina/vulva)
• Increase
in
mole
size
(Campbell
de
Morgan
&
number
(probable) spot)
• Pyogenic
granuloma
220
Dematoses in Pregnancy
Specific Skin Conditions
DERMATOSES
IN
PREGNANCY:
Specific
Skin
Conditions
Dermatoses in Pregnancy
Physiologic Skin Changes Specific Skin Conditions
Non-‐Pruritic Pruritic
• Pustular psoriasis of pregnancy
• Impetigo Herpetiformis
Dermatologic
Non-‐Primary Skin Lesion Primary Skin Lesion
• Intrahepatic cholestasis of pregnancy • Pemphigoid gestationis
(pruritis worse at night , 3rd trimester) • Pruritic urticarial plaques & papules of
221 pregnancy (PUPPP)
Disorders of Pigmentations
Hyperpigmentation
DISORDERS OF PIGMENTATION: Hyperpigmentation
Disorder of Pigmentation
Hypopigmentation Hyperpigmentation
Localized
Diffuse
Discrete
Areas
• Tanning
• Adverse
cutaneous
drug
eruption
• Addison’s
disease
• Hemochromatosis
• Porphyria
cutanea
tarda
Dermatologic
Congenital
Acquired
• Café au lait macules (neurofibromatosis • Freckles (ephelides)
or McCune Albright syndrome) • Lentigines
• Congenital melanocytic nevi • Melasma
• Tinea versicolor (more commonly
hypopigmented)
• Post-‐Inflammatory hyperpigmentation 222
Disorders of Pigmentations
Hypopigmentation
DISORDERS OF PIGMENTATION: Hypopigmentation
Disorder of Pigmentation
Hypopigmentation Hyperpigmentation
Localized Diffuse
Congenital
Congenital Acquired Generalized
hypopigmentation
of
hair,
Acquired
eyes,
skin
• Tuberous
sclerosis
(white
• Phenylketonuria • Vitiligo
“ash
leaf”
macules) • Albinism
Dermatologic
• Piebaldism
Scale
Acquired
• Tinea
versicolor
(can
also
be
• Vitiligo
hyperpigmented) • Post-‐Inflammatory
hypopigmentation
223 • Pityriasis
alba
Genital Lesion
GENITAL
LESION
Genital
Lesion
Elevated Depressed
Vesicles Papules/Plaques Erosions/Ulcers Excoriations
• Herpes simplex • Scabies
• Pubic lice
Infectious Non-‐Infectious Painful Painless
• Molluscum contagiousum • Herpes simplex • Primary syphilis (chancre)
• Human papilloma virus warts • Haemophilus ducreyi • Granuloma Inguinale
(condyloma acuminata) (chancroid) • Lymphogranuloma venereum
Dermatologic
• Secondary
Syphilis
• Behçet’s
syndrome
(condyloma
lata) • Pemphigus
vulgaris
• Reiter’s
syndrome
(circinate
• Lichen
Sclerosis
balanitis) • Erosive
Lichen
Planus
Inflammatory Non-‐Infectious
• Lichen planus • Squamous cell carcinoma (can be in situ)
• Psoriasis • Melanoma 224
Hair Loss (Alopecia)
Diffuse
HAIR LOSS (ALOPECIA): Diffuse
Hair Loss
Localized (focal) Diffuse
Scarring Non-‐Scarring
Irreversible-‐biopsy
required Reversible
• Lupus
erythematosus
• Lichen
planopilaris
Pattern Anagen Effluvium Discrete Patches Telogen Effluvium
• Androgenetic alopecia • Chemotherapy • Alopecia totalis (all scalp and
• Loose anagen syndrome facial hair)
• Alopecia universalis (all body
Dermatologic
hair)
Endocrine Dietary Drugs Stress Related
• Hypothyroidism • Iron deficiency • Oral contraceptives • Post-‐infectious
• Hyperthyroidism • Zinc deficiency • Hyperthyroid drugs • Post-‐operative
• Hypopituitarism • Copper deficiency • Anticoagulants • Psychological stress
• Post-‐Partum • Vitamin A Excess • Lithium
225
Hair Loss (Alopecia)
HAIR LOSS (ALOPECIA): Localized Localized
Hair Loss
Localized (focal) Diffuse
Scarring Non-‐Scarring
Irreversible-‐biopsy
required Reversible
Secondary to Skin Hair Shafts Intact or
Infectious Broken Hair Shafts
Disease Absent
Dermatologic
• Tinea
capitis
with
kerion • Discoid
lupus
erythematosus • Tinea
capitis • Alopecia
areata
• Folliculitis
decalvans • Lichen
planopilaris • Trichotillomania • Secondary
syphilis
• Pseudopelade
of
Brocq • Traction
alopecia
• Alopecia
Mucinosa • Congenital
hair
shaft
• Keratosis
Follicularis abnormalities
• Aplasia
cutis
226
Morphology of Skin Lesions
Primary Skin Lesions
MORPHOLOGY
OF
SKIN
LESIONS:
Primary
Skin
Lesions
Skin Lesion
Primary Skin Lesion Secondary Skin Lesion
Initial lesion not altered by trauma, manipulation Lesion that develops from trauma, manipulation
(rubbing, scratching), complication (infection), or (rubbing, scratching), complication (infection) of
natural regression over time. initial lesion, or develops naturally over time
Flat Elevated
• Macule
(≤
1
cm
diameter)
• Patch
(>
1
cm
diameter)
Solid Fluid-‐Filled OR Semi-‐Solid-‐Filled Fluid-‐Filled
• Cyst
Dermatologic
No Deep Component Deep Component Purulent Non-‐Purulent Fluid
• Papule (≤ 1 cm diameter) • Nodule (1-‐3 cm diameter) • Pustule • Vesicle (≤ 1 cm diameter)
• Plaque (> 1 cm diameter) • Tumor (> 3 cm diameter) • Bulla (> 1 cm diameter)
Firm/Edematous Transient/Itchy
227 • Wheals/Hives
Morphology of Skin Lesions
Secondary Skin Lesions
MORPHOLOGY
OF
SKIN
LESIONS:
Secondary
Skin
Lesions
Skin Lesion
Primary Skin Lesion Secondary Skin Lesion
Initial lesion not altered by trauma, manipulation Lesion that develops from trauma, manipulation
(rubbing, scratching), complication (infection), or (rubbing, scratching), complication (infection) of
natural regression over time. initial lesion, or develops naturally over time
Elevated Depressed
• Crust/Scab
(dried
serum,
blood,
or
pus
• Atrophic
Scar
(fibrotic
replacement
of
overlying
the
lesion) tissue
at
site
of
injury)
• Scale
(dry,
thin
or
thick
flakes
of
skin
• Ulcer
(complete
loss
of
epidermis
Dermatologic
overlying
the
lesion) extending
into
dermis
or
deeper;
heals
• Lichenification
(thickened
skin
with
with
scar)
accentuation
of
normal
skin
lines) • Erosion
(partial
loss
of
epidermis
only;
• Hypertrophic
Scar
(within
boundary
of
heals
without
scar)
injury) • Fissure
(linear
slit-‐like
cleavage
of
skin)
• Keloid
Scar
(extend
beyond
boundary
of
• Excoriation/Scratch
(linear
erosion
injury) induced
by
scratching)
228
Mucous Membrane Disorder
MUCOUS
MEMBRANE
DISORDER
(Oral
Cavity)
Oral Cavity
Mucous Membrane Disorder
Erosions/Ulcers/Blisters White Lesions
Primary
Dermatologic
Systemic
Disease Non-‐neoplastic Neoplastic
Diseases
• Aphthous
Stomatitis
• Systemic
lupus
• Leukoplakia
Dermatologic
(recurrent, punched out erythematosus • Squamous cell carcinoma
ulcers, often preceded by • Inflammatory bowel disease
trauma/emotional stress) (ulcerative colitis more than
• Herpetic gingivostomatitis Crohn’s disease)
• Pemphigus vulgaris • Behçet’s syndrome Candidiasis Lichen Planus
• Bullous pemphigoid White/cottage cheese like Reticular (lace-‐like) white lines &
plaques/scrape off easily papules
• Erythema multiforme
• Stevens-‐Johnson Syndrome
• Toxic epidermal necrolysis
229
Nail Disorders
NAIL DISORDERS: Primary Dermatologic DiseasePrimary Dermatologic Disease
Nail Disorder
Primary Dermatologic Disease Systemic Disease
Nail Plate Abnormality Nail Fold Abnormality
Inflammation
Discolouration Pitting Thickening Onycholysis Erythema,
Swelling,
Telangiectasia
Pain
• Psoriasis • Psoriasis • Psoriasis • SLE
• Alopecia
Areata • Onychomycosis • Onychomycosis • Scleroderma
• Onychogryphosis • Dermatomyositis
Brown/Black Proximal &
Dermatologic
Oil
Drop
Sign Fungal
Culture Lateral
Only
Linear
Streak Lateral
• Psoriasis •Junctional/ • Ingrown
Nail
Melanocytic
Nevus
• Malignant
White/Yellow-‐ Melanoma
Under
Acute
Green Chronic
Brown Nails Trauma/Infection
• Pseudomonas
• Drug-‐Induced
• Onychomycosis • Acute
Paronychia • Chronic
Paronychia
infection
230
Nail Disorders
Systemic Disease
NAIL DISORDERS: Systemic Disease
Nail Disorder
Primary Dermatologic Disease Systemic Disease
Nail Plate Abnormality Nail Fold Abnormality Nail Bed Abnormality
• SLE
• Scleroderma
• Dermatomyositis
Koilonychia Onycholysis Beau’s Lines Clubbing
Spoon-‐Shaped Plate Separating from Bed Horizontal Grooves
• Iron deficiency anemia • Hyperthyroidism • Any systemic disease severe
enough to transiently halt nail
growth (e.g.. shock, malnutrition)
Red
Discoloration
Blue
Discoloration White
Discoloration
Dermatologic
Splinter hemorrhages (dark red, thin lines, usually
painful)
• Medications • Bacterial endocarditis
• Wilson’s disease • Trauma
• Silver poisoning
• Cyanosis Terry’s Nails Half-‐and-‐Half Nails Muehrcke’s Lines
Proximal 90% 50% Transverse lines
• Liver cirrhosis • Chronic renal failure • Nephrotic syndrome
• Congestive heart failure • Uremia
231 • Diabetes Mellitus
Nail Disorders
Systemic Disease - Clubbing
NAIL DISORDERS: Systemic Disease -‐ Clubbing
Nail Disorder
Primary Dermatologic Disease Systemic Disease
Nail Plate Abnormality Nail Fold Abnormality Nail Bed Abnormality
Koilonychia Onycholysis Beau’s Lines Clubbing
Spoon-‐Shaped Plate Separating from Bed Horizontal Grooves
Dermatologic
Bronchopulmonary Cardiovascular
Gastrointestinal
Endocrine
Disease Other
Disease Disease Disease
• Bronchiectasis • Cyanotic
Heart
• Inflammatory
Bowel
• Hyperthyroidism
• Human
• Chronic
Lung
Infection Disease Disease
(Crohn’s
(Grave’s
Disease) Immunodeficiency
• Lung
Cancer Disease,
Ulcerative
Virus
• Asbestosis Colitis) • Congenital
Defect
• Cystic
Fibrosis • Gastrointestinal
• Chronic
Hypoxia Cancer 232
Pruritus
PRURITUS:
No
No Primary Skin Primary
Skin
Lesion
Lesion
Pruritus
Primary Skin Lesion No Primary skin Lesion
Primary Abnormal Finding
Liver Function Creatinine & CBC & Psychiatric
Blood Glucose TSH & T4
Tests/Enzymes BUN Differential Disease
Dermatologic
• Diabetes • Cholestatic liver • Chronic renal • Hypothyroidism • Lymphoma • Delusions of
Mellitus disease failure/uremia • Hyperthyroidism • Leukemia parasitosis
• Polycythemia
rubra vera
• Essential
Throbocythemia
• Myelodisplastic
syndrome
233
Pruritus
PRURITUS: Primary Skin Lesion Primary Skin Lesion
Pruritus
Primary Skin Lesion No Primary skin Lesion
Macules/Papules/Plaques Vesicles/Bullae Wheals/Hives
• Xerosis (dry skin) • Varicella zoster (chickenpox) • Urticaria
• Atopic dermatitis • Dermatitis herpetiformis
• Nummular dermatitis • Bullous pemphigoid
• Seborrheic dermatitis
• Stasis dermatitis
Dermatologic
• Psoriasis
• Lichen
Planus
• Infestations
(scabies,
lice)
• Arthropod
bites
234
Skin Rash
SKIN
RASH:
Eczematous
Eczematous
Skin Rash
Eczematous Papulosquamous Vesiculobullous Pustular Reactive
Pruritic/Scaly/Erythematous Erythrematous or violaceous
Blisters containing non-‐ Blisters containing purulent Reactive erythematous with
lesions. Usually poorly papules & plaques with
purulent fluid fluid various morphology
demarcated overlying scale
Atopic
Stasis
Nummular
Seborrheic
Dermatitis Dyshidrotic
Contact
Dermatitis Dermatits Dermatitis Eczema Dermatitis
Erythematous
(Eczema)
(Discoid
Eczema)
Yellowish-‐red
eruption
on
lower
(pompholyx) Well-‐demarcated
Erythematous
Coin
shaped
(discoid)
plaques
with
greasy
legs.
Secondary
to
Deep-‐Seated
erythema,
papules,
papules
and
vesicles
erythematous
distinct
margins
on
venous
insufficiency.
tapioca-‐like
vesicles
vesicles,
erosions
(acute)
or
plaques.
Usually
on
scalp/face/central
+/-‐ pigmentation,
on
hands/feet/sides
scaling
confined
to
lichenification
lower
legs chest
folds edema,
varicose
of
digits. area
of
contact
Dermatologic
(chronic)
veins,
venous
ulcers
Age
dependent
distribution:
Infants:
scalp,
face,
Allergic
extensor
extremities Irritant Delayed
onset
(12-‐
Children:
flexural
areas Rapid
onset,
requires
72
hrs).
Very
low
Adults:
flexural
high
doses
of
the
concentrations
areas/hands/face/
agent.
May
occur
in
sufficient.
Occurs
nipples anyone only
in
those
sensitized
235
Skin Rash
SKIN
RASH:
Papulosquamous Papulosquamous
Skin Rash
Eczematous Papulosquamous Vesiculobullous Pustular Reactive
Pruritic/Scaly/Erythematous Erythrematous or violaceous
Blisters containing non-‐ Blisters containing purulent Reactive erythematous with
lesions Usually poorly papules & plaques with
purulent fluid fluid various morphology
demarcated overlying scale
Pityriasis
Lichen
Planus
Rosea
Psoriasis Purple,
pruritic,
Oval,
tannish-‐pink
or
Tinea Secondary
Discoid
Lupus
polygonal,
planar
Well
demarcated
(flat-‐topped)
papules
salmon-‐coloured
(Ring
Worm)
Syphilis Erythematous
plaques,
thick
silvery
patches,
plaques
Annular
(Ring-‐ Scarring
and/or
on
Red
brown
or
copper
scale
on
elbows
&
with
scaling
border
shaped)
lesion
with
atrophic
red/purple
wrists/ankles/genital coloured
scaling
knees.
Auspitz
sign in
Christmas
tree
elevated
scaling,
red
plaques
with
white
s
(especially
penis) papules
and
plaques
Koebner’s
pattern
on
trunk,
border,
central
adherent
scales
on
Wickham’s
striae
Dermatologic
phenomenon clearing on
palms
and
soles
Koebner’s
begins
with
a
large
sun-‐exposed
area
phenomenon lesion
patch
(Herald’s
patch)
236
Skin Rash
SKIN
PustularRASH:
Pustular
Skin Rash
Eczematous Papulosquamous Vesiculobullous Pustular Reactive
Pruritic/Scaly/Erythematous Erythrematous or violaceous
Blisters containing non-‐ Blisters containing purulent Reactive erythematous with
lesions Usually poorly papules & plaques with
purulent fluid fluid various morphology
demarcated overlying scale
Acneiform Infectious
Erythematous
papules
and
pustules
on
face
Candidiasis
Acne
Vulgaris Folliculitis Impetigo “Beefy
red”
erythematous
Comedones
+/-‐ nodules,
Comedones
Absent Pustules
centered
around
Pustules
with
overlying
thick
patches
in
body
folds
with
Dermatologic
cysts,
scars
on
face
&
trunk hair
follicles honey-‐yellow
crusts satellite
pustules
at
periphery
Acne Rosacea Perioral Dermatitis
Telangiectasia, episodic Perioral, periorbital &
flushing after sunlight, nasolabial distribution,
alcohol, hot or spicy food & sparing vermillion borders of
drinks lips
237
SKIN RASH: Reactive Skin Rash
Reactive
Skin Rash
Eczematous Papulosquamous Vesiculobullous Pustular Reactive
Pruritic/Scaly/Erythematous Erythrematous or violaceous
Blisters containing non-‐ Blisters containing purulent Reactive erythematous with
lesions Usually poorly papules & plaques with
purulent fluid fluid various morphology
demarcated overlying scale
Erythema
Urticaria
Erythema
Nodosum Multiforme
Firm,/edematous
papules
&
Target
lesions
possibly
with
Tender
or
painful
red
plaques
that
are
transient
&
macules,
papules,
vesicles
nodules
on
shins
itchy.
Usually
lasts
<24hrs
Dermatologic
&/or
bullae
on
palms
soles
and
mucous
membranes
238
Skin Rash
Vesiculobullous
SKIN
RASH:
Vesiculobullous
Skin Rash
Eczematous Papulosquamous Vesiculobullous Pustular Reactive
Pruritic/Scaly/Erythematous Erythrematous or violaceous
Blisters containing non-‐ Blisters containing purulent Reactive erythematous with
lesions Usually poorly papules & plaques with
purulent fluid fluid various morphology
demarcated overlying scale
Vesicles NOT Fragile/NOT Easily
Vesicles Fragile/Easily Ruptured
Intraepidermal blisters, possibly crusts/erosions Ruptured
Subepidermal blisters, tense intact blisters
Reaction to Reaction to
Inflammatory Infectious Inflammatory Metabolic
Agent Agent
Dermatologic
• Pemphigus • Varicella zoster • Contact • Bullous • Porphyria • Phototoxic drug
vulgaris (chickenpox) dermatitis pemphigoid cutanea tarda eruption
• Pemphigus • Herpes zoster • Mucous • Diabetic bullae
foliaceus (shingles) membrane (bullous
• Herpes simplex pemphigoid diabeticorum)
• Bullous • Dermatitis
impetigo herpetiformis
• Bullous
systemic lupus
239 erythematous
Skin Ulcer by Etiology
SKIN ULCER BY ETIOLOGY
Skin Ulcer
Physical Vascular Hematologic Neoplastic Neurological Infectious Metabolic Drugs
• Trauma • Arterial • Squamous • Diabetic • Pyoderma • Coumadin
• Pressure Insufficiency cell neuropathy gangrenosum • Heparin
• Radiation • Venous carcinoma • Tabes • Diabetic • Bleomycin
insufficiency •Basal cell dorsalis dermopathy
• Vasculitis carcinoma (syphilis) • Necrobiosis
• Melanoma • Factitious lipoidica
• Mycosis disorder
fungoides • Delusions
(cutaneous t-‐ of
cell parasitosis
lymphoma)
Dermatologic
Hemoglobino-‐
Other Protozoan Viral Bacterial Fungal
pathy
• Sickle
cell
• Cryog-‐ • Leishmaniasis • Herpes
simplex • Tuberculosis • Histoplasmosis
anemia lobulinemia •Syphilis • Coccidioido-‐
•Thalessemia • Chlamydia
mycosis
trachomatis • Cryptococcosis
• Klebsiella
granulomatis 240
SkinULCER
SKIN
Ulcer
BY
by Location
LOCATION:
Genitals
Genitals
Skin Ulcer
Oral Head/Neck Trunk/Sacral Region Genitals Lower Legs/Feet
Painful Painless
• Herpes simplex • Primary syphilis (chancre)
• Haemophilus ducreyi (chancroid) • Granuloma inguinale
• Behçet’s syndrome • Lymphogranuloma venereum
• Pemphigus vulgaris
Dermatologic
• Lichen
sclerosis
• Erosive
lichen
planus
241
Skin Ulcer by Location
SKIN
ULCER
BY
LOCATION:
Head
and
Neck
Head & Neck
Skin Ulcer
Oral Head/Neck Trunk/Sacral Region Genitals Lower Legs/Feet
Neoplastic Metabolic Vascular Other
• Squamous cell carcinoma • Pyoderma gangrenosum • Wegner’s granulomatosis
• Basal cell carcinoma • Radiation
• Melanoma
Dermatologic
242
SkinULCER
SKIN
Ulcer
BY
by Location
LOCATION:
Lower
Legs
/
Feet
Lower Legs / Feet
Skin Ulcer
Oral Head/Neck Trunk/Sacral Region Genitals Lower Legs/Feet
Physical Vascular Neurological Metabolic Neoplastic Other
• Pressure • Arterial • Diabetic • Pyoderma • Squamous cell
• Trauma insufficiency neuropathy gangrenosum carcinoma
• Radiation • Vascular • Tabes dorsalis • Diabetic • Basal cell
insufficiency (syphilis) dermopathy carcinoma
Dermatologic
• Vasculitis • Necrobiosis • Melanoma
lipoidica
243
SKIN
ULCER
BY
LOCATION:
Oral
Ulcers Skin Ulcer by Location
Oral Ulcers
Skin Ulcer
Oral Head/Neck Trunk/Sacral Region Genitals Lower Legs/Feet
Single
Ulcer Multiple
Acute
Ulcers Multiple
Recurrent
Ulcers Multiple
Chronic
Ulcers
• Traumatic
ulcer • Viral
stomatitis • Aphthous
stomatitis • Pemphigus
vulgaris
• Angular
ulcer • Erythema
multiforme • Herpes
simplex
infection • Lichen
planus
• Aphthous
ulcer • Acute
necrotizing
ulcerative
• Lupus
erythematosus
Dermatologic
• Herpes
simplex gingivitis • Bullous
pemphigoid
244
SkinULCER
SKIN
Ulcer
BY
by Location
LOCATION:
Trunk
/
Sacral
Region
Trunk / Sacral Region
Skin Ulcer
Oral Head/Neck Trunk/Sacral Region Genitals Lower Legs/Feet
Neoplastic Physical Other
• Squamous cell carcinoma • Physical
• Basal cell carcinoma • Trauma
• Melanoma • Radiation
Dermatologic
• Mycosis fungoides (cutaneous t-‐cell
lymphoma)
245
VASCULAR
LESIONS Vascular Lesions
Vascular Lesions
Blanches with Pressure Does not blanche with pressure
Erythematous or violaceous discolorations of skin
Small, dilated superficial blood vessels
due to extravasation of RBCs in dermis
• Telangiectasia
Petechiae < 0.2 cm diameter
Purpura 0.2 -‐ 1.0 cm diameter
Ecchymosis > 1 cm diameter
Dermatologic
Congenital Acquired
• Hemangioma • Vasculitis
246
Musculoskeletal
Acute Joint Pain Vitamin CD��������������������������������� 249 Guide to Spinal Cord Injury������������������������������������ 262
Chronic Joint Pain���������������������������������������������������������250
Bone Lesion�����������������������������������������������������������������������251
Deformity / Limp�����������������������������������������������������������252
Infectious Joint Pain���������������������������������������������������� 253
Inflammatory Joint Pain�������������������������������������������� 254
Vascular Joint Pain������������������������������������������������������� 255
Pathologic Fractures�������������������������������������������������� 256
Soft Tissue���������������������������������������������������������������������������257
Fracture Healing������������������������������������������������������������ 258
Musculoskeletal
Osteoporosis BMD Testing������������������������������������ 259
Tumour����������������������������������������������������������������������������������260
Mytomes Segmental Innervation of Muscles
�����������������������������������������������������������������������������������������������261
247
Historical Editors Student Editors
Dr. Marcia Clark Angie Karlos (Co-editor)
Dr. Sylvain Coderre Ryan Iverach (Co-editor)
Dr. Mort Doran
Dr. Henry Mandin Faculty Editor
Graeme Matthewson Dr. Carol Hutchison
Katy Anderson
Tara Daley
Jonathan Dykeman
Kate Elzinga
Musculoskeletal
Bikram Sidhu
248
Acute Joint Pain
Vitamin CD
ACUTE
JOINT
PAIN-‐ VITAMIN
CD
Vascular -‐ See
vascular
joint
pain
Infectious -‐ See infectious joint pain
Trauma -‐ Multiple injury sites, Open Fracture, Infectious joint pain
Autoimmune -‐ See inflammatory joint pain
Metabolic -‐ See pathologic fractures
Iatrogenic -‐ Hx of prior surgery
Musculoskeletal
Neoplastic -‐ See Tumour
-‐ Scoliosis,
Talipes
Equinovarus,
Meta
tarsus
adductus,
Bow
leg,
Knock-‐
Congenital
Knee’d
Degenerative -‐ Degenerative Disc Disease, Osteoarthritis, Osteoporosis
249
Chronic Joint Pain
Musculoskeletal
250
Bone Lesion
BONE
LESION
Bone
Lesion
on
X-‐ray
Rule
Out
Osteomyelitis
&
Secondary
Metastases
Non-‐aggressive Aggressive
Narrow, <1mm margin Broad or Indistinct Margin
Exostotic Multiple Lytic Lesions
Reactive bone formation &/or Soft Tissue Invasion
• Osteochondroma • Multiple Myeloma
Malignant
Bone
Mineralization,
Asymptomatic
&/or
Non-‐ Symptomatic
&/or
Active
Benign Constitutional
Symptoms,
Active
Bone
Scam Bone
Scan No
Bone
Mineralization Codman’s
Triangle,
Excessive
Scalloping
&
Destruction
of
Cortical
Bone
Musculoskeletal
• Unicameral Bone Cysts • Enchondroma (can calcify • Osteosarcoma (Codman’s
• Aneurysmal Bone Cysts &/or turn malignant) Triangle)
•Non-‐ossifying Fibroma • Giant Cell Tumor (“Soap • Chondrosarcoma (“Popcorn”
Bubble” appearance) appearance)
• Ewing’s Sarcoma
Not Inflammatory
Inflammatory Appearance
Appearance
• Osteoid Osteoma (“Nidus” • Chondroblastoma
appearance) • Chondromyxoid Fibroma
• Osteoblastoma (may be
malignant or sclerotic in
251 appearance)
Deformity / Limp
DEFORMITY/LIMP
Deformity/Limp
Always check neurological and
vascular status one joint below the
injury
Infection Inflammation Other Causes Hip Joint Knee Joint Spine/Stature
• Septic Arthritis • Rheumatoid • Osteoarthritis • Hip Dysplasia • Patellofemoral • Osteoporosis
• Cortical Arthritis • Osteomalacia • Slipped Capital Syndrome • Scoliosis/Spinal
Hypertrophy • Toxic Synovitis • Rickets Femoral (Chondromalacia Curvature
• Osteomyelitis • Reactive Epiphysis Patellae) • Dwarfism
Arthritis • Legg-‐Calve-‐ • Osgood-‐
Musculoskeletal
Perthes
Disease Schlatter
Disease
• Patella
(e.g.,
Tendon
Rupture,
Dislocation,
Subluxation)
252
Infectious Joint Pain
INFECTIOUS
JOINT
PAIN
Infectious Joint Pain
Fever/Chills/Myalgia
Constant
Pain
Increased
Heat
and
Swelling
Signs
&
Symptoms
of
Viral
Infection
9E.g.,
Rhinitis/Cough)
Polyarticular Monoarticular
• Viral
Myalgia
• Viral
Arthritis
• Disseminated
Gonoccocal
Infection
Articular Peri-‐Articular
(Dermatitis,
Migratory
Arthralgia
&
Tenosynovitis)
• Cellulitis
• Secondary
Syphilis
(Red/Copper
Papules
&
• Necrotizing
Fasciitis
Mucosal
Lesions) • Septic
Bursitis
Musculoskeletal
• Fifth Disease (Erythema Infectiousum & • Abscess
Symmetrical Rash) • Osteomyelitis
• Rubella (Measles-‐ like rash)
• Lymphadenitis
• Primary HIV Infection • Warts
• Endocarditis
Acute Onset Insidious Onset
• Septic Arthritis • Fungal tuberculosis
253 • Lyme Disease (Erythema Migrans)
Inflammatory Joint Pain
Musculoskeletal
Granulomatosis with polyangiiis
(GPA)/microscopic polyangiiis (MPA) 254
Vascular Joint Pain
VASCULAR
JOINT
PAIN
Vascular Joint Pain
Constant Pain (Ischemia)
Acute Onset
Increased Pain with Activity (Claudication)
Cold Extremity or Hyperemia
Spasm Occlusion Disruption Compression
• Vasculitis • Sickle
Cell
Anemia • Trauma
to
Vessel
• Any
structure
compressing
• Peripheral
Vascular
Disease (dislocation/fracture) the
blood
vessels
• Atherosclerosis • Hemarthrosis
(Hemophilia
or
• Abscess
Musculoskeletal
• Deep Vein Thrombosis Trauma) • Cyst
• Septic Embolism (e.g. • Peripheral/Mycotic • Neoplasm
Infective Endocarditis) Aneurysm (e.g. Marfan’s • Dislocated Bone
• Fat Embolism (e.g. fractured Syndrome, Infective
long bone) Endocarditis, Atherosclerosis)
• Air Embolism
• Vasculitis
255
gility
Fractures
Pathologic Fractures
rcise/Repeated
Use
cal
and
vascular
status
PATHOLOGIC
FRACTURES
ow
the
injury
Pathologic/Fragility
Fractures
Low Energy/No Exercise/Repeated Use
Always Check neurological and vascular status
Metabolic Bone Disease one joint below the injury
Tumours Metabolic Bone Disease
See Bone Lesions Scheme
Renal Osteodystrophy Osteomalacia/Ricketts
Secondary to Chronic Renal Diffuse Pain/Proximal MDuscle
Paget’s isease Renal Osteodystrophy Osteomalacia/Ricketts
Osteoporosis
Failure Vertebrae/Hip/Distal Radius
Weakness
Skull/Spine/Pelvis Secondary to Chronic Renal Diffuse Pain/Proximal Muscle
Positive Alkaline Phosphatase Failure Weakness
• Vitamin D Deficiency • Vitamin D Deficiency
• Mineralization Defect • Mineralization Defect
• Phosphate Deficiency
• Phosphate Deficiency
Primary Secondary
Musculoskeletal
• Post-‐Menopausal • Gastrointestinal
Disease
• Elderly • Bone
Marrow
Disorder
• Endocrinopathy
• Malignancy
• Drugs
(e.g.
corticosteroids)
• Rheumatoid
Disease
Toronto
Notes
for
Medical
Students,
Inc.
(2009).
Toronto
Notes
209:
Comprehensive
• Renal
Disease Medical
Reference
and
Review
for
MCCQE
I
&
USMLE
II.
McGraw-‐Hill:
Toronto,
Ontario.
• Poor
Nutrition
• Immobilization
Toronto
Notes
for
Medical
Students,
Inc.
(2009).
Toronto
Notes
209:
Comprehensive
Medical
Reference
and
Review
for
MCCQE
I
&
USMLE
II.
McGraw-‐Hill:
Toronto,
Ontario.
256
Soft Tissue
257
Musculoskeletal
Fracture Healing
FRACTURE
HEALING
FRACTURE
HEALING
Fracture
Healing
FRACTURE
HEALING Fracture
Healing
FRACTURE
HEALING Fracture
Healing
Delayed
Union
(3
– 6
months) Non-‐Union
(after
6
months) Malunion
Delayed
Union
(3
– 6
months) Fracture
Healing
Non-‐Union
(after
6
months) Malunion
• Tobacco
/
nicotine
• NSAIDS• Tobacco
Delayed
/
nicotine
Union
(3
– 6
months) Non-‐Union
(after
6
months) Malunion
• NSAIDS
• Ca2+ /Vitamin
D
deficiency
• Ca
Delayed
2+ /Vitamin
D
deficiency
Union
(3
– 6
months) Non-‐Union
(after
6
months) Malunion
• Tobacco
/
nicotine Septic
Aseptic Functional Non
Functional
(R/O
First)Septic
• NSAIDS
• Tobacco
• Ca/2+
n/Vitamin
icotine D
deficiency Aseptic Functional Non
Functional
RED
F LAGS
( life
t hreatening) (R/O
First)
• NSAIDS
• • CaMulti-‐RED
F LAGS
traumaD
deficiency
2+ /Vitamin
( life
threatening)
Septic
• Small
deviations
• Inadequate
• Inadequate
Aseptic from
normal
• Small
axisdeviations
immobilization/
Non
Functional
• • Fracture
Pelvic
Multi-‐trauma Functional
• Fracture
Pelvic
Fracture
(R/O
First) from
normal
axis reduction
immobilization/
• RED
Femur
F LAGS
(life
threatening) Hypertrophic Septic Atrophic reduction
• Femur
Fracture Hypertrophic
(adequate
b(R/O
lood
First) Aseptic
(inadequate
blood
Atrophic Functional
• Small
deviations
Non
Functional
•Misalignment
• Inadequate
• High
• Cervical
Spine
Multi-‐trauma Fracture •Misalignment
before
immobilization/
casting
RED
•F•LAGS
High
Cervical
Pelvic
(Flife
racture
Spine
Fracture flow)(adequate
blood
threatening)
flow)
flow)(inadequate
blood
flow)
from
normal
axis before
•Premature
• Inadequate
cast
casting
• Small
deviations
reduction
• Multi-‐
• tFemur
raumaFracture • Mechanical
failure)
Hypertrophic •Tobacco
/Atrophic
nicotine removal •Premature
cast
• Mechanical
failure) •NSAIDS •Tobacco
/
n from
normal
axis
icotine immobilization/
•Misalignment
• Pelvic
• F racture
High
Cervical
Spine
Fracture • Excessive
m otion
(adequate
blood
(inadequate
b lood
removal
reduction
before
casting
Musculoskeletal
• Femur
Fracture • Excessive
Hypertrophic
•Excessive
bone
gapmotion •Medications
flow) Atrophic•NSAIDS flow)
•Excessive
(adequate
blood
bone
gap (inadequate
•Medications
blood
•Misalignment
•Premature
cast
• High
Cervical
Spine
Fracture •flow)
Mechanical
failure) •Allergies
•Tobacco
flow) •Allergies /
n icotine before
casting
removal
• Excessive
motion •Biologic
Failure
•NSAIDS •Premature
cast
• Mechanical
failure) •Tobacco
•Biologic
/
n icotine Failure
•Excessive
bone
gap •Medications removal
• Excessive
motion •NSAIDS •Allergies
Operative
Non-‐Operative
•Excessive
bone
gap •Medications
•Biologic
Failure
Fractures: Operative
FracturesNon-‐Operative
Inflammation •Allergies
Soft
Callus Hard
Callus Remodelling
• Open
Fractures: • ClosedFractures Inflammation •Biologic
Soft
FC
ailure allus Hard
Callus Remodelling
• Open
• Stable• Closed Hours-‐ Days Days-‐ Weeks Weeks-‐ Months Years
• Unstable
Operative
Non-‐ O perative
Hours-‐ Days Days-‐ Weeks Weeks-‐ Months Years
• Displaced • Unstable • Undisplaced • Stable
Fractures:
• Displaced Fractures
• Undisplaced Inflammation Soft
Callus Hard
Callus Remodelling
•Operative
Intra-‐
• Open
• Extra-‐
Non-‐ O perative
• Closed
articular
Fractures: • Intra-‐Fractures
• Unstable articular • Extra-‐
• Stable Inflammation
Hours-‐ Days Days-‐ Weeks
Soft
Callus Hard
Callus
Weeks-‐ Months
Remodelling
Years 258
• Open
articular • Closed articular
• Displaced • Undisplaced Hours-‐ Days Days-‐ Weeks Weeks-‐ Months Years
OSTEOPOROSIS-‐ BMD
testing
Osteoporosis
BMD Testing
OSTEOPOROSIS-‐ BMD
testing T-‐Scores:
Normal
> -‐1
Osteoporosis -‐2.49
<
Osteopenia
<
-‐1
Osteoporosis
-‐ < -‐ 2.5
T-‐Scores:
Normal
> -‐1
Osteoporosis -‐2.49
<
Osteopenia
<
-‐1
Osteoporosis
-‐ < -‐ 2.5
Age > 50 years Age < 50 years
• All men and women >65 • Fragility Fracture
• Prolonged Glucocorticoid use
Age >• 50 Prior
years fragility fracture Age < •50 yUse
earsof other high risk medicatio
• Prolonged glucocorticoid use
• Rheumatoid Arthritis • Aromatase Inhibitors
• All men and women >65 in past 12 months • Fragility Fracture • Androgen Deprivation
• Falls • Prolonged Glucocorticoid uTherapy se
• Prior fragility fracture
• Parental Hip Fracture
• Prolonged glucocorticoid • Use of other high
• risk m edications
Hypogonadism/Premature
• Other umseedications • Aromatase Inhibitors
• Rheumatoid Arthritis • Vertebral fracture Menopause
• Falls in past 12 •months • Androgen
• Deprivation
Malabsorption Syndrome
Osteopenia on X ray Therapy•
• Parental Hip Fracture• Smoking/ETOH Primary Hyperparathyroidism
• Other medications • Hypogonadism/Premature
• Other disorders strongly associa
• Low body weight (<60kg) or major loss (>10% of Menopause
Musculoskeletal
• Vertebral
fracture when
25) with
rapid
bone
loss
and/or
frac
• Osteopenia
on
X
ray • Malabsorption
Syndrome
• Smoking/ETOH • Primary
Hyperparathyroidism
• Low
body
weight
(<60kg)
or
major
loss
(>10%
of
• Other
disorders
strongly
associated
when
25) with
rapid
bone
loss
and/or
fracture
259 2010
Clinical
Practice
Guidelines
for
the
Diagnosis
and
Management
of
Osteoporosis
in
Canada
Tumour
TUMOUR
Tumour
Metastatic-‐
Primary
Most
common
tumour
in
adults
• Breast
• Prostate
• Thyroid
• Lung
• Renal
Malignant
Benign Aggressive,
Non-‐Malignant
Musculoskeletal
66%
of
adult
tumours
•Osteochondroma •Giant
Cell
Tumour •Multiple
Myeloma-‐ most
common
•Osteoid
osteoma •Enchondroma •Osteosarcoma
•Chondroblastoma •Aneurysmal
Bone
Cyst •Chondrosarcoma
•Friboxanthoma •Ewing’s
Sarcoma
•Fibrous
Dysplasia •Fibrosarcoma
•Non-‐ossifying
fibroma •Liposarcoma
•Chondromyxoid
Fibroma •Rhabdomyosarcoma
•Periosteal
Chondroma •Leiomyosarcoma
•Malignant
Fibrous
Histiocytoma
260
Mytomes
MYOTOMES:
Segmental
Innervation
of
Muscles
Segmental Innervation of Muscles
MYOTOMES:
Segmental
Innervation
of
Muscles
Muscle Group Action Myotome Peripheral Nerve
Muscle Group Action Myotome Peripheral Nerve
Shoulder Abduction C5 Axillary Nerve
Shoulder Adduction AbductionC6-‐C8 C5 Thoracodorsal Nerve Axillary Nerve
Elbow Flexion AdductionC5 C6-‐C8 Musculocutaneous Nerve
Thoracodorsal Nerve
Elbow Extension Flexion C7 C5 Radial N erve Musculocutaneous N
Wrist Extension Extension C6 C7 Radial Nerve Radial Nerve
Fingers Wrist Flexion Extension C8 C6 Median Nerve Radial Nerve
Fingers Abduction Flexion T1 C8 Ulnar Nerve Median Nerve
Hip Flexion AbductionL2 T1 Nerve to Psoas Ulnar Nerve
Hip Extension Flexion S1 L2 Inferior Gluteal NNerve
erve to Psoas
Abduction Extension L5 S1 Superior G luteal N erve Gluteal Nerve
Inferior
Knee Flexion AbductionL5 L5 Tibial Nerve Superior Gluteal Nerv
Knee Extension Flexion L3 L5 Femoral Nerve Tibial Nerve
Musculoskeletal
Ankle Dorsiflexion Extension L4 L3 Deep Peroneal Nerve Femoral Nerve
Ankle Plantarflexion S1
Dorsiflexion L4 Tibial Nerve Deep Peroneal Nerve
Plantarflexion S1 Tibial Nerve
N.B. There is considerable overlap between myotomes for some actions. The myotomes listed are the dominant segments involved.
261 N.B.
There
is
considerable
overlap
between
myotomes
for
some
actions.
The
myotomes
listed
are
the
dominant
segments
involved.
Guide to Spinal Cord Injury
GUIDE
TO
SPINAL
CORD
INJURY
Spinal
RRoot
Spinal
oot Sensory
Sensory Motor
Motor Reflex
Reflex
C4
C4 Acromioclavicular
JJoint
Acromioclavicular
oint Respiration
Respiration None
None
C5
C5 Radial
AAntecubital
Radial
ntecubital
FFossa ossa Elbow
FFlexion
Elbow
lexion Biceps
RReflex
Biceps
eflex
C6
C6 Dorsal
TThumb
Dorsal
humb Wrist
EExtension
Wrist
xtension Brachioradialis
RReflex
Brachioradialis
eflex
C7
C7 Dorsal
M
Dorsal
Middle
iddle
FFinger
inger Elbow
EExtension
Elbow
xtension Triceps
RReflex
Triceps
eflex
C8
C8 Dorsal
LLittle
Dorsal
ittle
FFinger
inger Finger
FFlexion
Finger
lexion None
None
T1
T1 Ulnar
AAntecubital
Ulnar
ntecubital
FFossa ossa Finger
AAbduction
Finger
bduction None
None
T7-‐12
T7-‐12 See
DDermatomes
See
ermatomes Abdominal
M
Abdominal
Muscles
uscles Abdominal
RReflex
Abdominal
eflex
L2
L2 Anterior
M
Anterior
Medial
edial
TThigh
high Hip
FFlexion
Hip
lexion Cremasteric
RReflex
Cremasteric
eflex
L3
L3 Medial
FFemoral
Medial
emoral
CCondyle
ondyle Knee
EExtension
Knee
xtension None
None
L4
L4 Medial
M
Medial
Malleolus
alleolus Ankle
DDorsiflexion
Ankle
orsiflexion Knee
JJerk
Knee
erk
RReflex
eflex
L5
L5 First
W
First
Web
eb
SSpace
pace
((11stst/2
/2nd
nd MTP)
MTP) Big
TToe
Big
oe
EExtension
xtension Hamstring
RReflex
Hamstring
eflex
S1
S1 Lateral
CCalcaneus
Lateral
alcaneus Ankle
PPlantarflexion
Ankle
lantarflexion Ankle
JJerk
Ankle
erk
RReflex
eflex
Musculoskeletal
S2
S2 Popliteal
FFossa
Popliteal
ossa Anal
SSphincter
Anal
phincter Bulbocavernosus
Bulbocavernosus
S3/S4
S3/S4 Perianal
RRegion
Perianal
egion Anal
SSphincter
Anal
phincter None
None
N.B.
TThere
N.B.
here
iis
s
cconsiderable
onsiderable
vvariability
ariability
iin
n
sspinal
pinal
ccord
ord
llevels
evels
ffor
or
mmotor
otor
aand
nd
rreflex
eflex
ttesting.
esting.
AAlways
lways
ttest
est
tthe
he
llevel
evel
aabove
bove
aand
nd
bbelow
elowthe
the
ssuspected
uspected
iinjury
njury 262
Psychiatric
Anxiety Disorders Associated with Panic���� 265
Anxiety Disorders Recurrent Anxious
Thoughts ���������������������������������������������������������������������266
Trauma & Stressor Related Disorders����������� 267
Obsessive-Compulsive & Related Disorders
����������������������������������������������������������������������������������������������268
Personality Disorder����������������������������������������������������269
Mood Disorders Depressed Mood������������������ 270
Mood Disorders Elevated Mood������������������������ 271
Psychotic Disorders ����������������������������������������������������272
Somatoform Disorders�����������������������������������������������273
Psychiatric
263
Historical Editors Student Editors
Dr. Jason Taggart Lundy Day (Co-editor)
Dr. Lauren Zanussi Michael Martyna (Co-editor)
Dr. Lara Nixon Emily Donaldson
Haley Abrams
Daniel Bai Faculty Editor
Kaitlin Chivers-Wilson Dr. Aaron Mackie
Carmen Fong
Leanne Foust
Aravind Ganesh
Leena Desai
Psychiatric
Qasim Hirani
264
Anxiety Disorders
Associated with Panic
Psychiatric
265
Anxiety Disorders
Recurrent Anxious Thoughts
Psychiatric
266
Trauma & Stressor
Related Disorders
Psychiatric
267
Obsessive-Compulsive & Related Disorders
Psychiatric
268
Personality DisorderDISORDER
PERSONALITY
PERSONALITY
DISORDER
PERSONALITY
DISORDER Personality
Personality
Disorder
Disorder
Personality
Disorder
• Enduring
• Enduring
pattern
pattern
of
experience
of
experience
and
baehaviour
nd
behaviour
that
d
that
eviates
deviates
from
fcrom
ultural
cultural
expectations,
expectations,
manifest
manifest
in
two
in
otwo
r
more
or
m
the
following
the
following
areas:
areas:
cognition,
cognition,
affectivity,
affectivity,
interpersonal
interpersonal
functioning,
functioning,
and
iampulse
nd
impulse
control control
• Enduring
pattern
of
experience
and
behaviour
that
deviates
from
cultural
expectations,
manifest
in
two
or
more
of
• The
•pThe
attern
is inflexible
pattern
is inflexible
and
paervasive
nd
pervasive
across
across
many
msany
ocial
the
following
areas:
cognition,
affectivity,
interpersonal
functioning,
and
impulse
control
social
and
paersonal
nd
personal
situations
situations
• aThe
• The
pattern
is inflexible
nd
•ppThe
attern
pattern
ervasive
laeads
leads
tm
cross
distress
o
any
to
distress
oar
social
impairment
nd
poersonal
r
impairment
in
important
situations in
important
areas
ao
reas
f
functioning
of
functioning
• The
•opThe
• The
pattern
leads
to
distress
r
attern
is
stable
pattern
impairment
n
simportant
iis
table
and
oaf
nd
long
of
ldong
areas
ouration,
duration,
with
w
f
functioning an
ith
onset
an
onset
that
cthat
an
bce
an
traced
be
traced
back
bto
ack
childhood
to
childhood
or
adolescence
or
adolescence
• The
pattern
is
stable
and
of
•
• The
long
duration,
pThe
attern
wis
is
not
pattern
ith
due
an
tdue
not oo
nset
that
another
to
can
another
be
m
mental
traced
back
ental
illness,
ato
gceneral
illness,
hildhood
moedical
r
am
a
general
dolescence
edical
condition,
condition,
or
substance
or
substance
use use
• The
pattern
is
not due
to
another
mental
illness,
a
general
medical
condition,
or
substance
use
Cluster
Cluster
B:
DB
ramatic,
:
Dramatic,
Emotional,
Emotional,
or
or
Cluster
Cluster
Cluster
A:
Odd
or
Eccentric A:
OAdd
:
OoCluster
dd
r
Eccentric
or
EBccentric
:
Dramatic,
Emotional,
or
Cluster
C:
Anxious
or
Fearful Cluster
Cluster
C:
Anxious
C:
Anxiou
o
Social Social
Social
Paranoid
• Paranoid
• Paranoid -‐ irrational
s•uspicion
or
-‐ irrational
-‐ irrational
s•uspicion
suspicion
Antisocial or
• Antisocial
or
for
social
-‐ disregard
• Antisocial
norms,
-‐ disregard
•-‐Avoidant
disregard
for
-‐ssocial
ocial
for
social
innhibition,
orms,
norms,
• Avoidant
• Avoidant
-‐ social
-‐ social
inhibition
inhib
mistrust mistrust
mistrust the
law,
and
rights
of
others the
law,
the
alaw,
nd
raights
nd
inadequacy,
rights
of
others
of
ohthers
ypersensitivity inadequacy,
inadequacy,
hypersensitivity
hypersensit
• Schizoid -‐ emotional
d•etachment,
Schizoid -‐lack
• Schizoidemotional
Borderline
•detachment,
-‐ emotional
-‐ instability
lack
lack
of
identity,
detachment,
• Borderline
• Borderline • Dependent
-‐ instability
-‐ instability
-‐ o
psychological
f
identity,
dependence
of
identity,
• Dependent
• Dependent-‐ psychological
-‐ psycholo
Psychiatric
of interest in social relationships relationships, and behaviour relationships, on baoehaviour
relationships,
and thers)
nd behaviour on others)
on others)
of interest
of interest
in social
in social
relationships
relationships
• Schizotypal -‐ Odd beliefs • Histrionic -‐ attention-‐seeking, • Obsessive-‐Compulsive -‐ rigid, inflexible
• Schizotypal
• Schizotypal
-‐ Odd
-‐ b Odd
eliefs • Histrionic
beliefs emotional expression
exaggerated • Histrionic
-‐ attention-‐
-‐ attention-‐
seeking,
conformity ules, order, and codes)• Obsessive-‐
to sreeking, • Obsessive-‐
Compulsive
Compulsiv -‐ rig
exaggerated
exaggerated
emotional
emotional
expression
expression conformity
conformity
to rules,
to rules,
order,
ord an
• Narcissistic -‐ grandiosity, need for
admiration, lack of empathy • Narcissistic
• Narcissistic
-‐ grandiosity,
-‐ grandiosity,
need nfeed
or for
admiration,
admiration,
lack olack
f empathy
of empathy
1. Black, D.W., and N.C. Andreasen (2011). Introductory Textbook of Psychiatry, 5th Ed. Washington: American Psychiatric Publishing, Inc. pp. 285-‐317
269 1. 1. Black, DBlack,
.W., aDnd
.W.,
N.C.
and
Andreasen
N.C. Andreasen
(2011). (I2011).
ntroductory
Introductory
Textbook
Textbook
of Psychiatry,
of Psychiatry,
5th Ed. 5W
th
ashington:
Ed. Washington:
American
American
Psychiatric
Psychiatric
Publishing,
Publishing,
Inc. pp. Inc.
285-‐317
pp. 285-‐317
Mood Disorders
Depressed Mood
Psychiatric
270
Mood Disorders
Elevated Mood
Psychiatric
271
Psychotic Disorders
Medical
Conditions:
PSYCHOTIC
DISORDERS Para/Neoplastic
Parkinson's
Infectious
Brain
tumour
AIDS,
syphilis
Cushing's
Stroke
Epilepsy
MS,
SLE
Medical
Conditions:
Degenerative Endocrine Vascular
Para/Neoplastic
Parkinson's
Brain
tumour
AIDS,
syphilis
Stroke
Epilepsy Psychotic
Disorder Drugs
of
Abuse:
Infectious Cushing's MS,
SLE Cocaine Alcohol
(rare)
Degenerative Endocrine Vascular Cannabis
Drugs of Abuse: Psychosis Amphetamines
Hallucinogens
Opiates (rare) PCP
Cocaine Alcohol
(rare) Rule
out
psychotic
disorder
due
to
substances
and/or
Cannabis
Medications:
Amphetamines Opiates
(rare) PCP general
medical
condition Amphetamines Methylphenidate Steroids
Hallucinogens
es
and/or
Dopamine
Agonist Anticholinergic L-‐Dopa
Medications:
Amphetamines Methylphenidate Steroids
Dopamine
Agonist Anticholinergic L-‐Dopa
Prominent
mood
syndrome
(major
Mood
syndromes
absent
(or
brief
depression,
mania)
present
for
relative
to
duration
of
psychotic
ood
syndromes
absent
(or
brief
significant
portion
of
illness symptoms
lative
to
duration
of
psychotic
symptoms
Psychotic
symptoms
Psychotic
symptoms
also
Psychotic
symptoms
Psychotic
symptoms
present
exclusively
during
present
outside
of
mood
not
limited
to
limited
to
non-‐bizarre
ymptoms
Psychotic
symptoms
major
mood
syndrome episodes delusions delusions
only
ted
to
limited
to
non-‐bizarre
ons delusions
only • Mood
disorder
with
• Schizoaffective
disorder
psychotic
features (bipolar
&
depressive)
Non-‐bizarre delusions Delusions developed in
context of close
Delusions developed in Duration of Duration of illness Duration of illness ≥ 1 month, no decline
Non-‐bizarre delusions relationship with a person
context of close illness ≤ 1 month 1-‐6 months ≥ 6 months in functioning, with already established
≥ 1 month, no decline
in functioning,
relationship with a person behaviour is not odd similar delusion
with already established
behaviour is not odd • Brief psychotic • Schizophreniform • Schizophrenia • Delusional disorder • Shared psychotic
Psychiatric
similar
delusion
disorder disorder disorder
(Folie
a
Deux)
• Delusional
disorder • Shared
psychotic
disorder
(Folie
a
Deux) 2
or
more
(1
must
be
1-‐3): Criteria:
see
schizophreniform
1
or
more: 1)
Delusions disorder
1)
Delusions 2)
Hallucinations Suicide =
10%
2)
Hallucinations 3)
Disorganized
speech Neuroleptic
Malignant
Syndrome:
3)
Disorganized
speech 4)
Grossly
disorganized
or
Side
effects
of
anti-‐psychotics
4)
Grossly
disorganized
or
catatonic
behaviour Sx:
Hyperpyrexia
(>38.5°C),
muscle
catatonic
behaviour 5)
Negative
sx
(affective
rigidity
and
mental
status
changes
flattening,
alogia,
20%
mortality
avolition)
272
Somatoform Disorders
SOMATOFORM
DISORDERS
Somatoform
Disorder
Patient presents with complex medical problem
or symptoms that cannot be explained medically
Symptoms Consciously Symptoms Not
Produced Consciously Produced
Motivation is Focus is the sick Focus is
primary gain (to Motivation is role; not Focus is a physical appearance;
assume the sick secondary gain accepting symptom exhibit significant
role) reassurance distress
• Factitious Disorder • Malingering • Illness Anxiety • Body Dysmorphic
Disorder Disorder
Psychiatric
Pain;
psychological Multiple
symptoms;
long
One
or
more
symptoms
for
Neurologic
factors
important history at
least
six
months
• Pain Disorder • Somatization Disorder • Conversion Disorder • Undifferentiated
Criteria Must have symptoms Somatoform Disorder
-‐4 pain sx affecting movement
-‐ 2 GI sx or sensation (non-‐
-‐ 1 sexual sx anatomic and
273 -‐ 1 pseudo-‐neuro sx unexplainable)
Otolaryngologic
Hearing Loss Conductive����������������������������������������277
Hearing Loss Sensorineural���������������������������������� 278
Hoarseness Acute�������������������������������������������������������� 279
Hoarseness Non-Acute��������������������������������������������280
Neck Mass���������������������������������������������������������������������������281
Otaligia���������������������������������������������������������������������������������� 282
Smell Dysfunction�������������������������������������������������������� 283
Tinnitus Objective��������������������������������������������������������� 284
Tinnitus Subjective������������������������������������������������������ 285
Otolaryngologic
275
Historical Editors Student Editors
Justin Lui Dilip V. Koshy
Andrew Jun Wesley Chan
Dave Campbell
Joanna Debosz Faculty Editors
Sarah Hajjar Dr. Doug Bosch
Dr. James Brookes
Dr. Justin Chau
Otolaryngologic
276
Hearing Loss
Conductive
Otolaryngologic
277
Hearing Loss
Sensorineural
Otolaryngologic
278
Hoarseness
Acute
HOARSENESS:
Acute
Hoarseness
If Hoarseness persists > 3 months, Refer to ENT
Acute
Non-‐Acute
<
3
weeks >
3
weeks
Constant Variable
Infectious Inflammatory Trauma Inflammatory Hyperfunction
Otolaryngologic
• Viral Laryngitis • Acute • Voice Overuse • Muscle Tension
• External
• Fungal Laryngitis Nonspecific Dysphonia
Laryngeal Trauma
(Monilia) Laryngitis • Iatrogenic
• Bacterial (GERD, -‐ Endoscopy
Laryngitis Smoking, -‐ Endotracheal
• Bacterial Allergies, intubation
Tracheitis Vocal Abuse)
• Inhaled
279 Steroids
Hoarseness
Non-Acute
HOARSENESS:
Non-‐Acute
Hoarseness
If Hoarseness persists > 3 months, Refer to ENT
Acute
Non-‐Acute
<
3
weeks >
3
weeks
Constant Variable
• Functional
Otolaryngologic
Benign
Mucosal
Infectious Inflammatory Trauma Neoplastic Neurological
Changes
• Bacterial • Chronic • External • Nodules • Malignancy: • Vocal Cord
Infection Laryngitis • Internal (Surgery, • Polyps Squamous Cell Paralysis
• Fungal • GERD Intubation) • Granuloma Cysts Carcinoma • Spasmodic
Infection • Smoking • Reinke’s Edema • Benign: Dysphonia
(Monilia) Papilloma (HPV 6 • Tremor
& 11)
• Dysplasia:
Leukoplakia 280
Neck Mass
NECK
MASS
Neck
Mass
Inflammatory Congenital Neoplasms
• Thyroglossal Duct Cyst
• Branchial Cleft Anomalies
• Dermoid Cyst
• Teratoma
• Lymphatic Malformation
• Hemangioma
Lymphadenitis Sialadenitis Primary Metastatic
Otolaryngologic
• Bacterial • Parotid Salivary Gland • Lymphoma • Squamous Cell
• Viral • Submandibular Salivary • Thyroid Neoplasm Carcinoma
• Granulomatous Disease Gland • Neoplasm of Salivary • Thyroid (Spread to
• Tuberculosis Glands Cervical Lymph Nodes)
• Atypical • Neurogenic Neoplasm • Melanoma
Mycobacterium • Schwannoma • Distant site (Stomach,
• Actinomycosis • Neuroblastoma etc.)
• Cat-‐Scratch • Ganglioneuroma
Disease • Paragangliomas
• Carotid Body
281 Tumors
Otaligia
OTALGIA
Otalgia
Otologic Referred Periauricular
• Via Vagus or Glossopharyngeal Nerves • TMJ Pathology
• Nasopharyngeal, Oropharyngeal, • Parotiditis
Laryngeal, Hypopharyngeal Pain
• Thyroiditis
• Aerodigestive Tract Malignancy
• Post-‐tonsillectomy
Increased Pain With Pain Unchanged With
Pinna Manipulation Pinna Manipulation
Otolaryngologic
Abnormal
Tympanic
Ulceration/
Abnormal
External
Auditory
Canal Mastoid Auricle
Membrane Tissue
Growth
• Otitis
Externa • Mastoiditis • Cellulitis/Perichondri • Acute
Otitis
Media • Squamous
Cell
• Osteomyelitis
of
tis • Barotrauma Carcinoma
Temporal
Bone
• Trauma
(Frostbite,
• Traumatic
Perforation • Sarcoma
Herpes
Simplex
Auricular
• Cholesteatoma
(Typically
Zoster
(Ramsay
Hung
Hematoma) Otorrhea)
Syndrome
if
Facial
• Autoimmune
Nerve
Paralysis) (Relapsing
• Furunculosis Polychondritis) 282
Smell Dysfunction
SMELL
DYSFUNCTION
Smell Dysfunction
ENT History, Physical Exam, Anterior Rhinoscopy
Sensory Testing, CT/MRI to Rule Out Neoplasms, Fractures
& Congenital abnormalities
Nasal Obstruction/ Endocrine/ Toxins and other
Trauma Neoplastic
URTI Metabolic Factors
• Septal Deviation • Foreign Body • Alcoholism • Nasal Polyps • Smoking
• Allergic Rhinitis • Nasal Surgery • Diabetes Mellitus • Juvenile • Drugs
Otolaryngologic
• Bacterial/ Viral • Base of Skull Fracture • Adrenal Nasopharyngeal • Radiation
Infection (Influenza) • Nasal Fracture Hypofunction Angiofibroma • Toxin Exposure
• Adrenal
Hyperfunction
• Vitamin B12
Deficiency
• Zinc Deficiency
• Malnutrition
283
Tinnitus
Objective
TINNITUS:
Objective
Tinnitus
Subjective Objective
(90%) Pulsatile
or
Rhythmic
(10%)
Vascular Muscular
Potentially
Auscultated
• Myoclonus
of
Stapedius/Tensor
Tympani/Palatal
Muscles
Arterial Venous • Degenerative
Disease
of
the
Head
and
Neck
Otolaryngologic
• Atherosclerosis • AV
Shunt • Eustachian
Tube
• Idiopathic
Intracranial
• High
Jugular
Bulb Dysfunction
Hypertension • Glomus
Jugulare
• Acute
Exacerbation
of
• Hyperthyroidism
Systemic
Hypertension
• Developmental
Anomaly
• Blood
flow
in
normal
artery
near
ear
• Persistent
Stapedial
Artery
• Glomus
Tympanicum
284
Tinnitus
Subjective
TINNITUS:
Subjective
Tinnitus
Subjective Objective
Heard
only
by
patient
(Common) Heard
by
others
(Rare)
Unilateral Bilateral
On
Audiogram
On
Audiogram
Perform
MRI
to
rule
out
RC
Lesion
• Acoustic
Neuroma
• Lesion
of
Cochlear
or
Auditory
Nerve
No
Hearing
Loss Hearing
Loss Somatic
• Brainstem
Lesion
• Multiple
Sclerosis
• Infarction • Metabolic
Causes:
• TMJ
Otolaryngologic
• Ménière's Disease Thyroid Dysfunction, • Bruxism
Vitamin A, B, Zinc • Whiplash
Deficiency. Conductive Sensorineural • Skull Fracture
• Psychogenic, Anxiety, Hearing Loss Hearing Loss • Closed Head Injury
Depression
• Drugs (Salicyclates, • Lesion of External • Noise Induced
Quinidine, or Middle Ear • Ototoxicity
Indomethacin) • Impacted • Presbycusis
• Idiopathic Cerumen • Drugs (Propranolol,
• Otitis Media Levodopa, Loop
• Otosclerosis Diuretics)
285 • Congenital
Ophthalmologic
Cross Section of the Eye & Acronyms�����������289
Approach to an Eye Exam��������������������������������������290
Acute Vision Loss Bilateral��������������������������������������291
Acute Vision Loss Unilateral��������������������������������� 292
Chronic Vision Loss Anatomic����������������������������� 293
Amblyopia�������������������������������������������������������������������������� 294
Diplopia�������������������������������������������������������������������������������� 295
Pupillary Abnormalities Isocoria������������������������296
Pupillary Abnormalities Anisocoria������������������ 297
Red Eye Atraumatic�����������������������������������������������������298
Ophthalmologic
Red Eye Traumatic�������������������������������������������������������299
Strabismus Ocular Misalignment���������������������300
Neuro-Ophthalmology Visual Field Defects
�����������������������������������������������������������������������������������������������301
287
Historical Editors Student Editors
Dr. John Huang Prima Moinul
Dr. Ying Lu Jessica Ruzicki
Anastasia Aristakhova
Jagdeep Doulla Senior Editor
Kathleen Moncrieff Dr. Monique Munro
Micah Luong
Nazia Panjwani Faculty Editor
Stephanie Yang Dr. Patrick Mitchell
Vikram Lekhi
Ophthalmologic
288
Cross Section of the Eye & Acronyms
Ophthalmology Acronyms
EOM Extra ocular movements
IOL Intraocular Lens
IOP Intraocular Pressure
OD Oculus Dexter (right eye)
OS Oculus Sinister (left eye)
OU Oculus Uterque (both eyes)
PERRLA Pupils Equal, Round, Reactive to
Light & Accommodation
RAPD Relative Afferent pupillary defect
Ophthalmologic
SLE Slit Lamp Exam
VA Visual Acuity
289
Approach to an Eye Exam
1 2 3 4 5
Obvious
Initial Slit Lamp
History Physical Fundoscopy
Assessment Exam
Trauma
A. Visual Acuity A. Lids / Lashes/ A. Retina
B. Pupils Lacrimal B. Optic Nerve/ Disc/
a. Light Reflex, B. Sclera/ Conjunctiva Cup: Disc Ratio
Accommodation, C. Cornea C. Macula
RAPD D. Anterior Chamber D. Fovea
C. Ocular Movements E. Iris E. Blood Vessels
(CN 3, 4, 6) F. Lens
Ophthalmologic
D. Visual Fields by G. Vitreous Humor
Confrontation
290
Acute Vision Loss
Bilateral
ACUTE VISION LOSS: Bilateral Clinical Pearl:
• Patients with bilateral acute
vision loss should have a CT.
Vision
Loss
ACUTE VISION LOSS: Bilateral Clinical Pearl:
• Patients with bilateral acute
vision loss should have a CT.
Vision Loss
Acute Chronic
Acute Chronic
Unilateral Bilateral
Ophthalmologic
Unilateral Bilateral
Complete/
Partial
Homonymous
Other
Hemianopia
• Infarct
• Migraine
• Intracranial
Hemorrhage • Systemic
Hypoperfusion
Complete/
Partial
Homonymous
291 • Tumor
Other
Hemianopia
Acute Vision Loss
ACUTE VISION LOSS: Unilateral Clinical Pearls:
Unilateral
• Optic neuritis causes pain with EOM
• Temporal arteritis causes temporalis
pain and pain with mastication
• Acute angle closure glaucoma
causes high intraocular pressure,
unilateral eye pain, mid-dilated pupil
Acute
Vision
Loss
and n/v
• Retinal detachment can present as a
veil over the vision and with flashes
and floaters.
• TIA, vein or artery occlusion requires
Unilateral Bilateral
stroke work-up
Painful Painless
Transient
Optic
Nerve
Cornea
Retina Vitreous
Ischemic
Attack
• Keratopathy
• Retinal
Detachment
• Retinal
Artery
Occlusion
• Retinal
Vein
Occlusion
• Ischemic
Optic
Neuropathy
No
Abnormalities
of
the
Abnormalities
of
the
Optic
Nerve
Optic
Nerve
Ophthalmologic
• Acute
Angle
Closure
• Temporal
Arteritis
Retina
Visible
Retina
Not
Visible
Glaucoma
(fixed
dilated
• Demyelination
Clinical Pearls: pupil) • MS
• Visual
Cortex
Infarction
• Retinal
Hemorrhage
• Optic neuritis causes pain with EOM • Idiopathic
• Temporal arteritis causes temporalis • Glaucoma
• Vitreous
Hemorrhage
pain and pain with mastication
• Acute angle closure glaucoma
causes high intraocular pressure,
unilateral eye pain, mid-dilated pupil
and n/v
• Retinal detachment can present as a
veil over the vision and with flashes
and floaters.
292
• TIA, vein or artery occlusion requires
stroke work-up
Chronic Vision Loss
Anatomic
CHRONIC VISION LOSS: Anatomic Clinical Pearls:
• Edema can cause halos
in the vision.
• Bilateral disc swelling
Chronic
Vision
Loss and any suspected mass
require imaging.
Perform slit-‐lamp exam to localize: Left →Right on Scheme
Retina Optic Nerve
Lens Macula Cotton wool spots, Optic Track
Cornea Pallor, Papilledema,
Obscure Red Reflex, Micro-‐aneurysms, Visual field defects,
Drusen or Edema Irregular Disc Large
Poor fundus Visibility Hemorrhage and decrease in color vision
Cup:Disc
Macular Edema
• Keratoconus • Cataract (Nuclear, • Age Related Macular • Diabetic • Glaucoma (Open-‐ • Optic Nerve
• Stromal Scaring Subcapsular, Cortical) Degeneration (Wet, Dry) Retinopathy Angle) Compression
• Neovascularization (Background, Pre-‐ • Pituitary Lesion
• Edema Proliferative, • Meningioma
Ophthalmologic
• Pterygium Proliferative) • Craniopharyngioma
• Retinitis
Pigmentosa
(Decreased night
vision, loss of
CHRONIC VISION LOSS: Anatomic peripheral vision)
• Systemic
Clinical Pearls:
• Edema can cause halos
inflammatory in the vision.
conditions • Bilateral disc swelling
293 Chronic Vision Loss and any suspected mass
require imaging.
Amblyopia
AMBLYOPIA Clinical Pearl:
• Congenital cataracts and
retinoblastoma’s cause leukocoria and
a decreased red reflex
AMBLYOPIA Clinical Pearl:
• Congenital cataracts and
Amblyopia retinoblastoma’s cause leukocoria and
a decreased red reflex
Amblyopia
Deprivational* Strabismic
Deprivational*
Refractive
Error Strabismic
Obstruction
of
Visual
Axis Refractive
Error Abnormal
Binocular
Interaction
Obstruction
of
Visual
Axis Abnormal
Binocular
Interaction
• Ptosis • Severe
Anisometripia
(Unequal
• Ptosis • Severe
Anisometripia
(Unequal
• Congenital
Cataracts
• Congenital
Cataracts
Refractive
Error)
Refractive
Error)
• •Congenital
Congenital
Corneal
Corneal
Opacities
Opacities • Hyperopia • Hyperopia
• •Hemangioma
Hemangioma • Astigmatism• Astigmatism
• •Retinal
Retinal
Disease/Damage
Disease/Damage
(undiagnosed
(undiagnosed
See
Strabismus
scheme
See
Strabismus
scheme
not
not
responsive
to
treatment)
responsive
to
treatment)
Ophthalmologic
Clinical Pearl:
• Congenital cataracts and
retinoblastoma’s cause leukocoria and
a decreased red reflex
*
Can
cause
permanent
visual
impairment
if
not
treated
urgently
in
infancy
294
Diplopia
DIPLOPIA
Diplopia
Clinical Pearls:
Monocular • Diplopia is almost always binocular. Binocular
• CN VI palsy is a red flag for intracranial masses.
• Look for ptosis with CN III palsy.
• Refractive
Error • Examine both eyes to determine which is affected.
• Cataract/Lens
Dislocation • Neurologic symptoms suggest a mass as the cause.
• Functional • Myasthenia Gravis is fatiguable.
• Corneal
Distortion/Scarring • Migraine is a diagnosis of exclusion.
• Vitreous
Abnormalities
Neuronal Extraocular Muscle
Neuromuscular Junction (Non-‐Comitant) Restriction/Entrapment
• Myasthenia Gravis • Orbital Inflammation
• Orbital Tumor
• Orbital Floor Fracture
Strictly Horizontal
(Cranial Nerve VI problem) Horizontal and/or Vertical
Ophthalmologic
Cannot Abduct
• Ischemia
• Diabetes
Mellitus
• Aneurysm Cranial
Nerve
IV
Cranial
Nerve
III Grave’s
• Tumor Eye
depressed,
abducted,
ptosis,
Eye
cannot
depress
when
looking
• Trauma large/unreactive
pupil medially Ophthalmopathy
• Ischemia • Ischemia • Hyperthyroidism
• Diabetes
Mellitus • Diabetes
Mellitus
• Aneurysm • Aneurysm
• Trauma • Trauma
295 • Subdural
Hemorrhage
Pupillary Abnormalities
Isocoria
PUPILLARY
ABNORMALITES:
Isocoria
Pupillary Abnormality
Equal (Isocoria) Unequal (Anisocoria)
Relative Afferent Pupil Defect Bilateral Impairment
• Optic
Neuritis
• Ischemic
Optic
Neuropathies Dilated
Pupils Constricted
Pupils
• Optic
Nerve
Tumor
(Mydriasis) (Miotic)
• Retinal
detachment
• Traumatic/Compressive
Optic • Syphilis
(light-‐near
dissociation)
Neuropathy • Pharmacologic
(e.g
Opioids,
Alcohol)
Ophthalmologic
Dorsal
Midbrain Neuromuscular
Junction
Pharmacologic
(Parinaud’s
Syndrome) Dysfunction
• Tumor • Botulism • Atropine
• Hemorrhage • LSD
• Hydrocephalus • Cocaine
• Amphetamines
296
Pupillary Abnormalities
Anisocoria
PUPILLARY
ABNORMALITIES:
Anisocoria Clinical Pearl:
• Pupils should be examined in both a light
and dark setting to determine whether the
Pupillary
Abnormality big pupil or the small pupil is abnormal.
Equal
Unequal
(Isocoria) (Anisocoria)
Physiological
Pathological Anisocoria
equal
in
light
and
dark,
10%cocaine:
pupils
dilate
symmetrically
• Simple
Anisocoria
(
<0.5mm)
Impaired
Dilation
Impaired
Constriction
Sympathetic
dysfunction/Horner’s
Parasympathetic
dysfunction
Fixed
Pupil Syndrome:
miosis,
anyhydrosis,
ptosis
Anisocoria
greater
in
light
Anisocoria
greater
in
dark
Large
pupil
abnormal
Small
pupil
abnormality
• Angle Closure Glaucoma (mid-‐fixed)
• Iritis/Synechiae (not complete fixation)
• Trauma (not complete fixation)
Ophthalmologic
Preganglionic
Neuromuscular
Postganglionic Preganglionic Postganglionic
Ptosis,
opthalmoplegia
Constriction
with
0.1%
Junction No
dilation
with
0.125%
Dilation
with
0.125%
Constriction
with
0.1%
No
constriction
with
0.1%
pilocarpine adrenaline adrenaline
pilocarpine pilocarpine
• Oculomotor
• Tonic
(Adie’s)
Pupil • Pharmacologic • Idiopathic • Cluster
Headache
Nerve/Fascicle (Ciliary
Ganglion • Factitious • Trauma • Carotid
Dissection
(Other
CN
III
Findings) Lesion) • Tumor
(Lung,
Breast, • Trauma
Thyroid) • Idiopathic
LLARY ABNORMALITIES: Anisocoria Clinical Pearl:
• Pupils should be examined in both a light
297 Pupillary Abnormality
and dark setting to determine whether the
big pupil or the small pupil is abnormal.
Red Eye
Atraumatic
RED EYE: Atraumatic Clinical Pearl:
• Orbital cellulitis can present with pain on
EOM and orbital signs of involvement
Red Eye
Traumatic Atraumatic
Lids/Orbit/ Lacrimal System Ocular Surface Intermediate Layers Intraocular
• Blepharitis • Subconjunctival • Episcleritis • Acute Angle Closure
• Stye/ Chalazion Hemorrhage • Scleritis Glaucoma
• Dacrocystitis • Conjunctivitis • Uveitis • Endophthalmitis
• Pre-‐septal cellulitis • Corneal Abrasion/ • Iritis
• Orbital Cellulitis Erosion
• Keratitis/Corneal
Ulcer
• HSV Keratitis
Ophthalmologic
Clinical Pearl:
• Orbital cellulitis can present with pain on
EOM and orbital signs of involvement
298
Red Eye
Traumatic
RED EYE: Traumatic Clinical Pearls:
• With chemical burns, it is important to
determine if the burn was caused by
acid or worse, alkali.
• With a globe-penetrating injury, call
Red
Eye ophthalmology, shield the eye, and
do not touch the eye.
Traumatic Atraumatic
Blunt Trauma Globe Penetrating Injury
Surface Injury Hyphema, diplopia, periorbital Hyphema, history of trauma/high Associated Injury
ecchymosis, subcutaneous velocity impact, reduced visual
emphysema of lid acuity
• Corneal Abrasion • Orbital Rim/Mid-‐facial • Lids: Swelling, Laceration
• Ultraviolet Keratitis Fracture • Conjunctiva: Subconjunctival
• Chemical (Acid, alkali) • Orbital Floor Fracture hemorrhage
• Orbital Apex Injury/ • Cornea: Abrasion
Ophthalmologic
Retrobulbar Fracture** • Iris: Laceration, iritis,
iridodialysis
** Urgent lateral canthotomy • Pupil: Traumatic mydriasis
• Lens: Cataract, dislocation
• Vitreous hemorrhage
Clinical Pearls:
• With chemical burns, it is important to
• Retina:
Tear,
hemorrhage,
choroidal
rupture
determine if the burn was caused by • Glaucoma
acid or worse, alkali. • Optic
Neuropathy
• With a globe-penetrating injury, call
Red
Eye ophthalmology, shield the eye, and
299 do not touch the eye.
Strabismus
Ocular Misalignment
STRABISMUS:
Ocular
Misalignment
Clinical Peal:
• Strabismus is most often seen
in pediatrics.
Strabismus
Rule Out Amblyopia
Phoria
Tropia
• Latent
deviation
• Manifest
deviation
• Symmetrical
corneal
light
reflex,
• Asymmetrical
light
reflex,
• Negative
cover
test
positive
• Positive
cover
test
cover/uncover
test
• Esophoria
(eye
moves
medial
à centre
when
uncovered)
• Exophoria
(eye
moves
lateral
à centre
Paretic Non-‐Paretic
when
uncovered) Non-‐comitant Comitant
Angle
of
misalignment
changes
with
direction
of
Angle
of
misalignment
unchanged
with
direction
of
Ophthalmologic
gaze gaze
• Accommodative
Esotropia
(onset
2-‐4yrs,
hyperopic)
Horizontal Horizontal
and/or
vertical • Congenital
Esotropia
(eso/exotropia) (Eso/exotropia,
hyper/hypotopia,
mixed) (contralateral
eye
deviates
medial
à straight
when
• CN
VI
problem • CN
III
Problem
(eye
is ipsilateral
covered)
(eye
cannot
abduct) depressed
and
abducted,
ptosis, • Exotropia
(contralateral
eye
large/unreactive
pupil) deviates
lateral
à straight
• CN
IV
Problem
(eye when
ipsilateral
covered)
Clinical Pearl:
Clinical Peal: cannot
depress
when
looking
• Orbital cellulitis can present with pain on
Strabismus is most often seen
EOM and orbital signs of involvement
in pediatrics.
medially)
300
Neuro-Ophthalmology
Neuro-Ophthalmology: Visual Field Defects
Visual Field Defects
Optic Nerve Lesion
(Monocular vision loss)
Optic Chiasm Lesion
(bitemporal hemianopia) !
• Pituitary/metastatic
tumor
• Craniopharyngioma
• Meningioma
!
Optic Tract Lesion • Optic nerve glioma
(Incongruous right • Aneurysm
homonymous hemianopia) • Infection
• MS
• Sarcoidosis
Ophthalmologic
Lateral Geniculate Nucleus Meyer’s Loop Lesion
Lesion (Incongruous superior
(Right homonymous homonymous quadrantanopia)
horizontal sectroanopia)
Right Parietal Lobe Lesion
(Inferior homonymous
hemianopia)
301
Pediatric
Developmental Delay������������������������������������������������ 307 Neonatal Jaundice��������������������������������������������������������319
School Difficulties���������������������������������������������������������308 Pediatric Diarrhea��������������������������������������������������������� 320
Small for Gestational Age���������������������������������������309 Constipation (Pediatric)��������������������������������������������� 321
Large for Gestational Age����������������������������������������310 Mouth Disorder (Pediatric)��������������������������������������322
Congenital Anomalies�������������������������������������������������311 Depressed / Lethargic Newborn����������������������323
Preterm Infant Complications������������������������������ 312 Cyanosis in the Newborn Non-Respiratory
Failure to Thrive Adequte Calorie ���������������������������������������������������������������������������������������������� 324
Consumption��������������������������������������������������������������313 Cyanosis in the Newborn Respiratory����������� 325
Failure to Thrive Inadequte Calorie Pediatric Dyspnea�������������������������������������������������������� 326
Consumption��������������������������������������������������������������314 Noisy Breathing Pediatric Wheezing��������������327
Hypotonic Infant (Floppy Newborn)����������������315 Noisy Breathing Pediatric Stridor���������������������� 328
Acute Abdominal Pain������������������������������������������������316 Pediatric Cough Acute���������������������������������������������� 329
Pediatric
Pediatric Vomiting Gastrointestinal Causes317 Pediatric Cough Chronic�����������������������������������������330
Pediatric Vomiting System Causes�������������������318 Respiratory Distress in the Newborn��������������331
303
Sudden Unexpected Death in Infancy��������� 332
Enuresis�������������������������������������������������������������������������������� 333
Acute Life Threatening Event������������������������������ 334
Pediatric Fractures������������������������������������������������������� 335
Salter Harris Physeal Injury Classification���336
Pediatric Seizure Unprovoked�����������������������������337
Pediatric Seizure Provoked����������������������������������� 338
Pediatric Seizure Spells������������������������������������������� 339
Pediatric Mood & Anxiety Disorder������������������340
Pediatric
304
Historical Editors Student Editors
Dr. Pamela Veale Debanjana Das Elbert Jeffrey Manalo
Dr. Susan Bannister Cody Flexhaug David Cook
Dr. Kelly Millar Carmen Fong
Dr. Mary Ann Thomas Carly Hagel Faculty Editor
Dr. Andrei Harabor Rebekah Jobling Dr. Marielena Dibartolo
Dr. Jean Mah Beata Komierowski
Dr. Henry Mandin Anuradha Surendra
Dr. Leanna McKenzie Shahbaz Syed
Dr. Ian Mitchell Gilbert Yuen
Dr. Katherine Smart
Dr. Sylvain Coderre
Pediatric
Jaskaran Singh
Christopher Skappak
305
306
Pediatric
Developmental Delay
DEVELOPMENTAL
DELAY
Developmental Delay
No Milestones Lost Milestones Lost
• Neurodegenerative
Disorder
Ensure
Normal
• Metabolic
Disorder
Vision
and
Hearing • Neoplastic
Disorder
Assess
Pattern
of
Delay
Global Developmental Language and Social
Isolated Domain Delay
Delay Impairment
• Syndromic • Autism Spectrum Disorder
• Genetic Disorder • Pervasive Developmental
• Teratogenic Disorder Disorder
Pediatric
Reduced (e.g. Fetal Alcohol • Landau-‐Kleffner Syndrome
Airway Obstruction
Respiratory Drive Spectrum Disorder) • Selective Mutism
• Mechanical (e.g. dental, cleft
• Cognitive Impairment • Cerebral Palsy palate)
(Mental Retardation, • Primary Muscle
Intellectual Handicap) Disorder
• Developmental
307 Language Disorder
School Difficulties
SCHOOL
DIFFICULTIES
School
Difficulties
History of Developmental Delay? See
Developmental Delay Scheme
Address Underlying Medical Disorders
and Vision or Hearing Impairments
Primarily Behaviour Academic and Primarily Academic
Difficulties Behavioural Difficulties Difficulties
• Check Criteria for
Attention Deficit
Hyperactive Disorder
• Consider other
Comorbidites
Social Skills Deficit and Isolated to Specific
Atypical Behaviour All Areas Impacted
Atypical Behaviour Academic Areas
• Consider Autism Spectrum • Learning Disability • Cognitive Impairment
Disorder (Mental Retardation,
Pediatric
Intellectual
Handicap)
Home Environment Psychiatric Illness Defiant Behaviour
• Neglect • Anxiety Disorder • Oppositional Defiant
• Abuse • Depressive Disorder Disorder/ Conduct Disorder
• Trauma 308
Small for Gestational Age
SMALL FOR GESTATIONAL AGE
Small for Gestational Age
Birth Weight < 10th Percentile
Intrauterine
Growth
Constitutionally
Small
Restriction
Maternal Fetal Placental Insufficiency
•Chronic Maternal Hypertension • Constitutionally Small • Placental/Cord Abnormalities
• Gestational Hypertension • Multiple Gestation • Chronic Abruption
•Autoimmune Disease • Intrauterine Infections • Placenta Previa
• Protein-‐calorie Malnutrition • Chromosomal Anomaly • Abnormal Cord Insertion
Pediatric
• Smoking/Alcohol • Genetic Syndromes
• Substance Abuse • Congenital Malformations
• Uterine Malformations
• Hemoglobinopathies (Sickle Cell)
• Renal Insufficiency
309 • Anti-‐phospholipid Antibodies
Large for Gestational Age
LARGE FOR GESTATIONAL AGE
Suspected LGA
Birth Weight > 90th Percentile
Rule
Out:
• Wrong
Dates,
Twins,
Polyhydramnios,
Fibroids
and
Pelvic
Mass
True LGA
Pediatric
Maternal
Factors Fetal
• Familial • Syndromes
• Diabetes
Mellitus
(Macrosomia) • Constitutionally
Large
• Maternal
Obesity
310
Congenital Anomalies
CONGENITAL
ANOMALIES
CONGENITAL
ANOMALIES
Congenital
Anomalies
Congenital Anomalies
Isolated Multiple
Isolated Multiple
Association
of
A
Malformation Deformation Disruption
(Syndrom
Association
Breakdown
oof
f
Anomalies
• Chromosomal
Malformation • Embryonic
development
Deformation • Abnormal
mechanical
forces
Disruption • Destruction/
failure
or
inadequacy
(often
distorting
otherwise
normal
(Syndromic)
previously
normal
tissue
(e.g.
• Single
Gene
multifactorial) structures
ischemia) • Teratogenic
• Embryonic
development
• Abnormal
mechanical
f(e.g.exoligohydramnios)
orces
• Destruction/
Breakdown
of
• Chromosomal • Association
(e.g.
V
failure
or
inadequacy
(often
distorting
otherwise
normal
previously
normal
tissue
(e.g.
• Single
Gene
multifactorial) structures
ischemia) • Teratogenic
(e.g.exoligohydramnios) • Association
(e.g.
VACTERL)
Pediatric
Things to Consider:
History – Prenatal: maternal health, exposures, screening, ultrasounds; delivery; neonatal
Family History – Three Generations: prior malformations, stillbirths, recurrent miscarriages, consanguinity
Things to Consider: Physical Exam – Variants, minor anomalies, major malformation
History – Prenatal: maternal hDiagnostic Procedures – Chromosomes, mdolecular/DNA, radiology, photography, metabolic
311 ealth, exposures,
Diagnostic
Family History – Three Generations: prior
screening,
Evaluations
malformations,
ultrasounds;
– Prognosis,
stillbirths,
elivery; neonatal
recurrence,
recurrent pm
renatal diagnosis,
iscarriages, surveillance, treatment
consanguinity
Physical Exam – Variants, minor anomalies, major malformation
Preterm Infant Complications
PRETERM INFANT COMPLICATIONS
Preterm
Infant
Complications
Respiratory Hemodynamics Gastrointestinal Neurologic Ophthalmology
• Transient Tachypnea • Persistent Ductus • Necrotizing • Intraventricular • Retinopathy of
of the Newborn (TTN) Arteriosis (PDA) Enterocolitis (NEC) Hemorrhage (IVH) Prematurity (ROP)
• Respiratory Distress • Neurodevelopmental
Syndrome (RDS) Impairments (NDI)
• Chronic Lung Disease
(CLD)
• Bronchopulmonary
Dysplasia (BPD)
Pediatric
• Apnea
of
Prematurity
(AOP)
312
Failure to Thrive
FAILURE
TO
THRIVE:
Adequte Calorie Adequate
Calorie
Consumption
Consumption
Failure to Thrive
Adequate Calorie Consumption Inadequate Calorie Consumption
Increased Losses Malabsorption Increased Demands Failure to Utilize
• Vomiting • Pancreatic Insufficiency • Congestive Heart Failure • Metabolic Disorders
• Gastroesophageal Reflux (Cystic Fibrosis) • Chronic Respiratory Failure • Syndromes
• Renal Tubular Acidosis • Celiac Disease
• Liver Disease
Pediatric
313
Failure to Thrive
FAILURE
TO
THRIVE:
Inadequate
Calorie
Consumption
Inadequte Calorie Consumption
Failure to Thrive
Adequate Calorie Consumption Inadequate Calorie Consumption
Organic Illness Protein-‐Energy Malnutrition Psychosocial Illness
• Chronic Renal Failure • Kwashiokor (inadequate protein intake) • Oral Aversion
• Esophagitis • Marasmus (inadequate protein and • Neglect
• Congenital Heart Defect energy intake) • Poverty
Pediatric
• Structural
Dystrophies • Disturbed
Parent-‐Child
Relationship
314
Hypotonic Infant
Hypotonic
(Floppy
Infant
Newborn)
(Floppy
Newborn)
Hypotonic
Infant
(Floppy
Newborn) Hypotonic
Infant
Hypotonic
Infant
Decreased
LOC,
Axial
Weakness,
Alert,
Responding
to
Surroundings,
Normal
Strength,
Normal
Reflexes
Profound
Peripheral
Weakness
Decreased LOC, Axial Weakness, Alert, Responding to Surroundings,
Normal Strength, Normal Reflexes Profound Peripheral Weakness Peripheral Nervous
Central Nervous System
System
Peripheral Nervous
Central Nervous System
System
Neuromuscular
Brain Spinal Cord Nerves Musc
Junction
• Hypoxic-‐Ischemic • Spinal Muscular Atrophy • Congenital
Neuromuscular • Congenital and Transient • Congenital
Brain Spinal Cord
Encephalopathy* • Trauma Nerves Hypomyelinating Myasthenia GMuscle
ravis Dystrophies
Junction
•Trisomy 21* • Hematoma Neuropathy • Infantile Botulism • Metabolic
• Hypoxic-‐Ischemic • Intracranial • Abscess • Congenital
• Spinal Muscular Atrophy • Infantile Neuroaxonal
• Congenital • Magnesium
and Transient Toxicity
• Congenital Myotonic • Central Co
Encephalopathy* Hemorrhage
• Trauma • Arteriovenous Fistula
Hypomyelinating Degeneration
Myasthenia Gravis • Aminoglycoside
Dystrophies Toxicity • Other Cong
•Trisomy 21* • CNS •Infection
Hematoma • Infantile Neuropathy
Neuronal • Infantile Botulism • Metabolic MyopathiesMyopathies
• Intracranial • Metabolic Diseases
• Abscess Degeneration • Infantile Neuroaxonal • Magnesium Toxicity • Central Core Disease
Pediatric
Hemorrhage • Prader-‐ Willi
• Arteriovenous Fistula • Poliomyelitis
Degeneration • Aminoglycoside Toxicity • Other Congenital
• CNS Infection • Intracranial Mass/lesion
• Infantile Neuronal Myopathies
• Metabolic Diseases • Other Congenital
Degeneration
• Prader-‐Willi Syndromes
• Poliomyelitis
• Intracranial Mass/lesion
• Other Congenital
315 Syndromes * Indicates most common causes of hypotonia
Acute Abdominal Pain
ACUTE ABDOMINAL PAIN
Acute Abdominal Pain
Focal Generalized/Migratory
• Intussusception
• Gastroenteritis
• Viral
Illness
• Diabetic
Ketoacidosis
• Bowel
Obstruction
• Henoch-‐Schonlein
Purpura
• Malrotation/Volvulus
• Urinary
Tract
Infection
• Peritonitis
• Somatization
• Sickle
Cell
Crisis
• Ileus
• Infantile
Colic
Right Upper Left Upper Right Lower Left Lower
Epigastric
Quadrant Quadrant Quadrant Quadrant
Pediatric
• Gastritis • Hepatitis • Viral
Illness
with
• Appendicitis • Ovarian
Cyst
• Peptic
Ulcer
Disease • Cholelithiasis Splenic
• Ovarian
Cyst • Ovarian
Torsion
• Pancreatitis • Cholecystitis Enlargement/Rupture • Ovarian
Torsion • Ectopic
Pregnancy
• Gastroesophageal
• Pyelonephritis • Pyelonephritis • Ectopic
Pregnancy • Pelvic
Inflammatory
Reflux
Disease • Right
Lower
Lobe
• Left
Lower
Lobe
• Pelvic
Inflammatory
Disease
Pneumonia Pneumonia Disease • Nephrolithiasis
• Nephrolithiasis
• Dysmenorrhea 316
Pediatric Vomiting
PEDIATRIC
VCauses
Gastrointestinal OMITING:
Gastrointestinal
causes
Vomiting
Gastrointestinal Disease Other Systemic Disease
Upper Gastrointestinal Hepatobiliary Lower Gastrointestinal
• Acute
Hepatitis
• Acute
Pancreatitis
Acute Chronic Acute Chronic
Pediatric
• Infectious Gastroenteritis • Gastroesophageal Reflux • Infectious Gastroenteritis • Intestinal Atresia
• Gastric/Duodenal Disease • Small/Large Bowel • Midgut malrotation
Obstruction • Peptic Ulcer Disease Obstruction
• Pyloric Stenosis • Gastroparesis • Intussusception
• Intussusception • Gastritis • Acute Appendicitis
• Gastric Volvulus • Incarcerated Hernia
317 • Necrotizing Enterocolitis
Pediatric Vomiting
PEDIATRIC VOMITING: Systemic causes System Causes
Vomiting
Gastrointestinal Disease Other Systemic Disease
Endocrine/Metabolic Other Drugs/Toxins Central Nervous System
• Pregnancy • Sepsis (e.g. Pyelonephritis, • Chemotherapy
• Diabetes/ DKA Pneumonia) • Antibiotics
• Uremia • Radiation Sickness • Carbon Monoxide
• Hypercalcemia • Poisoning
• Addison’s Disease • Food Allergy
• Thyroid Disease • Urinary Tract Infection
Vestibular
Pediatric
High
Intracranial
Pressure Psychiatric
(Inner
Ear)
• Hemorrhage • Ear
Infection
(Otitis
Media) • Self-‐Induced
(Bulimia)
• Meningitis • Motion
Sickness • Cyclic
Vomiting
• Head
Trauma • Vestibular
Migraine • Psychogenic
• Brain
Tumour • Ménière’s
Disease
• Hydrocephalus • Labrynthitis
318
Neonatal Jaundice
NEONATAL
JAUNDICE
Neonatal Jaundice
< 1 Week Old > 1 Week Old
Measure TSB and
Conjugated Bilirubin
Pre-‐Hepatic Hepatic Post-‐Hepatic
Measure TSB or TcB
Pathologic
Physiologic (Jaundice
before
24
hours
of
age,
rapid
elevation
of
serum
bilirubin
greater
that
80uM
and
peak
bilirubin
greater
than
350
uM)
Pediatric
Increased Production Decreased Metabolism Increased Re-‐Absorption
RBC Intrinsic RBC Extrinsic
319
Pediatric Diarrhea
PEDIATRIC DIARRHEA
Pediatric Diarrhea
Infectious Malabsorption Other
• Toddler’s Diarrhea
• Viral • Lactase Deficiency
• Constipation/Overflow Diarrhea
• Bacterial •Cystic Fibrosis
• Drugs
• Parasitic • Celiac Disease
• Laxative Abuse
• Primary Immuno-‐Deficiency
• Inflammatory Bowel Disease
• Dissacharidase Deficiency
• Overfeeding
• Short Bowel Syndrome
• Food Poisoning
• Irritable Bowel Syndrome
Pediatric
320
Constipation (Pediatric)
CONSTIPATION:
PEDIATRIC
Constipation
Infrequent Bowel Movements? Hard, Small
stools? Painful evacuation? Encopresis?
Neonate/Infant Older Child
Dietary/Functional Neurologic Dietary/Functional Anatomic Neurologic
• Insufficient Volume/ • Hirschsprung’s Disease • Bowel Obstruction • Hirschsprung’s Disease
• Insufficient Bulk/Fluid
Pediatric
Bulk • Imperforate Anus • Pseudo-‐obstruction • Spinal Cord Lesions
• Withholding
• Anal Atresia • Myotonia Congenita
• Painful (e.g. Fissures)
• Intestinal Stenosis • Guillain-‐Barré Syndrome
• Drugs (Narcotics,
• Intestinal Atresia • Muscular Dystrophy
Psychotropics)
• Cystic Fibrosis • Sexual Abuse
321
Mouth Disorder (Pediatric)
MOUTH
DISORDERS:
PEDIATRIC
Mouth Disorders
Teeth Mucous Membranes
• Teething
Painful Non-‐Painful
Gastrointestinal Other Non-‐Inflammatory Inflammation
• Crohn’s Disease • Gum Disease (e.g. Gingivitis) • Impetigo • Allergic Reaction
• Ulcerative Colitis • Hand, Foot and Mouth • Mucocele
• Candidiasis
Pediatric
Disease
(Coxsackie
Virus)
• Streptococcal
Throat
Infection
• Canker
Sore
• Herpes
Simplex
Virus
• Inflamed
Papillae
(e.g.
Burn)
322
Depressed / Lethargic Newborn
Depressed/Lethargic
Newborn
Depressed/Lethargic Newborn
Child Related Maternal Related
• Drugs (Ex. SSRI)
• Diabetes Mellitus
• Gestational Hypertension
Congenital Respiratory Other
Pediatric
• Birth Injury • Respiratory Distress Syndrome • Anemia
• Congenital Malformation • Birth Asphyxia • Shock
• TORCH Infection • Pneumothorax • Hypothermia
• Congenital Heart Defect • Meconium Aspiration • Hypoglycemia
• Sepsis
323
Cyanosis in the Newborn
Non-Respiratory
CYANOSIS IN THE NEWBORN: Non-‐Respiratory
Cyanosis
Central and Peripheral Peripheral Only
• Poor
Perfusion
• Acrocyanosis
Cardiovascular Hemoglobinopathy Respiratory
• Congenital
• Acquired
• Sulfhemoglobin
Left-‐to-‐Right Shunt Right-‐to-‐Left Shunt
Pediatric
• Patent
Ductus
Arteriosus • Transposition
of
the
Great
Arteries
• Ventricular
Septal
Defect • Tetralogy
of
Fallot
• Atrioventricular
Septal
Defect • Obstructive/Hypoplastic
Lesions
• Truncus
Arteriosus • Aortic
Atresia/Stenosis
• Atrial
Septal
Defect • Interruption
of
the
Aortic
Arch
• Total
Anomalous
Pulmonary
Venous
• Aortic
Coarctation
Return
324
Cyanosis in the Newborn
Respiratory
CYANOSIS
IN
THE
NEWBORN:
Respiratory
Cyanosis
Central and/or Peripheral Peripheral Only
• Poor
Perfusion
• Acrocyanosis
Cardiovascular Hemoglobinopathy Respiratory
Reduced
Respiratory
Airway
Obstruction Lung
Parenchyma Other
Drive
• CNS
Malformations • Atresia • Bronchopulmonary
Dyspnea • Persistent
Pulmonary
• Laryngomalacia
Pediatric
• Seizures • Pulmonary Edema Hypoplasia of the Newborn
• CNS Hemorrhage • Tracheomalacia • Pneumothorax •Transient Tachypnea of the
• CNS Infections • Extrinsic Compression • Malformation with Infection Newborn
• Asphyxia • Anatomic Compression • Aspiration • Diaphragmatic Hernia
• Metabolic Disease • Meconium Aspiration • Infection (RSV)
• Narcotics/Sedatives
325 • Sepsis
Pediatric Dyspnea
PEDIATRIC DYSPNEA
Pediatric Dyspnea
Normal
Breath
Stridor Wheeze Crackles Decreased
Air
Entry
Sounds
• Croup • Asthma • Pneumonia • Pneumonia • Pneumonia
• Foreign
Body • Bronchiolitis • Congestive
Heart
• Asthma • Foreign
Body
• Tracheitis • Foreign
Body Failure • Bronchiolitis • Heart
Disease
• Epiglottitis • Viral
Induced
Wheeze • Bronchiolitis • Foreign
Body • Diabetic
Ketoacidosis
• Laryngospasm • Foreign
Body • Pleural
Effusion • Pulmonary
Embolism
• Atelectasis
• Pneumothorax
Pediatric
326
NOISY
BREATHING:
Pediatric
Wheezing
Noisy Breathing
NOISY
BREATHING:
Pediatric
Wheezing
Pediatric Wheezing
Wheezing
in
a
Child
Wheezing in a Child
CXR Non Specific
• Pulm
CXR
Non
Specific
CXR
Abnormal
• Cong
• Bronc
• Pulmonary
Sequestration • Neur
• Congenital
Adenoid
Cystic
Malformation • Terat
• Bronchogenic
Cyst • Medi
• Neuroblastoma
• Teratoma
Relief
With Wheeze
Positive
Sweat
• Mediastinal
MassWith
R/O
Endobronch
Beta-‐Agonist Chloride
Feeding
Disease
Relief With Positive Sweat • Asthma*
Wheeze With • Cystic R/O
Fibrosis • Aspiration
Endobronchial • Vascular Compress
• Foreign Body Aspir
Beta-‐Agonist Chloride Feeding Disease • GE Reflux • Endobronchitis
• H-‐Type Esophageal
• Asthma* • Cystic Fibrosis • Aspiration • Vascular Compression Syndrome
Fistula • Structural Anomal
• GE Reflux • Foreign Body Aspiration*
Pediatric
• H-‐Type Esophageal • Endobronchitis
Fistula • Structural Anomaly
327 * Denotes acutely life-‐threatening causes
Pediatric Wheezing
Noisy Breathing
NOISY BREATHING: Pediatric Stridor Pediatric Stridor
Wheezing in a Child
Stridor in a Child
CXR Non Specific CXR Abnormal
Present Since Infancy • Pulmonary Sequestration Not Present Since Infancy
• Congenital Adenoid Cystic Malformation
• Bronchogenic Cyst
• Neuroblastoma
No Respiratory • Teratoma
Respiratory Distress
• Mediastinal Mass Non-‐Acute Onset Acute Onset
Distress
•Laryngomalacia • Laryngomalacia • Hemangioma
e Sweat Wheeze With R/O •• ELaryngeal
Hemangioma
Web
ndobronchial • Vocal Cord Dysfunction
• Subglottic Stenosis
ride Feeding Disease
• Vocal Cord Dysfunction • Laryngeal Papillomatosis
• Subglottic Stenosis
brosis • Aspiration • Vascular Compression Syndrome
• GE Reflux • Foreign Body Aspiration*
• H-‐Type Esophageal • Endobronchitis
Fistula • Structural Anomaly
Febrile Afebrile
Pediatric
• Peritonsillar/Retropharyn
geal
Abscess*
• Epiglottitis* Partially-‐Treated
Barking
Cough
• Mononucleosis Bacterial
Tracheitis
• Bacterial
Tracheitis*
• Croup
*
Denotes
acutely
life-‐threatening
causes • Atypical
Croup 328
NOISY
BREATHING:
Pediatric
Wheezing
Pediatric Cough
PEDIATRIC
Acute
COUGH:
Acute
Wheezing
in
a
Child
Acute Cough in Children
( < 3 wks )
CXR Non Specific
• Pulm
No
Fever,
No
Tachypnea Fever,
Tachypnea • Cong
• Bronc
• Neur
• Terat
URTI
No
URTI
CXR
Shows
• Medi
Normal
CXR CXR
Shows
Symptoms
Symptoms
Consolidation
Diffuse
Changes
• History
oRelief
r
With • Foreign
Positive
body
Sweat
• Bacterial
Wheeze
W•ith
Atypical
or
vR/O
iral
Endobronch
suspicion
of
aspiration* pneumonia pneumonia
Beta-‐ A gonist Chloride
Feeding
Disease
foreign
body? • Bronchitis/Bron
• Asthma*
chiolitis
• Cystic
Fibrosis • Aspiration • Vascular
Compress
Normal
Chest
Wheeze
and/or
• GE
Reflux • Foreign
Body
Aspir
Auscultation
Crackles
• H-‐Type
Esophageal
• Endobronchitis
Fistula • Structural
Anomal
• Post-‐nasal
drip • Asthma*
• Bronchiolitis/Bron
Pediatric
chitis
329 * Denotes acutely life-‐threatening causes
Pediatric Cough
PEDIATRIC COUGH: Chronic Chronic
Chronic Cough In Children
( > 3 wks )
Poor Growth Normal Growth
Sweat Chloride Test to R/O Exacerbated by
Cystic Fibrosis Abnormal CXR Normal CXR
Exertion/URTI
• Asthma • Chronic Sinusitis
• Post Nasal Drip
• GERD +/-‐ Aspiration
• Habit Cough
• Environmental Exposure
CT Scan
Abnormal CXR Non-‐Specific CXR
• Tumors
• Immunodeficiency • Congenital Anomaly
• Chronic Aspiration
Pediatric
• Environmental
Exposure
• Poorly
Controlled
Asthma
• Infection
CT
Scan
• Structural
Abnormality
• Tumor 330
NOISY
BREATHING:
Pediatric
Wheezing
Respiratory Distress in the Newborn
RESPIRATORY
DISTRESS
IN
THE
NEWBORN
Wheezing
in
a
Child
Respiratory
Distress
In
The
Newborn
CXR
Non
Specific
• Pulm
• Cong
• Bronc
Premature
Not
Premature
• Neur
• Terat
• Medi
Relief With Meconium
Positive Sweat Wheeze With R/O Endobronch
Normal CXR Beta-‐Agonist Aspiration Chloride Infectious Feeding Non-‐Infectious Disease
Abnormal CXR
• Apnea of Prematurity • Asthma*
• Respiratory Distress in Fibrosis • Sepsis* • Aspiration • Respiratory •DVascular
• Cystic
• Meconium istress Compress
• Sepsis* Syndrome (RDS)* Amniotic Fluid • GE Reflux
• Pneumonia Syndrome (•RDS)*
Foreign Body Aspir
• Intraventricular • Transient Tachypnea of • H-‐Type Esophageal • Endobronchitis
• Transient Tachypnea
Hemorrhage* the Newborn (TTNB) Fistula • Structural Anomal
of the Newborn
• Hypoglycemia* • Pneumonia (TTNB)
Pediatric
• Hypothermia* • Pneumothorax* • Pneumothorax*
• Narcosis • Congenital Abnormality • Congenital
Abnormality
331 * Denotes acutely life-‐threatening causes
UDDEN UNEXPECTED DEATH IN INFANCY (SUDI)
Sudden Unexpected Death in Infancy
SUDDEN UNEXPECTED DUEATH
Sudden IN IDNFANCY
nexpected eath (SUDI)
in Infancy
Sudden Unexpected Death
Must be Reported in
to Infancy
Medical Examiner
Must be Reported to
Medical Examiner
Congenital Sudden Infant Death
Infection Injury Other
Anomaly/ Disorder Syndrome (SIDS)
Cardiac Anomaly Congenital • Severe Pneumonia • Deliberate (abuse) • Acute Illness • Autopsy negative Sudden Infant Death
Infection Injury Other • 80% of SUDI
Anomaly/ D•isorder
Cardiac Arrhythmia Sepsis • Accidental* Syndrome (SIDS)
Neurologic Anomaly • Gastrointestinal • Risk Factors:
Pulmonary Anomaly• Cardiac Anomaly infection • Severe Pneumonia • Deliberate (abuse) • Acute Illness • Prone •Sleeping
Autopsy negative
• Cardiac Arrhythmia
Metabolic Disorders • Sepsis • Accidental* position• 80% of SUDI
• Neurologic Anomaly • Gastrointestinal • Risk Factors:
• Tobacco
• Pulmonary Anomaly infection exposure • Prone Sleeping
• Metabolic Disorders • Sharing a position
Pediatric
Sleeping
• Tobacco
Surface exposure
• Prematurity • Sharing
a
Sleeping
Surface
*
SUDI
with
negative
investigations
and
infant
found
in
prone
position
or
in
bed
with
parent
may
be
called
either
• Prematurity
SIDS
or
injury
(new
ideas
evolving) 332
Enuresis
ENURESIS
Enuresis
Rule in/out age-‐appropriate enuresis
Age Dry during day Dry during night
2 25% 10%
2.5 85% 48%
3 98% 78%
Nocturnal Enuresis Diurnal Enuresis
• Pediatric Unstable Bladder
• Infrequent Voiding (Urinary Tract Infection)
• Cystitis
Primary Secondary (Red Flag) • Behavioural/Psychogenic
(Urinary Control Never Achieved) (> 6 Month Continence Prior)
• Idiopathic
• Non-‐neurogenic (Hinman Syndrome)
• Delayed Maturation • Urinary Tract Infection
• Vaginal Voiding (Labial Adhesion)
(Familial) • Idiopathic
Pediatric
• Idiopathic • Behavioural/Psychogenic
• Sleep
Disorders
(Obstructive
(Child
Abuse)
Sleep
Apnea) • Cystitis
• Anatomic
Abnormality • Diabetes
Mellitus
• Other
(Diabetes
Insipidus,
Urethral
Obstruction,
Cerebral
Palsy,
Neurogenic
Bladder,
333 Seizure
Disorder)
Acute Life Threatening Event
APPARENT
LIFE
THREATENING
EVENT
Apparent
Life
Threatening
Event
Based on History from Parent
(Extent of investigations based
on initial examination)
Acute Illness Witnessed Choking Spell Injury Apnea
• Non-‐Accidental • Periodic Breathing
• Unnoticed • Apnea of Infancy
• Factitious by Proxy
Cardiac Metabolic Neurologic Respiratory Infectious Gastrointestinal
• Congenital • Inborn Errors of • Seizure • Anatomical • Pneumonia • Gastroesophageal
Pediatric
Heart
Disease Metabolism • Malignancy Foreign
Body
• Sepsis Reflux
• Arrhythmia • Reye’s
• Neuromuscular Aspiration • Upper
• Volvulus
• Cardiomyopathy Syndrome • Disorders • Breath-‐holding
Respiratory
Tract
• Gastroenteritis
• Myocarditis • Electrolyte
• Central
Apnea spell
(age-‐ Infection • Incarcerated
Disturbances dependent) • Empyema Hernia
• Urinary
Tract
Infection 334
Pediatric Fractures
PEDIATRIC
FRACTURES
Pediatric
Fractures
Non-‐Accidental Trauma (indication
Accidental Trauma
of child abuse)
Tibia Fibular Toddlers
Distal Radius Clavicle Fracture Elbow
Fracture Fracture
• Torus (junction of metaphysis) •Supra condylar • < 2 y.o.
• Green stick (bone bent at convex side •Lateral
•Complete (spiral, oblique, transverse) supracondylar
Femur # Scapular # Without Transverse Fractures
< 1 y.o. Traumatize Hx <3 y.o.
Pediatric
•Femur •Skull
•Humerus •Spine
•Tibia •Ulna
•Ribs •Fibula
•Radius
335
SALTER
HARRIS
PHYSEAL
INJURY
CLASSIFICATION
SYSTEM
Salter
SALTER
HARRIS
Harris
PHYSEAL
Physeal
INJURY
InjurySClassification
CLASSIFICATION
YSTEM
Type Population Features
I Type Younger Children
Population Separation through the physis Features S Straight through
I Younger Children Separation through the physis S Straight through
A Above
II Older Children (75%) Fracture through a portion of the physis that extends through the metaphyses
A Above
II Older Children (75%) Fracture through a portion of the physis that extends through the metaphyses L Lower
III Older
Children
(75%) Fracture
line
goes
below
the
physis
through
the
epiphysis,
and
into
the
joint L Lower
T Through
IVIII Older
Children
(75%) Fracture
Fracture
line
Line
goes
below
through
the
mthe
physis
through
etaphysis,
physis
atnd
he
eepiphysis
piphysis,
and
into
the
joint
T Through
Pediatric
R Crush
IV Fracture
Line
through
the
metaphysis,
physis
and
epiphysis
V Compression
fracture
of
the
growth
plate R Crush
V Compression fracture of the growth plate
http://www.jaaos.org/content/10/5/345/F1.large.jpg 336
http://www.jaaos.org/content/10/5/345/F1.large.jpg
Pediatric Seizure
Unprovoked
PEDIATRIC
SEIZURE:
Unprovoked
Seizure
Provoked
Unprovoked Spells
“DIMS”
Infantile Childhood
• Benign Focal Epilepsy of
Infancy
• West Syndrome
• Dravet Syndrome
Generalized Epilepsies Focal Epilepsies
Pediatric
• Childhood Absence Epilepsy • Rolandic Epilepsy
• Myoclonic Absence Epilepsy • Panayiotopoulas Syndrome
• Juvenile Absence Epilepsy • Landau-‐Kleffner Syndrome
• Juvenile Myoclonic Epilepsy
• Lennox Gastaut Syndrome
337
Pediatric Seizure
Provoked
PEDIATRIC SEIZURE: Provoked
Seizure
Provoked
Unprovoked Spells
“DIMS”
Drugs Infection Metabolic Structural
• Drug overdose • Febrile Seizures • Hypoglycemia • Head Injury
• Alcohol Withdrawal • Sepsis • Hyperglycemia • Stroke
• Poisoning • Meningitis • Hypocalcemia • Tumours
• Encephalitis • Hyponatremia • Congenital Abnormality
• Tuberous Sclerosis
• Sturge-‐Weber Syndrome
Pediatric
338
Pediatric Seizure
Spells
PEDIATRIC
SEIZURE:
Spells
Seizure
Provoked
Unprovoked Spells
“DIMS”
Childhood
and
Neonates
and
Infants Older
Infants
and
Toddlers
Adolescents
• Benign Sleep Myoclonus • Breath-‐holding spells • Daydreaming
• Shuddering attacks • Benign Paroxysmal Vertigo • Syncope
• Infantile Colic • Benign Paroxysmal • Migraine-‐variants
• Sandifer Syndrome Torticollis • Panic Attack
• Night Terrors • Transient Ischemic Attack
• Narcolepsy
Pediatric
• Cataplexy
339
Pediatric Mood & Anxiety Disorder
PEDIATRIC
MOOD
AND
ANXIETY
DISORDERS
PEDIATRIC
MOOD
AND
ANXIETY
DISORDERS
Mood or Anxiety Disorder
Mood or Anxiety Disorder
Mood Bipolar Anxiety
Mood Bipolar Anxiety
• Major Depressive Disorder • Panic Disorder and Agoraphobia
• Persistent
• Major Depressive
Depressive Disorder Disorder •D
• Panic Specific
isorder Pahobia
nd Agoraphobia
• Disruptive
• Persistent Mood
Depressive DD ysregulation
isorder • Social
• Specific Phobia
Phobia
Disorder*
• Disruptive Mood Dysregulation • Generalized
• Social Phobia Anxiety Disorder
Disorder* • Selective
• Generalized Mutism*
Anxiety Disorder
• Separation
• Selective Mutism*Anxiety Disorder*
• Separation Anxiety Disorder*
Pediatric
*More
commonly
or
exclusively
found
in
pediatric
populations
*More
commonly
or
exclusively
found
in
pediatric
populations 340
General Presentations
Fatigue����������������������������������������������������������������������������������� 343
Acute Fever����������������������������������������������������������������������� 344
Fever of Unknown Origin / Chronic Fever� 345
Hypothermia���������������������������������������������������������������������346
Sore Throat / Rhinorrhea�����������������������������������������347
General Presentations
341
Historical Editors Student Editors
Dr. Heather Baxter Adrianna Woolsey
Dr. Harvey Rabin Fatima Pirani
Dr. Ian Wishart
Brittany Weaver Senior Editor
Geoff Lampard Dr. Monique Munro
Harinee Surendra
Kathy Truong Faculty Editor
General Presentations
Dr. Sylvain Coderre
342
Fatigue
FATIGUE
Fatigue
Exclude Sleep Disturbance/Lifestyle Issues/Pregnancy
Organic Etiologies No Organic Etiologies
Endocrine/ Neoplastic/ Chronic
Infectious Pharmacologic Psychogenic Idiopathic
Metabolic Hematologic Disease
• Anemia • Endocarditis • Hypnotics • Anxiety • Chronic Fatigue
• Malignancy • Tuberculosis • Anti-‐ • Somatization Syndrome
• Epstein-‐Barr hypertensives Disorder
Virus • Anti-‐Depressants •Malnutrition/
General Presentations
• Hepatitis • Drug Abuse Drug Addiction
• HIV (e.g. Alcohol)
• Drug Withdrawal
Endocrine Metabolic
• Hypo/Hyper-‐ • Renal Failure Autoimmune/ Cardio-‐
thyroidism Neurologic
• Liver Failure Inflammatory pulmonary
• Diabetes • Hypercalcemia
• Pituitary • Rheumatoid • Congestive • Depression
Insufficiency Arthritis Heart Failure • Multiple Sclerosis
• Adrenal • Celiac Disease • Chronic • Stroke
Insufficiency • SLE Obstructive • Parkinson’s
• Polymyalgia Pulmonary • Myasthenia
343 Rheumatica Disease Gravis
Acute Fever
ACUTE FEVER
Fever (acute onset)
Infectious Non-‐infectious
Viral Bacterial Other Inflammatory Iatrogenic Endocrine Other
• Rhinovirus • Fungal • PE • Transfusion • Thyroid storm • Heat stroke
• Influenza Virus • Protozoa (eg. • Thrombophlebitis reaction • Acute Adrenal • Sickle Cell
• Parainfluenza Virus malaria) • DVT • Malignant Insufficiency disease
• Adenovirus • Other parasites • Pancreatitis Hyperthermia • Drug fever
• Enterovirus • Neuroleptic • MI
General Presentations
• Coronavirus malignant
• HIV syndrome
Bacteremia Septic Shock Acute Organ
Abscess
Specific Infection
• Intermittent Bacteremia • Upper Respiratory •Head and neck
• Continuous Bacteremia Tract Infection • Thoracic
• Urinary Tract • Abdominal
Infection • Pelvic
• Pneumonia • Extremity
• Pyelonephritis
• Meningitis
• Skin Infection 344
Fever of Unknown Origin / Chronic Fever
FEVER OF UNKNOWN ORIGIN/CHRONIC FEVER
Fever of unknown
origin/chronic fever
Infection Neoplasm Autoimmune Other
• NHL • SLE •Drug fever
• Hodgkin’s • RA • Factitious fever
lymphoma • Polyarteritis nodosum • Trauma Non-‐
• Leukemia • Giant cell arteritis infectious
• Solid tumors • Sarcoidosis hepatitis
• Recurrent PE
General Presentations
Bacterial Viral Other
• HIV • Fungal
• EBV • Protozoa
(eg.
Organ
Specific
Non-‐organ
specific • CMV malaria)
Infection • other
parasites
• Viral
hepatitis
• Infectious
•Brucellosis
• Enterovirus
endocarditis • Q-‐fever
• Osteomyelitis • Salmonella
• Occult
abscess • Yersinia
• Sinusitis • Tuleremia
• Cholangitis • Septic
Phlebitis
• UTI • Rheumatic
fever
• Meningitis • Lyme
disease
• TB
345 • Whipple’s
disease
Hypothermia
HYPOTHERMIA
Hypothermia
Environmental Acute Illness
• Immersion
• Non-‐Immersion
General Presentations
Lack
of
Body
Heat
Improper
Body
Heat
Loss Other
Generation Thermoregulation
• Drugs/Toxins • Hypothyroidism • Cerebrovascular
Accident • Trauma
• Iatrogenic • Adrenal
Insufficiency • Central
Nervous
System
• Sepsis
• Burns • Hypoglycemia Trauma • Vascular
Insufficiency
• Malnutrition • Multiple
Sclerosis • Uremia
• Drugs/Toxins
346
Sore Throat / Rhinorrhea
SORE
THROAT
/
RHINORRHEA
Sore Throat / Rhinorrhea
Common viral pathogens:
Rhinovirus, Coronavirus, Influenza virus, Parainfluenza Virus, Adenovirus, Herpes Simplex Virus,
Enterovirus (Coxsackie, Echo), Epstein Barr Virus, Cytomegalovirus, HIV
Most common bacterial pathogen:
Group A Beta Hemolytic Streptococcus pyogenes (GABHS)
Predominantly Rhinorrhea Predominantly Sore Throat
General Presentations
Acute Chronic Acute Chronic
• Acute Viral Sinusitis • Allergic/Vasomotor/Drug • GERD
• Acute Bacterial Rhinitis • Environmental
Sinusitis • Nasal Polyposis • Trauma
• Acute Head Cold • Chronic Sinusitis • Foreign Body
Syndrome • Nasopharyngeal Cancer • Neoplasm
Viral Bacterial
• Acute viral Pharyngitis • Streptococcal
• Acute Influenza Tonsillopharyngitis
• Acute Viral Laryngotracheitis • Peritonsillar Abscess
• Acute Viral Tracheobronchitis • Ludwig’s Angina
• Acute Infectious
Mononucleosis
347 • Herpangina
Historical Executive Student Editors
2016-2017 Joshua Nicholas, Peter Rogers & Scott Belyea
2015-2016 Jared McCormick & Hai (Carlos) Yu
2014-2015 Jared McCormick & Hai (Carlos) Yu
2013-2014 Yang (Steven) Liu & Brian Glezerson
2012-2013 Neha Sarna & Sarah Sy
2011-2012 Katrina Kelly & Harinee Surendra
2010-2011 Jonathan Dykeman & Kathy Truong
2009-2010 Lucas Gursky & Ting Li
2008-2009 Linnea Duke & Mustafa Hirji
2007-2008 Brett Poulin (Founder of the Calgary Black Book Project)
349
Scheme Creators
Students Faculty
M. Abouassaly V. Lekhi K. Burak A. Peets
A. Aristarkhova S. Lipkewich D. Burback G. Pineo
M. Broniewska C. Lu K. Busche M-C. Poon
P. Chen L. Luft S. Casha H. Rabin
M. Chow A. Lys M. Clark T. Remington
R. Cormack D. McDougall S. Coderre B. Ruether
P. Davis B. McLane M. Doran A. Smithee
L. Duke J. McMann P. Federico O. Suchowersky
J. Evinu J. Nadeau K. Fraser P. Veale
A. Geist B. Poulin S. Furtado B. Walley
F. Girgis V. Prajapati N. Hagen L. Welikovitch
A. Hicks N. Ramji J. Huang R.C. Woodman
J. Hodges K. Sahi N. Jette L. Zanussi
G. Ibrahim R. Schachar A. Jones
C. Johannes P. Schneider G. Klein
D. Joo R. Simms S. Kraft Missing a credit?
S. Khan A. Skinn A. Mahalingham If you are the creator of a
L. Kimmet U. Unligil H. Mandin scheme currently used in
M. Klassen C. Verenka J. Mannerfeldt the Blackbook and believe
J. Lawrence H. Waymouth K. McLaughlin you have not been credited
J. Laxton P. Zareba D. Miller appropriately, please
K. Leifso K. Swicker L. Parsons contact us at
J. McCormick V. David D. Patry blackbk@ucalgary.ca
350
Abbreviations
AAA Abdominal Aortic Aneurysm DKA Diabetic Ketoacidosis
ACE Angiotensin-Converting Enzyme DRE Digital Rectal Exam
ACTH Adrenocorticotropic Hormone DVT Deep Vein Thrombosis
ADPKD Autosomal Dominant Polycystic Kidney Disease EABV Effective Arterial Blood Volume
ADH Antidiuretic Hormone ECF Extracellular Fluid
AIN Acute Interstitial Nephritis ENaC Epithelial Sodium Channel
ALS Amyotrophic Lateral Sclerosis FEV1 Forced Expiratory Volume in One Second
ARB Angiotensin Receptor Blocker FJN Familial Juvenile Nephronophthisis
ARF Acute Renal Faliure FSGS Focal Segmental Glomerulosclerosis
ARPKD Autosomal Recessive Polycystic Kidney Disease FSH Follicle Stimulating Hormone
BPH Benign Prostatic Hypertrophy FVC Forced Vital Capacity
CCD Cortical Collecting Duct GBM Glomerular Basement Membrane
CHF Congestive Heart Failure GERD Gastrointestinal Esophageal Reflux Disease
CIN Chronic Interstitial Nephritis GFR Glomerular Filtration Rate
CLL Chronic Lymphocytic Leukemia GHRH Growth Hormone Releasing Hormone
CNS Central Nervous System GH Growth Hormone
COPD Chronic Obstructive Pulmonary Disease GI Gastrointestinal
CRF Chronic Renal Failure GN Glomerulonephritis
CRH Corticotrophic Releasing Hormone GnRH Gonadotropin Releasing Hormone
CT Computed Tomography GPA Granulomatosis with Polyangiitis
DCIS Ductal Carcinoma In Situ GRA Glucocorticoid
DHEA Dehydroepiandrosterone GTN Gestational Trophoblastic Neoplasm
DHEA-S Dehydroepiandrosterone Sulfate H+ Hydrogen
DIC Disseminated Intravascular Coagulation HCG Human Chorionic Gonadatropin
351
HDL High Density Lipoprotein LPL Lipoprotein Lipase
HELLP Hemolysis, Elevated Liver Enzymes, Low Platelets MCD Minimal Change Disease
HIV Human Immunodeficiency Virus MCH Mean Corpuscular Hemoglobin
HPL-1a Human Peripheral Lung Epithelial Cell Line 1a MCHC Mean Corpuscular Hemoglobin Concentration
HRT Hormone Replacement Therapy MCV Mean Corpuscular Volume
HSP Henoch-Schönlein Purpura MEN Multiple Endocrine Neoplasma
HSV Herpes Simplex Virus MI Myocardian Infarction
HUS Hemolytic-Uremic Syndrome MPA Microscopic Polyangiitis
IBD Irritable Bowel Disease MPGN Membranoproliferative Glomerulonephritis
IBS Irritable Bowel Syndrome MS Multiple Sclerosis
ICP Increased Intracranial Pressure MSK Musculoskeletal
ICU Intensive Care Unit Na+ Sodium
IGF Insulin-like Growth Factor NSAIDs Non-Steroidal Anti-Inflammatories
INR International Normalized Ratio OCP Oral Contraceptive Pill
ITP Idiopathic Thrombocytopenic Purpura OSM Osmolality
IUGR Intrauterine Growth Restriction PE Pulmonary Embolism
IV Intravenous PID Pelvic Inflamatory Disease
IVP Intravenous Pyelogram PMN Polymorphic Neutrophils
JVP Jugular Venous Pyelogram POSM Plasma Osmolality
K+ Potassium PPROM Preterm Premature Rupture of Membranes
KUB Kidney, Ureter, Bladder PROM Premature Rupture of Membranes
LCIS Lobular Carcinoma In Situ PT Prothrombin Time
LDL Low Density Lipoprotein PTH Parathyroid Hormone
LGA Large for Gestational Age PTT Partial Thromboplastin Time
LH Luteinizing Hormone PUD Peptic Ulcer Disease
LLN Lower Limit of Normal PUJ Pelviureteric Junction
LOC Level of Consciousness RAPD Right Afferent Pupillary Defect
352
RAS Renal Artery Stenosis
RBC Red Blood Cell
RTA Renal Tubular Acidosis
SGA Small for Gestational Age
SLE Systemic Lupus Erythematosus
TORCH Toxoplasmosis, Other (Hepatitis B, Syphilis,
Varicella-Zoster virus, HIV, Parvovirus B19), Rubella,
Cytomegalovirus, Herpes Simplex Virus
TSH Thyroid Stimulating Hormone
TSHR Thyroid Stimulating Hormone Receptor
TTKG Transtubular Potassium Gradient
TTP Thrombotic Thrombocytopenic Purpura
UTI Urinary Tract Infection
US Ultrasound
VACTERL Vertebral Anomalies, Anal Atresia, Cardiovascular
Anomalies, Tracheoesophageal Fistula, Esphageal
Atresia, Renal Anomalies, Limb Anomalies
VSD Ventricular Septal Defect
VUJ Vesicoureteral Junction
353
Notes
Superficially resembling flowcharts, schemes are a way to ease the
memorization of differential diagnoses by breaking large lists into
sets of smaller, conceptually-intuituve information packets. using
the Medical Council of Canada’s Clinical Presentation List,
Blackbook organizes the most common medical presentations
of patients into diagnostic schemes. As a tool for medical students,
residents, allied health trainees, and health care educators, medical
presentation schemes will ease the learning of the volume of
medical diagnoses, and will facilitate recall when needed.
Based on the medical presentation schemes used in the
University of Calgary Medical curriculum, Blackbook is a joint
production of the students and the Cumming School of Medicine
at the University of Calgary.
© 2018 Cumming School of Medicine, University of Calgary.
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