This document provides a summary of various gastrointestinal and liver conditions and diseases. It lists symptoms, risk factors, diagnostic tests, and treatments for issues ranging from vitamin deficiencies to cancers of the esophagus, stomach, pancreas, and liver. Some highlights include descriptions of achalasia with its characteristic "beak" appearance on x-ray and its association with dysphagia, as well as ulcerative colitis which involves the colon and terminal ileum without skip lesions and has complications of perforation, hemorrhage, and toxic megacolon. Celiac sprue, which has a gluten sensitivity and causes malabsorption, is also summarized.
This document provides a summary of various gastrointestinal and liver conditions and diseases. It lists symptoms, risk factors, diagnostic tests, and treatments for issues ranging from vitamin deficiencies to cancers of the esophagus, stomach, pancreas, and liver. Some highlights include descriptions of achalasia with its characteristic "beak" appearance on x-ray and its association with dysphagia, as well as ulcerative colitis which involves the colon and terminal ileum without skip lesions and has complications of perforation, hemorrhage, and toxic megacolon. Celiac sprue, which has a gluten sensitivity and causes malabsorption, is also summarized.
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This document provides a summary of various gastrointestinal and liver conditions and diseases. It lists symptoms, risk factors, diagnostic tests, and treatments for issues ranging from vitamin deficiencies to cancers of the esophagus, stomach, pancreas, and liver. Some highlights include descriptions of achalasia with its characteristic "beak" appearance on x-ray and its association with dysphagia, as well as ulcerative colitis which involves the colon and terminal ileum without skip lesions and has complications of perforation, hemorrhage, and toxic megacolon. Celiac sprue, which has a gluten sensitivity and causes malabsorption, is also summarized.
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato DOCX, PDF, TXT ou leia online no Scribd
Niacin Pellagra - Diarrhea, dermatitis, dementia, death
Pyroxidone (B6) Rare, neuropathy, Cheilosis (swollen cracked bright red lips)
Cobalamin (B12) Macrocytosis, Pernicious Anemia- megaloblastic, neuro chg. ataxia, Schilling test , more in Strict Vegitarian.
Folate Macrocytosis, megaloblastic anemia w/o neuro chgs., common in alcoholics
Vitamin C Scurvy, bleeding gums, Connective Tissue problems, Can manifest 1 yr post defic.
Failure to Thrive Org.= decr. wt gain w/ other disease; Nonorg.=growth failure due to neglect stimulation < 80% wt for Ht
Obesity mild 20-40%, moderate 41-100, severe <101%; age, black women, low income BMI= body wt (kg)/Ht (mm2) Normal 20-25 Pickwickian Syndrome = obesity, dyspnea, hypovent, CO2 retention, hypoxia
Boerhaave's Syndrome esophageal rupture due to forceful vomit; Gastromediastinal fistula, dyspnea w/o hemetemesis, + Hammonds sign = pneumomediastinum, L lung effusion
Dysphagia Obstructive - solids 1st; Motor -solids = liquids
Celiac Sprue Gluten sensitivity (wheat, rye, barley); amenorrhea 1st sx girls, Infants = FTT, abnormal stool, bloating, Adults = malabsorption, vit deficiency; X-ray - dilated loops of bowel with thin mucosal folds; most common cause of malbsorption
Tropical Sprue nutritional defic, small bowel mucosal abnormal; Acquired - Caribbean, India, SE Asia; Megaloblastic Anemia, glossitis, diarrhea, wt loss Tx Folic Acid & Tetracycline
Whipple's Disease Infectious; middle aged men; multi- organ; Thickened mucosal folds, Foamy macrophage with rod shaped bacilli that stain w/periodic acid (Schiff's Reagent)
Intestinal Lymphangiectasia Children & young adults; cong or acquired telangiectasia of intramucosal lymphatic Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/ triglyceride supplement
Toxic Megacolon Dilation > 6cm, Adults preceded by IBD (UC or Crohn's) Kids preceded by Hirschsprungs Ds; Sx: severely ill, incr. temp, abd pain, rebound, leukocytosis; X-ray - intraluminal gas along continuous seg of dilated bowel; Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids, Rectal tube may alleviate but can cause perforation
Inguinal Hernia Indirect = infants, persistent processus vaginalis, protrudes thru ring, lateral Inf Epig. Direct = Adults, medial to ing ring & inf epig artery, Weakness in Hesselbach's
Diverticular Disease Diverticulosis = false diverticulae, pearl sign on xray Diverticulitis = infection, acute abd pain usually on left, may form fistulas to bladder, vagina or skin, CT w/ water soluble contrast during acute attack
Crohn's Disease Granulomatous colitis; No bloody stools, 1st in terminal ileum, transmural, skip lesions, cobblestoning: Complications=small bowel abscess, obstruction, perianal disease, malabsorption, toxic megacolo, Colon CA. Surgery is not curative
Colon CA Right Sided=napkin ring, anemia Left Sided=Apple core, pencil stools; Genetic; Annual rectal>40, Annual Guaiac >50; Flex Sig q3-5y >50; Rectal CA-hematochezia
Volvulus Rotation of Bowel; Newborns & elderly; Double Bubble; Birds Beak on Barium Enema, Tx: Left Sided = decompression; Rt sided & kids = surgery
Intussusception Telescoping of large bowel into an adjacent section; most common cause of obstruction in kids under 2; Episodic Abd pain 1-2 min. Reflex = early vomit; Obstructive = omit late; Currant Jelly Stool; Small Infants = Pallor, sweating, and vomiting. Leukocytosis with hemoconcentration, BE to reduce x 2 before surgery
Necrotizing Enterocolitis Premature, decr. birth weight, older infants with malnutrition; bilious vomit, abd distention, bloody stool, lethargy; Thrombocytopenia; Small Bowel Distention; pneumatosis (air in bowel wall) TX; NG, TPN, IV antibiotics, surgical Rx necrotic part
Cholera Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic gulfcoast, Asia, Africa, Mid East; Severe dehydration, Metabolic Acidosis, Tx: Tetracycline or Doxycycline
Shigella Dysentery Small bact dose needed, Blood & mucous, Kids worse than adults, Fluid Replacement & Ciprofloxacin
Pseudomembraneous Colitis Antibiotic induced (clindamycin, ampicillin, cephalosporin) C. Diff; mail -> severe bloody diarrhea; Tx: stop antibiotics, oral metronidazole in severe cases
Acute Pancreatitis Pain radiates to back w/ N/V; Grey Turner's Sign (blue flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase incr. ; Ranson's Criteria: 3 or more = incr mortality Admission: >55, gluc>200, LDH >350, AST >250 WBC > 16000 Within 48 hrs: Hct decr. 10%, BUN incr. >5, Ca< 8, PaO2 < 60, Base Def > 4, Fluid Seq>6L
Chronic Pancreatitis ERCP to Dx; Alcoholics, Malabsorption & diabetes are results
Hepatitis Hep A = Fecal oral, shedding before Sx; IG to travelers & contact with HAV infected Heb B= Blood & STD; HbsAg early if persists = carrier; HbcIGM then HbcIgG for life HBIG for needle sticks and infants born to + moms; assoc w/ hepatocell CA Hep C Most common post transfusion hepatitis Hep D = Co infection with B; Hep E = fecal oral
Hepatocellular CA Mets 2x more than primary CA (breast, lung, colon), Budd Chari-thrombosis hep V. Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins (fungal metabolites)
Benign Hep Adenomas oral contraceptives
Exocrine Pancreatic CA Ductal CA, Courvoiser's Law=palpable nontender GB in a jaundiced patient is a head of Pancreas tumor. Tumor Body or Tail=splenic vein obstruction=> splenomegaly, gastritis, esoph varices
Insulinoma Insulin hypersecretion, hypoglycemic symptoms, Insulin levels still incr. after fasting Whipple Triad: confirms hypoglycemia as source of Sx 1. Hypoglycemia, 2. Relieved with carb ingestion 3. Sx occur while fasting
VIPoma Makes Vasoactive peptide (VIP); Sx WDHA (watery diarrhea, hypokalemia, achlohydria; unexplained secretory diarrhea; laparoscopy for Dx
Glucagonoma tumor of alpha islet cells; 80% women; 80% malignant; Necrolytic Exfoliating Erythema characteristic exfoliating lesion of the extremities
Pompe's Disease a 1,4 glucosidase deficiency; fatal by age 2
Ascites Complication of hepatic disease; Paracentesis to examine ascitic fluid values should equal serum if incr. albumin = malignant; incr. LDH > 60% of serum = malig or infective; incr. WBC = infection
GI Bleeding Upper GI = melaena (black tarry) ; Lower GI = hematochezia (bright red) decr. Lig Trietz
Intestinal Obstruction Vomiting common in small bowel, late in lg bowel, High pitched "tinkling" BS. X-ray - prox dist = lg bowel; dilated loops of bowel with air fluid levels = sm bowel
Ileus Paralytic obstruction of bowel due to loss of peristalsis
Meconium Ileus Abnormal thick Meconium with undigested protein, associated with CF
Hirschsprung's Disease No autonomic nerves in colon, Obstipation, late vomit, Megacolon, Toxic Enterocolitis if left untreated, BE proximal dilated & distal narrow, Colostomy
If it will help u guys just let me know I'll post rest of the systems Thxn 2 eaziz
Cheers
Here r all the systems that I have Very Happy (sorry for late reply Crying or Very sad ) ------------ CARDIOVASCULAR Contraindications to BP meds Asthma/COPD = Bblockers, DM = Thiazides & Bblockers, Cardiac Failure = Bblockers & Ca Channel Blockers; Pregnancy = Thiazides & ACE
VSD L=>R; pansystolic murmur left sternal border, thrill; most common defect; Eisenmenger's Syndrome = shunt direction reversed due to incr. pulm vasc resistance
Patent Ductus Arterio L=> R; Continuous machinery murmur; Indomethacin inject may close
Tetralogy of Fallot VSD, RVH, Pulmonic Stenosis, Overriding Aorta
Pulmonic Stenosis R=>L, Early systolic click, High pitched systolic ejection murmur, soft or absent S2
Coarction of the Aorta HTN arms but not legs, murmur heard on back, X-ray scalloping of ribs,
Bacterial Endocarditis Acute: S.aureus, Group A strep, N Gonh., Sub acute: Strep Viridans; New heart murmurs, petechia over incr. half of body, Splinter hemorrhages on fingernails, Osler's Nodules (nodules on fingertips) Roth's Spots (retinal hemorrhages)
Noninfective Endocarditis Libman Sacks Disease associated with SLE
Aortic Aneurysm Abdominal = pulsatile mass on exam, atherosclerosis, smoking HTN >4 cm = surgery Thoracic =Marfan's & syphilis >7c = surgery; Dissecting =split between medial & adventitial layers "ripping in chest" Normal EKG vs abnormal in MI
Raynaud's Phenomenon Pallor, cyanosis, erythema of fingers, most are idiopathic, others related to collagen vascular disease Tx vasodialators
Heart Dysfunction Diastolic = difficulty filling ventricles; Systolic = problem ejecting blood from ventricle
Polyarteritis Nodosa inflamed medium arteries- >ischemia in tissues; men 3x> women, usually 40-50; Dx confirmed by biopsy or angiography showing aneurysm of medium arteries
Giant Cell Arteritis Temporal Arteritis; women >50; severe temporal or occipital HA, Amaurosis Fugax (temp blindness 1 eye) Temporal artery swollen & tender, Dx confirmed by biopsy
Cor Pulmonale COPD most common cause; Dyspnea & syncope on exertion, S/Sx Rt heart failure
Mitral Stenosis Mitral facies = red rash on cheekbones, Loud S1 and opening snap after S2; Right heart failure TX with diuretics; LAH=>Pulm HTN=>RVH Bblockers & Ca Channel Blockers to decr. HR & preload; Progressive Dyspnea
Mitral Regurge Midsystolic click; Harsh blowing holosystolic murmur; MVP; LAH & LVH; wide S2 that widens more with inspiration; Bblockers for Sx Valve replacement
Aortic Stenosis Triad = Angina, Syncope & Dyspnea on exertion; Cong bicuspid valve, weak long pulse, LVH T wave invesions; Left sided failure; Bblockers decr. HR & incr. coronary flow
Aortic Regurge Decrescendo murmur, widened pulse pressure, "Water Hammer Pulse" (rapid up & down stroke); "Pistol Shot over femoral Artery; 2o Austin Flint murmur= diastolic murmur as blood goes thru AV to hit MV. Kids = cong VSD w/ MVP
Supraventricular Tachycardia Sudden attacks due to reentry rhythm, P on T on EKG; #1 AV Nodal Reentry #2 Wolff Parkinson White = reentry thru accessory muscle bundle, can cause V fib in a Pt with Afib; Torsades De Point is drug induced
Left Sided Failure Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, LVH
Right Sided Failure Most common cause is Left sided failure; Neck vein distention, Liver big, Edema
MI ST elevation, T wave inversion; CPK-MB 12 - 40 hr for peak; LDH peaks 3-6 days
Congestive Cardiomyopathy Alcohol = chronic; Infection Coxsackie B or Trypanosoma cruzi (Chagas Disease)
Hypertrophic Cardiomyopathy Cong or acquired VH with normal afterload; incr. venous pressure, JVD, ascites, edema, edema, pleural effusion, S4 on exam
Chronic Pericardtis Causes right sided failure; Kussmaul's Sign ( incr. neck vein distention on exertion) Dyspnea on exertion and Orthopnea; pulsus paradoxus; Surg removal of pericardium is curative.
Sarcoidosis non caseating granulomatous, increased Calcium, ground glass, bilateral hilar & paratracheal adenopathy is pathognomic
Asbestosis Increased risk of lung CA & mesothelioma, gradual dyspnea, nonproductive cough; no wheeze; diffuse linear opacities on xray
Silicosis increased risk of TB, SiO2 inhalation; metal mining; multiple small nodules & calcification of hilar lymph nodes
Resp Failure ABG=> PO2 50-60 mmHg; PCO2 >45 mmHg
Laryngeal CA squamous cell, smoking & alcohol, hoarsness for several weeks
Lung CA squamous>adeno>small(oat) cell; Squamous = hilar; Adeno = peripheral; Horner's Syndrome=invasion of the cervical symp. Ganglion= miosis, ptosis, anhydrosis Pancoast tumor = Horners + pain in arm or shoulder on affected side
Asthma PFTs decr. FEV1; ABG resp alkalosis, decr. CO2; If CO2 incr. or normal resp failure imminet
Massive Hemoptysis >600 ml blood in 24 hrs; trauma; PE, aortic aneurysm, heart failure
ARDS acute lung injury with non-cardiogenic pulm edema, ABG =acute resp alkalosis (O2 & CO2; Xray =pulm edema with normal cardiac silhouette, Positive pressure or PEEP ventilatory support
Pulmonary Edema Pink, frothy sputum, Kerley B lines on xray; Incr cardiac silhouette if cardiac origin
Pulmonary Embolism DVT (iliac & femoral) V/Q useful, angiography is god std for dx
RDS <37 wks gestation, Lung maturity: L/S ratio >2, + PG; Beclomethasone hastens maturity; artificial surfactant for kid
Pulm HTN Primary = dx of exclusion; secondary valvular heart disease, L=>R shunt, chronic ateletasis (localized collapse of alveoli)
ENDOCRINOLOGY Hypothyroid Weight gain, Lethargy, Coarse hair & dry skin, irregular menses, cold intolerance, myxedema; Acquired = Hashimoto's; Congenital = cretinism, severe I deficiency = hoarse cry; resp distress, cyanosis, poor feeding, decr bone growth, T4 incr. TSH Wolff Chaikoff effect = inhibition of thyroid hormone release due to high doses of I during thyroid scan
Hyperthyroid 1. GRAVES: most common, autoimmune, antibodies bind to TSH receptors; incr thyroid hormone, pretibial myxedema, Incr radio I uptake 2. SUBACUTE THYROIDITIS: tender, enlarged, Decr Radio I uptake, Sed Rate up, maybe followed by period of hypothyroid 3. SILENT LYMPHOCYTIC THYRODITIS: transient, postpartum, no pain or fever, Radio I uptake decr, lymphocytic infiltration, Tx Bblockers 4. TOXIC ADENOMA: multinodular goiter; nodules function autonomously, Excess T3 & T4; Scan shows a few hot spots with cold background 5. THYROTOXICOSIS FACTITIA: exogenous thyroid hormone, no goiter 6. PLUMMERS : multinodular goiter, nodules become autonomous and secrete thyroxine
Sick Euthyroid acutely ill patients; T3&T4 decr due to chgs in hormone metabolism; TSH not decreased => not truly hypothyroid
Thyroid CA Papillary = most common, best prognosis, Follicular = older, hematogenous spread to bone, lung, brain, liver; Anaplastic = worse prognosis, local invasion, hoarse & dysphagia; Medullary= Calcitonin producing Cells, MEN Type II(parafollicularC cells)
Diabetes Dx: elevated random glucose sx, fasting BS > 140 x 2 days; Oral challenge >200 after 2 hrs; Type I: alpha islet cells, HLADR3, HLADR4, HLADQ, ketoacidosis Type II: insulin resistance; no HLA association, endogenous production enough so no ketoacidosis but do get hyperosmolar coma(dehydrated, glucose 600- 2000
Parathyroid Hormone incr. Ca mobilization from bones, incr. Vit D production decr. phos reabsorption in distal tubules = decr. serum phos.
Hypoparathyroidism PTH, Ca, incr. Phos, Tingling, tetany, Chvostek's sign (tap on face & get muscle spasm) ; Trousseau's Sign (BP cuff up 3min => carpal tunnel sx; decr. Mg in alcoholics can lead to decr. Ca due to PTH secretions
Hyperparathyroid Bones, stones, abd. Groans and psychic moans; 1o = excess PTH; 80% benign adenoma; 2o due to decr. serum Ca=> vit D defic, renal tube prob and Ca loss
Diabetes Insipidus Lack of ADH, polyuria and polydypsia
Kallman's Syndrome Male, anosmic, small testicles, azospermic d/t head trauma; decr. FSH & LH, no GNRH
Acromegaly Excess GH; bone & tissue enlargement; glucose intolerance, osteoarthritis
Addison's Disease Decreased cortisol (aldosterone) Wt loss, fatigue, skin pigmentation, eosinophilia; Decr aldosterone, decr Na, incr K; Give ACTH if cortisol doesn't increase Dx made
Cushing's Syndrome Incr cortisol, Buffalo hump, moon facies, central obesity, Osteoporosis, #1 Cushing disease due to pit. Adenoma, #2 Ectopic- ACTH from lung tumor, #3 Adrenal Cortical tumor- incr. cortisol, ACTH suppressible, cortisol not #4 Chronic glucocorticoid Tx
Waterhouse Friedrickson Syndrome hemorrhagic infarct of adrenals, assoc w/ meningococcemia
Pheochromocytoma Episodic HTN, Dx by urinary catecholamines
Familial Hypercholesterolemia Autosomal dominant, Xanthomas (lipid on tendons) Xanthelasmas (lipids on eyelids) MI's in 40's, Homozygous usually has incr. total cholesterol
Familial Combined Hyperlipidemia Auto dominant, incr. trig and cholesterol; no xanthomas
Familial Dysbetalipo-proteinemia rare, problem with lipoproetin catabolism; palmar or tuberous xanthomas, incr. risk periph vasc disease & CAD, Abn VLDL, cholesterol & triglycerides
MEN I Parathyroid , pituitary & Pancreatic tumors
MEN II Pheochromocytoma, Parathyroid & medullary thyroid tumors
Hemochromatosis Auto recessive, incr. GI absorption of Fe; Excessive Fe, incr. Ferritin, incr. Transferrin saturation, cirrhosis, diabetes, bronze skin
Wilson's Disease Auto recessive, excessive Cu accumulation, ataxia & dementia, Kayser Fleisher rings on cornea
Hyperaldosteronism Aldosterone works on distal renal tubule to facilitate incr. Na retention and incr. K loss excretion due to decr. Na, decr. BP (renin angio), incr. K 1o Conn's Syndrome = adrenal hyperplasia, adrenal adenoma Tx: spironolactone 2o incr. renin angiotensin system activity => decr. BP
GENTOURINARY Neurogenic Bladder Bladder control requires: intact sensation(full) motor function (start void) Cerebral control (timing) Atonic, distended with overflow= acute spinal cord injury or sensory impaired Motor defect = sense full bladder but can't start emptying Autonomous = spinal cord injuries after acute; bladder fills & empties reflexively
Hydronephrosis dilation of renal pelvis, incr. pressure in urinary system w/ or w/o ureter dilation
Fanconi's Syndrome renal tubule defect; Urinary excretion of glucose, phos, AA; Tx: Vitamin D
Pyelonephritis & Pyelitis Pyelonephritis = dilation of renal parenchyma, pyelitis = dilation of renal pelvis; E. coli; Different from cystitis since there are WBC casts not just WBC's
Cystitis WBC in spun sample, E. coli, freq, urge, dysuria & suprapubic pain
Renal Artery Stenosis Cause of 2o HTN; Fibromuscular dysplasia (young women) Atherosclerosis (older)
Urolithiasis incr. Ca = Calcium stones; Struvite Stones = post UTI w/ urea splitting bact (proteus or pseudo) when urine basic MgNH4PO4 (struvite) stones ppt.
Glomerulonephritis Hematuria, proteinuria, RBC casts: Post strep = give Antibiotics only if still strep +, steroids no help; Goodpastures- autoimmune, high dose steroids, uremia 3-9 mos.
Nephrotic Syndrome Proteinuria > 3g/day, Edema, hypoalbuminemia & hyperlipidemia (milky serum); minimal chg disease in kids; idiopathic Glomerulonephritis in adults
Acute Tubular Necrosis most common cause of acute renal failure; ischemia or toxins; resolves in several weeks may need dialysis
Polycystic Kidney Disease Auto dominant; multiple bilateral renal cysts; gross hematuria, proteinuria, pyuria, HTN, UTI's; asymptomatic until adult; 15% have associated subarachnoid hemorrhage
Alport's Syndrome X-linked, Type IV collage, deafness & renal failure in males
Renal CA adenocarcinoma; Triad: hematuria, abd mass & flank pain
Chronic Renal Failure >90% glomeruli destroyed; uremia incr. K, Na incr. phos, Ca = renal osteodystrophy
Hypernatremia > 155 mEq/L; due to dehydration, CNS depression (neuronal shrinkage); Diabetes Insipidus= decr ADH = lots of dilute urine = dehydration = urine output incr.
Hyponatremia <135 mEq/L; pseudo if lipids are incr. incr. incr. high to displace polar Na; Osmotic = diabetes incr. Na 1.6 for 100 mg/dl glucose value is above 140.; SIADH, Central Pontine Myelinosis if corrected to fast
Hyperkalemia > 5.5 mEq/L; muscle weakness, cardiac arrhythmia, met acidosis, oliguria, K sparring diuretics
Hypokalaemia <3.5 mEq/L; muscle weakness, cardiac arrhythmias, resp failure, GI or renal loss
Urethritis GC (gram - rodds in WBC, + thayer martin culture); nonGC = chlamydial; coinfection, Ceftrixone for GC, Doxycycline for Chlamydia
Epididymitis Induration & tenderness of spermatic cord; support relieves pain
Torsion of the Testes adolescents, swelling & tenderness, superior displacement, support does not relieve pain, Emergent SURGERY
Hydrocele Painless lump, can be transilluminated; congenital process vaginalis remains in communication w/ abdomen = indirect inguinal hernias
Varicocele "bag of worms", assoc w/ infertility
Seminoma Painless lump; does not transilluminate, most common testicular neoplasm in men < 30; Undescended testes at greater risk even after surgical correction
BPH Enlarged rubbery prostate on rectal; Urinary retention, a blockers; TURP, transrectal US more sensitive for Dx; PSA can be falsely elevated
Prostate Ca Firm, nodular irregular prostate, Bone mets; Alk Phos and PSA are incr.
Bacters Syndrome pre-auricular skin tag and kidney agenesis
INFECTIOUS DISEASES & IMMUNOLOGY Fever most common cause immed post op = atelectasis; 3-5 days postop = infection; > 2 wks post op = PE or thrombophlebitis
Fever of Unknown Origin > 100F for > 3 weeks despite active search for cause for > 1 week; need to get CBC w/diff, blood cultures; kids = usually infection; adults = infectious, neoplasm, autoimmune
Inflamation Rubor, Tumor, Calor, Dolor
Types of Immunity Active Acquired= direct exposure - infection or vaccination; Passive Acquired = temporary, serum Ab given (IG, breast milk)
Bacteremia bacteria in blood but asymptomatic
Septicemia bacteria in blood with symptoms
Immunizations in Kids HEP B = mom + HbsAG = HBIG & 1st Hep B vaccine at birth DTP = contraindications => progressive neuro disorder, Hx encephalopathy w/ in 7 days of previous dose; Pertussis not given if > 7 y/o or if currently have pertussis H FLU = not in kids > 5 POLIO = IPV if immunocompromised MMR = not effective before age 1; don't give if less than 3 months since transfussion or IG use; ok for HIV +; suppresses TB - give Tine(PPD) & MMR at same time or 4-6 weeks apart.
Adult Immunizations TETANUS = booster q10y, No Hx immunization 2 td 1-2 mos apart then booster at 6-12 mos then on normal 10 y cycle FLU = chronic resp problems, metabolic diseases, adults > 65; can cause false positive HIV test
HIV/AIDS RNA retro, CD4 cells, Dx based on concurrent related diseases &/or CD4 , 200 cells/mm3; Flu-like illness, antibodies 1 - 6 months after infection
AIDS related infections CMV, HSV, VZV, EBV, TB, mycoplasma avium-intracellular, candida coccidioides, histoplasmosis, cryptococcus, Pneumocystic carnii (protozoa) Toxoplasmosis, cryptosporidiosis, Giardiasis
Macrocytic Anemia MCV > 100; FOLATE DEF. = most common cause, decr. folate normal B12; B12 DEFICIENCY: B12 absorbed when linked with IF from parietal cells, neuro sx,
Alpha Thalassemia Acanthocytes (rounded projections from cells); Poikilocytosis (variable size); target cells, Very low MCV but mild anemia, Hemoglobin H = a chain missing; Asians, Dx by Hb electrophoresis,
Beta Thalassemia Peripheral Smear = basophillic stippling, nucleated RBC, anisocytosis (chgs in size) Mediterranean & African heritage; Minor = heterozygous, Major = homozygous
Hemolytic Uremic Syndrome Usually caused by E. coli toxin, RBC fragments on smear, RBC destruction => acute renal failure, 2o thrombocytopenia, abd pain & diarrhea after a flu or URI prodrome; platelets derc, LDH greatly increased
Chronic Myelocytic Leukemia Philadelphia Chromosome (acquired translocation chromosome 9 & 22), tumor cells are more mature, Dx in middle aged, WBC > 150000; incr. uric acid, incr. B12 (B12 carrier protein produced by WBC); leukocyte alkaline phos decr or absent, RBC normal Blast crisis transforms it to acute leukemia
Chronic Lymphocytic Leukemia Disorder of mature B cells (rarely T); B cells don't differentiate into plasma cells, men > women; usually > 50; No Blast Crisis
Hairy Cell Leukemia B cell transformed into tumor cell with fine hair like projections; pancytopenia, red pulp of spleen infiltrated
Multiple Myeloma Plasma cell proliferation and monoclonal IG; men = women; peak 50 - 60, 1 - 3 year survival; xrays show osteolytic bone lesions, Increased urine protein (Bence Jones)
Waldenstrom's Macroglobulinemia single B cell line = monoclonal IM over production; decr. RBC with normal WBC & platelets; Rouleau Formation = RBC pile up forming cylinders
Mycosis Fungoides Clonal proliferation of CD4 T cells; infiltrates dermis & epidermis, thickened & nodular skin lesions
Polycythemia Vera overproduction of all 3 cell lines; RBC > 1,000,000, Hct > 60%; men & women peak age 60; Bone biopsy- hypercellular with absent Fe stores; R/O spurious polycythemia = incr. RBC due to dehydration; R/O 2o polycythemia = RBC mass incr. due to decr. oxygenation.
Eaton Lambert 90% assoc w/ small cell CA, decr. presynaptic Ca release = proximal muscle weakness; hyporeflexia, dysautonomia, function incr. w/ stimulation; weakest in AM (opposite MG) Tx Tubocurare
DERMATOLOGY Seborrheic Dermatitis Red skin with greasy scales, worse in winter & when under stress, Se or Tar soap
Psoriasis HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled plaques w/ sharp demarcations, Pitted fingernails
Pilonidal Cyst Hair lined tract in sacral area = "Jeep Seat"
Actinic Keratoses Firm, yellow scale, Due to sun exposure, can lead to squamous cell CA
Skin CA Basal Cell > Squamous; Basal Cell = pearly papule w/ dilated blood vessels and central depression; Squamous Cell: Red papule w/ crusted surface, later nodular and ulcerated, rarely mets; Assoc w/ sun exposure
Malignant Melanoma Change in size, shape or color of a mole, Usually superficial spreading, Mets incr. as invasion goes deeper than 0.76 mm; itchy & ulcerated
Contact Dermatitis 1o = irritant contact - direct injury, all w/ contact affected, Occurs w/ 1st exposure Allergic = type IV hypersensitivity, T cell medicated, Never 1st exposure
Carbuncle Abscess of skin caused by several boils coming together
Dermatopytoses TINEA CORPORIS: ring worm of body (round lesion w/ raised borders, spreads peripherally w/ central clearing) TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot; TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm of scalp;
NEVI PIGMENTED: (Benign) sun exposed areas in children & adolescents DYSPLASTIC: 2-12 mm, more irregular, unexposed areas, Multiple dysplastic Nevi = familial incr. risk of melanoma
Hemangiomas NEVUS FLAMMEUS: Port wine stain - flat, purple, does not fade CAPILLARY: strawberry mark, raised, bright red, regress spontaneously by age 5 CAVERNOUS: Raised red or purple, enlarged vascular spaces
Gout Affects big toe (Podagra), pinna of ear; Negatively birefringent crystals; Sodium urate; Colchicine or NASIDS for acute attacks
Pseudo Gout Calcium pyrophosphate dihydrate; Knee most affected; Positively birefringent
Phocomelia Hands & feet attached to trunk, Thalidomide
Slipped Capital Femoral Epiphysis Overweight Teens; stiffness=>weakness=>pain radiating down anteromed thigh to knee, ext rot of leg; avascular necrosis
Osteoporosis decr. mass of bone; hip & wrist fx most common; decr. estrogen, Ca & Phos normal; Risk factors = post menopause, Caucasian, Asian, smoking, alcohol, corticosteroids, Cushings, hyperparathyroid, hyperthyroid; Etidronate - inhibits osteoclast activity, used for men & women who can't take estrogen
Systemic Lupus Erythematosus Malar (butterfly) rash, arthralgias (raynauds), ANA sensitive; Anti dsDNA specific; Neuro = HA, psychosis, seizures, aseptic meningitis; Check for hemolytic anemia w/ Coombs; Renal = incr. BUN incr. Cr, + protein = immune complex glomerulonephritis
Shoulder Hand Syndrome Pain, stiffness, swelling in hand and shoulder; Occurs 1 month after MI or other acute disease
Bone Mets from Primary breast, lung, prostate, kidney, thyroid
Paget's Disease Osteolytic => osteoblastic; Frontal "bosing" (enlarged skull with rounded forehead) bow legs and shortened spine; incr. alk phos, Ca & phosphorus levels normal; "Cotton Wool" appearance on skull xray; high output cardiac failure
Congenital Hip Femoral head partially or completely dislocated from acetabulum; BARLOWS: dislocates hip when abducted and decr. pressure; ORTOLANI'S: reduces dislocation by abduction and flexion
Osteochondritis Inflammation of bone & cartilage; Osgood Schlaters - teens, tibial tubercle, pain& swelling at the insertion of the patellar tendon
Osteomyelitis Bone infection; Local or hemtogenous spread; Prepuberty infection is in metaphysis; Salmonella - sicklers; S. aureus; pseudomonas; incr. ESR; incr. WBC; Radionucleotide bone scan w/ in 72 hrs; 4-6 wks organism specific antibiotics
Septic Arthritis S, aureus = most common; N. Gon most common sexually active; synovial fluid = incr. WBC and + culture; Ceftriaxone NG infection; Nafcillin for others
Degenerative Disk Nucleus Pulposa herniates post or postlat.; Lumbosacral = sciatics = L3L4; + pain on straight leg raise;
CaudaEquina Syndrome Lg midline post. Hemorrhage compressing C.E. Urinary and bowel incontinence; bilateral leg weakness
NEUROLOGY Blindness visual acuity 20/400 with best possible correction
Open Angle Glaucoma Increased intraocular pressure, gradual, bilateral vision loss => tunnel vision, elderly, diabetics, African Americans, familial; halos around lights, cuping of ocular disc, Beta Adrenergic blockers to treat; decr. amt aqueous humor produces
Closed Angle Glaucoma Rapid rise in pressure due to blockage of aqueous drainage in the eye; Severe pain, blurred vision, halos, Nausea, Abd pain; Reddened eye, upper lid edema, steamy cornea, dilated non-reactive pupil; mannitol, oral glycerin or carbonic anhydrase in acute attack, Beta adrenergic blockers for prevention
Diabetic Retinopathy Black spots, "cobwebs", flashing lights; cotton wool spots (infarct of vessel wall) neovascularization, hard yellow exudates
Cataracts Painless clouding of lens; Age most common cause, Assoc. W/ smoking & alcohol; Absent red reflex.
Senile Macular Degeneration Main cause of vision loss in the elderly; Atrophic degeneration or Leakage of Retinal Vessels , gradual loss of VA, Decr central vision, hemorrhagic or pigmented regions in the macula; Neovascular Membranes (Bruch's membrane)
Conjunctivitis Acute inflammation, Adenovirus, a lot of discharge, no blurring, purulent if bacteria
Uveitis Inflammation of the uveal tract (iris, ciliary body & choriod layer), haziness, floating spots; Photophobia & redness = iridocyclitis; "salt & pepper fundus = syphillis
Central Retinal Occlusion sudden painless loss of sight in one eye, Pale fundus, cherry red spot fovea & boxcar appearance of veins
Central Vein Occlusion unilateral loss of sight that is more gradual, Swelling of optic disc, cotton wool spots & tortuous dilated veins
Retinoblastoma Childhood malignancy of immature retina, associated with other malignancies later in life, "white reflex or "cat's eye.
Hearing Loss Rinne's Test: hold against mastoid process then adjacent to pinna, norm = pinna louder, if not maybe conductive loss; Weber Test: Midline of forehead, unilateral conductive loss = louder in affected ear; unilateral sensorineural = louder in unaffected ear
Presbycusis normal loss of hearing associated with age, sensorineural
Mastoiditis Usually following otitis media, Redness & swelling w/ fever & pain; X ray = destroyed mastoid air cells & fluid in the air pockets, IV antibiotics
Meniere's Disease Severe vertigo w/ N/V, hearing loss, tinnitus worse during attack of vertigo
Migraine 2x women : men; Age of onset 10 - 30; gone by age 50; family Hx; stress, bright lights, menstruation, fatigue, tyramine, monosodium glutamate, nitrites; Aura prior to onset; visual, scintillating scotomas (small areas of visual loss) , dull throbbing, unilateral; N/V, photo & sound sensitivity;
Cluster Headache Men age 20-50; alcohol & vasodilators; severe, nonthrobbing, unilateral, recur same time each day for weeks, Horners syndrome & periorbital pain; Tx: ergot & lidocaine
Tension Headache cause unknown, most common type; bilateral, occipital, constant; muscles tight
Trigeminal Neuralgia Tic douloureux; severe, "lightening" pain in V1 & V2 distribution of CN V; Trigger Pts Tx: carbamazepine & phenytoin; Surgical decompression of CN V
Partial Seizures Simple = focal sx, conscious, Jacksonian = simple muscle twitch that spreads progressively; 2o generalization = simple becomes grand mal; Complex Partial = automatism, olfactory hallucinations, fear, deja vu, loss of contact w/ environment; postictal confussion
Generalized Seizures Absence = petit mal; brief, freq. Loss of consciousness w/o loss of muscle tone, rapid eye blinks, no aura, no postictal Grand Mal= tonic clonic, preceded by GI upset or mood chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax & contract of muscles, unconscious, then confussion & postictal
Status Epilepticus continuous seizures w/o regained consciousness, grand mal progress or withdrawal of anticonvulsants; Complications = high fever, circulatory collapse, brain damage; Diazapam until controlled, Treat potential causes (glucose, thiamine, narcan)
TIA sudden, brief, emboli or arterial stenosis, Risks: obesity, smoking, DM, hyperlipidemia, Carotid artery= unilateral, contralateral hemiparesis & parathesia w/ ipsilateral blindness; Aphasia if dominant hemisphere involved, Vertebrobasillar = brainstem dysfunction => vertigo, confusion, blindness, diplopia, weakness, parathesia of extremities
Aneurysm localized vessel dilation, Berry Aneurysm = circle of Willis assoc w/ polycystic kidney disease & coarction of aorta
Subarachnoid Hemorrhage between pia & arachoid; usually rupture of a cerebral artery aneurysm or AV malformation; Worst HA, syncope, nuchal rigidity, vomiting, nonfocal abnormalities, decr consciousness, CT first if neg then lumbar puncture mandatory.
Intracerebral Hemorrhage Chronic HTN or local thrombus 2o to ischemia; Supratentorial: transtentorial herniation, w/ brainstem compression & midbrain bleeding, hemiparesis; Cerebellar : acute hydrocephalus due to CFS flow blockage; Acute onset HA w/ progressive neurological chgs.
Cavernous Sinus Thrombosis CN palsies, fever, exophthalmos, papilledema, HA, decr. consciousness, occasional seizures; IV antibiotics immediately
Acute Subdural Hematoma rapid bleed between arachnoid & dural layers; Tearing of bridging veins, Sx slower to progress, Signs of transtentorial herniation w/ deepening coma, progression from decorticate to decerebrate posture, mid position or fixed & dilated pupils, spastic hemiplegia w/ incr. DTR. LP is contraindicated because may lead to herniation
Chronic Subdural Hematoma Delayed formation of a subdural clot, Sx weeks after head injury, Elderly & alcoholics; Progressive daily HA, fluctuating consciousness & mild hemeparesis
Epidural Hematoma Between dura & skull, less common than subdural, injury to arteries (middle meningeal); Rapid brain compression, permanent neurological problems or death; Brief lucid period after head injury; progressive neuro signs
Concussion Injury due to blunt trauma; short loss of consciousness w/ intact brainstem function; post traumatic confussion syndrome w/ transient retrograde or anterograde amnesia; HA, vertigo, mild cognitive dysfunction
Toxic Vestibulopathies Alcohol: positional vertigo & nystagmus w/ in 2 hrs of ingestion Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 1-2 wks after ending tx Salicylates: reversible vertigo, tinnitus, sensorineural hearing loss Quinine & Quinidine: cinchonism (color vision defects, tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain & sweating Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing loss, sensory neuropathy
Toxic Neuropathies Lead: multi motor neuropathy; acute encephalopathy in children Organophosphates: delayed motor neuropathies, cholinergic crisis Arsenic and Thallium: acute onset symetrical sensorimotor polyneuropathy Isoniazid: Reversible sensory polyneuropathy reversible w/ concurrent pyridoxine Gold: symetrical polyneuropathy
Bacterial Meningitis 1st month life = group B strep & E. coli; Older kids = H. flu; Adults = S. pneumonia N. meningiditis at any age = 50% have petechial rash Brudzinski sign = neck flexion when supine causes involuntary hip & knee flexion Kernig's Sign: extension of knee in pt w/ flexed hip is painful CSF: decr. glucose, incr. neutrophils, incr. protein, incr. opening pressure; Tx: ampicillin & cefotaxime = infants; 3rd generation cephlosporin in kids > 3mos and adults
Encephalitis Inflammation of brain tissue; Viral etiology = CSF lymphocytes, normal glucose & negative bacterial cultures; Acylcovir x10 days
Reye's Syndrome follows viral infection; fatty infiltrate of organs; Usually kids; Salicylates can induce Sudden onset of encephalopathy, severe vomiting, & liver dysfunction; liver biopsy w/ fatty infiltrates confirms Dx.
Neurosyphillis Argyll Robertson Pupil (small, reacts to light but not accommodation); Psych disorders, Tabes Dorsalis; Tx: Procaine Penn G x 21 days; Examine CSF q 3-6 months until normal x 2 yrs.
Rabies Dogs worldwide; wild animals in US, Sx: malaise, fever, restlessness 1st. Sx progress to extreme excitement w/ painful laryngeal & pharyngeal spasms, Tx: Passive IG and active vaccine
Polio Fecal-oral; aseptic meningitis, paralysis w/o loss of sensation; Asymmetric paralysis during a febrile illness suggests it; Tx is palliative; OPV for all except immunocompromised who get IPV
Primary Neoplasms Glioblastoma Multiforme: most common in adults, high mortality; Meningioma: most common benign tumor in adults; Cerebellar Astrocytoma & Medulloblastoma: most common in kids
Huntington's Disease Autosomal dominant, Age 30-50; subtle dementia, irritability, antisocial, chorea, death 10-15 yrs after onset, atrophy of caudate nucleus & cerebral cortex, Tx D2-receptor antagonists (haloperidol)
Parkinsonism Idiopathic - loss of dopaminergic cells in substantia nigra; Pin rolling temor, masklike facies, lack of arm swing when walking, cogwheel rigidity, difficulty initiating movement, small shuffling steps w/ increasing speed (festinating gait). Tx: Levadopa (dopamine precursor), Amantadine, bromocriptine (dopaminergic agonists), Benzotropine (anticholinergic)
ALS (Lou Gehrig's Disease) Progressive loss of anterior horn cell function; Initially = LMN dysfuntion w/ hand & foot weakness & atrophy; asymmetric progression, No sensory abnormalities; Later= UMN dysfunction w/ muscle spasticity, incr. DTR, extensor plantar reflexes
Tay Sachs Disease Autosomal recessive; Eastern Europe jews & french Canadians; Absence of Hexosaminidase A, can't metabolizes lipid gangliosides, build up in brain; Progressive dev. delay, paralysis, blindness, dementia; death by age 4
Guillain-Barre Syndrome polyneuropathy after mild viral illness, inoculation or surgery; Most common acquired demyelinating disorder; progressive bilateral weakness of legs, proximal weakness, abnormal DTR, instability of temp & BP; CSF = incr. protein w/ normal pressure, glucose & cell numbers; Plasmaphresis speeds recovery; Corticosteroids are contraindicated
Cerebral Palsy CNS damage before age 5; Risks: Prematurity, IUGR, inutero complcations, neonatal jaundice, birth trauma, asphyxia, spastic syndrome, incr. DTR, incr. tone, weakness, toe walking, scissors gait
Myasthenia Gravis autoimmune, antibodies against acetylcholine receptors at neuromuscular junctions, incr. women, age 20 - 40; Ptosis, diplopia, dysarthria, enhanced muscle fatigue, thymoma on chest x-ray; Tx exogenous anticholinesterase (edrophonium or neostigmine); Thymectomy in pts < 60; steroids or azathioprine if unresponsive to tx
Muscular Dystrophy Duchenne most common type; X linked recessive, mutation in dystrophin gene; CK incr. before onset of sx; By age 5 toe walking, waddling gait, can't run; Prox legs 1st then prox arms; Pseudohypertrophy of calves = fat infiltrates in muscles;
Coma dysfunction both cerebral hemispheres or RAS; Acute onset = subarachnoid hemorrhage or brainstem infarct; progressive min-> hours = Intracerebral hemorrhage; days => weeks = chronic subdural hematoma, tumor or abscess; No laterialization following delirium = metabolic; Pupil size: dilated nonreactive = at or below midbrain, pinpoint = pontine; opiod OD, Constriction intact w or w/o extraoccular impairment = metabolic; Localizing response to pain = superficial coma; Decorticate (flex @ elbow, ext leg) = thalamic lesion of compression; Decerebrate (elbow & leg extension) = midbrain; No response to pain = pontine or medullary
Gait Abnormality Cerebellar lesions = truncal ataxia, broad based, unsteady, irregular; can't turn Corticospinal = affected leg circumducts as it steps forward, scissors if bilateral Extrapyramidal = festinating gait, flexed posture, small rapid steps, no arm swing Motor System = Footdrop - anterior tibial; Calf muscle - can't toe walk; Pelvic muscle - waddling gait.
Arnold Chiari Syndrome Cong. Protrusion of medulla thru foramen magnum; unusual sensory & motor chgs, Onset ~ 40
Cold Calorics Test vestibular system, Slow deviation toward ear w/ cold water = brainstem intact, fast nystagmus away = contralateral cortex intact; COWS = cold opposite Warm same for fast component
Paget's Disease of Breast Intraductal Ca in main excretory ducts; crusting erosion of nipples w/ or w/o discharge
Polycystic Ovarian Disease incr. LH, decr. or normal FSH; hirsutism, obesity, menstrual irregularities, infertility
Menopause Avg age =51; incr. FSH & LH; Hot flashes, Atrophic vaginal epithelium
Urinary Incontinence Stress = incr. intra abd pressure, leak small amts of urine; Kegel exercises, estrogen Urge = detrussor instability; lg amts of urine leaked immediately after urge to void
1o Amenorrhea Absence age 16 w/ 2o sex development or absence by age 14 w/o 2o characteristics Anatomic Abnormalities; Ovary Failure ( incr. FSH & LH, decr. estradiol) (XO, turners, no ovary); Pituitary = Prolactinoma presents w/ galactorrhea (Bromocriptine to Tx), Hypothalamic = decr. FSH & LH, (anorexia, incr. exercise, stress); XY karotype
2o Amenorrhea Absence for 6 mos if prev normal; absence for 12 months if prev oligomenorrhea; r/o pregnancy; Galactorrhea = prolactinoma; Hirsutism = polycystic ovarian; Tx: 1st = progestin challenge (bleed w/ in 2 wks) if no bleed measure FSH levels
1o Dysmenorrhea correlates w/ 1st day of menses, cyclic, begins in adolescence, low back & abd pain, N/V/D, fatigue, HA
2o Dysmenorrhea acquired, Sx don't correlate w/ 1st day of cycle, Endometriosis most common cause
Asherman's Syndrome intrauterine adhesions after D&C; destruction of endometrium => amenorrhea
OBSTETRICS Hydantiform Mole Preeclampsia 1st TM, Very high Beta HCG, Snowstorm on US
Ectopic Pregnancy Beta HCG rises slowly, Amenorrhea, spotting, pain, Empty gestational sac on ultrasound, Ampulla of fallopian tube is most common site
Gestational Age Nagel's = Add 7 days to FDLMP subtract 3 months; fundal ht in cm after 13 weeks
Amniocentesis Adv maternal age, abn AFP - incr. Spina bifida, decr. Down's, detect lung maturity, early 2nd trimester
CVS Adv. Maternal age, late 1st trimester
Non stress Test > 2 fetal movements accompanied by incr. FHR of 15 bpm for at least 15 sec w/ in 20 min period
Contraction Stress Test Negative = 3 contractions in 10 min, lasting 40 sec w/o late decelerations Positive = consistent & late decelerations
Fetal HR normal 120-160, Brady = mild 100-120, < 100 severe; Tachy = mild 161-180; severe > 180
Decelerations Early = shape is mirror of contraction, head compression Variable = shape varies, cord compression Late = starts as contraction peaks, recovery after contraction is terminated, uteroplacental insufficiency
Placental Previa Partial - partially over os; Complete= covers OS, Marginal = at edge of OS, Complete Previa is indication for C section
Placental Abruption Premature separation of a normally implanted placenta, vag bleed, uterine tenderness, back pain, hypertonic uterus, fetal distress
Preeclampsia HTN w/ proteinuria & edema after 20 wks gestation
Eclampsia Preeclampsia + seizures
Gestational Diabetes 1 hr > 140 then do 3 hr; 3hr test = fast > 120, 1 hr > 190; 2 hr > 165, 3 hr > 145; Macrosomia, RSD, Cong abnormalities
Types of Pelvises Gynecoid = round inlet, nonprominent spines, wide subpubic angle Anthropoid = heart shaped inlet, decr. transverse and incr. AP diameters, decr. subpubic angle Android= triangular inlet, decr. subpubic angle, prominent spines Platypoid= incr. transverse and decr. AP diameters
Leopold's Maneuvers fundal palpation, sides of uterus from feet of mother, lower part of uterus, sides of uterus from head of mother
Stages of Labor 1. Onset contract => full dilation 2. Full dilation to delivery of head 3. Delivery of fetus to delivery of placenta 4. Delivery of placenta to 1 hr later