HIGH-YIELD SHELF NOTES

Surgery 2 – 26
Psychiatry 27 – 51
Obstetrics/gynecology 52 – 92
Medicine 93 – 150
Pediatrics 151 – 170

Young Kim, UCCOM c/o 2013

kim2yg@email.uc.edu
SURGERY

––––––––––––––––– CV ISSUES –––––––––––––––––
Goldman’s index: cardiac risk factors in surgery –
JVD (#1), recent MI (#2), PVCs and arrhythmias, age
>70, emergency surgery, aortic stenosis
JVD: indicates CHF, #1 CV risk factor overall, give
β-blockers, Ca2+-channel blockers, digitalis, and
diuretics if possible before surgery
MI: previous MI increases risk of post-op MI, so
consult cards and order a stress test
MI within 30 days: very high risk, delay surgery
Family Hx of MI: get a concentrated cardiac FHx,
EKG, and exercise stress test to assess risk factors
↑cholesterol: increased risk of coronary artery
disease, but do not postpone surgery
Premature ventricular contractions: at risk of
arrhythmia due to ventricular dysfunction,
indicated for stress test and echo
Ejection fraction: SV/EDV; normal EF >67%, an
EF<35% increases risk of operative MI
Diabetes: should be NPO 8 hours before surgery,
administer IVF with D5, check glucose morning of
surgery; if glucose >250 → 2/3 of insulin, if glucose
<250 → 1/2 of insulin
Hyperglycemia: ideal glucose is 100-250,
delay surgery until glucose is under control
Diabetic coma: absolute contraindication to
surgery; give IVF, correct acidosis and glucose
↓hct: important to determine underlying cause of
anemia, consider possible colorectal cancer
↑hct: either hypovolemia or polycythemia; if
hypovolemic → delay until hydrated, if polycythemic
→ important to determine underlying cause
Obesity: higher risk of HTN, cardiovascular disease,
post-op atelectasis, type 2 diabetes, DVTs; require
DVT prophylaxis and aggressive post-op pulmonary
care for preventing atelectasis
HTN: diastolic BP >110 is high risk of CV complications,
β-blockers reduce overall risk
Atherosclerosis: can present as acute coronary
syndome or peripheral vascular disease, always
evaluate pt’s cardiac risk factors
CV evaluation: EKG (and compare to old EKG),
persantine thallium stress test, dobutamine echo
LBBB: indicates underlying ischemic heart disease
RBBB: indicates significant pulmonary disease, but
can be normal in up to 10% of pts
Previous CABG: decreases cardiac risk if performed 6
months to 5 years before surgery, effect on cardiac
risk unclear if >5 years
Previous coronary angioplasty: high risk (33%) of
coronary restenosis, so stress test is indicated; if
angioplasty is recent, delay surgery for several
weeks
Angina: indicates coronary artery disease, evaluate
for possible coronary revascularization
AFib: give anticoagulation and β-blockers, and
cardiovert them to normal sinus rhythm
Carotid bruit: indicates carotid stenosis; indicated
for CEA if high grade (>70%) stenosis
Previous stroke: order a carotid duplex study, in
order to assess the carotid arteries
Gangrenous toe: peripheral revascularization is
more urgent than a full cardiac work-up
––––––––––––– RESPIRATORY ISSUES ––––––––––––
Smoking: up to 6× risk for post-op complications due
to compromised ventilation, must quit smoking for 2
months before surgery
COPD: give bronchodilators and try to improve
pulmonary status as much as possible
Severe COPD: very high risk for acute pulmonary
failure with surgery; teach patient about
incentive spirometry, give bronchodilators, and
mobilize post-op to prevent atelectasis
Green sputum: give oral antibiotics, and schedule
surgery after Tx is complete
Bloody sputum: indicates active infection or lung
cancer; requires a full work-up including CXR, CT
scan, and bronchoscopy
–––––––––––– HEPATOBILIARY ISSUES –––––––––––
Acute cholecystitis: presents as fever, RUQ pain,
WBC>15; get U/S → IVF, abx, lap chole w/in 72 hours
Child’s classification: stratifies risk of surgery in pts
with liver failure; measures 3 labs (albumin, bilirubin,
PT) and 3 clinical findings (encephalopathy, ascites,
nutrition)
Child’s group A: 0-5% mortality
Child’s group B: 10-15% mortality
Child’s group C: >25% mortality; not good surgical
candidates until Child’s status is improved
Alcohol use: delay surgery until pt has undergone
withdrawal, since post-op withdrawal syndrome has
a high risk of morbidity/mortality
Liver failure: make sure the pt is in a compensated
state, abstain from alcohol for 6-12 weeks, control
ascites, normalize nutrition status and coagulation
factors
Pressure necrosis on hernia: high risk of rupture
with a high mortality rate, requires urgent repair
Surgery – Preoperative Care
Delirium in liver failure: possible causes include
CNS abnormality, electrolyte imbalance, GI
bleeding, sepsis, or bacterial peritonitis; evaluate
for mental status change, and tap the ascites
Ascitic leakage: high risk of bacterial peritonitis;
manage by sending fluid to lab, giving IV
antibiotics, and urgent hernia repair
Hemorrhoids: suspect portal HTN in pt with
cirrhosis + hemorrhoids, high risk of hemorrhage
Malnutrition: indicated by recent weight loss (#1) or
albumin <3.0 (#2); give 7-10 days of pre-op nutritional
support ideally
––––––––––––––––– GU ISSUES –––––––––––––––––
Dysuria: get urinalysis and urine culture; if positive
for UTI, delay surgery until resolved
Chronic renal failure: delay surgery until pt is stable,
dialysis started, and any other problems resolved
CRF × K+ measurement: needs to be obtained
immediately before surgery, since CRF can result
in rapid electrolyte imbalances
CRF × operative bleeding: renal failure causes
platelet dysfunction secondary to uremia;
give desmopressin or FFP, but not platelets
CRF × operative hypotension: many possible
causes, consider glucocorticoid (aldosterone)
deficiency in a pt who has taken steroids before
Kidney transplant pt: require perioperative steroids
Post-op hyperkalemia: check EKG for peaked T
waves, Tx C BIG K DIe – calcium gluconate, bicarb-
insulin-glucose, kayexalate, and dialysis
–––––––––––––– VALVULAR ISSUES –––––––––––––
Mitral stenosis: elevated LA pressure can lead to
cor pulmonale (PH+RVH); management includes
cards consult, prophyactic abx for endocarditis, can
go to surgery if stable
Mitral stenosis × CHF: high risk of mortality;
requires extensive cardiac work-up, EKG, echo,
and operative monitoring of cardiac status
Aortic stenosis: Sx triad of angina, dyspnea, syncope,
and high possibility of sudden death; requires
cardiac work-up and operative monitoring
Endocarditis prophylaxis: recommended for GI
procedures, GU procedures, and HEENT procedures
Cardiomyopathy: high risk of arrhythmias, CHF,
heart failure, and sudden death; manage with cards
consult and full cardiac work-up
–––––––––––––––––– GI ISSUES –––––––––––––––––
Bowel prep: decreases fecal mass and bacterial
content in the colon → prevents colon surgery
 Surgery – Preoperative Care

complications; put pt on clears day before surgery,

NPO at midnight, and give a cathartic agent

GoLYTELY: an isotonic formula that causes no

change in electrolyte or water balance; fluid
remains in colon and causes a “volume washout”

Fleet’s Phospho-Soda: a sugar-rich, hypertonic

formula that works by drawing fluid into the GI
tract; risks include dehydration, metabolic
acidosis (loss of bicarb); avoid in diabetics

Magnesium citrate: an osmotic agent that draws

fluid into GI tract (mag is poorly absorbed); risks
include dehydration and hypermagnesemia; avoid
in renal failure

–––––––––––––––– OTHER ISSUES –––––––––––––––

Anesthesia of choice: multiple factors involved, so

it’s best to consult an anesthesiologist

Local anesthesia: ↓systemic effects, ↑pain

Spinal anesthesia: ↓pulmonary complications,

↓control over cardiac or vascular mechanisms

General anesthesia: ↑physiologic control,

↑pulmonary complications, ↓HR/BP

Aspirin use: stop aspirin use 7-10 days prior to

surgery, will affect platelet aggregation

NSAIDs use: stop NSAIDs 2 days prior, will affect

platelet aggregation

Cellulitis: active infections are associated with

higher risk of post-op wound infections; delay
surgery until infection is resolved

––––––––––––––– POST-OP FLUIDS ––––––––––––––
Post-op fluid management: replace blood lost
during surgery + provide maintenance IVF + make up
for fluid loss in drains/NG tubes/fistulas
Surgical blood loss: replace in a 3:1 ratio with IVF
(e.g. replace 500mL blood loss with 1.5L NS or LR)
Maintenance IVF: administer D5½NS+KCl,
using the 100/50/20 rule for daily fluid
requirements, or 4/2/1 rule for hourly fluids
Drains/NG tubes/fistulas: fluid loss should be
replaced milliliter for milliliter with regard to
specific electrolyte content
Third space: fluid sequestered into ISF due to
inflammation or injury, mobilized 3-5 days after
recovery → requires decrease in IVF rate
––––––––– OPERATIVE COMPLICATIONS ––––––––
Malignant hyperthermia: T>104 following
anesthesia w/ high risk of myoglobinuria; Tx
dantrolene, 100% O2, and cooling blankets
Bacteremia: T>104 and chills within 1 hour of an
invasive procedure; get blood Cx ×3 and start
empiric abx
Aspiration: complication of awake intubations;
leads to sudden death, chemical pneumonitis, or
secondary pneumonia
Aspiration management: prevent via NPO and
antacids before intubating, Tx BAL and broncho-
dilators (steroids are useless)
Tension PTX: complication of intubation in weak or
traumatized lungs, presents as “difficulty to bag”,
progressive hypotension and JVD; Tx emergent
needle decompression + chest tube
––––––––––– POST-OP COMPLICATIONS ––––––––––
Normal urine output: at least 0.5-1 mL/kg/hr
Post-op urine retention: presents as a need to
void, but inability to do so; Tx straight cath at 6
shours post-op and Foley after 2nd straight cath
UOP = 0: most likely a kinked or plugged Foley
UOP < 0.5: either fluid deficit (bleeding out) or
acute renal failure; give a bolus of 500mL IVF and
if UOP responds, then it’s due to fluid deficit
Post-op hematuria: consider bladder overdistention,
cancer, infection, kidney stones, trauma, prostatitis,
and cyclophosphamide; get urology consult
Post-op fever: consider the five Ws – wind
(atelectasis POD #1), water (UTI POD #3), walking
(DVT POD #5), wound infection (POD #7+), wonder
drug (drug-induced fever)
Atelectasis: partial lung collapse, Dx bilateral
inspiratory crackles, prevent with pulmonary
Surgery – Postoperative Care
toilet and incentive spirometry (can develop into volume depletion (slow) or altered MS (rapid); give
pneumonia on POD #3 if left untreated) D5½NS to correct imbalance
UTI: Dx urinalysis and urine Cx, Tx abx Hyponatremia: due to SIADH or isotonic fluid loss w/
free water resorption, presents as coma and
Urosepsis: UTI + septic shock; presents as cloudy convusions; Tx water restriction and LR/NS
urine, fever, hypotension, and ∆mental status;
Dx urinalysis and urine Cx, Tx empiric abx + IVF Hypokalemia: due to diarrhea or vomiting, give K+ at
a rate of <10 mEq/hr
DVT: Dx doppler studies, Tx heparin
Hyperkalemia: due to renal failure, aldosterone
Wound infection: Dx examine wound site for blockers, or release from dead tissue (crush injury,
erythema and fluctuance; if cellulitis → abx only, ischemic bowel, etc.); Tx C BIG K DIe – calcium
if abscess → drain pus and BID dressing changes gluconate, bicarb-insulin-glucose, kayexalate, and
dialysis
IV infection: Tx remove catheter and
inflammation should resolve, all IV sites should be Metabolic acidosis: pH<7.4 + HCO3<24, Tx correct
rotated every 4 days for prevention underlying problem (e.g. fluid resuscitation)
Suppurative phlebitis: infected thrombus at site Metabolic alkalosis: pH>7.4 + HCO3>24, Tx KCl
of venipuncture; Tx remove catheter and surgical
excision of infected vein to the first non-infected Respiratory acidosis: pH<7.4 + CO2>40 due to
branch, leave wound open, and give IV abx hypoventilation, Tx mechanical ventilation
GI fistula: causes leakage of GI contents from wound Respiratory alkalosis: pH>7.4 + CO2<40 due to
site; Tx NPO, TPN, and protect abdominal wall until hyperventilation caused by pain, fever, sepsis or
body can heal itself early ARDS; Tx correct underlying problem
Non-healing fistula: factors that prevent healing
are FRIEND – foreign body, radiation, infection,
epithelialization, neoplasm, distal obstruction
Fistula × peritonitis: requires surgical exploration
Fistula × abscess: requires percutaneous drainage
Post-op chest pain: consider MI or massive PE
MI: presents as chest pain +/- other classic signs;
Dx CK-MB or troponin I, treat the complications
Massive PE: presents as chest pain, hypoxia, and
prominent JVD; Dx V-Q scan, Tx heparin → IVC
filter if PE recur while anticoagulated
ARDS: presents as hypoxia due to septic shock, Tx
intubation w/ high PEEP and permissive hypercarbia,
then look for source of sepsis
Delirium tremens: presents as hallucinations in an
alcoholic POD #2-3, prevention is key and Tx is
controversial (benzodiazepines if choice is given)
Hepatic encephalopathy: presents as coma in a liver
failure pt s/p TIPS due to NH4+ toxicity
Wound dehiscence: presents as salmon-colored fluid
soaking dressings s/p open laparatomy POD #5;
stabilize wound site, surgical closure at a later date
Evisceration: dehiscence + intestines spilling out;
keep pt in bed and cover bowel w/ sterile dressings,
emergency surgical closure necessary
––––––––––– FLUIDS & ELECTROLYTES ––––––––––
Hypernatremia: every 3 Na+ over 140 indicates 1L
water loss (e.g. Na+ 146 = 2L water loss), presents as
 Surgery – Wound Healing

––––––––––––––– WOUND HEALING ––––––––––––– Prophylactic abx: recommended for any clean-
contaminated or contaminated procedures,
Primary intention: close approximation of wound insertion of prosthetic material, immunosuppression,
edges via sutures or staples or poor blood supply; give single dose 1 hour pre-op
and single dose post-op
Primary intention timing: epithelialized by POD
#2, max collagen in 5-7 days, avoid weight-lifting
for 4-6 weeks, complete healing by 6 months
(only 60-80% of original strength)

Secondary intention: contamined wounds left open

to prevent abscess formation; granulation tissue
forms first, then contraction via myofibroblasts,
then finally a delayed epithelialization

Third intention: wound initially left open, then

delayed primary closure afterwards

Secondary/tertiary intention timing: much more

delayed than healing by primary intention

Healing growth factors: PDGF, TGF-β, FGF, EGF

Suture knot: hard, knot-like structure below wound

site; absorbable sutures will resolve with time, non-
absorbable sutures can be taken out under lido/epi

Stitch abscess: infected suture that intermittently

drains pus, should be taken out under lido/epi

Incisional hernia: presents as bulging at wound site

with increased abd pressure (e.g. coughing), needs
to be repaired surgically

Red/sensitive scar: assuming no wound infection, it

could be completely normal; observe for 6 months
before considering surgical revision

Hypertrophic scar: raised scar within site of incision;

observe until scar is stable, then steroids + excision

Keloid: raised scar that extends beyond site of

incision; will grow back if excised

–––––––––––––– WOUND INFECTION ––––––––––––

Wound infection: red and tender area on incision

site; Tx drainage and BID wet-to-dry dressing
changes, no antibiotics unless cellulitis is spreading

Post-infection management: observation is slow

and can result in contractions; other options
include skin grafting (must have <105 bacteria per
gram of tissue) or healing by third intention

Wound types: clean, clean-contaminated,

contaminated, infected

Clean wounds: no entry into GI, GU, or

respiratory tracts; <1% infection rate, Tx primary
closure

Clean-contamined wounds: enters GI, GU, or

respiratory tract in a controlled manner;
<10% infection rate, Tx primary closure

Contaminated wounds: major wound

contamination (e.g. bowel spillage or stab
wounds); Tx secondary closure

–––––––––––––––– LUNG CANCERS ––––––––––––––
Coin lesion: solitary pulmonary nodule on CXR;
DDx primary lung cancer, granuloma (TB or fungal),
hamartoma, metastatic cancers
Coin lesion management: first thing is always to
get an older CXR for comparison studies → if
suspicious, sputum cytology and CT scan
Benign coin lesions: calcification = granuloma,
bull’s-eye shape, popcorn shape = hamartoma,
air-crescent sign = aspergilloma, Southwest
region = coccidioidomycosis, Ohio river valley =
histoplasmosis
Indeterminate coin lesions: resection indicated
Malignant coin lesions: spiculations or 20+ pack-
year smoking = primary lung cancer, multiple
lesions = metastatic cancer; resection indicated
Lung cancer management: first thing is always CXR
→ if suspicious, sputum cytology and CT scan → if
still suspicious, bronchoscopy and mediastinoscopy
w/ biopsy (“tissue is the issue”)
NSCLC staging: stage I is local, stage II involves hilar
LN, stage III involves distal LN, stage IV is metastatic
cancer
NSCLC Tx: stage I/II → first get spirometry and
V/Q scans to see if pt is a surgical candidate,
then do pneumonectomy or sleeve lobectomy;
stage III/IV → chemotherapy and radiation
Surgery contraindications: FEV1 <800mL,
mediastinal LN involvement, distal metastases
SCLC staging: limited stage involves ipsilateral lung
only, extensive stage involves contralateral lung
SCLC Tx: chemotherapy and radiation
Pancoast tumor: superior sulcus tumor at the apex
of the lung; presents as Horner syndrome – ipsilateral
ptosis, miosis, anhidrosis, flushing due to loss of
sympathetic tone (invades superior cervical ganglia)
Pancoast tumor Tx: two stages – irradiation for 6
weeks to shrink tumor, then surgical resection
Bronchial adenoma: tumors that arise from within
bronchi and cause obstruction; MC lung cancer in a
nonsmoker under 30 y/o, Sx hemoptysis and
atelectasis, Dx CT scan and bronchoscopy (beware
of possibility of bleeding)
Bronchial adenoma Tx: lobectomy is curative
Mesothelioma: cancer arising from pleural
mesothelium, shipyards and asbestos exposure are
risk factors, Dx CT scan shows thick pleural walls
Mesothelioma Px: not responsive to medical
therapy, most pts have <1 year to live w/o surgery
Mesothelioma Tx: extrapleural pneumonectomy
is curative, but high rate of morbidity/mortality
–––––––––––––––– LUNG DISEASES ––––––––––––––
Pleural effusion: fluid build-up in pleural space,
cancer in older pt until proven otherwise; DDx CHF,
bronchogenic carcinoma, mesothelioma, empyema,
pneumonia, TB effusions
Pleural effusion management: get thoracentesis
and culture pleural fluid, and a pleural biopsy
Spontaneous PTX: rupture of apical blebs in healthy
young people causes sudden chest pain and dyspnea;
Tx thoracostomy on water-seal drainage
Recurrent/persistent PTX: indicated for thorascopic
excision of blebs, and pleurodesis (either scraping or
talc application) causing pleural adhesions
Bilateral PTX: dangerous situation, indicated for
pleurodesis to prevent future recurrences
Empyema: collection of pus within pleural cavity;
presents with cough, fever, chest pain, and pleural
effusion on CT scan; MCC is Staph aureus
Empyema Tx: initiate appropriate antibiotics,
insert chest tube, evacuate pus collection, then
re-expand the lung
––––––––––––––– HEART DISEASES ––––––––––––––
Unstable angina: progressive ischemia of
myocardium resulting in increasing angina at rest
and an ischemic EKG pattern
Unstable angina management: cardiac catheter
and evaluate for potential revascularization, Tx
bypass or angioplasty
Ejection fraction: SV/EDV; normal EF is 67%, EF <50%
is abnormal, EF <35% is high-risk for operative MI
Coronary artery disease: blockage of coronary
arteries, high risk of sudden death due to ventricular
arrhythmias; Tx bypass or angioplasty
Left main disease: blockage of only LCA, worst Px
Three-vessel disease: blockage of LAD/RCA/LCX
Coronary artery bypass: open via median
sternotomy, isolate internal thoracic artery (best
choice) or greater saphenous vein, put on bypass
and stop the heart, sew grafts to arteries, restart the
heart and close up
CABG mortality: 3% overall, greater in high-risk
pts but they benefit the most from the surgery
Coronary angioplasty: insertion of stent to prolong
patency of clogged coronary arteries, 33% rate of
restenosis in 1 year
Cardioplegia solution: solution used to stop heart
mid-diastole to protect it from ischemia and provide
a motionless field; often used with hypothermia to
prolong time of safe ischemia (up to 2.5 hours)
Surgery – Cardiothoracic Surgery
Off-bypass coronary surgery: grafting of ITA or GSV
to coronary arteries without bypass in order to avoid
complications of bypass (e.g. general inflammatory
response); reserved for high-risk pts
Dilated cardiomyopathy: dilation of myocardium
causes systolic dysfunction leading to progressive
dyspnea and fatigue, often preceded by viral URI
DCM Px: 1/3 recover, 1/3 stay the same, 1/3 die
DCM Tx: β-blockers will improve heart function,
but heart transplant is indicated (requires
chronic immunosuppression)
Heart transplant: remove donor heart and isolate in
hypothermic cardioplegia solution, remove recipient
heart on bypass, suture donor heart in recipient;
MCC of death are infection due to immuno-
suppression, and accelerated coronary artery
atherosclerosis
Constrictive pericarditis: presents as dyspnea,
hepatomegaly, and ascites due to diastolic failure;
Dx cardiac cath shows “square root sign”, Tx
surgical correction
––––––––––––– VALVULAR DISEASES ––––––––––––
Valvular disease management: first detected on
auscultation → get an echocardiogram
Valve replacement: mechanical valves (durable
but require anticoagulation) and porcine valves
(nonthrombogenic but will deteriorate over time)
Aortic stenosis: angina, dyspnea, syncope, and high
risk of sudden death; Dx harsh mid-systolic murmur,
MCC is congenital bicuspid aortic valve with
dystrophic calcification, Tx valve replacement when
symptomatic
Aortic regurgitation: presents as loud, blowing
diastolic murmur and bounding pulses; if chronic →
valve replacement when symptomatic, if acute →
emergent valve replacement and long-term abx
Mitral stenosis: presents as dyspnea and fatigue,
caused by rheumatic fever, results in cor pulmonale
(RVH+PH) and AFib; Tx valve repair or replacement
Mitral regurgitation: presents as dyspnea and
fatigue, caused by MVP, Dx high-pitched holosystolic
murmur; Tx annuloplasty (preferred) or valve
replacement
Mitral prolapse: eccentric closure of mitral leaflets;
common in women, precedes severe disease in men
––––––––––– MEDIASTINAL DISEASES –––––––––––
Anterior mediastinal mass: thymomas, lymphomas,
teratomas, other metastatic germ cell neoplasms
Thymoma: often presents with progressive
muscle weakness secondary to myasthenia gravis,
Tx surgical removal via median sternotomy
Lymphoma: Tx radiation and chemotherapy
 Surgery – Cardiothoracic Surgery

Teratoma: contains hair and teeth, Tx surgical

removal via median sternotomy

Middle mediastinal mass: lymphomas, bronchogenic

cysts, pericardial cysts

Bronchogenic cysts: develop from foregut

remnants, Tx surgical removal via thoracotomy

Pericardial cysts: typical water bottle appearance,

Tx surgical removal via thoracotomy

Posterior mediastinal mass: neurogenic tumors

(MCC is neurilemoma)

Neurilemoma: dumbbell-shaped tumor found

adjacent to vertebral bodies, develops from
nerves and nerve sheathes, Tx surgical removal
via thoracotomy

–––––––––––––– CAROTID DISEASES –––––––––––––
Atherosclerosis: systemic disease that has multiple
manifestations (stroke, TIA, CAD, MI, mesenteric
ischemia, AAA, PVD); presence of any one of these
should raise suspicion for the others
Stroke: a neurologic deficit that doesn’t resolve
within 24 hours, Tx t-PA only within 3 hours
Stroke management: carotid duplex study,
observation for improvement; CEA is not
indicated until pt has stabilized
Transient ischemic attack: brief neurologic deficit
that fully resolves within 24 hours; due to thrombo-
embolus from internal carotid arteries
TIA management: physical exam (check carotid
bruids, neuro, cardiovascular) + carotid duplex;
Tx aspirin or carotid endarterectomy
TIA × amaurosis fugax: emboli from carotid
travels to retina causing transient blindness;
Dx fundoscopic exam reveals Hollenhorst plaque,
a bright shiny spot in a retinal artery
TIA × aphasia: emboli from left carotid travels to
speech center located in left hemisphere
CEA: indicated for >70% carotid stenosis with either
neurologic sx or asymptomatic bruits; complications
include 1-3% risk of perioperative stroke, or injury to
facial, vagus, or hypoglossal nerves
Post-CEA management: start aspirin, encourage
lifestyle modifications (e.g. diet and exercise, quit
smoking) since patient is still high-risk for MI
Asymptomatic carotid bruit: get a carotid duplex
study, indicated for CEA if >70% stenosis
–––––––––––– PERIPHERAL DISEASES –––––––––––
Subclavian steal syndrome: presents as nothing at
rest, but arm claudication and CNS sx with arm
activity due to subclavian artery atherosclerosis; Dx
arteriogram, Tx bypass surgery
Arterial embolus: presents as the 6 P’s – pain, pallor,
parasthesias, poikilothermia, pulselessness, paralysis;
clot source is usually Afib or recent MI
Embolus Tx: requires urgent revascularization
within 6 hours; give heparin and go to OR for
balloon catheter embolectomy +/- fasciotomy
Embolus post-op: start warfarin for anti-
coagulation, then get CT scan or aortography to
search for source of emboli
Compartment syndrome: revascularization of
acutely ischemic limb results in ischemia-reperfusion
injury, causing muscle edema within fascial compart-
ment and the 6 P’s
Compartment syndrome Tx: fasciotomy
Ankle-brachial index: ratio of BP in arm vs. leg;
ABI >1.0 is normal, ischemic ABI is 0.6-0.8
(claudication) or 0.3-0.5 (rest pain)
Doppler tracing: normally triphasic due to systolic
flow → elastic recoil → diastolic flow; ischemic
signal is either biphasic (mild) or monophasic (severe)
Claudication: exercise-induced ischemia that causes
reversible calf pain, MCC is an atherosclerotic SFA
Claudication management: if mild → not
indicated for surgery, so exercise and lifestyle
changes are recommended; if severe → get
Doppler tracing, then arteriogram to localize
Claudication Px: 1/3 improve on a non-op exercise
program, 1/3 stay the same, 1/3 get worse
Aortoiliac stenosis: presents as triad of claudication
+ absent femoral pulse + impotence
Aortoiliac stenosis Tx: depends on case;
bilateral loss of femoral pulse → aortofemoral
bypass graft, single segment iliac stenosis →
angioplasty, high risk pt → lifestyle changes
Severe claudication: presents as claudication + rest
pain or foot ulcers, common in diabetics; get a
vascular work-up and arteriogram to determine level
of occlusion, and assess general medical status
SFA stenosis Tx: reverse GSV to SFA graft
Iliac stenosis Tx: surgical revascularization or
balloon dilation
SFA + iliac stenosis Tx: both of the above, either
at the same time or sequentially (iliac first)
SFA + popliteal stenosis Tx: femoropopliteal
bypass to the best artery continuous with the
foot, failure likely in distal and severe disease
Multiple obstructions Tx: reconstruction may not
be possible, limb amputation indicated
Bypass pre-op: 10% risk of MI, arrhythmias, or heart
failure; requires evaluation of cardiac status (get
dipyridamole-thallium scintigraphy to rule out CAD)
Pre-op reveals <30% ejection fraction: high risk of
post-op heart failure
Pre-op reveals CAD: cancel or delay surgery,
perform a less invasive procedure, pre-op CABG
or PTCA, or intensive intraoperative monitoring
Pre-op reveals recent MI: delay surgery for 3 mo
Bypass post-op: daily duplex studies to check for
graft stenosis, give aspirin, educate on lipid control
and foot care; MCC death is CAD
Trash foot: post-op embolization of atherosclerotic
debris following bypass results in cyanotic toe;
Tx heparinization of clot and long-term aspirin use
–––––––––––– ABDOMINAL DISEASES –––––––––––
Surgery – Vascular Surgery
AAA: presents as painless pulsatile abdominal mass;
management is getting ultrasound and CT scan, then
elective graft repair if aorta is >5 cm
AAA repair post-op: major fluid shifts (third-space
loss on POD#1/2, third-space mobilization on
POD#3), cardiac problems due to aortic clamping,
and impotence due to damage of hypogastric
circulation or autonomic nerves around IMA
Ruptured AAA: presents as pulsatile mass, back and
abdominal pain, and hypotension; if unstable → OR,
if stable → get CT scan or ultrasound, then OR
Ruptured AAA repair: clamp aorta at level of
diaphragm to stop bleeding, then proceed with
repair; 80% risk of death by bleeding out in the OR
AAA repair × bloody diarrhea: indicates ischemic
colitis due to interrupted IMA; Dx sigmoidoscopy,
Tx bowel rest if limited to mucosa, colectomy and
colostomy if full-thickness involvement
AAA repair × delayed fever: indicates vascular
graft infection via S. aureus or S. epidermidis;
Dx CT scan, Tx graft removal, debridement, and
IV antibiotics
AAA repair × UGI bleed: indicates aortoduodenal
fistula, usually a small bleed followed 1-2 days
later by massive bleeding; Dx CT scan, Tx graft
removal and GI repair
Mesenteric ischemia: presents as postprandial abd
pain, weight loss, and multiple abd bruits due to
atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx
mesenteric angiogram, Tx revascularization;
follow-up with aspirin and evaluation for other
atherosclerotic diseases
Aortic dissection: presents as acute onset tearing
chest/back pain due to severe HTN (200/140), CXR
shows widened mediastinum
Aortic dissection management: Dx MRI, spiral CT,
transesophageal echo, or arteriography; if
ascending aorta → go to OR for surgical repair, if
descending aorta → β-blockers
–––––––––––––– VENOUS DISEASES –––––––––––––
Deep venous thrombosis: presents as acute onset
dull leg pain, unilateral swelling, and Homans’ sign
DVT risk factors: Virchow’s triad – stasis,
endothelial damage, and hypercoagulability
DVT management: Dx duplex ultrasound, Tx
therapeutic heparin or LMWH, followed by long-
term warfarin therapy (follow INR)
Post-thrombotic syndrome: occurs in 10% of DVT pts,
presents as severe leg edema and ulceration around
ankle area due to chronic venous HTN
 Surgery – Vascular Surgery

Post-thrombotic syndrome management:

prevention via chronic use of support hose, heal
ulcers if they’ve already developed

DVT prophylaxis: indicated if pt is at risk for DVT;

includes leg compression devices and subcutaneous
low-dose heparin

DVT prophylaxis for hip fx: fondaparinux and leg

compression devices

Pulmonary embolus: presents as acute onset chest

pain, dyspnea, and hyperventilation (↓PCO2), due to
DVT embolization into lung → wedge-shaped area of
lung infarction, S1Q3T3 on EKG

PE management: get EKG to rule out MI, ABGs

(shows ↓PCO2), CXR, and pulse oximeter;
mismatch on a V/Q scan is diagnostic, Tx identical
to DVT Tx

Recurrent PE: due to failure of heparin therapy;

indicated for IVC interruption with a metal filter

Anticoagulation: therapeutic/high-dose heparin or

LMWH for Tx DVT/PE, low-dose for prophylaxis;
IVC filters when anticoagulation fails or is contra-
indicated

Anticoagulation × HIT: rare heparin side-effects

include thrombocytopenia and paradoxical
arterial clots, d/c heparin immediately

Anticoagulation × skin necroses: rare side-effect

of warfarin therapy, start warfarin along with
heparin to prevent this from happening

Anticoagulation × UGI bleed: life-threatening

condition that requires immediate d/c, give pt a
metal filter instead for PE prophylaxis

Phlegmasia cerulea dolens: presents as acute onset

leg edema with pain and cyanosis due to venous
outflow obstruction, high risk of nerve damage and
venous gangrene

PCD management: elevate leg and immediate

anticoagulation, then order duplex ultrasound
and pelvic CT scan to confirm the Dx

–––––––––– OTHER VASCULAR DISEASES –––––––––

Temporal arteritis: presents as severe, unilateral

headache, visual changes, and nodularity of
temporal artery; give high-dose steroids right away
to prevent blindness

–––––––––––– ESOPHAGEAL CANCERS –––––––––––
Dysphagia: management includes barium swallow
and esophagoscopy w/ biopsy; DDx achalasia,
Zenker diverticulum, esophageal cancers, strictures
Esophageal cancer: SCC in upper 2/3 due to cigs and
EtOH, adenocarcinoma in lower 1/3 due to Barrett’s,
Sx progressive dysphagia and weight loss
EC management: esophagoscopy and biopsy,
then staging via endoscopic ultrasound and CT
scan, then specific Tx
EC staging: stage I invades submucosa only, stage
II invades muscularis +/- LN, stage III invades
adventitia + adjacent structures, stage IV is
metastatic
EC prevalence: adeno MC in US, SCC elsewhere
EC Tx: upper 1/3 – chemo and radiation only;
middle 1/3 – chemo and radiation to shrink the
tumor, then esophagectomy; lower 1/3 –
esophagectomy and proximal gastrectomy; never
operate on stage IV cancer
Advanced esophageal cancer: Sx severe dysphagia
and chronic cough (due to aspiration from TE fistula),
management is palliative care b/c surgery won’t help
––––––––––– ESOPHAGEAL DISEASES –––––––––––
Zenker diverticulum: pulsion diverticulum that
develops at upper esophagus due to abnormal
coordination of cricopharyngeal constriction;
Sx dysphagia, regurgitation, and bad breath
Zenker management: Dx barium swallow, Tx
cricopharyngeus myotomy
Traction diverticulum: diverticulum at middle
esophagus due to LN traction, indicates cancer
Esophageal motility disorders: achalasia (only one
treated surgically), nutcracker esophagus, spasms,
hypertensive LES
Achalasia: hypertonic and non-relaxing LES w/
poorly relaxing esophagus, Sx dysphagia of
liquids > solids
Achalasia management: Dx bird’s beak on barium
swallow and ↑LES pressure on manometry, Tx
Heller myotomy
Nutcracker esophagus: painful swallowing due to
high amplitude action potentials, Tx nifedipine
Diffuse esophageal spasms: uncoordinated 3°
peristalsis, Tx medically
Hypertensive LES: high LES pressure at baseline
but relaxes with swallow, Tx medically
Acute epigastric pain: DDx acute pancreatitis, GERD,
PUD (gastric ulcers or duodenal ulcers), cholelithiasis,
gastroenteritis
Pain × PMHx: gallstones or alcoholism = acute
pancreatitis (order amylase/lipase levels), NSAIDs
or steroid use = PUD
Esophageal varices: present as UGIB due to portal
HTN, often alongside coagulopathy (liver failure)
EV management: band the bleeding varices,
correct any coagulopathy, IV octreotide to lower
portal pressure → if bleeding continues, repeat
endoscopic banding → if bleeding continues,
TIPS or gastric balloon tamponade
EV follow-up: β-blockers to lessen chance of
rebleeding; good liver function → elective TIPS,
bad liver function → liver transplant
Mallory-Weiss syndrome: presents as UGIB due to
retching lacerating the lower esophagus, bleeding
usually stops spontaneously
Boerhaave syndrome: presents as epigastric pain
and fever due to retching perforating the esophagus;
Dx contrast swallow, Tx emergent surgical repair
Instrumental perforation: presents as retrosternal
pain, fever, and pneumomediastinum s/p upper GI
endoscopy; Dx contrast swallow, Tx surgical repair
GERD: presents as heartburn, regurgitation,
waterbrash (sour taste), dysphagia, cough
GERD Tx: PPIs → if it persists after six weeks, do
EGD w/ biopsy to see what’s going on
Normal EGD: PPIs or elective lap Nissen
Esophagitis: multiple, nonulcerating erosions in
stomach; mild to moderate esophagitis → PPIs
for 8-12 weeks, severe esophagitis → lap Nissen,
uncontrollable bleeding esophagitis → subtotal
gastrectomy
Barrett esophagus: intestinal metaplasia of
esophageal epithelium; no dysplasia → Tx PPIs or
lap Nissen; low-grade dysplasia → Tx lap Nissen +
annual surveillance; high-grade dysplasia → Tx
esophagectomy
Lap Nissen fundoplication: wraps fundus of stomach
around LES to keep it in abdominal cavity (must
check for intact esophageal peristalsis first); contra-
indicated in morbidly obese (gastric bypass instead)
Hiatal hernia: hernia from abdominal cavity, through
diaphragm, into chest cavity
Type 1 hiatal hernia: sliding hernia, risk of reflux
esophagitis, Tx PPIs
Type 2 hiatal hernia: paraesophageal hernia, risk
of incarceration/strangulation, Tx surgical repair
Type 3 hiatal hernia: presence of both types 1+2,
Tx surgical repair
–––––––– GASTRIC/DUODENAL DISEASES ––––––––
Peptic ulcer disease: gastric ulcers, duodenal ulcers
Surgery – Upper GI Surgery
PUD surgery indications: intractability,
perforation, obstruction, bleeding
Duodenal ulcers: caused by ↑acid secretion; most
commonly in 1st part of duodenum, DU in 2nd-4th part
indicates Zollinger-Ellison syndrome (gastrinoma)
DU types: posterior ulcers bleed due to gastro-
duodenal artery, anterior ulcers perforate
DU Tx: triple therapy → if ulcer persists, surgery
is indicated (HSV > TV+P >> TV+A), also get serum
gastrin levels to rule out Z-E syndrome
Perforated DU: CXR shows free air under
diaphragm; use omentum to patch the ulcer
(Graham patch), then stop acid w/ PPIs or HSV
Perforated DU × sepsis: complete Graham patch
as soon as possible, give PPIs and IV abx, then
monitor in ICU and plan surgery for a later date
Bleeding DU: due to posterior ulceration into
GDA; Tx oversew the ulcer, then stop acid w/ PPIs
Gastric ulcers: caused by ↓mucosal protection; type I
– lesser curvature at incisure, type II – duodenum
and stomach, type III – pylorus, type IV – GE junction
GU Tx: PPIs → if ulcer persists after six weeks, do
endoscopy and multiple marginal biopsies for
possibility of gastric cancer; if ulcer persists after
18 weeks, surgery is indicated
GU surgery: wedge resection or distal
gastrectomy (due to possibility of cancer), TV+P
for types II and III due to ↑acid production
Bleeding GU: Tx excision rather than oversewing
Gastric cancers: lymphoma, adenocarcinoma, GIST
(e.g. sarcomas and lipomas)
Gastric adenocarcinoma: often spreads to left
supraclavicular (Virchow’s) node and ovaries;
Tx proximal → total gastrectomy, if distal →
distal gastrectomy w/ anastomosis; take out D1
LN at lesser curvature
Linitis plastica: infiltrating carcinoma with desmo-
plastic reaction causing stomach to look fixed
and rigid; Tx total gastrectomy w/ splenectomy
Gastric lymphoma: first determine cancer stage
(CT scan, LN biopsy, and bone marrow Bx);
Tx partial thickness → radiation, full thickness →
surgical resection
GIST: any soft tissue tumor of stomach; Tx wedge
resection w/ 1 cm negative margins (no LN)
Gastric varices: present as UGIB due to portal HTN,
Tx uncontrollable bleeding w/ TIPS or splenectomy
instead of banding
 Surgery – Pancreatic/Hepatic Surgery

––––––––––––– GB/BILIARY DISEASES ––––––––––––
Biliary disease progression: cholelithiasis → biliary
colic → acute cholecystitis; choledocholithiasis →
ascending cholangitis or gallstone pancreatitis
Cholelithiasis: presents as nausea, vomiting, RUQ
pain w/o fever; only 15-20% are symptomatic
Cholelithiasis in pregnancy: manage non-op if
possible (hydration and pain meds), elective lap
chole can be done after delivery
Biliary colic: fatty meal → CCK release → gall
bladder contraction against non-lodged stone
resulting in transient RUQ pain for <6 hours; labs are
usually normal if episode has passed
Cholecystitis: presents as fever, WBC>15, RUQ pain
>6 hours; MC bacteria are E. coli, Bacteroides fragilis,
Klebsiella, Enterococcus
Cholecystitis management: Dx abdominal U/S,
order CBC and LFTs, Tx lap chole within 72 hrs
Cholecystitis in elderly: elderly pts respond to
sepsis with hypothermia and ↓WBC
Cholecystitis antibiotics: ciprofloxacin (Cipro)
and metronidazole (Flagyl) to cover GNR and
anaerobes; abx not indicated for cholelithiasis
Cholecystectomy indications: symptomatic
cholelithiasis, acute cholecystitis, and cholangitis;
do not operate on asx stones
Cholecystectomy complications: nicking the CBD
(jaundice) or right hepatic artery (hepatitis)
Post-op biliary leak: presents as Charcot’s triad;
get an U/S and HIDA scan → Tx biliary drainage
and temporary stent during ERCP
–––––––––––––––––– JAUNDICE –––––––––––––––––
Jaundice: elevated bilirubin and yellowing of skin;
three types – hemolytic, obstructive, hepatocellular
Hemolytic jaundice: ↑bilirubin (direct <20%),
search for what’s killing the RBCs
Hepatocellular jaundice: ↑bilirubin (direct 20-50%)
and ↑AST/ALT, consider HBV/HCV and alcoholism
Obstructive jaundice: ↑bilirubin (direct >50%) and
↑alk phos, caused by CBD stones and cancers
Painless jaundice: caused by biliary obstructive
tumors (ampullary cancer, duodenal cancer,
cholangiocarcinoma, pancreatic adenocarcinoma)
Painless jaundice management: Dx CT scan then
ERCP, Tx Whipple if no mets or local invasion
Painless jaundice × occult bleed: indicates
ampullary cancer, get CT scan then Whipple
–––––––––––– PANCREATIC DISEASES –––––––––––
Pancreatic head mass: check for metastases, then
perform Whipple if no mets
Pancreatic adenocarcinoma: presents as obstructive
jaundice, get a CT scan; cancer in head → Tx Whipple,
in body or tail → distal pancreatectomy, mets or
local invasion → palliative care (no surgery)
Acute pancreatitis: presents as epigastric pain
boring through to the back w/ ↑lipase/amylase;
amylase levels do not correlate with severity
Pancreatitis causes: I GET SMASHED – Idiopathic,
Gallstones (#1), EtOH (#2), Trauma, Steroids,
Mumps, Autoimmune, Scorpion sting, Hyper-
triglyceridemia (#3), Hypercalcemia, ERCP, Drugs
Chronic pancreatitis: presents as constant epigastric
pain, steatorrhea, and diabetes in a chronic alcoholic;
Tx insulin and pancreatic enzyme replacement
––––––––––––––– LIVER DISEASES ––––––––––––––
Liver cyst: simple cyst, leave it alone
Echinococcal cyst: multilocular cyst w/ calcified walls
due to parasite Echinococcus granulosus; inject
hypertonic saline inside cyst and carefully excise it
Liver abscess: multiple/small bacterial abscesses →
IV antibiotics; single/large bacterial abscess → perc
drain; amebic abscess (Mexicans) → metronidazole
Liver cancers: hepatic adenoma, focal nodular
hyperplasia, hemangioma, hepatoma
Hepatic adenoma: often presents as hypovolemic
shock and distended abdomen, related to OCPs
and anabolic steroid abuse; Tx d/c OCP → if it
persists, resect due to possibility of rupture
FNH: Dx central stellate scar or sunburst pattern
on CT scan, no OCP relationship, leave alone even
if symptomatic
Hemangioma: leave alone even if symptomatic,
never spontaneously rupture, do not needle
biopsy due to possibility of rupture
Hepatoma: presents as vague RUQ pain and mass
related to HBV/HCV and cirrhosis w/ ↑αFP; Dx CT
scan then Tx resection w/ negative margins
indicated as long as there’s no mets
Portal HTN: Sx esophageal varices, caput medusa,
hemorrhoids; Tx TIPS (connect portal vein to hepatic
vein to relieve pressure) as a “bridge to liver txp”

Post-op obstruction: presents as Charcot’s triad Edematous pancreatitis: get amylase/lipase,

due to stricture or retained stone; get an U/S and
HIDA scan → Tx biliary drainage and choledocho-
jejunostomy
Choledocholithiasis: presents as transient jaundice
and ↑alk phos; Dx U/S shows dilated bile ducts +/-
ERCP, Tx lap chole w/ CBD exploration
Acute cholangitis: presents as Charcot’s triad
(jaundice, fever, RUQ pain) or Reynold’s pentad
(shock, ∆MS) due to choledocholithiasis
Acute cholangitis management: IVF, antibiotics,
and U/S → ERCP to decompress biliary tree →
finally lap chole w/ CBD exploration
GB polyps: <2 cm observe, >2 cm take it out due to
risk of adenocarcinoma
GB adenocarcinoma: presents as mass in GB fossa;
Dx CT scan, Tx open chole + hilar LN resection + liver
resection w/ negative margins
Porcelain GB: dystrophic calcification of GB has 50%
risk of adenocarcinoma, take it out
then NPO, IVF, pain meds
Hemorrhagic pancreatitis: presents as MSOF,
ARDS, and hemodynamic instability; send to ICU
for resuscitation and serial CTs
Ischemic pancreatitis: Dx no blood flow to
pancreas on contrast CT, Tx IV abx and resection
Gallstone pancreatitis: if amylase returns to
normal → lap chole + cholangiogram; if
complicated → ERCP to remove stone
Pancreatic abscess: presents as septic shock 2 weeks
after acute pancreatitis; Dx dynamic CT scan, Tx perc
drain + antibiotics
Pseudocyst: abdominal pain and early satiety 5
weeks after acute pancreatitis, Tx cystogastrostomy
only if it’s symptomatic and has been present for 6+
weeks (must get Bx w/ frozen epithelial section and
see no epithelial lining before the ostomy since
epithelium indicates cancer)

––––––––––– SMALL BOWEL DISEASES –––––––––––
Small bowel obstruction: presents as colicky abd
pain, nausea/vomiting, and constipation; MCC are
adhesions from previous surgery and hernias
SBO management: get KUB → Dx air-fluid levels
and dilated loops; Tx NPO, NG suction, IVF, and
initially observation
SBO × electrolyte imbalance: “hypokalemic,
hypochloremic metabolic alkalosis” due to emesis
SBO × bloody diarrhea: indicates obstructive
tumor or ischemic bowel; Dx sigmoidoscopy →
observe if mucosal, resection if full-thickness
SBO × flatus: indicates partial SBO since gas can
get through, more likely to resolve w/o surgery
SBO × diarrhea: indicates partial SBO due to fecal
impaction and severe constipation
SBO × inguinal hernia: requires urgent hernia
repair to relieve strangulation
SBO × melanoma: melanoma is the MC tumor
that metastasizes to intestine, surgery indicated
since these don’t resolve spontaneously
SBO × other cancers: surgery indicated since
these don’t resolve spontaneously
SBO × peritonitis: presents as rebound tender-
ness, ↑WBC, fever, or metabolic acidosis due to
necrotic bowel; indicated for ex lap
SBO × adhesions: indicated for ex lap → lysis of
adhesions
SBO × closed loop obstruction: usually due to
adhesive band occluding two segments of bowel;
indicated for ex lap → lysis of adhesions,
resection of any dead bowel, and “second look”
operation if bowel viability is indeterminate
SBO × pneumoperitoneum: indicates perforation
due to ischemic or overdistended bowel;
indicated for ex lap → dead bowel resection
Nicked bowel during LOA: small hole → primary
repair, large or multiple holes → bowel resection;
high risk of leakage and EC fistula formation
Uncertain about SBO: get an upper GI series w/ small
bowel follow-through, barium contrast will stop at
site of obstruction if SBO exists
Mesenteric ischemia: presents as postprandial abd
pain, weight loss, SBO, and multiple abd bruits
usually due to atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx
mesenteric angiogram, Tx revascularization;
follow-up with aspirin and evaluation for other
atherosclerotic diseases
Mesenteric ischemia × peritonitis: presents as
rebound tenderness, ↑WBC, fever, or metabolic
acidosis due to necrotic bowel; ex lap indicated
Mesenteric ischemia × AFib: indicates emboli
shooting from left atrium to celiac trunk or SMA
Mesenteric ischemia × ↑hct: polycythemia due to
severe dehydration requires IV fluid resuscitation
Mesenteric ischemia × CHF: ischemia may be
secondary to a low-flow, nonocclusive state;
indicated for mesenteric vasodilation and
improve cardiac output
Mesenteric ischemia × aortic dissection:
dissected aorta can occlude mesenteric vessels;
Dx angiography, Tx surgical repair
Mesenteric ischemia × ↓BP: either ischemic
bowel causing septic shock, or hypotension
causing low-flow, nonocclusive ischemia
Left colon necrosis: bowel resection → anastomosis
if stable, otherwise colostomy and Hartmann pouch
Long segment necrosis: bowel resection → small
bowel syndrome requiring chronic TPN or transplant
Short segment necrosis: bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Small punctate necroses: indicates multiple small
emboli or low-flow state; bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Bowel ischemia but no necrosis: try to revascularize
the bowel via removing or bypassing the occlusion
Low-flow but no necrosis: non-op management of
hemodynamic status, surgery should be avoided
––––––– INFLAMMATORY BOWEL DISEASE –––––––
Inflammatory bowel disease: Crohn’s disease and
ulcerative colitis; presents as crampy abdominal pain,
bloody diarrhea, and recent weight loss
IBD management: colonoscopy to determine if
it’s UC, Crohn’s, or something else → abdominal
CT scan for confirmation of IBD
Crohn’s disease: inflammatory disease involving full
GI tract with skip lesions (terminal ileum is MC site),
Bx shows full thickness + noncaseating granulomas +
creeping fat, Dx terminal ileum string sign on CT scan
Crohn’s management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups
Crohn’s × SBO: due to stenotic terminal ileum;
manage with NPO, TPN, and observation → if it
fails to resolve, surgical stricturoplasty indicated
Crohn’s × perianal disease: metronidazole
Surgery – Lower GI Surgery
Crohn’s × rectal disease: rare, indicated for
subtotal colectomy and ileostomy
Ulcerative colitis: inflammatory disease involving
rectum and continuous proximal extension, Bx
shows mucosal involvement + crypt abscesses +
pseudopolyps, Dx lead pipe sign on CT scan
UC management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups, annual
colonoscopy for possibility of cancer
UC × severe dysplasia: total proctocolectomy,
ileal pouch formation, and ileo-anal anastomosis;
no further cancer surveillance needed
Pouchitis: presents as fever, bloody diarrhea, and
pain on defecation s/p ileal pouch formation for UC;
Tx metronidazole
Toxic megacolon: presents as fever, bloody diarrhea,
pain, and abdominal distention in a pt w/ UC
TM management: get KUB for confirmation, then
NPO, IVF, NG suction, IV steroids and abx;
improves → no surgery, stays the same or gets
worse → surgery necessary
TM × perforation: shows free air on upright CXR,
indicated for total colectomy and ileostomy w/
Hartmann pouch
TM × impending perforation: shows pneumatosis
on CT scan, indicated for surgery (see above)
––––––––––––––– APPENDICITIS –––––––––––––––
Appendicitis: presents as RLQ pain, low grade fever
and leukocytosis; MCC lymphoid hyperplasia
Appendicitis management: get CT scan or U/S
(U/S is cheaper); if uncomplicated → app’y, if
abscess (↑↑fever/↑↑WBC) → perc drain, interval
app’y
Appendicitis in kids: children with appendicitis
present more often with a ruptured appendix
Appendicitis in elderly: older pts usually don’t
have classic presentation of appendicitis, but
rather vague abdominal complaints, sepsis,
altered MS, or failure to thrive
Appendicitis in pregnancy: enlarged uterus can
push appendix upwards → RUQ pain; appy can
be performed safely w/o risk to mom or child
RLQ pain × dysuria: indicates appendicits, UTI, or
appendiceal abscess next to bladder
RLQ pain × minimal dysuria: likely appendicitis
RLQ pain × hematuria: indicates severe UTI or a
kidney stone
RLQ pain × h/o PID: could be appendicitis, recurrent
PID, or an ectopic; PID confirmed by cervical or
adnexal tenderness, or cervical discharge (get gyn
consult and stain discharge)

RLQ pain × h/o gastroenteritis: could be appendicitis
but likely gastroenteritis
RLQ pain × R pelvic tenderness: likely retrocecal
appendicitis, go to the OR
RLQ pain × BPH Sx: likely bladder outlet obstruction
due to enlarged prostate, Tx Foley catheter
RLQ pain × h/o IBD: IBD can present similarly to
appendicitis, get colonoscopy and CT scan and
manage appropriately
RLQ pain × crampy pain/diarrhea: indicates IBD,
constipation, or cancer rather than appendicitis
RLQ pain × corticosteroids: steroids can mask all Sx
of inflammation, be cautious since most steroid pts
won’t present until perforation occurs
App’y findings: inflamed appendix, perforated
appendix, normal appendix, inflamed cecum,
fecalith, carcinoid tumor, other tumors
Inflamed appendix: take it out
Normal appendix: take it out anyways unless
cecum is inflamed, check other areas for
abnormalities (terminal ileum for Crohn’s or
Meckel’s, perforated gastric or duodenal ulcer,
ovaries, etc.)
Inflamed appendix/cecum: take them both out
via right colectomy
Inflamed appendix + fecalith: confirms
appendicitis
Perforated appendix: take it out, I/D the abscess,
and leave a drain in to prevent wound infection
Appendiceal carcinoid: <2cm appendectomy,
>2cm right hemicolectomy; can present w/
carcinoid syndrome due to liver metastasis
Terminal ileal carcinoid: resection and check the
rest of bowel for other carcinoids; can present
w/ carcinoid syndrome due to liver metastasis
––––––––––––––– DIVERTICULITIS –––––––––––––––
Diverticulosis: presents as LGIB, 85% stop
spontaneously, may develop into diverticulitis
Diverticulitis: presents like left-sided appendicitis,
get CT scan and manage non-op if possible (IVF, NPO,
IV antibiotics) even with signs of LLQ peritonitis
Diverticulitis f/u: colonoscopy to confirm
presence of diverticula and absence of cancer
Surgery indications: uncontained perforation
that presents as 4-quadrant peritonitis or
pneumoperitoneum (air under diaphragm)
Elective surgery indications: recurrent episodes
(2x in 6 months, 3x in a year)
Diverticulitis complications: abscess (Tx perc drain),
obstructions, fistula (pneumaturia or fecaluria, Tx
surgical separation of colon from bladder)
––––––––––– LARGE BOWEL DISEASES ––––––––––
Pseudomembranous colitis: watery diarrhea and
↑↑WBC due to clindamycin-related C. diff overgrowth;
Dx stool toxin or colonoscopy, Tx stop clindamycin
and start metronidazole or vancomycin
Colon cancer screening: anyone above 50 y/o should
get yearly fecal occult blood test (flex sig and
colonoscopy also used, but less commonly)
Polyps: tubular/pedunculated have a stalk,
sessile/villous are flattened; progression from polyp
to cancer takes ~10 years
Pedunculated polyp: polypectomy w/ biopsy →
if dysplasia is not localized to head of polyp, then
segmental colectomy
Sessile polyp: biopsy → if any high grade
dysplasia, then colectomy
Benign polyps: juvenile, Peutz-Jeghers,
inflammatory, hyperplastic; leave these alone
Colon cancer: left side obstructs, right side bleeds;
Dx “apple core” lesion on barium enema, 99%
garden variety (∆MCC, ∆DCC, ∆RAS, ∆p53) and 1%
familial inheritance (FAP, HNPCC)
Stage I/II: localized cancer, Tx colectomy
Stage III: LN involvement, Tx colectomy and
chemo (5-FU + levimasole, only stage that chemo
will improve survival rates)
Stage IV: distal metastasis, Tx palliative chemo
unless there is a resectable mass in liver or lung
Colectomy: requires 12-14 LN removal for adequate
procedure; requires pre-op bowel prep and abx
Post-op wound infection: open fascia to make
sure it’s intact, then local wound care
Post-op feculent leak: indicates anastomotic leak,
get abd CT scan to check for undrained collection,
then NPO/IVF is sufficient for most cases
Post-op feculent vomit: indicates either post-op
ileus (due to leakage) or mechanical obstruction;
Tx NPO/IVF and NG tube
Post-op abscess: Dx CT scan, Tx perc drain
Post-op constipation: indicates either stricture or
cancer recurrence; Dx colonoscopy
FAP: ∆APC on chromosome 5p, autosomal dominant,
presents as >100 polyps in colon; Tx either total
proctocolectomy, or total abdominal colectomy +
strip anal mucosa + ileoanal anastomosis
Gardner syndrome: FAP + polyps in stomach (not
premalignant) and duodenum (premalignant);
Surgery – Lower GI Surgery
FAP pts should always get upper endoscopy and
remove the duodenal polyps
HNPCC: ∆MLH or ∆MSH mismatch repair genes →
microsatellite instability, Tx total abdominal
colectomy + ileorectal anastomosis
Colon cancer recurrence: f/u with colonoscopy, CEA
marker, CXR for lung mets, and LFTs for liver mets
–––––––––––– ANORECTAL DISEASES –––––––––––
All anorectal diseases: first step in management is to
scope and rule out cancer
Hemorrhoids: presents as blood streaks in stool and
extreme pain (external); Tx scope to r/o cancer →
fiber/stool softeners → if it keeps bleeding, excision
or banding
Non-healing hemorrhoids: indicates anal canal
cancer; Tx chemoradiation (5-FU) → APR if it
persists or recurs
LAR vs. APR: LAR is low anterior resection (high in
rectum), APR is abdominoperineal resection (low in
rectum)
Rectal cancer: Dx colonoscopy to r/o cancer, then
endoscopic U/S for staging → Tx depends on stage
Rectal cancer T1: transanal resection
Rectal cancer >T1: neoadjuvant chemoradiation
for 6 weeks to shrink the tumor → then LAR with
2cm distal margins → APR if margins not possible
Anal cancer: presentation is non-specific (bleeding,
pain, drainage, itching) and requires biopsy
Small anal cancer: Tx resection w/ negative
margins
Large anal cancer: often mistaken as “non-
healing hemorrhoids”, Tx chemoradiation (Nigro
protocol) → APR if it persists or recurs
Perirectal abscess: Tx I&D → 40% will develop a
fistula according to Goodsall’s rule (anterior straight
tract, posterior curved tract) → Tx fistulotomy
Pilonidal abscess: abscess in sacrococcygeal area of
lower back, Tx I&D and removal of hair
Anal fissure: presents as pain and blood with BM
due to increased sphincter tone; Tx fiber/stool
softeners → if it won’t heal, botox → still won’t heal,
lateral internal sphincterotomy
Recurring anal fissure: probably Crohn’s; biopsy
first for possible cancer, then Tx metronidazole if
biopsy reveals Crohn’s
Rectal prolapse: presents as rectal protrusion
following defecation; internal prolapse → high-fiber
diet to normalize BM, external/bleeding prolapse →
rectopexy or LAR
 Surgery – Lower GI Surgery

–––––––––––––––– GI BLEEDING ––––––––––––––––

Hematemesis: bloody vomiting, always UGIB

Melena: coffee ground blood in stool, usually UGIB

but can also be from ascending colon

Hematochezia: BRBPR, can be either UGIB or LGIB;

NG tube aspirate/lavage → LGIB if –blood/+bile,
UGIB if +blood, indeterminate if –blood/–bile

UGIB: GI bleeding proximal to Ligament of Treitz,

management is EGD

UGIB in ICU pt: most likely a stress ulcer

LGIB: GI bleeding distal to Ligament of Treitz, 85%

stop spontaneously; MCC are AVM, diverticulosis,
and colon cancer

LGIB management: must localize site of bleeding

w/ tagged RBCs (<1 cc/min) or angiography (>1
cc/min); if not currently bleeding, get upper and
lower endoscopy since localization won’t help

LGIB surgery indications: “hemodynamic

instability despite transfusion”, loss of 4-6 units in
24 hrs or 8-10 units in 48 hrs

LGIB scenario: GI bleed stops spontaneously →

get colonoscopy to determine cause and rule out
possibility of colon cancer → coagulate if AVM,
leave alone if diverticulosis

LGIB scenario: unstable patient, massive BRBPR,

no imaging to localize site of bleeding → total
colectomy since 85% of bleeding is from the colon

LGIB in kids: indicates Meckel’s diverticulum, Dx

technetium uptake into ectopic gastric mucosa

Dx tagged RBCs: sensitive for LGIB at 0.1 cc/min, but

not specific for localizing site of LGIB; bladder always
lights up first so ignore that part

Dx angiogram: less sensitive for LGIB at 1.0 cc/min,

but more specific for localizing site of LGIB; allows
for smaller LGI resection in surgery if necessary

––––––––––––– OTHER GI DISEASES ––––––––––––

Sigmoid volvulus: twisting of sigmoid colon around

mesentery results in closed-loop obstruction; Tx
“detorse” the colon via rigid scope and rectal tube,
then elective sigmoid colectomy

Cecal volvulus: twisting of cecum; Tx right

colectomy since detorsion usually won’t work

Ogilvie’s syndrome: pseudoobstruction and massive

colon dilation w/o mechanical obstruction; Tx
endoscopic decompression or neostigmine if >11 cm
due to possibility of cecal perforation

Constipation: do a rectal exam to make sure stool

isn’t impacted, then give enemas from below

–––––––––––––– THYROID DISEASES–––––––––––––
Thyroid embryology: derivative of foramen cecum
from the base of the tongue
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Thyroid nodule management: first get TSH levels →
if euthyroid, get FNA for cancer Dx; otherwise, work
up for hypo- or hyperthyroidism
Risk of malignancy: solid nodules, cold nodules
(lack of radioiodine uptake), size > 1.5 cm
Colloid nodule: benign nodule, manage medically
Hyperthyroidism: Graves’ disease (most common),
toxic adenoma (#2), toxic multinodular goiter (#3)
Graves’ disease (diffuse toxic goiter): auto-
immune disease due to IgG against TSH-R causing
exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women
Graves’ disease Tx: oral radioiodine (no surgical
risks) or surgery (won’t become hypothyroid)
Thyroid storm Tx: β-blockers, antithyroid drugs
Antithyroid drugs: propylthiouracil (PTU) and
methimazole block peroxidase, PTU also blocks
peripheral conversion of T4 to T3
Toxic adenoma: Dx hot nodule on scan with
peripheral suppression, Tx lobectomy if >2 cm,
radio-iodine if <2 cm
Toxic multinodular goiter: Tx surgical excision if
>2cm, radio-iodine if <2 cm
Hypothyroidism: chronic/Hashimoto thyroiditis
(most common), subacute/De Quervain thyroiditis,
acute bacterial thyroiditis
Hashimoto thyroiditis: autoimmune disease with
lymphocytic infiltration, Tx Synthroid
Hashimoto thyroiditis antibodies: anti-TSH,
anti-microsomal, anti-thyroglobulin, anti-
peroxidase
De Quervain thyroiditis: subacute, painful
granulomatous inflammation following viral URI,
Tx observation (condition will self-resolve)
Acute thyroiditis: painful, swollen, tender thyroid
mass due to Staph/Strep infection, Tx I&D
Thyroid cancers: 80% papillary, 10% follicular, 4%
medullary, 1% anaplastic; FNA can be used to Dx
papillary and medullary but not follicular (must see
capsular invasion to DDx adenoma vs. carcinoma)
Papillary cancer: associated with radiation,
lymphatic spread, best Px overall, Bx shows
Orphan Annie nuclei with psamomma bodies
Papillary cancer Tx: total thyroidectomy w/
central LN excision → modified radical neck
dissection if LN are positive for cancer
Follicular cancer: endemic to iodine-deficient
regions, hematogenous spread, 2nd best Px
Follicular cancer Tx: hemilobectomy with biopsy
because 80% are benign adenomas and 20% are
malignant carcinomas, total thyroidectomy if Bx
reveals malignant carcinoma
Medullary cancer: AD inheritance with MEN2A/2B
syndromes, Δret proto-oncogene, both lymphatic
and hematogenous spread, Bx amyloid deposits,
3rd best Px
Medullary cancer Tx: total thyroidectomy for
both cancer and ret+ prophylaxis w/ central LN
excision → modified radical neck dissection if LN
are positive for cancer
Anaplastic cancer: rare, worst Px
Anaplastic cancer Tx: palliative (e.g.
tracheostomy)
Thyroid lymphoma: associated w/ chronic
Hashimoto’s thyroiditis, Tx radiation therapy
Post-thyroidectomy f/u: take patient off T4 for 6
weeks (use T3 instead for its shorter T½), increase
TSH level, and make sure total thyroidectomy was
performed; give radioactive iodine exam after 6
weeks to check if any metastases will light up
Positive for metastases: get CT scan, macro →
excision, micro → oral radio-iodine therapy
Papillary cancer f/u: follow thyroglobulin levels
Follicular cancer f/u: follow thyroglobulin levels
Medullary cancer f/u: 24-hour urine for VMA or
metanephrines (MEN syndrome can present with
pheochromocytoma), follow calcitonin levels
Modified radical neck dissection: like radical neck
dissection, but spares sternocleidomastoid muscle,
CN XI, and internal jugular vein
Thyroid cancer Px: MACIS system – Metastasis (non-
lymph nodal), Age (<45 is better), Completeness of
resection, Invasion, Size (>2 cm has worse Px)
Thyroid surgery risk factors: superior laryngeal
nerve (soft/deep voice), recurrent laryngeal nerve
(hoarseness unilateral, dyspnea bilateral), para-
thyroid glands (hypoparathyroidism)
––––––––––––– PARATHYROID DISEASES –––––––––
Parathyroid glands: 30-50 mg each, brownish-yellow
color, sinks in water (to differentiate from fat)
Parathyroid embryology: 3rd branchial pouch
becomes inferior glands and thymus, 4th becomes
superior glands
Surgery – Endocrine Surgery
DiGeorge syndrome: congenital absence of both 3rd
and 4th branchial pouches → hypocalcemia, thymic
aplasia
PTH: secreted from chief cells; three functions –
renal ↑Ca++/↓P, bone ↑Ca++/↑P, stimulates 1α-
hydroxylase to activate vitamin D for indirect GI
resorption of Ca++
Osteitis fibrosa cystica: rapid, painful loss of bone
due to HPTH; “moth eaten skull”
Calciphylaxis: calcium deposition in soft tissue due
to HPTH
Multiple myeloma: punched-out lesions of bone due
to a B-cell neoplasm
Hypercalcemia Sx: kidney stones, painful bones,
abdominal groans (peptic ulcers, pancreatitis,
cholelithiasis), psychic overtones (↓mental status)
Hypercalcemia DDx: parathyroid adenoma (MCC
outpatient), metastases to bone (MCC inpatient)
1° HPTH: ↑PTH/↑Ca++/↓P, most sensitive test is Cl:P
ratio >33:1; causes include 90% adenoma, 9% hyper-
plasia, 1% carcinoma
1° HPTH management: straight to surgery if
symptomatic (4-gland exploration or minimally
invasive surgery), no imaging necessary
4-gland exploration: open exploration of neck
area; adenoma → take it out; hyperplasia → take
3½ glands out, or take all 4 out and auto-
transplant ½ gland back in; carcinoma → en bloc
resection of parathyroid and ipsi thyroid lobe
Minimally invasive surgery: needs positive
Sestamibi scan pre-op, big/abnormal gland during
exploration, and intra-operative decrease in PTH
levels by >50% following excision
2° HPTH: ↑↑PTH/↓Ca++/↑P, due to renal failure
2° HPTH management: medical management, 3½
gland excision if complications exist
3° HPTH: ↑PTH/↑Ca++/↓P, found in renal transplant
pts whose parathyroid glands work autonomously
3° HPTH management: 3½ gland excision if HPTH
persists for 1 year following transplant
Sestamibi scan: “lighting up” in parathyroid gland is
85% accurate for Dx parathyroid adenoma
Hypercalcemic crisis: Ca++>15 indicating carcinoma;
Tx flush with NS, then drain with furosemide (Lasix),
then treat the underlying cause
Parathyroid nodule: probably a thyroid nodule,
unless Ca++ ~15 indicating parathyroid carcinoma
2nd operation s/p adenoma removal: requires
localization studies, don’t just go back in there
 Surgery – Endocrine Surgery

Missing parathyroid glands: check thymus (MC
location/15%), up and down neck, open carotid
sheath, retro-esophageal area, esophageal groove,
and inside the thyroid gland itself
Median sternotomy: only indicated if pt is in a life-
threatening hypercalcemic crisis
–––––– MULTIPLE ENDOCRINE NEOPLASIA ––––––
Pituitary Cushing: due to ↑ACTH secretion,
suppressable by high dose dexamethasone;
Dx MRI, Tx transsphenoid hypophysectomy
Adrenal Cushing: due to ↑cortisol secretion
(causes ↓ACTH); Dx CT scan, Tx adrenalectomy
Ectopic Cushing: due to ↑ACTH secretion usually
from SCLC, not suppressable by high dose dexa

MEN1 (Wermer): pituitary adenoma, pancreatic Adrenal gland tumors: aldosteronoma, cortisoloma,
endocrine cancer (MC gastrinoma), parathyroid sex hormone-secreting tumor, pheochromocytoma,
hyperplasia incidentaloma

MEN1 Tx: excise parathyroid first since hyper- Aldosteronoma: presents as ↑Na, ↓K, ↓H, ↓renin;
calcemia can cause ↑gastrin levels; if Z-E can’t be Dx CT scan for mass (if no mass present or ↑renin,
controlled w/ PPIs → total gastrectomy since think RA stenosis), Tx adrenalectomy (adenoma)
MEN gastrinomas are multifocal or aldactone (hyperplasia)

MEN2A (Sipple): parathyroid hyperplasia, Cortisoloma: presents as adrenal Cushing’s, Tx

pheochromocytoma, thyroid medullary cancer adrenalectomy

MEN2B: pheochromocytoma, thyroid medullary Sex hormone-secreting tumor: Tx adrenalectomy

cancer, mucosal neuromas, Marfanoid habitus
MEN2A/2B Tx: excise pheochromocytoma first
since it can be life-threatening
Gastrinoma: give PPIs → if acid persists, get serum
gastrin levels → <200 absent, >500 present, 200-500
indeterminate and requires secretin stimulation test
→ if paradoxical ↑gastrin w/ secretin, present → get
CT scan to localize and cut it out
VIPoma: presents as “rice water” diarrhea; get CT
scan to localize and cut it out
Insulinoma: presents as hypoglycemia, Dx ↑C-
peptide levels or monitored fasting (to see if they’re
“faking it”); get CT scan and cut it out
Glucagonoma: presents as new-onset diabetes and
migratory rash from lower body upwards, Dx
glucose challenge test; get CT scan and cut it out
Metastatic glucagonoma: give somatostatin and
streptozocin since surgery is contraindicated
Pheochromocytoma: presents with HA, HTN,
palpitations, etc.; Dx 24 hour urinary VMA or
metanephrines, Tx α-blockers (phenoxybenz-
amine) then β-blockers then adrenalectomy
Intraoperative hypotension: give IVF
Incidentaloma: make sure it’s not secreting
hormones then work-up based on size; <5 cm →
leave alone, >5 cm → resection + check other organs
since adrenals are common site of metastasis
Aortic coarctation: presents as HTN in arms but
normal BP in legs; get CXR (scalloping of ribs) then
confirm w/ spiral CT, then surgical correction
Renovascular HTN: presents as HTN + abd bruits,
secondary to fibromuscular dysplasia (young women)
or atherosclerosis (old men) of the renal arteries;
get a doppler of renal vessels, then either balloon
dilation or surgical correction

Nesidioblastosis: presents as hypersecretion of

insulin in a newborn; Tx 95% pancreatectomy

–––––––––– OTHER ENDOCRINE DISEASES –––––––––

Pituitary adenoma: prolactinoma (#1), null cell tumor

(#2), ACTH (#3), GH (#4); may present as bitemporal
hemianopsia ◐◑ due to optic chiasm compression

Prolactinoma: presents with galactorrhea and

amenorrhea, Tx bromocriptine

Null cell tumor: doesn’t secrete anything

Cushing syndrome: presents as truncal obesity, abd

striae, buffalo hump, hyperglycemia, osteoporosis,
HTN, and immunosuppression due to ↑cortisol

Cushing causes: MCC is exogenous steroid use;

intrinsic causes include pituitary adenoma,
adrenal adenoma, and ectopic secretion of ACTH

––––––––––––––– SKIN CANCERS –––––––––––––––
Skin cancers: basal cell carcinoma (50%), squamous
cell carcinoma (25%), malignant melanoma (15%);
management is full-thickness incisional biopsy at
border of the lesion
Basal cell carcinoma: raised waxy lesion or non-
healing ulcer in upper face, doesn’t spread; Tx local
excision w/ 1 mm margins
Squamous cell carcinoma: non-healing ulcer in lower
face, spreads to LN; Tx local excision w/ 1 cm margins
and LN excision
SCC risk factors: draining fistulas, arsenic
exposure
Keratoacanthoma: variant of SCC that grows
rapidly and then dies off spontaneously
Dysplastic nevus: atypical mole, precursor of
malignant melanomas, requires close observation
Melanoma: ABCDE – Asymmetric, irregular Borders,
different Colors, Diameter >5mm, Evolving; Px
related to depth, highly metastatic and will be found
in weird places
Ulcerated melanoma: 1/3 reduction in survival
Depth <0.75 mm: Tx excision w/ 1 cm margin,
good prognosis
Depth 0.76-3.99 mm: Tx excision w/ 2 cm margin,
palpable LN → removal, no palpable LN →
sentinel LN biopsy w/ elective removal
Depth >4 mm: Tx excision w/ 2 cm margin,
remove palpable LN, pt will likely die from mets
Melanoma × LN involvement: remove regional LN,
then complete staging for mets (CXR, CT scan, LFTs,
brain MRI)
Melanoma × metastases: Tx radiation and
chemotherapy (interferons)
Lentigo maligna melanoma: superficial, spreading
melanoma on the face, good prognosis overall, Tx
excision w/ narrow margin
Acral lentiginous melanoma: melanoma on pale
areas of dark-skinned pts (sole of feet, palm of hand),
worst prognosis due to depth
Subungual melanoma: melanoma under fingernail or
toenail, Tx DIP amputation
Melanoma on face: Tx excision w/ smaller margins
for cosmetic purposes, consult plastic surgery
Melanoma in anus: all mucosal melanomas have bad
prognosis, Tx APR w/ palpable LN excision
Melanoma × SBO: presents as abd distention,
nausea and vomiting due to metastatic melanoma in
peritoneal cavity; Tx ex lap w/ excision
Surgery – Skin/Soft Tissue Surgery
–––––––––––––––– SARCOMAS –––––––––––––––– Hernia surgery types: open (Bassini, McVay,
Shouldice, Lichtenstein), laparoscopic (TAPP, TEP)
Sarcomas: present as firm, painless masses; Px
depends on size, grade, and distant metastases (no Bassini repair: inguinal ligament to conjoint
LN since sarcomas spread hematogenously) tendon, high tension, fixes direct and indirect
hernias
Sarcoma management: Dx incisional biopsy
parallel to resection margins, chest CT for mets, McVay repair: Cooper’s ligament to conjoint
Tx resection w/ 1 cm negative margins tendon; fixes direct, indirect, and femoral hernias
High-grade sarcomas: Tx radical amputation w/ McVay repair w/ relaxing incision: cut
post-op radiation therapy transversus abdominis aponeurosis to relax
tension on sutures
Sarcoma × lung mets: get chest CT to characterize
lesion and look for others → needle biopsy for Shouldice repair: inguinal ligament to reinforced
confirmation → Tx thoracic wedge resection transversalis fascia in two layers
Sarcoma × liver mets: biopsy for confirmation → Tx Lichtenstein repair: tension-free repair w/ mesh;
hepatic wedge resection or formal lobectomy fixes direct, indirect, and femoral hernias
––––––––––––––––– HERNIAS ––––––––––––––––– TAPP and TEP: TransAbdominal PrePeritoneal
and Totally ExtraPeritoneal lap procedures;
Hernia surgery indications: all abdominal hernias have steep learning curve and unproven results
due to possibility of strangulation, except sliding
esophageal hernias (Tx PPIs) and umbilical hernias in Hernia surgery complications: damage to genital
pts <2 yo (simple observation) branch of genitofemoral nerve, ilioinguinal,
iliohypogastric, or lateral femoral cutaneous nerves
Umbilical hernia management: <2cm watch, causing pain and sensory defects
>2cm fix, fix if it doesn’t regress before kinder-
garten regardless Hernia surgery post-op: avoid lifting for 6 weeks so
incision site has time to regain strength
Hernia × SBO: presents as abdominal distention,
nausea, and vomiting due to incarcerated or
strangulated hernia; Tx emergent hernia repair
Hernia × strangulation: presents as firm/tender
mass w/ fever, ↑WBC, metabolic acidosis; Tx
emergent hernia repair
Indirect hernia: through internal ring lateral to
inferior epigastrics vessels, due to patent processus
vaginalis; most common hernia overall (even in
women and elderly)
Indirect hernia in kids: high incidence of
bilaterality, repair is limited to high ligation of sac
w/o abdominal wall repair
Direct hernia: medial to inferior epigastric vessels,
due to weakening abdominal wall; more common in
elderly
Femoral hernia: below inguinal ligament into
femoral triangle, more common in women, highest
risk of strangulation (50% of all strangulations)
Sliding hernia: involves other viscera as part of the
hernia wall (e.g. bladder, cecum, sigmoid colon),
important to recognize sliding hernias as not to
injure any contained structures
Ventral hernia: hernia through incision site at linea
alba; Tx primary closure (small) or mesh repair (large)
Rare hernia causes: anything that increases
abdominal pressure – obesity, COPD, ascites, BPH
causing bladder obstruction, constipation, ascites;
these require further evaluation before surgery

–––––––––––– BREAST MANAGEMENT –––––––––––
Breast cancer screening: monthly self-exam, yearly
breast exam, yearly mammogram if >40 y/o (earlier if
there is a strong family Hx)
Breast mass on exam: first, get mammogram to
characterize mass and rule out other masses →
get core needle biopsy → excisional biopsy if
needle inadequate
Abnormality on mammogram: ‘probably benign’
→ follow-up; ‘suspicious’ → core needle biopsy,
excisional biopsy if needle inadequate
Breast cancer risk factors: family Hx (#1), BRCA1 and
BRCA2 genes, old age
MC breast masses: <25 fibroadenoma, 25-50 fibro-
cystic change, >50 infiltrating ductal carcinoma
–––––––––– BENIGN BREAST DISEASES –––––––––
Fibroadenoma: firm, mobile, rubbery mass in young
women; Dx FNA and U/S, Tx elective removal
Giant juvenile fibroadenoma: seen in teens with
rapid breast growth; Tx excision to avoid breast
deformity
Phyllodes tumor: huge, benign tumors that distort
the breast; Dx core or incisional biopsy since FNA is
insufficient, Tx excision w/ negative margins
Fibrocystic change: multiple, bilateral lumps that
vary with menstrual cycle; if dominant or persistent
lump → aspiration → excisional biopsy if mass
recurs or persists
Sclerosing adenosis: Tx careful observation or
prophylactic bilateral simple mastectomy; not
precancerous, but is a risk factor of cancers
Atypical ductal hyperplasia: Tx excision; not
precancerous, but high risk of becoming a cancer
Intraductal papilloma: presents as bloody nipple
discharge; Tx galactogram/ductogram-guided
excision (due to small risk of carcinoma)
Acute mastitis: breastfeeding women get
Staph/Strep infection through cracks in nipple w/
yellowish discharge, Tx antibiotics and warm
compresses, may develop into breast abscess
Breast abscess: pus pocket in lactating women;
Tx I&D and biopsy to rule out possible cancer
Periductal mastitis: subareolar infection in smokers,
both males and females affected
Gynecomastia: breast tissue hypertrophy in males;
common in puberty (will resolve spontaneously) and
older men (excision if it doesn’t regress on its own)
Dystrophic calcification: presents as breast lump
following trauma, but work up as a cancer until
proven otherwise (trick question!)
Surgery – Breast Surgery
–––––––– MALIGNANT BREAST DISEASES –––––––
Breast cancer buzzwords: family history, ill-defined
or fixed mass, skin or nipple retraction, peau
d’orange, nipple eczema, and palpable axillary LN
Breast cancer Tx: identical for all cancers (except
inflammatory, LCIS, DCIS); depends on cancer stage
Stage I-II: lumpectomy w/ 1 cm negative margins
+ axillary LN samping + post-op radiation; or
modified radical mastectomy
Stage III-IV: systemic chemotherapy
Axillary LN involvement: Tx chemotherapy if pre-
menopausal, tamoxifen if post-menopausal
Breast cancer × pregnancy: work-up and Tx is
identical, except no chemo during 1st trimester
and no radiation anytime; if stage III or IV,
chemoradiation is essential and abortion may be
necessary
Breast cancer × men: work-up and Tx is identical
Paget’s disease: presents as “crusty” nipple eczema,
indicates underlying infiltrating ductal carcinoma
Inflammatory cancer: resembles cellulitis w/ peau
d’orange, “tumor cells in dermal lymphatics”, Tx
requires pre-op chemo
DCIS: Tx simple mastectomy
LCIS: Tx careful observation or prophylactic bilateral
simple mastectomy; not precancerous, but is a risk
factor of breast cancers
–––––––– POST-SURGERY COMPLICATIONS –––––––
Small ipsilateral nodule: local recurrence until
proven otherwise, work-up like any other mass
Contralateral finding: most likely a new primary
cancer, work-up like any other mass
Elevated LFTs: indicates liver mets, get abd CT scan
Back pain: indicates bone mets, get bone scan then
X-ray
Pathologic fracture: indicates bone mets, get bone
scan then X-ray
Sensorimotor defects: indicates spine mets, get MRI
Severe headache: indicates brain mets, get MRI
New-onset seizures: indicates brain mets, get MRI
New-onset coma: indicates acute hypercalcemia due
to bone mets, get a renal panel for confirmation

–––––––––––– TRAUMA EVALUATION ––––––––––––
Evaluation of trauma pt: primary survey, get an
“ample” Hx, secondary survey
Primary survey: initial evaluation of trauma pt;
ABCDE – airway, breathing, circulation, disability
(neurological), environment/exposure
Ample Hx: things to ask a trauma pt – allergies,
meds, previous illnesses, last meal, events
surrounding injury
Secondary survey: full inspection of trauma pt
following clearance of life-threatening issues,
continual reassessment is necessary for changes
Airway: determine if airway is clear, quickest way to
evaluate is to see if pt can talk; use intubation,
cricothyroidotomy, or tracheostomy if obstructed
Blunt trauma to neck: consider possibility of
laryngeal edema developing into airway
obstruction
Breathing: evaluate via lung auscultation, CXR, and
pulse oximetry
Circulation: stop external hemorrhage, 2 large-bore
IV lines (14 or 16-gauge) w/ 2L crystalloid, followed
by packed RBC (type O–) if necessary
Cardiac tamponade: presents with Beck’s triad –
JVD, muffled heart sounds, hypotension;
Tx subxiphoid pericardiocentesis and go to OR
Hypovolemic shock: class I <15% and lactic acid;
class II 15-30% and ↑HR; class III 30-40% and ↓BP;
class IV >40% with lethargy and anuria
Hypovolemic shock Tx: 2 large-bore IV lines and
2L crystalloid infusion, resuscitation measured by
urine output, HR, BP, and mental status
Hypovolemic shock Tx unresponsive: search for
underlying cause, ex lap or thoracotomy may be
indicated for continuous internal bleeding
Closed head injury: brain edema and ischemia
causes Cushing reflex – peripheral vaso-
constriction (↑BP), bradycardia (↓HR), and
respiratory depression (↓RR)
Circulation × pregnancy: ↑HR is normal and may
not indicate shock, ↓hct of 31-35% is normal, best
evaluated laying on her left side
Disability: evaluate with GCS; 15 max, ≤8 coma, 3
nearly dead
Disability × awake: stabilize C-spine, palpate
posterior neck for tenderness, assess extremities
for motor/sensory function, and get lateral C-
spine imaging
Disability × comatose: C-spine cannot be cleared,
so precautions must continue
C-spine injury: suspected with neurological Sx,
radiological abnormalities, or C-spine tenderness;
intubation requires extreme caution
Priapism: indicates fresh spinal cord injury; check
for anal sphincter tone, bradycardia, and possibly
neurogenic shock
––––––––––––––– HEAD TRAUMA –––––––––––––––
Head trauma evaluation: begin with primary survey
(ABCs) → rapid neuro exam if stable → if any neuro
sx, get head CT and neurosurg consult
Rapid neuro exam: check pupils, cranial nerves,
peripheral motor/sensory function, and rate level of
consciousness via GCS
EDH: head CT shows convex lens hematoma;
presents as LOC → lucid interval → LOC →
ipsilateral fixed/dilated pupil, Tx craniotomy
SDH: head CT shows crescent moon hematoma,
high risk for brain herniation; Tx head elevation,
hyperventilate, sedate, mannitol + furosemide
Diffuse axonal injury: head CT shows blurred
gray-white junction and small punctate
hemorrhages; management is prevention of ↑ICP
Head trauma × hypovolemic shock: look for another
source of bleeding
Basal skull fx: raccoon eyes, hemotympanum,
otorrhea, rhinorrhea, ecchymosis behind the ear
(Battle’s sign); neurosurg consult is indicated
––––––––––––––– NECK TRAUMA –––––––––––––––
Neck stab wound: begin with primary survey (ABCs),
then careful exam for injured structures
Surgery indications: expanding hematoma,
deteriorating vital signs, coughing blood,
subcutaneous emphysema, all GSW and stab
wounds in zone 2 (zones 1+3 can be observed if
stable)
Stab × zone 1: below cricoid (includes lung);
observation and pre-op angiogram if stable,
otherwise exploration of neck is necessary
Stab × zone 2: between mandible and cricoid;
exploration of neck is mandatory
Stab × zone 3: above mandible; observation and
pre-op angiogram if stable, otherwise exploration
of neck is necessary
Stab × dysphagia: suggests injury to the
esophagus, Dx esophagoscopy or barium
swallow
Stab × hoarseness: suggests injury to the airway,
larynx (voicebox), or recurrent laryngeal nerve;
Dx laryngoscopy or exploration
Surgery – Acute/Critical Care Surgery
Stab × hemiparesis: suggests injury to the carotid
artery; get angiogram and either vascular or
neurosurg consult
Neck GSW: exploration of neck is mandatory in zone
2, observe if stable in zones 1+3
Neck blunt trauma: at risk of carotid dissection (Tx
anticoagulation) or laryngeal edema (Tx intubation)
––––––––––––––– SPINAL TRAUMA ––––––––––––––
Spinal cord injury management: get MRI to look at
spinal cord, then immediate high-dose steroids
Hemisection syndrome: always due to stab
wounds in posterior neck area, presents as ipsi
DCML/motor loss and contra ACL loss
Anterior cord syndrome: usually seen w/
vertebral burst fractures, presents as bilateral
ALS/motor loss but intact DCML
Central cord syndrome: usually seen w/ whiplash
(e.g. rear end collisions), presents as UE burning
pain and paralysis, but LE nerves intact
––––––––––––––– CHEST TRAUMA ––––––––––––––
Rib fx: painful breathing leads to shallow breaths →
atelectasis → pneumonia, Tx local nerve block
Chest stab wounds: suspect HTX or PTX, chest tube
insertion is indicated
Infraclavicular stab wounds: suspect injury to
subclavicular artery or vein, Dx angiogram if pt is
stable or urgent exploration if unstable
Nipple-level stab wounds: suspect additional
injury to diaphragm/abdominal organs, ex lap
indicated for abdominal organ damage
PTX: air in pleural space; insert a finger to make sure
of pleural space, then insert a chest tube, remove
when lung is fully inflated and no air leak present
Small PTX: simple observation is okay if it’s
asymptomatic, no free fluid present, not
expanding, and no other significant injuries
Sucking chest wound: seal with occlusive
dressing, insert chest tube in different location
Nonfunctioning chest tube: chest tube is in the
wrong location or not working properly;
reposition or replace chest tube
Continuous air leak into chest tube: major airway
injury with disruption of bronchus or trachea
Tension PTX: mediastinal shift, hypotension, JVD,
absent breath sounds, and hyperresonant to
percussion; Tx emergent needle aspiration and
chest tube insertion (do not wait for CXR or ABG)
HTX: blood in pleural space, go to OR if chest tube
drains 1.5L or >200 mL/hr for 3 hours

HTX × hypotension: suspect blood loss in left
chest, indicated for left chest tube insertion
Thoracic GSW: GSW is managed differently due to
unpredictable path of bullets vs. knife, mark both
entrance/exit sites and get imaging
Thoracic blunt trauma: suspect HPTX, chest tube
insertion is indicated; emergent thoracotomy if >1.5L
or >200mL/hr blood is extracted from tube
Aortic transection: presents as widened media-
stinum on CXR, confirm w/ aortic angiography or
chest CT → go to OR if transected
Flail chest: presents w/ paradoxic chest wall
movements due to multiple rib fx, suspect lung
contusions and aortic transection; manage by
inserting bilateral chest tubes and serial ABGs
Pulmonary contusions: presents as deteriorating
ABGs and “white out” of lungs on CXR; Tx colloid
(not crystalloid) + diuretics + fluid restriction
Ruptured diaphragm: CXR reveals stomach in left
chest; rapid eval of non-abd injuries → go to OR
Ruptured trachea/bronchi: presents as
continuous air leak into chest tube and
subcutaneous emphysema; go to OR
Air embolus: presents as sudden death in an
intubated/respirator pt; management is immediate
Trendelenburg position + cardiac massage
Fat embolus: presents as RDS and petechiae in
neck/axilla due to bone marrow embolization from
long bone fx; management is respiratory support
––––––––––––– ABDOMINAL TRAUMA –––––––––––
Abdominal GSW: mandatory OR for ex lap for all
GSW below nipple level
Abdominal stab wound: mandatory OR if stab
wound penetrates peritoneum (e.g. protruding
viscera, peritonitis, hemodynamic instability);
otherwise, digital exploration and observation
Abdominal blunt trauma: mandatory OR if signs of
peritonitis or hemodynamic instability despite
transfusion; otherwise, CT scan can be done safely
before proceeding
Trauma × flat/nontender abd: observe if no
mechanism, imaging if mechanism exists
Trauma × severe abd pain: suspect peritoneal
irritation due to blood or intestinal contents, Dx
FAST or CT → indicated for ex lap if positive
Trauma × tire mark across abd: indicates severe
direct trauma, high suspicion of internal injury
Trauma × coma: abd imaging mandatory since
physical exam is impossible on a comatose pt
Trauma × perforated viscera: CXR reveals free air
in abdomen; rapid eval of non-abd injuries →
repair perforated viscera in the OR
Trauma × hypotensive w/o hemorrhage:
indicated for FAST or DPL → ex lap in OR if
positive; CT scan inappropriate for unstable pts
Trauma × hypotensive w/ pelvic fx: suspect
vascular injury from branch of internal iliac, Dx
FAST, Tx control by embolization
Dx DPL/FAST: diagnostic peritoneal lavage (DPL)
or ultrasound (FAST) useful for quick Dx of
internal free fluid → positive DPL/FAST is
indicated for ex lap; may be false negative in
retroperitoneal injuries
Dx CT scan: useful for stable pts, avoid in
unstable or severely injured pts
Splenic laceration: ex lap if unstable, preserve
spleen if possible to avoid post-splenectomy sepsis,
avoid blood transfusion if possible, splenectomy
requires vaccination for SHiN bacteria
Liver laceration: ex lap if unstable, observe if stable
Mesentery injury: difficult to detect on CT so
mechanism must evoke suspicion, co-exists with
bowel injury since mesentery is tougher than bowel
Renal laceration: stable → angiography and planned
operative repair; unstable → IV pyelo to detect if
two kidneys present, then OR for nephrectomy
Hematoma in SMA region: suggests major injury to
abd aorta, major aortic branches, pancreas, or
duodenum; stable → angiography and assessment
before operation, unstable → urgent ex lap
Pancreatic transection: mandatory ex lap; minor
injury → debride and drain, major injury → resection
of devitalized pancreatic tissue and repair of
duodenal injury
Duodenal hematoma: common in kids hitting abd on
bicycle handlebars, hematoma causes GI obstruction;
Tx NPO/IVF, will resolve spontaneously in 5-7 days
Blood in ex lap: stop bleeding by packing all four
quadrants with gauze packs → attack injuries in
order of severity and attempt hemostasis → inspect
remainder of abd contents and repair injuries
Triad of death: acidosis, coagulopathy, hypothermia
Hemorrhage × hypothermia: can lead to
coagulopathy due to platelet dysfunction and
PT/PTT prolongation; rewarming indicated
Hemorrhage × low platelets: loss of platelets due
to hemorrhage puts pt at risk for coagulopathy;
platelet transfusion indicated
Hemorrhage × metabolic acidosis: results from
decreased tissue perfusion causing lactic acidosis;
crystalloid infusion indicated
Surgery – Acute/Critical Care Surgery
Hemorrhage × abd distention: bleeding into abd
cavity can lead to abd compartment syndrome,
which can cause decreased renal blood flow
(oliguria) and dyspnea (elevated diaphragm)
↓CO/↓CVP: hypovolemic shock, neurogenic shock
(e.g. spinal cord trauma, anaphylaxis)
↓CO/↑CVP: cardiogenic shock (e.g. CHF, MI, tension
PTX, pericardial tamponade)
––––––––– RETROPERITONEAL TRAUMA ––––––––
Retroperitoneal zones: central is zone 1, flank is
zone 2, pelvis is zone 3
Surgery indications: all zone 1 hematomas, zone 2
and 3 hematomas only if penetrating trauma
Zone 1 (central hematoma): may involve injury to
major vascular structure, indicated for ex lap
Zone 2 (flank hematoma): no exploration
warranted unless penetrating trauma, because
peritoneum will tamponade bleeding
Zone 3 (pelvic hematoma): no exploration
warranted unless penetrating trauma, because
peritoneum will tamponade bleeding
––––––––––––– UROLOGIC TRAUMA ––––––––––––
Urologic surgery indications: all GSW, stab wounds,
and other penetrating injuries
Urethral injury: presents as blood on meatus, scrotal
hematoma, and “high-riding” prostate; get a
retrograde urethrogram and suprapubic catheter
instead of Foley (may compound injury)
Bladder injury: associated w/ seatbelt trauma in
adults; get a retrograde cystogram and post-void
films, then surgical repair
Renal injury: associated w/ blunt trauma to back and
lower rib fx; get CT scan, manage non-op if possible
Scrotal hematoma: manage non-op unless testicle is
ruptured (seen on U/S)
Penis fx: associated w/ cowgirl sex; insert a
suprapubic catheter then repair surgically
–––––––––––––––– LIMB TRAUMA –––––––––––––––
Penetrating limb trauma: no vascular injury → give
tetanus PPx and clean wound; vascular injury
present → arteriogram if stable, OR if unstable
Combined limb trauma: order of repair is bone first,
then vascular repair, nerve last; fasciotomy required
to prevent compartment syndrome
Limb GSW: may require extensive debridements and
amputation if unsalvageable
Crushing limb trauma: high risk of myoglobinuria
leading to acute renal failure; Tx IV fluids + mannitol
+ acetazolamide to maintain a high urine output

––––––––––––––––––– BURNS ––––––––––––––––––
Burn assessment: determine depth of burn, type of
burn, and body surface area (%BSA) burned
First-degree burns: epidermis only, painful
Second-degree burns: extends into dermis,
causes pain and blistering, may develop into
third-degree burns w/o proper management
Third-degree burns: full thickness, painless
Burn management: tetanus PPx, IV pain meds,
topical agents (silver sulfadiazine is default, mafenide
acetate for deep penetration, triple abx ointment for
the eyes)
Rule of 9’s: estimates %BSA burned; head and upper
extremities are 9% each; anterior trunk, posterior
trunk, and lower extremities are 18% each; and
perineum is the last 1%
Parkland formula: estimates fluid replacement in
burn victims, LR volume = %BSA × kg × 4mL/kg;
give 50%LR in first 8 hours, 50%LR in next 16 hours
Fluid for infants: 20 mL/kg if BSA>20%
Chemical burns: alkaline burns are worse than acids
Chemical burn management: massive tap water
irrigation, don’t try acid-base neutralization,
except in ingestion – orange juice for alkali, milk
for acids
Electrical burns: may appear benign on surface, but
masks large amounts of interior damage to muscles,
nerves, and vessels; at risk of cardiac injury
(arrhythmias) and muscle injury (myoglobinuria)
Electrical burn management: IV fluids + mannitol
+ acetazolamide to maintain a high urine output
Inhalation burns: suspected with carbonaceous
sputum, facial burns, singed facial/nasal hairs,
hoarseness, etc. due to smoke inhalation
Inhalation burn management: confirm w/
fiberoptic bronchoscopy and order serial ABGs;
high COHb levels → Tx 100% O2
Circumferential burns: rapidly become thick and
contracted, causing restricted ventilation in the
chest and ischemia in extremities; Tx escharotomy
Scalding burns in kids: consider child abuse
Burns × methemoglobinemia: Sx chocolate-brown
blood, central cyanosis of trunk, arrhythmias,
seizures, coma; Dx ABGs (pulse ox is unreliable), Tx
IV methylene blue
––––––––––––––– BITES & STINGS ––––––––––––––
Bite management: all require tetanus PPx
Dog bites: rabies PPx only required if bite was
unprovoked and dog isn’t available for brain Bx
Surgery – Acute/Critical Care Surgery
Snake bites: don’t always result in envenomation; if
signs of venom evident (pain, swelling, discoloration)
then draw blood for labs and Tx anti-venin
Bee stings: may present as anaphylactic shock
(“warm and pink”) secondary to allergic response;
Tx stinger removal and epinephrine
Spider bites: black widows have neurotoxins, brown
recluses have necrotoxins
Black widow spiders: present w/ severe muscle
cramps, acute abdomen, and nausea/vomiting;
give IV calcium gluconate + muscle relaxants
Brown recluse spiders: present as an ulcerated
lesion; excise ulcer and skin graft
Human bites: requires extensive irrigation and
debridement due to high amounts of bacteria
––––––––––––––––– NUTRITION ––––––––––––––––
TPN: indicated for nutrition when gut is non-
functional or not availble, requires personalization of
formula for nutrition status
TPN × fever: examine catheter site for infection,
obtain cultures from catheter site and blood;
if –bacteria → change catheter site, if +bacteria
→ change catheter site and start antibiotics
TPN × metabolic coma: hyperglycemic,
hyperosmolar, nonketotic coma is commonly due
to excessive osmolar diuresis in hyperglycemia
TPN × elevated LFTs: very common (up to 30%),
TPN can cause fatty liver, structural liver damage,
and even cirrhosis with prolonged TPN
TPN × dry/scaly skin: indicates free fatty acid
deficiency, Tx FFA administration
Nitrogen in TPN: positive nitrogen balance is the
goal, since negative nitrogen balance indicates a
catabolic state; severity of injury correlates with a
higher amino acid requirement
BEE: basal energy expenditure, equal to (body
weight × 25 kcal/kg/day)
Nondepleted pts: 1.2× BEE calories needed; good
nutritional status before surgery
Depleted pts: 1.2-1.5× BEE calories needed;
malnourished before surgery
Hypermetabolic pts: 1.5-2× BEE calories needed;
severely stressed catabolic state due to trauma,
burns, sepsis, cancer, etc.
Macronutrients: carbs (4 kcal/gm), protein (4
kcal/gm), fat (9 kcal/gm), etoh (7 kcal/gm)

––––––––––––– PEDIATRIC SURGERY ––––––––––––
VACTERL syndrome: vertebral, anal atresia, cardiac,
TE fistula, esophageal atresia, renal, limbs (radius);
presence of any of these requires checking for the
others
Esophageal atresia: presents as excess salivation,
choking spells, coiling NG tube, and often a TE
fistula; Tx surgical repair (if delay is necessary,
gastrostomy)
Anal atresia: high rectal pouch → colostomy then
delayed repair, low rectal pouch → repair, if ano-
fistula present → delay repair since further
growth may correct condition
Congenital diaphragmatic hernia: presents as RDS
due to hypoplastic left lung; Dx CXR shows bowel in
left chest, Tx intubation w/ low-pressure ventilation
Gastroschisis: midline hernia to left of umbilical cord
tearing through peritoneum; Tx closure if small, silo
if large, and TPN for a month since GI doesn’t work
Omphalocele: midline hernia through the cord with
peritoneal covering; Tx closure if small, silo if large
Biliary vomiting: indicates SBO distal to ampulla of
Vater; DDx duodenal atresia, intestinal atresia
annular pancreas, or malrotation
Malrotation: presents as biliary vomiting and
double-bubble on X-ray; Dx contrast enema or
upper GI study, Tx emergency surgical correction
Intestinal atresia: presents as biliary vomiting and
multiple air-fluid levels on X-ray, aka apple-peel
atresia due to vascular accident in utero
Necrotizing enterocolitis: presents as feeding
intolerance, abd distention, and ↓platelets in
premies; Tx NPO, IVF, TPN, IV abx → surgical repair if
signs of intestinal necrosis/perforation present
Pyloric stenosis: presents as non-bilious projectile
vomiting in first-born boys; Dx palpable epigastric
olive, Tx rehydration and pyloromyotomy
Biliary atresia: presents as progressive jaundice in a
1-2 month old due to lack of CBD; Dx HIDA scan +
phenobarbital (to stimulate GB contraction), Tx liver
transplant
Hirschsprung’s disease: presents as chronic
constipation due to lack of nerves in distal colon,
rectal exam can decompress bowel; Dx X-ray shows
distended proximal colon, Tx surgical pull-through
Intussusception: presents as colicky abd pain that
lasts 1 minute then resolves, and currant jelly stools;
Dx/Tx barium or air enema (surgery if it doesn’t work)
Child abuse: presents as retinal hemorrhages, SDH,
multiple healed fx, and scalding burns; call child
protective services
Meckel’s diverticulum: presents as LGIB in a child,
Dx technetium uptake for ectopic gastric mucosa
Vascular rings: presents as stridor, RDS, crowing
respiration, and dysphagia in an infant due to
compression of trachea and esophagus; Dx barium
swallow and bronchoscopy, Tx surgical correction
Cardiac anomalies: all require prophylactic anti-
biotics for subacute bacterial endocarditis
L→R shunts: all present with murmurs and late-
onset cyanosis due to Eisenmenger syndrome
(pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur,
fixed S2, and frequent colds; Dx echo, Tx surgery
VSD: presents as pansystolic harsh-sounding
murmur with failure to thrive; Dx echo, Tx surgery
PDA: presents with machinery-like murmur, often
seen with congenital rubella syndrome; Dx echo,
Tx indomethacin or surgery
R→L shunts: all present with murmurs and early-
onset cyanosis
Tetralogy of Fallot: presents as cyanosis and
clubbing in a 5 y/o child who squats for relief;
Px determined by degree of pulmonary stenosis,
Dx echo shows RVH, Tx surgery
Transposition of great vessels: presents as life-
threatening cyanosis in a newborn; Dx echo, Tx
surgery
–––––––––––––– OPHTHALMOLOGY –––––––––––––
Strabismus: misaligned eyes due to uncoordinated
extraocular muscles; Tx surgical extraocular muscle
manipulation to prevent ambylopia
Amblyopia: vision impairment usually due to
strabismus in kids, Tx eyepatch the good eye to
develop the impaired one
Retinoblastoma: presents as a leukocoria in a baby,
Tx surgical enucleation (remove the eye)
Narrow-angle glaucoma: presents as severe eye pain,
headache, “seeing halos around lights”, eye feels as
hard as a rock; Tx iridotomy (give pilocarpine, aceta-
zolamide, or mannitol as first aid)
Orbital cellulitis: presents as cellulitis of eyelids w/
fixed/dilated pupil and limited eye ROM; get CT scan
then drain the pus
Chemical burns of eye: irrigate w/ plain water ASAP,
at hospital – irrigate w/ saline, remove corrosive
particles, and test pH before sending home; alkaline
burns are worse than acid burns
Retinal detachment: presents as flashes and floaters,
and a dark curtain being pulled down over the eye;
Tx emergency laser “spot welding”
Amaurosis fugax: emboli from carotid travels to
retina causing transient blindness; Dx fundoscopic
exam reveals Hollenhorst plaque, a bright shiny spot
in a retinal artery
Surgery –Subspecialty Surgery
Embolic occlusion of retinal artery: presents as
sudden unilateral loss of vision; Tx breathe into
paper bag and repeatedly press on eye to shake clot
into a more distal branch of retinal artery
––––––––––––– OTOLARYNGOLOGY ––––––––––––
Neck masses: three types – congenital, inflammatory,
neoplastic; differentiate via onset and resolution
Congenital neck masses: thyroglossal duct cyst
(midline), branchial cleft cyst (lateral), cystic
hygroma (base of neck)
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Branchial cleft cyst: lateral mass at anterior edge
of SCM, may have a small opening and blind tract
Cystic hygroma: dilated lymphatic duct at base of
neck, common in Turner syndrome, get CT scan
to find extent of mass before surgical removal
LN DDx: cancers are large (>2 cm), painless, fixed,
insidious onset, unusual site; infectious LN are small
(<2 cm), painful, rapid onset, mobile, normal site
Lymphomas: presents with multiple swollen LN,
fever, and night sweats; get excisional biopsy, then
Tx chemo
Supraclavicular metastases: MC primary sites are
pancreas and stomach; get excisional biopsy for Dx
Head/neck SCC: presents as persistent hoarseness,
painless ulcer in floor of mouth, or unilateral earache;
risk factors are EtOH, smoking, and AIDS
SCC management: get triple endoscopy to look
for primary tumor → biopsy tumor → CT scan to
determine stage; Tx resection, radical neck
dissection, cisplatin-based chemo
Acoustic neuroma: presents as unilateral deafness
due to Schwann cell proliferation on CN VIII, get MRI
Facial nerve tumor: presents as gradual-onset
unilateral facial paralysis (sudden-onset is Bell’s
palsy), get MRI
Parotid tumors: present as masses around angle of
mandible, two types – pleomorphic adenomas
(benign, painless) and mucoepidermoid carcinomas
(malignant, painful)
Parotid tumor management: get FNA or formal
superficial parotidectomy (open biopsy contra-
indicated due to CN VII)
Foreign bodies: any toddler w/ unilateral ENT sx
(earache, rhinorrhea, wheezing) has a toy stuck in
there; do endoscopy under anesthesia to remove
Ludwig angina: abscess in floor of mouth due to
tooth infection, Tx I&D and tracheostomy

Bell’s palsy: sudden CN VII paralysis for no evident
reason, Tx antivirals immediately
CN VII trauma: sudden CN VII paralysis following
facial trauma, will resolve spontaneously
Cavernous sinus thrombosis: presents as diplopia in
a pt w/ sinusitis due to nerve (CN III/IV/VI) injury, Tx
antibiotics, CT scan, and drainage of abscess
Epistaxis: nosebleed has different causes and
management depending on pt’s age
Epistaxis × children: due to nosepicking, Tx local
pressure and phenylephrine nasal spray
Epistaxis × teens: either cocaine abuse and septal
perforation (requires packing) or juvenile
nasopharyngeal angiofibroma (surgical resection)
Epistaxis × elderly: due to HTN; requires packing,
BP control, and often surgical ligation of vessels
Vertigo: dizziness can be attributed to diseases of
inner ear or brain itself
Vertigo × inner ear: “room is spinning”, Tx
meclizine, phenergan, or diazepam
Vertigo × brain: “room is stable, but patient is
spinning”, do a neurologic work-up
––––––––––––––– NEUROSURGERY ––––––––––––––
CNS diseases: vascular (sudden onset), metabolic
(hours), infectious (days-weeks), tumors (months),
degenerative disease (years)
Vascular CNS diseases: TIA, ischemic stroke,
hemorrhagic stroke, subarachnoid hemorrhage
TIA: brief neurologic deficit that fully resolves
within 24 hours; due to thromboembolus from
internal carotid arteries
TIA management: carotid duplex, then aspirin
and elective CEA (if >70% stenosis)
Ischemic stroke: a neurologic deficit that doesn’t
resolve within 24 hours due to thromboembolus
from internal carotid arteries, Tx t-PA within 3
hours, otherwise observe and rehab
Hemorrhagic stroke: severe headache and
neurologic deficit that doesn’t resolve within 24
hours in uncontrolled HTN; Dx CT scan, Tx rehab
and control of HTN
SAH: “worst headache of my life” due to rupture
of Charcot-Bouchard aneurysm in lenticulostriate
arteries; Dx CT scan to confirm SAH, then arterio-
gram to locate aneurysm, then surgical clipping
CNS abscess: presents as space-occupying lesions
but short-onset (weeks) and w/ nearby infections
(otitis media, mastoiditis); get CT scan then resect
CNS tumors: presents as space-occupying lesions
and progressive headache over months; get MRI
then resect (give mannitol, hyperventilate, and high-
dose steroids while waiting)
Frontal lobe tumors: present as disinhibition,
anosmia (CN I), ipsilateral blindness (CN II), and
contralateral papilledema
Craniopharyngioma: presents as GH deficit and
bitemporal hemianopsia ◐◑ in a kid, Dx calcified
lesion in sella turcica
Prolactinoma: presents as amenorrhea and
galactorrhea in a young woman, consider
possibility of MEN1 syndrome, Tx bromocriptine
Acromegaly: presents as huge hands, feet,
tongue, and jaws in a tall man due to ↑GH; Dx get
somatomedin C levels and MRI, then resection
Nelson syndrome: presents as bitemporal
hemianopsia ◐◑ and hyperpigmentation in an
adult due to pituitary microadenomas that grew
to full size; Dx MRI then Tx surgical resection
Pituitary apoplexy: presents with typical pituitary
adenoma sx, then sudden onset headache and
CNS sx due to bleeding into tumor; Dx MRI then
emergent steroid replacement
Pinealoma: presents as loss of upper gaze and
“sunset eyes” due to compression of vertical
gaze center in superior colliculi
Brain tumors in kids: present as cerebellar sx and
headaches relieved by knee-chest position, due to
posterior fossa lesions; Dx MRI, Tx resection
Spinal cord tumors: present as back pain in
someone who’s been treated for other cancers
(spine is a common site of mets); Dx MRI, Tx neuro-
surgical decompression
Neurogenic claudication: presents with pain on
exertion and relief with rest, but pain is position-
dependent and pulses are intact; Dx MRI, Tx neuro-
surgical decompression
Trigeminal neuralgia: severe facial pain lasting 60
seconds; Dx MRI to r/o organic cause, then Tx anti-
convulsants (radiofrequency ablation as backup)
Reflex sympathetic dystrophy: presents as severe
pain months after a crush injury w/ sympathetic
overload (cold, cyanotic, moist); Dx sympathetic
block, Tx surgical sympathectomy
–––––––––––––––––– UROLOGY –––––––––––––––––
Testicular torsion: presents as severe testicular pain
and “high riding testicle with horizontal lie” due to
twisting of the cord; Tx emergent surgical detorsion,
then orchiopexy (do not do any Dx tests)
Epididymitis: presents like testicular torsion but w/
fever, pyuria, and cord is also tender; Dx U/S to rule
out torsion, then Tx antibiotics
Obstructive UTI: presents as sepsis (fever, chills,
flank pain) in someone passing a kidney stone;
Surgery –Subspecialty Surgery
surgical emergency that requires immediate
decompression (stent or perc nephrostomy) in
addition to IV antibiotics
Lower UTI: presents as dysuria and cloudy, stinky
urine but no fever, chills, or flank pain; common in
young women, give antibiotics
Pyelonephritis: UTI that has ascended to the kidneys,
presents with fever, chills, flank pain; Dx urologic
work-up and Tx antibiotics
Prostatitis: presents as fever, chills, dysuria, back
pain, and tender prostate on rectal exam; give anti-
biotics and don’t do any more rectal exams
Urologic workup in kids: indicated for traumatic
hematuria and UTIs, since it may indicate congenital
abnormalities otherwise undiagnosed
Congenital malformations: posterior urethral valves,
hypospadias, epispadias, vesicoureteral reflex, low
implantation of ureter, ureteropelvic obstruction
Posterior urethral valves: presents as anuria in a
newborn boy; cathereterize to empty bladder,
then Dx voiding cystourethrogram, Tx resection
Hypospadias: presents as urethral opening on
ventral side of penis, never circumcise since
prepuce is needed for surgical correction
Epispadias: urethral opening on dorsal penis
VUR: presents as dysuria, fever, chills, and flank
pain in kids due to ascending UTI; give antibiotics
and Dx IV pyelo and voiding cystogram to look for
reflux, long-term abx until child “grows out of it”
Low implantation of ureter: asymptomatic in
boys, “wet with urine all the time” in girls b/c
ureter drips into vagina instead of bladder; Dx
physical exam or IV pyelo, Tx surgical correction
Ureteropelvic obstruction: usually asymptomatic,
but presents with colicky pain with large diuresis
(e.g. colicky pain following “beer drinking binge”)
Hematuria: always get IV pyelo (CT scan if allergic or
poor renal function) and cystoscopy to r/o cancers
Urologic cancers: renal cell carcinoma, transitional
cell carcinoma, prostatic cancer, testicular cancer
RCC: presents as hematuria, flank mass/pain, and
paraneoplastic syndromes (PAPER – PTHrP, ACTH,
prolactin, EPO, renin); get CT scan if suspected,
Tx surgical resection
Bladder TCC: presents as painless hematuria in
smokers; get IV pyelo and cystoscopy, then Tx
surgical resection, then lifelong f/u for high-rate
of local recurrence
Prostatic cancer: asymptomatic, detected as
rock-hard nodule on rectal exam; get U/S-guided
needle biopsy, then TURP or radiation therapy
(Tx flutamide and leuprolide if metastatic)
 Surgery –Subspecialty Surgery

Testicular cancer: presents as painless testicular

mass that doesn’t transilluminate; get radical
orchiectomy w/ biopsy, then f/u αFP or βHCG for
recurrence (Tx cisplatin or radiation if metastatic)

BPH: presents as dribbing, nocturia, and difficulty

voiding in an old man; put in Foley for 3 days, and Tx
α-blockers (tamsuosin), 5αR-blockers (finasteride)
+/- surgical prostate resection

Post-op urine retention: presents as a need to void,

but inability to do so; Tx straight cath at 6 hours
post-op and Foley after 2nd straight cath

Stress incontinence: presents as urine leaking w/

abd pressure due to weakened pelvic floor in a
multigravid woman; Tx surgical repair of pelvic floor

Kidney stones: presents as colicky flank pain and

hematuria +/- radiation to inner thigh, Dx plain X-rays;
Tx analgesics, fluids, and observation (<3 mm) or
shockwave lithotripsy (>3 mm)

Impotence: two types – organic and psychogenic,

management depends based on etiology

Psychogenic impotence: sudden onset w/o

traumatic cause, specific to partner or situation;
Tx psychotherapy

Organic impotence: sudden onset (trauma) or

gradual onset (atherosclerosis, diabetes); first-
line Tx is PDE5-blockers (sildenafil, Viagra)

–––––––––––– TRANSPLANT SURGERY –––––––––––

Transplant donors: almost everyone including brain-

dead pts, Hep and HIV pts to each other, metastatic
cancer pts for corneas

Transplant rejection: hyperacute (minutes), acute

(days/months), chronic (years)

Hyperacute rejection: preformed ab’s against donor

organ causes vascular thrombosis within minutes;
never seen since type-and-cross prevents this from
happening

Acute rejection: HLA mismatch causes macrophage

attack on donor tissue with lymphocytic infiltrate,
confirmed by biopsy

Liver rejection: indicated by elevated LFTs, first

step is to get U/S and Doppler to rule out biliary
obstruction and vascular thrombosis

Heart rejection: indicated by progressive heart

failure; management is getting routine ventricular
biopsies and Tx steroid bolus + OKT3

Chronic rejection: gradual deterioration of organ

function due to polymorphisms, irreversible and no
Tx available

–––––––––––– PEDIATRIC DISEASES ––––––––––––
Congenital hip dysplasia: presents as uneven gluteal
folds, posterior dislocating hips (with “snapping”) in
a newborn; Dx U/S since hip isn’t calcified for X-ray,
Tx splinting
Avascular necrosis of femoral head: presents in a kid
w/ limping, hip pain, and limited hip ROM; Dx X-ray,
Tx cast + crutches
Hip dislocation: presents as a chubby kid limping
due to groin pain, hip has limited internal rotation;
Dx X-ray, Tx pin femoral head back in place
Septic hip: presents in toddlers who refuse to move
hip following a septic illness; Dx hip aspiration unter
anesthesia, Tx perc drain
Osteomyelitis: presents in kids w/ severe localized
bone pain following a septic illness; Dx bone scan
since X-ray will be false negative, Tx antibiotics
Genu varum: aka bowlegs, <3 y/o observe since it’s
normal, >3 y/o surgical correction
Genu valgus: aka knock-knee, observation okay
Osgood-Schlatter disease: presents in teens w/
persistent pain over tibial tubercle, aggravated by
quad contraction; Tx immobilization in cast
Club foot: presents as bilateral inverted feet in a
newborn; Tx serial plaster casts on adducted
forefoot → hindfoot varus → equinus
Scoliosis: laterally curved spine, common in teenage
girls; Tx spine brace until mature, surgery if severe
––––––––––––––– BONE TUMORS –––––––––––––––
Osteosarcoma: presents as low-grade knee pain in a
10-25 y/o, X-ray shows Codman’s triangle and
sunburst appearance; consult a specialist
Ewing sarcoma: presents as low-grade epiphyseal
pain in a child, X-ray shows onion skinning, due to
t(11;22); consult a specialist
Metastatic bone cancers: usually from breast (lytic)
and prostate (blastic), causing bone pain and patho-
logic fx; Dx bone scan, Tx chemoradiation
Multiple myeloma: plasma B-cell tumor results in
CRAB – hyperCalcemia, Renal failure, Anemia, and
Bone pain (X-ray shows punched-out lesions); Dx
urinary Bence-Jones protein, Tx chemotherapy
–––––––––––– ORTHOPEDIC TRAUMA ––––––––––––
Fractures: all require 2 X-rays (90° from each other)
including joints above and below fractured bone;
anticoagulation of choice is fondaparinux + leg
compression devices
Clavicular fx: typically between mid-to-distal third of
clavicle; Tx figure-of-eight device for 4-6 weeks
Surgery – Orthopedic Surgery
Anterior shoulder dislocation: presents w/ outward Open fx: require cleaning and reduction within 6
rotated arm + deltoid numbness due to axillary palsy hours to prevent ischemia of distal limb
Posterior shoulder dislocation: rare, presents w/ Gas gangrene: presents as tender, swollen,
internally rotated arm held close to body discolored wound site w/ crepitus following a
penetrating injury; Tx high-dose penicillin G,
Colles fx: distal radial fx in osteoporotic women hyperbaric oxygen, and debridement
falling on outstretched hand; Tx reduction + cast
Monteggia fx: diaphyseal fx of proximal ulna + radial
dislocation, following direct trauma to ulna
Galeazzi fx: diaphyseal fx of distal radius + ulnar
dislocation, following direct trauma to radius
Scaphoid fx: presents as wrist pain and tender
anatomic snuffbox in a young person falling on
outstretched hand; Tx thumb spica cast
Metacarpal neck fx: presents as swollen and tender
hand after punching a wall; Tx splint or plate
Hip fx: presents as shortened and externally rotated
hip in an osteoporotic woman; Tx depends on
location of fx
Femoral neck fx: may lead to avascular necrosis of
femoral head; Tx prosthetic replacement of head
Intertrochanteric fx: less likely to cause avascular
necrosis; Tx ORIF
Femoral shaft fx: Tx intramedullary rod fixation,
high risk of hypovolemic shock and fat embolisms
Knee injury: all severe knee injuries present w/
swelling, and first step in management is an MRI
Unhappy triad: injury to ACL, MCL, and medial
meniscus following blow to lateral leg; Tx surgical
repair
ACL tear: presents as swelling, pain, and positive
anterior drawer sign; Dx MRI, Tx immobilization
and rehab
Meniscal tear: presents as pain, swelling, and
“clicking” of knee w/ forceful extension; Tx
arthroscopic repair to salvage meniscus
Tibial stress fx: presents as localized tibial pain in a
soldier following a long march; Tx cast and f/u X-ray
in 2 weeks
Leg fx: common in pedestrian vs. car accidents; Tx
cast for easily reduced fx, intramedullary nailing
otherwise, high risk of compartment syndrome
Achilles tendon rupture: presents as “popping noise”
in ankle following exertion w/ pain and swelling; Tx
cast or surgery
Ankle fx: common after falling on inverted or
everted foot; Tx ORIF
––––––––– ORTHOPEDIC EMERGENCIES –––––––––
Pain under cast: remove cast to examine
PSYCHIATRY

––––––– MENTAL STATUS EXAMINATION –––––––
Appearance: objective description of pt
Appearance buzzwords: pupil size = drug abuse
or withdrawal, bruises = abuse, needle
marks/tracks = drug abuse, eroding enamel =
bulimia, superficial cuts on arms = self-harm
Activity: amount/type of motor movement
Psychomotor agitation: excess, non-productive
motor activity in response to inner tension
Psychomotor retardation: visible slowing of
thoughts, speech, movement
Tics: involuntary, spasmodic motor movement
Akathisia: subjective feeling of muscular tension
resulting in restlessness, pacing, repeated sitting
and standing
Stereotypic movements: repetitive, fixed pattern
of physical action or speech (e.g. head banging)
Tardive dyskinesia: involuntary choreoathetoid
movements of head/limbs/trunk, due to
prolonged use of antipsychotics
Echopraxia: imitating movements
Echolalia: imitating speech
Dystonia: slow, sustained contraction of trunk or
limbs, usually a side-effect of drugs
Speech: pt’s ability to articulate thoughts; measured
in terms of rate, amount, volume, articulation, tone
Pressured speech: pt is uninterruptible and feels
compelled to continue speaking
Mood: what the pt feels in his own words; to assess
mood, ask “how are you feeling today?” or “rate your
mood on a scale of 1 to 10”
Affect: how pt’s mood appears to the examiner
Labile affect: laughing one moment, then crying
the next
Flat affect: pt remains expressionless and
monotone despite gravity of situation
Inappropriate affect: pt laughs when told he has
a serious illness, or told he faces criminal charges
Thought process: how the pt thinks
Goal-directed: normal thought process
Loosening of associations: no logical connection
from one thought to another
Flight of ideas: thoughts change rapidly from one
to another, characteristic of mania
Neologisms: made-up words
Word salad: incoherent collection of words
Clang associations: rhyming and punning (think
hip-hop)
Thought blocking: abrupt cessation of speech
before idea is finished
Tangentiality: never gets to goal, keeps breaking
off on a tangent
Circumstantiality: overinclusion of trivial or
irrelevant details
Perseveration: inability to change the topic, or
giving the same response to different questions
Thought content: what the pt thinks
Poverty of thought vs. overabundance: too few
or too many ideas expressed
Delusions: fixed, false beliefs
Suicidal/homicidal ideation: thoughts about
wanting to kill self or others; assess by directly
asking about suicide, not just “do you want to
hurt yourself?”
Phobias: persistent, irrational fears
Obsessions: persistent, intrusive thoughts that
can’t be repressed, associated w/ anxiety
Compulsions: repetitive behaviors (often acting
upon obsessions)
Ideas of reference: false belief that others are
talking about him/her
Ruminations: mood-congruent concerns that
accompany state of depression/anxiety
Perception: mental process by which sensory stimuli
are brought to awareness
Hallucinations: perceptions w/o external stimuli;
five types – auditory (risk factor for SI/HI), visual,
taste, olfactory, tactile
Illusions: misperception of external stimuli
Agnosia: inability to recognize people or objects
even w/ intact sensory function
Depersonalization: feeling that one is falling
apart, fragmenting, detached, not oneself, etc.
Derealization: feeling that the world is not real
Synesthesia: sensation of one modality perceived
by another (e.g. seeing sounds)
Cognition: pt’s ability to perform mental tasks
Alert + oriented x3: alertness controlled by
reticular activating system; orientation refers to
person, place, time
Ψ – Examination and Diagnosis
Memory: controlled by temporal lobes; three
main types – immediate, short-term (recent),
long-term (remote)
Fund of knowledge: ask pt about simple facts
(e.g. “who is the current president?”)
Concentration: ask pt to “spell WORLD forwards
and backwards” or do serial 7 test
Abstraction: ask pt to interpret a proverb, and
explain similarities between objects; lack of
abstraction → concrete thinking
Insight: pt’s awareness and understanding of his/her
own problem
Judgment: pt’s ability to understand the outcome of
his/her actions
–––––––––––––––– DIAGNOSIS ––––––––––––––––
DSM-IV: axis I – mental illnesses, axis II –personality
d/o and mental retardation, axis III – medical
conditions, axis IV – psychosocial stressors, axis V –
global assessment of function (scale 0-100)
GAF ≤30: criteria for hospitalization
Intelligence quotient: [IQ = 100 × (mental age /
chronological age)], mean IQ is 100 w/ standard
deviation of 15
IQ tests: Stanford-Binet test for kids age 2-18,
Wechsler Aduit Intelligence Scale (WAIS) for adults
age 16-75
Mental retardation: IQ < 70 and deficits in
adaptive skills
Personality tests: Minnesota Multiphasic Personality
Inventory (MMPI), Thematic Apperception Test (TAT),
Rorschach test
MMPI: objective personality test used to identify
both personality d/o and other psychopathology
TAT: pt creates stories based on pictures of
people in various situations, used to evaluate
motivation behind behaviors
Rorschach test: interpretation of inkblots
NSAID use: can ↓lithium excretion → ↑lithium
concentrations (except sulindac and aspirin)
 Ψ – Psychotic Disorders

–––––––––––––––– PSYCHOSIS ––––––––––––––––
Psychosis: distorted perception of reality presenting
as delusions, hallucinations, or severely disorganized
thought/behavior
Psychosis in elderly: evaluate for delirium w/ EEG
Psychosis-exacerbating drugs: β-blockers,
digoxin, steroids, anticholinergics
Delusion: fixed, false belief; two types – bizarre
(impossible) and nonbizarre (could be true)
Paranoid/persecution delusion: irrational belief
that one is being persecuted (e.g. CIA phone-tap)
Delusion of reference: belief that cues in
external environment are directed at individual
Delusion of control: thought insertion, thought
withdrawal, and thought broadcasting are unique
to SCZ
Delusion of grandeur: belief that one has
superpowers, or inflated self-esteem
SCZ phases: prodromal phase (prepsychotic
decline in functioning), psychotic phase, residual
phase (negative sx b/t episodes of psychosis)
Schizophrenia subtypes: paranoid, disorganized,
catatonic, residual, undifferentiated
PSCZ: characterized by delusions and AH/CH,
deafness is a risk factor
DSCZ: characterized by disorganized speech,
behavior, and flat or inappropriate affect
CSCZ: characterized by rigid posture,
inappropriate or repetitive movements,
echolalia/echopraxia, and waxy flexibility
RSCZ: prominent negative sx (5 As – Anhedonia,
flat Affect, Alogia, Avolition, poor Attention)
USCZ: doesn’t fulfill criteria for any other subtype
SCZ gender: men = women but men have earlier
onset (20 y/o) than women (30 y/o), winter/early
spring birthdays have ↑incidence (due to ↓sunlight
→ ↓vit D)
Schizoaffective disorder: SCZ + mood sx (either
manic, depressive, or mixed episode), delusions or
hallucinations w/o mood sx for 2 weeks; Tx
antipsychotics + mood stabilizers + supportive
psychotherapy
SAD vs. mood disorders: SAD has 2 week period of
psychotic sx w/o mood sx; worse Px than mood d/o
Delusional disorder: nonbizarre, fixed delusions for
1+ month w/o functional impairment; 4 subtypes –
paranoid, erotomaniac, jealous, somatic
Paranoid/persecution delusions: irrational belief
that one is being persecuted (e.g. CIA phone-tap)
Erotomaniac delusions: delusions regarding love
Jealous delusions: aka Othello syndrome,
delusions of unfaithfulness
Somatic delusion: false belief that one is
infected or has a certain illness (e.g. parasitosis)
Delusional disorder Tx: psychotherapy (drugs
ineffective)

Delusion of guilt: false belief that one is
responsible or guilty for something
Somatic delusion: false belief that one is
infected or has a certain illness
Illusion: misinterpretation of sensory stimulus
SCZ prevalence: 1% overall, 10% siblings, 50% twins
Postpsychotic depression: major depressive
episode after resolution of psychotic symptoms
Downward drift: ↑SCZ prevalence in lower socio-
economic groups (can’t hold onto good jobs)
Shared psychotic disorder (folie á deux): pt picks up
identical delusions as a significant other; Tx
separation + psychotherapy, antipsychotics if not
improved in 1-2 weeks following separation

Hallucination: sensory perception w/o stimulus SCZ pathophysiology: ↑dopamine in mesolimbic

Auditory hallucination: most common in
schizophrenia, command hallucinations are
specific AH that tell pt to do things
Visual hallucination: drug intoxication,
drug/alcohol withdrawal, delirium, Lewy body
dementia
Tactile hallucination: cocaine or amphetamine
intoxication, alcohol withdrawal
Olfactory hallucination: seizure disorder, must
r/o medical conditions
Gustatory hallucination: r/o medical conditions
pathway (positive sx), ↓dopamine in prefrontal ctx
(negative sx); also ↑5-HT, ↑NE, ↓GABA, ↓glutamate
SCZ brain: diffuse cortical atrophy w/ enlarged
ventricles
SCZ Px: good prognosis w/ later onset, good social
support, positive sx, mood sx, acute onset, females,
↓relapses, and good premorbid function; 10% suicide
SCZ Tx: atypicals first-line, typicals second-line,
clozapine if other antipsychotics don’t work
Antipsychotic side-effects: EPS (parkinsonism,
akathisia, dystonia), NMS, tardive dyskinesia, anti-
HAM, metabolic syndrome, ↑prolactin, etc.

Psychosis 2/2 GMC: CNS diseases, endocrinopathy, SCZ × bad family: increased relapse rate
B3/B9/B12 deficiency, lupus, or porphyrias; an axis I
disorder but the GMC goes on axis III –––––––– OTHER PSYCHOTIC DISORDERS ––––––––

Substance-induced psychotic disorder: prescription
meds, alcohol, cocaine, hallucinogens, marijuana,
sedative-hypnotics, or PCP
–––––––––––––– SCHIZOPHRENIA ––––––––––––––
Schizophrenia: >6 months with 2/5 for at least 1
month – delusions, hallucinations, disorganized
speech, disorganized/catatonic behavior, negative
symptoms
Brief psychotic disorder: SCZ-like for <1 month;
Tx antipsychotics + supportive psychotherapy
Brief psychotic vs. BPD: BPD can have brief, stress-
related psychoses that are part of the personality
d/o and not brief psychotic d/o
Schizophreniform disorder: SCZ-like for 1-6 months;
Tx antipsychotics + supportive psychotherapy

–––––––––––––––––– MOOD ––––––––––––––––––
Mood: inner emotional state
Mood episode: distinct period of abnormal mood;
includes major depressive, manic, hypomanic, and
mixed episodes
Mood disorder: loss of control over mood and
subsequent functional impairment; includes MDD,
bipolar I/II, dysthymic, and cyclothymic disorders
–––––––––––––– MOOD EPISODES ––––––––––––––
Major depressive episode: 5/9 SIGECAPS (including
depressed mood or anhedonia) for 2 weeks –
depressed mood, Sleep, Interest, Guilt, Energy,
Concentration, Appetite, Psychomotor activity,
Suicidal ideation
Manic episode: 3/7 DIGFAST (4/7 if irritable mood) for
1 week – Distractibility, Insomnia, Grandiosity, FOI,
↑Activity, Speech pressured, Thoughtlessness
Hypomanic episode: 3/7 DIGFAST (4/7 if irritable
mood) for 4+ days, no functional impairment or
psychotic features (vs. manic episodes)
Mixed episode: 5/9 SIGECAPS + 3/7 DIGFAST for every
day of 1 week
––––––––––––– MOOD DISORDERS –––––––––––––
Mood disorder 2/2 GMC: must have direct causal,
physiologic relationship to mood sx
Substance-induced mood disorder: β-blockers
(depression), steroids, levodopa, cocaine (mania),
OCP (depression)
Major depressive disorder: 1 major depressive
episode, no manic or hypomanic episodes
MDD prevalence: 16.2% (25-50% in elderly)
MDD risk factors: stroke (30-50%, lasts 2 years),
pancreatic cancer, loss of parent before age 11,
genetics (70% in twins)
MDD × sleep: difficulty falling asleep, multiple
awakenings, and early morning awakenings;
hypersomnia characteristic of atypical depression
MDD etiology: monoamine hypothesis is most
popular (↓5-HT/DA/NE), other causes include
↑cortisol, ↓thyroid, psychosocial and genetics
MDD brain: reduced frontal lobe blood flow and
metabolism
MDD Px: 15% suicide, 30-40% alcoholism, only 50%
receive Tx, 50-85% have another episode
MDD Dx: Beck depression inventory
MDD Tx: antidepressants ± psychotherapy; acute
risk → hospitalization, elderly → use lower dose,
unresponsive to drugs → add lithium or try ECT
Ψ – Mood Disorders
Antidepressants: all equally effective and take 4-8 Bipolar II disorder: 1 hypomanic episode + 1 major
weeks for effect, SSRI/SNRI are first-line, maintain depressive episode, no full manic episodes
for 6-9 months
BII Tx: mood stabilizers (see BI)
MDD in kids: presents as irritability and short temper,
rather than sadness or depression Rapid cycling disorder: 4+ mood episodes in 1 year
MDD in elderly: MC psychiatric disorder in elderly, Rapid cycling Tx: carbamazepine
↑incidence s/p MI, stroke, and new admits to nursing
homes Cyclothymic disorder: alternating hypomania and
dysthymia for 2 years, no asx interval of >2 months,
MDD subtypes: melancholic, atypical, catatonic, and no major depressive or manic episodes
psychotic, postpartum, seasonal affective disorder
CtD Tx: mood stabilizers (see BI)
Melancholic depression: characterized by
anhedonia, excess guilt, anorexia, early morning Minor depressive disorder: 2-4/9 SIGECAPS w/
awakenings, and psychomotor disturbance functional impairment, euthymic periods also seen
(vs. dysthymic disorder), 20% progress to MDD
Atypical depression: characterized by hyper-
somnia, hyperphagia, reactive mood, leaden Suicide risk factors: SAD PERSONS – Sex (male), Age
paralysis, hypersensitivity to rejection; Tx MAOIs (<19 or >45), Depression, Previous attempt, EtOH or
drugs, Rational thinking loss, Sickness, Organized
Catatonic depression: rare, characterized by plan, No spouse, Social support loss
catalepsy, purposeless movements, bizarre
postures, and echolalia; Tx ECT #1 suicide risk factor: previous attempt
Psychotic depression: MDD + delusions or
hallucinations; Tx SSRI + antipsychotic
Postpartum major depression: onset within 4
weeks of delivery, resolves w/o meds
Seasonal affective disorder: 2 consecutive years of 2
major depressive episodes during the same season,
Sx triad – irritability, carb cravings, hypersomnia; Tx
light therapy
Dysthymic disorder: depressive sx for 2 years (1 year
in kids) without overt major depressive episodes
DtD Tx: antidepressants ± CBT
DtD × psychosis: dysthymia can never have
psychotic features, consider another diagnosis
Double depression: major depressive disorder +
dysthymic disorder during residual periods
Grief: aka bereavement, normal reaction to a major
loss, does not present w/ SI or disorganization
Kübler-Ross stages of grief: denial, anger,
bargaining, depression, acceptance
Grief vs. depression: grief lasts <2 months and
has illusions but no delusions, hallucinations, or SI
Bipolar I disorder: aka manic depression, 1 manic or
mixed episode; 1% lifetime prevalence, 5-10% with
first-degree relatives
BI Tx: mood stabilizers (lithium ↓ suicidality,
carbamazepine for rapid cyclers, valproate for kids
<12); pregnant mania → atypicals, h/o postpartum
mania → lithium PPx but c/i to breastfeeding
BI × antidepressants: will flip into manic mode

–––––––––––––––––– ANXIETY ––––––––––––––––––
Anxiety: subjective experience of fear and its
sympathetic response (e.g. ↑HR, ↑BP, SOB, etc.)
Pathological anxiety: inappropriate to situation
and interferes w/ daily functioning
Anxiety NTs: ↑NE, ↓GABA/5-HT
Anxiety 2/2 GMC: hyperthyroidism, Graves disease,
Sjogren syndrome, PE, pheochromocytoma, seizure
disorders
Substance-induced anxiety disorder: caffeine,
theophylline, alcohol/sedative withdrawal, mercury,
arsenic, benzene, organophosphates, penicillin,
sulfonamides, sympathomimetics, antidepressants
–––––––––––– ANXIETY DISORDERS ––––––––––––
Anxiety disorders: panic disorder, agoraphobia,
specific and social phobias, OCD, PTSD, ASD, GAD,
anxiety 2/2 GMC or substance use
Anxiety d/o prevalence: 30% women > 19% men,
more frequent in higher socioeconomic groups
Panic attack: peak in 10 min and last <25 min; 4 of
the following PANICS – Palpitations, Abdominal
distress, Numbness/nausea, Intense fear of death,
Choking/chills/chest pain, Sweating/shaking/SOB
PA risk factors: mitral valve Prolapse, Pulmonary
embolus, Asthma, Angina, Anaphylaxis
PA management: order labs (TSH, metanephrine,
B12, etc.) to r/o medical and substance causes
Panic disorder: PA + 1 of the following for 1 month –
persistent concern of another PA, worry about
implications of PA, change in behavior due to PA;
may present as chest pain + normal EKG
PD etiology: dysregulation of autonomic nervous
system w/ NT imbalance (↑NE, ↓GABA/5-HT)
PD Tx: high-dose SSRI for 8-12 months + CBT,
short-term BDZs for immediate relief of attacks
Agoraphobia: anxiety in places where escape is
difficult or help is not readily available → avoidance
of situation
Common agoraphobias: bridges, crowds, buses,
trains, open areas outside the home
Specific phobia: persistent fear of object/situation
→ avoidance or tolerated w/ intense anxiety, must
be >6 months if <18 y/o, common comorbidities
include MDD and substance abuse
Common specific phobias: animals, blood or
needles, death, flying, heights, illness or injury
Specific phobia epidemiology: most common
mental disorder in the US, women > men
Ψ – Anxiety and Adjustment Disorders
Specific phobia Tx: CBT + desensitization is first- Generalized anxiety disorder: excess anxiety + 3/6
line, BDZs and β-blockers help w/ autonomic sx DRIFTS for 6 months – Difficulty concentrating,
Restlessness, Irritability, Fatigue, Tense muscles,
Social phobia: aka social anxiety disorder, same as Sleep disturbance
specific phobia but related to social settings
GAD epidemiology: 45% prevalence, women >
Common social phobias: public speaking, eating men; frequently comorbid w/ MDD, dysthymia, or
out, using public restrooms other anxiety disorders
Social phobia vs. shyness: shyness + impairment GAD Tx: CBT + drugs (SSRIs, buspirone,
of daily function = social phobia venlafaxine)
Social phobia Tx: SSRI (paroxetine) + CBT is first- GAD vs. phobias: anxiety is free-floating in GAD,
line, BDZs and β-blockers help w/ performance rather than being fixed to specific situation
anxiety
–––––––––– ADJUSTMENT DISORDERS ––––––––––
Obsession: intrusive, repetitive thought
Adjustment disorder: behavioral or emotional sx
Compulsion: ritualistic behavior following stressful life event, begins within 3 months
after the event and ends within 6 months
Obsessions of contamination: followed by
excessive hand-washing or avoidance of feared AD etiology: triggered by a non-life threatening
contaminant psychosocial stressor
Obsessions of doubt: followed by repeated AD Tx: psychotherapy, should resolve in 6
checking to avoid potential danger (e.g. turning months by definition
off stove, locking the door)
Adjustment vs. GAD: no stressor in GAD
Obsessions of symmetry/order: compulsively
slow performance of task Adjustment vs. PTSD: life-threatening event in PTSD
Intrusive thoughts: often sexual or violent Adjustment vs. MDD: consider MDD if sx last over 6
thoughts → distress but no compulsion months
Somatic obsessions: cause pts to view parts of Adjustment vs. normal experience: adjustment has
their body, waste, or secretions as abnormal impaired level of social or occupational functioning
Obsessive-compulsive disorder: ego-dystonic
obsessions → compulsions
OCD etiology: abnormal 5-HT regulation,
associated w/ head injury, epilepsy, basal ganglia
d/o, and postpartum conditions; onset triggered
by stressful life event in 60% of pts
OCD epidemiology: 2.5% prevalence, frequently
comorbid w/ ADHD and Tourette syndrome
OCD vs. OCPD: OCD is ego-dystonic (marked
distress over sx), OCPD is ego-syntonic
OCD Tx: SSRI (fluvoxamine) is DOC, clomipramine
is second line, last-resort is ECT or cingulotomy
Acute stress disorder: PTSD for 2 days – 1 month
ASD Tx: mobilize social supports
Post-traumatic stress disorder: traumatic event →
intense fear for >1 month; characterized by RAIN –
Re-experiencing the event, Avoidance of stimuli,
Increased arousal, Numbing of responsiveness
PTSD epidemiology: high MDD and substance
abuse
PTSD Tx: SSRIs are DOC, β-blockers good for
hyperarousal sx

–––––––––– PERSONALITY DISORDERS ––––––––––
Personality: stable, predictable emotional and
behavioral traits
Personality disorder: maladaptive, ego-syntonic
personality traits → functional impairment; 10-20%
prevalence
Cluster A: schizoid, schizotypal, paranoid;
↑association w/ psychotic disorders
Cluster B: antisocial, borderline, histrionic,
narcissistic; ↑association w/ mood disorders
Cluster C: avoidant, dependent, obsessive-
compulsive; ↑association w/ anxiety disorders
PD-NOS: passive-aggressive, depressive, sadistic,
self-defeating/masochistic
PD Tx: psychotherapy for all PDs except borderline
(use DBT) and antisocial
Personality traits vs. PD: PDs show impairment of
social or occupational functioning, traits don’t
––––––––––––––––– CLUSTER A –––––––––––––––––
Paranoid personality disorder: general distrust of
others → suspicious of spouse and others, grudges,
preoccupied w/ doubts, non-trusting, quick to
counterattack, etc.
PPD defense mechanism: projection (attributing
inappropriate thoughts/emotions onto another)
PPD vs. social isolation: pts w/o social support
system can react w/ suspicion to others, DDx by
getting collateral regarding baseline
PPD Tx: psychotherapy
Schizoid personality disorder: voluntary social
withdrawal → ↓friends, ↓sexual interest, emotional
detachment, indifferent to others, anhedonia, etc.
SPD defense mechanism: fantasy (imagination
used as an escape where others aren’t needed
for emotional fulfillment)
SPD vs. AVPD: SPD want to be alone, AVPD want
friends but are too shy to make any
SPD Tx: psychotherapy
Schizotypal personality disorder: eccentric thoughts
or behavior + discomfort w/ close relationships →
↓friends, ideas of reference, suspiciousness,
inappropriate/restricted affect, excessive social
anxiety, magical thinking, etc.
STPD vs. SPD: SPD + eccentric behavior = STPD
STPD Tx: psychotherapy
––––––––––––––––– CLUSTER B –––––––––––––––––
Antisocial personality disorder: selfish disregard for
others → CONDUCT – Capriciousness, Oppressive,
Nonconfrontational, Deceitful, Unlawful, Carefree,
Temper issues
ASPD epidemiology: ↑incidence in prisoners and
poor urban areas, high genetic component
ASPD vs. conduct disorder: conduct disorder if
<18 y/o, ASPD if ≥18 y/o
ASPD vs. drug abuse: antisocial behavior may be
2/2 drug use, need to find out which came first
ASPD Tx: psychotherapy is useless; SSRIs and
mood stabilizers help w/ reducing aggression
Borderline personality disorder: IMPULSIVE –
Impulsive, Moody, Paranoid, Unstable self-image,
Labile relationships, Suicidal, Inappropriate anger,
Vulnerable to abandonment, Emptiness
BPD buzzwords: “best doctor ever”, multiple
meds don’t work, >5 allergies, h/o cutting
BPD epidemiology: women > men, high rate of
childhood sexual abuse, 10% suicide rate
BPD defense mechanism: splitting (people are all
good or bad, no in-betweens)
BPD Tx: dialectical behavior therapy (DBT) +
setting clear boundaries
Histrionic personality disorder: excessive attention-
seeking and emotionality, inappropriately seductive,
flirtatious, exaggeration-prone
HPD defense mechanism: regression (reverting
back to childlike behavior) and repression
(unconsciously avoiding bad thoughts)
HPD vs. BPD: HPD pts generally more functional;
BPD pts more likely to have MDD, brief psychotic
episodes, and attempt suicide
HPD Tx: psychotherapy + setting clear boundaries
Narcissistic personality disorder: poor self-esteem
→ need for admiration, lack of empathy, sense of
entitlement, arrogance, “fishing for compliments”,
takes advantage of others, etc.
NPD vs. ASPD: both characterized by exploiting
others, but NPD is for self-elevation and ASPD is
for material gain or subjugation of others
NPD Tx: psychotherapy ± group therapy to learn
empathy
––––––––––––––––– CLUSTER C –––––––––––––––––
Avoidant personality disorder: intense fear of
rejection → AFRAID – Avoids occupation w/ others,
Fear of criticism, Reserved unless sure of being liked,
Always thinking rejection, Isolated from
relationships, Distant from others
Ψ – Personality Disorders
AVPD vs. SPD: SPD want to be alone, AVPD want
friends but are too shy to make any
AVPD vs. social phobia: social phobia is a fear of
embarrassment, AVPD is more a fear of rejection
AVPD vs. DPD: both cling to relationships, but
AVPD are slow to get involved while DPD actively
and aggressively seek relationships
AVPD Tx: psychotherapy + assertiveness training
Dependent personality disorder: excessive need to
be taken care of → OBEDIENT – Obsessive about
approval, Bound by others’ decisions, Enterprises
rarely initiated, Difficulty decision-making, Invalid
feelings while alone, Engrossed w/ fears, Needs to
be in a relationship, Tentative about decisions
DPD defense mechanism: regression (reverting
back to childlike behavior)
DPD vs. AVPD: both cling to relationships, but
AVPD are slow to get involved while DPD actively
and aggressively seek relationships
DPD vs. BPD/HPD: DPD have long-lasting
relationships w/ one person, BPD/HPD are unable
to maintain a long-lasting relationship
DPD Tx: psychotherapy (especially groups and
social skills training)
Obsessive-compulsive personality disorder: pre-
occupation w/ orderliness, control, and perfection at
the expense of efficacy
OCPD epidemiology: men > women, oldest child
OCPD vs. OCD: OCD is ego-dystonic (marked
distress over sx), OCPD is ego-syntonic
OCPD vs. NPD: both involve achievement, but
OCPD loves the work and NPD loves the status
OCPD Tx: psychotherapy
–––––––––––––––––– PD-NOS ––––––––––––––––––
Passive-aggressive personality disorder: stubborn,
inefficient procrastinors that alternate between
compliance and defiance, make excuses and
manipulate others into doing their chores/errands
PAPD Tx: psychotherapy
Depressive personality disorder: chronically
unhappy, pessimistic, self-doubting, distressed, etc.

–––––– SUBSTANCE ABUSE & DEPENDENCE ––––––
Abuse: 1/4 WILD for 1 year – Work/school/home
obligation failure, Interpersonal consequences,
Legal problems, Dangerous use
Dependence: 3/7 for 1 year – tolerance, withdrawal,
time-consuming, can’t cut down, ↓activities, use >
intended amount, use despite problems
Tolerance: need ↑amount to achieve same effect
Withdrawal: substance-specific syndrome due to
cesssation following heavy and prolonged use
Substance-use epidemiology: 17% prevalence, MC
substances are alcohol and nicotine, men > women
(think VA population)
Substance types: sedatives, stimulants, opioids,
hallucinogens
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs
and barbiturates), inhalants
Stimulants: strong – cocaine, amphetamines,
MDMA/MDEA; weak – caffeine, nicotine
Opioids: heroin, oxycodone, codeine,
dextromethorphan (cough syrup), morphine,
methadone, meperidine (Demerol)
Hallucinogens: phencyclidine (PCP), ketamine,
psilocybin, mescaline, LSD, marijuana
––––––––––––––––– SEDATIVES –––––––––––––––––
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs
and barbiturates), inhalants
Alcohol: potent CNS depressant (↑GABA, ↑5-HT,
↓VGCC, ↓glu), MC abused substance in the US
Alcohol metabolism: alcohol + dehydrogenase →
acetaldehyde + dehydrogenase → acetic acid;
common cause of ↑anion gap metabolic acidosis
Alcohol intoxication: ↓fine motor control (BAL 20-
50), ↓judgment and coordination (50-100), ataxic
gait and balance (100-150), lethargy and amnesia
(150-250), possible coma and death (>300)
EtOH intoxication Dx: breathalyzer test,
blood/urine testing (more accurate); labs show
↑LFTs (AST:ALT >2, ↑GGT, ↑CDT) + ↑MCV
EtOH intoxication Tx: ABCs and banana bag;
possible injury → head CT, massive EtOH within
past hour → GI evacuation
EtOH × H2-blockers: ↑EtOH levels
EtOH × sedative-hypnotics: respiratory
depression → death
EtOH × NSAIDs: GI bleeding
EtOH × acetaminophen/INH: hepatotoxicity
EtOH × metronidazole/sulfa drugs: N/V
EtOH × pregnancy: fetal alcohol syndrome,
leading cause of MR/DD in US
Banana bag: thiamine + folate + MVI + MgSO4 + IVF
Alcohol withdrawal: starts in 6-24 hrs and lasts 1 wk;
mild sx = irritability, hand tremors, insomnia;
moderate sx = ↑sympathetic activity; severe = DTs
Delirium tremens: delirium, VH/TH, gross tremor,
autonomic instability, seizures → 15-25% mortality
EtOH withdrawal Tx: BDZ taper, banana bag,
monitor sx w/ CIWA scale
Alcohol dependence: 2/4 CAGE – Cut down, Annoyed
by criticism, Guilty about drinking, Eye opener
EtOH dependence Tx: disulfiram (Antabuse)
blocks aldehyde DH → aversive reaction;
naltrexone blocks opioid-R → ↓cravings;
acamprosate → ↑GABA/↓glu → ↓cravings
Wernicke-Korsakoff syndrome: COAT RACK
Wernicke encephalopathy: acute thiamine
deficiency → reversible Confusion, Ophthalmo-
plegia (CN6 palsy), Ataxia, Thought disturbances;
Tx IV thiamine
Korsakoff psychosis: chronic thiamine deficiency
→ irreversible Retrograde /Anterograde amnesia,
Confabulations
Sedative-hypnotics: BDZs, barbiturates, zolpidem,
zaleplon, GHB, meprobamate, etc.
BDZs: ↑GABA frequency, used for anxiety
Barbiturates: ↑GABA duration, used as
anesthetics and antiepileptics, lower margin of
safety vs. BDZs
Sedative-hypnotic intoxication: drowsiness,
confusion, slurred speech, incoordination, ataxia, etc.
SH intoxication Dx: +UDS for variable amount of
time
SH OD: respiratory depression → death,
especially when combined w/ EtOH
SH intoxication Tx: BDZs → flumazenil,
barbiturates → IV NaHCO3
Sedative-hypnotic withdrawal: life-threatening,
presents similar to alcohol withdrawal; barbiturate
withdrawal has highest mortality rate of all drugs
SH withdrawal Tx: BDZ taper
GHB: aka sodium oxybate, CNS depressant that
causes memory loss, respiratory distress, coma;
common date rape drug, used to Tx cataplexy
Inhalants: CNS depressants; includes solvents, glue,
paint thinners, fuels, isobutyl nitrates
Ψ – Substance-Related Disorders
Inhalant intoxication: perceptual disturbances,
psychosis, N/V, euphoria, lethargy → stupor → coma
Inhalant OD: death 2/2 ↓RR or arrhythmias
Inhalant intoxication Tx: ABCs, identify solvent
b/c some (e.g. leaded gas) may require chelation
Inhalant withdrawal: rare
–––––––––––––––– STIMULANTS ––––––––––––––––
Stimulants: strong – cocaine, amphetamines,
MDMA/MDEA; weak – caffeine, nicotine
Cocaine: blocks DA reuptake → stimulant effect +
activates reward system; blocks NE reuptake →
vasoconstriction
Cocaine intoxication: euphoria, ↑self-esteem,
↑sympathetic activity, TH, paranoia; possible death
by MI, stroke, seizure, arrhythmia, or ↓RR
Cocaine intoxication Dx: +UDS for 2-4 days
Cocaine intoxication Tx: mild agitation/anxiety →
BDZs, severe agitation/psychosis → haloperidol,
T>102 → ice bath or cooling blanket
Cocaine × alcohol: cocaethylene metabolite has
24× mortality vs. cocaine alone
Cocaine dependence: purely psychological
Cocaine dependence Tx: psychotherapy, no FDA-
approved pharmacotherapy exists
Cocaine withdrawal: aka crash, non-life threatening,
extreme exhaustion following coke binge, severe
depression → risk of suicide
Cocaine withdrawal Tx: refer to Narcotics
Anonmyous, resolves w/o meds
Amphetamines: D-amphetamine, methylphenidate,
methamphetamine; blocks DA/NE reuptake and
causes DA/NE release → stimulant effect
Amphetamine intoxication: dilated pupils, ↑libido,
sweating, ↓RR, chest pain; heavy use →
amphetamine psychosis (mimics SCZ)
Amphetamine intoxication Dx: +UDS for 1-3 days
Amphetamine OD: hyperthermia, dehydration,
rhabdomyolysis → renal failure
Amphetamine intoxication Tx: IVF + electrolytes,
treat hyperthermia
Chronic amphetamine use: acne + meth mouth
Amphetamine withdrawal: prolonged depression
MDMA/MDEA: aka ecstasy and eve, both stimulants
and hallucinogens that induce sense of closeness w/
others, associated w/ clubs and raves
MDMA/MDEA × SSRI: serotonin syndrome

Caffeine: adenosine antagonist + PDE blocker →
↑cAMP, stimulant effect via dopaminergic system
Caffeine intoxication: ↑sympathetic activity, anxiety,
diuresis, insomnia, GI distress
Caffeine OD: tinnitus, severe agitation, and
arrhythmias (>1 g); seizures → death (>10 g)
Caffeine intoxication Tx: supportive care
Caffeine withdrawal: headache, fatigue, irritability,
drowsiness, mild depression
Caffeine withdrawal Tx: self-resolves in 1 week
Nicotine: nicotinic agonist, addictive effect through
the dopaminergic system
Nicotine prevalence: 21%, MCC of preventable
morbidity and mortality in US
Nicotine withdrawal: intense craving and dysphoria,
anxiety, irritability, restlessness
Nicotine withdrawal Tx: varenciline (Chantix) and
buproprion (Zyban) are partial nicotinic agonists;
nicotine patch or gum
Nicotine × pregnancy: low birth weight and chronic
pulmonary hypertension
–––––––––––––––––– OPIOIDS ––––––––––––––––––
Opioids: opiate receptor (μ/κ/δ) agonists; heroin,
oxycodone, codeine, dextromethorphan (cough
syrup), morphine, methadone, meperidine (Demerol)
Opioid intoxication: respiratory depression,
pupillary constriction (except Demerol → Dilation),
sedation, ↓pain, ↓GI motility
Opioid intoxication Dx: +UDS for 2-4 days;
methadone and oxycodone are false negatives,
poppy seed bagels are false positive
Opioid OD: classic triad RAM – Respiratory
depression, Altered mental status, Miosis
Opioid intoxication Tx: ABCs, naloxone or
naltrexone will help respiratory depression but
can precipitate withdrawal syndrome
Meperidine × MAOI: serotonin syndrome
Opioid withdrawal: violent yawning, dilated pupils,
abdominal cramps, ↑secretions (lacrimation,
rhinorrhea, sweating, nausea/vomiting, diarrhea);
not life-threatening
Opioid withdrawal Tx: moderate → CLIP –
Clonidine, Loperamide, Ibuprofen, Promethazine;
severe → methadone or buprenorphine detox,
monitor sx w/ COWS scale
–––––––––––––– HALLUCINOGENS ––––––––––––––
Hallucinogens: psilocybin (shrooms), mescaline
(peyote cactus), LSD (acid); LSD acts on 5-HT system
Ψ – Substance-Related Disorders
Hallucinogen intoxication: perceptual changes,
labile affect, dilated pupils, ↑RR/↑BP/↑HR usually
lasting 6-12 hrs
Hallucinogen intoxication Tx: monitor closely,
agitated psychosis → BDZ or antipsychotics
Hallucinogen withdrawal: no withdrawal syndrome,
but LSD flashbacks can occur due to storage in fat
PCP: aka angel dust, NMDA antagonist
PCP intoxication: RED DANES – Rage, Erythema,
Dilated pupils, Delusions, Amnesia, Nystagmus
(vertical or rotary is pathognomonic), Excitation,
Skin dryness
PCP intoxication Dx: +UDS for 3-8 days, labs show
↑CPK and ↑AST
PCP OD: seizures, coma, possible death
PCP intoxication Tx: monitor closely; mild
agitation/anxiety → lorazepam, severe
agitation or psychosis → haloperidol
PCP withdrawal: no withdrawal syndrome, but
flashbacks can occur due to storage in body fat
Ketamine: aka special K, NMDA antagonist but less
potent than PCP, often used as a date rape drug
Ketamine intoxication: tachycardia, tachypnea,
hallucinations, and amnesia
Marijuana: aka weed, main ingredient is THC →
cannabinoid receptor agonist → inhibit adenylate
cyclase → ↓cAMP
Marijuana intoxication: euphoria, red eyes, dry
mouth, munchies, anxiety, perceptual disturbances
MJ intoxication Dx: +UDS for 3 days (single use)
to 4 weeks (heavy users)
MJ intoxication Tx: psychosocial interventions
Chronic MJ use: respiratory sx + gynecomastia
Marijuana withdrawal: irritability, anxiety,
restlessness, depression, headaches, etc.
MJ withdrawal Tx: supportive care
Dronabinol (Marinol): pill-form of THC used to Tx
anorexia in AIDS pts and N/V in chemotherapy pts
 Ψ – Cognitive Disorders

Cognitive disorder: significant change in cognition Dementia × hypothyroidism: reversible, presents LBD Tx: AChE-inhibitors for VH, antiparkinsonians
from previous level of functioning; two types – as obesity, coarse hair, constipation, and cold and psychostimulants for motor sx
delirium and dementia intolerance; Dx TSH and T4 levels
Pick disease/frontotemporal dementia: diverse
Delirium Dementia Dementia × ↓B12: presents as diminshed position group of dementias, average 5 yrs from onset to
Definition waxing-and- impairment in and vibration sensation; Dx B12 levels death (more rapid than Alzhimer)
waning change in memory and
pt’s level of other cognitive Dementia × neurosyphilis: presents as diminshed Pick/FTD Sx: profound changes in personality and
consciousness functions
position and vibration sensation, and Argyll- social conduct, disinhibition, hyperorality, hyper-
Onset acute chronic
Robertson pupils (accomodates but doesn’t sexuality; good memory and language though
Duration 3 days – 2 wks months – yrs
Px reversible irreversible respond to light); Dx CSF FTA-ABS or VDRL levels
Amnesia immediate and recent and Pick/FTD brain: gross – marked atrophy of frontal
recent memory remote memory Dementia × Wilson disease: presents as tremor, and temporal lobes; microscopic – neuronal loss
Alert no yes ↑LFTs, and Kayser-Fleischer corneal rings; Dx and astrocytosis of cortical layer II
Oriented no sometimes ↓serum ceruloplasmin levels
Dx abnormal EEG abnormal MRI Pick/FTD Tx: anticholinergics and antidepressants
Mini Mental State Exam (MMSE): screening test to help w/ behavior but not cognition
––––––––––––––––– DELIRIUM ––––––––––––––––– Dx dementia; 30 is perfect score, <25 is dementia
HIV-associated dementia: MCC dementia due to
Delirium: aka encephalopathy, waxing-and-waning Alzheimer disease: MCC dementia → gradual infectious disease, neutropenia → infection →
change in pt’s level of consciousness; commonly progressive decline in memory and other cognitive dementia
presents w/ VH, short attention span, and impaired functions, average 10 yrs from onset to death
recent memory HAD Sx: rapid decline in memory, cognition,
AD NTs: ↓ChAT → ↓ACh synthesis behavior, and motor skills; depression and social
Delirium risk factors: common in elderly, ICU pts, withdrawal also common
s/p surgery pts, and cancer pts AD etiology: amyloid cascade hypothesis – high
risk genes (presenilin I, presenilin II, APP, and HAD Tx: HAART
Delirium management: r/o life-threatening apoE4) predispose to excess Aβ-amyloidosis
causes, then ID and Tx the underlying cause Huntington disease: AD disorder due to CAG
AD Dx: diagnosis of exclusion, definitive diagnosis trinucleotide repeats on chromosome 4, shows
Delirium causes: AEIOU TIPS – Alcohol/drug toxicity requires brain biopsy anticipation (longer CAG repeats correlates with
or withdrawal, Electrolyte imbalance, Iatrogenic, earlier age of onset)
Oxygen hypoxia, Uremia/hepatic encephalopathy, AD brain: gross – diffuse atrophy with enlarged
Trauma, Infection, Poison, Seizures, Stroke ventricles and flattened sulci; microscopic – senile HD Sx: chorea, apathy, depression, and dementia
plaques, neural plaques, and neurofibrillary with onset at 35-50 y/o, ↑rate of suicide
Delirium × CVA/mass lesion: presents as focal tangles (not specific to Alzheimer)
neuro sx (e.g. hemiparesis); Dx brain CT/MRI HD brain: atrophy of caudate nucleus
AD Tx: AChE-inhibitors for mild-to-moderate AD
Delirium × HTN encephalopathy: presents as ↑BP (tacrine, donepezil, rivastigmine, galantamine),
and papilledema; Dx brain CT/MRI NMDA antagonist for moderate-to-severe AD
(memantine)
Delirium × drug intoxication: presents as ↑HR
and dilated pupils; Dx urine toxicology screen Alzheimer × Down syndrome: trisomy 21 → triple
apoE4 expression → inevitable Alzheimer by 40 y/o
Delirium × meningitis: presents as fever, nuchal
rigidity, and photophobia; Dx lumbar puncture Vascular dementia: 2nd MCC dementia, due to
accumulation of multiple small infarcts → stepwise
Delirium × thyrotoxicosis: presents as ↑HR, loss of function + focal neurological sx Parkinson disease: loss of dopaminergic neurons →
tremor, and thyromegaly; Dx TSH and T4 levels
both physical and cognitive impairment
VD Dx: multiple small lacunar infarcts on CT scan,
Delirium × hepatic encephalopathy: due to sensitive but not specific for vascular dementia PD Sx: early PD presents as TRAP – Tremor,
↑ammonia, Tx lactulose + neomycin
Rigidity, Akinesia, Postural instability; late PD
VD risk factors: previous stroke, diabetes, HTN presents as Alzheimer-like dementia
Sundowning: worsening of delirium at night
VD Tx: no effective cure; AChE-inhibitors and PD brain: neuronal death in substantia nigra,
––––––––––––––––– DEMENTIA ––––––––––––––––– antihypertensives can help senile plaques, and neurofibrillary tangles

Dementia: progressive and irreversible impairment
in memory and other cognitive functions w/o change
in level of consciousness
Dementia epidemiology: prevalence doubles
every 5 years (1.5% at 60, 40% at 90)
Dementia management: r/o reversible causes
Dementia types: Alzheimer (#1), vascular (#2), Lewy
body (#3), Pick/FTD, HIV-associated, Huntington,
Cruetzfeldt-Jakob, normal pressure hydrocephalus
VD × frontal lobe infarct: sx of schizophrenia,
depression, and bipolar I disorder
Lewy body dementia: 3rd MCC dementia, due to
Lewy body and neurite accumulations in the basal
ganglia
LBD Sx: presents as waxing-and-waning
parkinsonism, VH, and antipsychotic sensitivity
LBD Dx: onset of dementia within 12 mo of
parkinsonism (after 12 mo of onset is Parkinson’s)
PD Tx: early PD → carbidopa + levodopa
(Sinemet), late PD → subthalamic nucleus deep
brain stimulation; antipsychotics will exacerbate
dementia due to PD
Prion diseases: Creutzfeldt-Jakob disease, kuru,
Gerstmann-Straussler syndrome, fatal familial
insomnia, bovine spongiform encephalopathy
Creutzfeldt-Jakob disease: rapidly progressive CNS
degeneration due to abnormal prion accumulation;
either inherited, sporadic, or acquired
 Ψ – Cognitive Disorders

CJD Sx: rapidly progressive dementia, myoclonus

(muscle spasms), and personality changes

CJD Dx: probable – clinical picture + periodic

generalized sharp waves on EEG; definitive –
spongiform change on brain biopsy

Normal pressure hydrocephalus: potentially

reversible dementia due to ↑CSF pressure →
enlarged ventricles

NPH Sx: 3 Ws – Wet (urinary incontinence),

Wobbly (gait apraxia), Wacky (dementia)

NPH Tx: CSF shunt to relieve pressure

Pellagra: vitamin B3 (niacin) deficiency → 3 Ds –

Diarrhea, Dermatitis, Dementia

Herpes encephalopathy: involves temporal lobes

 Ψ – Geriatric Psychiatry

––––––––––––– GEROPSYCHIATRY ––––––––––––– BAD Tx: antidepressants ± psychotherapy; acute

Normal aging: ↓brain volume w/ enlarged ventricles,
↓muscle, ↑fat, ↓vision/hearing, minor forgetfulness
Elderly × MDD: MC psychiatric disorder in elderly,
↑incidence s/p MI, stroke, and new admits to nursing
homes
Elderly × suicide: white elderly males have highest
rate of successful suicides
risk → hospitalization, unresponsive to drugs →
ECT (safe and effective in elderly)
Elderly × alcohol abuse: elderly have ↓alcohol
dehydrogenase → ↑BAL w/ fewer drinks; ↑CNS
sensitivity to alcohol
Medical conditions worsened by alcohol: liver
diseases, GI diseases, CV diseases, gout, diabetes,
depression, anxiety

Pseudodementia Dementia Elderly × sleep: ↓sleep efficiency and ↓total sleep

Definition MDD + cognitive impairment in (↑stage 1-2, ↓stage 3-4, ↓REM latency, ↓total REM);
defects due to memory and ↑incidence of sleep disorders
underlying other cognitive
depression functions
Periodic leg movements: restless leg movements
Onset acute chronic
during sleep, due to dopamine imbalance
Features often answers “I confabulates
don’t know”, answers,
aware of unaware of Sleep disturbance Tx: fix sleep hygiene, stop
problems problems drinking, stop napping, fix underlying causes;
Tx cognitive defects cognitive hydroxyzine or trazodone are second-line
respond to anti- defects persist
depressants despite anti-
Elderly × antidepressants: elderly are very sensitive
depressants
to anticholinergic side-effects, including dry mouth,
constipation, blurry vision, etc.
Pseudodementia: MDD + cognitive defects due to
underlying depression, often mistaken for dementia
–––––––––– OTHER GERIATRIC ISSUES ––––––––––

Pseudodementia Tx: supportive psychotherapy +

Restraints: should be used as a last resort in non-
low-dose antidepressants (SSRIs > TCAs/MAOIs,
emergency situations, consider pt health and safety
use nortriptyline if TCA is preferred); depression +
low appetite + insomnia → mirtazapine
Medications: polypharmacy is common in elderly,
↑side-effects due to ↓liver/kidney function and ↓lean
Dementia: progressive and irreversible impairment
body mass
in memory and other cognitive functions w/o change
in level of consciousness
Elderly abuse: 10% incidence, perpetrator is usually
the caregiver of the victim; can be physical, psycho-
Dementia epidemiology: prevalence doubles
logical, neglect, or exploitation (rarely sexual)
every 5 years (1.5% at 60, 40% at 90)

Nursing homes: provide care and rehab for both

Dementia types: Alzheimer (#1), vascular (#2),
chronically ill and short-term care pts; 50% stay on
Lewy body (#3), Pick/FTD, HIV-associated,
permanently, 50% are d/c after a few months
Huntington, Cruetzfeldt-Jakob, normal pressure
hydrocephalus

Dementia Tx: behavioral and environmental Tx

preferred over pharmacotherapy (see cognitive
disorders for specifics)

Grief: aka bereavement, normal reaction to a major

loss, does not present w/ SI or disorganization

Kübler-Ross stages of grief: denial, anger,

bargaining, depression, acceptance

Normal grief: normal response to loss, lasts <2

months and has illusions but no delusions,
hallucinations, or SI

Complicated grief: lasts ≥6 months and 4/8 Tired

And NUMBED – Trouble accepting loss, Agitation,
Numbness, Untrusting, Meaninglessness, Bitterness,
Emptiness, Difficulty moving on

Bereavement-associated depression: essentially

MDD following death or loss, similar to complicated
grief but may have delusions, hallucinations, or SI

––––––––––– MENTAL RETARDATION –––––––––––
Mental retardation: IQ ≤ 70 and deficits in adaptive
skills, with onset before 18 y/o
MR/DD types: profound <25, severe 25-40,
moderate 40-55, mild 55-70 (intervals of 15)
MR/DD causes: 50% idiopathic, Down syndrome (MC
genetic), Fragile X (MC inherited), fetal alcohol
syndrome (overall MCC); prenatal, perinatal, or
postnatal pathology
TORCHES complex: perinatal infections than can
lead to MR/DD, includes Toxoplasmosis, Rubella,
CMV, Herpes simplex, Syphilis
Prader-Willi syndrome: partial deletion of 15q →
MR/DD, obesity, hypogonadism, almond eyes
Fragile X syndrome: MC inherited form of MR/DD;
X-linked CGG trinucleotide expansion in FMR1
gene causes DSM-IV – Discontinued chromosomal
staining, Shows anticipation, Males, Mental
retardation, Macrognathia, Macroorchidism
Learning disorders: achievement in reading, writing,
or math that is significantly lower than expected;
must r/o sensory deficits first
Learning disorder types: reading disorder (MC),
mathematics disorder, writing disorder
Learning disorder Tx: remedial education
–––––– DISRUPTIVE BEHAVIOR DISORDERS ––––––
Disruptive behavior disorders: includes oppositional
defiant disorder and conduct disorder
Oppositional defiant disorder: >6 months of hostile
and defiant behavior towards parents/teachers, but
perfectly fine w/ peers
ODD Tx: individual psychotherapy + family
involvement
Conduct disorder: hostile and defiant behavior
towards everyone
CD in boys: cruelty to animals, fighting, stealing,
fire-setting, vandalism
CD in girls: lying, running away, promiscuity
CD Px: 40% of conduct d/o → ASPD
CD Tx: multimodal approach w/ family and
teacher involvement
CD vs. ASPD: conduct disorder <18 y/o, ASPD ≥18 y/o
CD vs. ODD: unlike conduct disorder, ODD doesn’t
involve physical aggression or violation of basic
rights of others
CD vs. pyromania: pyromaniacs light things on fire
due to inner tension, not out of anger issues
Attention deficit disorder: >6 months of hyper-
activity, inattentiveness, or both; onset before 7 y/o
ADHD types: inattentive type, hyperactive-
impulsive type, combined type
ADHD prevalence: boys > girls, >50% have
comorbid psychiatric diagnosis
ADHD Px: 50% go onto adulthood untreated
ADHD Tx: CNS stimulants are DOC w/ 75% success
rate, second-line is atomoxetine and α2-agonists
(clonidine, guanfacine)
ADHD vs. MR/DD: both struggle w/ academic
performance, so differentiate via IQ tests
––– PERVASIVE DEVELOPMENTAL DISORDERS –––
Pervasive developmental disorders: includes autism,
Asperger, Rett, and childhood disintegrative d/o
Autistic disorder: characterized by problems w/
social interaction, impaired communication, and
repetitive/stereotyped patterns of behavior and
activity; must be present by 3 y/o
Autism prevalence: 70% meet criteria for MR/DD;
associated w/ fragile X syndrome, tuberous
sclerosis, and seizures
Autism Px: most important predictors of adult
outcome are intelligence and communication
Autism Tx: no cure, but remedial education and
behavioral therapy can help w/ developing skills
Autism vs. deafness: toddler w/ ↓communication
skills needs hearing test to r/o deafness
Asperger disorder: mild autism w/ normal language
skills and cognitive development, often rigid and
overly formal in social interaction
Aspie Tx: supportive Tx similar to autism
Rett disorder: normal development for 5 months,
followed by ↓rate of head growth and loss of
purposeful hand movements; then ataxia, ↓language
skills, and “hand wringing”
Rett etiology: ΔMECP2 on X chromosome (only
girls get the disease, guys all die in utero)
Rett Px: cognitive development never progresses
beyond first year of life, ↑risk of sudden death
Rett Tx: supportive care
Childhood disintegrative disorder: normal develop-
ment for >2 years, then loss of previously acquired
skills before 10 y/o
CDD prevalence: boys > girls, ↑rate of abnormal
EEG and seizures
CDD Tx: supportive care
Ψ – Child Psychiatry
CDD vs. Rett: similar loss of previously acquired skills,
but CDD has no ↓head growth or hand wringing
–––––––– OTHER PEDIATRIC DISORDERS ––––––––
Tic disorders: characterized by sudden, repetitive,
involuntary movements (motor tics) or vocalizations
(vocal tics); one of few DSM-IV Dx that don’t require
significant distress as a qualifier
Coprolalia: repetitive speaking of obscene words
Echolalia: exact repetition of words
Tourette disorder: most severe tic disorder w/
multiple daily motor/vocal tics, onset before 18 y/o
Tourette prevalence: very rare; ↑rate of comorbid
OCD (40%) and ADHD (50%)
Tourette etiology: multifactorial, involves
impaired dopamine regulation in caudate nucleus
Tourette Tx: risperidone and α2-agonists
(clonidine, guanfacine) are DOC; severe cases →
typical antipsychotics, tics+OCD → SSRIs
Enuresis: involuntary urination (bed-wetting) after 5
y/o, ≥2/week for 3 months
Enuresis etiology: genetics, stress (MC), small
bladder, or ↓nocturnal ADH
Enuresis Tx: DDAVP is DOC, imipramine is second-
line
Encopresis: involuntary defecation after 5 y/o,
≥1/month for 3 months
Encopresis etiology: genetics, stress, lack of
sphincter control, or constipation w/ overflow
incontinence (MC)
Encopresis Tx: usually remits spontaneously,
bowel catharsis + stool softeners if it doesn’t
Selective mutism: refusal to speak in certain
situations for ≥1 month despite normal language and
comprehension skills
Mutism Tx: psychotherapy, behavioral therapy,
management of anxiety
Separation anxiety disorder: excessive fear of
leaving parents or other figures for ≥4 weeks
SAD Px: risk factor for development of panic d/o
or agoraphobia as an adult
SAD Tx: family therapy, CBT, low-dose
antidepressants
Child abuse: either physical abuse, emotional abuse,
sexual abuse, or neglect (MC); doctors must report
to child protective services
Sexual abuse prevalence: 15-25%, perpetrator is
usually the child’s parent
 Ψ – Dissociative Disorders

–––––––––– DISSOCIATIVE DISORDERS ––––––––––
Dissociation: loss of memory, identity, or sense of
self; often following trauma, may involve NE + glu
Abreaction: strong reaction pts get when retrieving
traumatic memories
Dissociative disorders: dissociative amnesia,
dissociative fugue, dissociative identity disorder,
depersonalization disorder, dissociative disorder
NOS
Dissociative amnesia: 1+ episode of inability to recall
personal information; not due to TBI, medical
condition, substance abuse, or ordinary amnesia
DA epidemiology: MC dissociative disorder,
↑incidence of MDD and anxiety disorders
DA Tx: psychotherapy; most acute cases return to
normal after min-days, lorazepam or amobarbital
often used to help pt talk freely during interview
DPD epidemiology: women > men, severe stress
is a risk factor, ↑incidence of MDD and anxiety
disorders
DPD Tx: usually chronic, anxiety or MDD →
anxiolytics or SSRIs
DPD vs. normal stress: transient depersonalization is
common during times of stress
Dissociative disorder NOS: loss of memory, identity,
or sense of self; but doesn’t meet criteria for other
dissociative disorders
Ataque de nervios: Puerto Rican culturally-bound
trance disorder that consists of convulsive
movements, fainting, crying, and visual problems
Ganser syndrome: giving of approximate answers
to simple questions (e.g. “how many legs do you
have?”)

DA vs. dementia: DA can’t recall common personal

info but can remember obscure details, dementia
can remember personal info but not obscure details

Dissociative fugue: sudden, unexpected travel away

from home + inability to recall one’s past

DF epidemiology: rare, usually follows stressful

life event or personal conflict

DF Tx: same as DA

DF vs. DA: DA pts are aware of what they can’t seem

to remember, DF don’t acknowledge the amnesia

DF vs. transient global amnesia: DA pts show loss of

identity, global amnesia have difficulty with more
recent events but identity remains intact

Dissociative identity disorder: 2+ distinct identities +

inability to recall information about non-dominant
personalities; not due to substance abuse or medical
condition, existence is controversial

DID epidemiology: usually women w/ prior

trauma (e.g. childhood sexual abuse); ↑incidence
of MDD, anxiety, BPD, substance abuse, suicide

DID Tx: psychotherapy; worst Px of all

dissociative disorders

DID DDx: DID-like sx may be seen in BPD, psychosis,

or malingering (factitious disorder)

Depersonalization: feeling that one is falling apart,

fragmenting, detached, not oneself, etc.

Derealization: feeling that the world is not real

Depersonalization disorder: persistent or recurrent

episodes of being detached from one’s body or
mental processes; not due to substance use or
medical condition
 Ψ – Somatoform and Factitious Disorders

––––––––––––––––––– GAIN ––––––––––––––––––– Conversion × neuropathy: consider multiple

Primary gain: internal motives (e.g. stress, anxiety)
as the cause of symptoms
Secondary gain: external motives (e.g. attention,
money, avoiding law) as the cause of symptoms
Münchhausen syndrome: aka factitious disorder,
consciously feigning symptoms to play the sick role
(primary gain)
sclerosis
Hypochondriasis: preoccupation w/ fear of having or
contracting a disease, based on misinterpretation of
bodily sx, for >6 months
Hypochondriasis epidemiology: 80% have
comorbid GAD or MDD (vs. 50% in other somato-
form d/o), men = women (vs. women > men in
other somatoform d/o)

Münchhausen Sx: triad of 3 Ps – Peregrination, Hypochondriasis Tx: regularly scheduled visits w/

Pseudologia phantastica, Polysurgery a single PCP

Münchhausen Tx: establish therapeutic alliance,
avoid confrontation and unnecessary procedures
Münchhausen by proxy: intentionally producing
symptoms in someone else, usually one’s children →
must report child abuse
Hypochondriasis vs. somatization: somatization pts
have a long list of sx, hypochondriacs are worried
about a specific disease
Hypochondriasis vs. BDD: hypochondriasis + about a
specific body part = body dysmorphic disorder

Malingering: consciously feigning symptoms for Body dysmorphic disorder: self-consciousness +

external motives (secondary gain), presents w/ preoccupation w/ imagined defect in appearance
multiple vague complaints and a long medical hx
BDD Tx: optional CBT ± SSRIs, avoid cosmetic
–––––––––– SOMATOFORM DISORDERS –––––––––– procedures

Somatoform disorders: not consciously feigning
symptoms, though no direct link to medical cause;
50% have comorbid anxiety d/o or MDD
Somatoform disorders × gender: women > men,
except hypochondriasis where women = men
Somatization disorder: onset before 30 y/o with
multiple sx (4 pain + 2 GI + 1 sexual/GU + 1 neuro)
that are not intentionally produced
Pain disorder: significant pain as the CC, not fully
accounted for by a medical condition, not feigned,
and not regarding sex only (dyspareunia); acute if <6
months, chronic if >6 months
Pain Tx: validate pt’s pain, moderate →
biofeedback and relaxation techniques, severe →
antidepressants (not analgesics)

Somatization Px: chronic and debilitating, worse

under stress

Somatization Tx: r/o potential medical causes,

regularly scheduled visits w/ a single PCP who
limits extensive medical work-ups

Somatization vs. conversion: somatization pts are

concerned over condition, conversion don’t care

Conversion disorder: conversion of a psych issue

into a neurological one, not limited to pain or sexual
dysfunction, preceeded by conflict or stressors

Conversion Sx: commonly paralysis, blindness,

mutism, parasthesias, seizures, globus hystericus

La belle indifference: apathy despite severity of

condition

Conversion Tx: most spontaneously recover;

if it persists → insight-oriented psychotherapy,
hypnosis, or relaxation therapy

Conversion in elderly: high chance of real neuro

deficit, get a neuro consult

Conversion × seizures: use EEG to differentiate

between epileptic vs. nonepileptic seizures
 Ψ – Impulse Control Disorders

–––––––– IMPULSE CONTROL DISORDERS ––––––––

Impulse control disorders: IED, kleptomania,

pathological gambling, trichotillomania, pyromania

Core qualities: anxiety before act, repetitive or

compulsive act in spite of consequences, lack of
control during act, relief or satisfaction after act

Intermittent explosive disorder: recurrent episodes

outbursts of aggression against people or property
that remit quickly and spontaneously

IED Dx: ↓5-HIAA in CSF

IED Tx: SSRIs + lithium + propanolol; individual

psychotherapy is difficult and ineffective

IED vs. amok: amok has amnesia and only in Asians

Kleptomania: inability to resist urges to steal objects

not needed for personal use or monetary reasons

Klepto etiology: multifactorial but ↑ with stress;

↑incidence of OCD, mood disorders, and eating
disorders (25% of bulimics are klepto)

Klepto Tx: insight-oriented psychotherapy +

behavioral therapy + SSRIs; anecdotal evidence
exists for naltrexone

Pathological gambling: persistent and recurrent

maladaptive gambling behavior

Gambling etiology: multifactorial; ↑incidence of

OCD, mood disorders, and anxiety disorders

Gambling Tx: Gamblers Anonymous is first-line,

after 3 months of abstinence → insight-oriented
psychotherapy, treat comorbid problems

Trichotillomania: recurrent, repetitive, intentional

pulling out of one’s hair causing visible hair loss

Tricho etiology: multifactorial; ↑incidence of

OCD/OCPD, borderline PD, and mood disorders

Tricho Tx: behavioral therapy + SSRIs, lithium, or

antipsychotics

Pyromania: 1+ episode of deliberate fire setting +

fascination or attraction to fire; not for monetary
gain, expression of anger, or political statement

Pyro Tx: supervision + behavioral therapy + SSRIs

 Ψ – Eating Disorders

––––––––––––– EATING DISORDERS ––––––––––––– Bulimia complications: SPARKED – Sialadenosis,

Petechiae, Aspirations, Arrhythmias due to ↓K+,
Eating disorders: anorexia nervosa, bulimia nervosa, Russell’s sign, Kleptomania (25%), Esophagitis,
binge-eating disorder (eating disorder NOS) Edema, Dental erosions or caries

Anorexia nervosa: fear of being fat → <85% ideal Russell’s sign: calloused knuckles due to hitting
body weight, amenorrhea in postmenarchal females incisor teeth when inducing the gag reflex

Anorexia subtypes: restrictive type doesn’t eat Bulimia lab values: vomiting → contraction alkalosis,
and has OCPD traits; binge/purge type binge eats laxatives → metabolic acidosis; ↑BUN, ↑HCO3-,
followed by vomiting or exercising ↑amylase, ΔT4/T3, Δcortisol

Anorexia prevalence: 1%, most commonly in Bulimia vs. binge-eating disorder: both like to binge,
women in industrialized countries but bulimics try to control their weight afterwards

Anorexia Px: 10% mortality due to starvation, Binge-eating: excessive food intake within 2 hr
suicide (57× normal rate), or cardiac failure period + sense of lack of control

Anorexia Tx: food (behavioral therapy + family Binge-eating disorder: recurrent binge-eating w/o
therapy + supervised weight-gain programs); compensatory behavior, 2/wk for 6 months
excessive weight preoccupation → low-dose 2G
antipsychotics, preprandial anxiety → BDZs BED Tx: psychotherapy + behavioral therapy +
diet/exercise program; drugs can be used as an
Anorexia complications: BATCH – Bone loss adjunct (stimulants, orlistat, sibutramine)
(osteopenia/osteoporosis), Amenorrhea, ↓Thyroid,
Constipation, Heart problems (cardiomyopathy, ACS,
MVP, arrhythmias due to ↓K+)

Anorexia lab values: ↑cortisol, QTc, chol, BUN, GH;

↓RBC/WBC, LH/FSH, E/T, T4/T3, glucose

Anorexia × purging: contraction (hypokalemic,

hypochloremic metabolic) alkalosis

Anorexia DDx: endocrine disorders, GI diseases,

genetic disorders, cachexia (due to cancer/AIDS),
MDD, bulimia

Anorexia vs. bulimia: both may binge and purge, but

bulimics are normal weight and anorexics are <85%

Anorexia vs. MDD: both may refuse to eat, but

anorexics starve in spite of a good appetite and MDD
have poor appetite

Refeeding syndrome: occurs when severely

malnourished pts are refed too quickly → fluid
retention and ↓Ca/Mg/Ph → RADS – Respiratory
failure, Arrhythmias, Delirium, Seizures

Refeeding syndrome Tx: slow feedings and

replace electrolytes

Bulimia nervosa: binge eating + behaviors intended

to counteract weight gain, 2/wk for 3 months

Bulimia subtypes: purging type involves vomiting,

laxatives, enemas, or diuretics; nonpurging type
involves excessive exercise or fasting

Bulimia prevalence: 1-4%, most commonly in

women in industrialized countries

Bulimia Px: chronic and relapsing, but better Px

than anorexia nervosa

Bulimia Tx: SSRIs (fluoxetine) + therapy (CBT);

avoid buproprion which can ↓seizure threshold

––––––––––––––––––– SLEEP –––––––––––––––––––
Normal sleep cycle: non-rapid eye movement sleep
(stages 1-4) alternating w/ REM sleep every 90 min
NREM: deeper sleep progression through stages;
stage 2 is tooth grinding, stage ¾ (delta sleep) is
sleepwalking, bedwetting, and sleep terrors
REM: dreaming, loss of motor tone, erections,
sympathetic activity (↑HR, ↑RR, ↑BP)
Sleep EEG waveforms: BATS Drink Blood – Beta
(awake), Alpha (resting), Theta (1), Sleep spindles
and K complexes (2), Delta (¾), Beta (REM)
Sleep disorders: dyssomnias and parasomnias
––––––––––––––– DYSSOMNIAS –––––––––––––––
Dyssomnias: ↑/↓ or altered timing of sleep
Primary insomnia: ↓sleep duration and/or quality;
acute insomnia 1-4 wks, chronic insomnia >1 month
PI subtypes: sleep-onset insomnia (can’t go to sleep),
sleep-maintenance insomnia (can’t stay asleep),
sleep-offset insomnia (early morning awakenings),
nonrestorative sleep (wake up still tired)
PI etiology: usually poor sleep hygiene
PI Tx: fix sleep hygiene, Chronic insomnia → CBT,
acute insomnia → long-term BDZs or non-BDZ
hypnotics, insomnia + depression → trazodone
Obstructive sleep apnea: difficulty breathing during
sleep → snoring and apneic episodes → sleep
fragmentation → excessive daytime sleepiness
OSA etiology: repetitive upper airway collapse
due to obesity and/or airway narrowing
OSA Tx: first-line is weight loss and exercise,
second-line is CPAP or BiPAP, third-line is surgery
Narcolepsy: excess daytime sleepiness, cataplexy
(suddenly fainting w/ intense emotion), hypnogogic
and hypnopompic hallucinations
Narcolepsy etiology: loss of hypothalamic
neurons that contain hypocretin, may have auto-
immune component
Narcolepsy Tx: fix sleep hygiene, excess daytime
sleepiness → stimulants (e.g. amphetamines,
modafinil), cataplexy → sodium oxybate (GHB)
Idiopathic hypersomnia: excess daytime sleepiness,
prolonged nocturnal sleep, frequent urges to nap
Kleine-Levin syndrome: excess daytime sleepiness,
aggression, hyperphagia, hypersexuality
Circadian rhythm: sleep-wake cycle controlled by
suprachiasmic nucleus (SCN) in the hypothalamus
Ψ – Sleep Disorders
Circadian rhythm sleep disorders: caused by defect Periodic limb movement disorder: aka nocturnal
in circadian pacemaker or impaired entrainment; myoclonus, frequent limb movement during sleep
includes DPSD, APSD, SWD, and jet lag disorders
Delayed sleep phase disorder: sleep onset and
awakening are delayed, but normal duration/quality
DPSD Tx: bright light phototherapy in the
morning, melatonin in the evening
Advanced sleep phase disorder: sleep onset and
awakening are early, but normal duration/quality
APSD Tx: bright light phototherapy in the evening
Shift-work disorder: sleep schedule is messed up
due to nontraditional work hours
SWD Tx: avoid risk factors, severe → modafinil
Jet lag disorder: sleep schedule is messed up due to
travel across multiple time zones
Jet lag Tx: resolves by itself 2-3 days after travel
––––––––––––––– PARASOMNIAS –––––––––––––––
Parasomnias: unusual sleep-related behaviors (e.g.
movements, emotions, dreams, autonomic activity)
Sleepwalking: walking around during stage ¾ sleep
with “glassy look” on eyes, confusion or violence on
forced awakening, amnesia for episode
Sleepwalking etiology: unknown, usually not
associated w/ any psychiatric problems
Sleepwalking Tx: ensure child safety and wait;
refractory cases → BDZs (clonazepam) or TCAs
Sleep terrors: sudden arousal w/ screaming during
stage ¾ sleep, sympathetic activity, confusion or
violence on forced awakening, amnesia for episode
Sleep terror etiology: ↑comorbidity w/ restless
leg syndrome and sleep-disordered breathing
Sleep terror Tx: ensure child safety and wait;
refractory cases → BDZs (clonazepam)
Nightmare disorder: recurrent nightmares w/ vivid
recall, no confusion or disorientation on awakening
Nightmare etiology: seen in >50% PTSD pts
Nightmare Tx: image rehearsal therapy (IRT),
severe → antidepressants
REM sleep behavior disorder: dream enactment
(talking, yelling, walking, punching, etc.) that often
presents as injury to the pt or bed partner
RBD etiology: unknown, usually in senior males
RBD Tx: clonazepam, ensure safety
Restless leg syndrome: irresistable urge to move
one’s legs while going to sleep; caused by pregnancy,
anemia, renal failure, or other metabolic d/o
 Ψ – Sexual Disorders

–––––––––––– NORMAL SEXUALITY ––––––––––––
Sexual response cycle: desire to EXPLORE – desire,
EXcitement, PLateau, Orgasm, REsolution
Refractory period: post-resolution period in
which men can’t reexperience orgasm
Sex × male aging: desire unchanged but requires
↑stimulation and time to orgasm, ↓intensity of
ejaculation, ↑refractory period
Sex × female aging: desire unchanged but ↓estrogen
levels → vaginal dryness and thinning
Sex × drugs: ↑libido – cocaine, amphetamines,
marijuana, and acute alcohol use; ↓libido – narcotics
and chronic alcohol use
Sex × NTs: DA ↑libido, 5-HT inhibits sexual function
Sex × hormones: testosterone ↑libido, progesterone
↓libido, postmenopausal ↓estrogen levels → vaginal
dryness and thinning
Substance-induced sexual dysfunction: anti-HTN,
anticholinergics, antipsychotics, antidepressants
(esp. SSRIs), or substance abuse
Sexual dysfunction 2/2 GMC: atherosclerosis (ED),
diabetes (ED + neuropathy), pelvic adhesions
(dyspareunia), depression or anxiety
––––––––––––– SEXUAL DISORDERS –––––––––––––
Sexual disorders: problems involving any stage of
sexual response cycle or pain during intercourse, not
due to substance use or GMC
MC sexual disorders: premature ejaculation and 2°
ED in men, HSDD and orgasmic disorder in women
Hypoactive sexual desire disorder: deficient or
absent libido
Orgasmic disorder: can’t orgasm or achieves orgasm
w/ great difficulty
Male OD Tx: gradually progress from extravaginal
ejaculation (via masturbation) to intravaginal
Female OD Tx: masturbation ± vibrator
Dyspareunia: genital pain before, during, or after
sexual intercourse; women > men, often associated
w/ vaginismus
Dyspareunia Tx: gradual desensitization to
achieve intercourse (muscle relaxation → erotic
massage → sexual intercourse)
Vaginismus: involuntary muscle contraction of
outer 1/3 of vagina during insertion; ↑incidence in
higher socioeconomic groups and strict religious
upbringing
Vaginismus Tx: manual dilation
Homosexuality: sexual/romantic desire for same sex,
not a sexual disorder, etiology unknown
Homosexual × depression: consider MDD or
adjustment d/o due to conflict w/ societal values;
homosexuality is not a disorder
Homosexual × prepuberty: same-sex exploratory
activities are common in prepubescent kids and
don’t signify latent homosexuality
Transsexuality: aka gender identity disorder, strong
cross-gender identification + persistent discomfort
w/ own sex
Transsexuality Tx: therapy, family involvement
for younger pts, possibly sex reassignment
Transsexual vs. transvestite: transsexuals identify
with the other sex, transvestites like to wear other
gender’s vestments (clothing)
Masochism: sexual excitement from being hurt
or humiliated
Fetishism: sexual preference for inanimate
objects (e.g. women’s shoes)
Transvestic fetishism: sexual gratification in men
from wearing women’s clothing
Necrophilia: sexual pleasure from f-ing a corpse
Telephone scatologia: sexual excitement from
calling unsuspecting women and having phone
sex with them
Paraphilia Px: good prognosis w/ self-referral (vs.
police arrest), sense of guilt, and low frequency of
behavior
Paraphilia Tx: insight-oriented psychotherapy +
aversion therapy; antiandrogens for refractory
hypersexual paraphilias in men
Paraphilia vs. normal fantasy: occasional fantasies
are normal if <6 months and don’t interfere w/ daily
functioning
Transvestic fetishism vs. homosexuality: dressing up
as a woman doesn’t mean you’re turned on by men
–––––– TREATMENT OF SEXUAL DISORDERS ––––––
Sexual disorder Tx: psychotherapy, medications,
and mechanical therapy all play a role
Psychotherapy: dual sex therapy for marriage or
couple issues, behavioral therapy for maladaptive
behaviors, hypnosis for anxiety
Pharmacotherapy: (see specific disorders)
Mechanical therapy: (see specific disorders)

HSDD Tx: hormone replacement therapy –––––––––––––––– PARAPHILIAS ––––––––––––––––

Sexual aversion disorder: avoidance of genital Paraphilias: engagement or preoccupation w/

contact w/ sexual partner unusual sexual urges or fantasies, must last >6
months and interfere w/ daily life
Erectile dysfunction: aka impotence, can’t get it up,
either 1° (never had one) or 2° (had it but lost it) MC paraphilias: pedophilia, voyeurism, exhibitionism

ED Tx: PDE5-inhibitors (sildenafil) or alprostadil Pedophilia: getting turned on by kids <13 y/o,
injection are first-line; vacuum pumps, surgical pedophile must be >16 y/o and at least 5 years
tube insertion, or constrictive rings older than the child

ED vs. psychological condition: men w/ psych
condition can get it up at other times (e.g. other
partners, masturbating, morning wood)
Sexual arousal disorder: can’t get it wet
Frotteurism: sexual pleasure from touching or
rubbing up against a nonconsenting person
Voyeurism: watching unsuspecting nude people
for sexual pleasure

Premature ejaculation: ejaculation earlier than Exhibitionism: exposing self to others

expected
Sadism: sexual excitement from hurting or
Premature ejaculation Tx: SSRIs or TCAs can humiliating others
prolong time to ejaculation

––––––––––––– FREUD’S THEORIES –––––––––––––
Topographic theory: mind is composed of three
types of thoughts – conscious, preconscious, and
unconscious
Conscious thoughts: current thoughts and 2°
process thinking (logical, mature, organized, etc.)
Preconscious thoughts: memories that are not
immediately aware but easy to recall
Unconscious thoughts: repressed thoughts that
are out of one’s awareness, involves 1° process
thinking (primitive and pleasure-seeking)
Structural theory: mind is composed of three
identities – id, ego, and super-ego
Id: primitive; involves sexual/aggressive urges
and 1° process thinking
Ego: realistic; mediates id, super-ego, and
external environment using defense mechanisms
Super-ego: idealistic; represents morals, society,
and parental teaching
Normal development: id is present at birth, ego
develops after birth, superego begins at age 6
––––––––––– DEFENSE MECHANISMS –––––––––––
Defense mechanisms: used by ego to mediate id,
super-ego, and external environment; three types –
mature, neurotic, and immature
Mature defenses: mature women wear a SASH –
Sublimation, Altruism, Suppression, Humor
Sublimation: satisfying socially objectionable
impulses in an acceptable manner
Altruism: performing acts that benefit others to
feel better about oneself
Suppression: consciously avoiding unacceptable
impulse or emotion (vs. repression)
Humor: using comedy to express thoughts or
feelings w/o discomfort to self or others
Neurotic defenses: RIDICulous – Rationalization,
Reaction formation, Repression, Intellectualization,
Displacement, Isolation of affect, Controlling
Rationalization: making reassuring but incorrect
explanations for outcome or behavior
Reaction formation: doing the exact opposite of
an unacceptable impulse
Repression: unconsciously avoiding unacceptable
impulse or emotion (vs. suppression)
Intellectualization: using excessive abstract
thinking to avoid experiencing disturbing feelings
Displacement: redirecting thoughts or feelings
about one thing onto something more tolerable
Isolation of affect: separation of an unpleasant
idea from the feelings it evokes
Controlling: regulating aspects of external
environment to relieve anxiety
Immature defenses: acting out, denial, distortion,
fantasy, regression, passive aggression, projection,
projective identification, splitting, undoing
Acting out: giving into an impulse, even if it’s
socially inappropriate
Denial: not accepting reality that is too painful,
first stage of Kubler-Ross grief model
Distortion: grossly reshaping external reality to
suit inner needs
Fantasy: substituting fantasy for reality to resolve
inner conflicts; characteristic of schizoid PD
Regression: reverting back to childlike behavior;
characteristic of histrionic PD and dependent PD
Passive aggression: nonconfrontational
expression of aggression towards others
Projection: attributing one’s inappropriate
thoughts or emotions onto another (e.g. stealing
from a friend you suspect is stealing from you)
Projective identification: attributing one’s
inappropriate thoughts onto another, then
identifying with the countertransference
Splitting: labelling people as all good or all bad;
characteristic of borderline PD
Undoing: attempting to reverse a situation by
adopting a new behavior
–––––––––––––– PSYCHOANALYSIS ––––––––––––––
Split treatment: one psychiatrist provides
medication, another provides the therapy
Psychoanalysis: resolving unconscious conflicts by
making pt aware of repressed experiences and
feelings, then integrating them into consciousness;
an insight-oriented approach, 5 times/wk for years
Psychoanalysis techniques: free association, dream
interpretation, therapeutic alliance, interpretation of
transference
Free association: pt says whatever comes to mind
Dream interpretation: dreams represent conflict
between urges and fears, interpret for resolution
Therapeutic alliance: bond between pt and
therapist
Transference: pt projects unconscious feelings onto
doctor (e.g. therapist seen as father figure)
Ψ – Psychotherapy
Countertransference: doctor projects unconscious
feelings onto pt (e.g. all antisocial pts are
malingering for benzos)
Psychoanalysis-related therapies: brief dynamic
(psychoanalytically-oriented) therapy, interpersonal
therapy, supportive therapy
Brief dynamic therapy: like psychoanalysis but
briefer and face-to-face instead of lying on a
couch
Interpersonal therapy: focuses on development
of social skills
Supportive therapy: focuses on helping pt feel
safe during a difficult time, builds up healthy
defense mechanisms, not insight-oriented
–––––––––– OTHER PSYCHOTHERAPIES ––––––––––
Behavioral therapy: uses learning theory to get rid of
bad behaviors and replace w/ healthy alternatives
Learning theory: behaviors can be learned by
conditioning, and extinguished by deconditioning
Classical conditioning: stimulus can eventually
evoke a conditioned response (e.g. Pavlov’s dog)
Operant conditioning: uses positive (rewards)
or negative reinforcement (removing an aversive
stimulus) to encourage behavior
Systematic desensitization: pt uses relaxation
techniques while being exposed to increasing
doses of anxiety-provoking stimuli
Flooding and implosion: pt is exposed to real
(flooding) or imagined (implosion) anxiety-
provoking stimuli and not allowed to withdraw
until he/she feels calm and in control
Aversion therapy: uses punishment to
discourage behavior (e.g. electric shock)
Token economy: rewards (tokens) given after
specific behaviors for positive reinforcement
Biofeedback: vital signs given to pts as they try to
mentally control physiological states
Negative reinforcement vs. aversion therapy:
negative reinforcement removes aversive stimulus
to encourage behavior, aversion therapy adds an
aversive stimulus to discourage behavior
Cognitive therapy: identifying bad thoughts and
replacing them w/ positive ones
Cognitive behavioral therapy: identifying bad
thoughts, making the connection w/ bad behaviors,
then setting an agenda to change thoughts in order
to change behavior
Dialectical behavioral therapy: CBT subtype used to
↓self-destructive behavior, ideal Tx for borderline PD
 Ψ – Psychotherapy

Group therapy: 3+ pts w/ similar problems meet w/

therapist for behavioral, cognitive, or supportive
therapy; useful for substance abuse, adjustment d/o,
and personality d/o

Peer led group therapy: no therapist (e.g. AA)

Family therapy: sessions w/ entire family to reduce

conflict, help understand each others’ needs (mutual
accomodation), and cope w/ internally destructive
forces

Boundaries and triangles: boundaries between

family members may be too rigid or permeable;
triangles are two family members against a third

Couples therapy: used to address conflicts, sexual

problems, and communication issues within couples

Couples therapy types: conjoint therapy (see

couple together), concurrent therapy (see both
separately), collaborative therapy (one therapist
per pt), four-way therapy (all of the above)

––––––––––– NEUROTRANSMITTERS –––––––––––
Anti-H2: sedation, weight gain
Anti-A1: orthostatic hypotension, sexual dysfunction
Anti-M: dry mouth, blurry vision, constipation,
urinary retention, exacerbates Alzheimer disease
Anti-D2: anti-psychosis, EPS, ↑prolactin
Anti-5-HT1c: weight gain
5-HT2: agitation, akathisia
5-HT3: diarrhea, nausea/vomiting
––––––––––––––– SIDE-EFFECTS –––––––––––––––
Anti-HAM side-effects: TCAs and low-potency anti-
psychotics can cause anti-H2, anti-α1, anti-M
Serotonin syndrome: ↑5-HT → fever, confusion,
flushing, sweats, tremor, hypertonicity, rhabdo-
myolysis → renal failure, death
Serotonin syndrome combos: SSRI+MAOI,
SSRI+OTC cough medicine, SSRI+linezolid,
MAOI+meperidine, MAOI+MDMA/MDEA
Serotonin syndrome Tx: cyproheptadine or BDZ,
avoid taking within 5 weeks of each other
Hypertensive crisis: MAOI+tyramines or sympatho-
mimetics can cause ↑NE/↑epi (severe HTN)
Extrapyramidal side-effects: high-potency typical
antipsychotics can cause Parkinsonism, akathisia,
and dystonia within days
EPS Tx: acute dystonia → benztropine or
diphenhydramine, akathisia → β-blockers or BDZ,
Parkinsonism → levodopa or amantadine
Tardive dyskinesia: high-potency typical anti-
psychotics can cause choreoathetosis of mouth and
tongue after years of use
TD Tx: irreversible, so monitor sx with AIMS
(abnormal involuntary movement scale)
Withdrawal dyskinesia: tendency for TD to
temporarily increase following d/c antipsychotic
Hyperprolactinemia: high-potency antipsychotics
and risperidone can ↑prolactin (galactorrhea,
amenorrhea, ↓libido, infertility), due to ↓dopamine in
tuberoinfundibular pathway
Neuroleptic malignant syndrome: all antipsychotics
can cause FALTER – Fever, Autonomic instability,
Leukocytosis, Tremor, Elevated CPK, “lead pipe”
Rigidity; mortality rate is 20%
NMS Tx: dantrolene or bromocriptine
Metabolic syndrome: atypical antipsychotics can
↑BP, ↑insulin, ↑body fat, ↑risk of CAD/stroke/diabetes;
switch to typical antipsychotic if pt is at risk
CYP450: liver enzymes that metabolize drugs;
CYP450 inducers ↓drug levels, CYP450 inhibitors
↑drug levels
CYP450 inducers: smoking, carbamazepine,
barbiturates, St. John’s wort
CYP450 inhibitors: fluvoxamine, fluoxetine,
paroxetine, duloxetine, sertraline
Teratogenic drugs: TCAs (fetal limb defects), VPA
(neural tube defects), lithium (Ebstein’s anomaly),
BDZs (cleft palate + FAS facies)
––––––––––––– ANTIDEPRESSANTS –––––––––––––
Antidepressants: SSRIs, TCAs, MAOIs, and atypicals;
all have similar efficacy but differ in side-effect
profile, require 3-4 week trial to take effect, none
cause elation or have abuse potential
Withdrawal phenomenon: dizziness, headache,
N/V, insomnia, malaise after stopping most anti-
depressant use; may require tapering
SSRIs: first-line for MDD due to low incidence of
side-effects and safe in OD; includes fluoxetine,
sertraline, paroxetine, fluvoxamine, (es)citalopram
SSRI side-effects: sexual dysfunction, GI distress,
serotonin syndrome, black box for suicidality
SSRI × sexual dysfunction: switch to bupropion
Fluoxetine (Prozac): longest T½ (fewest
withdrawal sx)
Sertraline (Zoloft): highest GI distress
Paroxetine (Paxil): shortest T½ (highest
withdrawal sx), most anticholinergic side-effects
Fluvoxamine (Luvox): Tx OCD
Citalopram (Celexa): fewest drug interactions,
fewest sexual side-effects
Escitalopram (Lexapro): L-enantiomer of
citalopram, even fewer side-effects but more $$$
Venlafaxine (Effexor): SNRI, ↑↑BP
Desvenlafaxine (Pristiq): SNRI, active metabolite of
venlafaxine, more $$$
Duloxetine (Cymbalta): SNRI, good for painful
diabetic neuropathy, more $$$
Buproprion (Wellbutrin): no sexual side-effects,
contraindicated with seizures and eating disorders
(↑risk of seizures)
Trazodone (Desyrel): can cause sedation and
priapism (Tx epi injection into penis)
Nefazodone (Serzone): can cause sedation, black
box for hepatotoxicity
Ψ – Psychopharmacology
Mirtazapine (Remeron): can cause weight-gain and
sedation
TCAs: inhibit 5-HT/NE reuptake, rarely first-line since
OD can be lethal (Tx NaHCO3); three types – tertiary
tricyclics, secondary tricyclics, tetracyclics
TCA side-effects: anti-HAM + 3 Cs – Cardiotoxicity
(↑QTc), Convulsions, Coma; lots of interactions
(highly protein bound) and lethal in OD
2° vs. 3° TCAs: tertiary are more anticholinergic
and sedating, and more lethal in OD; secondary
are active metabolites of tertiary amines
Imipramine (Tofranil): Tx enuresis
Amitriptyline (Elavil): strong anticholinergic side-
effects
Clomipramine (Anafranil): very sedating, Tx OCD
Doxepin (Sinequan): very sedating, useful as a
sleep aid in low doses
Nortriptyline (Pamelor, Aventyl): fewest anti-
HAM side-effects
Desipramine (Norpramin): more activating, less
sedating, least anticholinergic
Amoxapine (Asendin): metabolite of loxapine,
only antidepressant that can cause EPS
Maprotiline (Ludiomil): ↑rate of seizures,
arrhythmias, and fatality w/ OD
MAOIs: not first-line due to side-effects but useful
for atypical depression; includes phenelzine (Nardil),
tranylcypromine (Parnate), isocarboxazid (Marplan),
selegiline (Emsam)
MAOI side-effects: serotonin syndrome (MAOI+
SSRI within 5 weeks), HTN crisis (MAOI+tyramine)
–––––––––––––– ANTIPSYCHOTICS ––––––––––––––
Antipsychotics: typical (1G) and atypical (2G) are
both good for positive psychotic sx, but atypicals are
better for negative psychotic sx
Depot antipsychotics: long-acting decanoate forms
ideal for noncompliant psychotic pts; includes
haloperidol, fluphenazine, risperidone, paliperidone
Typical vs. atypicals: typicals have more EPS, tardive
dyskinesia, anti-HAM, and lethality in OD due to QTc
prolongation; atypicals have more weight gain, DKA,
and metabolic syndrome
Typical antipsychotics: blocks DA only
Typical side-effects: EPS (parkinsonism +
akathisia + dystonia), ↑prolactin, anti-HAM,
tardive dyskinesia (1% annual incidence), NMS
Low potency: ↑anti-HAM, ↓EPS and TD; includes
chlorpromazine (corneal pigmentation + photo-

sensitivity) and thioridazine (retinal pigmentation →
night blindness)
Mid-potency: midrange properties; includes
loxapine (↑seizures), thiothixene (ocular
pigmentation), trifluoperazine (↓anxiety), and
perphenazine
High potency: ↑EPS and TD, ↓anti-HAM;
includes haloperidol, fluphenazine, pimozide
Atypical antipsychotics: blocks both DA and 5-HT
Atypical side-effects: weight gain, DKA,
metabolic syndrome (monitor weight and lipids)
Clozapine (Clozaril): ↓suicide but ↑weight gain,
seizures, agranulocytosis (requires weekly WBC
counts), R-sided obstipation
Risperidone (Risperdal): #1 for ↑prolactin and
dystonic reactions
Paliperidone (Invega): metabolite of risperidone
Quetiapine (Seroquel): can cause sedation and
orthostatic hypotension
Olanzapine (Zyprexa): ↑weight gain
Ziprasidone (Geodon): ↓weight gain
Aripiprazole (Abilify): #1 for akathisia (Tx β-
blockers or BDZ)
Ziprasidone doesn’t work: pt wasn’t eating, food is
required to activate Geodon in the body
––––––––––––– MOOD STABILIZERS –––––––––––––
Mood stabilizers: Tx acute mania and prevent
relapses of manic episodes, includes lithium and
anticonvulsants (valproic acid, lamotrigine,
carbamazepine)
Lithium: DOC for acute mania and PPx for manic
episodes, takes 5-7 days for onset, only mood
stabilizer to ↓suicidality
Li+ side-effects: LMNOP – Lithium causes
Movement (tremors → Tx propanolol),
Nephrogenic DI, Narrow TI (0.6-1.2),
hypOthyroidism (Tx Synthroid), Pregnancy
problems (Ebstein’s anomaly)
Li+ level factors: NSAIDs (↑ except aspirin),
dehydration (↑), salt deprivation (↑), sweating
(↑), renal failure (↑), diuretics (↑)
Lithium overdose: if blood level >4.0, hemodialysis
Lithium duration: maintain use for 1 year following
single episode, maintain for lifetime if 3+ relapses
Lithium × HTN: Tx Ca2+-channel blockers
––––––––––––– ANTICONVULSANTS –––––––––––––
Anticonvulsants: includes carbamazepine,
oxcarbazepine, valproic acid, lamotrigine,
gabapentin, pregabalin, tiagabine, topiramate
Carbamazepine (Tegretol): good for rapid-cycling
bipolar disorder and trigeminal neuralgia; takes 5-7
days for onset and requires CBC/LFT monitoring
CBZ side-effects: BATHS – Blood dyscrasias,
P450 Autoinduction, Teratogenic, Hepatotoxic,
Stevens-Johnson syndrome
Valproic acid (Depakote): requires CBC/LFT/VPA
monitoring
VPA side-effects: 4 Fs – Fat (weight gain), Farts
(GI distress), Fatal hepatotoxicity, Fetal teratogen
(neural tube defects)
Lamotrigine (Lamictal): can ↓VPA levels, causes
Stevens-Johnson syndrome so raise levels slowly
Topiramate (Topamax): causes weight loss,
cognitive slowing (aka Dopamax), kidney stones
Gabapentin (Neurontin): good for chronic pain
Oxcarbazepine (Trileptal): rarely used
Pregabalin (Lyrica): rarely used
Tiagabine (Gabatril): rarely used
–––––––––––––––– ANXIOLYTICS ––––––––––––––––
Anxiolytics: benzodiazepines, barbiturates, and non-
benzodiazepine hypnotics/anxiolytics
Benzodiazepines: three types based on T½ (<6 hrs,
6-20 hrs, >20 hrs), choice of BDZ depends on onset,
duration, and metabolism
BDZ overdose: give flumazenil
Non-liver metabolized BDZ: LOT – Lorazepam,
Oxazepam, Temazepam
Long-acting BDZ: T½ >20 hrs; includes diazepam
(Valium) and clonazepam (Klonopin)
Intermediate-acting BDZ: T½ 6-20 hrs; includes
alprazolam (Xanax), lorazepam (Ativan), oxazepam
(Serax), and temazepam (Restoril)
Short-acting BDZ: T½ <6 hrs; includes triazolam
(Halcion) and midazolam (Versed), used mainly in
medical and surgical settings
Barbiturates: rarely used b/c lethal in overdose
Barbiturate overdose: Tx IV NaHCO3
Non-benzo hypnotics: zolpidem (Ambien), zaleplon
(Sonata), and eszopiclone (Lunesta); Tx short-term
insomnia, no tolerance/dependence
Ψ – Psychopharmacology
Chloral hydrate (Somnote): sedative, rarely used due
to tolerance/depedence and liver toxicity
Ramelteon (Rozerem): melatonin MT-2/3 agonist
used for sedation, no tolerance/depedence
Buspirone (BuSpar): 5-HT1A partial agonist given for
anxiety, useful in alcoholics (no EtOH potentiation
like BDZ)
Diphenhydramine (Benadryl): antihistamine given
for sedation, ↑anticholinergic side-effects
Hydroxyzine (Atarax): antihistamine given for
anxiety, ↑anticholinergic side-effects
Propanolol: β-blocker used to Tx panic attacks,
performance anxiety, and akathisia
––––––––––––––– OTHER DRUGS –––––––––––––––
Psychostimulants: Tx ADHD and refractory
depression; includes D-amphetamine, amphetamine
salts, methylphenidate, atomoxetine, modafanil
Amphetamines (Dexedrine, Adderall): schedule II
(↑abuse potential), monitor BP and watch for weight
loss, insomnia
Methylphenidate (Ritalin, Concerta): schedule II
(↑abuse potential), monitor BP/CBC/LFTs and watch
for weight loss, insomnia
Atomoxetine (Stattera): ↓appetite suppression and
insomnia, but ↑hepatotoxicity and SI in adolescents
Modafanil (Provigil): used in narcolepsy
Cognitive enhancers: used in dementia
AChE inhibitors: Tx mild Alzheimer disease; includes
donepezil, galantamine, rivastigmine, tacrine
Memantine (Namenda): NMDA blocker used for
moderate-severe Alzheimer disease
–––––––––––– OTHER TREATMENTS ––––––––––––
Electroconvulsive therapy: Tx refractory depression;
8-12 sessions given 3/week then monthly ECT to
prevent relapse; safe for pregnant and elderly
ECT method: pt put under general anesthesia and
muscle relaxant, then electrodes induce a seizure;
efficacy based on length of postictal suppression
ECT side-effects: amnesia (MC), headaches,
muscle soreness, confusion
ECT electrodes: bilateral electrodes ↓number of
sessions but ↑amnesia and confusion
ECT efficacy: 75%
ECT c/i: recent MI, anything w/ possibility of
hemorrhagic stroke (raised ICP, aneurysms,
bleeding d/o, BBB distruption)
 Ψ – Psychopharmacology

Deep brain stimulation: Tx chronic pain, Parkinson’s

disease, tremor, and dystonia

DBS method: implant device in brain that sends

regular electrical impulses to specific regions,
high risk of surgical complications

Repetitive transcranial magnetic stimulation:

noninvasive method to excite neurons via electro-
magnetic induction, Tx psychiatric conditions but
modest effects at best

rTMS side-effects: rare seizures, discomfort at

the delivery site

Light therapy: Tx seasonal affective disorder


––––––––––––––– LEGAL ISSUES –––––––––––––––
Forensic psychiatry: psychiatry + legal issues
Legal issues: two types – criminal if being charged
with a crime, civil if other rights are violated
Standard of care: skill level and knowledge base of
the average psychiatrist
Negligence: practicing below standard of care
Malpractice: act of being negligent as a doctor;
must meet the 4 Ds – Deviation (neglect) from
Duty that was the Direct cause of Damage
Damages: reward for malpractice case, includes
compensatory damages (financial reimbursement)
and punitive damages (money awarded to punish
the doctor)
Confidentiality: nondisclosure of information except
to another authorized person
Exceptions: COPS – Child abuse, Other staff
involved in pt’s care, Potential harm to others,
Subpoena, Suicidality
Tarasoff duty: legal obligation to breach patient
confidentiality and warn potential victims about a
pt who may physically harm them
Child abuse: doctors are required to contact child
protective services, lawyers are not
Informed consent: pt knowingly and voluntarily
agrees to a treatment or procedure; includes 4 Rs –
Reason for Tx, Risks and benefits, Reasonable
alternatives, and Refused Tx consequences
Exceptions: medical emergencies, suicide or
homicide prevention, unemancipated minors
receiving obstetric care, STD Tx, or substance
abuse Tx
Emancipated minors: do not need parental consent
to make medical decisions; minors are emancipated
if self-supporting, military, married, or have children
Capacity vs. competence: both refer to pt’s ability to
make informed treatment decisions, but capacity is a
medical term and competence is a legal term
Decisional capacity: task specific
Guardian: appointed to make treatment decisions
for incompetent pts
Voluntary admission: pt checks self into psych ward,
may not have the right to be discharged immediately
upon request
Involuntary admission: pt checked in for potential
harm or inability to provide for basic needs;
supported by legal principles of police power and
parens patriae
Police power: protecting citizens from each other
Ψ – Forensic Psychiatry
Parens patriae: protecting citizens who can’t care
for themselves
––––––––––– DISABILITY & INSANITY –––––––––––
Mental impairment: loss or derangement of a
mental function
Mental disability: inability to meet personal, social,
or occupational demands due to mental impairment
Competence: legal term for pt’s ability to make
informed treatment decisions; 6th + 14th amendments
require competence to stand trial
6th amendment: right to counsel and to confront
witnesses
14th amendment: right to due process of law
Conviction: judgment of guilty in a criminal case;
requires both actus reus (evil deed) and mens rea
(evil intent)
Insanity defense: if someone is declared legally
insane, they are not criminally responsible for the act
(i.e. not guilty by reason of insanity, NGRI)
Insanity defense standards: M’Naghten rules,
American Law Institute (ALI) model, Durham test
M’Naghten Rules: person does not understand
what he was doing or its wrongfulness
ALI Model: person could not appreciate right
from wrong or could not control his/her actions
(aka “irresistible impulse” test)
Durham Test: person’s criminal act has resulted
from mental illness
Violence risk assessment: h/o violence (#1 factor),
h/o impulsivity, specific threat w/ a plan, psychiatric
illness, substance abuse
––––––––––––––– OTHER ISSUES –––––––––––––––
Expert witness standards: evidence must be
accepted by appropriate scientific community (Frye
1923), and judge decides if evidence is based on
relevant and reliable science (Daubert 1993)
Malingering: feigning or exaggerating sx for
secondary gain (e.g. money, drugs, avoiding work)
Malingering buzzwords: ASPD, h/o substance
abuse, “doctor shopping”, textbook description
of illness, symptomatic only when observed
Child forensic psychiatry: involves child custody,
child abuse/neglect, termination of parental rights
Correctional psychiatry: involves balancing
confidentiality vs. violence

–––––––– EXAMINATION AND DIAGNOSIS ––––––––
Prevention: PDR – 1° is Prevention, 2° is Detecting
disease, 3° is Reduction of disability
Circumlocution: substitution of a word or
description for a word that can’t be recalled (e.g.
“that thing you write with”)
Tangentiality vs. circumstantiality: tangentiality
never comes back to original topic, circumstantiality
eventually does
Abuse vs. dependence: inability to quit despite
knowledge of harm best indicates dependence over
abuse
Verbigeration: repetitive, meaningless talking
Glossolalia: ability to speak a new language suddenly
––––––––––– PSYCHOTIC DISORDERS –––––––––––
Dementia praecox: another name for SCZ
Psychogenic polydipsia: SCZ pt drinks too much
water causing hyponatremia (Na+ <135)
SCZ brain: diffuse atrophy with decreased size of
hippocampus, parahippocampal gyrus, amygdala
Koro: Asian pt believes that his penis is shrinking and
will disappear causing his death
Amok: sudden unprovoked outbursts of violence of
which the person has no recollection (think “to run
amok”)
Brain fag: headache, fatigue, and visual disturbances
in African male students
Ataque de nervios: Puerto Rican trance d/o with
convulsions, fainting, crying, and visual problems
Mal de ojo: Mediterranean “evil eye”
Sangue dormido: Portugese d/o with numbness,
tremors, paralysis, convulsions, stroke, heart attack
Dhat: anxiety and hypochondriasis regarding semen
discharge
Windigo: Native American d/o regarding possession
by a demon that murders and eats human flesh
Autoscopic psychosis: VH of transparent phantom of
one’s own body, aka doppleganger
Capgras syndrome: delusion that friends/family have
been replaced by identical impostors
Lycanthropy: delusion that one is a werewolf (or
another animal)
Cotard syndrome: delusion that one has lost
everything, including one’s internal organs
Kluver-Bucy syndrome: presents as docility,
hyperphagia, hypersexuality, and disinhibition due to
bilateral amygdala lesions
––––––––––––– MOOD DISORDERS –––––––––––––
Postpartum blues: 20-40%, dysthymia that lasts <2
weeks, resolves spontaneously
Postpartum depression: 10-15%, resembles MDD
Postpartum psychosis: 0.1%, a subtype of bipolar
disorder, admit into inpatient care → Tx anti-
psychotic + antidepressant
Bipolar disorder: 25% among relatives, average age
of onset is 30 y/o
Porphyria: presents as psychotic or manic sx +
abdominal pain → get urinary porphobilinogen
Hamilton Depression Scale: used to measure
depressive sx
––––––– SUBSTANCE-RELATED DISORDERS –––––––
Nasal septum erythema: cocaine abuse
Rotary or vertical nystagmus: PCP abuse
Injected eyes: marijuana (cannabis) abuse
––––––––––– COGNITIVE DISORDERS –––––––––––
Delirium Dx: abnormal EEG
Dementia Dx: MRI
Multiple sclerosis brain: multiple plaques of frontal
white matter
Pseudoseizure: resembles seizure but normal EEG
Localized amnesia: memory loss surrounding a
discrete period of time
Selective amnesia: inability to recall certain aspects
of an event
–––––––––– PSYCHOPHARMACOLOGY ––––––––––
Placebos: 33% efficacy for depression
Antidepressants: 70% efficacy for depression
ECT: 75% efficacy for depression
NE: synthesized in locus ceruleus
5-HT: synthesized in raphe nucleus
DA: synthesized in substantia nigra
ACh: synthesized in nucleus accumbens
–––––––––––––––––– ETHICS ––––––––––––––––––
Depressed pt: ask about suicidal ideation
Ψ – Additional Notes
Suicidal pt: admit to inpatient care (against will if
necessary)
Homicidal pt: admit to inpatient care
Psychotic pt: acknowledge pt’s distress
Angry pt: encourage discussion about what’s
bothering the pt
Inappropriate pt: respond firmly but politely, remain
professional
Anorexic pt: admit to inpatient care if <75% ideal
body weight and/or medical complications
Abused pt: ask about abuse in an empathetic, open-
ended question
Suspected child abuse: complete a thorough
physical exam, then get X-rays, then call child
protective services if necessary
Breaking bad news: set the stage and assess pt’s
comprehension, then deliver news in empathetic
manner
Medical error: admit the mistake and apologize
Colleague makes medical error: always act in pt’s
best interest
Pt refuses tx: respect pt wishes, unless it puts others
at risk (e.g. infx) → requires involunary admit
Parents refuse tx for minor: nonemergent and not
fatal → respect parent wishes; nonemergent but
potentially fatal → get court order; emergent →
proceed w/ tx; one parent agrees → proceed w/ tx
Kid w/ imaginary friends: completely normal
Teen w/ behavioral changes: get urine tox screen
Pt requests medical records: give it to them
Relative requests dx not be revealed to pt: ask
relative about reasoning, since pt has right to know
Family disagrees w/ advance directives: discuss
situation w/ family, if unresolved after meeting →
call ethics committee
Pregnant woman vs. fetus: woman has right to
refuse tx, even if it puts the fetus at risk
OBSTETRICS/GYNECOLOGY
 OB 1 – Pregnancy

Terminology Embryo: 0-8 wk

Fetus: 8 wk – delivery
Infant: delivery – 1 yr

GXPTPAL Gravidity: number of times a woman’s been pregnant

Parity: number of times a woman’s delivered
T: >37 wk
P: 20-36 wk
A: <20 wk
L: living births
Grand multip: parity ≥5

Pregnancy signs Chadwick sign: bluish discoloration of vagina/cervix

Goodell sign: softening of cervix
Hegar/Ladin sign: softening of uterus

Fetal dating Naegele’s rule: EDC = LMP + 1y – 3m + 7d

U/S indications: not mandatory, but useful for uncertain gestational age, size/date discrepancies, multiple gestations, etc.
Physical landmarks: pubic symphysis at 12 wk, umbilicus at 20 wk

Physiologic changes CV: hyperdynamic (↑CO), hypotensive (↓SVR → ↓BP) state

Pulmonary: ↑TV creates ↑CO2 gradient w/ fetus for gas exchange
GI: ↑E/P/hCG results in morning sickness, hyperemesis gravidarum if severe
Renal: ↑GFR by 50%, ↑risk of pyelonephritis
Blood: hypercoagulable, dilutional anemia (due to ↑↑plasma despite ↑RBC)
Endocrine: ↑E/P, ↑hCG, ↑hPL, ↑TBG
hCG: doubles every 48 hrs until peaking at 10-12 wks, then declines to steady state at 15 wk
hPL: maintains fetal nutrition (lipolysis → ↑FFA), blocks insulin (can cause GDM)
MSK: hyperlordosis (due to lower center of gravity)
Skin: ↑E causes spider angiomata and palmar erythema, ↑MSH causes linea nigra and melasma/chloasma

Nutrition ↑: kcal, folate (neural tube defects), iron (RBC), vitamin C, Ω3 fatty acids
↓: vitamin A (teratogenic), calcium (need more but chelates iron)

Common pregnancy Complaint Management

complaints Lower back pain d/t hyperlordosis; Tx mild exercise + stretching, Tylenol
Constipation Tx fluids, exercise, fiber supplement
Braxton-Hicks contractions irregular contractions w/o cervical dilatation, normal
Dehydration Tx PO fluids
Edema Tx leg elevation + r/o preeclampsia
GERD Tx antacids, PPIs or H2-blockers if severe
Hemorrhoids Tx topical steroids, fiber, stool softeners, sitz baths
PICA eating inedible items; Tx encourage immediate cessation + toxicology
consult
Round ligament pain shooting pelvic pain due to ligament stretching; Tx Tylenol + warm
compresses
Urinary frequency normal, but get UA/UCx to r/o UTI
Varicose veins Tx leg elevation + pressure stockings
Hyperemesis gravidarum Tx NPO ×3 days, IV fluids + antiemetics; if severe → doxylamine + vitamin B6

Prenatal labs Prenatal visits: first visit in first trimester, then q4wks until 28th, q2wks until 36th, and qwk until delivery

Lab test Management

CBC check for anemia or hemoglobinopathies
Blood type for future transfusion
Rh status if Rh–, give RhoGAM at week 28 and postpartum (if fetus is Rh+)
HBsAg if HBsAg+, get LFTs and hepatitis panel to determine acute vs. chronic infx;
Tx infant HBIG and HBV vaccine
HIV ELISA if ELISA+, confirm w/ Western blot; if WB+ then give anti-HIV meds, elective
C/S, or IV ZDV during labor
RPR-VDRL if RPR+, confirm with FTA-ABS; if FTA-ABS+ then determine syphilis stage and
Tx benzathine PCN G
UA/UCx if positive, Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN
during labor
Rubella Ab if rubella ab–, stay away from sick ppl and vaccinate postpartum
GC/chlamydia if GC/CT+, Tx ceftriaxone + azithromycin

Antenatal assessment NST (non-stress test): continuous fetal monitoring (toco + HR), look for reactivity (2×15×15)
BPP (biophysical profile): U/S evaluation on a 10 pt scale
BPP >8: normal
BPP =6: get CST
BPP <4: deliver
CST/OCT (ctx stress test/oxytocin challenge test): give oxytocin, look for 3 ctx/10 min w/o late decels
 OB 2 – Pregnancy × Early Complications

Ectopic pregnancy Ectopic pregnancy: Implantation outside uterine cavity, MC site is fallopian tube
Heterotopic pregnancy: one normal + one ectopic pregnancy
Sx: unilateral abd pain ± vaginal bleeding
Risk factors: prior ectopic, tubal scarring (STIs or PID), IUD, assisted fertility, endometriosis
Incidence: 1:100 pregnancies
Management:
Ectopic pregnancy?

screen ↑β-HCG
confirm TV U/S

yes r/o ectopic

ruptured not ruptured if no definitive dx,

f/u serial β-HCG Q 48hrs
stabilize w/ IVF Tx MTX
ex lap

if β-HCG doesn’t fall 15%

in 4-7 days, repeat MTX

1st trimester SAB Sx: vaginal bleeding, abdominal pain, cramping, ↓sx of pregnancy
Causes: abnormal chromosomes (MCC)
Management:

1st trimester abortion?

labs: β-HCG, CBC, type/cross

pelvic exam to r/o other sources of bleed
stabilize w/ IVF

complete abortion incomplete abortion threatened abortion

inevitable abortion
missed abortion

f/u for recurrent bleed or signs of infx Tx D+C, prostaglandins, f/u for continued bleeding
or allow to finish on its own give RhoGAM if Rh-

2nd trimester SAB Sx: vaginal bleeding, abdominal pain, cramping, ↓sx of pregnancy
Causes: anatomic defects (MCC), infx, maternal disease, trauma, fetotoxic agents
Management:
2nd trimester abortion?

r/o PTL + incompetent cervix

Tx D+E, high-dose oxytocin,

or prostaglandins

Incompetent cervix Incompetent cervix: painless dilation and cervical effacement before term, usually 2nd trimester
Causes: surgery or trauma (MCC), uterine abnormalities, DES exposure
Management:
Incompetent cervix?

Dx dilated cervix on PE,

or hourglass membranes on U/S

viable (>24 wks) previable (<24 wks)

Tx betamethasone + emergent cerclage

strict bed rest

if cerclage fails,
transabdominal cerclage

Hx of incompetent cervix: offer elective prophylactic cerclage at 12-14 wks

Cerclage: surgical closure of cervix at external os (McDonald) or internal os (Shirokar)
Complications: rupture of membranes, PTL, infx
 OB 2 – Pregnancy × Early Complications

Recurrent preg loss Recurrent pregnancy loss: 3+ consecutive SABs

Causes: APA syndrome (↑clots) and luteal phase defect (↓P) are MCC
Management: look for etiology, then Tx accordingly

Etiology Dx Tx
Abnormal chromosomes karyotype of both parents IVF or preimplantation dx
Anatomy (e.g. bicornuate uterus) screen w/ HSG (hysterosalpingogram), surgery (may not be correctable)
confirm w/ hysteroscopic or ex lap
APA syndrome RPR-VDRL, lupus anticoagulant, ANA, low-dose aspirin
coag panel, anticardiolipin antibody
Luteal phase defect ↓progesterone levels progesterone
Infection cx cervix, vagina, endometrium abx
Hypothyroidism ↑TSH, ↓T4 Synthroid
 OB 3 – Prenatal Diseases

Epidemiology
Disease+ Disease–
Dx+ TP FP (type I)
Dx– FN (type II) TN

Sensitivity: TP / (TP+FN)
Specificity: TN / (TN+FP)
PPV: TP / (TP+FP)
NPV: TN / (TN+FN)

Cystic fibrosis Cystic fibrosis: AR ΔCFTR (Cl- channel) → thicker mucus → chronic bronchitis
recurrent Pseudomonas pneumonia
bronchiectasis
pancreatic insufficiency
male infertility
ADEK deficiency
meconium ileus
Dx: screen mom and dad for ΔF508/G542X, confirm w/ fetal dx
Tx: N-acetylcysteine loosens mucus plugs, pancreatic enzyme replacement

Sickle-cell disease Sickle-cell disease: AR ΔHbE6V (hemoglobin β-chain) → hemolytic anemia, vasoocclusive crises, autosplenic infarction
Dx: screen mom w/ Hb electrophoresis, then dad if positive, then confirm w/ fetal dx
Epidemiology: heterozygote advantage – allows for resistance to P. vivax malaria in Africans

Tay-Sachs disease Tay-Sachs disease: AR ΔHexA → ganglioside accumulation → progressive neurodegeneration

developmental delay
“cherry red spot” on macula
onion-skin lysosomes
Dx: screen all high-risk carriers, confirm w/ fetal dx
Epidemiology: founder effect – high frequency in Ashkenazi Jews due to small ancestral group

β-thalassemia β-thalassemia: AR deletion of β-chain → ↑α:β ratio

Dx: screen w/ CBC, if microcytic anemia then confirm w/ Hb electrophoresis

α-thalassemia α-thalassemia: cumulative deletions of α-chain → ↓α:β ratio

Silent carrier: 1-2 gene deletion; asx
HbH disease: 3 gene deletion → ↑HbH (β4) → severe microcytic anemia
Barts disease: 4 gene deletion → ↑HbBarts (γ4) → hydrops fetalis (IUFD)
Dx: screen w/ CBC, if microcytic anemia then confirm w/ Hb electrophoresis

Chromosomal defects Disease Δ Sx Dx

Down syndrome trisomy 21 flat facies, epicanthal folds, simian crease, quad screen at 15-20 wk (↑β-HCG, ↑inhibin,
Alzheimer by 40 y/o, MR ↓αFP, ↓estriol) + nuchal translucency on
U/S ; MCC abnormal value is error in dating
Edwards syndrome trisomy 18 micrognathia, clenched hands, rocker-bottom triple screen (↓β-HCG, ↓αFP, ↓estriol)
feet, MR; death by 1 y/o
Patau syndrome trisomy 13 cleft lip/Palate, holoProsencephaly, Polydactyly, found on routine U/S
rocker-bottom feet, MR; death by 1 y/o
Turner syndrome 45/X Coarctation of aorta ---
Lymphedema
Ovarian dysgenesis
Webbed neck (cystic hygroma)
Nipples spread (shield chest)
Short stature
Klinefelter syndrome 47/XXY female traits on a man (long legs, gyno, high- ---
pitched voice, female habitus, etc.)
Cri-du-chat syndrome 5p- microcephaly, cardiac problems, high-pitched ---
meowing, epicanthal folds, MR
Williams syndrome 7q- Elfin facies, Extreme friendliness w/ strangers, ---
well-developed English, MR
DiGeorge & velo- 22q11 Cleft palate ---
cardiofacial syndrome Abnormal facies
Thymic aplasia
Cardiac defects
Hypocalcemia
 OB 3 – Prenatal Diseases

Embryogenesis Week 0 fertilization, cell division (blastula → morula → blastocyst)

Week 1 implantation + β-HCG secretion
Week 2 bilaminar disc (epiblast + hypoblast)
Week 3 gastrulation (3 tissues), neurulation
Week 3-8 organogenesis (most susceptible to teratogens)
Week 4 heart (4 chambers), limbs (4 limbs)
Week 8 fetus

Endoderm: becomes GI and respiratory systems

Mesoderm: becomes CV, MSK, GU systems
Ectoderm: becomes CNS, skin, etc.

Neural tube defects NTDs: ↓folate → defective neural tube closure at 4 wk

Etiology: low dietary folate, Δmethyl-THF reductase
Myelomeningocele: Dx screen ↑αFP, confirm U/S shows lemon sign (concave frontal bones) and banana sign (flat caudal cerebellum); Tx surgery in utero
Spina bifida occulta: asx lumbar tuft of hair

Cardiac defects Echogenic intracardiac focus (EIF): calcification of papillary muscle on U/S, usually insignificant
L→R shunts: all present with murmurs + late-onset cyanosis due to Eisenmenger syndrome (pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur, fixed S2, and frequent colds
VSD: presents as pansystolic harsh-sounding murmur with failure to thrive
PDA: presents with machinery-like murmur, often seen with Congenital Rubella Syndrome
R→L shunts: all present with murmurs + early-onset cyanosis
Tetralogy of Fallot: presents as cyanosis and clubbing in a 5 y/o child who squats for relief; Px determined by degree of pulmonary stenosis
Transposition of great vessels: presents as life-threatening cyanosis in a newborn

Dx: fetal echocardiogram

Tx: surgery, indomethacin for PDA

Potter syndrome Potter syndrome: failure of mesonephros and metanephros to meet at ureteropelvic junction → bilateral renal agenesis → anhydramnios (no amniotic fluid)
→ pulmonary hypoplasia + limb contractures
Dx: U/S shows anhydramnios or oligohydramnios (AFI <5)
Tx: none available

Prenatal diagnosis Prenatal sampling: amniocentesis, chorionic blood sampling (CVS), percutaneous umbilical blood sampling (PUBS)

Method Technique Advantages/disadvantages

Amniocentesis insert needle transabdominally into uterus
and withdraw amniotic fluid
CVS insert catheter into intrauterine cavity and
aspirate chorionic villi from placenta
PUBS insert needle transabdominally into uterus
and withdraw umbilical cord blood
+ 1:200 risk of PTL, PROM, injury
– 2nd trimester
+ 1st trimester
– >1:200 risk of PTL, PROM, injury
+ rapid karyotype analysis
– may take maternal blood

Prenatal imaging: level-I U/S at 18-22 wk is standard of care

 OB 4 – L&D

Labor Labor: ctx + cervical dilation

Timing: preterm <37 wks
term 37-42 wks
postterm >42 wks
Prodromal (false) labor: irregular Braxton-Hicks ctx w/o cervical dilation

3 Ps of labor 3 Ps of labor: Power, Passenger, Passage determine progression of labor

Power: ctx frequency + intensity + duration
Adequate ctx: 3-5 ctx/10 min + >200 MVU

Passenger: fetus
Fetal lie: longitudinal, transverse, or oblique
Fetal presentation: first part in vagina; cephalic/vertex or breech
Fetal position: depends on occiput position…
Leopold maneuver: used to determine presentation, position, engagement
fetal position
Passage: pelvis type
Gynecoid: MC type, best px
Platypelloid: seen in Asians, can lead to deep transverse arrest

pelvis types

Induction of labor Induction of labor: attempt to begin labor in nonlaboring pt

Methods: prostaglandins (Cytotec), oxytocin (Pitocin), or amniotomy (AROM)
Indications: postterm (>42 wk), PROM (≥34 wk), preeclampsia, IUGR, nonreassuring fetal testing
PGE contraindications: maternal asthma or glaucoma, >1 prior C/S
IOL success: vaginal delivery; progress measured by Bishop score
Augmentation of labor: increasing ctx in already laboring pt

Bishop score: cervical exam w/ 5 components – dilation, effacement, station, position, consistency
Dilation: diameter of internal os (range 0-10 cm)
Effacement: thinning out of cervix (range 0-100%)
Station: 0 station (midpoint) is ischial spines, measure in cm above/below (range -5 to +5 cm)
Position: advancement of cervix as labor progresses (range posterior to anterior)
Consistency: softening of cervix as labor progresses (Hegar or Ladin sign)

Progress of labor: Bishop score Management

0-4 cytotec
5-9 pitocin
10+ expectant management
 OB 4 – L&D

Stages of labor Stage 1: onset to complete dilation (10 cm)

Phases: latent phase is 0-4 cm and slow, active phase is >4 cm and rapid
Active phase arrest: no change in dilation or station for 2 hrs, indicated for C/S
Stage 2: dilation to delivery
Prolonged stage 2: >2 hrs if nulliparous, >1 hr if multiparous (add 1 hr w/ epidural)
Ritgen maneuver: pressure on fetal head to help shoulders pass through
Stage 3: delivery to placenta delivery (10 min)
Retained placenta: stage 3 lasts >30 min; Tx manual extraction + abx
Signs of placental separation: gush of blood, lengthening of cord, change in shape of uterine fundus
Too much traction: ↑risk of cord avulsion, uterine inversion
Stage 4: placenta delivery to 2 hrs postpartum

Episiotomy: incision in perineum to facilitate delivery, two types – median and mediolateral
Lamaze method: classes to teach natural birthing techniques (relaxation, breathing, etc.)

Cardinal movements Cardinal movements: 1. Engagement (0 station)

2. Flexion
3. Descent
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion

Operative vaginal Operative vaginal delivery: usage of forceps or vacuum to deliver fetus
delivery Forceps: ↑risk of CN VII palsy
Vacuum: ↑risk of cephalohematoma and shoulder dystocia
Conditions: experienced operator (most important), full dilation, ruptured membranes, engaged w/ >2 station, knowledge of fetal position, anesthesia, empty
bladder, no evidence of cephalopelvic distortion

Perineal lacerations 1st degree: superficial tear

2nd degree: extends into perineal body
3rd degree: extends into anal sphincter
4th degree: extends into rectum

Caesarian section C/S: delivery by uterine incision

Indications: MC primary is failure to progress in labor, MC overall is prior C/S

VBAC: vaginal birth after C/S; only true c/i is previous vertical (classical) C/S
TOLAC: trial of labor after C/S, MC complication is rupture of uterine scar
Rupture sx: sudden onset severe abd pain ± vaginal bleed, subjective “pop” sensation

Anesthesia Pudendal block: indicated for operative vaginal delivery, direct needle towards jxn of ischial spine and sacrospinous ligament
Local anesthesia: indicated for episiotomy and laceration repairs
Epidural anesthesia: more commonly used during labor, can lengthen stage 2
Spinal anesthesia: more commonly used during C/S
 OB 4 – L&D

Fetal HR Fetal HR: baseline + variability + periodic changes

Baseline HR: normal is 110-160 bpm; tachy >160 for 10 min, brady <110 for 10 min
Variability: determined by SNS-PSNS interplay; ↑↑ and ↓ variability is bad sign

Periodic changes Early decel: along w/ ctx, due to head compression → CN X stimulation
Variable decel: no relation w/ ctx, due to cord compression (possibly oligohydramnios)
Late decel: happens after ctx, due to uteroplacental insufficiency
Prolonged decel: >15 bpm for 2-10 min
Accelerations: reactive if 2× (15 bpm × 15 sec) / 20 min
Sinusoidal pattern: sine-wave shaped, due to fetal anemia (e.g. fetal vx rupture)

Category 1 (best): FHR 110-160, moderate variability, no late/var decels

Category 2: everything else
Category 3 (worst): absent variability + recurrent late/var decels, bradycardia, sinusoidal pattern

FHR tracing management:

obtain FHR pattern

category 1 category 2 category 3

routine mgmt evaluation and resuscitative measures,

surveillance prepare for delivery

if no accels or variability,
resuscitative measures

if not improved, prompt delivery

Resuscitative measures: give O2 + change maternal position

 OB 5 – Antepartum Hemorrhage

Terminology Placenta previa: placenta develops over internal os

Placenta accreta: placenta adheres to uterine wall
Placenta increta: placenta invades into myometrium
Placenta percreta: placenta penetrates through to uterine serosa
Circumvallate placenta: membranes form dense ring around placenta
Vasa previa: fetal vessels develop over internal os
Velamentous placenta: fetal vessels insert between amnion and chorion
Succenturiate placenta: extra lobe of placenta ± blood fetal vessels between two lobes
Abruptio placentae: premature separation of placenta from uterine wall

Antepartum Obstetric causes: placenta previa (20%), abruptio placentae (30%), fetal vessel rupture, uterine rupture
hemorrhage Non-obstetric causes: cervical/vaginal lacerations, hemorrhoids, infx, neoplasms
DDx: present as spotting (not frank bleeding), no contractions or abdominal pain
Px: simple management, good outcomes (vs. obstetric causes)

Placenta previa Placenta previa: placenta develops over internal os

Subtypes: complete, partial, marginal
Sx: painless vaginal bleeding + risk of hemorrhagic shock
Previa management:
Placenta previa?

Dx transabdominal or translabial U/S

(vaginal exam is c/i due to hemorrhage)
if prior to 3rd trimester,
repeat U/S to see if it’s resolved
labs: H+H, type/cross
give RhoGAM if Rh-

unstable stable

stabilize w/ IVF expectant management

emergent C/S tocolytics + betamethasone (<34 wk)

Placenta accreta Placenta accreta: placenta adheres to uterine wall

Placenta increta: placenta invades into myometrium
Placenta percreta: placenta penetrates through to uterine serosa
Sx: usually asx during pregnancy, presents as vaginal bleed + inability to separate placenta after delivery
Tx: puerperal hysterectomy

Abruptio placentae Abruptio placentae: premature separation of placenta from uterine wall
Subtypes: revealed/external (80%), concealed (20%)
Sx: 3rd trimester vaginal bleeding + severe abd pain, strong ctx
Complications: hemorrhagic shock, DIC, premature delivery, uterine tetany, fetal death (35%)
Risk factors: HTN (#1), trauma, previous abruption, smoking, cocaine
Abruption management:
Abruptio placentae?

Dx clinical presentation

stabilize w/ IVF
labs: H+H, type/cross
RhoGAM if Rh-
betamethasone (<34 wk)
delivery (unstable or FHR nonreassuring)

Uterine rupture Uterine rupture: rupture of uterus associated w/ prior uterine scar (C/S or other surgery)
Sx: sudden onset severe abd pain ± vaginal bleeding, subjective “pop” sensation
Tx: emergent ex lap and delivery

Fetal vessel rupture Vessel rupture causes: velamentous placenta, succenturiate placenta, vasa previa
Vasa previa: fetal vessels develop over internal os
Velamentous placenta: fetal vessels insert between amnion and chorion
Succenturiate placenta: extra lobe of placenta ± blood fetal vessels between two lobes
Sx: vaginal bleeding + sinusoidal pattern on FHR [tachy → brady → sinusoidal]
Dx: Apt test (examine blood for fetal/nucleated RBCs, pink indicates fetal blood)
Tx: emergent C/S
 OB 6 – L&D × Complications

Preterm labor PTL: labor <37 wks

PTL management: tocolytics + betamethasone for lung maturity
PTD: delivery <37 wks, occurs in 10% of pregnancies

Complications: RDS, intraventricular hemorrhage, necrotizing enterocolitis

Tocolysis Tocolysis: delaying premature labor for 48 hrs, to allow for fetal lung maturity w/ betamethasone

Tocolytic MOA Side-effects

Nifedipine Ca-channel blocker (1st line) headache, flushing, dizziness
MgSO4 competes w/ Ca2+ for Ca-channels headache, flushing, dizziness, pulmonary edema,
cardiac arrest (high dose)
Terbutaline β2-agonist headache, tachycardia, anxiety
Ritodrine β2-agonist headache, tachycardia, anxiety
Indomethacin NSAID (blocks PGF2α production) fetal PDA closure, pulmonary hypertension, renal
failure → oligohydramnios

Premature rupture ROM: disruption of the amniotic sac

of membranes ROM Dx: pool test (visualize fluid pooling)
nitrazine test (alkaline pH turns nitrazine paper blue)
fern test (see ferning under scope)
amnio dye/tampon test (inject dilute indigo-carmine dye into amniotic sac and look for leakage into tampon)

PROM: rupture >1 hr before labor, ↑risk of infx

Risk factors: smoking, chorioamnionitis (Tx IV abx + delivery), ↑latency w/ ↓GA
PROM management: depends on GA…
≥34 wk: delivery
24-33 wk: expectant management, tocolytics + betamethasone
<24 wk: pt counseling, expectant management or induced labor
Prolonged PROM: rupture >18 hrs before labor, ↑↑risk of infx
PPROM: rupture >1 hr before labor, preterm

Cephalopelvic CPD: fetal head is too big to pass through maternal pelvis; MCC active phase prolongation
disproportion CPD management: suspected CPD → trial of labor anyways, if CPD confirmed by CT or U/S → C/S

Breech presentation Breech presentation: fetus presents w/ buttocks first, 2%

Complete breech: thighs and legs flexed
Frank breech: thighs flexed, legs straight
Incomplete (footling) breech: feet first

Breech management: Dx Leopold maneuvers, vaginal exam, or U/S →

Tx external version to vertex, C/S, or breech delivery (rare)
Complications of breech delivery: cord prolapse, head entrapment, neurologic injury

Malpresentation of Malpresentation: includes face, brow, compound, persistent OP and OT

vertex Face presentation: face first
Brow presentation: orbital ridge first
Compound presentation: vertex/breech + limb, high-risk for cord prolapse
Persistent OP: facing anterior, may require external version to OA
Persistent OT: facing sideways, high-risk of deep transverse arrest w/ platypelloid pelvis type
Malpresentation management: vaginal delivery but needs close monitoring

Fetal bradycardia Bradycardia: <110 bpm for >10 min (2-10 min is prolonged decel)
Preuterine causes: maternal hypotension or hypoxia (seizure, PE, AFE, MI, etc.)
Uteroplacental causes: placental abruption, infx, hemorrhage
Postplacental causes: cord prolapse, cord compression, fetal vx rupture
Bradycardia management: place in LLD/RLD → start 2L O2 NC → look for cause → Tx appropriately
 OB 6 – L&D × Complications

Shoulder dystocia Shoulder dystocia: anterior shoulder gets caught behind pubic symphysis
Complications: fetal humerus/clavicle fx, brachial plexus injury, phrenic nerve palsy, hypoxia → brain injury → death
Risk factors: previous dystocia, ↑fetal size (macrosomia, diabetes, maternal obesity, postterm delivery), prolonged stage 2

Dystocia management: special maneuvers → if failed, cut clavicle or pubic symphysis → if failed, Zavanelli maneuver
Suprapubic pressure: add pressure to dislodge anterior shoulder
McRoberts maneuver: sharp flexion of maternal hips increases pelvic AP diameter
Rubin maneuver: apply pressure behind either shoulder to decrease fetal diameter
Wood corkscrew: apply pressure behind posterior shoulder to rotate infant
Posterior arm delivery: deliver posterior arm first, then rotate infant to for anterior shoulder
Zavanelli maneuver: push head back in + perform C/S

Hypotension Hypotension: maternal BP <80/40; causes include regional anesthesia, hemorrhage, vasovagal events, AFE, anaphylaxis
Hypotension management: start IV fluids + ephedrine, then Tx cause (e.g. Benadryl for anaphylaxis)

AFE: high mortality rate, Dx fetal cells in pulmonary vasculature at autopsy

Seizure Seizure vs. syncope: check for postictal disorientation (found in sz but not syncope)
Seizure management: Tx IV or IM MgSO4, get PEII panel, consult neuro if negative for eclampsia
 OB 7 – Pregnancy × Complications

Fetal growth SGA: <10th percentile, either symmetric or asymmetric

LGA: >90th percentile
Macrosomia: >4500 g
LBW: <2500 g

SGA & LBW SGA: <10th percentile, two types – IUGR and ↓growth potential
↓growth potential: congenital abnormalities (chromosomal d/o), infx (CMV, rubella), teratogens (EtOH, cigs)
MCC: cigarettes
IUGR: intrauterine growth restriction, unable to achieve potential size despite good growth potential
Etiology: maternal systemic dz → ↓placental perfusion → IUGR

SGA management: confirm accuracy of dating → Dx serial U/S + umbilical artery doppler → check for underlying etiology
Serial U/S results: low growth potential stays small, IUGR progressively falls off growth curve
Doppler results: low or absent diastolic flow indicates ↓placental resistance, reversed diastolic flow is high-risk for IUFD

LGA & macrosomia LGA: >90th percentile

Risk factors: diabetes, maternal obesity, postterm pregnancy, multiparity, advanced maternal age
Complications: birth trauma, hypoglycemia, jaundice, ↓Apgar scores, childhood tumors, shoulder dystocia

LGA management: confirm accuracy of dating → Dx U/S → consider IOL prior to macrosomic status

Amniotic fluid Amniotic fluid physiology: produced by fetal kidneys, resorbed by fetal swallowing
Amniotic fluid index: measure of fluid in quadrants via U/S; AFI <5 is oligo, AFI >20 is poly

Oligohydramnios Oligohydramnios: AFI <5, FHR shows variable decels

Causes: ROM (MCC), ↓placental perfusion, ↓fetal fluid production, renal malformations (e.g. Potter syndrome)
Complications: pulmonary hypoplasia, limb contractures, cord compression → fetal asphyxiation → death
Oligo management:
Oligohydramnios?

Dx AFI <5

preterm term/postterm ROM congenital anomaly meconium in

amniotic fluid
compatible incompatible
expectant deliver induce labor w/ life w/ life amnioinfusion
management
genetic counseling deliver

Polyhydramnios Polyhydramnios: AFI >20

Causes: congenital abnormalities, diabetes, TTTS, hydrops fetalis
Complications: cord prolapse
Poly management: careful verification of presentation, observe for cord prolapse

Erythroblastosis Erythroblastosis fetalis: Rh– woman w/ Rh+ fetus → anti-Rh IgG crosses placenta → hemolytic anemia → hydrops fetalis (edema, ascites, heart failure)
fetalis Rh– prevalence: 15% in caucasians, lower in other races
Rh– management:
Rh– woman

unsensitized sensitized

give RhoGAM at week 28 and follow closely w/ serial U/S

postpartum (if fetus is Rh+) and amniocentesis (for bilirubin
levels indicating hemolysis)

Intrauterine fetal IUFD: fetal death in utero

demise Causes: usually unknown, often chronic placental insufficiency or “cord accident”
Retained IUFD: high-risk of DIC if fetus is left >3 wks
IUFD management: Dx U/S → Tx delivery (not emergent) → f/u autopsy to search for cause
 OB 7 – Pregnancy × Complications

Postterm pregnancy Postterm pregnancy: gestational age >42 wks

Complications: macrosomia, oligohydramnios, meconium aspiration, IUFD, dysmaturity syndrome
Dysmaturity syndrome: chronic IUGR from uteroplacental insufficiency
MCC: inaccurate dating
Management: get accurate dating → induce labor, increased fetal surveillance

Cleavage Cleavage: chorion separates day 4, amnion separates day 8

Di-Di twins: cleavage b/t day 1-3
Mo-Di twins: cleavage b/t day 4-8, at risk for TTTS
Mo-Mo twins: cleavage b/t day 8-13
Siamese twins: cleavage b/t day 13-15

Multiple gestations Multiple gestations: two types – monozygotic and dizygotic

Monozygotic twins: 1 sperm + 1 ova → identical DNA; no predisposing factors
Dizygotic twins: 2 sperm + 2 ova → separate DNA; ↑ in Africans, IVF, clomiphene citrate
Complications: PTL, placenta previa, postpartum hemorrhage, preeclampsia, cord prolapse, malpresentation, GDM, incompetent cervix
Management: Siamese twins → C/S
Mo-Mo twins → C/S
vertex/vertex twins → vaginal delivery
vertex/nonvertex twins → vaginal delivery or C/S
nonvertex/nonvertex twins → C/S
triplets and above → C/S ± selective reduction

TTTS TTTS: unequal blood flow in shared placenta of Mo-Di twins → small/anemic twin + large/polycythemic twin
TTTS management: serial U/S Q 2 wks in all Mo-Di twins → Tx serial amnioreduction in larger twin
 OB 8 – Pregnancy × HTN

Gestational HTN Gestational HTN: HTN (>140/90) without proteinuria (<300 mg/day)
GHTN management: labetalol, nifedipine

Preeclampsia Preeclampsia: HTN (>140/90) + proteinuria (>300 mg/day) + edema

Etiology: multiorgan vasospasm → brain (severe HA, seizure, stroke)
liver (liver damage, RUQ pain, n/v)
kidneys (renal failure, proteinuria, edema)
placenta (IUGR, IUFD)
small vx (thrombocytopenia, DIC)
Risk factors: nulliparity, multiple gestation, chronic HTN, family hx
Preeclampsia management: Dx PEII panel (labs + 24hr urine protein) → Tx control HTN (labetalol, nifedipine) + seizure ppx (MgSO4 – 4g load + 2g/hr) +
delivery if term or unstable

Severe preeclampsia: severe HTN (>160/110), proteinuria (>5 g/day or 3+ dipstick), presence of other complications; must deliver (IOL > C/S)
First-trimester preeclampsia: consider hydatidiform moles

HELLP syndrome HELLP syndrome: Hemolysis (schistocytes, ↑LDH, ↑bilirubin), Elevated LFTs, Low Platelets in preeclamptic pts

Acute Fatty Liver of AFLP: fatty liver + HTN (>140/90) ± proteinuria

Pregnancy AFLP management: supportive care, liver txp if necessary

Eclampsia Eclampsia: tonic-clonic (grand mal) seizures in preeclamptic pts

Seizure timing: ¼ before labor, ½ during, ¼ afterwards
Eclampsia management: control HTN (hydralazine) + seizure ppx (MgSO4) + delivery after pt is stabilized

MgSO4 side-effects: pulmonary edema

MgSO4 overdose: DTR depression (first sign), respiratory depression, coma, cardiac arrest; Tx calcium gluconate

Chronic HTN Chronic HTN: HTN occuring before conception, before 20 wks GA, or lasting >6 wks postpartum
Chronic HTN management: control HTN (labetalol, nifedipine) + baseline EKG + 24hr urine protein

Superimposed preeclampsia: 24hr urine protein >300 mg in previously HTN pt

 OB 9 – Pregnancy × DM

Pregestational DM Pregestational DM: diabetes diagnosed prior to pregnancy

GDM GDM pathophysiology: ↑hPL/E/P → insulin antagonism

Epidemiology: 5-8% incidence, ↑risk of developing T2DM later in life
Risk factors: prior GDM, family hx, obesity, race (non-whites)
Maternal complications: polyhydramnios, preeclampsia, miscarriage, etc.
Fetal complications: macrosomia → shoulder dystocia, hypOcalcemia, hypOglycemia, polycythemia → hyperviscosity
Fetal malformations: CV defects, NTDs, caudal regression syndrome, situs inversus, duplex ureter, IUGR

GDM Dx: screen w/ GCT at week 26-28 → if ≥140 mg/dL, confirm w/ OGTT
GDM management: tight glucose control w/ diet (1st line), insulin (2nd line), glyburide (3rd line); induce at 39-40 wk, C/S if macrosomic
Ideal glucose: between 70-110 mg/dL
Ideal HbA1c: less than 6.5%

White classification Class Definition

of diabetes A1 GDM, diet controlled
A2 GDM, insulin controlled
B onset >20 y/o, duration <10 yrs
C onset 10-19 y/o, duration 10-19 yrs
D onset <10 y/o, duration >20 yrs
F neFropathy
R Retinopathy
RF Retinopathy + neFropathy
H ischemic Heart disease
T prior renal Txp

UTIs UTI: presents as dysuria, urinary frequency/urgency, suprapubic tenderness
Etiology: E. coli (MCC), S. saprophyticus (#2), Enterococcus (#3), other GNB
Complications: septic shock (urosepsis), ARDS
Management: Dx UA/UCx → Tx Bactrim or Cipro (not pregnant)
Tx nitrofurantoin (pregnant)
Tx IV cephalosporins + admit (upper UTI)
Asymptomatic bacteriuria: >105 CFU on UA
Management: Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN during labor
Chorioamnionitis Chorioamnionitis: presents as maternal fever, uterine tenderness, ↑WBC, ↑fetal HR
Etiology: MCC are GBS and E. coli
Management: Dx amniocentesis and cx amniotic fluid → Tx IV abx + delivery
Other infections Infx Presentation
Bacterial vaginosis thin homogenous vaginal discharge + fishy
(Gardnerella vaginalis) odor; complications include preterm
delivery, PPROM, and puerperal infx
CMV subclinical illness or mono-like syndrome
Cytomegalic Inclusion Disease (CID):
“blueberry muffin” rash, hepato-
splenomegaly, jaundice, thrombo-
cytopenia, periventricular calcifications
GBS UTIs, chorioamnionitis, endomyometritis,
neonatal sepsis (MCC)
GC/chlamydia Neonatal GC/chlamydia: conjunctivitis,
ophthalmia, otitis externa, pneumonia
HBV ---
HIV (usually asx)
HSV fluid-filled vesicles and irritation
Neonatal herpes: skin lesions, viral sepsis,
pneumonia, herpes encephalitis
Parvovirus B19 Erythema infectiosum: slapped cheek rash
in kids
hydrops fetalis in pregnant women
Rubella rash, arthritis/arthralgia, diffuse LN-opathy
Congenital Rubella Syndrome (CRS):
cataracts + PDA + deafness
Syphilis Early congenital syphilis: rash, snuffles,
hepatosplenomegaly, jaundice, LN-opathy
Late congenital syphilis: CN VIII deafness,
saber shins, mulberry molar, Hutchinson’s
teeth, saddle nose
Toxoplasmosis Congenital toxoplasmosis: fever, seizure,
chorioretinitis, microcephaly, jaundice,
head CT shows ring-enhancing lesions
VZV chickenpox or shingles
Congenital varicella syndrome: fulminant
disseminated infx → death
OB 10 – Pregnancy × Infx
Management
Dx “clue cells” on wet prep → Tx
PO metronidazole
postpartum GCV
no tx exists
routine screening at 35-37 wk → if
GBS+, Tx IV PCN during labor
screen mom for STDs → Tx
ceftriaxone + azithromycin
screen mom w/ HBsAg → get LFTs
and hepatitis panel to determine
acute vs. chronic infx → Tx infant
HBIG and HBV vaccine
screen mom w/ ELISA → confirm
with Western blot → Tx anti-HIV
meds, elective C-section, or IV ZDV
during labor
deliver by C/S or Tx IV ACV
Dx viral cx of herpetic lesions → Tx
IV ACV
---
if suspected, Dx parvo IgM → Tx
serial U/S + fetal transfusion w/
signs of hydrops
---
if mom is rubella ab negative, stay
away from sick ppl and vaccinate
postpartum
screen mom w/ RPR-VDRL →
confirm with FTA-ABS → determine
syphilis stage and Tx benzathine
PCN G
pregnant women should avoid
cats/cat litter; Dx amniocentesis →
Tx pyrimethamine + sulfadiazine
---
Tx VZIG for both mom and fetus
 OB 11 – Pregnancy × Complications

Hyperemesis Hyperemesis gravidarum: severe n/v + intolerance of PO diet

gravidarum HG management: Tx NPO ×3 days, IV fluids + antiemetics; if severe → doxylamine + vitamin B6; get β-HCG to r/o moles

Morning sickness: n/v in pregnancy is common and resolves by week 16, HG is more severe and has PO intolerance
Boerhaave syndrome: rupture of esophagus following severe emesis

Seizure d/o Seizure d/o: both seizures and AEDs can cause fetal malformations, pregnancy is a ↑seizure state
Etiology: either ↑AED metabolism, ↓pt compliance, ↓seizure threshold, or hormonal changes
AED teratogenicity: folate antagonism → NTDs, epoxide generation (fetal hydantoin syndrome)

Sz d/o management: monotherapy w/ lowest AED dose

level II U/S at 19-20 wk (look for congenital anomalies)
folate supplement
vit K supplement at 27 wk

Heart disease High-risk heart dz: primary PH, Eisenmenger syndrome, severe MS or AS, Marfan syndrome
Marfan syndrome: AD Δfibrillin → elastic tissue dysfxn → MVP, aortic aneurysms (cystic medial necrosis), or aortic dissection
Heart dz management: terminate pregnancy (first line)
baseline EKG + medical stabilization
d/c teratogenic drugs (ACEI/ARBs, diuretics, coumadin)
if severe MS/AS → surgical or valvuloplasty repair (1 yr prior)
if delivering → early epidural, careful fluid monitoring, assisted vaginal delivery, abx ppx for SBE

Peripartum cardiomyopathy: dilated cardiomyopathy 2/2 pregnancy, presents w/ sx of CHF (dyspnea/orthopnea/PND)

PPCM management: Dx echo shows dilated heart w/ EF <40% → deliver if ≥34 wk, medical mgmt if <34 wk

Renal disease CKD stages: stage 1 is GFR 90-100

stage 2 is GFR 60-89
stage 3 is GFR 30-59
stage 4 is GFR 15-29
stage 5 (ESRD) is GFR <15 or dialysis
Mild renal dz: ↑risk of preeclampsia and IUGR
Moderate/severe renal dz: ↑↑risk of preeclampsia and IUGR, and worsening of renal dz postpartum

Renal dz management: careful monitoring of renal fxn and fetal status

Renal txp management: requires ↑immunosuppressants (e.g. prednisone) dosage due to ↑risk of acute rejection

Coagulation d/o Coagulation d/o: pregnancy is a hypercoagulable state; increased risk for SVT, DVT, PE
Virchow’s triad: ↑risk of blood clots w/ stasis, hypercoagulability (pregnancy), endothelial damage

Coagulation d/o Presentation Management

SVT painful, palpable, venous cord w/ local erythema
and edema
DVT acute onset dull leg pain, unilateral swelling, and
Homans’ sign (calf pain w/ dorsiflexion)
PE acute onset chest pain, dyspnea, and
hyperventilation (↓PCO2); right-sided heart failure
→ MCC maternal death
Tx warm compresses + analgesics
Dx duplex U/S → Tx heparin or
Lovenox (enoxaparin); warfarin is
contraindicated in pregnancy
Dx D-dimer to r/in, V/Q scan to r/o
→ Tx heparin or Lovenox; t-PA if <3
hrs and no contraindications

Hyperthyroidism Hyperthyroidism: Graves’ disease (MCC), toxic adenoma (#2), toxic multinodular goiter (#3)
Graves’ disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women
Thyroid storm Tx: β-blockers
Hyperthyroidism management: screen for TSIs → if elevated, Tx PTU + monitor fetus for goiter and IUGR
Infantile hyperthyroidism: maternal TSI (IgG) crosses placenta and attacks fetal thyroid gland

Hypothyroidism Hypothyroidism: Hashimoto thyroiditis (MCC), surgical thyroidectomy (#2)

Hypothyroidism management: requires ↑Synthroid dosage
 OB 11 – Pregnancy × Complications

SLE SLE: I’M DAMN SHARP – Immunoglobulins Serositis (pleuritis, pericarditis)

Malar rash Hematologic d/o
Discoid rash Arthritis
ANA Renal d/o
Mucositis (oropharyngeal ulcers) Photosensitivity
Neurologic d/o
Complications: ↑risk of preeclampsia, IUGR, and spontaneous abortion
1/3 rule: 1/3 of SLE improves, 1/3 stays the same, 1/3 gets worse
SLE antibodies: ANA (sensitive), anti-dsDNA or anti-smith (specific), antihistone (drug-induced lupus)
SLE management: low-dose aspirin, heparin, or corticosteroids for ppx

Lupus flare vs. preeclampsia: can present similarly, DDx w/ complement levels (SLE has ↓C3-C5)
Lupus flare management: Tx high-dose corticosteroids, cyclophosphamide if unresponsive

Neonatal lupus Neonatal lupus syndrome: maternal ag-ab complexes cross placenta and cause lupus in neonate
Congenital heart block: anti-Ro (SSA) can cross placenta and attack fetal heart → 3° heart block

Substance abuse Substance Presentation Management

Alcohol Fetal Alcohol Syndrome: abnormal facies, stop use
IUGR, MR, cardiac teratogenic effects
Caffeine ↑risk of SAB w/ >150 mg/day reduce to <150 mg/day
Cocaine placental abruption, MR stop use
Nicotine IUGR, placental abruption, preterm stop use
delivery, fetal death
Opiates (heroin, no teratogenic effects w/ opiate abuse; but enroll in methadone program
methadone) withdrawal can cause miscarriage, preterm (opiate withdrawal is worse for
delivery, fetal death fetus than chronic abuse)
 OB 12 – Postpartum

Postpartum care Postpartum period: first 6 wks after delivery

S/p SVD: issues include pain control + perineal care
S/p C/S: issues include pain control + wound care

Breastfeeding benefits: ↓childhood infx dz (maternal IgA in milk), maternal weight loss, ↓risk of future T2DM
Breastfeeding c/i: only c/i are HIV and active HBV infx

Postpartum Postpartum intercourse: pelvic rest recommended until after 6 wks

contraception Postpartum tubal ligation: very effective, permanent
Condom use: can be used by anyone
Diaphragms/cervical cap use: requires refitting after 6 wks, due to dilated cervix
IUD use: best placed after 6 wks, due to dilated cervix
OCP use: use progestin-only pills if breastfeeding, wait til 4-6 wks to use combined pills if not

Postpartum PPH: >500 mL s/p SVD, >1000 mL s/p C/S

hemorrhage PPH causes: consider placenta accreta and 4 Ts – Tone (uterine atony, MCC)
Tissue (retained POCs)
Trauma (cervical or vaginal lacerations, uterine rupture, uterine inversion)
Thrombin (bleeding d/o)
Placenta accreta: presents as vaginal bleed + inability to separate placenta after delivery; Tx puerperal hysterectomy
Uterine atony: Tx IV oxytocin + bimanual uterine massage (1st line), methylergonovine (c/i with HTN), carboprost (c/i with asthma)
Risk factors: tocolytics, increased uterine size (multifetal gestation, polyhydramnios, macrosomia)
Retained POCs: Tx manual extraction; if unsuccessful → D+C and abx
Vaginal/cervical lac: Tx surgical repair
Uterine rupture: sudden onset severe abd pain ± vaginal bleeding, subjective “pop” sensation; Tx emergent ex lap and delivery
Uterine inversion: due to pulling too hard on cord; Tx manual replacement of uterus, if unsuccessful → laparotomy

Sheehan syndrome: pituitary infarction, usually w/ PP hypovolemia; presents as acute cessation of lactation

Postpartum fever Postpartum fever: consider endometriitis, acute mastitis, and the 5 Ws – Wind (atelectasis POD #1)
Water (UTI POD #3)
Walking (DVT POD #5)
Wound infx (POD #7+)
Wonder drug (drug-induced fever)

Disease Presentation Management

Endometritis polymicrobial infx → fever, uterine tenderness, Tx clindamycin + gentamicin
foul-smelling lochia
Acute mastitis breastfeeding women get Staph/Strep infection Tx dicloxacillin, do not stop breast-
through cracks in nipple w/ yellowish discharge feeding
Atelectasis partial lung collapse Dx bilateral inspiratory crackles;
prevent with pulmonary toilet and
incentive spirometry
UTI dysuria, urinary frequency + urgency Dx UA/UCx, Tx Cipro or Bactrim
Urosepsis UTI + septic shock Dx UA/UCx, Tx empiric abx + IVF
DVT acute onset dull leg pain, unilateral swelling, and Dx duplex U/S → Tx IV heparin or
Homans’ sign (calf pain w/ dorsiflexion) Lovenox
Wound cellulitis pain, swelling, erythema, heat at incision site Tx Bactrim or Keflex
Wound abscess pain, swelling, erythema, heat, fluctuance at Tx I+D and BID dressing change
incision site
Wound separation of incision site → salmon-colored fluid Tx stabilize wound site, surgical
dehiscence soaking dressings closure at a later date

Postpartum mood Postpartum mood d/o: three types – blues (30-70%), depression (10-20%), psychosis (0.1%)
changes Postpartum blues: self-resolves by day 10
Postpartum depression: Tx SSRIs (sertraline)
Postpartum psychosis: admit and consult psych
 GYN 1 – Lower GU

Vulva/vagina Labial fusion: due to excess androgen exposure (MC overall) or to 21-hydroxylase deficiency (MC endogenous)
congenital anomalies Excess androgens: Tx d/c androgens + reconstructive surgery
21-OH deficiency: Dx ↑17-OHP → Tx cortisol + reconstructive surgery
Imperforate hymen: presents as primary amenorrhea + cyclic abdominal pain; Dx mucocolpos/hematocolpos → Tx surgery
Transverse vaginal septum: presents as primary amenorrhea + cyclic abdominal pain; Dx short vagina that ends in blind pouch → Tx surgery
Imperforate hymen vs. septum: presence of hymenal ring indicates transverse vaginal septum

Vaginal atresia: failure of lower vagina to develop, presents as primary amenorrhea + cyclic abdominal pain; Dx U/S or MRI → Tx surgery (pull-through)
Vaginal agenesis: aka MRKH syndrome, absence of vagina w/ partial uterus and tubes; Tx surgery (create neovagina w/ McIndoe procedure)

Vulvar/vaginal Epithelial d/o management: Dx palpation + colpo + bx to r/o cancer; Tx (see below)
epithelial disorders
Disorder
Lichen sclerosis
Atopic eczema (squamous
cell hyperplasia)
Lichen simplex chronicus
Lichen planus
Vulvar psoriasis
Vaginal adenosis
Atrophic vaginitis
Presentation Tx
vaginal thinning and atrophy in postmenopausal topical steroids
women, 10% associated w/ cancer
chronic irritation → pruritis w/ hyperkeratotic topical steroids
changes
chronic irritation → pruritis w/ reactive changes topical steroids
shiny purple papules ± vaginal adesions steroid suppository +
surgery for adhesions
silvery scaling plaques, Auspitz sign (bleeding when topical steroids or UV
plaques are removed) light
red spots/patches in upper 1/3 vagina due to DES close f/u
exposure in utero; precursor for clear cell adeno
vaginal dryness ± bleeding in postmenopausal topical estrogen
women

Vulvar/vaginal cysts Epidermal inclusion cysts: MC vulvar cyst, due to blocked hair follicle; Tx I+D or excision if infected
Sebaceous cysts: due to blocked sebaceous gland, often multiple and asx; Tx I+D if infected
Apocrine cysts: due to blocked apocrine sweat glands; found only on groin and axillary region
Hidradenitis suppurativa: superinfx of apocrine cysts → abscess formation; Tx I+D or excision
Fox-Fordyce disease: multiple pruritic apocrine cysts
Skene cysts: appear at 12-o’clock
Bartholin cysts/abscess: appear at 4- and 8-o’clock
Bartholin management: usually self-resolves; if >40 y/o → bx to r/o cancer; if large/symptomatic → I+D w/ Word catheter or marsupialization
Gartner duct cysts: remnant of mesonephric (Wolffian) ducts; Tx excision

Cervical lesions DES-associated anomalies: vaginal adenosis, clear cell adenocarcinoma, other cervical or uterine anomalies
Nabothian cysts: benign; occurs when ectocervix (strat squamous) overgrows endocervix (simple columnar)
Cervical endometriosis: reddish-purple, presents w/ sx of endometriosis (dyspareunia/dyschezia/dysmenorrhea)
Cervical polyps: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources
Cervical fibroids: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources
Cervical stenosis: Tx cervical dilataion
 GYN 2 – Upper GU

Uterine anatomic Uterine anomalies: septate uterus (#1), bicornuate uterus, uterus didelphys; associated w/ urinary tract anomalies and inguinal hernias
anomalies Etiology: problems in fusion of paramesonephric (Mullerian) ducts
Sx: amenorrhea, dysmenorrhea, infertility, recurrent pregnancy loss (2nd trimester), PTL
Management: Dx imaging (pelvic U/S, CT, MRI, HSG, etc.) → leave alone if asx
Tx surgery for septate uterus and bicornuate uterus

Leiomyoma Fibroids: benign, estrogen-sensitive smooth muscle proliferation of myometrium

(uterine fibroids) Pseudocapsule: compressed smooth muscle cells surrounding fibroids
Degenerative changes: fibroid outgrows blood supply → infarction and degeneration → pelvic pain
Incidence: 20-30% of reproductive-age women; 50% of black women
Subtypes: submucosal (most likely to bleed), intramural (MC), subserosal, pedunculated
Sx: usually asx; can cause menorrhagia (MC), pelvic pain and pressure, infertility (rare)
Management: Dx pelvic U/S → leave alone if asx
temporary shrinkage w/ ↓E (progesterone, danazol, leuprolide)
Tx myomectomy if fertility desired
Tx hysterectomy (definitive)
Tx uterine artery embolization if bad surgical candidate

Leiomyosarcoma: sarcoma of uterine smooth muscle, no relation to fibroids

Endometrial polyps Endometrial polyps: benign overgrowth of endometrial glands/stroma

Sx: vaginal bleeding between periods (metrorrhagia)
Management: Dx pelvic U/S → Tx D+C + bx to r/o cancer

Endometrial Endometrial hyperplasia: presents as vaginal bleeding; precursor to endometrial cancer

hyperplasia “Penny, nickel, dime, quarter”: simple hyperplasia w/o atypia = 1% progression to cancer
complex hyperplasia w/o atypia = 3-5%
simple hyperplasia w/ atypia = 8-10%
complex hyperplasia w/ atypia = 25-30%

Risk factors: ↑E levels – unopposed E therapy (↑E w/o P)

tamoxifen use (weak E)
obesity/HTN/DM (↑aromatase in fat cells)
PCOS/chronic anovulation (↑E w/o P)
nulliparity (↑total cycles)
early menarche/late menopause (↑total cycles)
granulosa cell tumor (↑E synthesis)
Protective factors: COC/POP/combination HRT (↑P)
multiparity (↓total cycles)
diet and exercise (↓fat cells)

Management: Dx endometrial bx or D+C → Tx progestins for 3 mo + repeat endo bx; hysterectomy if complex/atypia

Ovarian cysts Ovarian mass management:

Palpable ovarian/adnexal mass?

low-risk high-risk
(premenarchal, postmenopausal,
size >8 cm, or persists >60 days)

Dx pelvic U/S ex lap for cancer

Follicular cysts: MC ovarian cyst, due to unruptured follicle, usually asx

Management: observe for 8-12 wks, then repeat pelvic U/S; if unresolved → Tx cystectomy or oophorectomy
Corpus luteum cysts: due to hemorrhage into persistent corpus luteum, presents as dull abd pain (unruptured) or acute abdomen (ruptured)
Management: resolves spontaneously, if recurrent → suppress w/ OCPs
Theca-lutein cysts: multiple/bilateral due to FSH/LH stimulation; associated w/ moles and choriocarcinoma
Chocolate cysts: ovarian endometriosis
PCOS: enlarged ovaries w/ multiple subcortical cysts
 GYN 3 – Endometriosis & Adenomyosis

Endometriosis Endometriosis: presence of endometrial tissue outside endometrial cavity

Etiology: three mechanisms – coelomic metaplasia, reverse menses, lymphatic/hematogenous spread
Incidence: 10-15% of reproductive-age women
Sx: 3 Ds – dysmenorrhea (hallmark = cyclic pelvic pain, worst 1-2 days before menses)
dyspareunia
dyschezia (due to endometrial implants in pouch of Douglas)
Physical exam: uterosacral nodularity on rectovaginal exam, fixed retroverted uterus
Complications: intraabdominal inflammation → scarring + adhesions → chronic pelvic pain, infertility
Management: Dx requires direct visualization → temporary relief w/ ↓E (progesterone, danazol, leuprolide) + NSAIDs
Tx surgical ablation if fertility desired
Tx hysterectomy + LOA + removal of implants (definitive)

Endometrioma: endometriosis in the ovary, aka chocolate cyst

Adenomyosis Adenomyosis: extension of endometrial tissue into myometrium

Etiology: ↑E → hyperplasia of stratum basalis of endometrium → myometrial invasion
Incidence: 10-15% of reproductive-age women
Sx: dysmenorrhea, menorrhagia, or both
Physical exam: diffusely enlarged, boggy uterus
Management: Dx pelvic U/S → temporary relief w/ ↓E (progesterone, danazol, leuprolide) + NSAIDs
Tx hysterectomy (definitive)

Adenomyoma: well-circumscribed endometrial tissue collection in myometrium, not encapsulated (vs. intramural fibroids)
 GYN 4 – Lower GU × Infx

UTI UTI: presents as dysuria, urinary frequency/urgency, suprapubic tenderness

Etiology: E. coli (MCC), S. saprophyticus (#2), Enterococcus (#3), other GNB
Complications: septic shock (urosepsis), ARDS
Management: Dx UA/UCx → Tx Bactrim or Cipro (not pregnant)
Tx nitrofurantoin (pregnant)
Tx IV cephalosporins + admit (upper UTI)

STDs and other

Infx Bug Presentation
genital infx
Candidiasis Candida albicans thick, white curd-like discharge,
itching, satellite lesions, no odor
Syphilis Treponema pallidum 1° syphilis: painless chancre +
inguinal LN-opathy
2° syphilis: palmar/plantar rash,
fever, LN-opathy, condyloma lata
3° syphilis: neurosyphilis (tabes
dorsalis), CV syphilis, gummas
HSV HSV-1/2 recurrent, painful oral/genital
vesicles that can rupture
Chancroid Haemophilus ducreyi painful chancre + inguinal LN-
opathy
LGV Chlamydia trachomatis, 1° LGV: transient, painless ulcer
L1-L3 serotypes 2° LGV: painful LN-opathy
3° LGV: anogenital syndrome
(proctocolitis, rectal stricture,
rectovaginal fistula, elephantiasis)
Condyloma acuminata HPV-6/11 genital warts (MC overall STD)
Molluscum contagiosum MCV domed papule w/ umbilicated
center
Scabies vs. pediculosis Sarcoptes scabiei vs. itching, irritation, vesicles,
Phthirus pubis burrows
Bacterial vaginosis Gardnerella vaginalis thin homogenous discharge, fishy
odor
Trichomoniasis Trichomonas vaginalis green-gray frothy discharge, odor,
strawberry cervix (petechiae)
Gonorrhea Neisseria gonorrhoeae cervicitis, PID, TOA, Bartholin
abscess
Chlamydia Chlamydia trachomatis cervicitis, PID, TOA, usually asx
(MC bacterial STD)
Management
Dx budding yeast + pseudo-
hyphae on KOH prep → Tx
fluconazole (Diflucan)
Dx screen w/ RPR-VDRL →
confirm w/ FTA-ABS → Tx
benzathine penicillin G
Tx IV penicillin G
Dx Tzanck smear or viral cx →
Tx ACV/VACV + palliative care
Dx “school of fish” on Gram
stain → Tx azithromycin or
ceftriaxone
Dx PE or complement fixation
→ Tx doxycycline
Dx PE → Tx removal
Dx PE → Tx removal
Dx PE → Tx permethrin cream
Dx “clue cells” on wet prep →
Tx metronidazole
Dx mobile trichomonads on
wet prep → Tx metronidazole
Tx ceftriazone (± azithromycin)
Tx azithromycin (± ceftriaxone)

Jarisch-Herxheimer rxn: acute febrile rxn s/p syphilis tx (MC w/ 2° syphilis), due to dead spirochetes → endotoxin release
 GYN 5 – Upper GU × Infx

Endometritis Endometritis: polymicrobial infx → fever, uterine tenderness, ↑WBC, foul-smelling lochia
Risk factors: postpartum period, instrumentation of endometrial cavity
Management: Dx clinical judgment → if sure, Tx clindamycin + gentamicin
if unsure, get endometrial bx showing plasma cells

PID PID: Chlamydia or GC infx → inflammation of uterus, fallopian tubes, ovaries

Risk factors: MC in sexually active women <25 y/o
Complications: infertility, chronic pelvic pain, adhesions, ectopic pregnancy, TOA/TOC, Fitz-Hugh-Curtis syndrome
Management: Dx pelvic/abd pain + cervical, adnexal, or uterine motion tenderness → Tx clindamycin + gentamicin (pregnant)
Tx ceftriaxone + doxycycline (not pregnant)

Chronic cervicitis: cervicitis has cervical motion tenderness but rest of exam is benign (vs. PID); Tx azithro + ceftriaxone

Tubo-ovarian TOA: abscess in tubes/ovary in the setting of PID

abscess Management: Dx adnexal mass w/ PID sx → confirm w/ pelvic U/S → Tx admit + IV abx → drainage if unresponsive

Toxic shock TSS: S. aureus → TSST-1 exotoxin → fever, rash, desquamation of palms/soles
syndrome Risk factors: tampons
Management: Dx clinical judgment → Tx admit + stabilize + IV nafcillin (prevents recurrence, not current toxin-mediated illness)

HIV HIV: retroviral virus infects CD4+ TH cells → ↓cellular immunity → AIDS-related opportunistic infx → death
Primary HIV infx: presents as mono-like syndrome ± maculopapular rash
Latent stage: CD4+ >500, asymptomatic
Symptomatic stage: CD4+ 200-500, mild HIV sx
AIDS: CD4 + <200 or presence of AIDS OI
Transmission: sexual, parenteral, vertical or via breast milk
Management: Dx ELISA screen → confirm w/ WB → Tx HAART (2 NRTIs + 1 NNRTI or PI) + OI tx/ppx

HIV+ during pregnancy: give anti-HIV meds, elective C/S, or IV ZDV during labor
HIV+ postpartum: avoid breastfeeding
 GYN 6 – Prolapse

Pelvic organ prolapse Pelvic floor: levator muscles + fascia + ligaments + nerves
Pelvic organ prolapse: weakened pelvic floor → bladder prolapse (cystocele)
urethra prolapse (urethrocele)
rectum prolapse (rectocele)
bowel prolapse (enterocele)
uterine prolapse (procidentia)
Vaginal vault prolapse: inversion of vagina into vaginal canal; MC s/p hysterectomy

1° prolapse: in upper 2/3 of vagina

2° prolapse: down to introitus
3° prolapse: protrudes outside vagina (partial)
4° prolapse: entire structure outside vagina (complete)

Etiology: chronic ↑ abdominal pressure (cough, constipation, heavy lifting, tumors)

pelvic floor weakness (intrinsic weakness, birth trauma, atrophy w/ aging)
Sx: pelvic pressure/pain, dyspareunia, bowel or bladder dysfxn, urinary incontinence
Management: Dx H+P → imaging as needed → nonsurgical tx (Kegel exercises, pessaries, E replacement)
cystocele → anterior colporrhaphy
rectocele → posterior colporrhaphy
procidentia → hysterectomy
vaginal vault prolapse → vaginal suspension
 GYN 7 – Incontinence

Continence Continence: voluntary control of urination

Sympathetic: hypogastric n → α1R → detrusor relaxation, int sphincter constriction

Parasympathetic: pelvic splanchnic n → MAChR → detrusor constriction, int sphincter relaxation
Somatic: pudendal n → ext sphincter constriction

Incontinence Incontinence: involuntary urine leakage

Management: first step is always to get UA/UCx to r/o UTI

Type Definition Etiology Management

Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
Bypass incontinence
Functional incontinence
urine leakage w/ exertion or
straining
urine leakage d/t involuntary
bladder contractions
(detrusor overactivity)
stress + urge incontinence
urine leakage d/t urinary
retention and overdistention
urine leakage d/t fistula
following pelvic surgery or
pelvic radiation
urine leakage d/t physical or
psychological issues;
common in nursing home or
gero pts
chronic ↑ abdominal
pressure, pelvic relaxation,
old age (↓estrogen → loss of
mucosal coaptation)
idiopathic (MCC), UTIs,
bladder stones or cancer,
urethral diverticula, foreign
bodies
---
medications, neurologic
disease
vesicovaginal, urethrovaginal,
or ureterovaginal fistulas
physical impairment,
dementia or delirium,
medications
surgery to stabilize
hypermobile urethra (best),
Kegel exercises, pessaries
anticholinergics (oxybutinin),
TCAs (imipramine)
---
intermittent self-cath,
cholinergics (↑bladder
contactility) + α1-blockers
(↑urethral resistance)
Dx methylene blue or indigo
carmine dye → Tx surgery to
repair fistula
Tx underlying cause
 GYN 8 – Menstrual Cycle

Puberty Adrenarche: regeneration of adrenal gland zona reticularis

Gonadarche: pulsatile GnRH starts → gonadal development
Thelarche: breast development, measured by Tanner stages
Pubarche: growth of pubic hair ± axillary hair
Menarche: onset of menstruation, 2½ yrs after thelarche

Puberty timing: “Always go (to) the pub, men.”

adrenarche gonadarche thelarche pubarche/ menarche
peak growth
at 7 y/o at 8 y/o --- at 10 y/o at 11 y/o at 12 y/o

Tanner stages Stage 1 kid

Stage 2 breast buds
Stage 3 breast elevation
Stage 4 areolar mound (look 4 big nipples)
Stage 5 adult

HPO axis GnRH DA TRH

FSH/LH PRL TSH stimulates

inhibits

E2/P4 T3/T4

Hypothyroidism × infertility: ↓T3/T4 → ↑TRH → ↑prolactin → ↓GnRH; Tx replacement T3/T4 (Synthroid)

Hyperprolactinemia × infertility: ↑prolactin → ↓GnRH; Tx dopamine analogs (cabergoline, bromocriptine) vs. surgery
Kallman syndrome: congenital ↓GnRH

Menstrual cycle Ovarian follicle:

Endometrium:

Hormones:

Theca/granulosa cells Theca cells: stimulated by LH to make desmolase (cholesterol → androgens)

Granulosa cells: stimulated by FSH to make aromatase (androgens → estrogens)

Menopause Menopause: cessation of menses and estrogen-deficient state for >12 months; avg age is 51 y/o
Sx: HAVOC – hot flashes, atrophy of vagina, osteoporosis, coronary artery dz
Management: Dx ↑FSH, Tx lowest dose HRT (estrogen + progesterone) for only 6-12 months
HRT benefits: prevention of osteoporosis, relief of menopausal sx
HRT risks: ↑risk of endometrial hyperplasia/cancer
HRT contraindications: h/o clotting dz, liver dz, pregnancy, estrogen-dependent neoplasm, undiagnosed vaginal bleeding
 GYN 9 – Amenorrhea

Amenorrhea 1° amenorrhea: absence of menarche by age 16, or 4 yrs after thelarche

2° amenorrhea: absence of menses for 6 months, had periods at one time

1° amenorrhea 1° amenorrhea: absence of menarche by age 16, or 4 yrs after thelarche

Etiology: three types – outflow tract obstruction, end-organ d/o, central regulatory d/o

Outflow tract obstruction: something getting in the way of blood from leaking out
Imperforate hymen: Dx PE shows bulging red/purple membrane (hematocolpos), Tx surgery (hymenotomy)
Transverse vaginal septum: Dx PE shows septum and presence of hymenal ring, Tx surgery
MRKH syndrome: mullerian agenesis or dysgenesis → lack of uterus and upper vagina
Vaginal atresia: distal vagina fibrosed but mullerian system intact, Tx surgery
Androgen insensitivity syndrome: ΔT-receptor → 46/XY female w/ blind pouch vagina, Tx surgery
Central regulatory d/o: something wrong with either GnRH or FSH/LH release
Kallmann syndrome: lack arcuate + olfactory nuclei (no GnRH + anosmia), Dx olfactory challenge, Tx exogenous GnRH (pulsatile)
Craniopharyngioma: Rathke’s pouch tumor → pituitary compression; Dx supracellar calficied cysts
End-organ d/o: ovaries won’t respond to FSH/LH
Savage syndrome: ΔFSH/LH-receptor → primary ovarian failure
Turner syndrome: 45/XO → rapid ovarian atresia → streak gonads w/o oocytes left; Tx GH + estrogen
17α-hydroxylase deficiency: can’t produce testosterone but still have MIF → 46/XY female w/ blind pouch vagina
Swyer syndrome: male w/o testes → 46/XY female w/ both internal and external female genitalia

1° amenorrhea management: 1° amenorrhea labs:

1° amenorrhea? Central d/o: ↓FSH/LH, ↓E2

Ovarian d/o: ↑FSH/LH, ↓E2
uterus no uterus Outflow d/o: normal FSH/LH, normal E2
(lacks MIF) (MIF present)

vagina no vagina Dx karyotype …… …...

(46/XY females)
outflow tract
breasts no breasts obstruction
(E present) (lacks E)

P challenge P challenge negative

2° amenorrhea 2° amenorrhea: absence of menses for 6 months, had periods at one time
Etiology: four types – pregnancy (MC), acquired abnormalities, hyperprolactinemia, HPO axis d/o

Pregnancy: MCC secondary amenorrhea, always r/o w/ ↑β-HCG

Acquired abnormalities: either anatomic or ovarian abnormalities causing 2° amenorrhea
Asherman syndrome: D+C, surgery, or endometritis → intrauterine adhesions ; Tx lysis of adhesions + estrogen
Cervical stenosis: surgical or obstetric trauma → scarring of cervical os; Tx surgical dilation or laminaria
PCOS: ↑LH, ↓FSH, ↑T/E → anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss

Hyperprolactinemia: anything that elevates prolactin inhibits GnRH (↑TSH, ↓DA, tumors)
Progesterone challenge test: give P for 1-2 wks and check for withdrawal bleeding afterwards (checks to see if endometrium is estrogenized)
2° amenorrhea management:

2° amenorrhea?

β-HCG (r/o preg)

↑prolactin prolactin normal

TSH normal ↑TSH P challenge test

get cone view and Tx Synthroid negative positive

prolactin levels
r/o Asherman syndrome
cone view normal cone view abnormal and cervical stenosis
and prolactin <100 or prolactin >50 or visual sx
FSH >40 FSH <40 hirsute nonhirsute
repeat prolactin q 6 mo, head CT or MRI
cone views q 1-2 yrs ovarian failure severe hypothalamic
dysfunction
microadenoma (<10 mm) macroadenoma (>10 mm) PCOS mild hypothalamic
or hyperplasia dysfunction

Tx bromocriptine Tx surgery
or cabergoline
 GYN 10 – Menstrual Abnormalities

Dysmenorrhea Dysmenorrhea: pain and cramping during menstruation that interferes w/ normal activity

1° dysmenorrhea: ↑PGF2α → uterine ctx → dysmenorrhea w/o organic cause; Tx NSAIDs and/or COCs
2° dysmenorrhea: dysmenorrhea 2/2 endometriosis, adenomyosis, fibroids, cervical stenosis, pelvic adhesions
Cervical stenosis: surgical or obstetric trauma → scarring of cervical os; Tx surgical dilation or laminaria
Pelvic adhesions: infx (PID), inflammation, or prior surgery → scarring of endometrium; Dx/Tx laparoscopy

PMS/PMDD PMS/PMDD: luteal phase sx (HA, bloating, weight gain, dysphoric mood) for 2+ consecutive cycles
Etiology: interaction between 5-HT and E/P
Management: Dx menstrual diary → Tx SSRI/SNRI, Xanax (alprazolam), Yaz OCP (E + drospirenone), diet and exercise

AUB AUB Pattern MCC

Normal menses 3-5 days Q 4 wks, 30-50 mL/cycle ---
Menorrhagia heavy flow cervical or endometrial lesions
Hypomenorrhea light flow hypogonadotropic hypogonadism in athletes/anorexics
Metrorrhagia irregular timing cervical or endometrial lesions
Menometrorrhagia heavy flow + irregular timing cervical or endometrial lesions
Oligomenorrhea slow cycles (>5 wks, <6 months) anovulation, PCOS, pregnancy, thyroid dz
Polymenorrhea fast cycles (<3 wks) anovulation
DUB heavy or irregular bleeding w/o anovulation
identifiable cause, dx of exclusion

AUB management: Dx labs (β-HCG, TSH, prolactin, FSH) + endometrial bx (>35 or obese) + pelvic U/S; Tx the underlying cause
Fibroids: Tx myomectomy vs. hysterectomy
Adenomyosis: Tx NSAID/OCP vs. hysterectomy
Cervical polyps: Tx polypectomy
Endometrial polyps: Tx hysteroscopy vs. polypectomy ± D+C
Endometrial hyperplasia: Tx progestins vs. hysterectomy
Endometrial cancer: Tx hysterectomy + BSO + radiation
Pregnancy: Tx expectant management vs. delivery
Miscarriage: Tx expectant management vs. D+C
Ectopic pregnancy: Tx MTX vs. surgery
Hypothyroidism: Tx Synthroid
Hyperprolactinemia: Tx bromocriptine or cabergoline
Anovulation: Tx cyclic OCP or progestins

DUB DUB: heavy or irregular bleeding w/o identifiable cause, dx of exclusion

Etiology: anovulatory cycles (endometrium continues to grow w/o progesterone, sloughs off at random intervals)
DUB management:

DUB?

r/o AUB w/ labs (β-HCG, TSH, prolactin, FSH) +

endometrial bx (>35 or obese) + pelvic U/S

acute hemorrhage chronic DUB

Tx 25mg IV estrogen Tx NSAIDs + COC

(POP if estrogen c/i)

surgery if not responsive to meds

(D+C, endometrial ablation, hysterectomy)

Postmenopausal Postmenopausal bleeding: any vaginal bleeding 12+ months after LMP
bleeding Etiology: vaginal/endometrial atrophy and exogenous estrogens are MCC, must r/o endometrial cancer
Postmenopausal bleeding management: Dx labs (CBC, TSH, prolactin, FSH) + endometrial bx + pelvic U/S; Tx the underlying cause
Lacerations: Tx repair
Vaginal atrophy: Tx estrogen cream
Cervical polyps: Tx polypectomy
Endometrial polyps: Tx hysteroscopy vs. polypectomy ± D+C
Endometrial hyperplasia: Tx progestins vs. hysterectomy
Endometrial cancer: TAHBSO ± pelvic/paraaortic LN-ectomy and radiation (if high-risk)
 GYN 11 – Hirsutism/Virilization

Hirsutism vs. Hirsutism: excess male-pattern hair growth

virilization Virilization: hirsutism + secondary male sex characteristics (clitoromegaly, deep voice, etc.)

Initial management:
Hirsutism or virilization?

Labs: free T, DHEAS, 17-OHP, ±cortisol

If adrenal, CT scan for adrenal tumor

If ovarian, pelvic U/S or CT for ovarian tumor

Tx underlying cause
Cosmetic tx of hirsutism

Hirsutism labs ↑free T: either adrenal or ovarian source

↑DHEAS: adrenal source
↑17-OHP: indicates congenital adrenal hyperplasia
↑cortisol: indicates Cushing syndrome

Hirsutism diseases Disease Mechanism/presentation Management

Cushing syndrome excess production of cortisol from pituitary adenomas, Dx ↑cortisol → dexamethasone
adrenal tumors, or paraneoplastic syndromes suppression test to confirm → Tx surgery
CAH congenital deficiency of 21α-hydroxylase (MC), 11β- Dx ↑DHEAS + ↑17-OHP → Tx cortisol
hydroxylase, or 3β-HSD replacement, consult endocrinology
PCOS Rotterdam criteria: 2/3 of the following – polycystic Dx LH:FSH ratio >3:1 + ↑estrone → Tx
ovaries on U/S, anovulation, signs of hyperandrogenism OCPs, clomiphene, metformin, weight-
loss; and screen for fasting blood sugars
Theca-lutein cysts ↑LH or βHCG (pregnancy, moles) → bilateral ovarian Dx ovarian bx → should resolve
cysts → possible androgen production postpartum or s/p mole removal
Stromal ovarian hyperplasia in postmenopausal women → Dx ovarian bx
hyperthecosis possible androgen production
Sertoli-Leydig cell androblastoma, secretes testosterone Dx pelvic U/S → Tx unilateral salpingo-
tumors oophrectomy
Exogenous due to drug use Tx d/c meds
hirsutism
Idiopathic hirsutism absence of adrenal or ovarian causes, not drug-induced Dx normal T and DHEAS → look for
increased peripheral 5-αR activity → Tx
finasteride (5αR blocker) if elevated
 GYN 12 – Contraception

Contraception Method Mechanism Failure rate Benefits Risks Contraindications

and sterilization COC blocks LH surge, thickens
cervical mucus, slows tubal
peristalsis, creates hostile
environment
~1% normalizes cycles $30/month smokers >35, clotting
↓cervical and hypercoagulability dz (PE, DVT, stroke,
ovarian cancer hepatic adenoma CAD), uncontrolled
↓benign breast dz HTN, migraines w/
↓dysmenorrhea aura, CHF, estrogen-
↓PID dependent cancers,
↓acne pregnancy, liver dz

Ortho Evra COC as a transdermal patch; “ “ “ women >198 lbs

3 weeks on, 1 week off
NuvaRing COC as a vaginal ring; “ “ “ ---
3 weeks in, 1 week out
POP thickens cervical mucus 0.3% indicated for must take at same ---
lactating women time everyday
indicated for irregular vaginal
women >40 y/o bleeding
reversible bone
demineralization
prolonged
amenorrhea
weight gain
depression
Depo-Provera thickens cervical mucus, 0.3% effective irregular vaginal ---
injection Q 12-14 wks bleeding
reversible bone
demineralization
prolonged
amenorrhea
weight gain
depression
Implanon thickens cervical mucus, --- good for 3 yrs --- ---
implantable rod in arm no weight gain,
depression, or bone
demineralization
Condoms prevent sperm and ova from ~5% low cost --- ---
mating STI prophylaxis
Diaphragms prevent sperm and ova from ~5% low cost toxic shock ---
mating syndrome
↑UTIs
must leave inside
6-8 hrs after sex
needs to be fitted
by MD
Cervical caps prevent sperm and ova from ~10% nullip low cost ↑↑failure rate ---
mating ~25% multip needs to be fitted
by MD
must have nl Pap
Nonoxynol-9, spermicide 20-30% used in combo w/ ↑STI susceptibility ---
octoxynol-9 other methods
Mirena IUD inhibits sperm motility, <1% indicated for ↑ratio of ectopics pregnancy, uterine
(levonorgestrel) creates hostile environment monogamous pts ↑cramping anomalies, infx,
good for 5 yrs needs to be placed unresolved vaginal
low maintenance by MD bleeding, breast
↓menstrual flow risk of PID, uterine cancer
perforation, SAB
ParaGard IUD inhibits sperm motility, <1% indicated for ↑menstrual flow pregnancy, uterine
(copper-T) creates hostile environment monogamous pts ↑ratio of ectopics anomalies, infx,
good for 10 yrs ↑cramping unresolved vaginal
low mainenance needs to be placed bleeding, copper
by MD allergy or Wilson dz
risk of PID, uterine
perforation, SAB
Natural family periodic abstinence measured ~20% free ↑↑failure rate ---
planning by basal body temperature or self-managed variability
cervical mucus methods between cycles
Lactational prolactin-induced GnRH --- free ↑↑failure rate
amenorrhea suppression only use for max
of 6 months
Emergency plan B (levonorgestrel) given --- 90% effective nausea/vomiting >5 days
contraception within 72 hrs, or copper IUD not abortifacient headache
inserted within 5 days breast tenderness
Tubal ligation blocks ova passage ~1% 99% effective permanent women <25 y/o,
surgical risks uninformed about
risk of regret (10- other methods,
15%) making decision
no STD protection under pressure
Vasectomy blocks sperm passage, must ~1% 99% effective permanent men <25 y/o,
use alternative methods for more reversible surgical risks uninformed about
90 days while sperm die off than tubal ligation no STD protection other methods,
safer and more must wait 3 making decision
effective than tubals months before sex under pressure
 GYN 13 – Abortion

1st trimester abortion 1st trimester abortion: suction D+C (MC), manual vacuum extraction, medical abortion (≤7 wk)
MCC death during abortion: general anesthesia

Suction D+C: 90% of all abortions, safest method, most effective 7-13 wk

Medical abortion: indicated ≤7 wk only, requires f/u in 2 wks for β-HCG levels
Mifepristone (RU-486): blocks progesterone stimulation → embryo detachment
Methotrexate: blocks DHF reductase → ↓cell division → blocks placental proliferation
Misoprostol: ripens cervix; use w/ MTX or RU-486 to ↑efficacy rates
Side-effects: abd pain/cramps, uterine bleeding, nausea/vomiting

2nd trimester abortion 2nd trimester abortion: D+E or induction of labor (IOL is better, since intact fetus can be used for autopsy)

D+E: like D+C, but requires wider cervical dilation + use of special forceps to extract fetal parts
Complications: trauma, infx, retained tissue, uterine perforation

Induction: cervical ripening w/ misoprostol (Cytotec) → amniotomy → induction w/ high-dose oxytocin (Pitocin)
Complications: trauma, infx, retained tissue

3rd trimester abortion 3nd trimester abortion: illegal ≥24 wk, unless necessary for preservation of maternal life
 GYN 14 – Infertility

Infertility Infertility: failure to conceive after 12 mo of unprotected sex (6 mo if woman >35 y/o)
Fecundability: ability to get pregnant in one cycle

Categories: male factor (35%)

female factor (45-55%)
combined (10-20%)
unexplained (10%)

Infertility management:

Female factor
Category Disease Tx
infertility
Ovarian factors PCOS OCPs, clomiphene, metformin, weight-loss, and screen for
fasting blood sugars
Advanced maternal age ART
PMOF ART
Hyperprolactinemia cabergoline or bromocriptine
Hypothyroidism Synthroid
Tubal factors Endometriosis surgical ablation (if fertility desired)
hysterectomy + LOA + removal of implants (definitive)
Pelvic adhesions surgery (lysis of adhesions)
PID IV clindamycin + gentamicin (pregnant)
IV ceftriaxone + doxycycline (not pregnant)
Tubal ligation IVF/ICSI
Uterine factors Asherman syndrome hysteroscopic lysis of adhesions + estrogen
Polyps hysteroscopic polypectomy
Submucosal fibroids hysteroscopic myomectomy
Congenital malformations surgery, may not be treatable
Endometritis IV clindamycin + gentamicin
Cervical factors Cervical stenosis cervical dilation or IUI
Chronic cervicitis IVF/ICSI
DES exposure none
Congenital malformations surgery, may not be treatable

Male factor Male factor infertility: 3 categories – sexual problems, endocrine d/o, sperm abnormalities
infertility Management: stay away from risk factors (drugs, radiation, heat) + Tx underlying cause

Unexplained Unexplained infertility: no underlying cause found during initial assessment

infertility Management: refer to REI clinic → Tx IVF/ICSI or use donor sperm

Assisted reproductive ART: any therapy where sperm/egg are handled for increasing rate of conception
technologies
Clomiphene: blocks E-receptors in hypothalamus → ↑FSH/LH → promotes ovulation
Indications: chronic anovulation, hypothalamic insufficiency
Letrozole: aromatase inhibitor → ↓E → ↑FSH/LH → promotes ovulation
HMGs: FSH/LH analogs → promotes ovulation
Indications: second line to Clomid
Complications: antiestrogen effects, ovarian hyperstimulation syndrome (OHSS), multiple gestation
OHSS: overstimulation of ovaries → ↑risk of torsion or rupture

IVF: insert fertilized gamete into uterus

ICSI: inject sperm into oocyte before IVF
 ONC 1 – Vulvar/Vaginal Cancer

Squamous neoplasia Squamous neoplasia: defined by depth of epithelial involvement (xIN if not invasive, SCC if invasive)
Risk factors: multiple sexual partners (#1), sex at young age, high-risk HPV strains, smoking, immunosuppression, other xINs

VIN VIN: premalignant dz of vulvar epithelium, three grades (VIN I-III)

Sx: usually asx but can have vulvar itching and irritation; classic presentation is “fungal infx” that doesn’t resolve w/ antifungal cream
Management: Dx vulvar bx → Tx wide local excision if unifocal, vulvectomy or laser ablation if multifocal

Vulvar SCC Vulvar SCC: malignant dz of vulvar epithelium, 90% are unifocal
Sx: vulvar itching, pain, bleeding, ulceration
Management: Dx vulvar bx → Tx (see below)
Px: depends on LN+ status – good if 0-2, <15% if 3+

Stage TNM criteria Tx

Ia <2 cm, <1 mm depth wide local excision + ipsi LN-ectomy
Ib <2 cm, >1 mm depth "
II >2 cm radical vulvectomy + bilat LN-ectomy
III LN+ or local spread (lower urethra, distal vagina, anus) radical vulvectomy + bilat LN-ectomy +
pelvic exenteration
IVa local met+ (bladder or rectum) "
IVb distal met+ "

Verrucous carcinoma: well-differentiated subtype of vulvar SCC, good px

VAIN VAIN: premalignant dz of vaginal epithelium, 50-90% associated w/ VIN or CIN

Sx: usually asx but can have vaginal discharge or postcoital spotting; classic presentation is persistent abnl Pap but nl cervical bx
Management: Dx colpo-directed bx → Tx local excision, laser ablation, or topical 5-FU

Vaginal SCC Vaginal SCC: malignant dz of vaginal epithelium, usually in upper 1/3 and posterior wall
Sx: usually asx but can have vaginal discharge, itching, or bleeding
Management: Dx colpo-directed bx + check for spread (CXR/cystoscopy/proctosigmoidoscopy/IVP) → Tx (see below)

Stage TNM criteria Tx

0 carcinoma in situ surgical resection
I within vaginal wall "
II spread into subvaginal tissue radiation tx
III spread into pelvic wall "
IVa local met+ (bladder or rectum) "
IVb distal met+ "

Vaginal clear cell Vaginal adenosis: red/superficial ulcer, precursor to clear cell adenocarcinoma
adenocarcinoma Clear cell adenocarcinoma: vaginal cancer in women <20 y/o w/ in utero DES exposure

Extramammary Paget disease: red, velvety lesions + scarred white plaques; 20% associated w/ underlying adenocarcinoma
Paget disease Paget vs. melanoma: Paget “halo” cells are PAS+, mucicarmine+, Alcian blue+; melanoma cells are PAS-
Sx: classic presentation is vulvar itching and pain in women >60 y/o
Management: Dx vulvar bx → Tx wide local excision + r/o underlying adeno
Px: high local recurrence rate, fatal if LN+

Sarcoma botryoides Sarcoma botryoides: embryonal rhabdomyosarcoma, resembles grape-like mass protruding from vagina in girls <5 y/o
Management: Dx bx shows desmin+ spindle-shaped rhabdomyoblasts, Tx excision
 ONC 2 – Cervical Cancer

HPV HPV-1-4: verruca vulgaris (common warts)

HPV-6/11: low-risk strains cause condyloma acuminata (genital warts)
HPV-16-18/31/33/45: high-risk strains cause cervical dysplasia/cancer
Gardasil: quadrivalent 3-series HPV vaccine for strains 6/11/16/18; indicated for women 11-26 y/o

Pap smears Pap smear: scrape transformation zone w/ spatula, then sample endocervical canal w/ brush
Screening protocol: start age 21, Q2 yrs 21-29 y/o, Q3 yrs >30 y/o after 3 negative Paps
Exceptions: annual if HIV, immunosuppressed, DES, previous CIN II+; don’t need s/p total hysterectomy

Bethesda system Pap result Definition Management

ASC-US atypical squamous cells, undetermined significance HPV DNA testing → repeat Pap in 1 yr if
HPV–, colpo + cervical bx if HPV+
ASC-H atypical squamous cells, can’t r/o high grade colpo + cervical bx
LSIL low-grade squamous intraepithelial lesion = CIN I "
HSIL high-grade squamous intraepithelial lesion = CIN II-III "
SCC squamous cell carcinoma "
AGC atypical glandular cells "

Diagnostic cone bx Cone indications: Microinvasion <3mm

ECC positive
Discrepancy of 2 steps (high-grade Pap, not confirmed on bx)
Inadequate colpo (can’t see all borders of TZ or lesion)
Adenocarcinoma in situ
Cone complications: bleeding or infx (common), cervical stenosis, incompetent cervix, PROM/PTL

CIN CIN: premalignant dz of cervical epithelium due to high-risk HPV strains, three grades (CIN I-III)
MC timing: during menarche and after pregnancy
MC location: anterior lip of transformation zone, multifocal
Stage Definition Management
CIN I dysplasia in basal 1/3 of epithelium, mild repeat Pap Q 6 mo ×2 or HPV testing in
12 mo (65% regression rate) → LEEP if
persistent for 2 yrs
CIN II dysplasia in basal 2/3 of epithelium, moderate LEEP
CIN III dysplasia >2/3 to full epithelium, severe LEEP
2-step discrepancy (e.g. HGSIL on pap but normal bx) diagnostic cone bx

Cervical SCC Cervical SCC: malignant dz of cervical epithelium defined by basement membrane invasion
Epidemiology: US incidence ↓↓ after Pap smear; #1 cancer killer of women in 3rd world countries
Sx: usually asx, can present as postcoital bleeding

Stage TNM criteria Tx Px (5 yr)

0 carcinoma in situ simple hysterectomy or cold knife cone ---
Ia cervix only,<7 mm " >80%
Ib cervix only, >7 mm or visible lesion radical hysterectomy or radiation tx "
IIa involves upper 2/3 vagina, no parametrium " 60%
IIb involves upper 2/3 vagina, parametrium chemoradiation (external and internal "
radiation + cisplatin chemotherapy)
IIIa involves lower 1/3 vagina, no pelvic wall " 40%
IIIb involves lower 1/3 vagina, pelvic wall and/or " "
hydronephrosis or nonfunctional kidney
IVa local met+ (bladder or rectum) " 20%
IVb distal met+ " "
Simple hysterectomy: removes uterus only
Radical hysterectomy: removes uterus + parametria, upper vaginal cuff, uterosacral/cardinal ligaments, local vascular and lymphatic supply
 ONC 3 – Endometrial Cancer

Endometrial Endometrial hyperplasia: precursor to type I endometrial cancer

hyperplasia “Penny, nickel, dime, quarter”: simple hyperplasia w/o atypia = 1% progression to cancer
complex hyperplasia w/o atypia = 3-5%
simple hyperplasia w/ atypia = 8-10%
complex hyperplasia w/ atypia = 25-30%

Risk factors: ↑E levels – unopposed E therapy (↑E w/o P)

tamoxifen use (weak E)
obesity/HTN/DM (↑aromatase in fat cells)
PCOS/chronic anovulation (↑E w/o P)
nulliparity (↑total cycles)
early menarche/late menopause (↑total cycles)
granulosa cell tumor (↑E synthesis)
Protective factors: COC/POP/combination HRT (↑P)
multiparity (↓total cycles)
diet and exercise (↓fat cells)

HNPCC/Lynch II syndrome: high-risk for colon, endometrial, ovarian cancer; get annual endo bx ≥35 y/o

Endometrial cancer Endometrial cancer types:

Type Etiology % Race Age Px

Type I E-dependent neoplasm preceded by hyperplasia 80% white perimenopausal good
Type II E-independent neoplasm, not preceded by 20% black, postmenopausal bad
hyperplasia (papillary serous or clear-cell) asian

Sx: presents as postmenopausal bleeding or other abnormal vaginal bleeding

Management: (premenopausal) Dx endometrial bx → Tx (see below)
(postmenopausal) Dx U/S → if endometrial stripe >5 mm then endometrial bx → Tx (see below)

Stage TNM criteria Tx

Ia uterus, endometrium only TAHBSO ± pelvic/paraaortic LN-ectomy
and radiation (if high-risk)
Ib uterus, <50% myometrial invasion "
Ic uterus, >50% myometrial invasion "
IIa endocervix, glands only "
IIb endocervix, stroma "
IIIa in serosa "
IIIb in vagina "
IIIc pelvic/paraaortic LN+ "
IVa spread beyond true pelvis, or in bladder or rectum "
IVb distal met+ "
Pelvic recurrence High-dose progestins ± chemotherapy
Vaginal recurrence Vaginal radiation

Px: grade is #1 factor; three grades – G1 shows <5% solid growth pattern, G2 6-50%, G3 >50%
High-risk endo cancers: >50% myometrial invasion
type 2 (papillary serous or clear-cell)
grade 3 (>50% solid growth)
stage 3+
size >2 cm
LN+
 ONC 4 – Ovarian/FT Cancer

Ovarian cancer Ovarian cancer: four types – epithelial (90%), germ cell, sex-cord stromal, metastatic
Sx: asx in early stages; present w/ vague abd pain, bloating, distention, early satiety in later stages
Etiology: chronic uninterrupted ovulation → ↑cellular repair → ↑opportunities for gene deletion/mutation
CA-125: ovarian tumor marker useful for testing tx response and recurrence, but not screening or dx

Risk factors: family hx (#1), familial ovarian cancer syndrome, uninterruped ovulation, old age
Familial ovarian cancer syndrome: BRCA1/2, HNPCC (Lynch II)
Uninterrupted ovulation: nulliparity, infertility, early menarche, late menopause
Protective factors: OCPs, multiparity, breastfeeding, chronic anovulation (all ↓ ovulation)

Management: Dx pelvic U/S → stage → Tx (see below)

Stage TNM criteria

Ia one ovary
Ib two ovaries
Ic Ia/Ib + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+
IIa invades FT or uterus
IIb invades other pelvic tissue
IIc IIa/IIb + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+
IIIa abd peritoneal met+, <2 cm
IIIb abd peritoneal met+, >2 cm
IIIc pelvic/paraaortic/inguinal LN+
IV distal met+

Class Tx
Epithelial surgery (TAHBSO, omentectomy, pelvic/paraaortic LN-ectomy) + carboplatin/paclitaxel
Germ cell USO + BEP (bleomycin/etoposide/cisplatin)
Sex-cord stromal USO only

Ovarian cancer Carcinomatous ileus: intraperitoneal tumor spread → ascites and bowel encasement → intermittent bowel obstruction
complications Sister-Mary-Joseph nodule: ovarian cancer metastasis to umbilicus
Pseudomyxoma peritonei: “jelly belly” associated w/ appendiceal carcinoma and mucinous cystadenocarcinoma
Meigs syndrome: fibroma + ascites + right-sided hydrothorax
Latzko triad: pain, profuse watery d/c, pelvic mass; associated w/ FT adenocarcinoma
Precocious puberty: granulosa cell tumor

Epithelial tumors Epithelial tumors: slow growing and usually asx, thus found at stage III+
MC type: serous cystadenocarcinoma
Serous cystadenoma: bilateral, lined w/ FT-like epithelium
Serous (papillary) cystadenocarcinoma: bilateral, Dx Psamomma bodies
Mucinous cystadenoma: multilocular cyst lined w/ mucus-secreting epithelium
Mucinous cystadenocarcinoma: pseudomyxoma peritonei
Endometrioid carcinoma: resembles endometrial cancer, good px
Clear cell carcinoma: masses of glycogen-filled clear cells, poor px
Brenner tumor: benign, resembles bladder (transitional epithelium) Psammoma body

Germ cell tumors Germ cell tumors: rapidly growing in women <20 y/o, thus found at early stages
MC type: mature teratoma aka dermoid cyst (MC overall), dysgerminomas (MC malignant)
Teratoma: tumor of totipotent fetal tissue
Mature teratoma: benign, contains hair/teeth/calcifications
Immature teratoma: aggressively malignant, contains neural tissue
Struma ovarii: monodermal, contains thyroid tissue
Dysgerminoma: ↑LDH, associated w/ Turner syndrome (45/XO), good px due to radiosensitivity
Endodermal sinus (yolk sac) tumor: ↑AFP, Dx Schiller-Duval bodies resembling primitive glomeruli
Choriocarcinoma: ↑β-hCG, also a malignant type of GTD Schiller-Duval body

Sex-cord stromal Sex-cord stromal tumors: slow growing, steroid hormone secreting tumors
tumors MC type: granulosa cell tumor
Granulosa cell tumor: secretes estrogen → ↑risk of endometrial hyperplasia, Dx Call-Exner bodies
Fibroma: pulling sensation in groin, Dx bundles of spindle-shaped fibroblasts
Sertoli-Leydig cell tumor: androblastoma, secretes testosterone → virilization Call-Exner body

Metastatic tumors Krukenberg tumor: metastatic stomach cancer, Dx mucin-containing signet ring cells

FT cancer FT adenocarcinoma: very rare (0.5%), mets to FT are more common than primary FT cancer
Sx: 15% present as Latzko’s triad – Pain, Profuse watery discharge (hydrops tubae profluens), Pelvic mass
Management: Dx pelvic U/S → Tx same as epithelial ovarian cancers
 ONC 5 – Gestational Trophoblastic Disease

GTD GTD: group of diseases 2/2 abnl proliferation of trophoblastic (placental) tissue
Benign GTD: complete and partial hydatidiform moles (80%)
Malignant GTD: persistent/invasive moles (15%), choriocarcinoma (<5%), PSTTs (rare)

Benign GTD Hydatidiform moles: two types – complete (90%) and partial (10%)
Epidemiology: highest incidence in Asian women
Risk factors: extremes in age, prior GTD, nulliparity, low β-carotene/folate/fat diet

Complete moles (90%) Partial moles (10%)

Etiology empty egg + sperm
Karyotype 46/xx (both paternal)
β-hCG ↑↑↑ (>100,000),
14 wks to return to normal
Pathology enlarged uterus + “grape cluster” villi ±
bilateral theca-lutein cysts
Presentation presents as abnormal vaginal bleeding
Other sx severe hyperemesis gravidarum, 1st
trimester preeclampsia, hyperthyroidism,
anemia (all related to ↑β-hCG)
Malignant potential 15-20% overall, 2% choriocarcinoma
Management Dx ↑↑↑β-hCG and pelvic U/S showing
“snowstorm” pattern → Tx D+C ±
oxytocin → f/u serial β-hCG and reliable
contraception for 6 months
egg + 2 sperm
69/XXY
normal or slightly ↑,
8 wks to return to normal
normal-sized uterus, fetal parts found
on autopsy of abortion prodcuts
presents as a missed abortion
rare
<5% overall, no choriocarcinoma
Dx pelvic U/S shows “swiss cheese”
uterus → Tx D+C ± oxytocin → f/u serial
β-hCG and reliable contraception for 6
months

Malignant GTD Nonmetastatic: confined to uterus

Metastatic: spread beyond uterus
Low-risk: duration <4 mo, β-hCG <40k, liver/brain met–, no prior chemo
High-risk: duration >4 mo, β-hCG >40k, liver/brain met+, failed chemo, GTD following pregnancy

Persistent/invasive moles Choriocarcinoma PSTTs

Etiology remnant of benign
hydatidiform moles
Presentation presents as plateauing or ↑β-
hCG s/p molar evacuation
Management Dx ↑β-hCG and pelvic U/S →
Tx single-agent chemo (non-
met or low-risk), multi-agent
chemo (high-risk) → f/u serial
β-hCG and reliable
contraception for 6 months
malignant, necrotizing tumor
presents w/ sx of metastasis
(lungs, vagina, liver, brain,
kidneys)
Dx ↑β-hCG and pelvic U/S →
check for mets → Tx single-
agent chemo (non-met or
low-risk), multi-agent chemo
(high-risk) → f/u serial β-hCG
and reliable contraception for
6 months
rare tumors that arise
from placental invasion
site, have no villi
presents as abnormal
vaginal bleeding
Dx ↓β-hCG (persistently
<100) and pelvic U/S →
Tx hysterectomy + multi-
agent chemo
 ONC 6 – Breast Disease/Cancer

Breast anatomy Blood supply: internal mammary (off subclavian) + lateral thoracic (off axillary) arteries
and physiology Lymph drainage: axillary LN (97%) + internal mammary LN (3%)

Estrogen: promotes ductal development + fat deposition

Progesterone: promotes lobular-alveolar (stromal) development
Prolactin: promotes milk production
Oxytocin: promotes milk letdown, uterine ctx

Breast pain Breast pain management:

Breast pain?

H+P

likely benign h/o trauma high-risk

reassurance, NSAIDs, U/S mammogram

sports bra, compresses

Nipple discharge Bloody discharge: intraductal papilloma

Milky discharge: pregnancy, hyperprolactinemia, hypothyroidism, drug-induced (e.g. antipsychotics)
Yellowish discharge: fibrocystic change, galactocele, acute mastitis
Green/sticky discharge: mammary duct ectasia
Purulent discharge: breast abscess

Breast cancer Incidence: 1 in 8 women

Screening: annual mammogram (>50, >40 if strong family hx); monthly self-exam + annual physician exam (>20)
Risk factors: family hx (#1), previous breast cancer, old age, BRCA1 and BRCA2 genes (only 5-10% are genetic)
MC location: upper outer quadrant (has most breast tissue)
Mets sx: bone → pathologic fx, back pain, coma (hypercalcemia)
liver → jaundice, elevated LFTs
lung → dyspnea, cough, hemoptysis
brain → severe HA, seizures
pleura → pleuritic chest pain

Breast masses MC breast masses: <25 y/o fibroadenoma

25-50 y/o fibrocystic change
>50 y/o infiltrating ductal carcinoma
Benign masses: soft/rubbery, smooth surface, mobile, painful, <50 y/o
Malignant masses: firm/hard, irregular surface, fixed, painless, >50 y/o

Breast mass management:

Breast mass?

<30 y/o ≥30 y/o

Nonpalpable abnormal
U/S mammogram finding?

cystic solid
wire-guided excision
needle drainage mammogram +
FNA core needle bx
resolves bloody/recurrent

f/u in 4 wks core needle bx excisional bx if

nondiagnostic

BI-RADS Cat Definition Management Risk of malignancy

0 incomplete additional imaging needed ---
1 negative routine f/u 0%
2 benign routine f/u 0%
3 probably benign short-term f/u (6 mo) ≤2%
4 suspicious of malignancy core needle bx 2-95%
5 probably malignant core needle bx ≥95%
6 malignant tx 100%
 ONC 6 – Breast Disease/Cancer

Benign tumors Fibroadenoma: firm, mobile, rubbery mass <5 cm in young women; Tx elective removal
Giant juvenile fibroadenoma: ≥5 cm, seen in teens with rapid breast growth; Tx excision to avoid breast deformity
Intraductal papilloma: presents as bloody nipple discharge; Tx galactogram/ductogram-guided excision (due to small risk of carcinoma)
Phyllodes tumor: huge, benign tumors that distort the breast; Dx core or incisional biopsy since FNA is insufficient, Tx excision w/ negative margins

Malignant tumors DCIS: mammogram shows clustered microcalcifications, Tx simple mastectomy

LCIS: multiple/bilateral; Tx close observation ± tamoxifen
Infiltrating ductal carcinoma: MC breast cancer, Tx (see below)
Infiltrating lobular carcinoma: multiple/bilateral, Tx (see below)
Paget disease: “crusty” nipple eczema, indicates underlying infiltrating ductal carcinoma, Tx (see below)
Inflammatory carcinoma: resembles cellulitis w/ peau d’orange, “tumor cells in dermal lymphatics”, Tx pre-op chemo + (see below)

Breast cancer Tx Stage TNM criteria Tx

I T1 (<2 cm) lumpectomy + ALND/SLN + post-op radiation;
or modified radical mastectomy
II T2+ (>2 cm) or N1 (mobile ipsi ALN+) "
III N2+ (fixed ipsi ALN+) chemotherapy
IV M1 (distal met+) "

ALND/SLN+: indicates LN involvement; Tx chemotherapy

ER/PR–: indicates poor px; Tx chemotherapy
ER/PR+: indicates good px; Tx tamoxifen or aromatase inhibitors (letrozole, anastrazole, exemstane)
HER2/neu+: indicates poor px; Tx trastuzumab (Herceptin), most associated w/ comedocarcinomas

Modified radical mastectomy: removes breast + pectoralis major/minor + axillary LN

Complications: winged scapula (cut long thoracic nerve), arm lymphedema (lymphatic blockage)
Breast reconstruction: add implants or autogenous tissue, good for psychosocial benefits

Breast diseases Fibrocystic change: painful, multiple/bilateral lumps that vary with menstrual cycle; Tx reduction in tea/caffeine/chocolate
Dominant lump: Tx aspiration → excision if mass recurs or persists
Atypical ductal hyperplasia: Tx excision; not precancerous, but high risk of becoming a cancer
Acute mastitis: breastfeeding women get Staph/Strep infection through cracks in nipple w/ yellowish discharge, Tx dicloxacillin + continue breastfeeding
Periductal mastitis: subareolar infection in smokers, both males and females affected
Breast abscess: pus pocket in lactating women; Tx I&D + biopsy to r/o possible cancer
Mammary duct ectasia: bilateral breast pain and green/sticky discharge in perimenopausal women; Tx excision + biopsy to r/o possible cancer
Dystrophic calcification: presents as breast lump following trauma, but work up as a cancer until proven otherwise (trick question!)
INTERNAL MEDICINE
 MEDICINE × CV

ISCHEMIC HEART DZ Coronary artery dz: atherosclerotic occlusion of coronary vx → asx

stable angina increasing
unstable angina severity
acute MI
sudden cardiac death
Acute coronary syndrome: ruptured atherosclerotic plaque → unstable angina or acute MI

Dz Presentation Management Other

Stable angina substernal “gripping” chest EKG Positive stress test: chest pain,
pain or pressure on exertion, ST depression, hypotension, or
relieved w/ rest or NTG normal abnl ST or T-wave significant arrhythmias
Pharmacological stress test: IV
exercise stress test Tx for unstable angina adenosine, dipyridamole, or
(pharmacological if dobutamine can stress the heart
unable to exercise) in place of exercise

positive negative Coronary steal: dipyridamole

causes blood flow redistribution
catheterization close f/u to nondiseased vx in stress test

• mild (1 vx) → Tx β-blocker + aspirin + nitrates

Acute coronary syndrome
Prinzmetal (variant) angina
CHF
unstable angina
↓ +biomarkers
NSTEMI
↓ +EKG change
STEMI
Unstable angina: ruptured
atherosclerotic plaque →
increasing pain or pain at rest
NSTEMI/STEMI: ruptured
atherosclerotic plaque →
typical MI-pattern chest pain;
can be asx in elderly, diabetics,
women, s/p heart txp
transient coronary vasospasm
→ episodic angina at rest
Left-sided CHF: dyspnea,
orthopnea, PND
Right-sided CHF: pitting edema,
hepatic congestion, JVD, ascites
NYHA class I: sx only w/
vigorous activity (e.g. sports)
NYHA class II: sx w/ moderate
activity (e.g. stairs)
NYHA class III: sx w/ ADLs
NYHA class IV: sx at rest
• moderate (2 vx) → Tx (above) vs. PTCA/CABG
• severe (3 vx) → Tx CABG
• Dx EKG + cardiac enzymes
• Tx MONABASH – Morphine (analgesia)
O2
Nitrates (analgesia)
Aspirin ± clopidogrel
β-blockers
ACE inhibitor (remodeling)
Statins
Heparin vs. enoxaparin
• (only ASA, β-blockers, ACEI reduce mortality)
• angina/NSTEMI → medical management
• STEMI → call cath lab for PTCA or CABG
• Dx EKG (ST-elevation during episode),
• inducible by IV ergonovine
• Dx EKG + cardiac enzymes (r/o MI) + ↑BNP +
• echo (best test, estimates EF)
• class I → Tx loop diuretic + ACE inhibitor
• class II-III → add β-blocker
• class IV → add digoxin
CK-MB: peaks in 24 hrs and lasts
2-3 days, good for recurrence
Troponin I: peaks in 24 hrs and
lasts 1-2 weeks, most specific
EKG changes: peaked T waves,
ST-elevation, ST-depression, Q
waves, T wave inversion
Lateral: I, aVL
Inferior: II, III, aVF
Anterior: V1-V4
Posterior: V1-V2
Complications: CHF, arrhythmias,
recurrent infarction, free wall
rupture, papillary muscle
rupture, acute pericarditis,
tamponade, Dressler syndrome
Frank-Starling curve: normal
heart has ↑contractility with
↑preload, but impaired in CHF
Systolic etiology: post-MI (MCC)
Diastolic etiology: LVH due to
chronic HTN (MCC)

CARDIAC DRUGS Adenosine toxicity: HA, flushing, nausea, SOB, chest pressure
Nitrate toxicity: headache, orthostatic hypotension, tolerance, syncope
Digoxin toxicity: atrial tachycardia w/ AV block
 MEDICINE × CV

ARRHYTHMIAS Arrhythmia EKG tracing Management/Other

PAC early P wave that looks differently than other P waves • reassurance
PVC wide QRS without preceding P wave • no risk factors → reassurance
• recurrrent PVCs w/ underlying
• heart dz → implantable defib

Couplet: 2 PVCs
Bigeminy: sinus beat + PVC
Trigeminy: sinus beat + 2 PVCs
AFib • acute, stable → anticoagulate +
• rate control w/ Ca-blockers
• then cardioversion
• acute, unstable → immediate
“irregularly irregular” rhythm
• cardioversion
• chronic → anticoagulate +
• rate control w/ Ca-blockers
AFlutter • (same as AFib)

saw-tooth baseline w/ HR = 150

MAT looks like AFib but the P waves are variable, need 3 different P waves for dx • Tx improve oxygenation

Etiology: end-stage COPD (MCC)

PSVT • Tx IV adenosine if stable, •
• cardioversion if unstable

HR > 200
WPW syndrome • Tx ablation

“delta wave” reflects accessory conduction pathway from atria to ventricles

VTach • sustained → Tx IV amiodarone
• nonsustained → reassurance
• torsades → Tx IV mag sulfate

Sustained VTach: lasts >30 sec, always symptomatic

Nonsustained VTach: lasts <30 sec, usually asx
Torsades de pointes: rapid, polymorphic VTach due to QT prolongation
VFib • Tx immediate defib + CPR, then
• continue IV amiodarone

Pulseless electrical activity: EKG

Sinus bradycardia
Sick sinus syndrome
1° AV block
shows activity but no pulses felt
sinus rate <60 bpm • usually insignificant; if sx → Tx
• atropine (blocks vagus nerve)
persistent sinus bradycardia; presents as dizziness, syncope, fatigue • Tx pacemaker
• reassurance

PR interval >0.2 sec (1 block)

2° AV block (Mobitz type 1) • reassurance

progressive PR prolongation until QRS drops, dz in AV node

2° AV block (Mobitz type 2) • Tx pacemaker (can convert to
• 3° w/o Tx)

random QRS drop, dz in bundle of His

3° AV block (complete) • Tx pacemaker

P waves and QRS complexes function independently


MYOCARDIAL DZ Dz Presentation
DCM ↓contractility → CHF sx
HCM exertional dyspnea, angina,
syncope, “sudden death in a
young athlete”, murmur
enhanced by ↓preload (e.g.
handgrip, Valsalva)
RCM infiltration of myocardium →
↓compliance → CHF sx
Myocarditis usually asx, can present w/
fever, chest pain, pericarditis
PERICARDIAL DZ Dz Presentation
Acute pericarditis pleuritic positional chest pain
(relieved by leaning forward),
pericardial friction rub; can lead
to pericardial effusion and
cardiac tamponade
Constrictive pericarditis fibrous pericardial scarring →
↑systemic venous pressure →
edema, ascites, hepatic
congestion, JVD, pericardial
knock, Kussmaul sign
Pericardial effusion muffled heart sounds, soft PMI,
±pericardial friction rub
Cardiac tamponade pulsus paradoxus + Beck’s triad
(hypotension, JVD, muffled
heart sounds)
VALVULAR DZ Valvular dz: all require warfarin (anticoagulate) + amoxicillin (SBE ppx)
Dz Presentation
Mitral stenosis loud S1, opening snap w/ late
diastolic rumble
Mitral regurgitation holosystolic blowing murmur
Aortic stenosis systolic crescendo-decrescendo
murmur following opening
snap, “parvus et tardus”; triad
of angina, syncope, dyspnea
Aortic regurgitation high-pitched blowing diastolic
murmur, wide pulse pressures,
head bobbing, pulsating uvula,
pistol-shot over femoral arteries
Tricuspid regurgitation holosystolic blowing murmur,
pulsatile liver
Mitral valve prolapse midsystolic click, late systolic
crescendo murmur; enhanced
by ↑TPR (Valsalva, hand grip)
Management
• Dx echo + CXR
• Tx for CHF + heart txp (MC indication)
• Dx echo + family hx
• asx → avoid exercise
• sx → β-blockers vs. myomectomy vs.
• pacemaker implantation
• Dx echo + endomyocardial bx to find cause
• Tx underlying cause
• Dx ↑cardiac enzymes, ↑ESR
• Tx underlying cause
Management
• Dx EKG (diffuse ST elevation + PR dePRession)
• Tx NSAIDs
• pericarditis + uremia → Tx hemodialysis
• Dx EKG shows AFib, cardiac cath shows
• “square root sign”
• Tx pericardiectomy
• Dx echo (gold standard), CXR shows “water
• bottle” silhouette
• small/asx → repeat echo in 1-2 wks
• rapidly developing → pericardiocentesis
• Dx echo (gold standard), EKG shows electrical
• alternans
• nonhemorrhagic, stable → close monitoring
• nonhemorrhagic, unstable →
• pericardiocentesis
• hemorrhagic → ER thoracotomy
Management
• asx → nothing
• sx → Tx balloon valvuloplasty
• asx → medical management
• sx → Tx valve replacement
• asx → nothing
• sx → Tx valve replacement
• asx → medical management
• sx → Tx valve replacement
• acute-onset → emergent valve replacement
• asx → medical management
• sx → Tx valve replacement
• reassurance
MEDICINE × CV
Other
Etiology: MI (MCC), infx, alcohol,
doxorubicin (Adriamycin), etc.
Etiology: most are autosomal
dominant, few are sporadic
Etiology: CASHES – carcinoid
syndrome, amyloid, sarcoid,
hemochromatosis, endocardial
fibroelastosis (kids), scleroderma
Etiology: coxsackie B virus (MCC)
Other
Etiology: coxsackie B virus (MCC)
Dressler syndrome: post-MI
pericarditis, “feels like a second
heart attack”; Tx NSAIDs
Constrictive pericarditis vs.
tamponade: pericarditis fills
rapidly then stops suddenly,
tamponade fills slowly through-
out diastole
Etiology: acute pericarditis
(MCC)
Etiology: trauma, pericarditis,
post-MI w/ free wall rupture
Rate vs. amount: rate is more
important than amount b/c
pericardium has ability to stretch
Other
Etiology: rheumatic heart
disease (MCC)
Etiology: ischemic heart dz, MVP,
LV dilation
Etiology: calcified tricuspid valve
(old), calcified bicuspid aortic
valve (young)
Px: usually asx until old age, then
1-3 yrs after development of sx
Etiology: bicuspid aortic valve,
syphilitic aortitis, rheumatic fever
Etiology: tricuspid endocarditis
(IVDA), RV dilation
Etiology: connective tissue d/o,
MCC Marfan’s
 MEDICINE × CV

ENDOCARDITIS Endocarditis: diseases of endocardial lining of heart, most commonly in valves

Dz Presentation Management Other

Rheumatic fever
Rheumatic heart disease
Infx endocarditis
Marantic (thrombotic)
endocarditis
Libman-Sacks endocarditis
strep throat (GAS) → anti-M ab
→ type 2 hypersensitivity →
FEVERSS – fever, erythema
marginatum, valvular damage,
↑ESR, red-hot joints (migratory
polyarthritis), subcutaneous
nodules, Sydenham chorea
repeated episodes of rheumatic
fever → scarring of mitral valve
Acute: S. aureus on normal
valves → rapid onset
Subacute: dental procedures →
S. viridans (or GU/GI procedures
→ enterococcus) on damaged
valves → insidious onset
metastatic cancer → hyper-
coagulable state → clots form
on valves → can embolize
SLE → wart-like vegetations on
both sides of mitral valve →
mitral regurg > mitral stenosis
• Dx ASO titers
• strep throat → Tx PCN or erythromycin
• rheumatic fever → Tx steroids
• Tx valve repair
• Dx Duke’s criteria (sustained bacteremia,
• endocardial involvement, fever, immune or
• vascular phenomena, +blood cx, +echo)
• Tx IV abx
• Tx heparin (controversial)
• Dx ANA
• Tx underlying SLE + anticoagulate
MC murmur: mitral regurgitation
MC murmur: mitral stenosis
Rapid onset: S. aureus
Dental procedures: S. viridans
GI/GU procedures: enterococcus
Colon cancer: Strep bovis,
Clostridium septicum
IVDA: S. aureus on tricuspid valve
>> Pseudomonas, Candida
Prosthetic valves: S. epidermidis
Cx-negative: HACEK group

CONGENITAL HEART DZ CHD × endocarditis: all CHD require amoxicillin (SBE ppx) before dental procedures
Eisenmenger syndrome: L-to-R shunts → pulmonary HTN → reversal of shunting → late-onset cyanosis

Dz Presentation Management Other

ASD low-grade diastolic rumble
murmur w/ fixed split S2
VSD holosystolic murmur at mid-LSB
PDA continuous, machinery-like
murmur
Aortic coarctation HTN in upper extremities,
hypotension in lower
extremities; midsystolic
murmur heard over back
• Dx echo
• asx → reassurance
• sx → Tx surgical repair
• Dx echo
• asx → reassurance
• sx → Tx surgical repair
• Dx echo
• infants → Tx indomethacin
• adults w/o Eisenmenger → surgical ligation
• adults w/ Eisenmenger → surgery is •
• contraindicated
• Dx CXR (rib notching + “figure 3” aorta)
• Tx surgical decompression
Paradoxical emboli: venous clots
can travel through ASD and
cause stroke instead of PE
Congenital rubella syndrome:
PDA + deafness + cataracts
MCC death: heart failure,
infectious endocarditis
Aortic coarctation in short
women: Turner syndrome
 MEDICINE × CV

ARTERIAL DZ (vasculitides in MSK section)

Dz Presentation Management Other

HTN urgency BP >220/120
HTN emergency BP >220/120 + end-organ
damage (e.g. headache, renal
failure, pulmonary edema)
Aortic dissection acute-onset tearing chest pain
(type A) or interscapular back
pain (type B), asymmetric BP, pt
usually in severe distress
AAA usually asx, can present as
pulsatile mass on abd exam
Ruptured AAA triad of tearing abdominal pain,
hypotension, pulsatile mass
Peripheral vascular dz peripheral atherosclerosis →
intermittent claducation (mild),
rest pain and ischemic ulcers
(severe)
Acute arterial occlusion emboli → arterial occlusion →
6 Ps – pain, pallor, paralysis,
parasthesias, poikilothermia,
pulselessness
Cholesterol embolization surgical or radiographic
syndrome procedure → disruption of
atherosclerotic plaque →
cholesterol emboli → small
areas of tissue ischemia (e.g.
black/blue spots on toes)
Mycotic aneurysm bacterial (not fungal) infx →
aortic aneurysm
Luetic heart tertiary syphilis → aortic
aneurysm + aortic regurg +
coronary artery stenosis
• lower BP gradually over 24 hrs w/ PO meds
• lower BP by 25% in 1-2 hrs w/ IV nitroprusside
• severe HA → get head CT to r/o intracranial
• bleeding → lumbar puncture if CT is negative
• Dx screen w/ CXR (widened mediastinum),
• confirm w/ TEE or CT scan
• type A → Tx β-blockers + surgery
• type B → Tx β-blockers
• Dx abdominal U/S
• <5 cm → close f/u vs. elective repair
• >5 cm or sx → Tx synthetic graft
• Tx emergency laparotomy (don’t waste time
• on dx tests)
• Dx arteriogram (gold standard)
• Dx ABI (normal ≥1.0, mild <0.7, severe <0.4;
• calcified arteries give false readings)
• mild → conservative management
• severe → bypass graft vs. angioplasty
• Dx arteriogram
• Tx IV heparin + surgical embolectomy (<6 hrs)
• vs. amputation (>6 hrs)
• Tx fasciotomy for compartment syndrome ppx
• Tx supportive care
• severe → amputation
• Tx IV abx + surgical excision
• Tx IV PCN G + surgical repair
Etiology: HTN, connective tissue
diseases
Stanford classification: type A
involves Ascending aorta, type B
involves descending aorta
MC site: below the renal arteries
MC pts: old smoking men
Aortoenteric fistula: small herald
bleed followed by massive UGIB
s/p aortic graft placement
Signs of impending rupture:
Cullen sign (umbilical
ecchymoses), Grey-Turner sign
(flank ecchymoses)
MC site: superficial femoral
artery
Risk factors: diabetes, smoking
Leriche syndrome: PVD of distal
aorta above bifurcation →
bilateral claudication, impotence,
↓femoral pulses
Etiology: AFib (MCC)
MC site: common femoral artery

VENOUS DZ Virchow’s triad: ↑risk of blood clots w/ stasis, hypercoagulability, endothelial damage
Heparin vs. enoxaparin: enoxaparin (Lovenox) and dalteparin (Fragmin) have longer T½ for qday dosing, more $$$

Dz Presentation Management Other

SVT painful, palpable venous cord
w/ local erythema and edema
DVT acute-onset dull leg pain,
unilateral swelling, and
Homans’ sign (calf pain w/
dorsiflexion)
PE acute-onset chest pain,
dyspnea, hyperventilation,
hemoptysis, right-sided heart
failure → death
Phlegmasia cerulea dolens venous outflow obstruction →
acute onset leg edema with
pain and cyanosis
Post-thrombotic syndrome DVT damages valves → chronic
(chronic venous insufficiency) venous HTN → severe leg
edema and ulceration around
ankle area
• mild → Tx aspirin Migratory SVT: consider
• severe → Tx aspirin + warm compresses pancreatic cancer (Trousseau
• septic → remove IV cath + give IV abx phenomenon)
• Dx duplex U/S
• Tx heparin + warfarin
• PPx compression boots + early ambulation ±
• heparin/LMWH
• Dx D-dimer to r/o, spiral CT or V/Q to confirm PE on EKG: sinus tachycardia is
• Tx heparin + warfarin more common than S1Q3T3
• Tx tPA to speed up clot resolution (massive
• PE, unstable, right heart failure, no c/i)
• recurrent PE → Tx IVC filter
• Dx duplex U/S or pelvic CT scan
• Tx heparin + venous thrombectomy
• Tx compression stockings + leg elevation;
• wet-to-dry TID for ulcers
 MEDICINE × CV

SHOCK Shock: inadequate tissue perfusion

Types of shock: cardiogenic (JVD)
hypovolemic
septic (warm skin)
neurogenic (↑CO, warm skin)
Initial shock management: ABCs → 2 large-bore IVs + 2L IV fluids (except cardiogenic) → EKG, CXR, labs (CBC/renal/coags)

Dz Presentation Management Other

Cardiogenic shock typical shock sx (∆MS, ↓BP/↑HR,
pale cool skin) + JVD
Hypovolemic shock Class I: <15% + asx
Class II: 15-30% + ↑HR
Class III: 30-40% + ↓BP
Class IV: >40% + ∆MS, anuria
Septic shock SIRS: 2+ of the following – ↑/↓T,
↑RR, ↑HR, ↑/↓WBC
Sepsis: SIRS + positive blood cx
Septic shock: sepsis + ↓BP
MODS: multiple organ dysfxn
syndrome 2/2 septic shock
Neurogenic shock sympathetic denervation →
loss of vascular tone → typical
shock sx (∆MS, ↓BP/↑HR, warm
skin)
• (initial shock management) but use dopamine Etiology: acute MI (MCC),
• or IABP instead of IV fluids cardiac tamponade, tension PTX,
• Dx EKG + echo to find underlying cause massive PE, etc.
• Tx underlying cause
• (initial shock management)
• hemorrhagic → find and stop source of bleed
• nonhemorrhagic → stabilize w/ IVF + close
• monitoring for improvement
• (initial shock management) Complications: septic shock is
• Tx IV abx + IV fluids, dopamine (2nd line) MCC of ARDS + ICU death
• (initial shock management)
• Tx IV fluids + supine or T-berg position

CARDIAC NEOPLASMS Dz Presentation Management Other

Cardiac metastases
Atrial myxoma
Cardiac rhabdomyoma
---
pedunculated, benign mass that
presents like intermittent mitral
stenosis
MC heart tumor in kids
• Dx CT scan more common than primary
• Tx surgical excision tumors (75%)
Etiology: most are sporadic, few
are autosomal dominant
Etiology: associated w/ tuberous
sclerosis

EKG READING EKG reading: 0. find old EKG for comparison

1. Rate: use 300-150-100-75-60-50 rule, or count long strip x12
2. Rhythm: look at long strip
• Irregularly irregular: AFib or MAT
3. Axis: look at leads I and II
• I+/II+: normal
• I+/II–: left-axis deviation
• I–/II+: right-axis deviation
4. Intervals: look at PR interval, QRS complex, QT interval
• PR interval: normal <0.2 sec, heart block >0.2 sec
• QRS complex: normal <0.12 sec
• LBBB: WiLLiaM – W in V1-V2, M in V3-V6
• RBBB: MaRRoW – M in V1-V2, W in V3-V6
• QT interval: normal if T-wave doesn’t go past mid QRS-QRS, prolonged QT is risk of torsades de pointes
5. Waves: look for chamber enlargement and signs of ischemia/infarct
• LAE: lead II wide P-wave (>0.12 sec)
• RAE: lead II tall P-wave (>2.5 mm)
• LVH: left-axis deviation + V1/V2 and V5/V6 overlapping
• RVH: right-axis deviation + lead V1 R-wave >7 mm
• Ischemia: T-wave inversion, ST elevation or depression
• Infarct: T-wave inversion, ST elevation, significant Q waves

OBSTRUCTIVE LUNG DZ Lung volumes:
Obstructive lung dz: ↑TLC, ↓FEV1/FVC (<70%), ↑compliance, ↓elasticity
Restrictive lung dz: ↓TLC, ↑FEV1/FVC, ↓compliance, ↑elasticity
COPD: emphysema + chronic bronchitis, commonly coexist, MCC of both is smoking
Dz Presentation
Emphysema destruction of alveolar walls →
permanent alveolar dilation →
“pink puffers”, thin w/ barrel
chest, expiration w/ pursed lips
Chronic bronchitis chronic productive cough of 3
months/year for 2 years →
“blue bloaters”, overweight
and cyanotic, may have signs of
cor pulmonale
Asthma Asthma attack: airway
inflammation → reversible
airflow obstruction →
wheezing, shortness of breath,
cough, chest tightness
Status asthmaticus: sustained
asthmatic state, not responsive
to meds
Bronchiectasis destruction of bronchial walls
→ permanent bronchiolar
dilation → chronic cough w/
“cupfuls” of sputum, dyspnea,
hemoptysis, recurrent
Pseudomonas pneumonia
Management
• Dx spirometry shows FEV1/FVC <70%
• Dx CXR shows hyperinflated lungs and
• increased AP diameter (emphysema only)
• <50 y/o → Dx A1AT levels
• stage I (FEV1 ≥80%) → Tx short-acting
• bronchodilators (albuterol, ipratropium)
• stage II (FEV1 50-80%) → add long-acting
• bronchodilators (salmeterol, tiotropium)
• stage III (FEV1 30-50%) → add inhaled steroids
• (fluticasone, triamcinolone)
• stage IV (FEV1 <30% or <5o% w/ hypoxia) →
• add O2 therapy for 18 hrs/day
• COPD exacerbation → Tx bronchodilators +
• abx + systemic steroids + O2 therapy
• Dx spirometry shows reversible FEV1/FVC <70%
• 1-2 atk/wk → prn SABA (albuterol)
• 2+ atk/wk → add low-dose inhaled steroids
• daily atk → add LABA (salmeterol)
• continuous → add high-dose inhaled steroids
• Dx high-res CT scan shows “signet rings”
• Tx bronchodilators + abx for acute
• exacerbations
MEDICINE × PULMONARY
Other
Etiology: smoking causes centri-
acinar emphysema in upper
lungs; A1AT deficiency causes
panacinar emphysema in lower
lungs in pts <50 y/o
Etiology: smoking (MCC)
Extrinsic asthma: IgE-mediated
rxn to environmental triggers
Intrinsic asthma: not related to
triggers or atopy
Atopy: asthma + allergic rhinitis +
atopic dermatitis (eczema)
Triad asthma: asthma + aspirin
sensitivity (↑LT) + nasal polyps
ABPA: asthma + pulmonary
infiltrates + Aspergillus allergy
Churg-Strauss syndrome:
asthma + eosinophilia +
granulomatous vasculitis
Etiology: cystic fibrosis (MCC),
Kartagener syndrome (∆dynein)

LUNG NEOPLASMS Dz Presentation
Lung cancer cough, hemoptysis, dyspnea,
wheezing, recurrent PNA in
same lobe
Pancoast tumor: superior sulcus
tumor at the apex of the lung;
presents as Horner syndrome –
ipsilateral ptosis, miosis,
anhidrosis, flushing due to loss
of sympathetic tone (invades
superior cervical ganglia)
Bronchial adenoma: MC cancer
in women and nonsmokers
Solitary pulmonary nodule solitary pulmonary nodule
(“coin lesion”) found incidentally on a CXR;
DDx primary lung cancer,
granuloma (TB or fungal),
hamartoma, metastatic cancers
PLEURAL DZ Dz Presentation
Pleural effusion fluid build-up in pleural space;
two types – transudative (thin)
and exudative (thick)
Empyema collection of pus within pleural
cavity → nonproductive cough,
fever, chest pain
PTX air pocket in pleural space →
chest pain, cough, dyspnea
Tension PTX PTX + building pressure →
mediastinal shift, hypOtension,
JVD, absent breath sounds,
hyperresonance to percussion
Mesothelioma cancer of mesothelial lining →
dyspnea, cough, weight loss
Management
• Dx CXR → if suspicious, sputum cytology and
• CT scan → if still suspicious, bronchoscopy and
• mediastinoscopy w/ biopsy (“tissue is the
• issue”)
• NSCLC stage I (local) → pneumonectomy vs.
• sleeve lobectomy
• NSCLC stage II (hilar LN) → pneumonectomy
• vs. sleeve lobectomy
• NSCLC stage III (distal LN) → chemo/radiation
• NSCLC stage IV (mets) → chemo/radiation
• SCLC limited (ipsi) → chemo/radiation
• SCLC extensive (contra) → chemo/radiation
• Bronchial adenoma → lobectomy is curative
• Pancoast tumor → irradiation for 6 weeks to
• shrink tumor, then surgical resection
• Dx get an older CXR for comparison studies →
• if suspicious, sputum cytology and CT scan
• Benign coin lesions (calcification = granuloma,
• bull’s-eye shape, popcorn shape = hamartoma,
• air-crescent or halo sign = aspergilloma,
• Southwest region = coccidioidomycosis, Ohio
• river valley = histoplasmosis) → leave alone
• Indeterminate coin lesions → resection
• indicated
• Malignant coin lesions (spiculations or 20+
• pack-year smoking = primary lung cancer,
• multiple lesions = metastatic cancer) →
• resection indicated
Management
• Dx CXR shows blunting of costophrenic angle
• Dx thoracentesis + 4 Cs – chemistry (glucose,
• protein), cytology, CBC+diff, culture
• transudative → Tx diuretics + Na+ restriction
• exudative → Tx underlying disease
• parapneumonic → abx ± chest tube drainage
• Dx CXR or CT scan
• Tx abx + insert chest tube, evacuate pus
• collection, then re-expand the lung
• Dx CXR shows visceral pleura line or deep
• sulcus sign
• small/asx → observation
• large or sx → Tx chest tube drainage
• recurrent → Tx pleurodesis (scraping vs. talc)
• always get CXR after transthoracic needle
• aspiration, chest tube, or central line to r/o
• Dx H+P, do not get a CXR
• Tx immediate needle decompression (2nd •
• intercostal space) + chest tube
• Dx CT scan shows thick pleural walls
• Tx extrapleural pneumonectomy (high rate of
• morbidity/mortality)
MEDICINE × PULMONARY
Other
Complications: SPHERE – SVC
syndrome, Pancoast tumor →
Horner syndrome, Endocrine
(paraneoplastic), Recurrent
laryngeal nerve (hoarseness),
Effusions (pleural or pericardial)
Lambert-Eaton myasthenic
syndrome (LEMS): SCLC → anti-
VGCC antibodies → myasthenia
gravis-like presentation
Paraneoplastic syndromes:
squamous cell makes PTH-rP,
SCLC makes ADH and ACTH
Other
Light’s criteria: pleural fluid is
exudative if any of the following
– p/s protein <0.5, p/s LDH <0.6,
p LDH at upper 2/3 of normal
Pleural fluid analysis:
• amylase = esophageal rupture,
• pancreatitis, malignancy
• milky fluid = chylothorax
• purulent fluid = empyema
• bloody fluid = cancer
• lymphocytic fluid = TB
• pH <7.2 = empyema or
• parapneumonic effusion
• glucose <60 = r/o RA
Etiology: Staph aureus is MCC
1° spontaneous PTX: rupture of
apical blebs in healthy young
people
2° spontaneous PTX: due to
underlying lung dz (MCC COPD)
Traumatic PTX: s/p transthoracic
needle aspiration, chest tube, or
central line
Etiology: asbestos exposure
(especially shipyards, rooftops)

INTERSTITIAL LUNG DZ ILD presentation: dyspnea, nonproductive cough, fatigue
ILD management: Dx spirometry (↓TLC, ↑FEV1/FVC) → get CXR + tissue bx + UA if hematuria
Honeycomb lung: end-stage ILD → scarred, shrunken lung w/ dilated air spaces
Dz
Drug-induced pulmonary
fibrosis
Sarcoidosis
Histiocytosis X
Wegener granulomatosis
Churg-Strauss syndrome
Coal worker pneumoconiosis
Asbestosis
Silicosis
Berylliosis
Hypersensitivity pneumonitis
(extrinsic allergic alveolitis)
Eosinophilic pneumonia
Goodpasture syndrome
Pulmonary alveolar proteinosis
Idiopathic pulmonary fibrosis
(IPF)
Cryptogenic organizing
pneumonitis (COP)
Radiation pneumonitis
Presentation
(classic ILD sx) s/p amiodarone,
busulfan, bleomycin, MTX, or
nitrofurantoin
young black female w/
respiratory complaints,
erythema nodosum, and blurry
vision (anterior uveitis)
(classic ILD sx)
triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract, and
necrotizing glomerulonephritis
→ hematuria + hemoptysis
triad of asthma + eosinophilia +
necrotizing vasculitis
inhalation of coal dust
containing carbon and silica →
(classic ILD sx)
inhalation of asbestos →
fibrosis of lower lungs + pleural
plaques
inhalation of silicon → fibrosis
of upper lungs
inhalation of beryllium →
sarcoidosis-like presentation
Acute form: inhalation of
antigenic agent (e.g. bird
droppings) → type III and IV
hypersensitivity → flu-like sx
Chronic form: (classic ILD sx)
(classic ILD sx) + fever +
eosinophilia
anti-GBM antibodies attack
alveolar and glomerular
basement membrane (type II)
→ hematuria + hemoptysis
accumulation of surfactant-like
protein and phospholipids in
alveoli → (classic ILD sx)
(classic ILD sx) → death in 3-7
yrs
infectious pneumonia-like
presentation (cough, dyspnea,
flu-like sx) but unresponsive to
abx
s/p thoracic radiation for lung or
breast cancer → alveolar
thickening and pulmonary
fibrosis → (classic ILD sx)
MEDICINE × PULMONARY
Management Other
• Tx d/c meds
• Dx CXR shows bilateral hilar LN-opathy Complications: GRAINeD – ↑IgG,
• (pulmonary fibrosis is end-stage finding) rheumatoid arthritis, ↑ACE, ILD,
• Dx tissue bx shows noncaseating granulomas noncaseating granulomas, ↑1α-
• w/ Schaumann and asteroid bodies hydroxylase → ↑vitamin D
• Tx steroids
• Dx CXR shows honeycomb lung
• Dx tissue bx shows eosinophilic granulomas
• Tx steroids vs. lung txp (if not responding)
• Dx ↑c-ANCA
• Dx tissue bx shows necrotizing granulomas
• Tx cyclophosphamide
• Dx ↑p-ANCA
• Tx steroids
--- Caplan syndrome: rheumatoid
nodules + pneumoconiosis
• Dx CXR shows lower lung fibrosis + pleural Etiology: shipyards, naval bases,
• plaques rooftops
• Dx tissue bx shows ferruginous bodies Complications: bronchogenic
• Tx supportive care carcinoma >> mesothelioma
• Dx CXR shows upper lung fibrosis + “egg shell” Etiology: mining, stone cutting,
• calcifications glass manufacturing
• Tx supportive care
• Dx beryllium lymphocyte proliferation test
• Tx steroids
• Dx CXR shows pulmonary infiltrates (acute
• form), interstitial fibrosis (chronic form)
• Tx steroids + avoid birds
• Dx CXR shows peripheral infiltrates, CBC+diff
• shows eosinophilia
• get p-ANCA to r/o Churg-Strauss
• Tx steroids
• Dx tissue bx shows linear staining
• get c-ANCA to r/o Wegener
• Tx steroids + cyclophosphamide +
• plasmapheresis
• Dx CXR shows ground glass appearance w/
• bat-shaped bilateral alveolar infiltrates
• Dx tissue bx (definitive)
• Tx lung lavage vs. GM-CSF
• Dx CXR shows honeycomb lungs w/ temporal
• heterogeneity
• Dx tissue bx shows UIP (usual interstitial PNA)
• Tx steroids (temporizing), lung txp
• Dx CXR shows bilateral patchy infiltrates
• Tx steroids
• Dx CT scan shows diffuse infiltrates (CXR is
• usually normal)
• Tx steroids
• PPx not useful

RESPIRATORY FAILURE Dz Presentation
Acute respiratory failure dyspnea (first sx), cough,
respiratory distress, etc.
Types: hypoxia (PaO2 <60),
hypercapnia (PCO2 >50)
ARDS diffuse inflammatory response
→ neutrophil activation →
interstitial damage and alveolar
collapse → massive shunting →
dyspnea + respiratory distress
Neonatal RDS: due to preterm
birth <34 wks w/o surfactant
VENTILATION Ventilation goals: maintain alveolar ventilation, correct hypoxia
Ventilator settings: 1. AC (assisted control) – has backup RR, gives preset VT per attempted breath
2. SIMV (synchronous intermittent mandatory ventilation) – has backup RR, does not have preset VT per breath
3. CPAP (continuous positive airway pressure) – no backup RR, continuous PEEP support
4. PSV (pressure support ventilation) – PEEP support only with attempted breath
Key parameters: RR and VT control CO2
FiO2 and PEEP control O2
Tracheomalacia: softening of tracheal cartilage w/ prolonged ventilation; PPx tracheostomy if ventilator-dependent for 2+ wks
PULMONARY VX DZ Dz Presentation
Pulmonary HTN PA pressure >25 mmHg (rest) or
>30 mmHg (exercise) →
presents as exertional dyspnea,
fatigue, chest pain, ±syncope
1° pulmonary HTN (PPH) pulmonary HTN w/o identifiable
cause (a dx of exclusion)
Cor pulmonale pulmonary HTN + RVH
PE acute onset chest pain,
dyspnea, hyperventilation,
hemoptysis, right-sided heart
failure → death
OTHER LUNG PROBLEMS Dz Presentation
Pulmonary aspiration either acute onset respiratory
distress, or delayed onset of
respiratory sx (cough, SOB,
fever, tachypnea, dypsnea, etc.)
Management
• Dx ABG analysis…
↑CO2 CO2 nl
↑A-a V/Q mismatch vs. shunting
(DDx w/ supplemental O2)
A-a nl hypoventilation ↓inspired PaO2
• Dx CXR, CBC/renal, cardiac enzymes if needed
• Tx underlying cause, supplemental O2,
• CPAP/BIPAP if conscious, ventilation if not
• Dx CXR shows diffuse bilateral pulmonary
• infiltrates (white-out of lungs)
• Dx ABG shows hypoxia (PaO2 <60) not
• responsive to O2 therapy
• Dx PCWP shows no evidence of CHF
• Tx ventilation w/ ↓FiO2, ↑PEEP
Management
• Dx loud P2 + subtle sternal lift on auscultation
• Dx find the underlying cause via CXR, PFTs,
• ABG, EKG, echo, catheterization
• Tx underlying cause + bosentan
• Dx (see above)
• Tx pulmonary vasodilators (CCB) + lung txp
• Dx (see above)
• Tx underlying cause + bosentan
• Dx D-dimer to r/o, spiral CT or V/Q scan to r/in
• Tx heparin + warfarin
• Tx tPA to speed up clot resolution (massive
• PE, unstable, right heart failure, no c/i)
• recurrent PE → Tx IVC filter
Management
• Dx CXR + H+P
• Tx ABCs, O2 mask, supportive care
• aspiration pneumonia → Tx abx
• obstruction → Tx bronchoscopy
MEDICINE × PULMONARY
Other
V/Q mismatch: imbalance
between lung perfusion and
ventilation, presents as ↓O2 but
nl CO2
Shunting: lack of ventilation in
well-perfused areas (e.g. PNA,
atelectasis); not responsive to
supplemental O2
Hypoventilation: not breathing
↓inspired PaO2: high altitudes
Etiology: septic shock (MCC),
aspiration pneumonia, trauma
Other
Etiology: ∆BMPR2 → uninhibited
smooth muscle growth →
↑pulmonary resistance
Px: mean survival 2-3 yrs
Etiology: COPD (MCC), recurrent
PE, ILD, asthma, sleep apnea, CF,
pneumoconioses
PE on EKG: sinus tachycardia is
more common than S1Q3T3
Fat embolism: dyspnea, ∆MS,
petechiae in a pt w/ long bone fx
Amniotic fluid embolism: intra-
or postpartum, or amniocentesis
Other
Etiology: gastric aspirates (can
lead to ARDS), oral flora (can
lead to abscess), foreign bodies
Risk factors: ∆MS, alcoholics,
instrumentation, esophageal d/o

ABDOMINAL PAIN RUQ pain: • liver (hepatitis)
• common bile duct (cholecystitis, cholangitis)
• lungs (PE, pneumonia)
• duodenum (ulcer)
RLQ pain: • bowels (appendicitis, perforated ulcer, IBD,
• inguinal hernia)
• male GU (testicular torsion)
• female GU (ectopic, PID, ovarian cyst)
• ureters (ureterolithiasis)
COLON DZ Dz Presentation
Colorectal cancer Proximal colon: bleeding →
melena, iron-deficiency anemia,
fatigue, dull pain
Distal colon: obstruction →
constipation, colicky pain,
hematochezia
Rectal cancer: hematochezia,
rectal mass, tenesmus
Metastatic: portal drainage to
liver → jaundice, ↑LFTs
Polyps asx
Diverticulosis low-fiber diet → need more
strain to poop → outpouching
of sigmoid colon → erosion →
painless rectal bleeding
Diverticulitis fecalith impacts in diverticula →
necrosis → infx → LLQ pain,
fever, ↑WBC (no bleeding)
Angiodysplasia (vascular AV malformation in submucosa
ectasia, AVM) of colon wall → erosion → LGI
bleed (MCC)
Acute mesenteric ischemia compromised blood supply to
SMA or SMV → ischemia ±
infarction → acute onset severe
abd pain
Arterial embolism: MCC, most
sudden and severe
Arterial thrombosis: gradual
onset and less severe
Nonocclusive ischemia: due to
↓CO, seen in critically ill pts
Venous thrombosis: rare,
slowest onset and least severe
Chronic mesenteric ischemia atherosclerosis of celiac artery,
SMA, or IMA → postprandial
dull abd pain
Ogilvie syndrome colonic pseudoobstruction w/o
mechanical cause → bloating,
obstipation, nausea/vomiting
Pseudomembranous colitis abx use → kills off colonic flora
and allows C. diff overgrowth →
profuse watery diarrhea
Volvulus twisting of redundant bowel →
acute-onset colicky pain,
obstipation, nausea/vomiting
MEDICINE × GI
LUQ pain: • pancreas (pancreatitis)
• spleen (splenic dz)
• lungs (PE, pneumonia, subphrenic abscess)
LLQ pain: • bowels (diverticulitis, IBD, inguinal hernia)
• male GU (testicular torsion)
• female GU (ectopic, PID, ovarian cyst)
• ureters (ureterolithiasis)
Management Other
• >50 y/o → colonoscopy screen q 10 yrs Risk factors: old age (>50),
• Dx barium enema (“apple core”) + CEA marker villous adenomas, IBD, family hx,
low-fiber diet, major polyposis
syndromes
FAP: AD ∆APC → thousands of
polyps → 100% progression to
CRC; Tx ppx colectomy
Gardner syndrome: FAP +
osteomas, soft tissue tumors
Turcot syndrome: FAP + CNS
• tumors
Peutz-Jeghers syndrome:
• Duke stage A (local) → Tx surgery multiple nonmalignant
• Duke stage B (invasive) → Tx surgery hamartomas throughout GI tract
• Duke stage C (LN) → Tx surgery + chemo w/ pigmented spots around
• (5-FU, leucovorin) + Radiation if Rectal mucus surfaces
• Duke stage D (mets) → Tx surgery + chemo HNPCC/Lynch syndrome: AD
• (5-FU, leucovorin) + Radiation if Rectal ∆DNA repair genes → hundreds
of polyps → 80% progression to
CRC
• Dx colonoscopy Hyperplastic polyps: MC type,
• Tx polypectomy leave alone, no malig potential
Juvenile polyps: polyps in kids,
remove due to vascularity
Inflammatory (pseudo) polyps:
associated w/ UC
Adenomatous polyps: high risk
of malig potential, worst types
are large villous polyps
• Dx barium enema Complications: hypovolemic
• Tx stool softeners (high-fiber diet, psyllium) shock, diverticulitis
• Dx CT scan Complications: abscess, bowel
• first episode → Tx IVF, NPO, IV abx obstruction, colovesical fistulas,
• recurrent episodes →Tx surgery perforation
• Dx colonoscopy Heyde syndrome: angiodysplasia
• Tx observation (90% stop spontaneously), + aortic stenosis
• colonoscopy w/ coagulation (2nd line)
• Dx screen w/ ↑LDH, confirm w/ mesenteric (equivalent to MI or unstable
• angiography angina of the bowels)
• Tx IVF, NPO, IV abx; intra-arterial papaverine if
• arterial, heparin if venous
• dead bowel → Tx surgery
• Dx mesenteric angiography (equivalent to stable angina of
• Tx surgical revascularization the bowels)
• Dx of exclusion (r/o other causes) Etiology: surgery or trauma,
• Tx underlying cause, decompressive serious medical illnesses, drugs
• colonoscopy (2nd line), neostigmine (3rd line) (e.g. opiates)
• colon >10 cm → Tx emergent decompression
• Dx C. diff stool toxins Complications: toxic megacolon,
• Tx Flagyl (1st line), PO vancomycin (2nd line) perforation
• Dx KUB shows Omega loop sign (dilated MC site: sigmoid colon
• sigmoid colon) or coffee bean sign (cecal
• volvulus causing RLQ air-fluid level)
• sigmoid volvulus → Tx sigmoidoscopy w/
• decompression ± elective surgery
• cecal volvulus → Tx emergent surgery

APPENDICEAL DZ Dz Presentation
Acute appendicitis lymphoid hyperplasia or fecalith
in appendix → ischemia → infx
and necrosis → perforation →
peritonitis
Nonruptured sx: umbilical abd
pain that migrates to RLQ,
anorexia, n/v
Ruptured sx: severe abd pain w/
guarding in all 4 quadrants
Carcinoid tumor neuroendocrine tumor that
secretes 5-HT, most commonly
found in appendix (no systemic
effects b/c liver metabolism)
Carcinoid syndrome: metastasis
of carcinoid tumor to liver →
systemic 5-HT effects → flush +
diarrhea + wheezing + TIPS
(tricuspid insufficiency,
pulmonary stenosis)
STOMACH DZ Dz Presentation
Peptic ulcer disease (PUD) aching or gnawing epigastric
pain, either relieved (DU) or
exacerbated (GU) by eating
Duodenal ulcers: due to ↑acid
secretion; most commonly in 1st
part of duodenum, DU in 2nd-4th
part indicates Z-E syndrome
Gastric ulcers: due to ↓mucosal
protection; type I – lesser
curvature, type II – duodenum
and stomach, type III – pylorus,
type IV – GE junction
Perforated ulcer: severe abd
pain, hemodynamic instability
Gastric outlet obstruction: early
satiety, nausea/vomiting
Bleeding ulcer: iron-deficiency
anemia (slow) or hypovolemic
shock (rapid)
Acute gastritis inflammation of gastric mucosa
→ aching or gnawing epigastric
pain
Chronic gastritis either H. pylori or pernicious
anemia → atrophy of gastric
mucosa → aching or gnawing
epigastric pain
Gastric adenocarcinoma presents as epigastric abd pain,
weight loss, early satiety, etc.
Linitis plastica: “leather bottle”
stomach due to full thickness
infiltration and fibrosis, poor px
Gastric lymphoma presents as epigastric abd pain,
weight loss, early satiety, etc.
MEDICINE × GI
Management Other
• Dx CT scan + CBC (↑WBC) + β-HCG (r/o ectopic Rovsing sign: LLQ pressure
• in females) causes referred RLQ pain
• Tx appendectomy Psoas sign: right psoas flexion
causes RLQ pain
Obturator sign: right obturator
flexion causes RLQ pain
McBurney point: 2/3 distance
from umbilicus to right ASIS
• Dx CT scan
• Tx appendectomy (<2 cm), right
• hemicolectomy (>2 cm)
• Dx urinary 5-HIAA
• Tx resection
Management Other
• Dx EGD Etiology: NSAIDs and H. pylori
• H. pylori → Dx stool ag > urease breath test, (MCC); EtOH, uremia, burns
• Tx triple or quad therapy (Curling), smoking, stress, head
injury (Cushing)
• Tx triple therapy → if ulcer persists, surgery
• (HSV) + get serum gastrin levels to r/o Z-E Zollinger-Ellison syndrome:
gastrinoma → ↑gastrin →
parietal cell stimulation → ↑HCl
• Tx PPIs → if ulcer persists for 6 wks, EGD w/ bx → ulcer formation
• to r/o gastric cancer → if ulcer persists for 18
• wks, surgery (wedge resection or distal
• gastrectomy)
• Dx CXR (pneumoperitoneum)
• Tx emergent surgical repair
• Dx barium swallow
• Tx NPO/IVF/NG tube
• Dx EGD
• Tx PPIs (slow) or surgical repair (rapid)
• Dx EGD w/ bx
• Tx d/c NSAIDs, triple therapy for H. pylori
• Dx EGD w/ bx Complications: PUD, gastric
• Tx d/c NSAIDs, triple therapy for H. pylori adenocarcinoma or lymphoma
• Dx EGD w/ bx, then CT scan for staging Krukenberg tumor: ovarian mets
• Tx surgical resection (bx shows “signet ring” cells)
Blumer shelf: rectal mets
SMJ node: periumbilical LN mets
Virchow node: left supra-
clavicular LN mets
Irish node: left axillary LN mets
Risk factors: type A blood,
Japanese (smoked foods)
• Dx EGD w/ bx
• Tx radiation (partial thickness) or surgical
• resection (full thickness)
 MEDICINE × GI

GI BLEEDING Dz Presentation Management Other

UGIB GI bleed proximal to Ligament
of Treitz → hematemesis,
melena, hematochezia (if rapid)
LGIB GI bleed distal to Ligament of
Treitz → hematochezia, melena
(if slow)
• Dx NG tube aspirate/lavage…
• • +blood/±bile is UGIB
• • –blood/+bile is LGIB
• • –blood/–bile is indeterminate
• UGIB → Dx/Tx EGD
• LGIB → Dx colonoscopy
• bleeding won’t stop → Dx tagged RBCs or
• angiography to localize site of bleeding
• “hemodynamic instability despite
• transfusion”, loss of 4-6 units in 24 hrs, or 8-10
• units in 48 hrs → Tx ex lap
• unstable pt w/ massive BRBPR, no imaging to
• help localize site → Tx total colectomy
Etiology: PUD (#1), NSAID use
(#2), esophageal varices (#3)
UGIB in ICU pt: stress ulcer
UGIB in alcoholics: esophageal
varices, Mallory-Weiss tear,
Boerhaave syndrome
UGIB s/p aortic graft: aorto-
enteric fistula (small herald bleed
followed by massive UGIB)
Etiology: diverticulosis (#1), AVM
(#1), colon cancer (#3)
LGIB in kids: Meckel diverticulum

ESOPHAGEAL DZ Dz Presentation Management Other

Esophageal cancer dysphagia of solids > liquids +
weight loss ± odynophagia (if
severe)
SCC: found in upper 2/3, due to
smoking and EtOH abuse
Adenocarcinoma: found in
lower 1/3, due to GERD/Barrett’s
Achalasia hypertonic and nonrelaxing LES
w/ poorly relaxing esophagus
→ dysphagia of liquids > solids
Diffuse esophageal spasm uncoordinated esophageal
peristalsis → dysphagia +
angina-like chest pain
Hiatal hernia Type 1 HH: sliding hernia, can
present as GERD or reflux
esophagitis
Type 2 HH: paraesophageal
hernia, high risk of incarceration
and strangulation
Type 3 HH: both type 1+2
Mallory-Weiss syndrome retching → laceration of lower
esophagus → UGIB
Boerhaave syndrome retching → perforation of lower
esophagus → epigastric pain,
fever, pneumomediastinum
Plummer-Vinson syndrome iron deficiency → anemia,
upper esophageal webs
(dysphagia), koilonychia
Schatzki ring ingestion of acids, alkali, bleach,
or detergents → lower
esophageal webs → usually asx,
dysphagia if severe
Esophageal divertula Zenker diverticulum: lack of
cricopharyngeal relaxation →
diverticulum at upper
esophagus → food gets stuck
→ halitosis + dysphagia
Traction diverticulum: TB or
cancer → LN-opathy → traction
→ diverticulum at middle
esophagus
Epiphrenic diverticulum:
esophageal motility d/o →
diverticulum at lower
esophagus
• Dx esophagoscopy w/ bx, then staging via
• endoscopic U/S + CT scan
• upper 1/3 → Tx chemo + radiation
• middle 1/3 → Tx chemo + radiation, then
• esophagectomy
• lower 1/3 → Tx esophagectomy + proximal
• gastrectomy
• Dx screen w/ barium swallow (bird’s beak),
• confirm w/ manometry (↑LES pressure)
• Tx botox vs. Heller myotomy
• Dx screen w/ barium swallow (corkscrew),
• confirm w/ manometry (uncoordinated)
• Tx nifedipine, nitrates
• Tx PPIs vs. lap Nissen
• Tx surgical repair
• Tx surgical repair
• Dx upper GI endoscopy Etiology: alcoholics (MCC),
• Tx observation (bleeding stops on its own) hyperemesis gravidarum, etc.
• Dx barium swallow Etiology: alcoholics (MCC),
• Tx emergent surgical repair hyperemesis gravidarum, etc.
• Tx esophageal dilatation + PO iron supplement
• dysphagia → Tx esophageal dilatation Complications: esophageal
• full-thickness necrosis → Tx esophagectomy stricture or cancer
• Dx barium swallow
• Tx cricopharyngeal myotomy
• Dx barium swallow
• Tx observation
• Dx barium swallow
• Tx esophagomyotomy

SI DZ Dz Presentation
SBO colicky abd pain, n/v,
obstipation or constipation
Paralytic ileus lack of peristalsis
Celiac sprue gluten hypersensitivity → villi
atrophy w/ dietary wheat →
malabsorption, diarrhea, weight
loss, bloating
IBD IBD: Crohn’s disease and ulcerative colitis
Dz Presentation
Crohn disease flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss
Ulcerative colitis flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss
Pouchitis: fever, bloody
diarrhea, and dyschezia s/p ileal
pouch formation in a UC pt
Toxic megacolon: huge flare →
paralyzes the colon → fever,
bloody diarrhea, abd distention
in a UC pt
Management
• Dx KUB (dilated loops w/ air-fluid levels)
• Tx NPO/IVF/NG tube, observation
• adhesions → Tx LOA + resect dead gut
• hernias → Tx herniorrhaphy + resect dead gut
• Dx KUB (uniform gas in SI, colon, rectum)
• Tx NPO/IVF/NG tube, observation
• Dx anti-gliadin or anti-endomysial ab
• Tx avoid wheat/gluten in diet
Management
• Dx KUB (terminal ileum string sign), flex sig,
• tissue bx (transmural, noncaseating
• granulomas, creeping fat)
• Tx steroids + 5-ASA (sulfsalazine)
• perianal Crohn → Tx metronidazole
• rectal Crohn → Tx subtotal colectomy
• Dx KUB (lead pipe sign), flex sig, tissue bx
• (mucosa only, crypt abscesses, pseudopolyps)
• Tx steroids + 5-ASA (sulfsalazine)
• severe dysplasia → Tx total proctocolectomy
• Tx metronidazole
• Dx KUB (dilated colon)
• Tx NPO/IVF/NG tube, IV steroids, abx
MEDICINE × GI
Other
Etiology: adhesions from prior
abd surgery (MCC), hernias (#2)
Complications: septic shock,
gangrene, peritonitis, bowel
perforation
Etiology: s/p abd surgery, meds
(e.g. narcotics, anticholinergics),
spinal cord injury, shock, hypo-
kalemia, peritonitis
Dermatitis herpetiformis: skin
lesions found in celiac sprue
Other
Location: “mouth to anus” w/
skip lesions, terminal ileum is MC
site
Complications: erythema
nodosum, SBO, fissures/fistulae
Location: colorectal only,
continuous lesions
Complications: CRC, pyoderma
gangrenosum, sclerosing
cholangitis, cholangiocarcinoma,
pouchitis, toxic megacolon

LIVER DZ Dz Presentation
Cirrhosis fibrosis → disruption of liver
architecture → portal HTN +
impaired biosynthetic function
→ multiple complications
Varices: portal HTN → dilated
veins in butt (hemorrhoids), gut
(esophageal varices), and caput
(caput medusae)
Ascites: portal HTN + hypo-
albuminemia → fluid
accumulation in abd cavity
Hepatic encephalopathy: ↓NH4
metabolism → ↑NH4 → CNS
toxicity → ∆MS, asterixis,
rigidity, hyperreflexia, fetor
hepaticus
Hepatorenal syndrome: end-
stage liver dz → renal vx vaso-
constriction → progressive
renal failure (despite normal
kidneys)
Spontaneous bacterial
peritonitis (SBP): infx of ascitic
fluid → abd pain, fever, n/v,
rebound tenderness
Hyperestrinism: ↓estrogen
metabolism → ↑estrogen →
spider angiomas, palmar
erythema, gynecomastia,
testicular atrophy
Coagulopathy: ↓clotting factor
synthesis → ↑risk of bleeding
Wilson disease AR ∆ceruloplasmin → copper
(hepatolenticular degeneration) accumulation in liver (cirrhosis),
corneas (Kayser-Fleischer rings),
brain (movement d/o), RBCs
(schistocytes)
Hemochromatosis (“bronze ↑iron → accumulation in liver
diabetes”) (cirrhosis), heart (restrictive
CM), joints (arthritis), skin
(bronze suntan), pancreas (DM)
Hepatic adenoma usually asx, can present as
hypovolemic shock and
distended abdomen if ruptured
Cavernous hemangioma usually asx, MC benign liver
tumor
Focal nodular hyperplasia (FNH) usually asx
Hepatocellular carcinoma (HCC) vague RUQ pain and mass +
s/sx of chronic liver dz (portal
HTN, ascites, jaundice)
Nonalcoholic steatohepatitis fatty liver in a nonalcoholic pt,
(NASH) usually asx
Gilbert syndrome AD ∆UDP-glucuronyltransferase
→ usually asx, but can present
w/ mild jaundice after fasting
Hemobilia injury to liver or biliary tract →
blood drains into duodenum via
CBD → UGIB, jaundice, RUQ
pain
Liver cysts Polycystic liver: ADPKD →
simple cyst in liver and kidneys
Hydatid cysts: Echinococcus
granulosus (dog tapeworm) →
multilocular cyst w/ calcified
walls
Liver abscess multiple types, all present as
fever, RUQ pain, jaundice
Budd-Chiari syndrome occlusion of hepatic vein
outflow → hepatic congestion +
portal HTN → hepatomegaly,
RUQ pain, ascites, jaundice
MEDICINE × HEPATOBILIARY/PANCREATIC
Management Other
• Dx liver bx Etiology: alcohol (MCC), HBV and
HCV (2nd), other causes
Child’s classification: stratifies
• PPx β-blockers risk of surgery in pts w/ liver
• bleeding esophageal varices → Tx band the failure; measure 3 labs (albumin,
• varices, correct coagulopathy, IV octreotide to bilirubin, PT) and 3 clinical
• lower portal pressure → if bleeding continues, findings (encephalopathy,
• repeat banding → if bleeding continues, TIPS ascites, nutrition)
• or gastric balloon tamponade
• Dx PE (shifting dullness, fluid wave) +
• paracentesis (to determine cause)
• Tx salt restriction + loop diuretic
• Tx lactulose (prevents NH4 absorption) +
• neomycin (kills GI flora that make NH4) + low
• protein diet
• Tx liver txp
• Dx paracentesis (↑WBC)
• Tx IV abx + repeat paracentesis in 2-3 days
---
• Dx ↑PT/PTT
• Tx FFP transfusion (vit K won’t work)
• Dx ↓ceruloplasmin, ↑AST/ALT, liver bx
• Tx D-penicillamine (copper chelating agent) +
• zinc (copper uptake competition)
• Dx ↑ferritin, ↓TIBC, liver bx 1° hemochromatosis: AR dz that
• Tx repeated phlebotomies ↑GI iron absorption
2° hemochromatosis: ↑iron 2/2
multiple transfusions or chronic
hemolytic anemia
• Dx CT scan or U/S Etiology: associated with OCP
• Tx d/c OCP, if it persists → Tx resection due to and anabolic steroid use
• possibility of rupture
• Dx CT scan or U/S Etiology: VAT – vinyl chloride,
• Tx reassurance aflatoxin, thorotrast
• Dx CT scan (central stellate scar or sunburst
• pattern)
• Tx reassurance
• Dx CT scan, ↑αFP Etiology: cirrhosis (MCC), A1AT
• Tx resection w/ negative margins (as long as deficiency, hemochromatosis,
• there’s no mets) Wilson dz, smoking, chemical
carcinogens
• Dx mild ↑ALT/AST
• Tx controversial
• Tx reassurance
• Dx arteriogram (gold std); EGD shows Etiology: trauma (MCC), surgery
• bleeding from ampulla of Vater (CBD exploration), tumors, infx
• Tx supportive care, stop bleeding if severe
• Tx reassurance
• Tx inject hypertonic saline inside cyst and
• carefully excise it + post-op mebendazole
• multiple/small bacterial abscesses → Tx IV abx
• single/large bacterial abscess → Tx perc drain
• amebic abscess (in Mexicans) → Tx Flagyl
• Tx TIPS as a “bridge to liver txp” Etiology: polycythemia vera
(MCC), OCPs (#2)

LFTS ↑AST/ALT (ALT>AST): chronic viral hepatitis (virALT)
↑AST/ALT (AST>ALT): acute alcoholic hepatitis (toAST)
↑↑AST/ALT: acute viral hepatitis
↑↑↑AST/ALT: severe hepatic necrosis
↑AΦ + GGT nl: pregnancy or bone dz (e.g. Paget’s)
↑AΦ + ↑GGT: biliary obstruction
↑bilirubin (conjugated <20%): hemolytic jaundice
↑bilirubin (conjugated 20-50%): hepatocellular jaundice (viral or alcoholic hepatitis)
↑bilirubin (conjugated >50%): obstructive jaundice (cancer, choledocholithiasis)
↓albumin: chronic liver dz, nephrotic syndrome, malnutrition, inflammatory states
BILIARY DZ Dz Presentation
Gallstone dz
cholelithiasis
fatty meal
passes biliary colic
into CBD lodge/infx
acute cholecystitis
choledocholithiasis
lodge/infx
acute cholangitis lodge
gallstone pancreatitis
Cholelithiasis: presence of
stones in GB, usually asx
Biliary colic: cholelithiasis →
RUQ pain after fatty meals ± n/v
Acute cholecystitis: impacted
stone in cystic duct → infx →
RUQ pain, n/v, Murphy’s sign
Choledocholithiasis: presence
of stones in CBD
Gallstone pancreatitis:
impacted stone in pancreatic
duct → reflux of pancreatic
enzymes → midepigastric pain
Acute cholangitis: impacted
stone in CBD → infx → Charcot
triad → Reynold pentad
Acalculous cholecystitis acute cholecystitis (RUQ pain,
n/v, Murphy’s sign) w/o stones
in the cystic duct, usually found
in ICU pts
GB adenocarcinoma presents as a mass in GB fossa
1° sclerosing cholangitis (PSC) thickening of bile duct walls →
narrowed lumens → gradual
jaundice and pruritus → liver
failure, cirrhosis, portal HTN
1° biliary cirrhosis (PBC) AMA → destruction of intra--
hepatic bile ducts → gradual
jaundice and pruritus → liver
failure, cirrhosis, portal HTN
Cholangiocarcinoma tumor of bile ducts → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
Choledochal cysts cystic dilation of biliary tree →
RUQ mass/pain, jaundice, fever
Biliary stricture iatrogenic injury → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
Biliary dyskinesia motor dysfxn of sphincter of
Oddi → recurrent biliary colic
w/o stones
MEDICINE × HEPATOBILIARY/PANCREATIC
AΦ
bilirubin
albumin
Management
• Dx RUQ U/S (HIDA scan if inconclusive) + get
• ERCP for choledocholithiasis/acute cholangitis
• Tx reassurance
• Tx elective lap chole
• Tx NPO, IVF, abx → lap chole within 24 hrs
• Tx NPO, IVF, ±abx → ERCP to remove stone
• if amylase returns to normal → Tx lap chole
• if amylase elevated → ERCP to remove stone
• Tx NPO, IVF, abx → ERCP to decompress CBD
• → finally lap chole
• Tx NPO, IVF, abx → lap chole within 24 hrs;
• perc drain w/ cholecystostomy if nonsurgical
• candidate
• Dx CT scan
• Tx radical cholecystectomy (GB + hilar LN +
• liver resection w/ negative margins)
• Dx ERCP (beading of bile ducts)
• Tx cholestyramine (helps w/ pruritus), liver txp
• (definitive)
• Dx screen w/ AMA (anti-mitochondrial ab),
• confirm w/ liver bx
• Tx ursodeoxycholic acid
• Dx ERCP
• Tx Whipple if resectable
• Dx ERCP
• Tx resection
• Dx ERCP
• Tx endoscopic stent (1st line), surgical bypass
• Dx HIDA scan (fill up GB w/ contrast and give
• CCK to determine ejection fraction)
• Tx lap chole
AST
ALT
Other
Boas sign: referred right scapular
pain of biliary colic
Charcot triad: RUQ pain, fever,
jaundice
Reynold pentad: Charcot triad +
∆MS, hypotension
Gallstone ileus: gallstone enters
bowel through cholecystenteric
fistula → gets stuck in terminal
ileum → SBO
Porcelain GB: dystrophic
calcification of GB has 50% risk of
adenocarcinoma, take it out
Etiology: idiopathic, but highly
associated w/ UC
2° biliary cirrhosis: progressive
cirrhosis 2/2 biliary obstruction,
sclerosing cholangitis, cystic
fibrosis, or biliary atresia
Etiology: PSC (MCC US),
Chlonorchis sinensis (MCC China)
Klatskin tumor: tumor of
proximal 1/3 of CBD, poor px
since it’s not resectable
Complications: 2° biliary cirrhosis,
acute cholangitis, liver abscess

PANCREATIC DZ Dz Presentation
Acute pancreatitis stabbing epigastric pain boring
through to the back
Hemorrhagic pancreatitis:
presents as MSOF, ARDS, hemo-
dynamic instability, signs of
ecchymoses (Grey-Turner, Fox,
Cullen signs)
Pancreatic abscess: presents as
abd pain and early satiety 2 wks
s/p acute pancreatitis
Pseudocyst: presents as abd
pain and early satiety 5 wks s/p
acute pancreatitis
Chronic pancreatitis chronic epigastric pain,
steatorrhea, diabetes mellitus
Pancreatic cancer dull abd pain + s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
Management
• Dx screen w/ ↑lipase, confirm w/ CT scan
• Tx NPO/IVF/pain meds
• Dx CT scan
• Tx admit to ICU for close monitoring
• Dx CT scan
• Tx perc drain + IV abx
• Dx CT scan
• Tx observation (<5 cm), perc drain (>5 cm)
• Dx stool elastase test
• Tx insulin + pancreatic enzyme replacement,
• IVF/NPO/pain meds for acute attacks
• Dx CT scan
• cancer in head → Tx Whipple
• cancer in body or tail → Tx distal
• pancreatectomy
• mets or local invasion → palliative care
• f/u tumor markers CA 19-9, CEA
MEDICINE × HEPATOBILIARY/PANCREATIC
Other
Etiology: I GET SMASHED –
idiopathic, gallstones (#1), EtOH
(#2), trauma, steroids, mumps,
autoimmune, scorpion sting,
hypertriglyceridemia (#3),
hypercalcemia, ERCP, drugs
Grey-Turner sign: flank
ecchymoses
Cullen sign: periumbilical
ecchymoses
Fox sign: ecchymoses of inguinal
ligament
Etiology: alcoholism (MCC
adults), cystic fibrosis (MCC kids)
Trousseau phenomenon:
migratory SVT in 10% of
pancreatic cancer pts
Courvoisier sign: palpable GB
w/o pain in 30% of cancer pts
 MEDICINE × ENDOCRINE

THYROID DZ Dz Presentation Management Other

Thyroglossal duct cyst remnant of thyroglossal duct →
mobile midline neck mass
Hyperthyroidism Graves disease (diffuse toxic
goiter): autoimmune dz due to
TSI (anti-TSH) → hyperthyroid
sx, exophthalmos, thyroid
bruits, pretibial myxedema
Plummer disease (toxic
multinodular goiter): multiple
hyperfunctioning areas in
thyroid → hyperthyroid sx
Toxic adenoma: single hyper-
functioning nodule → hyper-
thyroid sx
Thyroid storm precipitating factor (stress,
infx) → hyperthyroidism
exacerbation → marked fever,
tachycardia, agitation, GI sx
Hypothyroidism Hashimoto thyroiditis:
autoimmune dz w/ lymphocytic
infiltration → hypothyroid sx
De Quervain thyroiditis: painful
granulomatous inflammation
following viral URI → hypo-
thyroid sx
Acute thyroiditis: painful,
swollen, tender thyroid mass
due to Staph/Strep infx → hypo-
thyroid sx
Riedel thyroiditis: firm, painless
thyroid → hypothyroid sx
Myxedema coma precipitating factor (stress,
infx) → hypothyroidism
exacerbation → marked
hypothermia, ∆MS, respiratory
depression
Thyroid nodules thyroid nodule found on
physical exam
• Tx Sistrunk operation (take out cyst, trunk, and
• medial portion of hyoid bone)
• Dx ↓TSH, ↑free T4 Hyperthyroidism in elderly:
• Tx PTU (pregnant), methimazole (not presents as weakness, weight
• pregnant), oral radioiodine (can become loss, atrial fibrillation
• hypothyroid), subtotal thyroidectomy
• (permanent)
• Dx ↓TSH, ↑free T4 + patchy uptake on T3 scan
• Tx oral radioiodine (<2 cm), subtotal
• thyroidectomy (>2 cm)
• Dx ↓TSH, ↑free T4 + hot nodule on T3 scan
• Tx oral radioiodine (<2 cm), lobectomy (>2 cm)
• Tx β-blockers + antithyroid drugs Px: 20% mortality rate
• Dx ↑TSH, ↓/nl free T4 Hashimoto abs: anti-TSH, anti-
• Tx Synthroid microsomal, anti-thyroglobulin,
anti-peroxidase (TPO)
• Dx ↑TSH, ↓/nl free T4
• Tx NSAIDs + observation (will self-resolve)
• Dx ↑TSH, ↓/nl free T4
• Tx I+D
• Dx ↑TSH, ↓/nl free T4
• Tx Synthroid vs. surgery
• Tx IV thyroxine + hydrocortisone + supportive
• care
Dx TSH (normal) MC type: benign colloid nodule
Malignancy signs: solid nodules,
Dx FNA cold nodules (lack of radioiodine
uptake), size >1.5 cm
benign indeterminate malignant

Dx thyroid scan

hot cold

Thyroid cancer thyroid nodule or mass found
on physical exam; 80% papillary,
15% follicular, 4% medullary, 1%
anaplastic
Papillary cancer: lymphatic
spread, “Psamomma bodies w/
Orphan Annie nuclei”, best px
Follicular cancer: hemato-
genous spread, endemic to
iodine-deficient areas
Medullary cancer: lymphatic
and hematogenous spread,
amyloid deposits
Anaplastic cancer: rare, worst
px
Hürthle cell cancer: aggressive ,
lymphatic-spreading variant of
follicular cancer
observation Tx surgery
• Dx FNA (for all types except follicular, must
• see capsular invasion for adenoma/carcinoma)
• Tx total thyroidectomy w/ central LN excision
• → modified radical neck dissection if +LN
• f/u thyroglobulin levels
• Tx hemilobectomy + frozen bx → total
• thyroidectomy if bx shows carcinoma
• f/u thyroglobulin levels
• Tx total thyroidectomy w/ central LN excision
• → modified radical neck dissection if +LN
• f/u calcitonin levels + 24-hr urinary VMA
• (MEN2 syndrome also has pheos)
• Tx palliative care
• Tx total thyroidectomy w/ central LN excision
• → modified radical neck dissection if +LN
• f/u thyroglobulin levels
Risk factors: Post-radiation
(Papillary), MEN2 syndrome
(Medullary)
Px: MACIS system – Metastasis,
Age (<45), Completeness of
resection, Invasion, Size (>2 cm)
Surgery complications: recurrent
laryngeal nerve (hoarseness),
superior laryngeal nerve (soft,
deep voice), parathyroid glands
(hypocalcemia)

PARATHYROID DZ Hypocalcemia sx: neuromuscular irritability (tingling, tetany), prolonged QT, arrhythmias
Hypercalcemia sx: stones (kidney)
bones (bone pain, osteitis fibrosa cystica)
groans (peptic ulcers, pancreatitis)
psychic overtones (depression, anxiety, ∆MS)
Dz Presentation
Hypoparathyroidism head/neck surgery → accidental
PTH-ectomy → hypocalcemia sx
Pseudohypoparathyroidism end-organ resistance to PTH →
hypocalcemia sx
1° HPTH 90% adenoma, 9% hyperplasia,
1% carcinoma → hypercalcemia
sx
2° HPTH renal failure → ↓1α-hydroxylase
→ ↓vit D → ↓Ca →
compensatory ↑PTH
3° HPTH 2° HPTH pts get renal txp but
parathyroid glands still
hypersecretory despite ↑Ca
Hypercalcemic crisis Ca >15
PITUITARY DZ Polyuria/polydipsia DDx: DM, DI, diuretic use, primary polydipsia (Ψ d/o)
Dz Presentation
Pituitary adenoma tumor of anterior pituitary
gland → bitemporal hemi-
anopsia (◐◑) + hyperpituitary
or hypopituitary sx
Prolactinoma: ↑PRL →
galactorrhea, amenorrhea,
infertility, ↓libido
Acromegaly: ↑GH →
overgrowth of brow, jaw,
hands, and feet; MCC death is
CV disease
Pituitary Cushing: ↑ACTH →
truncal obesity, abd striae,
buffalo hump, hyperglycemia,
osteoporosis, HTN, immuno-
suppression
Hypopituitarism: ↓FSH/LH,
↓ACTH, ↓TSH, ↓PRL, ↓GH
Craniopharyngioma embryological remnant of
Rathke pouch → bitemporal
hemianopsia (◐◑), headache,
papilledema, ∆MS
Diabetes insipidus (DI) polyuria, polydipsia
Central DI: ↓ADH secretion from
posterior pituitary
Nephrogenic DI: normal ADH
but kidneys don’t respond
SIADH ↑ADH secretion from posterior
pituitary → volume expansion,
hyponatremia (coma/sz/death if
acute, asx if chronic)
MEDICINE × ENDOCRINE
Management Other
• Dx ↓PTH, ↓Ca, ↑P Chvostek sign: tapping on Cheek
• Tx vit D + calcium replacement causes muscle contractions
Trousseau sign: inflating BP cuff
causes carpal muscle spasms
DiGeorge syndrome: thyroid +
parathyroid hypoplasia
• Dx ↑PTH, ↓Ca, ↑P Knuckle-knuckle-dimple-dimple
• Tx vit D + calcium replacement sign: hand morphology seen w/
pseudohypoparathyroidism
• Dx ↑PTH, ↑Ca, ↓P + Cl:P ratio >33:1
• Tx surgery (adenoma → take it out,
• hyperplasia → 3½ gland removal, carcinoma
• → en bloc resection of parathyroid and ipsi
• thyroid lobe)
• Dx ↑↑PTH, ↓Ca, ↑P
• Tx vit D + calcium replacement, low P diet
• Dx ↑PTH, ↑Ca, ↓P
• Tx observation for 1 year, then 3½ gland
• excision if still problematic
• Tx “flush and drain” (NS then Lasix), then
• surgery for parathyroid carcinoma
Management Other
• Dx MRI
• Dx ↑PRL + β-HCG/TSH (r/o 2° causes)
• Tx bromocriptine or cabergoline (<1 cm),
• transsphenoid hypophysectomy (≥1 cm)
• Dx oral glucose test
• Tx transsphenoid hypophysectomy +
• octreotide (suppress GH)
• Dx ↑ACTH + dexa suppression test (pituitary
• Cushing is suppressable)
• Tx transsphenoid hypophysectomy
• Dx hormone levels
• Tx hormone replacement
• Dx MRI (supracellar calcified cysts)
• Tx transsphenoid hypophysectomy
• Dx water deprivation test (normal pts increase
• urine osm >280, central DI <280 but normalize
• w/ ADH, nephrogenic DI <280 and don’t
• normalize w/ ADH)
• Tx DDAVP
• Tx HCTZ
• Dx Na <135, plasma osm <270 Central pontine myelinolysis:
• Tx water restriction rapid correction of hyponatremia
will cause demyelination and
locked-in syndrome, so replace
Na at a max of 0.5/hr

ADRENAL DZ Dz Presentation
Cushing syndrome ↑cortisol → truncal obesity, abd
striae, buffalo hump,
hyperglycemia, osteoporosis,
HTN, immunosuppression
Pituitary Cushing: ↑ACTH
secretion from pituitary gland
Adrenal Cushing: ↑cortisol
secretion from adrenal gland
Ectopic Cushing: ↑ACTH
secretion from SCLC
(paraneoplastic syndrome)
Iatrogenic Cushing: MCC
0verall, d/t exogenous steroids
Pheochromocytoma episodic catecholamine excess
→ 5 Ps – Pressure (BP), Pain
(HA), Perspiration, Palpitations,
Pallor
1° hyperaldosteronism (Conn 67% adenoma, 33% hyperplasia
syndrome) → ↑aldosterone → ↑Na (HTN),
↓K, ↓H (metabolic alkalosis)
Adrenal insufficiency ↓cortisol/↓aldosterone →
hypoglycemia, HTN, fatigue,
hyperpigmentation, weight
loss, abd pain
1° adrenal insufficiency
(Addison disease): autoimmune
(MC US), TB (MC 3rd world),
Waterhouse-Friderichsen
syndrome (N. meningitidis)
2° adrenal insufficiency: due to
abrupt cessation of steroid use
(MCC overall)
Congenital adrenal hyperplasia congenital deficiency of 21α-
hydroxylase (MC) or 11β-
hydroxylase → hirsutism,
virilization, ↓Na/↑K/↑H
Incidentaloma adrenal tumor found
incidentally on CT scan
PANCREATIC DZ Dz Presentation
Insulinoma ↑insulin → Whipple’s triad
(hypoglycemia, worse w/
fasting, better w/ glucose)
Gastrinoma (ZE syndrome) ↑gastrin → ↑gastric acid
secretion → ulcers
Glucagonoma ↑glucagon → new-onset
diabetes + necrolytic migratory
erythema
Somatostatinoma ↑SST → triad of gallstones,
diabetes, steatorrhea
VIPoma ↑VIP → “rice water” diarrhea
MEN SYNDROME Dz Presentation
MEN 1 (Wermer syndrome) pituitary adenoma, pancreatic
endocrinoma (MC gastrinoma),
parathyroid hyperplasia
MEN 2A (Sipple syndrome) parathyroid hyperplasia,
pheochromocytoma, thyroid
medullary cancer
MEN 2B pheochromocytoma, thyroid
medullary cancer, mucosal
neuromas, Marfanoid habitus
MEDICINE × ENDOCRINE
Management Other
Cushing syndrome
Dx ACTH, cortisol,
dexamethasone suppression test
↑ACTH, ↑cortisol ↓ACTH, ↑cortisol
adrenal Cushing
(Dx abd CT)
>50% suppression <50% suppression
pituitary Cushing ectopic Cushing
(Dx head MRI) (Dx chest/abd CT)
• Tx transsphenoid hypophysectomy
• Tx adrenalectomy
• Tx underlying cause
• Tx taper steroids slowly
• Dx 24 hr urinary VMA/metanephrines Rule of 10’s: 10% malignant, 10%
• Tx α-blockers (phenoxybenzamine) then bilateral, 10% extraadrenal, 10%
• β-blockers then adrenalectomy calcify, 10% kids, 10% familial
(MEN2A/2B)
• Dx abd CT scan
• Tx adrenalectomy (adenoma), spironolactone
• (hyperplasia)
• Dx ↓cortisol + ACTH levels (↑ACTH if primary,
• ↓ACTH if secondary)
• Tx glucocorticoid (prednisone) +
• mineralocorticoid (fludrocortisone)
• Tx glucocorticoid (prednisone) only
• Dx ↑17-OHP
• Tx glucocorticoid (prednisone) +
• mineralocorticoid (fludrocortisone)
• <5 cm → leave alone
• >5 cm → Tx resection + check other organs
• since adrenals are common site of metastasis
Management Other
• Dx ↑C-peptide levels or monitored fasting (to
• see if they’re “faking it”)
• Tx resection
• Dx gastrin levels (<200 absent, >500 present); Gastrinoma triangle: neck of
• if 200-500, get secretin stimulation test pancreas, cystic duct, junction
• (paradoxical ↑gastrin w/ secretin) b/t 2nd and 3rd part of duodenum
• Tx resection
• Dx glucose challenge test
• Tx resection
• Tx resection
• Tx resection
Management Other
• Tx excise parathyroid first (since hyper
• calcemia can cause ↑gastrin), then gastrinoma,
• then pituitary adenoma (w/ cabergoline)
• Tx excise pheo first (life-threatening) Etiology: AD ret proto-oncogene
• Tx excise pheo first (life-threatening) Etiology: AD ret proto-oncogene

DIABETES MELLITUS Dz Presentation
Impaired glucose tolerance asx
T1DM autoimmune destruction of β-
cells → lack of insulin → pt
usually presents in acute DKA
T2DM obesity → ↑FFA release →
↑insulin resistance → ↑glucose
→ classic sx (polyuria, poly-
dipsia, polyphagia) + blurry
vision, weight loss, recurrent
vaginal yeast infx
DM complications Macrovascular complications:
nonenzymatic glycosylation
(NEG) → atherosclerosis →
CAD, MI, PVD, stroke/TIA, etc.
Diabetic nephropathy: NEG of
basement membrane → loss of
negative charge → micro-
albuminuria → proteinuria →
CKD → ESRD
Diabetic retinopathy: NEG of
retinal vx → either background
or proliferative retinopathy
Diabetic neuropathy: NEG of
peripheral nerves → damage →
“stocking/glove” burning pain,
numbness, tingling
Diabetic foot: peripheral
neuropathy + PVD (ischemia) →
repetitive injuries → ulcers and
nonhealing
DKA T1DM exacerbation → ↓insulin
→ hyperglycemia + ketosis →
osmotic diuresis, dehydration,
fruity breath, Kussmaul
respiration, etc.
HHNS T2DM exacerbation → ↓insulin
→ hyperglycemia → hyper-
osmolarity, osmotic diuresis,
severe dehydration
Hypoglycemia ↓glc → ↑epinephrine
(sympathetic sx), CNS
dysfunction at 40-50 (HA,
weakness, drowsiness, coma)
MEDICINE × ENDOCRINE
Management Other
• Dx fasting glc 110-126
• Tx insulin, 0.5-1 u/kg (2/3 morning, 1/3 evening)
• inpatient → Tx SSI
• Dx fasting glc >126, random glc >200 w/ sx, or Ideal levels: HbA1c <7%, fasting
• HbA1C >6.5% glc <130, post-prandial glc <180,
BP <130/80, LDL <100
T2DM
Insulin dosage: “basal bolus” –
fasting glc <240 fasting glc >240 long-acting Lantus + short-acting
Novolog w/ meals
lifestyle changes
(still high)
Tx metformin or Tx insulin
sulfonylurea
(still high) (still high)
add another PO drug
Outpatient mgmt: q day – glucose
q visit – BP, foot chk
q 3 mo – HbA1c
q 6 mo – neuropathy chk
q yr – microalbuminuria,
BUN/Cr, lipids, eye chk
• PPx reduction of risk factors (BP, lipids, Microalbuminuria: 20-200
• smoking, diet, exercise) μg/min or 30-300 mg/day
• PPx annual microalbuminuria screening
• Tx ACE inhibitors
• PPx annual ophtho referral
• Tx photocoagulation
• neuropathy → Tx amitriptyline (1st line),
• gabapentin or duloxetine (2nd line)
• gastroparesis → Tx metoclopramide
• PPx regular foot check
• Tx wound care, amputation (last resort)
• Dx ↑glc, ↑ketones, metabolic acidosis
• Tx insulin + IVF (NS) + potassium (paradoxical)
• Dx ↑glc, ↑osmolarity, no acidosis or ketosis
• Tx insulin + IVF (NS)
• Dx ↓glc Etiology: insulin overdose (MCC),
• Dx C-peptide, insulin levels, anti-insulin ab, and factitious hypoglycemia (low C-
• sulfonylurea levels (look for underlying cause) peptide levels), insulinoma, etc.
• Tx underlying cause + sugary foods or IV D50W
 MEDICINE × NEURO

STROKE Stroke types: ischemic (85%), hemorrhagic (15%)

Stroke in young pt: cocaine abuse

Carotid bruit: either internal carotid artery stenosis, or referred heart murmur

Dz Presentation Management Other

Subclavian steal syndrome
Transient ischemic attack (TIA)
Ischemic stroke
Hemorrhagic stroke
asx at rest, but arm claudication • Dx arteriogram
and CNS sx with exercise due to • Tx bypass surgery
stenotic subclavian artery (can
present like a TIA)
focal neuro sx <24 hrs (usually • CV risk factor analysis, since risk of stroke is
<1 hr) • much higher in the near future
• anterior circle TIAs → Dx carotid duplex;
Carotid TIA: abrupt • consult surg for CEA if ≥70% stenosis
contralateral sx
Vertebrobasilar TIA: ipsilateral
CN palsy, contralateral
hemiplegia
Drop attacks: brief paralytic
spells resulting in pt dropping
to knees w/o LOC
Transient global amnesia: TIA in
temporal lobes or thalamus →
rapid retrograde memory loss +
confusion but preservation of
self-identity
Amaurosis fugax: TIA in retinal
artery → temporary unilateral
loss of vision
focal neuro sx >24 hours • Dx head CT w/o contrast (dark areas) Risk factors: HTN (#1), old age
• Tx TPA <3 hrs, aspirin ≥3 hrs or TPA c/i (#2), CAD, CHF, acute MI, AFib,
ACA syndrome: contralateral diabetes, male sex, Black race,
leg hemiparesis, incontinence • AFib-related stroke → Tx heparin/warfarin smoking, alcohol, OCPs
MCA syndrome: contralateral • lacunar strokes → Tx control HTN
face/arm hemiparesis • anterior circle strokes → Dx carotid duplex; Etiology: embolic stroke (AFib,
PCA syndrome: homonymous • consult surg for CEA if ≥70% stenosis endocarditis), thrombotic stroke
hemianopia (atherosclerosis), lacunar stroke
Vertebrobasilar syndrome: (HTN)
ipsilateral CN palsy,
contralateral hemiplegia
Cerebellar infarction:
headache, nausea, vomiting,
vertigo, nystagmus
Lacunar syndromes: pure
motor or sensory stroke, clumsy
hand-dysarthria syndrome
ICH: bleeding into brain • Dx head CT w/o contrast (white areas) Risk factors: HTN (#1)
parenchyma → focal neuro sx + • Tx intubate and hyperventilate, slowly lower
sudden headache + vomiting • BP, control ↑ICP w/ mannitol, admit to ICU
SAH: rupture of berry aneurysm • Dx head CT w/o contrast (white areas),
→ bleeding into subarachnoid • do an LP if not sure (blood, xanthrochromia)
space → “worst headache of my • Tx bed rest in dark/quiet room, analgesics for
life” • headache, nifedipine for vasospasm ppx,
• consult neurosurg to clip berry aneurysm

HEAD TRAUMA Basal skull fx: raccoon eyes, hemotympanum, otorrhea, rhinorrhea, ecchymosis behind the ear (Battle sign)
Coup-contrecoup injury: injury at site of impact + opposite point of impact
Diffuse axonal injury: global damage to entire brain during impact → severe neuro dysfxn, coma

Dz Presentation Management Other

EDH temporal bone fx → tear in • Dx head CT (convex lens hematoma)
middle meningeal artery → • Tx emergent craniotomy
bleeding into epidural space →
LOC w/ lucid interval
SDH tear in bridging veins → venous • Dx head CT (crescent moon hematoma) Risk factors: shrunken brain
bleed into subdural space → • Tx craniotomy (acute), reassurance (chronic) states (alcoholics, elderly)
∆MS, headache, cortical dysfxn, SDH in kids: consider child abuse
possible herniation if acute
Concussion brief LOC following blunt head • no tx available
trauma w/ confusion, dizziness,
impaired concentration, etc.
 MEDICINE × NEURO

MOVEMENT D/O Movement d/o in young pt: consider Wilson disease

Dz Presentation Management Other

Parkinson disease (PD)
Huntington chorea
loss of dopaminergic neurons
→ early PD presents as TRAP –
pill-rolling Tremor, cogwheel
Rigidity, Akinesia, Postural
instability; late PD presents as
Alzheimer-like dementia
AD CAG trinucleotide repeats on
chromosome 4 → ↓GABA →
chorea, apathy, depression,
dementia w/ onset at 35-50 y/o
• early PD → Tx Sinemet (carbidopa + levodopa)
• late PD → Tx subthalamic nucleus deep brain
• stimulation
• Dx MRI (caudate atrophy), DNA testing
• no tx available
PD brain: neuronal death in
substantia nigra, senile plaques,
Lewy bodies
Shy-Drager syndrome: PD +
autonomic insufficiency
Progressive supranuclear palsy
(PSP): PD w/o ophthalmoplegia
or tremors

Anticipation: longer CAG repeats

correlates with earlier age of
onset
Essential tremor AD tremor w/ intentional • Tx β-blockers
activity but not at rest,
improved w/ EtOH use
Ataxia gait instability, loss of balance, • Tx underlying cause
impaired limb coordination

Acquired ataxia: ataxia 2/2

Tourette syndrome
EtOH, B12/thiamine deficiency,
cerebellar dz, demyelinating dz,
or 3° syphilis
Friedreich ataxia: ataxia w/
staggering gait, nystagmus, pes
cavus and hammer toes
Ataxia-telangiectasia:
Friedreich ataxia +
telangiectasias
most severe tic disorder w/ • Tx clonidine or pimozide (Haldol if severe) Coprolalia: involuntary swearing,
multiple daily motor/vocal tics, pathognomonic but rare in
onset before 18 y/o; associated Tourette syndrome
w/ OCD and ADHD
 MEDICINE × NEURO

DEMENTIA Normal aging vs. dementia: no impairment of daily functioning w/ normal aging
Delirium vs. dementia: Delirium Dementia
Definition waxing-and- impairment in
waning change in memory and
pt’s level of other cognitive
consciousness functions
Onset acute chronic
Duration 3 days – 2 wks months – yrs
Px reversible irreversible
Amnesia immediate and recent and
recent memory remote memory
Alert no yes
Oriented no sometimes
Dx abnormal EEG abnormal MRI

Dementia: progressive and irreversible impairment in memory and other cognitive functions w/o change in level of consciousness
Causes of dementia: Alzheimer (#1), vascular (#2), Lewy body (#3), others

Dz Presentation Management Other

Pseudodementia
Secondary dementia
Alzheimer disease (AD)
Vascular dementia
Lewy body dementia
Pick disease (frontotemporal
dementia)
HIV-associated dementia
Creutzfeldt-Jakob disease
Normal pressure hydrocephalus
severe depression that can • Tx SSRIs
present like dementia in elderly
dementia 2/2 hypothyroidism, • Tx underlying cause
B12/folate deficiency, thiamine
deficiency, neurosyphilis, or
medication use
↓ACh → gradual progressive • Dx MMSE (<25), head CT (diffuse atrophy w/ Amyloid cascade hypothesis:
decline in memory and other • enlarged ventricles, flat sulci) high risk genes (presenilin I,
cognitive functions • r/o secondary causes presenilin II, APP, apoE4) can
• Tx AChE-inhibitors for mild/moderate AD predispose to Aβ-amyloidosis
• (tacrine, donepezil), NMDA antagonist for Alzheimer × Down syndrome:
• severe AD (memantine) trisomy 21 → triple apoE4
expression → inevitable by 40
y/o
accumulation of multiple small • Dx MMSE (<25), head CT (multiple small
infarcts → stepwise loss of • lacunar infarcts)
function + focal neurological sx • no tx available
Lewy body and neurite • Dx MMSE (<25), clinical judgment
accumulations in the basal • manage like Alzheimer disease
ganglia → dementia, waxing-
and-waning parkinsonism,
visual hallucinations, sensitivity
to antipsychotics
profound changes in • Dx MMSE (<25), head CT (marked atrophy of
personality and social conduct, • frontal and temporal lobes)
disinhibition, hyperorality, • no tx available
hypersexuality; good memory
and language though
neutropenia → infection → • Tx HAART
rapid decline in memory,
cognition, behavior, motor
skills; depression and social
withdrawal also common
abnormal prion accumulation • Dx EEG (generalized sharp waves), confirm w/
→ rapidly progressive • postmortem brain bx (spongiform change)
dementia, myoclonus (muscle
spasms), personality changes
3 Ws – Wet (urinary • Dx MRI (large ventricles)
incontinence), Wobbly (gait • Tx CSF shunt
apraxia), Wacky (dementia)
 MEDICINE × NEURO

ALTERED MS ICP: normally 5-15; ICP >20 → bilateral fixed/dilated pupils → herniation → death
Cushing triad: triad of vital signs in ICP – ↑BP, ↓HR, irregular RR

Glasgow coma scale: GCS score = E+M+V / 15

Abnl pupillary light reflex: mass lesions, pupil drugs, hypoxia, eye drops
Bilateral fixed/dilated pupils: severe anoxia
Unilateral fixed/dilated pupil: herniation w/ CN III compression
Pinpoint pupils: narcotics, ICH (in pons)

Dz Presentation Management Other

Delirium waxing-and-waning change in
level of consciousness; can also
have visual hallucinations, short
attention span, and impaired
recent memory
Sundowning: worsening of
delirium at night
Coma damage to RAS or bilateral
hemispheres → depressed LOC,
unresponsive to any stimuli
“Locked in” syndrome damage to ventral pons →
coma-like state but pt is fully
conscious and can control
blinking, vertical eye movement
Brain herniation edema or mass lesion → ↑ICP
→ brain tissue moves past
anatomic barriers
• Dx MMSE (<25) Etiology: AEIOU TIPSS – Alcohol
• r/o life-threatening causes, then ID and Tx and drug toxicity or withdrawal,
• underlying cause Electrolyte imbalance,
Iatrogenic, Oxygen hypoxia,
Uremia/hepatic encephalopathy,
Trauma, Infection, Poison,
Seizures, Stroke
• Dx GCS (≤8)
• r/o life-threatening causes, then ID and Tx
• underlying cause
---
• Dx head CT
• Tx intubate, lower ICP, consult neurosurg

CN III: ipsilateral “blown pupil”

PCA: contralateral
homonymous hemianopia
Crus cerebri: ipsilateral paresis
Brainstem: Duret hemorrhages,
death
Brain death irreversible absence of brain • Dx EEG (no activity)
function despite adequate • d/c life support
oxygenation/ventilation, no
brainstem reflexes

DEMYELINATING DZ Dz Presentation Management Other

Multiple sclerosis selective CNS demyelination → • Dx MRI (multiple white plaques), LP w/ CSF
optic neuritis, intranuclear analysis (oligoclonal bands)
ophthalmoplegia (crazy eyes), • Tx IFN-β (prevent relapses), high-dose steroids
transient sensory deficits, etc. (for acute attacks)

Guillain-Barré syndrome rapid PNS demyelination → • Dx CSF (↑protein), EMG (↓nerve conduction)
ascending weakness/paralysis, • Tx IVIG vs. plasmapheresis
possible respiratory arrest

CNS NEOPLASMS Ring-enhancing lesions: MALT – metastases, abcesses, lymphoma, toxo

Brain cancer sx: mass effect → headache, seizures, focal neuro sx

MC brain cancers: metastases (overall), astrocytoma (adults), infratentorial tumors (kids)

Dz Buzzwords Management Other

GBM can cross corpus callosum • Dx MRI
(butterfly glioma), pseudo- • Tx resection (if resectable), radiation
palisading necrosis, GFAP+ • (astrocytomas, oligodendrogliomas,
Astrocytoma Rosenthal fibers, GFAP+ • lymphoma, metastases)
Oligodendroglioma “fried egg” cells, chicken-wire
capillary pattern
Meningioma Psamomma bodies, attached to
dura
Acoustic schwannoma S-100+, CN VIII Bilateral schwannoma: NF type 2
CNS metastases multiple ring-enhancing lesions Mets source: lung > breast > skin
> kidney > colon
Primary CNS lymphoma AIDS/immunosuppression
Meningeal carcinomatosis cancer that metastasizes to • Dx LP w/ CSF analysis (malignant cells)
meninges via bloodstream → • Tx intrathecal chemotherapy
focal neuro sx, meningitis,
hydrocephalus

NEUROMUSCULAR DZ Dz
Myasthenia gravis
Lambert-Eaton myasthenic
syndrome (LEMS)
Duchenne muscular dystrophy
Becker muscular dystrophy
NEUROCUTANEOUS Dz
SYNDROMES Neurofibromatosis type I
(von Recklinghausen disease)
Neurofibromatosis type II
Tuberous sclerosis
Sturge-Weber syndrome
Von Hippel-Lindau disease
SPINAL CORD DZ CS tract: descending motor signals, crosses at medulla
DCML tract: ascending touch and proprioception, crosses at medulla
ALS tract: ascending pain and temperature, crosses in spinal cord
Dz
Syringomyelia
Brown-Sequard syndrome
Transverse myelitis
Poliomyelitis
MEDICINE × NEURO
Presentation Management Other
anti-nAChR → gradually • Dx ↑anti-nAChR (best), edrophonium test,
progressive muscle weakness • EMG (decreased response w/ repetitive
(initial sx is ptosis, diplopia, • stimulation), chest CT to look for thymoma
blurry vision) that get worse w/ • Tx pyridostigmine, plasmapheresis (if severe),
repetitive muscle use • thymectomy (if thymoma)
• myasthenic crisis → emergent ventilation
SCLC → anti-VGCC → gradually • Dx ↑anti-VGCC
progressive muscle weakness • Tx underlying cause
that get better w/ repetitive
muscle use
XR ∆dystrophin → muscle cells • Dx ↑CPK, DNA testing
die off → ascending weakness • no tx available
w/ Gowers maneuver, calf
pseudohypertrophy, death by
15 y/o
XR ∆dystrophin → same as • Dx ↑CPK, DNA testing
DMD, but later onset and less • no tx available
severe sx
Presentation Management Other
AD ∆NF1 → café-au-lait spots, • NF pt w/ HTN → Dx urinary metanephrines
Lisch nodules (iris hamartomas),
CNS tumors, pheo
AD ∆NF2 → bilateral acoustic ---
neuromas, juvenile cataracts
AD ∆TSC1/2 → CNS/retinal ---
hamartomas, sebaceous
adenomas, hypopigmented
“ash leaf spots”, Shagreen
patches, renal angiomyo-
lipoma, cardiac rhabdomyoma
facial “port-wine stain” w/ ---
ipsilateral brain AVM
AD ∆VHL → hemangio- ---
blastomas, bilateral RCC,
pheochromocytomas
Presentation Management Other
central cavitation of cervical • Dx MRI
cord → bilateral “cape-like” • Tx syringosubarachnoid shunt
loss of ALS, ipsilateral CS
stab wound → spinal cord ---
hemisection → ipsilateral loss
of DCML and CS, contralateral
loss of ALS
viral infx → loss of function of • Dx MRI
entire spinal cord at a single • Tx high-dose steroids
level → bilateral loss of
CS/DCML/ALS below level of
lesion + sphincter dysfunction
polio infx (fecal-oral) → • PPx vaccination
bilateral lower motor neuron
loss of function → asymmetric
muscle weakness w/ normal
sensation
 MEDICINE × NEURO

OTHER CNS DZ Syncope vs. seizures: prolonged LOC or bowel/bladder incontinence indicates seizures

Dz Presentation Management Other

Vertigo “spinning of the room”, five
types (BLAME) – BPPV,
Labyrinthitis, Acoustic
neuroma, Meniere disease,
EtOH/drug-induced
Syncope Cardiac syncope: sudden LOC
w/o prodromal sx; d/t massive
MI, arrhythmias, or obstruction
(e.g. aortic stenosis)
Vasovagal syncope: paradoxical
PSNS activity during intense
emotion → LOC w/ premonitory
sx (pallor, sweating, nausea)
Orthostatic hypotension: delay
in peripheral venoconstriction
→ LOC w/ sudden or prolonged
standing
Seizures Simple partial sz: transient
unilateral movements w/o LOC
Complex partial sz: transient
automatisms w/ LOC →
postictal confusion
Grand-mal sz: sudden LOC →
rigidity (tonic phase) →
musculature jerking (clonic
phase) → postictal confusion
Absence sz: “staring into
space” for a few seconds
Amyotrophic lateral sclerosis upper and lower motor neuron
(Lou Gehrig disease) lesions → progressive muscle
weakness → death in 5-10 yrs
• Tx underlying cause + meclizine for nausea
• first step is to r/o cardiac causes (get EKG,
• CV-focused physical)
• cardiac syncope → Tx underlying cause
• vasovagal syncope → Dx tilt-table study,
• Tx β-blockers + disopyramide
• orthostatic hypotension → Dx orthostatics,
• Tx fluid/sodium intake
• first time → Dx labs (renal panel, glucose) + Etiology: 4 Is + 4 Ms – Infx,
• EEG + MRI (r/o mass lesions) Ischemia (stroke/TIA), ↑ICP,
• epileptic → check anticonvulsant levels Intoxication, Metabolic and
electrolytes, Mass lesions,
• partial sz → Tx phenytoin or CBZ Missing drugs (anticonvulsants,
• grand-mal sz → Tx phenytoin or CBZ sedatives/EtOH), Misc
• absence sz → Tx ethosuximide Pseudoseizure: looks like sz but
no EEG changes
Secondary generalization:
partial sz → generalized sz
Status epilepticus: brain is stuck
in a state of persistent seizure
• Dx EMG (fasciculations, fibrillations), nerve
• conduction studies (↓conduction velocity)
• Tx supportive care + riluzole (glutamate-
• antagonist that delays death by 3-5 months)

Aphasia Wernicke aphasia: superior • usually resolves on its own Etiology: stroke (#1), trauma,
temporal gyrus lesion → fluent tumors, Alzheimer dz
w/ impaired comprehension
Broca aphasia: inferior frontal
gyrus lesion → nonfluent w/
intact comprehension
Conduction aphasia: both gyri
lesion → nonfluent w/ impaired
comprehension
Global aphasia: arcuate
fasciculus lesion → can’t repeat
“no ifs, ands, or buts”
Bell palsy weakness or paralysis of facial • usually resolves on its own Etiology: trauma, Lyme disease,
muscles innervated by CN VII • Tx steroids if ≥10 days, ACV if shingles, tumors, Guillan-Barre syndrome,
• doxycycline if Lyme disease shingles
Bilateral Bell: Lyme disease or
Guillain-Barre syndrome
Trigeminal neuralgia (tic severe, recurrent pain attacks in • Tx CBZ
douloureux) trigeminal distribution
 MEDICINE × MSK

BUZZWORDS HLA-B27: PAIR – psoriatic arthritis, ankylosing spondylitis, IBD, Reiter syndrome
HLA-DR2: SLE
HLA-DR3: SLE, Sjögren syndrome
HLA-DR4: Rheumatoid 4rthritis, mixed CT disease

C-ANCA: Wegener granulomatosis

P-ANCA: Churg-Strauss syndrome, microscopic polyangiitis

Anti-basement membrane: Goodpasture syndrome

Anti-CCP: rheumatoid arthritis
Anti-centromere: CREST syndrome
Anti-desmosome: pemphigus vulgaris
Anti-dsDNA: SLE
Anti-endomysial: celiac sprue
Anti-Fc IgG (RF): SLE, RA, many others
Anti-gliadin: celiac sprue
Anti-hemidesmosome: bullous pemphigoid
Anti-histone: drug-induced lupus
Anti-Jo-1: polymyositis/dermatomyositis
Anti-microsomal: Hashimoto thyroiditis
Anti-mitochondrial (AMA): primary biliary cirrhosis
Anti-nAChR: myasthenia gravis
Anti-nuclear (ANA): SLE, RA, many others
Anti-peroxidase: Hashimoto thyroiditis
Anti-Scl-70 (anti-topoisomerase): scleroderma (diffuse)
Anti-Sm: SLE
Anti-smooth muscle: autoimmune hepatitis
Anti-SSA/SSB (anti-Ro/La): Sjögren syndrome
Anti-thyroglobulin: Hashimoto thyroiditis
Anti-TSH (TSI): Graves disease
Anti-U1-RNP: mixed CT disease
Anti-VGCC: Lambert-Eaton myasthenic syndrome

CONNECTIVE TISSUE DZ Dz Presentation Management Other

SLE type 3 HS → flare-and-remission • Dx screen w/ ANA, confirm w/ anti-dsDNA, MC pts: Af-American women
pattern of I’M DAMN SHARP – • anti-Sm, or ↓C3-C5
↑IgG • Tx low-dose aspirin, corticosteroids for flares,
Malar rash • cyclophosphamide for lupus nephritis
Discoid rash
ANA
Mucositis (throat ulcers)
Neurologic d/o
Serositis (pleuritis, pericarditis)
Hematologic d/o
Arthritis
Renal d/o (“wire loops”)
Photosensitivity
Drug-induced lupus drugs → type 3 HS → SLE-like • Dx anti-histone Etiology: HIPP – Hydralazine,
presentation but no kidney or • Tx d/c meds INH, Procainamide, Phenytoin
CNS involvement
Neonatal lupus maternal ag-ab cross placenta • Tx close management during prenatal care
→ lupus sx; anti-SSA attacks
fetal heart → 3° AV block
APA syndrome hypercoagulability in SLE or • Dx lupus anticoagulant or anticardiolipin ab
other collagen-vascular dz → • Tx anticoagulation (warfarin)
high-risk for venous (DVT, PE)
and arterial clots (stroke, MI),
recurrent abortions
Raynaud disease digital vasospasm → fingertips • Tx underlying disorder, keep hands warm,
go from blue-to-white-to-red • Ca-blockers if severe
Scleroderma (diffuse) severe, widespread fibrosis of • Dx anti-Scl-70 (anti-topoisomerase)
skin (sclerodactyly) and viscera • Tx palliative care
Scleroderma (CREST syndrome) Calcinosis of fingers, Raynaud • Dx anti-Centromere
phenomenon, Esophageal • Tx palliative care
dysmotility, Sclerodactyly (only
face and fingers), and
Telangiectasias (over fingers)
Sjögren syndrome autoimmune attack of salivary • Dx anti-SSA/SSB (anti-Ro/La)
and lacrimal glands → dry eyes, • Tx pilocarpine, artifical tears, oral hygiene
dry mouth, arthritis
Mixed CT disease “overlap syndrome” of SLE, • Dx anti-U1-RNP
RA, scleroderma, polymyositis • Tx predominant dz

ARTHRITIS Dz Presentation
Osteoarthritis wear-and-tear of joints →
degeneration of cartilage →
deep, dull joint pain, worse w/
activity and improved w/ rest
Joints: weight-bearing joints
(hips, knees, spine), PIP+DIP
(Heberden, Bouchard)
Rheumatoid arthritis type 3 HS → symmetric
polyarthritis w/ morning
stiffness, rheumatoid nodules
Joints: wrists (ulnar deviation),
MCP+PIP (Boutonniere, swan
neck, Z-thumb deformities)
Gout cold, stress, EtOH, red meat →
hyperuricemia → MSU deposits
in joints → sudden-onset
monoarthritis (e.g. podagra),
chronic tophi
Pseudogout (CPPD) calcium pyrophosphate
deposits in joints → sudden-
onset monoarthritis
MYOSITIS -myositis: weakness, may have pain
-myalgia: pain, no weakness
Dz Presentation
Polymyositis hip and shoulder muscle
weakness ± pain
Dermatomyositis hip and shoulder muscle
weakness ± pain, skin rashes
(heliotrope rash, Gottron
papules, V sign, shawl sign)
Inclusion body myositis symmetrical proximal and distal
muscle weakness
Polymyalgia rheumatica hip and shoulder muscle pain
w/o weakness, profound
morning stiffness
Fibromyalgia widespread muscle pain and
stiffness associated w/ trigger
points
SERONEGATIVE Seronegative spondyloarthropathies: PAIR – Psoriatic arthritis, Ankylosing spondylitis, IBD, Reiter syndrome
SPONDYLOARTHROPATHY Common features: inflammatory oligoarthritis, negative RF, HLA-B27 association
Dz Presentation
Ankylosing spondylitis bilateral sacroiliitis + gradual-
onset upward fusion of spine +
enthesitis (pain at tendon
attachment sites)
Reiter syndrome (reactive triad of anterior uveitis,
arthritis) urethritis, arthritis (“can’t see,
can’t pee, can’t climb a tree”)
following a bacterial GI infx
(Salmonella, Shigella, Campy,
Chlamydia, Yersinia)
Psoriatic arthritis asymmetric polyarthritis in 10%
of psoriasis pts, usually fingers
MEDICINE × MSK
Management Other
• Dx X-ray (joint space narrowing, osteophytes Risk factors: old age, obesity,
• aka bone spurs, sclerosis, subchondral cysts) joint overuse, trauma
• Tx weight loss + physical therapy (1st line),
• acetaminophen/NSAIDs (2nd line), steroid
• injections (3rd line), joint replacement (4th line)
• Dx ↑RF, ↑anti-CCP , X-ray (joint space Felty syndrome: RA +
• narrowing, bony erosions) neutropenia + splenomegaly
• Tx NSAIDs or low-dose steroids (for pain); Juvenile RA: RA before 18 y/o
• MTX, hydroxychloroquine, TNFα-blockers
• Dx arthrocentesis (needle-shaped, negatively Etiology: ↓uric acid excretion
• birefringent yellow crystals) (90%), ↑uric acid production (10%)
• Tx indomethacin > colchicine (acute attacks),
• probenecid or allopurinol (chronic ppx) Lesch-Nyhan syndrome: AR
∆HGPRT → gout, self-mutilation,
yellow sand in diapers
• Dx arthrocentesis (rhomboid-shaped, weakly
• positively birefringent blue crystals)
• Tx indomethacin > colchicine (acute attacks) +
• Tx underlying cause
Management Other
• Dx ↑CK, anti-Jo-1, muscle bx
• Tx steroids
• Dx ↑CK, anti-Jo-1, muscle bx Complications: ovarian cancer
• Tx steroids
• Dx slightly ↑CK, muscle bx
• Tx steroids
• Dx ↑ESR (CK is normal) Complications: aortic aneurysms,
• Tx steroids temporal arteritis
• Dx PE (multiple trigger points) Complications: depression,
• Tx SSRIs, CBT anxiety, axis II diagnoses
Management Other
• Dx X-ray (bamboo spine) Complications: restrictive lung
• Tx NSAIDs + physical therapy dz, cauda equina syndrome,
spine fx w/ spinal cord damage,
osteoporosis, spondylodiscitis
• Dx joint aspiration (r/o infx arthritis)
• Tx NSAIDs
• Dx X-ray (pencil-in-cup deformity) Complications: dactylitis
• Tx NSAIDs (sausage fingers)
 MEDICINE × MSK

VASCULITIS Small vessel vasculitis: type 3 HS, “palpable purpura”

Muscular artery vasculitis: claudication/infarction
Elastic artery vasculitis: granulomatous dz, pulselessness

Dz Presentation Management Other

Temporal arteritis (giant cell
arteritis)
Takayasu arteritis
Polyarteritis nodosa
Buerger disease
(thromboangiitis obliterans)
Behçet syndrome
Churg-Strauss syndrome
Wegener granulomatosis
Hypersensitivity vasculitis
elderly pt w/ unilateral
headache, jaw claudication,
visual changes
young Asian woman w/ absent
pulses and asymmetrical BP
vasculitis of renal and visceral
vx → abd pain (bowel angina),
fatigue, joint pain, renal failure;
associated w/ HBV infx
smokers w/ gangrene and
autoamputation of fingers/toes
recurrent oral and genital
ulcers, arthritis, uveitis, CNS sx
triad of asthma + eosinophilia +
granulomatous vasculitis
triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract, and
necrotizing glomerulonephritis
→ hematuria + hemoptysis
drug-induced type 3 HS →
palpable purpura
• Dx ↑ESR Complications: polymyalgia
• Tx emergent high-dose steroids (can become rheumatica, blindness, aortic
• blind if you wait too long) aneurysms
• Dx arteriogram
• Tx steroids, angioplasty for stenosed vx
• Dx tissue bx, ↑P-ANCA
• Tx steroids
• Tx smoking cessation
• Dx tissue bx
• Tx steroids
• Dx tissue bx, ↑P-ANCA
• Tx steroids
• Dx tissue bx (necrotizing granulomas),
• ↑C-ANCA
• Tx cyclophosphamide
• Dx tissue bx
• Tx steroids, d/c meds
 MEDICINE × RENAL

URINALYSIS ↑protein: proteinuria >150 mg/day, nephrotic syndrome >3.5 g/day

↑albumin: microalbuminuria is earliest sign of diabetic nephropathy
↑glucose: diabetes
↑RBC: microscopic hematuria >3 RBC/HPF, gross hematuria visible to naked eye
↑ketones: DKA or starvation
↑nitrites: indicates bacteria in urine
↑LE: indicates WBC in urine
↑eosinophils: acute interstitial nephritis

RBC casts: glomerulonephritis, ischemia, or malignant HTN

WBC casts: pyelonephritis, tubulointerstitial dz, or txp rejection
Granular casts: acute tubular necrosis (ATN)
Broad waxy casts: CRF w/ dilated ducts
Fatty casts: nephrotic syndrome
Hyaline casts: nonspecific

RENAL FAILURE BUN: normally reabsorbed, can’t be reabsorbed if kidney is damaged

Azotemia: ↑BUN
Uremia: ↑BUN w/ sx (usually BUN >60)
Cr: freely filtered and not reabsorbed, measure of GFR

Acute renal failure: rapid decline in renal fxn → ↑BUN, ↑creatinine

Oliguric phase: UOP <500 mL/day, lasts 10-14 days
Diuretic phase: UOP >500 mL/day, due to diuresis of retained fluids/electrolytes
Recovery phase: recovery of tubular function

Prerenal ARF Intrinsic ARF Postrenal ARF

Etiology ↓renal blood flow → damage to renal bilateral urinary tract
↓GFR (hypotension, parenchyma (ATN, obstruction (stones,
CHF, etc.) toxins, glomerulo- BPH, cancer, etc.)
nephritis, etc.)
Urine osm >500 <350 <350
Urine Na+ <10 >20 >40
FENa <1% >2% >4%
BUN/Cr >20:1 <15:1 >15:1

Ischemic ATN: ↓renal blood flow → proximal/distal tubules don’t enough O2 for Na/K pump → cell death → ARF
Nephrotoxic ATN: toxin-mediated damage to proximal tubules → cell death → ARF (e.g. IV dye, gentamycin, Hb/Mb)

Chronic renal failure: irreversible, progressive reduction in GFR

Etiology: DM (#1), HTN (#2), chronic glomerulonephritis (#3)
Stages: stage 1 GFR 90-100
stage 2 GFR 60-89
stage 3 GFR 30-59
stage 4 GFR 15-29
stage 5 GFR <15 or dialysis (aka ESRD)

ARF/CRF complications: ↓GFR → electrolyte retention → ↑Na, ↑K, ↑H → HTN, CHF

uremia → n/v, pericarditis, asterixis, encephalopathy, platelet dysfxn
↓EPO → normocytic anemia
↓vit D → renal osteodystrophy, 2° HPTH, calciphylaxis

DIALYSIS Dialysis: artifical removal of electrolytes/toxins from blood

Dialysate: articifial solution that resembles human plasma
Indications: AEIOU – Acidosis (severe metabolic acidosis)
Electrolytes (severe hyperkalemia)
Intoxication (methanol, ethylene glycol, lithium, aspirin)
Overload (severe hypervolemia)
Uremia (severe uremia, pericarditis, BUN >150)
Limitations: doesn’t help w/ kidney synthetic functions (e.g. EPO, vitamin D)

Hemodialysis Peritoneal dialysis

Method blood from AV fistula pumped
through dialyzer, filtrated, then
sent back into pt body
Frequency MWF or TuThSa
Advantages faster/more efficienct
can be initiated quickly
Disadvantages risk of removing too much
fluid or electrolytes
requires vascular access
“first-use syndrome” –
chest and back pain, rare
anaphylaxis w/ new machine
high-glucose dialysate infused into
peritoneal cavity, then drained from
abdomen
q 4-8 hrs
mimics normal kidney fxn
self-dialysis
risk of hyperglycemia
risk of peritonitis
increased abdominal girth

PROTEINURIA AND Dz Presentation
HEMATURIA Proteinuria >150 mg protein/24 hr
Hematuria Microscopic hematuria:
>3 RBC/HPF
Gross hematuria: visible to
naked eye
Nephritic vs. nephrOtic syndrome: Nephritic syndrome
Etiology glomerular
inflammation
Sx - hematuria
- oliguria
- HTN
- azotemia
- proteinuria (<3.5 g)
Glomeruli hypercellular
Casts RBC casts
GLOMERULAR DZ Nephritic syndrome × chronic pain: analgesic nephropathy
Nephritic syndrome × hemoptysis: Goodpasture, Wegener
Nephritic syndrome × s/p strep throat: post-strep GN
NephrOtic syndrome × deafness/blindness: Alport syndrome
NephrOtic syndrome × kids: minimal change dz
NephrOtic syndrome × HBV: MGN
NephrOtic syndrome × HCV: MPGN
NephrOtic syndrome × HIV: FSGS
NephrOtic syndrome × Hodgkin lymphoma: minimal change dz
Dz Presentation
Minimal change dz nephrOtic syndrome in kids
following a viral infx
FSGS nephrOtic syndrome in adults
and HIV+ pts, steroid-resistant
Membranous glomerulo- nephrOtic syndrome in adults;
nephritis (MGN) associated w/ drugs, infx, SLE,
and solid tumors
IgA nephropathy (Berger’s dz) nephritic syndrome following
URI or gastroenteritis;
associated w/ Henoch-Schonlein
(palpable) purpura in kids
Alport syndrome XR ∆type 4 collagen → split
GBM (nephritic and nephrOtic
syndromes), deafness, ocular
and nerve disorders
Diabetic nephropathy nephrOtic syndrome in DM pts
HTN nephropathy nephrOtic syndrome in HTN pts
Lupus nephropathy ag-ab deposits → nephritic
syndrome in SLE pts
Membranoproliferative nephrOtic syndrome in HCV+
glomerulonephritis (MPGN) pts
Poststreptococcal GN coke-colored urine and
periorbital edema in a kid w/
strep throat or cellulitis
Goodpasture syndrome anti-GBM → attacks glomeruli
and alveoli → hematuria +
hemoptysis
MEDICINE × RENAL
Management Other
• Dx screen w/ dipstick and UA, then get 24 hr
• urine collection
• asx/transient → reassurance
• asx/persistent → Dx check BP and examine
• urine sediment; Tx underlying cause
• sx → Tx underlying cause + ACE inhibitors
• Dx screen w/ dipstick and UA, then get Etiology: glomerular dz
• imaging of upper/lower urinary tracts
• Tx underlying cause Etiology: postrenal causes
(trauma, stones, cancer)
NephrOtic syndrome
loss of GBM negative
charge
- proteinuria (>3.5 g)
- edema
- hypoalbuminemia
- hyperlipidemia
- hypercoagulability
normo-/hypocellular
fatty casts
Management Other
• Dx EM (foot process effacement)
• Tx steroids
• Dx LM (segmental sclerosis)
• Dx LM (diffuse GBM thickening), EM (“spike
• and dome” appearance)
• Dx LM (mesangial deposits), IF (IgA stain)
• Dx family hx
• Dx microalbuminuria, LM (mesangial
• expansion, Kimmelsteil-Wilson nodules)
• Tx ACE inhibitors
• Tx underlying HTN
• Dx LM (“wire loops”), EM (subendothelial
• deposits), IF (“full house”)
• Tx underlying SLE
• Dx EM (“tram tracks” or “dense deposits”)
• Dx ↑ASO, LM (“lumpy-bumpy” appearance)
• Tx reassurance
• Dx LM (crescent shaped), IF (linear staining)

TUBULOINTERSTITIAL DZ Dz
Acute interstitial nephritis (AIN)
Chronic interstitial nephritis
Renal papillary necrosis
Renal tubular acidosis (RTA)
Hartnup syndrome
Fanconi syndrome
RENAL CYSTIC DZ Dz
Adult polycystic kidney dz
(ADPKD)
Medullary sponge kidney
Simple renal cysts
RENAL VASCULAR DZ Dz
RA stenosis (renovascular HTN)
RV thrombosis
Hypertensive nephrosclerosis
Sickle cell nephropathy
MEDICINE × RENAL
Presentation Management Other
drug allergy → acute renal • Dx UA (eosinophuria) Etiology: gentamycin, IV dye,
railure, rash, fever, eosinophilia • Tx d/c meds Hb/Mb
slowly progressive nephritis → ---
asx, but can lead to progressive
scarring, renal failure, and ESRD
damage to renal papillae → • Dx excretory urogram Etiology: analgesic nephropathy
necrosis → slough off and • Tx underlying cause (chronic NSAID/Tylenol use),
cause ureteral obstruction diabetic nephropathy, sickle cell,
obstruction, txp rejection
Type 1 (distal) RTA: collecting • Tx IV HCO3-
duct can’t excrete H+ →
metabolic acidosis, hypo-K,
nephrolithiasis, alkaline urine
Type 2 (proximal) RTA: • Tx underlying cause
proximal tubule can’t reabsorb
HCO3- → metabolic acidosis,
hypo-K, hypophosphatemic
rickets, alkaline urine
Type 3 RTA: type 1 + type 2 ---
Type 4 (hyper-K) RTA: either • Tx fludrocortisone
hypoaldosteronism or lack of
response to aldosterone →
metabolic acidosis, hyper-K,
acidic urine
AR ∆neutral amino acid • Tx niacin replacement
transporter → ↓neutral amino
acids → ↓tryptophan for niacin
synthesis → pellagra (3 Ds –
diarrhea, dermatitis, dementia)
proximal tubule dysfxn → • Tx electrolyte replacement
defective transport of glucose,
amino acids, HCO3-, phosphate
→ glucosuria, aminoaciduria,
type 2 RTA, hypophosphatemic
rickets, etc.
Presentation Management Other
AD ∆APKD1/2 → multiple, large • Dx renal U/S (multiple large cysts)
bilateral cysts that can destroy • no tx available
renal parenchyma → renal
failure, HTN, berry aneurysms,
liver cysts
cystic dilation of collecting • Dx IV pyelo (sponge-like calyx)
ducts → resembles sponge in • no tx available
medulla → hematuria,
recurrent UTIs, kidney stones
benign incidental finding • leave it alone
Presentation Management Other
RA stenosis → ↓renal blood • Dx renal arteriogram (if pt is in renal failure, Etiology: fibromuscular dysplasia
flow → kidney thinks you’re • use MRA instead since dye is nephrotoxic) (young women), atherosclerosis
hypotensive → RAA system → • Tx angioplasty (old men)
HTN, abdominal bruits, ↓renal
function
intrinsic clot or extrinsic • Dx renal venography
compression → ↓renal blood • Tx underlying cause
outflow → flank pain, HTN,
hematuria, proteinuria
Benign nephrosclerosis: hyaline • Tx BP control, sodium nitroprusside for
arteriolosclerosis in chronic • malignant HTN
HTN
Malignant nephrosclerosis:
hyperplastic (“onion skin”)
arteriolosclerosis in rapidly
progressive HTN
recurrent sickling → papillary • Tx ACE inhibitors (w/ hydroxyurea for SCD)
infarction → eventual papillary
necrosis, renal failure, UTIs

STONES/OBSTRUCTIONS Dz Presentation
Nephrolithiasis (kidney stones) colicky flank pain ± radiation to
groin, hematuria, n/v
Calcium stones: most common
type, 2/2 hypercalciuria or
hyperoxaluria
Uric acid stones: radiolUcent
(rest are all radioopaque), 2/2
gout or tumor lysis syndrome
Struvite stones: 2/2 urease+
bugs (P. mirabilis), can form
large staghorn caliculi
Cystine stones: 2/2 cystinuria
Urinary tract obstruction colicky flank pain ± radiation to
groin (if acute), asx (if chronic)
GU NEOPLASMS Dz Presentation
Prostate cancer usually asx, “elderly man w/ low
back pain” if invasive
Renal cell carcinoma (RCC) abdominal mass, flank pain,
hematuria, and paraneoplastic
syndromes (PAPER – PTH-rP,
ACTH, prolactin, EPO, renin)
Bladder cancer painless hematuria
Testicular cancer firm, painless testicular mass
Penile cancer exophytic penile mass in a
noncircumcised dirty old man
OTHER GU DZ Dz Presentation
Testicular torsion twisting of spermatic cord →
severe testicular pain + “high
riding testicle w/ horizontal lie”
Epididymitis presents like testicular torsion,
but w/ fever, pyuria, and cord is
also tender
Management
• Dx KUB
• Tx analgesics + fluids (<0.5 cm), shockwave
• lithotripsy (0.5 – 2 cm), percutaneous
• nephrolithotomy (≥2 cm)
• recurrent calcium stones → PPx HCTZ
• uric acid stones → PPx allopurinol, Tx
• potassium citrate
• cystine stones → Dx urinary sodium nitro-
• prusside test, Tx acetazolamide
• Dx renal U/S (shows dilation), then IV pyelo
• Tx underlying cause
Management
• Dx screen w/ PSA (≥10) or DRE (firm nodule);
• confirm w/ U/S-guided needle bx
• Tx radical prostatectomy (local), radiation +
• flutamide + leuprolide (invasive)
• Dx abdominal CT
• Tx radical nephrectomy
• Dx IV pyelo + cystoscopy w/ bx
• Tx resection + close f/u for high recurrence
• Dx transillumination (doesn’t light up),
• testicular U/S (solid mass)
• Tx radical orchiectomy, then CT chest/A/P for
• staging, then radiation (if seminoma),
• retroperitoneal LN-ectomy (if nonseminoma)
• f/u αFP + βHCG levels
• Dx skin bx
• Tx local excision
Management
• Tx emergent surgical detorsion, then
• orchipexy (don’t waste time on dx tests)
• Dx U/S to r/o torsion
• Tx abx
MEDICINE × RENAL
Other
Hematuria + pyuria: stone w/
concomitant UTI
Kidney stone diet: high fluids
(#1), low sodium, low protein,
high calcium (counterintuitive),
low oxalate
MC location: ureteropelvic jxn
Complications: renal
insufficiency, hydronephrosis
Other
Cancers that rarely metastasize:
prostate, esophageal, skin
(nonmelanoma), oropharyngeal
Risk factors: smoking (#1),
obesity
Bilateral RCC: von Hippel-Lindau
Risk factors: Pee SAC – pain killer
abuse, smoking (#1), aniline dyes,
cyclophosphamide
Bladder SCC: Schistosoma
haematobium
Etiology: HPV-16/18 infx
Other
Cremasteric reflex: stroking of
inner thigh causes elevation of
testicle; absent w/ torsion
Etiology: GC or CT in young men,
E. coli in kids and elderly
Cystine crystals Struvite crystal Calcium oxalate crystals
(think Proteus mirabilis)

Budding yeast
Uric acid crystals
(think gout or TLS)

Oval calcium
oxalate crystals RBCs

Cystine Uric acid

crystal crystal
 Broad waxy cast Granular casts RBC casts WBC casts
(think CRF w/ dilated ducts) (think nephritic syndrome) (think acute pyelonephritis)

Normal RBC Ghost RBC

Crenated RBC Normal RBC
Nephritic Dz SLE Class II Anti-GBM Crescents + Fibrin
PostInfx IgA Neprho
Light

Class
III/IV

MSG
PMNs Hyper-
Cellular “Wire Loops”
-ity

IF Granular CapillaryIgG/C3 Linear Capillary IgG/C3

Granular MSG IgA Full House:

MSG Deposits
EM Subepi Humps Subepi
Normal

Subendo
Nephrotic Dz Diabetic Neph
FSGS MembranousNeph
Minimal Change Thick Cap
walls

Light Normal

Art. Hyalinosis
Spikes&Holes
in BM
Segmental Sclerosis
Nodulesl
IF
Granular
Capillary
Normal IgG
Normal

Pseudolinear
Capillary IgG

Subepi Deposits

EM Thick GBM

Nodular MSG
Foot process Expansion
effacement
 MEDICINE × FEN

FLUIDS 60-40-20 rule: 60% of body weight is water, 40% is ICF, 20% is ECF (5% plasma, 15% ISF)
Starling forces: hydrostatic pressure drives fluid into ISF, oncotic pressure sucks it back out

Blood osmolarity: 2×Na + BUN/2.8 + gluc/18; normally 285-300 mOsm/L

Urine osmolarity: 70-1200 mOsm/L, controlled by ADH
Urine output: normally 0.5-1.0 mL/kg/hr

IV fluids: NS, LR, D5½NS, D5W

NS: good for dehydrated pts
LR: good for trauma pts
D5½NS: standard maintenance fluid
D5W: good for hypernatremic pts
100-50-20 rule: maintenance fluids for 24 hrs (100 mL/kg for first 10 kg, then 50 for next 10 kg, then 20 for each kg over)
4-2-1 rule: maintenance fluids for 1 hr (4 mL/kg for first 10 kg, then 2 for next 10 kg, then 1 for each kg over)

ELECTROLYTES ADH: causes water reabsorption (V2, aquaporins) and vasoconstriction (V1)
Aldosterone: causes ↑Na, ↓K, ↓H
PTH: causes ↑Ca, ↓P, ↑vit D
Calcitonin: causes ↓Ca, ↓P
Vit D: causes ↑Ca, ↑P

Imbalance Etiology Presentation Management

Hypernatremia water loss due to 6 Ds – Diuresis, thirst and signs of volume depletion • Tx PO fluids > IV fluids (correct gradually due
Dehydration, Diabetes insipidus, (slow) or ∆MS (rapid) • to risk of cerebral edema)
Docs (iatrogenic), Diarrhea,
Diseases
Hyponatremia SIADH (MCC) confusion, coma, convulsions • Tx water restriction + NS (correct gradually
• due to risk of central pontine myelinolysis)
Hyperkalemia renal failure, K-sparing diuretics, nausea/vomiting, intestinal colic, • first, confirm w/ repeat blood draw
release from dead tissue (crush weakness • Dx EKG (peaked T waves, sine waves)
injury, ischemic bowel, etc.) • Tx C BIG K DIE – calcium gluconate, bicarb
• insulin-glucose, kayexalate, dialysis (if severe)
Hypokalemia diarrhea, vomiting, diuretics weakness, muscle cramps, ileus, • Dx EKG (scooped T waves)
digoxin toxicity (K and dig compete for • Tx KCl (<10 mEq/hr)
same Na/K receptors on heart)
Hypercalcemia hyperparathyroidism (MCC stones (kidney), bones (bone pain, • Dx EKG (short QT)
outpt), cancer (MCC inpt) osteitis fibrosa cystica), groans (PUD, • Tx “flush and drain” (NS + furosemide),
pancreatitis), psychic overtones • bisphosphonates if mild
(depression, anxiety, ∆MS)
Hypocalcemia hypoparathyroidism (MCC) neuromuscular irritability (tingling, • confirm w/ corrected Ca = [measured Ca +
tetany), arrhythmias, Chvostek and • 0.8 x (4 – albumin)]
Trousseau signs
• Dx EKG (prolonged QT)
• Tx vit D + calcium replacement
Hypermagnesemia renal failure (MCC) delirium, ↓DTRs, cardiac arrest • Tx IV calcium gluconate + NS + furosemide
Hypomagnesemia alcoholism (MCC), DKA refractory hypo-K • Tx mag replacement
Hyperphosphatemia renal failure (MCC) kidney stones, metastatic calcifications • Tx antacids (binds phosphate in GI tract)
Hypophosphatemia alcoholism (MCC), DKA rickets, osteomalacia • Tx phos replacement

ACID-BASE Acid-base algorithm: pH <7.4 pH >7.4

CO2 <40 met acidosis* resp alkalosis
CO2 >40 resp acidosis met alkalosis

*if met acidosis, calculate anion gap (Na+ – (Cl- + HCO3-)), nl 8-12

Respiratory acidosis
Respiratory alkalosis
Anion-gap metabolic acidosis
Non anion-gap metabolic acidosis
Metabolic alkalosis
Causes Management
hypoventilation Tx mechanical ventilation
hyperventilation 2/2 pain, fever, Tx underlying cause
sepsis, or early ARDS
MUDPILES – Methanol, Uremia, Tx underlying cause
DKA, Paraldehyde, Iron, INH,
Lactic acidosis, Ethylene glycol,
Salicylates
diarrhea, glue sniffing, RTA, Tx underlying cause
hyperchloremia
vomiting, diuretics, antacids, Tx chloride or potassium replacement
hyperaldosteronism

pH changes: CO2 ↑10 → pH ↓0.08

HCO3 ↑10 → pH ↑0.15

Post-ictal AGMA: will resolve on its own in 60-90 minutes, recheck labs then
Aspirin overdose: tinnitus, fever, hyperventilation → respiratory alkalosis (early), metabolic acidosis (late)
Iron overdose: AGMA, shock, abdominal pain, UGIB
 MEDICINE × HEM/ONC

TRANSFUSION PRBCs: Hb +1, Hct +3; indicated if Hb ≤7 or acute bleed

Platelets: platelets +10,000
FFP: contains clotting factors 1-12; ↓PT, ↓PTT
Cryoprecipitate: contains factors 1+8 only; ↓PTT
Whole blood: contains everything, rarely used

RBC PANEL MCV: RBC size, normally 80-100

Ferritin: iron levels in blood
TIBC: transferrin levels (protein that binds ferritin); serum ferritin has a negative feedback on TIBC levels
RDW: variability in RBC size; characteristic ↓RDW in thalassemias
RI: measure of immature RBCs; <2% indicates impaired bone marrow function

LDH: enzyme of anaerobyic glycolysis; ↑ w/ intravascular hemolysis or tissue hypoxia

Haptoglobin: enzyme in blood that binds free Hb; ↓ w/ intravascular hemolysis
Schistocytes + helmet cells: indicates hemolytic anemia
Coombs test: detects antibody or complement on RBCs

ANEMIA Anemia?

microcytic normocytic macrocytic

(MCV <80) (MCV 80-100) (MCV >100)

IDA (↑TIBC) folate deficiency

ACD (↓TIBC) B12 deficiency
thalassemias (↓RDW) reticulocytosis
sideroblastic anemia

calculate reticulocyte index

(retic count × hct/45)

impaired erythropoiesis normal erythropoiesis

(RI <2%) (RI >2%)

acute hemorrhage intrinsic RBC defects extrinsic RBC defects

acute IDA or ACD
aplastic anemia
anemia of CRF (↓EPO)
membrane defects (PNH, spherocytosis) AIHA
abnormal hemoglobin (sickle cell) prosthetic valves
deficient enzymes (G6PD, PK) MAHA
chronic hemorrhage

Anemia sx: conjunctival pallor, headache, fatigue; ↑HR/↓BP if severe

Pseudoanemia: ↓Hb/↓Hct/↓WBC/↓plt secondary to dilution (e.g. fluid overload)

Dz Presentation Management Other

Iron-deficiency anemia (IDA) (typical anemia sx)
Anemia of chronic disease (typical anemia sx)
(ACD)
β-thalassemia β-thal minor: heterozygous
∆β-chain → mild anemia sx
β-thal major: homozygous
∆β-chain → severe anemia sx
α-thalassemia Silent carrier: 1-2 α-chain
deletion → asx
HbH disease: 3 α-chain deletion
→ severe anemia sx
Barts disease: 1-2 α-chain
deletion → fetal hydrops
Sideroblastic anemia biochemical abnormalities →
iron gets stuck in mitochondria
→ can’t make Hb → anemia sx
Aplastic anemia bone marrow failure →
pancytopenia (anemia, neutro-
penia, thrombocytopenia) →
anemia sx + ↑infx + petechiae
Folate deficiency ↓folate → ↓methionine (RBC)
→ anemia sx, glossitis
Vit B12 deficiency ↓vit B12 → ↓methionine (RBC) +
impaired FA synthesis (myelin)
→ anemia sx, glossitis,
peripheral neuropathy
• Dx RBC panel (MCV <80, ↓Fe, ↑TIBC, ↑RDW)
• Tx underlying cause + PO iron supplements
• Dx RBC panel (MCV <80, ↑Fe, ↓TIBC, ↑RDW)
• Tx underlying cause
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis
• Tx reassurance
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis (↑HbF)
• Tx frequent transfusions
---
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis (↑HbH)
• Tx frequent transfusions
• Dx post-mortem autopsy
• Dx blood smear (ringed sideroblasts)
• Tx underlying cause, vit B6 supplements
• Dx CBC (↓RBC, ↓WBC, ↓plt); confirm w/ bone
• marrow bx
• Tx transfusions, bone marrow txp
• Dx RBC panel (MCV >100), hypersegmented
• neutrophils, ↓folate
• Tx underlying cause, folate supplements
• Dx RBC panel (MCV >100), hypersegmented
• neutrophils, ↓vit B12; DDx w/ Schilling test
• Tx underlying cause, vit B12 injections
Etiology: Meckel diverticulum
(MCC kids), menorrhagia (MCC
women), peptic ulcers (MCC
men), colon cancer (MCC elderly)
Etiology: cancer, chronic infx,
systemic inflammation, trauma
Etiology: lead poisoning, vit B6
deficiency, INH or EtOH use
Fanconi anemia: aplastic anemia
+ short stature, hypopigmented
areas, eye/ear deformities
Folate source: leafy vegetables
Etiology: “tea and toast” diet,
alcoholics, phenytoin or MTX use
Vit B12 source: meats
Etiology: pernicious anemia (lack
of IF), s/p gastrectomy, strict
vegans, terminal ileal dz (Crohn),
D. latum fish tapeworm
 MEDICINE × HEM/ONC

HEMOLYTIC ANEMIA Intravascular hemolysis: ABO-mismatched blood → hemolysis within blood stream → immediate fever/chills, nausea, vomiting, chest and flank pain,
dyspnea → risk of hypovolemic shock, DIC, renal failure
Extravascular hemolysis: minor antigen-mismatched blood (e.g. Kell) → delayed hemolysis within spleen → mild fever, jaundice, anemia

Dz Presentation Management Other

Sickle cell disease
Hereditary spherocytosis
G6PD deficiency
Autoimmune hemolytic anemia
(AIHA)
Paroxysmal nocturnal
hemoglobinuria (PNH)
AR ∆HbE6V (β-chain) → sickling
of RBCs w/ ↓O2 conditions →
small vessel occlusion → extra-
vascular hemolysis, painful
vasoocclusive crises,
autosplenic infarction
AR ∆spectrin → spherical RBCs
get stuck in spleen →
extravascular hemolysis
XR ∆G6PD → ↓glutathione for
handling oxidant stressors →
intravascular hemolysis, back
pain, hemoglobinuria in men
Warm AIHA: IgG against RBC →
chronic, extravascular
hemolysis
Cold AIHA: IgM against RBC →
acute, intravascular hemolysis
triggered by cold
acquired ∆DAF → lack of
complement inactivation on
RBCs → hemolytic anemia +
hepatic vein thromboses
• Dx blood smear (sickled RBCs), confirm w/ Hb
• electrophoresis
• Tx avoid crises + hydroxyurea (↑HbF) + early
• SHiN vaccination
• Dx osmotic fragility test
• Tx splenectomy
• Dx blood smear (Heinz bodies, bite cells)
• Tx avoid precipitants
• Dx Coombs test (coating w/ IgG is warm,
• complement is cold)
• Tx steroids (warm), avoid cold exposure (cold)
• Dx ↑urine hemosiderin
• Tx steroids, bone marrow txp
Sickle cell trait: painless
hematuria in young black male
Splenic sequestration crisis:
sudden, rapid pooling of blood
into spleen → splenomegaly,
hypovolemic shock, death
Aplastic crisis: spherocytosis +
parvovirus B19 infx, prevent w/
folic acid supplements
Etiology: sulfa drugs, anti-
malarials, infx, fava beans
AIHA × lymphoma: CLL is a
trigger for both warm/cold AIHA
AIHA × PNA: Mycoplasma
pneumoniae is a trigger for cold
AIHA

PLATELET D/O Platelet range: >750 ↑risk of clots

>450 thrombocytosis by definition
150-450 normal
<150 thrombocytopenia by definition
<70 ↑risk of bleeding during surgery/trauma
<20 petechiae
<5 major spontaneous bleeding

Thrombocytopenia sx w/ normal plt count: aspirin or NSAID use

Dz Presentation Management Other

Thrombocytopenia
Heparin-induced
thrombocytopenia (HIT)
Idiopathic thrombocytopenic
purpura (ITP)
Thrombotic thrombocytopenic
purpura (TTP)
Bernard-Soulier syndrome
Glanzmann thrombasthenia
plt <150,000; most common sx • Tx underlying cause, plt transfusion (severe) Asx thrombocytopenia: consider
is petechiae HIV testing
HIT type 1: heparin directly • Tx reassurance
causes platelet aggregation,
within 0-2 days
HIT type 2: heparin induces • Tx d/c heparin
auto-antibodies against platelet
factor 4, after 3-12 days
auto-antibodies against • Dx plt <20, ↑megakaryocytes
gpIIb/IIIa → platelet clearance • Tx steroids, plt transfusion then splenectomy
→ petechiae, ecchymoses, etc. • (severe)
HUS: tons of clots form in small • Dx CBC (↓plt, ↓RBC) + blood smear HUS × diarrhea: EHEC (O157:H7)
vx (e.g. renal vx) → micro- • (schistocytes)
angiopathic hemolytic anemia + • Tx emergent plasmapheresis
thrombocytopenia + renal
failure
TTP: HUS + fever + ∆MS
AR ∆gpIb → platelets can’t ---
adhere to subendothelium
AR ∆gpIIb/IIIa → platelets can’t ---
aggregate
 MEDICINE × HEM/ONC

COAGULATION PTT: measures intrinsic pathway (12→→1)

PT/INR: measures extrinsic pathway (7→→1)
Thrombin time: measures fibrinogen levels (2→1)
Bleeding time: measures platelet function
Shortest T½: factor 7

ANTICOAGULATION Heparin: potentiates AT-III to inhibit factors 2/10 → ↑PTT

Heparin side-effects: bleeding, HIT, osteoporosis
Heparin reversal: protamine sulfate

LMWH: longer T½, less side-effects, but more $$$

Warfarin: blocks vitamin K from activating factors 2/7/9/10/C/S → ↑PT/INR

Warfarin side-effects: bleeding, skin necroses (d/t protein C/S), teratogen
Warfarin reversal: vit K if mild, FFP if severe

tPA: activates plasmin to break down existing clots

tPA side-effects: severe bleeding (c/i in active bleed, recent surg, prior ICH)
tPA reversal: aminocaproid acid

Therapeutic INR: 2-3 normally, 2.5-3.5 for prosthetic valves

COAGULATION D/O Dz Presentation Management Other

von Willebrand disease (vWD) vWD type 1: AD ↓vWF →
bleeding diathesis
vWD type 2: AD ∆vWF →
bleeding diathesis
vWD type 3: AD lack of vWF →
severe bleeding diathesis
Hemophilia A (classic XR ∆factor 8 → hemarthroses,
hemophilia) hematomas, and ICH in men
Hemophilia B (Christmas XR ∆factor 9 → hemarthroses,
disease) hematomas, and ICH in men
Disseminated intravascular abnl activation of clotting
coagulation (DIC) factors → microthrombi all over
blood stream → run out of
factors → bleed out → die
Vit K deficiency ↓vit K → can’t γ-carboxylate
factors 2/7/9/10/C/S → bleeding
diathesis
Coagulopathy of liver disease liver can’t make coagulation
factors → bleeding diathesis
AT-III deficiency can’t break down factors 2-12 →
hypercoagulability that doesn’t
respond to heparin
Factor V leiden protein C can’t block factor 5 →
hypercoagulability
• Dx ↓/∆/no vWF, ↑bleeding time
• Tx DDAVP (types 1-2), factor 8 concentrate
• (refractory type 2, type 3)
• Dx ↑PTT, ↓factor 8 Hemophilia A vs. factor 8
• Tx factor 8 concentrate; analgesia + RICE (for inhibitor: mix pt’s plasma w/
• acute hemarthroses) normal plasma; if PTT fails to
normalize, then factor 8 inhibitor
• Dx ↑PTT, ↓factor 9
• Tx factor 9 concentrate; analgesia + RICE (for
• acute hemarthroses)
• Dx ↑PT/↑PTT, ↑D-dimer, ↓fibrinogen, ↓plt, Etiology: G– septic shock (MCC),
• blood smear (schistocytes) obstetric complications, cancer,
• Tx underlying cause, supportive measures massive burns, rattlesnakes, etc.
• Dx ↑PT/↑PTT, everything else is nl Vit K source: leafy vegetables,
• Tx vit K supplements, FFP if severe intestinal flora
Etiology: critically ill pts that are
NPO and on broad-spectrum abx
(MCC), fat malabsorption,
warfarin overdose, neonates
• Dx ↑PT/↑PTT, ↓fibrinogen, everything else is nl
• Tx FFP
---
---

PLASMA CELL D/O Dz Presentation
Multiple myeloma monoclonal plasma cell
proliferation → makes lots of
monoclonal IgG and eats up
bone marrow space → CRAB –
hyperCalcemia, Renal failure,
Anemia, Bone lesions/fx
Monocolonal gammopathy of (asx, precursor of myeloma)
undetermined significance
(MGUS)
Waldenstrom monoclonal IgM plasma cell
macroglobulinemia proliferation → ↑IgM →
hyperviscosity (IgM is big),
anemia, splenomegaly, LN-
opathy
MEDICINE × HEM/ONC
Management Other
• Dx SPEP (monoclonal spike), urinalysis (Bence MCCOD: recurrent lung or
• Jones protein), X-ray (punched out lytic bone urinary tract infx (↓normal IgG)
• lesions), blood smear (rouleaux formation)
• Tx chemo/radiation only if symptomatic
• Dx SPEP (monoclonal spike), urinalysis (Bence Px: <20% convert to myeloma in
• Jones protein) 10-15 yrs
• Tx close f/u
• Dx SPEP (monoclonal spike), urinalysis (Bence
• Jones protein), ↑IgM, no bone lesions
• no tx exists
 LYMPHOMA
Is the lymph node swollen due to malignancy
or is it an inflammatory process?

LYMPHOMA vs. REACTIVE HYPERPLASIA high grade

Burkitt’s lymphoma V
- painless - painful - t(8;14)
- large (>2 cm) - small (<2 cm) - EBV association, common childhood NHL
- insidious onset - rapid onset - “starry sky” appearanceW
- fixed (fibrotic) - mobile - jaw lesion in endemic form in Africa
- unusual site - normal site - pelvis/abdomen in sporadic form
B-cell NHL (80-85%) high grade
Diffuse large B-cell lymphoma
- most common adult NHL
- 20% are T-cell origin (counterintuitive)
middle grade
Mantle cell lymphoma
- t(11;14)
- poor prognosis, CD5+
Non-Hodgkin’s lymphoma low grade
- multiple, peripheral nodes with noncontiguous spread Follicular lymphoma
- fewer constitutional “B” symptoms - t(14;18)
- associated with HIV/immunosuppression - overexpression of BCL-2 anti-apoptosis gene
low grade
MALT/extranodal lymphoma
- H. pylori (stomach), Sjogren’s syndrome (salivary glands)
high grade
Adult T-cell lymphoma V
- adults with aggressive cutaneous lesions
T-cell NHL (10-15%) - HTLV-1 association
high grade
Mycosis fungoides
- skin lesions with Pautrier’s microabscesses
- CD4+ T-cell neoplasm
- Sezary syndrome is leukemic phase of mycosis fungoides
65-75%
RS << lymphocytes Nodular sclerosing HL
- female-dominant
- supraclavicular nodes + anterior mediastinal nodes
25%
RS = lymphocytes Mixed cellularity HL V
Hodgkin’s lymphoma - male-dominant
- Reed-Sternberg cells (CD15+/CD30+) - numerous RS cells, EBV association
- localized, single group of nodes with contiguous spread 6%
- “B” symptoms – fever, night sweats, weight loss Lymphocyte-predominant HL
RS << lymphocytes
- prognosis: stage of disease and HL subtype are most important factors - “popcorn cells”
- infrequent classic RS cells
- excellent prognosis
rare
RS > lymphocytes
Lymphocyte-depleted HL
- older males with disseminated disease
- poor prognosis

V = viral association
 LEUKEMIA
AGE BRACKETS
(extremely important)

0-14 ALL
15-60 AML/CML
60+ CLL myeloid lineage subtypes
AML Acute promyelocytic leukemia
- age: median onset ~60 y/o - t(15;17), defect in retinoic acid
- Auer rods in myeloblasts - Tx retinoic acid, possible DIC
Acute leukemias Acute monocytic leukemia
B-cells (90%), T-cells (10%)
- >20% blasts ALL - gum infiltration
- accumulation of immature cells - age: <15 y/o
- pre-B cells (90%); CALLA+/TdT+
- CNS and testicle involvement
- t(12;21) offers good prognosis
myeloid
lineage
CML
- age: 30-60 y/o
- Philadelphia chromosome t(9;22) or Bcr-Abl gene
- ↓LAP score
RBC lineage
Polycythemia vera
- ↑plasma volume, ↑RBC mass, normal SaO2, ↓EPO
Myeloproliferative neoplasms - 4 H’s: hyperviscosity, hypervolemia, histaminemia, hyperuricema
Leukemia
- bone marrow proliferation of myeloid lineages MKC lineage
- associated with specific TK abnormalities Essential thrombocythemia
- abnormal appearing platelets
Chronic leukemias MKC lineage
- <5% blasts w/ fibroblasts Primary myelofibrosis
- marrow fibrosis (dry bone marrow aspirate)
- accumulation of mature cells
- extramedullary hematopoiesis → splenomegaly
- tear drop RBCs
B-cells
CLL
- B-cell neoplasm, ↓γ-globulins
- MCC generalized lymphadenopathy >60 y/o
- smudge cells
Chronic lymphoid neoplasms B-cells
Hairy cell leukemia
- positive TRAP stain
- splenomegaly
- Tx with purine nucleosides

myeloid lineage
Pre-leukemia Myelodysplastic syndrome
- severe anemia in elderly
- 30% develop AML
- ringed sideroblasts

RESPIRATORY INFX Dz Bug(s)
Pneumonia Typical CAP: Strep pneumo
(#1), H. influenzae (#2),
aerobic GNR
Atypical CAP: Mycoplasma
(#1), Chlamydia, Legionella
Nosocomial PNA: Staph
aureus (#1), Pseudomonas,
aerobic GNR
PNA × alcoholics: Klebsiella
PNA × immigrants: TB
PNA × nursing home:
nosocomial pathogens
PNA × AIDS: Pneumocystis
carinii (PCP), TB
Lung abscess oral anaerobes (Prevotella,
Peptostreptococcus, Fuso-
bacterium, Bacteroides)
Tuberculosis M. tuberculosis
Influenza influenza virus
CNS INFX Dz Bug(s)
Meningitis Meningitis × neonates: GBS >
E. coli > Listeria
Meningitis × kids: MC > Strep
pneumo > H. influenzae
Meningitis × adults: Strep
pneumo > MC > H. influenzae
Meningitis × elderly: Strep
pneumo > MC > Listeria
Encephalitis viruses (HSV-1 in temporal
lobe, arbovirus, enterovirus),
toxoplasmosis, aspergillosis
Brain abscess Staph, Strep, anaerobes
Abscess × AIDS: toxo, fungi
Abscess × DKA: zygomycosis
GU INFX Dz Bug(s)
Asymptomatic E. coli (#1), Staph sapro-
bacteruria phyticus (#2), Enterococcus
(#3), other GNB
Lower UTI (cystitis) " dysuria, ±hematuria, frequency/urgency,
Upper UTI " (same as above) + fever/chills, flank pain,
(pyelonephritis)
Prostatitis E. coli (kids/elderly), STDs
(young adults)
Presentation
Typical CAP: sudden-onset fever/chills,
productive cough, pleuritic chest pain
Atypical CAP: insidious-onset sore throat,
headache, nonproductive cough, dyspnea
Complications: pleural effusions,
empyema, acute respiratory failure
aspiration → cough w/ foul-smelling
sputum, SOB, fever/chills
1° TB: granulomatous inflammation in lower
lobes → infx contained → usually asx
2° TB: reactivation in upper lobes →
fever/chills, night sweats, weight loss,
cough w/ hemoptysis
Miliary TB: hematogenous “miliary seed”
spread of TB → sx depend on organs
Pott disease: TB in vertebral body → bone
pain, risk for pathological fx
rapid-onset fever/chills, malaise, headache,
sore throat, nonproductive cough
2° bacterial infx: pt gets better from flu,
then sick again d/t bacterial colonization
Presentation
triad of fever, nuchal rigidity, ∆MS
Kerning sign: inability to fully extend knees
when lying supine w/ hips flexed
Brudzinski sign: flexion of head causes
flexion of hips/knees when lying supine
Disseminated meningococcal infx:
meningitis, purpura fulminans, bilateral
adrenal hemorrhage (W-F syndrome)
∆MS, focal neuro sx, s/sx of meningitis
mass effect → headache, ∆MS, seizures,
nausea/vomiting, focal neuro sx
Presentation
(asx)
suprapubic tenderness
Risk factors: diabetes, females (shorter
urethra), sexual intercourse, Foley catheter
CVA tenderness
Risk factors: (same as above) + VUR
Acute prostatitis: fever/chills, dysuria,
frequency, urgency, low back pain
Chronic prostatitis: usually asx
MEDICINE × ID
Management
• Dx CXR (consolidations)
• suspect TB → acid-fast stain
• suspect Legionella → urinary ag
• HIV+ → silver stain (fungi, PCP)
• admit if 2/5 of CURB-65 – Confusion, Uremia,
• RR ≥30, BP <90/60, age ≥65
• outpatient → Tx azithromycin (<60 y/o),
• ceftriaxone (≥60 y/o)
• inpatient → Tx azithromycin + either
• ceftriaxone or fluoroquinolone
• PPx annual flu vaccine, Pneumovax if ≥65 y/o
• Dx CXR (cavitation w/ air-fluid levels, most
• commonly in right lower lobe)
• Tx IV abx
• Dx screen w/ tuberculin skin test (≥15 mm,
• ≥10 mm if high-risk, ≥5 mm if HIV+ or CXR+);
• confirm w/ CXR (cavitation in upper lobe)
• active TB → Tx SPIRE (streptomycin,
• pyrazinamide, INH, rifampin, ethambutol) for
• 2 months, then INH + rifampin for 4 months
• latent TB → Tx INH only
• Tx supportive care + oseltamivir if ≤48 hrs
Management
• Dx head CT to check for ↑ICP, then lumbar
• puncture + CSF analysis
• Tx IV abx
• Dx head CT to check for ↑ICP, then lumbar
• puncture + CSF PCR
• Tx admit + ACV (for HSV), GCV (for CMV)
• Dx head CT or MRI
• Tx IV abx, surgical drainage, ±steroids
Management
• Dx UA/UCx (≥105 CFU w/o squamous cells)
• Tx only if pregnant (nitrofurantoin) or before
• urologic surgery, otherwise reassurance
• Dx UA/UCx (≥105 CFU w/o squamous cells)
• Tx Bactrim or Cipro, nitrofurantoin if pregnant,
• low-dose Bactrim ppx if recurrent
• Dx UA/UCx (≥105 CFU w/o squamous cells,
• WBC casts)
• uncomplicated → Tx Bactrim or Cipro
• complicated → Tx admit + IV amp/gent
• Dx DRE (boggy tender prostate) + UA/UCx
• Tx Bactrim or Cipro
• Dx prostatic secretion analysis (↑WBC)
• Tx long-term Cipro

GI INFX Dz Bug(s)
Viral hepatitis HAV (fecal-oral)
HBV (parenteral or sexual)
HCV (parenteral)
HDV (parenteral or sexual)
HEV (fecal-oral)
Botulism Clostridium botulinum
preformed exotoxin (from
canned food or wound infx)
Intra-abdominal abscess polymicrobial
Diarrhea Diarrhea × n/v: viral gastro-
enteritis or food poisoning
Diarrhea × fever/blood:
Shigella, Salmonella, Campy,
EHEC
Diarrhea × mayonnaise:
Staph aureus (<6 hrs),
Salmonella
Diarrhea × raw chicken:
Salmonella, Shigella
Diarrhea × raw seafood:
Vibrio, Salmonella, hep A
Diarrhea × abx: C. diff
Diarrhea × travel: ETEC
Diarrhea × daycare: rotavirus,
Shigella, Giardia
Diarrhea × AIDS:
Cryptosporidium
SKIN/SOFT TISSUE INFX Dz Bug(s)
Cellulitis skin flora (Strep pyogenes,
Staph aureus)
Cellulitis × fight bite:
Eikenella
Erysipelas Strep pyogenes
Necrotizing fasciitis Strep pyogenes, Clostridium
(“gas gangrene”) perfringens
Lymphadenitis skin flora (Strep pyogenes,
Staph aureus)
Tetanus Clostridium tetani exotoxin
Toxic shock syndrome Staph aureus TSST-1 exotoxin
MEDICINE × ID
Presentation Management
jaundice, dark-colored urine, RUQ pain, n/v • Dx HAV IgM = acute infx
• Dx HAV IgG = previous infx or immunity
Buzzwords: Asx (usually), daycare, travel • Tx supportive care
jaundice, dark-colored urine, RUQ pain, n/v • Dx HBsAg = acute/chronic infx
• Dx HBsAb = previous infx or immunity
Buzzwords: polyarteritis nodosa, MGN • Dx HBeAg = infectivity
• Dx HBcAb IgM = window period
• Tx IFN-α
jaundice, dark-colored urine, RUQ pain, n/v • Dx HCV RNA
• Tx IFN-α + ribavarin, liver txp if severe
Buzzwords: Cryoglobulinemia, Chronic infx,
Cirrhosis, Carcinoma, Carriers, IVDA, MPGN
jaundice, dark-colored urine, RUQ pain, n/v • Dx HDV Ab
• Tx IFN-α
Buzzwords: Deadly, HBV co-infection
jaundice, dark-colored urine, RUQ pain, n/v • Dx HEV Ab
• Tx supportive care
Buzzwords: cruise ships, fatal in pregnancy
symmetric, descending flaccid paralysis • Dx toxin assay
• Tx admit + antitoxin
fever/chills, abd pain, mass • Dx CT scan (cavitation w/ air-fluid levels)
• Tx I&D + IV abx
--- acute diarrhea
H+P
not complicated complicated
(blood, fever, n/v)
Tx symptomatic relief
(rehydrate, ±loperamide) Dx fecal leukocytes
–WBC +WBC
stool cx,
C. diff toxin
• bacteria → Tx ciprofloxacin x5 days
• C. diff → Tx Flagyl or PO vancomycin
Presentation Management
infx of skin and subcutaneous tissue → • Tx Keflex or Bactrim, consult ophtho if orbital
erythema, warmth, pain, swelling • involvement
“fiery red”, painful skin lesion on face or • Tx PCN or erythromycin
extremities
infx of deeper fascia → extreme fever and • Tx rapid surgical exploration + debridement,
pain, evident tissue necrosis, crepitus • broad-spectrum IV abx
infx of LN → tender LN w/ local cellulitis • Tx Keflex or Bactrim, warm compresses
blocks GABA and glycine release → trismus • Tx tetanus antitoxin (TIG) in one site, Td
(lockjaw), opisthotonos (spastic back), • immunization in a different site
risus sardonicus (spastic smile)
fever, rash, desquamation of palms/soles; • Tx admit + stabilize + IV nafcillin (prevents
associated w/ menstruation and tampons • recurrence, not current toxin-mediated illness)
 MEDICINE × ID

STDS Dz Bug(s) Presentation Management

Chlamydia Chlamydia trachomatis Women: cervicitis, PID, TOA, usually asx • Dx Chlamydia NAAT
Men: urethritis • Tx azithromycin ± ceftriaxone
Gonorrhea Neisseria gonorrhoeae Women: cervicitis, PID, TOA, usually asx • Dx discharge Gram stain (G– diplococci)
Men: urethritis • Tx ceftriaxone ± azithromycin

Disseminated gonoccocal infx: migratory

polyarthritis, endocarditis, skin rash
Fitz-Hugh-Curtis syndrome: perihepatitis
causing RUQ pain, ↑LFTs, “violin string”
adhesions
Vaginal candidiasis Candida albicans thick, white curd-like discharge, itching, • Dx KOH prep (budding yeast + pseudohyphae)
satellite lesions, no odor • Tx fluconazole (Diflucan) or miconazole cream
Syphilis Treponema pallidum 1° syphilis: painless chancre + inguinal LN- • Dx screen w/ RPR-VDRL, confirm w/ FTA-ABS;
opathy • or definitive dx w/ Darkfield microscopy
2° syphilis: palmar/plantar rash, fever, • Tx Benzathine PCN G (1°/2°), IV PCN G (3°)
condyloma lata, generalized LN-opathy
3° syphilis: neurosyphilis (tabes dorsalis),
CV syphilis (luetic heart), gummas

Jarisch-Herxheimer rxn: acute febrile rxn

s/p syphilis tx (MC w/ 2° syphilis), due to
dead spirochetes → endotoxin release
Chancroid Haemophilus ducreyi painful chancre + inguinal LN-opathy • Dx Gram stain (“school of fish” appearance)
• Tx azithromycin or ceftriaxone
HSV HSV-1/2 recurrent, painful oral (HSV-1) or genital • Dx Tzanck smear (multinucleated giant cells)
(HSV-2) vesicles that can rupture • or viral cx
• Tx ACV/VACV + palliative care
Herpetic whitlow: painful, paronychia-like
lesions in fingers of healthcare workers
LGV Chlamydia trachomatis, L1-L3 1° LGV: transient, painless ulcer • Dx complement fixation
serotypes 2° LGV: painful LN-opathy • Tx doxycycline
3° LGV: anogenital syndrome (proctocolitis,
rectal strictures, rectovaginal fistulae,
genital elephantiasis)
Condyloma acuminata HPV-6/11 genital warts • Dx PE
• Tx removal
Bacterial vaginosis Gardnerella vaginalis thin homogenous discharge, fishy odor • Dx wet prep (clue cells)
• Tx metronidazole
Trichomoniasis Trichomonas vaginalis green-gray frothy discharge, odor, • Dx wet prep (mobile trichomonads)
strawberry cervix (petechiae) • Tx metronidazole
HIV/AIDS HIV-1/2 (sexual, parenteral, Primary infx: presents as mono-like • Dx screen w/ HIV ELISA, confirm w/ WB
vertical, or breastmilk) syndrome ± truncal maculopapular rash • Tx HAART (2 NRTIs + 1 NNRTI or PI)
Asx stage: CD4+ >500, asx
Sx stage: CD4+ 200-500, mild sx
(generalized LN-opathy, fungal infx, night
sweats, weight loss, diarrhea)
AIDS: CD4+ <200, or presence of AIDS OI
Pediculosis pubis Phthirus pubis severe itching, irritation, vesicles, burrows • Dx hair under microscope
(“crabs”) • Tx permethrin shampoo

BONE/JOINT INFX Dz Bug(s) Presentation Management

Osteomyelitis Staph aureus (#1), coag-neg hematogenous or direct spread → infx of • Dx needle aspiration + cx (best), MRI
Staph epidermidis (#2), others bone → bone pain w/ local inflammation • Tx admit + IV abx + debride dead bone

OM × IV catheter: Staph • f/u serial ESR/CRP to monitor response to tx

aureus
OM × prosthetic joint: coag-
neg Staph epidermidis
OM × diabetic foot:
polymicrobial
OM × nosocomial:
Pseudomonas
OM × IVDA: Pseudomonas
OM × sickle cell: Salmonella
OM × vertebra: TB (Pott dz)
OM × cat/dog bite: Pasturella
multocida
Infx arthritis Staph aureus (#1), others hematogenous or direct spread → infx of • Dx joint aspiration + analysis
joints → swollen, painful joint w/ ↓↓ROM • Tx admit + IV abx, drain if shoulder or knee
Arthritis × sexually-active
young adults: N. gonorrhoeae
Arthritis × IVDA:
Pseudomonas
Arthritis × sickle cell:
Salmonella
 MEDICINE × ID

ZOONOSES AND Dz Bug(s) Presentation Management

ARTHROPOD-BORNE INFX Lyme disease Borrelia burgdorferi via Ixodes
tick vector
Rocky Mountain Rickettsia rickettsii via tick
spotted fever vector
Malaria Plasmodium falciparum (24h),
P. vivax and ovale (48h),
P. malariae (72h) via
Anopheles mosquito vector
Rabies rabies virus via animal host
Stage 1: erythema chronicum migrans
(target-shaped lesion)
Stage 2: bilateral Bell palsy + AV block
Stage 3: chronic arthritis
triad of HA + fever + rash (vasculitis that
starts on extremities and comes inward)
cyclic fever/chills, headache, anemia,
splenomegaly
pain at bite location → fever, malaise →
agitation, photophobia, hydrophobia
(foaming) → paralysis, coma → death
• Dx screen w/ ELISA, confirm w/ WB
• Tx doxycycline
• Tx doxycycline
• Dx blood smear w/ Giemsa stain
• Tx chloroquine (mefloquine if resistant) ±
• primaquine for P. vivax/ovale hypnozoites
• Dx viral cx, Negri bodies on Purkinje cell bx
• Tx emergent passive + active immunization

FUNGAL INFX Dz Bug(s) Presentation Management

Candidiasis Candida albicans Vaginal candidiasis: thick, white curd-like
discharge, itching, satellite lesions, no odor
Thrush: thick, white plaques in oral mucosa
Cutaneous candidiasis: erythematous,
eroded patches w/ satellite lesions
• Dx KOH prep (budding yeast + pseudohyphae)
• Tx fluconazole or miconazole cream (vaginal),
• nystatin powder (cutaneous), nystatin “swish
• and-swallow” (thrush)

Risk factors: DM, abx use, immuno-

Aspergillosis Aspergillus fumigatus
Cryptococcosis Cryptococcus neoformans via
pigeon droppings
Histoplasmosis Histoplasma capsulatum via
bat/bird droppings in caves
Blastomycosis Blastomyces dermatitidis
Coccidioidomycosis Coccidioides immitis
Sporotrichosis (“rose Sporothrix schenkii via rose
gardener disease”) thorn prick
suppression, HIV/AIDS
ABPA: asthma + pulmonary infiltrates +
Aspergillus allergy
Aspergilloma: prior lung cavitation, filled
up w/ Aspergillus ball → chronic cough ±
hemoptysis
Invasive aspergillosis: acute-onset fever,
cough, respiratory distress, hemoptysis
meningitis/encephalitis in HIV+ pts
usually asx, mild respiratory sx
inflammatory lung dz, granulomatous
nodules in skin and bone
usually asx, mild respiratory sx after
earthquakes in SW US
local ulcer + ascending LN-opathy
• Dx CXR (air-crescent sign for aspergilloma)
• Tx avoidance (ABPA), lung lobectomy
• (aspergilloma), IV ampho B (invasive
• aspergillosis)
• Dx LP + India ink stain (thick capsules)
• Tx IV ampho B + flucytosine
• Dx bx (macrophage-filled spores)
• Tx itraconazole
• Dx bx (Broad Based Buds)
• Tx itraconazole
• Dx bx (huge spherule w/ endospores)
• Tx itraconazole
• Dx bx (cigar-shaped yeasts)
• Tx itraconazole or potassium iodide

PARASITIC INFX Dz Bug(s) Presentation Management

Giardiasis Giardia lamblii bloating, flatulence, foul-smelling fatty • Dx stool sample
diarrhea • Tx metronidazole
Amebiasis Entamoeba histolytica flask-shaped ulcers in ascending colon → • Dx stool sample
bloody diarrhea; “anchovy paste” abscess • Tx metronidazole (for diarrhea and abscess)
in liver → RUQ pain
Cryptosporidiosis Cryptosporidium parvum mild diarrhea, severe diarrhea in HIV+ pts • Dx acid-fast stain
• (no tx exists)
Ascariasis Ascaris lumbricoides usually asx, can cause bowel obstruction • Dx stool sample
• Tx mebendazole
Hookworm Ancylostoma duodenale (old), hooks onto bowel walls and sucks blood → • Dx stool sample
Necator americanus (new) iron-deficiency anemia • Tx mebendazole
Pinworm Enterobius vermicularis perianal pruritus, worse at night • Dx Scotch tape test
• Tx mebendazole
Tapeworm Taenia saginata (beef), usually asx, D. latum eats vitamin B12 → • Dx stool sample
Taenia solium (pork), macrocytic anemia • Tx praziquantel
Diphyllobothrium latum (fish)
Schistosomiasis S. haematobium S. mansoni/japonicum cause fibrosis of liver • Dx stool/urine sample
and spleen; S. haematobium causes bladder • Tx praziquantel
S. mansoni infx → dysuria, bladder SCC
S. japonicum

OTHER INFX Dz Bug(s) Presentation Management

Catheter-related sepsis Staph aureus (#1), coag-neg
Staph epidermidis (#2)
Mononucleosis EBV (#1), CMV (#2)
erythema around an IV cath left in for too
long (>3 days)
fever/chills, sore throat, malaise, myalgias,
severe cervical LN-opathy after making out
w/ someone
• Dx remove and send tip for cx
• Tx IV abx
• Dx Monospot (heterophile agglutination) test
• Tx supportive care + avoid contact sports to
• prevent splenic rupture
 MEDICINE × SKIN

COMMON SKIN DZ Dz Presentation Management Other

Acne vulgaris obstruction of sebaceous • Tx clean skin (1st line), topical benzoyl Risk factors: male sex, puberty,
follicles → proliferation of P. • peroxide, retinoids, or abx (2nd line), systemic Cushing syndrome, oily skin,
acnes → noninflammatory • abx (3rd line), isotretinoin (last line/teratogen) androgens, meds
comedones (pimples) → Steroid acne: not associated w/
inflammatory acne underlying comedones
Rosacea red forehead, nose, cheeks w/o • Tx topical metronidazole (1st line), systemic Rhinophyma: large, bulbous,
underlying comedones • abx (2nd line), isotretinoin (last line) greasy nose in men
Seborrheic dermatitis usually asx; can present as scaly • Tx sunlight + dandruff shampoo (1st line),
patches on scalp (dandruff), • topical ketoconazole (2nd line), topical steroids
hairline, behind ears, eyebrows, • (last line)
armpits, groin area
Contact dermatitis skin rash w/ vesicles and oozing • Dx patch test if unsure Etiology: ACD is delayed (type 4)
(acute) or crusted, thickened • Tx cold compresses, topical steroids, systemic HS to poison ivy, oak, sumac,
skin (chronic) • steroids (severe) iodine, nickel, rubber, cosmetics
• PPx avoid allergen
Irritant contact dermatitis:
physical or chemical insult to
skin → rash shortly after
exposure
Allergic contact dermatitis:
reexposure to allergen → rash
hours-to-days after exposure
Pityriasis rosea herald patches (ringworm-like), • Tx reassurance
then generalized “Christmas
tree” rash
Erythema nodosum painful, red, subcutaneous • Dx CXR (for TB, sarcoidosis), VDRL, CBC, ESR, Etiology: Strep, sarcoidosis, IBD,
nodules over shins • skin cx/bx to look for underlying cause fungal infx, syphilis, TB,
• Tx underlying cause + symptomatic relief (bed pregnancy, meds, idiopathic
• rest, leg elevation, NSAIDs, heat pads)
Lichen planus 4 Ps – pruritic, purple, polygonal • Tx systemic steroids
papules
Bullous pemphigoid anti-hemidesmosome ab → • Tx systemic steroids
tense blisters on skin but not
oral mucosa
Pemphigus vulgaris anti-desmosome ab → tense • Tx systemic steroids
blisters on skin and oral mucosa
w/ acantholysis

INFX SKIN DZ Dz Presentation Management Other

Warts HPV infx → epithelial growth → • Tx removal (cryotherapy, salicylic acid,
fleshy asx mass, plantar warts • podophyllin, surgical or laser excision)
can be painful on walking

Common wart: verruca vulgaris

found on elbows, knees, palms,
and fingers
Flat wart: verruca plana found
on chin/face, dorsum of hands,
and legs
Plantar wart: verruca plantaris
found on sole of foot
Anogenital wart: condyloma
acuminatum found on genital
areas
Molluscum contagiosum poxvirus infx → highly • Tx removal (cryotherapy, podophyllin, surgical
contagious domed papules w/ • or laser excision)
umbilicated center
Shingles (zoster) reactivation of latent VZV • Tx ACV + analgesics MC sites: thorax and trigeminal
(chicken pox) infx → pain and • PPx shingles vaccine for elderly nerve distribution
rash in dermatomal distribution Complications: postherpetic
neuralgia, uveitis, dissemination,
meningoencephalitis, deafness
Dermatophytes Tinea capitis: found on scalp of • Dx scrape lesions + KOH prep
kids w/ itching and hair loss • Tx PO griseofulvin for tinea capitis and
Tinea corporis: ringworm, • onychomycosis, topical antifungals for others
found on body/trunk
Tinea unguium: onychomycosis,
found on finger- and toenails
Tinea pedis: athlete’s foot,
found on webbing of toes
Tinea cruris: jock itch, found in
groin and inner thighs
Scabies Sarcoptes scabiei skin mite → • Dx scrape lesions + microscopy
tunnel in epidermis → burrows • Tx permethrin cream for pt and close contacts
and severe pruritus

SKIN CANCERS Dz Presentation
Actinic (solar) keratosis small, rough, scaly lesions on
face of fair-skinned people;
precursor to SCC
BCC raised waxy lesion or non-
healing ulcer in upper face,
doesn’t spread
SCC non-healing ulcer in lower
face, spreads to LN
Melanoma ABCDE – asymmetric, border
irregularity, colors, diameter >6
mm, elevated; highly metastatic
OTHER SKIN DZ Dz Presentation
Decubitis ulcers (pressure prolonged pressure → tissue
sores) ischemia and necrosis → ulcers
Stage 1: skin intact
Stage 2: partial-thickness skin
loss
Stage 3: full-thickness skin loss
Stage 4: full-thickness skin loss
that extends into underlying
muscle, bone, joints, tendons
Psoriasis abnormal proliferation of skin
cells → silvery, scaling plaques
w/ Auspitz sign (bleeding upon
removal)
Seborrheic keratosis “pasted on” dark, oily plaques
common in older pts
Vitiligo irregular depigmentation of
skin, most commonly on face
ALLERGIC REACTIONS Type 1 HS: allergen exposure → IgE-mediated mast cell degranulation → HA release, atopic/anaphylactic
Type 2 HS: IgG or IgM against cell surface, cytotoxic
Type 3 HS: ab-ag complex deposition → complement activation → cell damage
Type 4 HS: T-cell mediated activation of macrophages, delayed-type
Dz Presentation
Urticaria (hives) type 1 HS → edematous wheals
(hives) that cause intense
pain/pruritus
Erythema multiforme severe urticaria + target lesions
(“bulls-eye lesions”)
Stevens-Johnson syndrome severe erythema multiforme +
mucus membrane involvement
Toxic epidermal necrolysis severe Stevens-Johnson
syndrome
Angioedema fluid extravasation into
subcutaneous tissue → painful
swelling of eyelids, lips, tongue,
genitalia, hands, or feet
Drug allergy types 1-4 HS → skin eruptions
(MC), lung, kidney, hematologic
complications, anaphylaxis
Food allergy type 1 HS → skin eruptions
(MC), GI sx, anaphylaxis
Insect sting allergy Nonallergic rxn: localized
swelling, pain, pruritis, redness
Allergic rxn: looks like cellulitis
Anaphylaxis severe type 1 HS → skin
eruptions followed by airway
obstruction, then shock
Management
• Tx removal (cryotherapy, surgical scraping,
• or topical 5-FU)
• Tx excisional bx w/ 1 mm margins
• Tx excisional bx w/ 1 cm margins + LN excision
• Tx excisional bx w/ 1 cm margins + search for
• mets
Management
• Tx local wound care, surgical debridement,
• BID wet-to-dry for deeper ulcers
• PPx turn and reposition q 2 hrs
• mild → Tx topical steroids, calcipotriene
• severe → Tx MTX, infliximab, cyclosporine A
• Tx removal (cryotherapy, surgical excision)
• only for cosmetic reasons
• Tx topical steroids or photochemotherapy
Management
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• Tx remove offending agent, admit to ICU
• Tx remove offending agent, admit to ICU
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• laryngeal edema → Tx epinephrine
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• anaphylaxis → Tx epinephrine
• Tx remove offending agent, symptomatic
• relief (anthistamines)
• anaphylaxis → Tx epinephrine
• nonallergic → Tx ice pack
• allergic → Tx ice pack + antihistamines
• anaphylaxis → Tx epinephrine
• Tx ABCs, epinephrine, antihistamines, steroids
MEDICINE × SKIN
Other
Risk factors: sunlight exposure,
draining fistulas, arsenic, HPV
Keratoacanthoma: variant of SCC
that grows rapidly and dies off
spontaneously
Marjolin’s ulcer: SCC arising from
a chronic wound
Growth phases: initially grows
radially, then vertically; px
related to depth of invasion
Dysplastic nevus: atypical mole,
precursor to melanoma
Spitz nevus: well-circumscribed,
raised lesion confused w/
melanoma
Other
MC sites: sacrum, greater
tuberosity, ischial tuberosity
Risk factors: immobilization,
dementia, peripheral vascular dz
Complications: secondary
bacterial infx (cellulitis, osteo-
myelitis, nec fasc, gangrene)
Other
Etiology: sulfa drugs (MCC),
other drugs, HSV infx
Etiology: sulfa drugs (MCC),
other drugs
Etiology: sulfa drugs (MCC),
other drugs
Etiology: ACE inhibitors (MCC)
Hereditary angioedema: C1-
esterase inhibitor deficiency
Adverse drug reaction: broad
category including drug allergy,
side-effects, drug interactions,
toxicity, etc.
Adverse food reaction: broad
category including food allergy,
food poisoning, metabolic
conditions, malabsorption, etc.
Etiology: Hymenoptera spp.
(wasps, yellow jackets, honey-
bees, hornets)
 MEDICINE × OUTPATIENT

CARDIOVASCULAR DZ Dz/CC Presentation Management Other

HTN asx, but can present w/ end-organ Dx BP cuff Pre-HTN: 120-139/80-89
complications... Stage 1 HTN: ≥140/90
H+P Stage 2 HTN: ≥160/100
Heart: LVH, MI, CHF lifestyle modifications HTN urgency: ≥220/120
Eyes: retinopathy, papilledema HTN emergency: ≥220/120 + end-
Kidney: CKD not at goal BP organ damage
Brain: stroke, TIA
Arteries: PVD, aortic dissection stage 1 stage 2 compelling 1° (essential) HTN: 95%, no
indications underlying cause
2° HTN: 5%, due to renovascular
Tx HCTZ Tx HCTZ + Tx specific drug dz (MCC), OCPs (MCC young
ACEI/ARB/BB/CB women) or other meds,
stimulants, endocrine dz, etc.
not at goal BP

optimize dose or add drug

• if diabetic, stroke → Tx ACE inhibitor

• if CAD, CHF → Tx β-blocker
• if pregnant → Tx Ca-blocker
• if refractory → check for compliance

• H+P: ask about CP, SOB, HA, side-effects;

• labs (renal panel, fasting lipids)
• Lifestyle modifications: weight loss,
• DASH eating plan, sodium restriction,
• aerobic exercise, moderate alcohol use
• Goal BP: <140/90, <130/80 if CKD or DM
HLD asx, but can present w/ end-organ Dx fasting lipid panel
complications…
initial evaluation +
Atherosclerosis: MI, CAD, stroke, lifestyle modifications
PVD, AAA
↑LDL: xanthelasma, xanthoma not at goal lipids
↑TG: acute pancreatitis
LDL >130 (if high risk) TG >500
LDL >160 (if med risk)
LDL >190 (if low risk)

Tx statins Tx niacin

not at goal lipids

optimize dose or add drug

• Initial evaluation: look for 2° causes + labs

• (TSH, LFTs, renal, fasting glucose)
• Lifestyle modifications: diet + exercise
• Goal lipids: <130, <100 if CHD or DM

Hyperlipidemia drugs: LDL HDL TG Side-effects

Statins ↓↓↓ ↑ ↓ hepatotoxicity, rhabdomyolysis (check
CK, LFTs)
Niacin ↓ ↑↑ ↓↓ flushing, hyperglycemia,
hyperuricemia (check CK, LFTs)
Bile acid resins (colestipol, ↓↓ ↑ ↑ GI distress, poorly tolerated
cholestyramine)
Fibrates (gemfibrozil) ↓ ↑ ↓↓↓ hepatotoxicity, rhabdomyolysis,
cholesterol gallstones (check CK, LFTs)
 MEDICINE × OUTPATIENT

HEADACHE 1° HA types: tension, cluster, migraines

2° HA causes: VOMIT – Vascular (SAH, SDH, EDH, ICH, temporal arteritis)
Other (malignant HTN, psedomotor cerebri, post-LP, pheo)
Meds (nitrates, alcohol withdrawal, analgesic withdrawal)
Infx (meningitis, encephalitis, abscess, sinusitis, shingles, fever)
Tumor

Severe HA w/ HTN: get noncontrast head CT to r/o ICH, then get LP

Dz/CC Presentation Management Other

Tension HA tight band-like pain encircling
entire head + tightness in
posterior neck muscles
Cluster HA unilateral, episodic “burning,
searing, or stabbing pain”
behind eye + ipsi tearing, flush,
or nasal discharge in men
Migraine HA unilateral, throbbing HA ± n/v,
phono-/photophobia in women
Rebound analgesic HA “migraine” after discontinuing
long-term analgesic use
• Tx NSAIDs or Tylenol if mild/moderate, Etiology: unknown
• sumatriptan (Imitrex) if severe
• Tx sumatriptan + O2 for acute attacks, Etiology: unknown
• use verapamil for ppx
• Tx sumatriptan for acute attacks, Etiology: stress → ↓5-HT →
• use TCA or propranolol for ppx vasospasm → headache
• Tx wean pt from analgesics (do not give pt
• more narcotics)

UPPER RESPIRATORY DZ Viral vs. bacterial URI: common sx – fever, cough

viral only – rhinorrhea, myalgia, headache
bacterial only – yellow sputum

“Double sickening”: cold that gets better for a few days then gets worse, consider 2° bacterial infx

Dz/CC Presentation Management Other

Cough ---
Acute bronchitis cough (dry or productive),
±fever, ±shortness of breath
“Common cold” (viral dry cough, sore throat, malaise,
rhinosinusitis) rhinorrhea, nasal congestion
Sinusitis nasal stuffiness, purulent
discharge, cough, sinus pain or
pressure (maxillary sinuses may
resemble dental pain)
Laryngitis hoarseness, sore throat, ±other
viral URI sx
Sore throat ---
• suspect pulmonary dz → Dx CXR
• suspect infx → Dx CBC
• suspect asthma → Dx PFT
• Tx underlying cause (if known) + symptomatic
• relief (codeine syrup, hydration, expectorants)
• smoker → Tx cessation
• postnasal drip → Tx antihistamine +
• decongestant
• suspect PNA → Dx CXR
• Tx symptomatic relief (codeine syrup)
• Tx symptomatic relief (codeine syrup,
• hydration, expectorants, analgesics)
• PPx hand washing
• Dx (think viral if <7-10 days, bacterial if
• >7-10 days)
• viral → Tx decongestant (pseudoephedrine)
• bacterial → Tx decongestant + amoxicillin; if
• not improved after 2 wks, Tx penicillinase
• resistant abx ± ENT consult
• Tx voice rest
• Dx rapid strep test, throat cx
• suspect mono → Dx Monospot test
• Tx symptomatic relief (salt water gargling,
• throat lozenges, analgesics)
• strep throat → Tx PCN x10 days
Acute cough: <3 wks, MCC
viruses
Chronic cough: >3 wks, due to
smoking, postnasal drip, GERD,
or asthma
Etiology: MCC viruses
Etiology: MCC viruses, through
hand-to-hand transmission
Complications: 2° bacterial infx
Etiology: viruses, Strep pneumo,
H. flu, Moraxella catarrhalis
Complications: mucocele,
polyps, infx spread (cellulitis,
osteomyelitis, abscess)
Etiology: MCC viruses
Etiology: MCC viruses, bacterial
tonsillitis, strep throat, mono

GASTROINTESTINAL DZ Dz/CC Presentation Management
Dyspepsia spectrum of epigastric sx • suspect severe GI dz → Dx endoscopy +
(pain/discomfort, heartburn, • urease breath test
bloating, indigestion) • suspect MI → Dx EKG + cardiac enzymes
• Tx underlying cause, make lifestyle changes,
• antacids for acid reflux
• H. pylori → Tx triple or quadruple therapy
GERD heartburn, regurgitation, • Tx PPIs → if it persists >6 wks, Dx EGD w/ bx
waterbrash (sour taste), cough, • to see what’s going on
dysphagia
• Esophagitis: multiple nonulcerating erosions;
• mild Tx → PPIs, severe → lap Nissen
• Barrett esophagus: intestinal metaplasia of
• esophageal epithelium; no dysplasia → Tx
• PPIs, low-grade dysplasia → Tx lap Nissen +
• annual surveillance, high-grade dysplasia →
• Tx esophagectomy
Diarrhea --- acute diarrhea
H+P
not complicated complicated
(blood, fever, n/v)
Tx symptomatic relief
(rehydrate, ±loperamide) Dx fecal leukocytes
–WBC +WBC
stool cx,
C. diff toxin
• bacteria → Tx ciprofloxacin x5 days
• C. diff → Tx Flagyl or PO vancomycin
Constipation --- • suspect 2° cause → Dx TSH, renal panel
• suspect CRC → Dx CBC, FOBT
• suspect obstruction → Dx KUB
• Tx underlying cause, make lifestyle changes
• (exercise, fluids, high-fiber diet)
• obstruction → surg consult
IBS altered bowel habits (diarrhea, • Dx CBC and FOBT to r/o organic causes
constipation, or both) that • constipation → Tx fiber, lubiprostone (2nd line)
improve w/ defecation + chronic • diarrhea → Tx loperamide
abdominal pain
Nausea/vomiting --- • Dx (ask food intake, meds, recent abdominal
• surgery, define vomitus)
• suspect 2° cause → Dx CBC, renal panel, LFTs
• women → Dx β-HCG
• suspect obstruction → Dx KUB
• Tx underlying cause, symptomatic relief
• (promethazine or prochlorperazine)
• severe dehydration → Tx admit + IVF (½NS+K)
Hemorrhoids dilated perianal veins; can • Tx symptomatic relief (high-fiber diet, stool
present as BRBPR or painful • softeners, sitz baths, steroid suppository)
thrombosis • severe → Tx hemorroidectomy or rubber
• band ligation (internal only)
MEDICINE × OUTPATIENT
Other
Etiology: 90% due to GI causes
(PUD, GERD, gastritis, nonulcer
dyspepsia); must r/o acute MI
Etiology: ↓LES tone →
retrograde flow of stomach
contents into esophagus
Complications: erosive
esophagitis, peptic strictures,
esophageal ulcers, Barrett
esophagus, recurrent PNA w/
lipid-laden macrophages
Acute diarrhea: <2 wks, due to
viruses (MCC), bacteria, or meds
Chronic diarrhea: >4 wks, IBS
(MCC), lots of causes
Diarrhea × n/v: viral gastro-
enteritis or food poisoning
Diarrhea × fever/blood: Shigella,
Salmonella, Campy, EHEC
Diarrhea × mayonnaise: Staph
aureus (<6 hrs), Salmonella
Diarrhea × raw chicken:
Salmonella, Shigella
Diarrhea × raw seafood: Vibrio,
Salmonella, hep A
Diarrhea × abx: C. diff
Diarrhea × travel: ETEC
Diarrhea × daycare: rotavirus,
Shigella, Giardia
Diarrhea × AIDS:
Cryptosporidium
Diarrhea × appendicitis-like pain:
Yersinina enterocolitica
Diarrhea × mycotic aneurysm:
Salmonella
Diarrhea × PNA × hyponatremia:
Legionella
Electrolyte imbalance:
hypokalemic metabolic acidosis
Etiology: diet (lack of fiber),
meds, IBS, obstruction, etc.
Complications: hemorrhoids,
rectal prolapse, anal fissures,
fecal impaction
Etiology: unknown, but more
common in women and high
prevalence of Ψ d/o
Etiology: viral gastroenteritis or
food poisoning (MCC), lots of
causes
Complications: dental caries,
aspiration pneumonitis, Mallory-
Weiss or Boerhaave syndrome
Electrolyte imbalance:
hypokalemic, hypochloremic
metabolic alkalosis
Internal hemorrhoids: above the
dentate line, painless but can
prolapse
External hemorrhoids: below
the dentate line, painful
 MEDICINE × OUTPATIENT

MUSCULOSKELETAL DZ Dz/CC Presentation Management Other

Low back pain Lumbar strain: dull LBP after
physical activity
Herniated disc: sciatic-type LBP
radiating to butt/thigh, worse w/
sitting or leaning forward
Degenerative disc dz: chronic
LBP, worse w/ activity
Cauda equina syndrome: bilat
sciatica + bowel/bladder sx,
neuro sx
Vertebral osteomyelitis: LBP +
fever, tender to palpation
Malignancy: LBP + night pain,
h/o cancer, weight loss, failure
to improve
Spinal stenosis: LBP worse w/
activity, better w/ sitting or
leaning forward
Compression fx: well-localized
LBP, worse w/ activity
Spondylolisthesis: LBP worse w/
hyperextension
Ankle sprain tenderness directly over injured
ligament (ATFL or CFL)
Tendinitis Supraspinatus tendinitis: aka
impingement syndrome, dull
pain over lateral deltoid w/ arm
aBduction
Lateral epicondylitis: aka tennis
elbow, pain at lateral elbow w/
supination or pronation
Medial epicondylitis: aka
golfer’s elbow, pain at medial
elbow w/ wrist flexion
De Quervain dz: pain at radial
wrist w/ thumb gripping
Bursitis Olecranon bursitis: swelling
“bag of fluid” and pain at point
of elbow
Trochanteric bursitis: greater
trochanter painful on palpation
Carpal tunnel syndrome carpal tunnel tightness →
median nerve compression →
pain, numbness, tingling over
median nerve distribution;
usually worse at night
LBP
H+P
no red flags red flags
(night pain, pain at rest,
Tx rest + NSAIDs fever, neuro sx, trauma,
bowel/bladder sx, IVDA)
focused work-up
• suspect radiculopathy → Dx straight leg raise
• suspect compression fx, tumor mets, or
• osteomyelitis → Dx X-ray
• suspect cauda equina → Dx emergent MRI +
• consult neurosurg
• Dx ankle X-ray only if Ottawa rules are met
• (can’t walk 4 steps, bony tenderness over
• either malleolus, navicular bone, or base of 5th
• metatarsal)
• Tx RICE + physical therapy
• Tx steroid injections, surgical acromioplasty
• Tx forearm splint, physical therapy
• Tx forearm splint, physical therapy
• Dx Finkelstein test (clench thumb under other
• fingers then ulnar deviate wrist)
• Tx thumb spica splint + NSAIDs
• Tx reassurance
• Tx NSAIDs, steroid injections
• Dx screen w/ Tinel’s sign (tapping median
• nerve causes tingling), Phalen’s test (palmar
• flexion for 1 min causes tingling)
• Dx confirm w/ EMG
• Tx wrist splints (1st line), steroid injections (2nd
• line), surgical carpal tunnel release (3rd line)

Osteoarthritis (OA) wear-and-tear of joints →
degeneration of cartilage →
deep, dull joint pain, worse w/
activity and improved w/ rest
Osteoporosis decreased bone mass (≤2.5 std
deviations) → asx, but can
present w/ complications
• Dx X-ray (look for joint space narrowing,
• osteophytes aka bone spurs, sclerosis, and
• subchondral cysts)
• Tx glucosamine-chondroitin supplements
• Tx weight loss + physical therapy (1st line),
• acetaminophen or NSAIDs (2nd line), steroid
• injections (3rd line), joint replacement (4th line)
• screen women ≥65 w/ DEXA scan q 2 yrs
• Dx DEXA scan
• Tx calcium + vitamin D + weight-bearing
• exercise (1st line), bisphosphonates or HRT
MC joints: hips, knees, spine
Risk factors: old age, obesity,
joint overuse, trauma
HeberDen nodes: OA at DIP
Bouchard nodes: OA at PIP
Risk factors: postmenopause,
old age, steroid or heparin use
Complications: vertebral body
compression fx (→ kyphosis),
Colles fx (distal radius), hip fx

EYE DZ Dz/CC Presentation
Age-related macular degeneration of macula → loss
degeneration (ARMD) of central vision, scotoma
Wet ARMD: sudden onset
Dry ARMD: gradual onset
Glaucoma ↑intraocular pressure → optic
nerve damage → loss of
peripheral vision, blindness
Open-angle: gradual onset,
usually asx for years
Closed-angle: sudden onset w/
severe eye pain, tearing, n/v
Cataracts opacification of lens → gradual
loss of visual acuity
Red eye Conjunctivitis: (see below)
Subconjunctival hematoma:
blood vx rupture → blotchy red
spot in eye
Keratoconjunctivitis sicca: dry
eyes
Blepharitis: eyelid inflammation,
due to Staph aureus
Scleritis:inflammation of sclera
→ eye pain, blurry vision
Uveitis/iritis: inflammation of iris
→ circumcorneal injection, eye
pain, blurry vision
HSV keratitis: presents similar to
conjunctivitis but fluorescein
stain shows dendritic ulcer
Conjunctivitis Viral conjunctivitis: adenovirus
infx → swollen, red eye w/
watery discharge
Bacterial conjunctivitis: Strep
pneumo infx → rapid-onset red
eye w/ mucopurulent discharge
Hyperacute conjunctivitis: N.
gonorrhoeae infx → rapid-onset
red eye w/ copious purulent
discharge
Allergic conjunctivitis: bilateral
red eye w/ itching, tearing, other
upper respiratory sx
Amaurosis fugax internal carotid artery plaque →
embolize to retinal artery →
suddent, transient monocular
loss of vision
SLEEP D/O Dz/CC Presentation
Sleep apnea neck obesity or structural
abnormalities → intermittent
airflow obstruction → episodic
apenic/hypoxic periods →
snoring + fragmented sleep →
daytime sleepiness, brain
damage, HTN/pulmonary HTN
Narcolepsy REM sleep disregulation →
excessive daytime sleepiness,
cataplexy, sleep paralysis,
hypnogogic/hypnopompic
hallucinations
Insomnia ---
MEDICINE × OUTPATIENT
Management Other
• Dx ophthalmoscope shows drusen (yellow-
• white deposits under pigmented epithelium)
• no effective tx exists, but ranibizumab →
• ↓rate of vision loss due to wet ARMD
• Dx ophthalmoscope to check CN II damage,
• visual field testing, tonometry to measure IOP
• open angle → Tx topical β-blockers, α
• agonists, acetazolamide, or prostaglandins
• closed angle → Tx pilocarpine drops +
• emergent iridectomy
• Dx ophthalmoscope Etiology: old age (MCC),
• Tx surgery smoking, diabetes, etc.
“Second sight”: pts w/ cataracts
become increasingly near-
sighted and no longer need
reading glasses
red eye
H+P
no red flags red flags
(severe eye pain, flashes,
Tx cause floaters, trauma, recent
eye surgery, orbital cellulitis,
corneal ulcer/opacification)
consult ophtho
• subconjunctival hematoma → reassurance
• keratoconjunctivitis sicca → Tx artificial tears
• blepharitis → Tx warm compress
• scleritis → consult ophtho (Tx steroids)
• uveitis/iritis → consult ophtho
• HSV keratitis → Tx topical ACV
• viral → Tx cold compress
• bacterial → Tx topical Cipro
• hyperacute → Tx topical + PO ceftriaxone
• allergic → Tx topical antihistamines
• Dx ophthalmoscope shows Hollenhorst plaque
• Dx carotid U/S and cardiac work-up (lipid
• panel, EKG)
• Tx resolves spontaneously
Management Other
• Dx polysomnography
• mild-moderate → Tx weight loss
• severe → Tx CPAP, surgery (last resort)
• Tx methylphenidate (Ritalin), modafinil
• Tx underlying cause, short-term symptomatic
• relief (Ambien, Lunesta, Sonata)
 MEDICINE × OUTPATIENT

OTHER PROBLEMS Dz/CC Presentation Management Other

Hearing loss Conductive hearing loss: lesion
in external or middle ear →
decreased perception of low-
volume sounds
Sensorineural hearing loss:
lesion in CN VIII or CNS →
decreased perception of low-
and high-volume sounds w/
tinnitus
Urinary incontinence Stress incontinence: urine
leakage w/ exertion or straining
Urge incontinence: urine
leakage d/t involuntary bladder
contractions (detrusor hyper-
activity)
Overflow incontinence: urine
leakage d/t urinary retention
and overdistention
Bypass incontinence: urine
leakage d/t fistula following
pelvic surgery or pelvic radiation
Functional incontinence: urine
leakage d/t physical or psych
issues; common in nursing home
or gero pts
Fatigue ---
Chronic fatigue syndrome
(CFS): profound fatigue for >6
months, not due to medical or
psych d/o
Erectile dysfunction (ED) can’t get it up
Alcoholism ---
Smoking ---
• Dx whisper test, audiogram, Weber/Rinne test
• suspect CNS lesion → Dx MRI
• cerumen impaction → Tx Debrox eardrops
• conductive → Tx underlying cause
• sensorineural → Tx underlying cause, consider
• cochlear implants
• Tx surgery to stabilize hypermobile urethra
• (best), Kegel exercises, pessaries
• Tx anticholinergics (oxybutinin), TCAs
• (imipramine)
• Tx intermittent self-cath
• Dx methylene blue or indigo carmine dye
• Tx surgery to repair fistula
• Tx underlying cause
• Dx CBC (anemia), TSH, fasting glucose, renal
• panel, UA, LFTs to r/o organic causes
• Tx underlying cause
• CFS → Tx CBT ± SSRIs
• Tx sildenafil (nitrates c/i)
• Dx CAGE screening (cut down, annoyed by
• criticism, guilt, eye opener)
• Dx labs show ↑LFTs (AST:ALT >2, ↑GGT, ↑CDT),
• ↑MCV (folate deficiency)
• Tx AA referral
• Tx disulfiram (Antabuse) blocks aldehyde
• dehydrogenase → aversive reaction;
• naltrexone blocks opioid-R → ↓cravings;
• acamprosate → ↑GABA/↓glu → ↓cravings
• Tx varenciline (Chantix) and buproprion
• (Zyban) are partial nicotinic agonists; nicotine
• patch or gum
Etiology: cerumen impaction
(MCC conductive), presbycusis
(MCC sensorineural), lots of
other causes
Etiology: chronic ↑ abdominal
pressure, pelvic relaxation, old
age (↓estrogen → loss of
mucosal coaptation)
Etiology: idiopathic (MCC), UTIs,
bladder stones or cancer,
urethral diverticula, foreign
bodies
Etiology: medications,
neurologic disease
Etiology: vesicovaginal, urethro-
vaginal, ureterovaginal fistulas
Etiology: physical impairment,
dementia or delirium,
medications
Etiology: depression (MCC), lots
of other causes
Etiology: penile vasculature
atherosclerosis (MCC), meds
(anti-HTN), alcohol abuse, etc.
Wernicke encephalopathy:
acute thiamine deficiency →
reversible Confusion,
Ophthalmoplegia (CN VI palsy),
Ataxia, Thought disturbances
Korsakoff psychosis: chronic
thiamine deficiency →
irreversible Retrograde and
Anterograde amnesia,
Confabulations
Complications: CV dz (CAD, MI,
stroke, PVD), COPD, cancers,
osteoporosis, Buerger dz, etc.

HEALTH MAINTENANCE Dz Population Screening test

HTN adults ≥18 measure BP
HLD adults ≥18 fasting lipid panel q 5 yrs (more frequently if
increased risk of CAD)
Colorectal cancer adults ≥50 annual FOBT + either colonoscopy q 10 yrs or
flex sigmoidoscopy q 5 yrs
Prostate cancer --- not recommended
Breast cancer women ≥20 monthly self-exam + physician exam q 3 yrs until
40, then q yr + mammogram q 1-2 yrs ≥40
Cervical cancer women 21-65 Pap smear q 2 yrs 21-29, q 3 yrs >30 after 3
negative Paps (don’t need s/p hysterectomy)
STDs sexually active women <25, cervical sampling + RPR-VDRL ± HIV ELISA
other high-risk women
Osteoporosis women ≥65 DEXA scan q 2 yrs
Smoking adults ≥18 screen + counsel
Alcohol adults ≥18 screen + counsel
Depression adults ≥18 screen + counsel if clinic has adequate
mechanisms for dx, tx, and f/u
Diabetic retinopathy diabetic pts referral to ophtho for annual fundoscopic exam
Hearing loss adults ≥65 hearing test
Atherosclerosis complications adults ≥65 assess risk factors
(PVD, stroke, CAD)
PEDIATRICS
 Pediatrics – Shelf notes

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GENERAL PEDS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

★ Developmental milestones
Gross motor Fine motor Speech Social
3 mo holds head up, rolls --- cooing recognizes parents, social smile
front-to-back
6 mo sits up raking grasp babbling stranger anxiety
1 yr walks throws object, 3 blocks 10 words comes when called, imitates
actions, object permanence
2 yr climbs stairs turns pages, 6 blocks 40 words, 2-word sentences, parallel play
50% understandable
3 yr rides tricycle draws circle, 9 blocks 900 words, 3-word sentences, group play
75% understandable
4 yr hops on one foot draws cross counts to ten, tells stories, cooperative play, imaginary
100% understandable friends

Speech delay: deafness, autism, child abuse

Vaccinations: only contraindication across all vaccines is a severe allergic response
DTaP contraindications: severe allergic response, encephalopathy within 7 days
Adverse response to DTaP: give DT instead, since rxn is due to pertussis component
Foot drop s/p injection: needle injection in lower/inner gluteal quadrant → iatrogenic damage to sciatic nerve
Orthopedic issues
Clavicle fx: presents w/ clavicular crepitus or callus, ↑risk w/ LGA infants and breech deliveries; Tx reassurance > figure-of-8 splint
Supracondylar fx: MC fx in kids, due to trauma to humerus; Tx ortho c/s + check radial pulse since brachial artery can be injured
Toddler fx: nondisplaced spiral fx of distal tibia in infants; Tx splint immobilization
Nursemaid elbow: pulling on hand → subluxation of radial head from annular ligament → kid holds arm in a pronated position; Tx manual
reduction via supinating motion
Radial epiphyseal separation: falling out outstretched arm → separation of radius at epiphyseal plate
Genu varum (bowlegs): observe in kids <2 y/o, called Blount disease in kids >2 y/o and requires ortho c/s
Genu valgus (knock-knees): observation okay
Metatarsus adductus: congenital foot deformity, forefoot pointing inwards
Presentation Management
Type I metatarsus adductus overcorrects into position w/ passive and active movements Tx reassurance
Type II metatarsus adductus corrects into position w/ passive and active movements Tx orthosis or corrective shoes
Type III metatarsus adductus doesn’t correct into position w/ passive or active movements Tx surgical correction

Clubfoot: congenital foot deformity, inward and downward-pointing feet, ↑risk of associated spina bifida; Tx stretching + manipulation +
serial casts (<3 mo), surgery (>3 mo)
★ Legg-Calve-Perthes disease: avascular necrosis of femoral head, presents as painless limp in a boy <10 y/o, requires ortho c/s
★ Slipped capital femoral epiphysis: painful limp in a fat boy; Dx X-ray, requires ortho c/s
★ Osgood-Schlatter disease: overuse injury of quads and patellar tendon → traction apophysitis of tibial tuberosity → localized
pain/swelling; Tx RICE + NSAIDs
Congenital hip dysplasia: presents as uneven gluteal folds and “snapping hips” during physical exam in a newborn; Dx U/S (not calcified
enough for X-ray), Tx splinting
Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg for 3
days), Tx admit + IV abx
Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx drainage + IV nafcillin
Osteogenesis imperfecta: AD ∆type 1 collagen → abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss;
often mistaken as child abuse
Osteosarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows Codman’s triangle and “sunburst appearance”, Tx ortho c/s for
surgery
Ewing sarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows “onion skin” appearance, Tx ortho c/s for surgery
Growing pains: deep aching pain in leg muscles w/o any “red flags” (fever, swelling, systemic sx); Tx reassurance
Patellofemoral syndrome: chronic anterior knee pain, worse w/ exercise or prolonged sitting; Tx strengthening exercises
★ Skin rashes
Presentation Management
Eczema (atopic dermatitis) chronic pruritic rash on cheeks, behind ears, Tx moisturizers (calamine or eucerin
extensor surfaces, flexural areas lotion) + topical steroids
Urticaria allergic reaction → pruritic “wheal and flare” Tx antihistamines + PO steroids + avoid
rash allergen
Chickenpox (varicella) VZV infx → “dew drops on a rose petal” Tx antihistamines, ACV if onset <24 hrs
vesicular rash in an ill child
Staphylococcal scalded skin syndrome Staph aureus exfoliatoxins A/B → fever + Tx abx + local skin care
(SSSS) severe, painful rash that develop into bullae,
rupture, and eventually desquamate
Pityriasis rosea single oval herald patch (resembles Tx reassurance
ringworm), followed by diffuse “Christmas
tree” pattern rash on back 5-10 days later
Lichen planus Purple Polygonal Pruritic Papules (rare in Tx PO steroids
children)
Contact dermatitis skin rash w/ vesicles and oozing (acute) or Tx antihistamines + topical steroids +
 Pediatrics – Shelf notes

crusted, thickened skin (chronic) in an avoid exposure

exposure pattern (e.g. linear for poison ivy,
localized for nickel)
Psoriasis thick silvery scales that bleed upon removal Tx topical steroids + calcipotriene (mild),
(Auspitz sign) MTX/infliximab/cyclosporine A (severe)
Henoch-Schonlein (anaphylactoid) IgA-mediated small vessel vasculitis → Tx steroids vs. symptomatic relief, will
purpura “palpable purpura” on buttocks and legs, self-resolve
renal disease (IgA mesangial expansion),
ileocecal edema → colicky abdominal pain +
↑risk for intussusception
Scabies Sarcoptes scabeii infx under skin → pruritic Tx permethrin cream (lindane causes
bullae and pustules (not burrows like adults) seizures in kids/elderly)
Impetigo Staph aureus infx → vesicles/pustules on face Tx topical mupirocin > PO erythromycin
and extremities w/ classic “golden crust”
Porphyria cutanea tarda ∆uroporphobilinogen decarboxylase → ---
photosensitivity to UV light, tea-colored urine,
recurrent attacks of abdominal pain

Behavioral issues
★ Enuresis: involuntary urination >5 y/o; Dx UA to r/o UTI, Tx bed-wetting alarm > desmopressin > imipramine
★ Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows dilated/stool-
filled colon, Tx bowel catharsis + miralax
Breath-holding spells: child holds breath and passes out, due to pain or being upset; Tx avoid reinforcing behavior
Night terrors: child wakes up screaming/agitated, but falls back asleep and remembers nothing in the morning
Nightmares: child wakes up scared and crying, remembers incident
Learned behavior: child wakes up scared and crying, in order to gain sympathy and sleep in mommy’s bed; Tx avoid reinforcing behavior
Somnambulism: sleepwalking, don’t wake up the child
Somniloquy: sleeptalking, benign
Conduct disorder: Capriciousness, Oppressive, Nonconfrontational, Deceitful, Unlawful, Carefree, Temper issues; <18 y/o
Antisocial personality disorder: conduct disorder >18 y/o
★ ADHD: short attention span, impulsivity, hyperactivity for >6 months in 2+ settings (e.g. home and school); ↑risk of aggression; Dx
Vanderbilt scale, Tx dextroamphetamine or methylphenidate
Mental retardation (MR/DD): IQ <70; MCC overall is fetal alcohol syndrome, MC genetic cause is Down syndrome, MC inherited cause is
Fragile X syndrome
Abnormal physical exam findings
Head lice: due to Pediculosis capitis; Tx permethrin shampoo (lindane causes seizures in kids/elderly)
Traction alopecia: linear hair-loss in kids who tie their hair too tightly
Alopecia areata: hair stops growing suddenly → small patches of complete hair loss w/ “exclamation point” stubs
Asymmetric red reflex: retinoblastoma (AD ∆Rb on chromosome 13), juvenile cataracts (galactosemia, congenital rubella syndrome,
neurofibromatosis II, myotonic muscular dystrophy)
Cherry-red macula: Tay-Sachs disease (AR ∆hexosaminidase A) w/o HSM, Niemann-Pick disease (AR ∆sphingomyelinase) w/ HSM
Strabismus: cross-eyes; Tx ophtho c/s to patch the good eye (uncorrected strabismus can lead to ambylopia)
Blue sclerae: osteogenesis imperfecta
Pinpoint pupils: opioids (Tx naloxone), organophosphates (Tx atropine + pralidoxime)
Cholesteatoma: small whitish debris-containing sac on TM, ↑risk w/ recurrent otitis media; Tx ENT c/s for surgical removal
Nasal polyps: cystic fibrosis, triad asthma (aspirin-sensitive)
Strawberry tongue: Kawasaki disease, scarlet fever, toxic shock syndrome
Primary teeth eruption: central incisors (at ~6 mo), lateral incisors, first molars, canines
Permanent teeth eruption: central incisors (at ~6 yr), lateral incisors, canines, first molars, second molars, third molars
Tooth decay: prolonged use of bottles → high sugar concentration → extensive tooth decay of all but mandibular front teeth
Tooth avulsion: facial trauma → knocked out teeth; Tx transport teeth in mouth or milk/saline, then replant permanent teeth within 30 min
(earlier is better)
Retained primary teeth: Job syndrome (hyper-IgE)
Single central incisor: GH deficiency
Thyroid nodule: Dx TSH levels, if euthyroid then get FNA
Café-au-lait spots: neurofibromatosis I, McCune-Albright syndrome
Knuckle-knuckle-dimple-knuckle sign: brachydactyly of 4th digit = Turner syndrome
Knuckle-knuckle-dimple-dimple sign: brachydactyly of 4th/5th digits = pseudohypoparathyroidism
Erythema nodosum: painful red nodules on shins; MCC in kids is Strep pyogenes (not sarcoidosis like adults)
Pes cavus: high-arched foot associated w/ Friedreich ataxia, Charcot-Marie-Tooth disease
Micropenis: GH deficiency
★ Child abuse: suspect w/ retinal hemorrhages, subdural hematoma, multiple healed fx, posterior rib fx, metaphyseal corner (“bucket
handle”) fx, long-bone spiral fx (except distal tibia), cigarette burns, stocking-and-glove scalding water injury, or genital trauma/STDs; first
r/o medical causes, then do a complete physical exam, then get whole-body X-rays, then call CPS if necessary
Neonatal HIV: suspect w/ thrush, generalized LAD, hepatomegaly, and FTT; Dx HIV PCR (not ELISA since mom’s ab can cause false-positive),
requires Bactrim ppx for PCP pneumonia
Environmental exposure
Dog/cat bite: Tx copious irrigation, make sure tetanus is up-to-date, allow healing by 2° intention, PPx Augmentin for Pasturella cellulitis
Human bite + cellulitis: due to Eikenella or other oral anaerobes; Tx admit + debridement + IV abx, leave open to heal by secondary intention
 Pediatrics – Shelf notes

Black widow bite: neurotoxin → severe abdominal cramps, acute abdomen, n/v; Tx IV calcium gluconate + muscle relaxants
Brown recluse bite: necrotoxin → local skin ulceration; Tx excise ulcer + skin graft
Heat stroke: T>105 after playing in the sun, #1 risk factor is dehydration, ↑risk of rhabdomyolysis → renal ATN; Tx emergent cold water bath +
IV fluids
Frostnip: cold exposure → small/firm/cold/white blisters on exposed skin; Tx rewarming
Frostbite: cold exposure → dead tissue → numb/white extremities followed by erythema and pain on reexposure to heat
Chilblain: cold exposure → small, ulcerated lesion on ears and fingertips; Tx reassurance
Cold panniculitis: cold exposure → destruction of fat cells; “popsicle panniculitis” found on lips/cheeks of kids during summertime
Hypothermia: cold exposure → T<95, lethargic, tired, uncoordinated, bradycardia; Tx gradual rewarming
Trench foot: prolonged cold/moisture exposure → foot becomes cold, clammy, numb, pale, swollen

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NEWBORN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

APGAR score: score of 0-10 taken at 1 and 5 minutes; score of 0-3 requires resuscitation
0 1 2
Appearance all blue/pale mixed blue/pale and pink all pink
Pulse 0 <100 >100
Grimace no response to stimulation grimace active cough
Activity limp some flexion of limbs active flexion of limbs
Respirations 0 slow/irregular regular

Primitive reflexes: originate from brainstem and vestibular (CN VIII) nuclei
Moro reflex: limb flexion when extending head
Grasp reflex: grasps at finger when placed in baby’s palm
Rooting reflex: turns face towards cheek stimulation
Placing reflex: steps up when stimulating dorsum of feet
Tonic neck reflex: turning neck causes arm extension (ipsi) and flexion (contra)
Babinski reflex: fanning of toes when scratching dorsum of feet
Parachute reflex: startled arm extension when dropping baby
★ Neonatal skin rashes
Milia: benign, tiny white bumps on nose
Salmon patch (nevus flammeus): benign, splotchy red rash on forehead, eyelids, or back of neck; more prominent with exercise or emotion
Pustular melanosis: benign, little pustules that leave a hyperpigmented spot when ruptured
Erythema toxicum: benign, yellow-white papules w/ surrounding erythema, fluid exam shows eosinophils
Mongolian spots: benign, bluish macules on back and buttocks
Seborrheic dermatitis: greasy scaly rash, usually on scalp in newborns (“cradle cap”), can result in dandruff; Tx sunlight + mild shampoo
Sebaceous nevus: raised, yellow-orange hairless lesion on scalp; Tx resection before adolescence (can undergo malignant degeneration)
Neonatal acne: pimples on healthy newborn due to maternal hormones; Tx reassurance (mild), topical benzoyl peroxide or tretinoin (severe)
Strawberry hemangioma: small reddish capillary malformations
Incontinentia pigmenti: XR, inflammatory bullae that evolve into hyperpigmented lesions, lethal in males
★ SIDS: sudden-death in infants w/o underlying cause; prevent by putting infant on “back to sleep”, don’t smoke around your kid
Breastfeeding contraindications: HIV, HSV on breast, active TB, chemotherapy, galactosemia, PKU, lithium, EtOH, iodine
LP contraindications: elevated ICP w/o open fontanelle, severe cardiorespiratory distress, puncture site cellulitis, severe coagulopathy
Circumcision contraindications: hypospadias (foreskin used to repair defect)
Oligohydramnios: renal problems → ↓amniotic fluid → pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet)
Polyhydramnios: GI obstruction or maternal diabetes → ↑amniotic fluid
Twin-twin transfusion syndrome (TTTS): abnormal vascular flow between mono-di twins → donor twin oligohydramnios/anemia, recipient twin
polyhydramnios/polycythemia; Dx hct difference >15
Coombs test: indicated for neonatal jaundice in type-O or Rh- moms
★ ABO hemolytic disease: type-O mom w/ type-A/B baby develops anti-A/B IgG → crosses placenta and attacks fetal RBCs → causes fetal
hydrops; ↑risk of late-onset high output CHF; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions
★ Rh hemolytic disease (erythroblastosis fetalis): Rh- mom w/ 2nd Rh+ baby develops anti-D IgG → crosses placenta and attacks fetal RBCs
→ causes fetal hydrops; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions
Neonatal care
Neonatal shots: HBV vaccine, vitamin K
★ Choanal atresia: non-canalized nasal passages → difficulty breathing while feeding but normal when crying; Dx nasal catheter or checking
for fog under nares, Tx nasal tubes
★ Meconium aspiration: suspect w/ meconium staining, low Apgar scores, respiratory distress, can result in systemic hypoxia and
pulmonary hypertension; Tx intubation + tracheal suction + O2 mask
★ Transient tachypnea of the newborn (TTN): tachypnea, grunting, possible cyanosis in a c/s infant due to retained fetal lung fluid; Dx CXR
shows pulmonary vascular markings, Tx 100% O2 (will resolve in 3 days)
TTN vs. RDS: TTN improves w/ O2, RDS persists despite O2
Neonatal bloody stool: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal
Neonatal hypothermia: ↑risk of hypoglycemia; Tx place under a warmer
Neonatal hypoglycemia: increase feedings if glucose <40, start IV if <20
AGA: Appropriate for Gestational Age, 10th–90th percentile
SGA: Small for Gestational Age, <10th percentile; ↑risk of congenital malformations, hypoglycemia (low glycogen/fat stores), future growth
retardation
 Pediatrics – Shelf notes

LGA: Large for Gestational Age, >90th percentile; ↑risk of shoulder dystocia, type 2 DM, future obesity
Hyperviscosity syndrome: fetal hypoxia → reactive polycythemia (hct >65%) → sludging/clotting of blood in lungs (respiratory distress),
brain (seizures, tremors), kidney (renal vein thrombosis), GI (necrotizing enterocolitis); Tx partial exchange transfusion
Narcosis: lethargic/limp neonate in mom that got intrapartum opioids for pain control; Tx NICU admit + naloxone
Diaphragmatic hernia: bowels herniate into chest cavity → respiratory distress in a newborn; first put in a orogastric tube, then Dx CXR
shows bowels in chest cavity, Tx surgical repair (high morbidity/mortality)
★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
★ Duodenal atresia: presents as bilious vomiting and polyhydramnios, ↑risk w/ Down syndrome; Dx KUB shows “double bubble”
appearance, Tx surgical repair
★ Intestinal atresia: aka “apple peel” atresia; presents like duodenal atresia, due to vascular accidents in utero; Dx KUB shows “triple bubble”
appearance, Tx surgical repair
Cleft lip/cleft palate: complications include recurrent OM, hearing loss → speech defects; Tx surgical repair (CL in 2-3 months, CP in 6 mo)
Pierre-Robin sequence: micrognathia → posteriorly displaced tongue (glossoptosis) → cleft palate + airway obstruction
Neonatal hypothyroidism : thyroid dysgenesis → lack of T4/T3 synthesis → subtle, nonspecific sx (constipation → distended abdomen →
umbilical hernia, bradycardia, hypothermia, large fontanelles, etc.); Dx ↑TSH, Tx Synthroid
Neonatal thyrotoxicosis: maternal TSI crosses placenta → hyperthyroidism → tachycardia, tachypnea, irritability, diarrhea, vomiting, CHF,
etc.; Dx ↓TSH, Tx propylthiouracil (PTU) for 2-4 months until mom’s ab disappear
★ Neural tube defects: anencephaly, spina bifida occulta (“tuft of hair”), meningocele, myelomeningocele; Dx ↑AFP, PPx folate
supplements before 4th week of gestation
Thumb polydactyly: rare, requires full genetic work-up
Pinky polydactyly: Tx surgical removal, also get echo for white (but not black) kids since white kids have cardiac issues as well
Neonatal tetanus: tetanus toxin (found in dirt) infects umbilical stump → rigidity, trismus, opisthotonus, risus sardonicus
Neonatal thrush: acquired from mom’s vag, does not indicate immunodeficiency; Tx nystatin swish-n-spit
AVM of great vein of Galen: presents w/ cranial bruits + high-output CHF
Colic: unexplained crying for >3 hrs in an infant <3 months, Tx swaddle infant to calm him/her
Premature infants: increased risk of necrotizing enterocolitis, intraventricular hemorrhage, neonatal RDS
★ Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis
intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated
Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Tx VP shunt
★ Neonatal RDS: prematurity or infant of diabetic mother → lack of surfactant → respiratory distress in a newborn; Dx L:SM ratio <2, PPx 48
hrs of maternal steroids, Tx surfactant + O2 therapy + CPAP
Retinopathy of prematurity: disorganized growth of retinal blood vx in premies → scarring and retinal detachment; ↑risk w/ both hypoxia
and oxygen toxicity
Harlequin syndrome: transient erythema on dependent half of body, more common in premies
Cerebral palsy: cerebral anoxia in utero → brain damage → non-progressive impairment of motor function (hypotonia, hyperactive DTRs, learning
disabilities, low APGAR at birth)
★ TORCHES
Presentation Management
Congenital toxoplasmosis chorioretinitis + hydrocephalus + intracranial Tx pyrimethamine + sulfadiazine
calcifications
Congenital rubella syndrome cataracts + deafness + PDA Tx supportive care
Congenital CMV usually asx, MC sequelae is sensorineural ---
hearing loss
CMV inclusion disease “blueberry muffin” rash, HSM/jaundice, Tx IV GCV + supportive care
thrombocytopenia, periventricular calcifications
Neonatal HSV vesicular rash, HSV pneumonitis, temporal lobe Tx IV ACV + vidarabine if disseminated/systemic
encephalitis (focal seizures)
Neonatal HIV suspect w/ thrush, generalized LAD, Dx HIV PCR (not ELISA since mom’s ab can cause
hepatomegaly, and FTT false-positive), requires Bactrim ppx for PCP
pneumonia, give IV ZDV to all neonates of
infected mothers
Early congenital syphilis maculopapular peeling rash, snuffles (rhinitis w/ Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTA-
serous, purulent, or bloody discharge), HSM, ABS, Tx PCN + supportive care
jaundice, generalized LAD
Late congenital syphilis deafness, saber shins, mulberry molars, Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTA-
Hutchinson teeth, saddle nose ABS, Tx PCN + supportive care
Congenital varicella syndrome limb hypoplasia, clear vesicles → cutaneous Tx VZIG if mom has chickenpox from 5 days prior
scars, chorioretinitis, cortical atrophy to 2 days after delivery, otherwise reassurance

Neonatal head trauma

★ Caput succedaneum: soft-tissue swelling of scalp where baby was delivered, crosses midline
★ Cephalohematoma: bleeding between periosteum and skull → “squishy” feel to scalp that doesn’t cross midline
Subgaleal hemorrhage: bleeding under galeal aponeurosis → “squishy” feel to rapidly expanding scalp that crosses midline; Tx NICU admit
for possible hemorrhagic shock
Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Dx head CT, Tx VP shunt
Epidural hematoma: head trauma to temporal bone → torn middle meningeal artery → LOC w/ “lucid interval” → uncal herniation → death;
Dx head CT shows convex lens, Tx emergent craniotomy
Subdural hematoma: “shaken baby syndrome”
 Pediatrics – Shelf notes

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– FEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Length: 1× at birth → 1.5× in 1 yr → 2× in 5 yrs

Weight: 1× at birth → 0.9× in 1 wk (ECF diuresis) → 1× in 2 wks → 2× in 6 mo → 3× in 1 yr
Adiposity rebound: period of growth where BMI increases faster than height, average 5 yrs
Vision: 20/200 at birth → 20/40 at 6 mo → 20/20 at 4 yr
★ Failure to thrive: growth <5th percentile in 2+ of the following – height, weight, head circumference; most commonly due to nonorganic causes; Dx
bone age (left wrist X-ray), Tx underlying cause
Constitutional growth delay: bone age < real age, tracks along low percentile on growth chart, good prognosis
Familial short stature: bone age = real age, usually have short parents, poor prognosis
Pathologic short stature: craniopharyngioma, hypothyroidism, GH deficiency, Turner syndrome, renal tubular acidosis
★ Vitamins
Deficiency Toxicity
Vitamin A: used to treat cystic acne, night blindness, dry skin increased CSF pressure (headache, blurry
measles, and AML (M3 type) vision), dry skin, teratogenic; found in
animal liver consumption
Vitamin B1 (thiamine): given to kids dry beriberi (peripheral neuropathy), wet ---
before IV D5 to prevent iatrogenic beriberi (CHF), Wernicke-Korsakoff (ataxia,
Wernicke-Korsakoff amnesia, confabulations, etc.)
Vitamin B2 (riboflavin) cheilosis (dried cracks along corners of lips), ---
corneal vascularization
Vitamin B3 (niacin) pellagra (diarrhea, dermatitis, dementia) flushing, pruritus (Tx NSAIDs)
Vitamin B6 (pyridoxine) peripheral neuropathy, seizures, ---
sideroblastic anemia; found in INH usage
Vitamin B7 (biotin) seborrheic dermatitis, enteritis, alopecia; ---
found in kids who eat raw eggs (avidin binds
biotin) and biotinidase deficiency
Vitamin B9 (folate): given to sickle cell megaloblastic anemia w/o neuro sx, neural ---
kids to help hematopoiesis tube defects; found in babies fed goat’s milk
Vitamin B12 (cobalamin) megaloblastic anemia w/ neuro sx; found in ---
strict vegan diets and pernicious anemia
Vitamin C scurvy (bleeding gums) uric acid stones
Vitamin D: given to breast-fed kids who rickets (bowed legs, rachitic rosary) metastatic calcifications, kidney stones
don’t get enough sunlight
Vitamin E hemolytic anemia hemorrhagic diathesis
Vitamin K: all infants get vitamin K shot hemorrhagic diathesis ---
at birth

ADEK deficiency: malabsorption syndromes (cystic fibrosis, celiac sprue, tropical sprue, Whipple disease, abetalipoproteinemia, pancreatic
insufficiency, lactose intolerance, etc.)
★ Goat milk: ↓folate → megaloblastic anemia
★ Cow milk: ↓iron → microcytic anemia ± pica, fatigue, pallor; Tx PO iron supplements
★ Breast milk: ↓vitamin D → nutritional rickets
Zinc deficiency: acrodermatitis enteropathica (erythematous desquamating rash on hands/feet, scalp, buttocks, mouth)
Selenium deficiency: CHF
Kwashiorkor: protein malnutrition → FTT, anemia, edema, apathy, fatty liver
Marasmus: overall lack of calories → FTT, subcutaneous fat loss, muscle atrophy, premature aged look
Fluids/electrolytes
Serum osmolarity: 2×Na + BUN/2.8 + glucose/18
Maintenance fluids: D5½NS+20KCl using 100/50/20 rule for daily fluids, 4/2/1 rule for hourly fluids
Resuscitation fluids: 20 mL/kg bolus of NS or LR
★ Vomiting: hypokalemic, hypochloremic, metabolic alkalosis
★ Diarrhea: hypokalemic, metabolic acidosis
Dehydration: diarrhea or vomiting → lethargy, ↑HR, ↓BP, delayed capillary refill; Tx PO fluids (mild), 20 mL/kg bolus of NS/LR (severe)
Parkland formula: fluid resuscitation for burn victims; give LR at 4 mL/kg × %BSA, ½ over first 8 hrs then ½ over the next 16 hrs
Hyponatremia + pancytopenia: consider RMSF

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– DRUGS/POISONS –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

★ Poisons
Presentation Management
Acetaminophen n/v, malaise, liver damage (↑LFTs) wait 4 hrs then get acet levels, determine
need for N-acetylcysteine at that time (no
harm in waiting up to 8 hrs before giving
antidote)
Aspirin, oil of wintergreen triad of fever, tinnitus, tachypnea → causes Tx sodium bicarb vs. hemodialysis
mixed respiratory alkalosis + AGMA
Caustic agents, drain cleaner, lye esophageal erosion, possible perforation Dx endoscopy to determine extent of
damage, Tx controversial (call poison
control)
Cyanide headache → agitation/confusion → seizures Tx nitrites + hydroxocobalamin +
and metabolic acidosis thiosulfate
Hydrocarbons usually asx, may have transient gagging and Dx CXR to r/o aspiration pneumonitis,
 Pediatrics – Shelf notes

coughing admit + observe for 24 hrs

Iron upper GI bleed, abd pain, metabolic acidosis,
shock
Lead LEAD – Lead lines (basophilic stippling),
Encephalopathy, Anemia and Abdominal pain,
wrist Drop, foot Drop; MC source is paint in
old homes (before 1950)
Methanol, ethylene glycol AMS and AGMA after drinking “homemade
alcohol”, methanol has optic disc hyperemia,
EG has renal failure (oxalic acid crystals)
Opioids miosis, bradypnea, bradycardia, hypotension
Organophosphates “kid playing in garden shed found
salivating/unconscious”, blocks ACh-esterase
→ muscarinic sx (LUSHPADS BBB)
Phenothiazine, metoclopramide extrapyramidal sx (e.g. torticollis,
opisthotonus, dysphagia)
Shellfish perioral parasthesias/numbness, generalized
weakness, paralysis
TCAs AMS, hypotension, anticholinergic effects
(dilated pupils, etc), widened QRS complex
Warfarin hemorrhagic diathesis
Dx iron levels, Tx deferoxamine
Dx blood lead >10 μg/dL, Tx CaEDTA +
dimercaprol + dimercaptosuccinic acid
Tx EtOH vs. fomipezole (4-MP)
Tx naloxone
Tx atropine + pralidoxime (2-PAM)
Tx diphenhydramine
Tx supportive care, may need mechanical
ventilation
Tx sodium bicarb or Fab antibody
fragments
Dx ↑PT/↑PTT, Tx vitamin K + FFP if severe

Teratogens: worst when exposed within first 8 weeks of gestation

Effect
ACE inhibitors renal dysgenesis
Alcohol fetal alcohol syndrome (MR, abnormal facies, smooth philtrum, IUGR, congenital heart defects)
Alkylating agents adactyly
AmiNOglycosides Nephrotoxicity, Ototoxicity
Cocaine fetal addiction, IUGR, placental abruption
DES vaginal clear-cell adenocarcinoma
Folate antagonists NTDs

Iodide goiter, hypothyroidism

Lithium Ebstein anomaly
Maternal diabetes fetal macrosomia (risk of shoulder dystocia), caudal regression syndrome (anal atresia to sirenomelia), CV
defects
Retinoic acid CNS defects, hydrocephalus, microtia/anotia, micrognathia, athymia
Smoking preterm labor, IUGR, ADHD
Tetracyclines tooth discoloration
Thalidomide phocomelia (hands attached to shoulders)
Valproic acid blocks folate absorption → NTDs; best management for anticonvulsants is monotherapy at lowest effective
dose w/ careful monitoring
Warfarin bone deformities, fetal bleeding, abortion
X-rays, CT scans multiple anomalies

Common side-effects
Side-effects
Corticosteroids infection, HTN, hyperglycemia, cataracts, osteoporosis, truncal obesity w/ abdominal striae, etc.
Cyclophosphamide hemorrhagic cystitis (Tx mesna)
Diphenhydramine drowsiness
Doxorubicin (Adriamycin) dilated cardiomyopathy
Erythromycin ↑risk of pyloric stenosis in <1 mo
HCTZ hyperGLUC – hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia
Inhaled corticosteroids thrush
Local epinephrine vasoconstriction (contraindicated in end-organ supply)
Nitrates methemoglobinemia (Tx IV methylene blue)
NSAIDs platelet dysfxn, renal impairment, peptic ulcers
Pseudoephedrine sympathetic stimulation (tachycardia, hypertension, etc.)
Sodium nitroprusside cyanide poisoning
Topical benzocaine (Orajel) methemoglobinemia (Tx IV methylene blue)
Vincristine peripheral neuropathy

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GENETICS ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Triplet expansion syndromes: Fragile X, DMD, Huntington chorea, Friedreich ataxia

★ Genetic syndromes
Mutation Presentation
Patau syndrome trisomy 13 MR, cleft lip/Palate, holoProsencephaly, Polydactyly, rocker-bottom
feet, death by 1 y/o
Edward syndrome trisomy 18 MR, VSD, micrognathia, clenched hands, rocker-bottom feet, death
by 1 y/o
Down syndrome trisomy 21 (95%), MR, flat facies, epicanthal folds, simian crease, AVSD (endocardial
Robertsonian cushion defect), GI issues (Hirschsprung dz, duodenal atresia),
translocation (5%) ↑↑incidence of ALL, Alzheimer by 40 y/o; high-risk in women >35 y/o
[note: Down syndrome + UMN sx = atlantoaxial instability]

Fragile X syndrome
Williams syndrome
Cri-du-chat syndrome
DiGeorge/velocardiofacial
syndromes
Klinefelter syndrome
47, XYY males
Turner syndrome
Noonan syndrome
VACTERL syndrome
AngelMan syndrome
Prader-Willi syndrome
Cornelia de Lange syndrome
Marfan syndrome
Ehlers-Danlos syndrome
Beckwith-Wiedemann syndrome
Holt-Oram syndrome
Jeune syndrome (asphyxiating
thoracic dysplasia)
Crouzon syndrome
Neurofibromatosis I (von
Recklinghausen disease)
Neurofibromatosis II
Tuberous sclerosis
Sturge-Weber syndrome
PHACES syndrome
Von Hippel-Lindau syndrome
Alport syndrome
Waardenburg syndrome
Achondroplasia
Frohlich syndrome (adiposogenital
dystrophy)
Laurence-Moon-Biedl syndrome
Kartagener syndrome
Friedreich ataxia
★ Inborn errors of metabolism: suspect w/ neonatal vomiting + metabolic acidosis, unusual odor of urine/sweat, HSM, MR, hyperammonemia, FHx of
early infant death, seizures
PKU
Maple syrup urine disease
(MSUD)
Pediatrics – Shelf notes
XR ∆FMR1 (CGG DSM-V – Discontinued chromosomal staining, Shows anticipation,
trinucleotide repeats) Males-only, MR, Macrognathia, Macroorchidism, Mitral valve
prolapse
7q– (includes elastin) MR, elfin facies, extreme friendliness, English skills, hypercalcemia,
CV defects (supravalvular aortic stenosis)
5p– MR, high-pitched “mewing” cry, microcephaly, epicanthal folds, CV
defects
22q11– CATCH-22 – Cleft palate, Abnormal facies, Thymic aplasia (no T-cells),
CV defects, Hypocalcemia (no PTH), 22q11–; Dx intradermal Candida
test, requires irradiated transfusions (prevent GVHD)
47, XXY female traits on a male (e.g. long legs, small balls, gyno, high-pitched
voice, etc.)
47, XYY aggressive, antisocial behavior
45, XO CLOWNS – Coarcted aorta, Lymphedema (knuckle-knuckle-dimple-
knuckle), Ovarian dysgenesis, Webbed neck (cystic hygroma), Nipples
spread (shield chest), Short stature; Tx GH replacement + ppx
bilateral gonadectomy
--- phenotypically similar to Turner syndrome but AD (males = females),
associated w/ pulmonic stenosis rather than aortic coarctation
--- Verbetral defects, Anal atresia, CV defect, TE fistula, Esophageal
atresia, Renal/Radial defects, Limb defects
Maternal 15q11– “happy puppet syndrome” – MR, ataxia, flailing arms, outbursts of
laughter
Paternal 15q11– MR, hypotonia, hyperphagia/obesity, hypogonadism, “almond eyes”;
Tx GH replacement + dietary caloric restriction
--- MR, bushy eyebrows + hirsutism, limb defects, self-injurious behavior
AD ∆fibrillin (15q) elongated body habitus, MVP, aortic aneurysms, aortic dissection,
lens subluxation [note: Marfan + clotting sx = homocystinuria]
AD ∆type 3 collagen thin fragile skin, joint hypermotility/dislocations, MVP, aortic
aneurysms, aortic dissection
--- generalized overgrowth, large tongue, neonatal hypoglycemia,
certain cancers (Wilms tumor, hepatoblastoma (Dx ↑AFP))
AD ∆TBX5 upper limb abnormalities (hypoplastic thumb, hypoplastic radii,
missing pectoralis major) + cardiac abnormalities (Heart-Arm
syndrome)
--- long/narrow thorax → hypoplastic lungs, fibrotic liver, death due to
pulmonary causes
--- craniosynostosis, wide-eyes w/ proptosis, “beak nose”
AD ∆NF1 café-au-lait spots, Lisch nodules (iris hamartomas), optic gliomas, CNS
tumors, pheos [note: NFI + HTN = Dx 24 hr urinary metanephrines to
r/o pheo]
AD ∆NF2 bilateral acoustic neuromas, juvenile cataracts
AD ∆TSC CNS/retinal hamartomas, sebaceous adenomas, hypopigmented “ash
leaf” spots, Shagreen patches, renal angiomyolipomas, cardiac
rhabdomyomas
--- facial “port-wine stain” w/ ipsilateral AVM (Dx head CT shows
“gyriform calcifications”)
--- Sturge-Weber syndrome + other commonly-associated defects;
Posterior fossa tumors, Hemangiomas on face, Arterial abnormalities,
Coarctation of aorta, Eye abnormalities, Sternal defects
AD ∆VHL bilateral RCC, hemangioblastomas, pheos
XR ∆type 4 collagen nephritic syndrome (hematuria), deafness, ocular defects
AD or associated w/ wide-eyes, broad nasal bridge, medial hyperplasia of eyebrows, white
advanced paternal age forelock (think Rogue), heterochromia, deafness
AD ∆FGFR3 or short limbs but normal-sized torso (think Mini-me)
associated w/ advanced
paternal age
--- hypothalamic tumor → hyperactive feeding center (childhood
obesity) + ↓GnRH secretion (secondary hypogonadism); similar to
Prader-Willi syndrome
--- obesity + MR, hypogonadism, polydactyly, retinitis pigmentosa →
night blindness
∆dynein → immotile situs inversus (right-sided heart), recurrent pulmonary infx, infertility
cilia
AR ∆frataxin (GAA staggering gait + frequent falls, kyphoscoliosis, pes cavus, hammer
triplet repeats) toes; MCC death is hypertrophic cardiomyopathy
Mutation Presentation Management
AR ∆phenylalanine MR, mousy body odor, blue eyes, Dx Guthrie test, Tx dietary
hydroxylase blond hair ↓phe/↑tyr, can relax dietary
restrictions over time but must
reinstate during pregnancy to
prevent maternal PKU
AR ∆branched-chain inability to digest isoleucine, leucine, Tx dietary ↓ile/↓leu/↓val
amino acid valine (“I LoVe maple syrup”) →
 Pediatrics – Shelf notes

decarboxylase PKU-like sx w/ sweet-smelling urine

Galactosemia AR ∆gal-1P inability to digest galactose → Tx dietary ↓lactose/↓galactose
uridyltransferase profound illness following first
milk/formula feedings, ↑risk of E. coli
sepsis
Hereditary fructose AR ∆aldolase B inability to digest fructose → Tx dietary ↓sucrose/↓fructose
intolerance profound illness following first fruit
juice feedings
Biotinidase deficiency AR ∆biotinidase inability to synthesize biotin (vitamin Tx biotin supplements
B7) → seborrheic dermatitis,
enteritis, alopecia
Tyrosinemia AR ∆fumarylaceto- inability to digest tyrosine → failure Tx nitisinone (enzyme that helps
acetate hydrolase to thrive, hepatomegaly, liver failure bypass metabolite accumulation)
Von Gierke disease AR ∆glucose-6- inability to run glycolysis → FTT, ---
phosphatase hypoglycemia, hepatomegaly, lactic
acidosis, characteristic appearance
(short w/ fat cheeks, thin arms, big
abdomen)
Pompe disease AR ∆acid maltase inability to run glycolysis → FTT, ---
hypoglycemia, cardiomegaly
A1AT deficiency AR ∆α1-antitrypsin inability to export enzyme → builds ---
up in liver (cirrhosis) + can’t break
down proteolytic enzymes in lungs
(early-onset panacinar emphysema)
Mitochondrial diseases --- maternal inheritance w/ ---
heteroplasmy, affects permanent
cells (heart, skeletal muscle, brain);
diseases include MERFF, MELAS,
LHON, and Kearns-Sayre syndrome
Lysosomal storage diseases --- inability to digest cellular debris → Dx urinary mucopolysaccharides, Tx
systemic effects of mucopoly- bone marrow txp + enzyme
saccharide accumulation (coarse replacement therapy
facial features, HSM, joint
contractures, MR, etc.)
Fabry disease: XR ∆β-galactosidase, “bathing trunk” angiokeratomas
Gaucher disease: AR ∆β-glucosidase, “Erlenmeyer-flask” appearance of long
bones, “wrinkled paper” cells
Metachromatic leukodystrophy: AR ∆arylsulfatase A
Niemann-pick disease: AR ∆sphingomyelinase, “cherry-red macula” w/ HSM
Tay-Sachs disease: AR ∆hexosaminidase A, “cherry-red macula” w/o HSM,
exaggerated startle response (hyperacusis)
Sandhoff disease: AR ∆hexosaminidase A+B
Hurler syndrome AR ∆α-L-iduronidase inability to digest glycosamino- Dx urinary dermatan sulfate and
glycans → coarse facial features heparan sulfate
(“gargoyle-like”), HSM, progressive
developmental delay, death
OTC deficiency XR ∆ornithine inability to digest amino acids in Tx arginine, benzoic acid, or
transcarmbamylase urea cycle → profound illness phenylacetate to get rid of
following first protein feedings ammonia; dialysis if unresponsive
Alkaptonuria AR ∆homogentisate accumulation of homogentisate in ---
oxidase urine and joints → urine that turns
brown/black on air exposure, adult-
onset arthritis
Homocystinuria AR ∆cystathionine β- HOMOCysteine – Hypercoagulable, Tx vitamin B6 + cysteine
synthase Optic lens dislocation, MR,
Marfanoid habitus, Osteoporosis,
Cysteine becomes essential in diet
Lesch-Nyhan syndrome XR ∆HGPRT impaired purine metabolism → MR, ---
hyperuricemia, gout, self-mutilation
Medium-chain acyl-CoA AR ∆fatty acid oxidase can’t break down FA for energy → Tx L-carnitine + avoid prolonged
deficiency (MCADD) hypoketotic hypoglycemia w/o fasting
acidosis

Collagen defects
Osteogenesis imperfecta: AD ∆type 1 collagen → abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss;
often mistaken as child abuse
Ehlers-Danlos syndrome: AD ∆type 3 collagen → thin stretchy skin, joint hypermotility/dislocations, MVP, aortic aneurysms, aortic dissection
Alport syndrome: XR ∆type 4 collagen → nephritic syndrome (hematuria), deafness, ocular defects

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– CARDIOVASCULAR ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Antibiotic ppx for dental procedures: give amoxicillin only if prior endocarditis, prosthetic valve, heart txp, or severe or repaired congenital heart
defects (do not give for innocent childhood murmurs)
Cyanosis: normal if peripheral (doesn’t involve mucus membranes), diagnostic for R-to-L shunt if central (involves mucus membranes)
Benign murmurs: asymptomatic, <grade II, normal S2, no clicks, normal pulses
Pathologic murmurs: symptomatic, >grade III, diastolic or continuous
 Pediatrics – Shelf notes

★ Congenital heart defects: 1% incidence, 2-6% w/ one sibling, 20-30% w/ two siblings
L-to-R shunts: late-onset cyanosis due to Eisenmenger syndrome; includes VSD, ASD, PDA
ASD: presents w/ fixed-split S2 + exercise intolerance
Thrombocytopenia-absent radius syndrome (TAR): thrombocytopenia + bilateral absent radii + ASD
VSD: MC CHD overall, presents w/ holosystolic blowing murmur at LLSB, louder is better, most resolve spontaneously
PDA: presents w/ continuous machinery-like murmur + bounding pulses; Tx keep Patent w/ PGE1 and closed w/ indomethacin,
surgical closure if >1 mo (won’t close spontaneously)
Eisenmenger syndrome: pulmonary hypertension reverses L-to-R shunts into R-to-L shunts
R-to-L shunts: early-onset cyanosis; includes ToF, TGV, TAPVR, Tricuspid atresia
Tetralogy of Fallot: PROVe – Pulmonic stenosis (determines Prognosis), RVH, Overriding aorta, VSD; presents as cyanotic “tet
spells” and clubbing in a kid who squats for relief; Dx CXR shows “boot-shaped heart”, Tx shunt placement
Transposition of the great vessels: presents w/ life-threatening cyanosis in a newborn + single loud S2 without murmur; Dx CXR
shows “egg on a string” w/ RVH, Tx emergent PGE1 then cath lab for atrial septostomy
TAPVR: presents w/ cyanosis + dyspnea; Dx CXR shows “diffuse reticular pattern” from pulmonary edema
Tricuspid atresia: lack of tricuspid valve + hypoplastic RV → cyanosis + LVH; Tx emergent PGE1 to keep PDA open and consult
surgery
Aortic coarctation: suspect w/ weak femoral pulse or treatment-resistant HTN at young age, consider Turner syndrome in short women; Dx
CXR shows rib-notching and “figure 3” aorta, Tx balloon angioplasty
Ebstein anomaly: RA hypertrophy + atrialized RV + tricuspid valve dilatation; associated w/ antenatal lithium use
Mitral valve prolapse: AD; presents w/ mid-systolic click and late-systolic rumble, does not require abx ppx for dental procedures
Carotid artery dissection: trauma to head/neck/soft palate → dissection of internal carotid artery → stroke-like presentation, may have delayed onset
relative to traumatic incident; Dx MRI, Tx observation vs. anticoagulation vs. surgical repair
Cardiac diseases
Myocarditis: coxsackie B virus infx → inflammation of myocardium results in systolic dysfxn → fever + lethargy + CHF sx
Dilated cardiomyopathy (DCM): ventricular dilatation → systolic dysfunction → CHF sx (dyspnea, orthopnea, PND); Tx diuretics + inotropes,
heart txp if severe
Hypertrophic cardiomyopathy (HCM): AD ∆β-myosin heavy chain → exertional dyspnea, angina, syncope, “sudden death in a young athlete”,
systolic murmur enhanced by ↓preload; Dx echo + family hx, Tx β-blockers vs. myomectomy vs. pacemaker
Restrictive cardiomyopathy (RCM): endocardial fibroelastosis is MCC in kids
★ Rheumatic fever: strep throat → anti-M ab → type 2 hypersensitivity → carditis, arthritis (MC), erythema marginatum, chorea,
subcutaneous nodules; Dx ASO titer, Tx amoxicillin + PO steroids
★ Kawasaki disease: CRASH and BURN – Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet swelling, fever >5 days; Tx IVIG +
high-dose aspirin (watch out for Reye syndrome)
Postpericardiotomy syndrome: pericardial effusion w/ possible tamponade s/p cardiac surgery; presents w/ Beck triad (hypOtension, JVD,
muffled heart sounds)
Arrhythmias
Premature atrial beats: premature, abnormally-shaped P wave, benign
Premature ventricular beats: premature, wide QRS complex, benign
Supraventricular tachycardia (SVT): MC symptomatic arrhythmia in kids; re-entrant mechanism → HR >200 → sx of low cardiac output
(dyspnea, pallor, syncope); Tx vagal maneuvers (carotid massage) or IV adenosine
WPW syndrome: presence of atrioventricular accessory tract → SVT + “delta wave” on EKG; Tx radiofrequency ablation
Congenital heart block: maternal SLE → anti-Ro/SSA attacks fetal heart conduction → complete (3°) heart block
Prolonged QT syndrome: prolonged QT interval → uncoordinated repolarization → torsades de pointes (Tx IV mag) → death
Prolonged QT + deafness: Jervell-Lange-Nielsen syndrome
Widened QRS + ingestion: TCAs (imipramine, amitriptyline, etc.); Tx sodium bicarb
★ Neurocardiogenic syncope: presents as 6 Ps – syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or
light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– RESPIRATORY ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Acute respiratory failure: hypoxemia (PO2 <50) or hypercapnea (PCO2 >60) → cyanosis, tachypnea, grunting, nasal flaring, chest retractions; Tx ABCs,
then adequate oxygenation (may require intubation), then address underlying cause
Wheezing: asthma (MCC), bronchiolitis, cystic fibrosis, foreign body aspiration, tracheomalacia
★ Asthma: reversible airway obstruction → wheezing, cough, chest tightness, dyspnea; normal PCO2 is a bad sign (retaining CO2 despite
hyperventilation); Dx reversible FEV1/FVC <70%
Asthma + thrush: due to inhaled corticosteroids; Tx rinse mouth after inhaler use
Asthma + hypokalemia: β2-agonists can cause potassium to go into cells
Triad asthma: asthma + aspirin sensitivity (↑LT) + nasal polyps
Churg-Strauss syndrome: asthma + eosinophilia + vasculitis
Frequency Tx
Mild intermittent asthma <2 times/wk prn SABA (albuterol)
Mild persistent asthma 2+ times/wk add low-dose inhaled steroids
Moderate persistent asthma daily + nighttime sx 1/wk add LABA (salmeterol)
Severe persistent asthma continuous + frequent nighttime sx add high-dose inhaled steroids
Asthma exacerbation --- albuterol nebulizer + PO steroid burst
Status asthmaticus unresponsive to meds admit + intubate

Foreign body aspiration: sudden-onset respiratory distress + focal wheezing, can have recurrent PNA in same lobe; Dx/Tx rigid bronchoscopy
 Pediatrics – Shelf notes

Respiratory infx
★ Croup: parainfluenza infx → barking cough, low-grade fever, respiratory distress; Dx AP neck X-ray shows “steeple sign”, Tx PO steroids +
O2 therapy > racemic epinephrine > intubation
Bacterial tracheitis: rare complication of croup (superinfection), presents w/ biphasic stridor, spiking fever, respiratory distress;
Tx emergency intubation + IV abx
★ Epiglottitis: H. flu infx of epiglottis → sore throat, fever, inspiratory stridor, drooling, “sitting on a table leaning forward”; Dx lateral neck
X-ray shows “thumbprint sign”, Tx emergency intubation + IV abx
★ Bronchiolitis: RSV infx during wintertime → bronchiolar inflammation → wheezing, URI sx, respiratory distress, ↑risk of developing
asthma; Tx supportive care w/ monitoring of O2 and hydration status (ribavarin if severe, pavilizumab ppx for high-risk infants)
Typical PNA: Strep pneumo (MCC) infx → acute-onset fever, chest pain, productive cough; Dx CXR shows lobar consolidation, Tx ceftriaxone
or respiratory fluoroquinolones
Atypical PNA: Mycoplasma (MCC), Legionella, or Chlamydia infx → inflammation of lung interstitium → presents w/ fever, malaise,
nonproductive cough; Dx CXR shows interstitial infiltrates, Tx azithromycin
Empyema: Strep/Staph infx of pleural space → respiratory distress; Dx CXR shows unilateral “white out” of lung, Tx vancomycin + chest tube
drainage
Tuberculosis: Mycobaterium tuberculosis infx → cough/hemoptysis, fever, weight loss; Dx Tb skin test (>15 mm w/o risk factors, >10 mm w/
risk factors, >5 mm w/ immunosppression or known contacts) → if positive, get CXR
Latent TB: negative CXR, Tx INH x 9 months
Active TB: positive CXR, Tx RIPE (Pyrazinamide + INH + Rifampin + Ethambutol) x 6 months
TB meningitis: Dx CSF shows lymphocytosis + low glucose; Tx RIPE + steroids
★ Retropharyngeal abscess: Staph/Strep or oral anaerobe infx of posterior pharyngeal wall → fever, sore throat, “muffled voice”, drooling;
Dx lateral neck X-ray shows bulging mass, Tx emergent I+D
★ Peritonsillar abscess: Staph/Strep or oral anaerobe infx → fever, sore throat, “hot potato voice”, deviated uvula; Tx emergent I+D
★ Pertussis: Bordetella pertussis via respiratory droplets → “whooping cough” (short bursts of cough followed by loud inspiratory sound);
Dx CBC (lymphocytosis), confirm w/ nasopharyngeal swab if necessary, Tx azithromycin for pt + all close contacts (regardless of
immunization status)
Subcutaneous emphysema 2/2 cough: get CXR to r/o PTX
Respiratory malformations
Bronchopulmonary dysplasia: inadequate repair of acute lung injury in premies → arrested lung development → chronic respiratory sx,
need for O2 beyond 1 month; Dx abnormal CXR (nonspecific), Tx long-term supplemental O2
Congenital cystic adenomatoid malformation (CCAM): improper development of bronchioles → cystic mass in lungs → asx if small,
respiratory distress w/ mediastinal shift if large; Dx chest U/S, Tx surgical excision
Laryngomalacia: soft, small, underdeveloped larynx → inspiratory stridor in neonates; Dx fiberoptic bronchoscopy, Tx reassurance (will
resolve w/ growth), feed child only while upright and keep him upright for 30 min afterwards
★ Vascular rings: congenital abnormalities of aortic arch or branches → rings around airway can compromise ventilation → inspiratory
stridor relieved w/ opisthotonic position (“crowing” respiration); Tx surgery
★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
Neonatal apnea: breath-holding spells >20 seconds (<20 seconds is normal) w/ possible cyanosis or bradycardia, due to immature respiratory center
(central) or airway obstruction
Apparent life-threatening event (ALTE): apnea + color change (cyanosis, pallor), change in muscle tone (limpness), choking/gagging
Central apnea: Tx underlying cause, theophylline or caffeine can help
Obstructive sleep apnea: Dx polysomnography, Tx underlying cause (tonsillectomy/adenoidectomy, weight loss, CPAP)
Idiopathic pulmonary hemosiderosis: unknown etiology → bleeding into lungs → recurrent PNA w/ hemoptysis, rapid clearing of CXR findings, iron-
deficiency anemia; Dx BAL shows hemosiderin-laden macrophages, Tx steroids
Tension PTX: PTX + building pressure → mediastinal shift, hypOtension, JVD, absent unilateral breath sounds, hyperresonant to percussion; Tx emergent
needle thoracostomy + chest tube
★ ABG analysis
Dx Causes Management
Respiratory acidosis pH <7.4, CO2 >40 hypoventilation increase ventilation
Respiratory alkalosis pH >7.4, CO2 <40 hyperventilation 2/2 pain, fever, Tx underlying cause
ARDS, sepsis
NAGMA pH <7.4, CO2 <40, AG 8- diarrhea, glue sniffing, RTA, Tx underlying cause
12 hyperchloremia
AGMA pH <7.4, CO2 <40, AG >12 MUDPILES Tx underlying cause
Metabolic alkalosis pH >7.4, CO2 >40 vomiting, antacids, Tx underlying cause
hyperaldosteronism

Anion gap: [Na – (Cl + HCO3)], normally 8-12

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– GI/HEPATOBILIARY ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Cyclical vomiting: idiopathic, recurrent self-limited episodes of n/v in children, no abdominal pain or constipation/diarrhea; Tx antiemetics
Upper GI: proximal to Ligament of Treitz
Infant GERD: common complaint, presents w/ regurgitation of recently ingested food; Dx esophageal pH probe (gold standard but rarely
necessary), Tx thickened feeds + reassurance (will resolve by 1-2 y/o)
Eosinophilic esophagitis: allergic response to food in esophagus → GERD-like sx unresponsive to PPIs; Dx EGD + bx shows eosinophils in
esophagus, Tx PO steroids
★ Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
Bleeding esophageal varices: Tx octreotide, PPx β-blockers
 Pediatrics – Shelf notes

Mallory-Weiss syndrome: forceful emesis → small mucosal tears in esophagus → streaks of blood in vomitus; Tx reassurance
Boerhaave syndrome: forceful emesis → esophageal rupture → severe retrosternal pain + acute distress; Tx surgical repair
Caustic ingestion: alkali are worse than acids; Dx endoscopy to determine extent of damage, Tx controversial (call poison control)
Foreign body ingestion: Tx emergent removal of disc batteries stuck in esophagus, other materials can be watched
★ Pyloric stenosis: presents w/ non-bilious projectile vomiting in first-born boys; Dx palpable epigastric olive + abdominal U/S, Tx
pyloromyotomy
PUD: presents w/ gnawing epigastric pain (can persist at night) + occult GI bleed; Dx EGD, Tx PPIs
Lower GI: distal to Ligament of Treitz
Milk protein intolerance: neonate w/ bloody diarrhea + eosinophils in stool
★ Volvulus (malrotation): incomplete rotation of GI tract during development → bilious vomiting, abdominal pain/distention; Dx barium
enema shows malposition of the cecum, Tx emergent surgical correction (↑risk of short gut)
★ Meconium ileus: pathognomonic for CF, presents in newborn w/ bilious vomiting, abdominal pain/distention; Dx KUB shows dilated
megacolon but barium enema shows microcolon from disuse, Tx gastrograffin enema
★ Acute appendicitis: lymphoid hyperplasia or fecalith impaction → obstructed appendix w/ bacterial overgrowth → presents w/ fever,
anorexia, n/v, diffuse abdominal pain that localizes to RLQ; Dx ↑WBC + CT scan or U/S, Tx appendectomy
Mesenteric adenitis: Yersinia enterocolitica infx → appendicitis-like presentation, associated w/ chitterlings and daycare centers
★ Intussusception: presents w/ colicky abdominal pain that lasts 1 min then resolves + “currant jelly” stools, RUQ “sausage-like mass” on
abdominal exam; Dx/Tx air contrast enema
★ Hirschsprung disease: neural crest cells fail to migrate → lack of nerves in distal colon → chronic constipation since birth; Dx screen w/
barium enema, confirm w/ rectal bx, Tx surgical pull-through
★ Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis
intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated
Anal atresia: Tx surgical repair (low pouch), colostomy then delayed repair (high pouch)
Congenital inguinal hernia: patent processus vaginalis → indirect inguinal hernia → incarcerated bowel is common; Tx elective
herniorrhaphy prior to d/c
★ Meckel diverticulum: MCC painless LGIB in a child; Dx technetium uptake for ectopic gastric mucosa, Tx surgery if symptomatic
Neonatal GI bleed: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal
Functional constipation: infrequent large/hard stools + normal physical exam; Dx KUB shows stool-filled megacolon, Tx reassurance +
dietary counseling
★ Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows stool-filled
megacolon, Tx bowel catharsis + miralax
Toddler diarrhea: chronic explosive diarrhea in an infant w/ normal physical exam; Tx reassurance
Malabsorption syndromes: present w/ steatorrhea + vitamin ADEK deficiency
★ Cystic fibrosis: AR ∆CFTR (∆F508) → thick mucus → recurrent Pseudomonas pneumonia, bronchiectasis, infertility, chronic pancreatitis →
malabsorption/steatorrhea + type 1 diabetes, meconium ileus (uncommon but pathognomonic), focal biliary cirrhosis, nasal polyps; Dx sweat
chloride test x2 (>60), Tx pancreatic enzymes + vitamins ADEK + chest physiotherapy + mucolytics (N-acetylcysteine)
Lactose intolerance: lactase (disaccharidase) deficiency at brush border → lactose provides osmotic gradient for water + acts as GI flora
nutrient → bloating, flatulence, diarrhea; Dx hydrogen breath test, Tx dietary ↓lactose
Celiac disease: AR ∆MTTP (microsomal TG transfer protein) → gluten hypersensitivity → chronic non-bloody diarrhea ± dermatitis
herpetiformis; Dx anti-gliadin or anti-endomysial ab, Tx dietary ↓wheat/↓gluten
Abetalipoproteinemia: celiac disease-like presentation but normal GI bx; Tx ADEK supplements + low-fat diet

★ Inflammatory bowel disease (IBD): presents w/ flare-and-remission pattern of crampy abdominal pain, bloody diarrhea, and weight loss
Crohn disease Ulcerative colitis
Location “mouth to anus” w/ skip lesions, rectal sparing colorectal, continuous lesion
Morphology transmural inflammation, cobblestoning, mucosal inflammation, crypt abscesses and
noncaseating granulomas pseudopolyps
Complications strictures, fistulas, SBO toxic megacolon, colorectal cancer
Dx +calprotectin, +ASCA, KUB shows terminal ileal +calprotectin, +p-ANCA, KUB shows “lead pipe sign”
“string sign”
Tx steroids + 5-ASA steroids + 5-ASA + annual colonoscopy

Neonatal hyperbilirubinemia
★ Physiologic hyperbilirubinemia: appears after day 2, direct bilirubin <1, total bilirubin <12
★ Pathologic hyperbilirubinemia: suspect w/ jaundice on day 1, direct bilirubin >2, total bilirubin >20 (risk of kernicterus), rate of rise >5/day;
MCC neonatal hepatitis and biliary atresia
Biliary atresia: lack of CBD → progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan, Tx hepatoportoenterostomy
(Kasai procedure)
Choledochal cyst: cyst in CBD → biliary tree obstruction → progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan,
Tx surgery
★ Breast-feeding jaundice: ↓feeding → dehydration → retained meconium → ↑enterohepatic circulation of bilirubin; Tx ↑feeding frequency
Breast-milk jaundice: d/t glucuronidase and indirect bilirubin in breast milk
Dubin-Johnson syndrome: neonatal direct hyperbilirubinemia + ↑LFTs + “black liver”
Rotor syndrome: neonatal direct hyperbilirubinemia + ↑LFTs + no black liver
Hepatobiliary/pancreatic
Acute cholecystitis: inflammation of gallbladder → Charcot triad (RUQ pain, n/v, fever); Dx RUQ U/S, Tx NPO/IVF/abx then lap chole within
24 hrs
 Pediatrics – Shelf notes

Acute pancreatitis: I GET SMASHHED (recall acronym) → inflammation of pancreas → stabbing epigastric pain boring through to the back,
exacerbated w/ eating; Dx screen w/ ↑amylase/↑lipase, confirm w/ abdominal U/S, Tx NPO/IVF/pain meds
Viral hepatitis: presents w/ jaundice, RUQ pain, n/v, dark-colored urine
Buzzwords Management
HAV (fecal-oral) asymptomatic, daycare, travel Dx HAV IgM (acute), HAV IgG (immune or previous
infx); Tx supportive care
HBV (parenteral, sexual) polyarteritis nodosa, MGN Dx HBsAg (acute), HBsAb (immune or previous
infx), HBcAb IgM (window), HBeAg (infectious); Tx
IFN-α
HCV (parenteral, sexual) cryoglobulinemia, chronic infx, carriers, Dx HCV RNA (acute or chronic); Tx IFN-α + ribavarin
cirrhosis, carcinoma, IVDA, MPGN
HDV (parenteral, sexual) deadly, defective, HBV co-infection Dx HDV Ab; Tx IFN-α
HEV (fecal-oral) cruise ships, fatal in pregnancy Dx HEV Ab; Tx supportive care

A1AT deficiency: AR ∆α1-antitrypsin → inability to export enzyme → builds up in liver (cirrhosis) and can’t break down proteolytic enzymes in
lungs (early-onset panacinar emphysema)
Wilson disease (hepatolenticular degeneration): AR ∆ATP7B (copper-transporting ATP-ase) → copper overload → cirrhosis + movement
disorder + hemolytic anemia + Kayser-Fleischer corneal rings; Dx ↑LFTs/↓ceruloplasmin/↓total copper/↑free copper, Tx D-penicillamine
Reye syndrome: viral infx + ASA = fatty liver/liver failure, vomiting, AMS, 40% mortality rate (due to cerebral edema → herniation)
Gilbert syndrome: AD ∆UGT-glucuronyltransferase → mild jaundice following stress or starvation; benign

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– RENAL/GU ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Renal
Nephrotic syndrome: loss of negative charge on GBM → proteinuria → edema, hypoalbuminemia, hyperlipidemia; Dx UA shows fatty casts
Asymptomatic proteinuria: repeat dipstick, then quantify w/ 24 hr urine, then refer to nephro if still positive
Nephritic syndrome: inflammation of glomeruli → hematuria, oliguria, HTN, azotemia; Dx UA shows RBC casts
Asymptomatic hematuria: repeat UA, then get renal imaging if still positive
★ Minimal change disease: nephrotic syndrome in kids following a viral URI, MCCOD is spontaneous bacterial peritonitis; Tx steroids, salt-
restriction + diuretics during flares
★ WAGR syndrome: ∆WT1 on chromosome 11 → Wilms tumor (kidney), Aniridia, GU anomalies, mental Retardation, hemihypertrophy
★ Neuroblastoma: N-myc amplification → proliferation of neural crest cells in adrenal gland → abdominal mass/pain + opsoclonus-myoclonus
syndrome (muscle jerks + eyelid jerks) ± bone mets (pancytopenia); Dx urinary ↑HVA/↑VMA
Goodpasture syndrome: anti-GBM antibodies attack pulmonary and renal basement membranes → hemoptysis + hematuria; Dx renal bx +
linear-staining immunofluorescence
Fanconi syndrome: proximal tubule dysfunction → defective resorption of amino acids, bicarb, glucose, phosphate → polydipsia, polyuria,
glucosuria, aminoaciduria, type 2 RTA, hypophosphatemic rickets, etc.
Type 1 RTA: “distal RTA”, collecting duct can’t excrete H+ → metabolic acidosis + urinary alkalosis, hypo-K
Type 2 RTA: “proximal RTA”, proximal tubule can’t resorb bicarb → metabolic acidosis + urinary alkalosis, hypo-K
Type 3 RTA: (does not exist)
Type 4 RTA: “hyperkalemic RTA”, ↓aldosterone or ∆aldosterone-R → metabolic acidosis + urinary acidosis, hyper-K
Low implantation of ureter: asx in boys, “wet w/ urine all the time” in girls b/c ureter drips into vagina instead of bladder; Dx IV pyelo, Tx
surgical correction
★ Posterior urethral valve: presents w/ oliguria + lower abdominal mass (distended bladder) in a neonate; first catheterize to empty bladder,
then Dx VCUG, Tx resection
Myoglobinuria: rhabdomyolysis (heat, niacin, etc.) → myoglobin in urine → ↑risk of renal failure; Dx ↑CPK, UA shows heme but no RBC
Alport syndrome: XR ∆type 4 collagen → nephritic syndrome (hematuria), deafness, ocular defects
★ Enuresis: involuntary urination >5 y/o; Tx bed-wetting alarm > desmopressin > imipramine
Idiopathic hypercalciuria: persistent excretion of calcium irritates urinary tract → dysuria, ↑risk of kidney stones, microscopic hematuria w/
recurrent episodes of gross hematuria
Kidney stones: presents w/ flank pain radiating to groin + hematuria; Dx U/S or CT scan, Tx hydration (<½ cm), shockwave lithotripsy (½–2
cm), surgery (>2 cm)
Dialysis indications: AEIOU – Acidosis (severe metabolic acidosis), Electrolytes (severe hyperkalemia), Intoxication, Overload (severe hypervolemia),
Uremia (BUN >150, pericarditis)
Kidney infx
Lower UTI (acute cystitis): presents w/ dysuria, frequency/urgency; ↑risk in uncircumcised males; Dx UA/UCx, Tx Bactrim > Cipro
Upper UTI (acute pyelonephritis): presents w/ dysuria, frequency/urgency, flank pain, fever/chills; Dx UA/UCx, Tx ceftriaxone
VCUG: indicated to r/o VUR in all males w/ UTIs, girls <5 y/o, or girls >5 w/ 2+ UTIs
★ Vesicoureteral reflux (VUR): ureters implanted into wrong site on bladder → no mechanism for preventing retrograde urine reflux →
recurrent UTIs at young age; Dx VCUG, Tx long-term abx until kid grows out of it (low grade), surgical reimplantation of ureter (high grade)
Chronic pyelonephritis: VUR → recurrent upper UTI → kidney scarring w/ “blunted calyces” on IV pyelo
Nephronia: halfway between pyelonephritis (dysuria, frequency/urgency, flank pain, fever/chills) and renal abscess; Dx CT scan shows
“distinct tissue” in kidney, Tx long-term IV abx
★ Poststreptococcal GN: GAS infx (strep throat, impetigo, cellulitis) → ag-ab complexes deposit in GBM → nephritic syndrome sx
(hematuria, HTN, oliguria, azotemia, edema); Dx ↑ASO titers, Tx supportive care
Male GU
Inconspicuous penis: normal in fat boys, retract foreskin and measure → refer to urology if <2.5 std dev
Micropenis: GH deficiency
Phimosis: inability to retract foreskin, Tx reassurance (normal for <3 y/o), urology consult (>3 y/o)
 Pediatrics – Shelf notes

Paraphimosis: inability to relocate foreskin after retraction; Tx urology consult

★ Hypospadias: urethral opening on ventral penis, ↑risk of UTIs; Tx urology consult, do not circumcise
Epispadias: urethral opening on dorsal penis; Tx urology consult
Urethritis: GC or CT infx → dysuria, frequency/urgency, urethral discharge; Dx GC/CT tests, Tx azithromycin + ceftriaxone
★ Testicular torsion: twisting of spermatic cord → severe testicular pain and “high riding testicle w/ horizontal lie”, lacks cremasteric reflex;
first consult surgery, then Dx U/S to r/o epididymitis (similar presentation), Tx emergent surgical detorsion (<6 hrs) + orchiopexy
★ Epididymitis: presents like testicular torsion but w/ fever and pyuria; Dx U/S, Tx abx (usually for GC/CT)
Varicocele: incompetent valves in spermatic vein → dilation of pampiniform plexus → “bag of worms” appearance when standing up but
disappears lying down; Tx reassurance (kids), surgical correction (adults w/ infertility issues)
Hydrocele: accumulation of fluid in tunica vaginalis → dilated, fluid-filled sac around testicle; Dx transillumination shines through (vs.
testicular cancers). Tx reassurance (small), surgical correction (large)
Hydrocele vs. scrotal edema: scrotal edema feels like a big scrotum, hydrocele feels like a big nut
Cryptorchidism: undescended testis → high risk for testicular torsion and seminoma; Dx U/S of inguinal canal, Tx orchipexy if undescended
by 1 y/o (to avoid sterility and cancer)
★ Potter sequence: bilateral renal agenesis (or other renal abnormalities) → inability to secrete amniotic fluid in utero → oligohydramnios
w/ amnion nodosum (granules on amnion) → pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet)
★ Prune belly syndrome: congenital malformation in males that consists of lax abdominal wall → marked distention, dilated urinary tract →
Potter sequence, bilateral cryptorchidism
Female GU
Labial adhesions: benign fusion of labia minora; Tx estrogen cream
Labial adhesions + electrolyte imbalances: congenital adrenal hyperplasia
★ Infant menstruation: maternal estrogen withdrawal → endometrial sloughing → sticky gray discharge (may be blood-tinged) in a 2-week
girl; Tx reassurance (normal phenomenon)
★ “Bubble-bath” vaginitis: vaginal irritation in little girls due to chemicals from bubble baths; Tx d/c bubble baths, wear cotton underwear,
wipe front-to-back after potty
Polycystic ovarian syndrome (PCOS): ↑LH, ↓FSH, ↑E/T → anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss ±
metformin
Pelvic inflammatory disease (PID): polymicrobial infx of upper female genital tract (endometritis, salpingitis, peritonitis) → nonspecific
lower abdominal pain → ↑risk for infertility, ectopic pregnancy, pelvic adhesions, abscesses; Dx STD tests + “cervical motion tenderness”, Tx
ceftriaxone + doxycycline
PID + pelvic mass: tubo-ovarian abscess; Dx transvaginal U/S, Tx I+D
Umbilical cord
Delayed cord separation: leukocyte adhesion deficiency; Dx flow cytometry (∆CD11b)
Umbilical granuloma: red nodule on separated umbilical cord; Tx topical silver nitrate
★ Omphalocele: intestines protrude into umbilical cord w/ peritoneal covering, ↑risk of associated cardiac defects; first sterile wrapping,
then Dx echo to r/o cardiac defects, then Tx closure if small, silo if large
★ Gastroschisis: intestines tear through abdominal wall w/o peritoneal covering; first sterile wrapping, then Tx closure if small, silo if large
★ Umbilical hernia: associated w/ neonatal hypothyroidism, Beckwith-Wiedemann syndrome; Tx reassurance (<2 cm), surgical repair (>2 cm
or persistent into kindergarten)
Patent urachus: failure of urachus to obliterate → urination from umbilical cord
Vitelline fistula: failure of vitelline duct to obliterate → meconium from umbilical cord

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– NEURO/MSK ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Muscular dystrophy
Duchenne muscular dystrophy (DMD): XR ∆dystrophin → muscle cells die off → ascending weakness w/ Gowers maneuver, calf
pseudohypertrophy, death by 15 y/o; Dx ↑CPK + muscle bx, no tx available
Becker muscular dystrophy (BMD): XR ∆dystrophin → milder form of DMD
Myotonic muscular dystrophy: AD; delayed muscle relaxation (can’t release handshake) + distal muscle wasting (older kids), neonatal
respiratory distress (newborn), cataracts, ptosis, baldness, hypogonadism; Dx ↑CPK + muscle bx, no tx available
Charcot-Marie-Tooth disease: intrinsic foot muscle atrophy (pes cavus), then intrinsic hand muscle atrophy
Muscle weakness/paralysis
Myasthenia gravis: anti-nAChR → gradually progressive muscle weakness (initial sx is ptosis, diplopia, blurry vision) that get worse w/
repetitive use; Dx edrophonium test + get chest CT to r/o thymoma, Tx pyridostigmine
Acute disseminated encephalomyelitis (ADEM): autoimmune demyelination after viral infx → multiple sclerosis-like sx but in kids <10 y/o; Dx
MRI shows white matter demyelination, Tx high-dose corticosteroids
Acute infantile hemiplegia: trauma, infx, hypercoagulable state, arteritis, or metabolic d/o → MCA stroke in infant → abrupt onset
hemiplegia
★ Guillain-Barre syndrome: rapidly ascending paralysis after viral infx (or other infx), ↑risk of respiratory arrest (Tx mechanical ventilation);
Dx CSF shows ↑protein, Tx IVIG or plasmapheresis
Bell palsy: facial nerve palsy 2 weeks after viral infx; Tx eyedrops (to prevent keratitis), will resolve on its own
Bilateral Bell palsy: 2° Lyme disease, Guillain-Barre syndrome
★ Phrenic nerve palsy: presents w/ respiratory distress and unilateral decreased breath sounds in neonate (phrenic nerve innervates
hemidiaphragm); Dx chest U/S or fluoroscopy shows “seesaw diaphragm”
★ Erb-Duchenne palsy: C5/C6 palsy after difficult delivery → “waiter’s tip” posture
★ Klumpke palsy: C7-T1 palsy after difficult delivery → total hand paralysis + ipsilateral Horner syndrome
Werdnig-Hoffman disease (SMA type 1): ∆SMN gene (protects neuroblasts from atrophy) → progressive degeneration of CNS motor
neurons → respiratory distress + tongue fasciculations in newborn; Tx supportive care
 Pediatrics – Shelf notes

Seizures
Simple partial seizure: automatisms
Complex partial seizure: automatisms + LOC + postictal confusion
Absence (petit mal) seizure: “brief staring spells”; Dx EEG shows 3-Hz spike-and-wave pattern, Tx valproic acid > ethosuximide
Tonic-clonic (grand mal) seizure: LOC + rigidity (tonic phase) + muscular jerking (clonic phase) + postictal confusion
Pseudoseizure: seizure-like activity w/o EEG changes, usually don’t have bowel/bladder incontinence or self-injury; Tx psych consult
Febrile seizure: brief seizure in febrile child usually 2/2 bacterial or viral infx, doesn’t require extensive work-up, #1 risk factor is rate of temp
change; Tx underlying cause, phenobarbital if necessary
Phenytoin toxicity: gingival hyperplasia; Tx good dental hygiene
Todd paralysis: focal weakness for 1-2 days following grand-mal seizure
Malignant hyperthermia: AD ∆ryanodine receptor → T>104 + muscle rigidity + rhabdomyolysis following anesthesia; Dx caffeine contracture test, Tx
dantrolene sodium, 100% O2, cooling blankets
★ Craniosynostosis: premature fusion of skull sutures → abnormal head shape + impaired brain development, 80% sporadic, 20% genetic (e.g. Crouzon
syndrome); Tx surgical correction
Apert syndrome: AD, craniosynostosis + syndactyly of fingers/toes
Crouzon syndrome: craniosynostosis + wide-eyes w/ proptosis, “beak nose”
Scaphocephaly: isolated craniosynostosis of sagittal suture → long, narrow skull
Headaches
Migraine headache: bifrontal headache w/o aura, or diffuse “throbbing” headache, atypical presentation in kids (no nausea/vomiting,
photophobia, phonophobia)
Tension headache: bilateral, tight “squeezing” pain + posterior neck muscle stiffness
Cluster headache: unilateral, episodic “burning, stabbing” pain behind eye + ipsilateral tearing, flush, rhinorrhea
Factitious headache: recurrent headache on Mon-Fri mornings
★ Pseudotumor cerebri: fat girl w/ pulsatile headache/tinnitus, high risk of blindness; first get imaging to r/o mass lesion (can have empty
sella), then get LP w/ opening pressure to r/o infx causes, Tx acetazolamide vs. serial LPs
Brain abscess: headache + focal neuro sx + fever, ↑risk w/ congenital heart defects; Dx head CT/MRI, Tx surgery + IV abx (unifocal), IV abx (multifocal)
Brain tumor: headache + focal neuro sx + subacute onset; infratentorial more common <10 y/o, supratentorial more common >10 y/o
★ Craniopharyngioma: embryological remnant of Rathke pouch in sella turcica → headache, bitemporal hemianopsia, papilledema; Dx MRI
shows suprasellar calcified cysts, Tx transsphenoid hypophysectomy
Pinealoma: brain tumor at rostral midbrain → vertical gaze paralysis (Parinaud syndrome) + eyelid retraction (Collier sign) + ↑ICP sx
Retinoblastoma: AD ∆Rb on chromosome 13 → retinoblastoma (MCC leukocoria in kids) + ↑risk of osteosarcoma later in life
Cushing triad: brain mass lesion → ↑ICP → ↓HR, ↑BP, irregular RR
Epidural hematoma: head trauma to temporal bone → torn middle meningeal artery → LOC w/ lucid interval → uncal herniation → death; Dx head CT
shows convex lens, Tx emergent craniotomy
Infantile botulism: ingestion of C. botulinum bacteria (not toxin) in raw honey → bacteria releases toxin in GI tract → constipation (initial sx) then
gradual flaccid paralysis; Tx BabyBIG (botulinum immunoglobulin) + ventilator support
Dandy-Walker syndrome: enlargement of 4th ventricle (hydrocephalus) + agenesis of cerebellar vermis
Acute cerebellar ataxia: autoimmune attack on cerebellum after a viral infx → cerebellar sx (ataxia, nystagmus, dysarthria); Dx of exclusion
Rasmussen encephalitis: autoimmune attack on brain → rapid degeneration, initially presents w/ frequent and worsening seizures; Dx MRI, Tx
hemispherectomy
Pervasive developmental disorders
★ Autism: characterized by problems w/ social interaction, communication skills, and repetitive/stereotyped patterns of behavior and
activity before 3 y/o; must get hearing test to r/o deafness
Asperger syndrome: mild autism w/ normal language skills and cognitive development
Rett syndrome: ∆MECP in girls → normal development for 5 months, then ↓rate of head growth + loss of purposeful hand movements, then
ataxia, ↓language skills, “hand wringing”
Childhood disintegrative disorder: normal development for >2 years, then loss of previously acquired skills
★ Learning disability: significant discrepancy between IQ and ability in one of the following – math, reading, or writing
★ Neurocardiogenic syncope: presents as 6 Ps – syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or
light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration
Transient tic disorder of childhood: nonrhythmic, spasmodic, involuntary behaviors (e.g. blinking, throat clearing) that last <1 yr; Tx reassurance
Tourette syndrome: severe tic disorder w/ multiple daily motor/vocal tics, may have echolalia or coprolalia (rare), ↑association w/ OCD and ADHD; Tx
haloperidol > α2-agonists (clonidine, guanfacine)

–––––––––––––––––––––––––––––––––––––––––––––––––––––––– INFECTIOUS DISEASES ––––––––––––––––––––––––––––––––––––––––––––––––––––––––

★ Ophthalmia neonatorum
Timing Management Features
Chemical conjunctivitis day 0-1 Tx reassurance not seen anymore since silver nitrate
drops are rarely used
Gonococcal conjunctivitis day 2-5 Tx topical erythromycin + IV ceftriaxone can cause corneal ulceration
Chlamydia conjunctivitis day 5-14 Tx PO erythromycin can cause chlamydial pneumonia
(“staccato cough” + eosinophilia)

STDs
Bugs Presentation Management
Chlamydia Chlamydia trachomatis urethritis in men; cervicitis, PID, TOA, often Dx Chlamydia NAAT, Tx
asx in women azithromycin (+ ceftriaxone)
 Pediatrics – Shelf notes

Gonorrhea Neisseria gonorrhoeae urethritis in men; cervicitis, PID, TOA, often Dx discharge Gram stain, Tx
asx in women ceftriaxone (+ azithromycin)
Vaginal candidiasis Candida albicans thick, white curd-like discharge, severe Dx KOH prep shows
itching, satellite lesions pseudohyphae, Tx diflucan vs.
miconazole cream
Syphilis Treponema pallidum 1° – painless chancre + LAD Dx screen w/ RPR-VDRL,
2° – palmar/plantar rash, condyloma lata, confirm w/ FTA-ABS, definitive
general LAD dx w/ Darkfield microscopy; Tx
3° – neurosyphilis + CV syphilis (luetic heart) benzathine PCN G
+ gummas
Chancroid Haemophilus ducreyi painful chancre + LAD Dx discharge Gram stain, Tx
azithromycin or ceftriaxone
Herpes simplex HSV-1/2 recurrent, painful oral or genital vesicles Dx Tzanck smear, Tx ACV/VACV
that can rupture within 48 hrs
Lymphogranuloma Chlamydia trachomatis, 1° – transient, painless ulcer Dx complement fixation, Tx
venereum L1-L3 serotypes 2° – painful LAD doxycycline
3° – anogenital syndrome (proctocolitis,
rectal strictures, rectovaginal fistulas,
genital elephantiasis)
Condyloma acuminata HPV-6/11 genital warts Tx removal
Bacterial vaginosis Gardnerella vaginalis thin homogenous discharge w/ fishy odor Dx wet prep (clue cells), Tx
metronidazole
Trichomoniasis Trichomonas vaginalis green-gray frothy discharge, odor, Dx wet prep (motile
strawberry cervix trichomonads), Tx
metronidazole
HIV/AIDS HIV-1/2 1° – mono-like syndrome w/ maculopapular Dx screen w/ ELISA, confirm w/
rash WB, HIV PCR in infants; Tx
asx stage – CD4 >500, asx HAART (2 NRTIs + 1 NNRTI or
sx stage – CD4 200-500, general LAD, PI)
fungal infx, night sweats, weight loss,
diarrhea
AIDS – CD4 <200 or opportunistic infx
Crabs (pediculosis pubis) Phthirus pubis severe itching, irritation, burrows, vesicles Dx hair under microscope, Tx
permethrin shampoo

Rule-out sepsis: T >100.4 in any neonate (<28 days) gets admitted and the full work-up (UA/UCx, CSF, blood cx, CXR, etc.), MCC viral infx; Tx amp+gent
until cx negative
Bacteria
Neonatal PNA: MCC GBS; presents as respiratory distress, fever/hypothermia, leukocytosis/leukopenia w/ left-shift; Dx CXR, Tx ampicillin +
gentamicin
Neonatal meningitis: MCC GBS; presents as fever, irritability, AMS, ±bulging fontanelle, and may not have meningeal signs; Tx ABCs then LP
then ceftriaxone + vancomycin (different from adults, where you’d get CT then LP)
Meningitis + subdural effusions: common, benign finding
Listeria meningitis: due to maternal ingestion of lunch meats or unpasteurized dairy products
Meningococcal meningitis: Tx penicillin
Acute bacterial sinusitis: Strep pneumo > H. flu > Moraxella catarrhalis superinfx of viral URI → sinus tenderness, nasal congestion/discharge,
headache, low-grade fever; Tx amoxicillin
Otitis media: Strep pneumo > H. flu > Moraxella catarrhalis; Tx amoxicillin
Otitis externa: Tx cipro drops
Diphtheria: due to Corynebacterium diphtheriae; presents as mild sore throat that leads to pseudomembranous pharyngitis, LAD with “bull
neck” appearance, possible respiratory compromise
Shigellosis: watery/bloody diarrhea, fever, tonic-clonic seizures can precede GI sx (Ekiri syndrome); Dx stool cx, Tx IV fluids + ceftriaxone
★ Strep throat: GAS infx of pharynx → sore throat, fever, tonsillar exudates, palatal petechiae; Dx rapid strep test, Tx amoxicillin
★ Scarlet fever: due to GAS exotoxin; presents w/ sore throat, fever, strawberry tongue, “sandpaper rash” w/ possible
desquamation of palms/soles; Dx ASO titers or rapid strep test, Tx amoxicillin
Arcanobacterium haemolyticum: strep throat/scarlet fever-like presentation but throat cx grows out Arcanobacterium instead
★ Toxic shock syndrome: due to S. aureus TSST, often found in tampons; presents w/ septic shock, diffuse maculopapular rash
(desquamation of palms/soles is late finding), strawberry tongue; Tx admit + stabilize + IV nafcillin (prevents recurrence)
Staph food poisoning: ingestion of preformed S. aureus enterotoxin → diarrhea, vomiting, abdominal cramps within 6 hrs
★ Meningococcemia: meningitis, purpura fulminans (“petechiae becoming purpura in front of your eyes”), death by bilateral adrenal
hemorrhage (W-F syndrome); Dx blood cx x3, Tx IV abx, PPx Rifampin for Roommates
Leptospirosis: due to Leptospira interrogans; presents as fever/chills, sore throat, myalgias, headache, cervical LAD, scleral injection,
photophobia, and can lead to meningitis (but most infx are subclinical)
Weil disease: leptospirosis + renal failure + liver failure
Infx endocarditis: usually due to Strep/Staph; presents as FROM JANE – Fever, Roth spots, Osler nodes, Murmurs, Janeway lesions, Anemia,
Nailbed hemorrhage, Embolic phenomena; Dx blood cx x3, Tx IV abx
Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg), Tx
admit + IV abx
Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx admit + drainage + IV abx
Dacryocystitis: infx of medial canthus of eye; Tx warm compresses + abx drops
Orbital cellulitis: cellulitis around eye, requires emergent ophtho c/s
 Pediatrics – Shelf notes

Orbital vs. preseptal cellulitis: consider preseptal w/ eyelid discoloration; consider orbital w/ proptosis, limited eye movement,
pain w/ movement, or loss of vision
RMSF: due to Rickettsia rickettsii from Dermacentor ticks; causes fever/chills and rash that starts on hands/feet and moves inward, can result
in pancytopenia + hyponatremia; Tx doxycycline (regardless of age)
Lyme disease: due to Borrelia burgdorferi from Ixodes ticks; 1° Lyme = erythema chronicum migrans, 2° Lyme = bilateral Bell palsy + AV block,
3° Lyme = chronic arthritis; Tx amoxicillin (<9 y/o), doxycycline (>9 y/o)
Lyme disease + hemolytic anemia: due to Babesia microtii also from Ixodes ticks; Dx RBC smear, Tx clindamycin + quinine
Tularemia: “rabbit fever” due to Francisella tularensis; MC presentation is ulceroglandular syndrome (nonhealing ulcer + ascending LAD); Tx
streptomycin
Pseudomonas: G– oxidase+ rod; commonly found in burns, tennis shoe puncture wounds, swimming pools, hot tubs, cystic fibrosis
Peptic ulcer disease: presents as dyspepsia and upper GI bleed; Dx EGD+bx or H. pylori breath test, Tx “triple therapy” (2 abx + 1 PPI)
★ HUS: due to EHEC O157:H7; presents w/ bloody diarrhea and possible renal failure (MCCOD) after eating undercooked hamburgers; Dx
stool cx on MacConkey (sorbitol) agar, Tx TPN + peritoneal dialysis (do not use abx)
Lymphadenitis: Staph aureus infx → swollen, tender, erythematous LN; Tx dicloxacillin
Cat scratch disease: Bartonella henselae infx from cats (flea vector) → Parinaud oculoglandular syndrome (nonpainful conjunctivitis +
preauricular LAD); Tx azithromycin
Typhoid fever: Salmonella typhi infx → fever, diarrhea, HSM, abdominal pain w/ “rose spot” rash; Dx ↑fecal leukocytes + stool cx
Campylobacter gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; ↑risk of Guillain-Barre syndrome
Yersinia gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; ↑risk of mesenteric adenitis (appendicitis-like presentation);
associated w/ chitterlings and daycare centers
Pseudomembranous colitis: broad-spectrum abx use → C. difficile proliferates in colon → profuse watery diarrhea; Dx stool toxins, Tx
metronidazole > PO vancomycin
Fungi
Sporotrichosis: “rose gardner disease” due to Sporothrix schenckii; presents as nonhealing ulcer + ascending LAD; Tx potassium iodide
★ Tinea capitis: due to Trichophyton tonsurans; presents as boggy scalp lesion w/ hair loss; Dx KOH prep, Tx PO griseofulvin
Cryptosporidiosis: chronic diarrhea in HIV+ pts
PCP pneumonia: opportunistic infx that indicates T-cell deficiency (AIDS, SCID, DiGeorge, etc.); Dx BAL, PPx azithromycin, Tx Bactrim
Viruses
Viral meningitis: due to enterovirus infx (echo, coxsackie); Dx CSF shows ↑lymphocytes + normal glucose, Tx supportive care
★ Bronchiolitis: due to RSV; presents w/ wheezing, URI sx, respiratory distress; Tx supportive care (ribavarin if severe, pavilizumab ppx for
high-risk infants)
★ Erythema infectiosum (fifth disease): due to Parvovirus B19; presents w/ fever, URI sx, “slapped cheek” and lacy rash on extremities, can
cause aplastic anemia in SCD or spherocytosis, hydrops fetalis in pregnant women (rare)
Hand-foot-mouth disease: due to Coxsackie A16; presents w/ sores/blisters on hand, feet, mouth, genitalia; Tx supportive care
Mononucleosis: due to EBV; presents w/ fever/chills, sore throat, myalgia, cervical LAD, HSM after making out w/ someone; Dx Monospot
(heterophile agglutination) test, Tx avoid contact sports
★ “Amoxicillin rash”: rash s/p amoxicillin in a misdiagnosed “strep throat” is pathognomonic for EBV infx
Mumps: parotitis, orchitis, meningitis, pancreatitis
Rabies: commonly found in bats, skunks, raccoons, foxes, coyotes; give reassurance if pet is sterile, kill animal for bx if unknown, give post-
exposure ppx for any bat exposure
★ Rubeola (measles): cough, coryza (head cold), conjunctivitis, Koplik spots, then diffuse maculopapular rash; Tx vitamin A
★ Rubella: diffuse maculopapular rash (starts on face and migrates down) w/ low-grade fever, marked LAD, sore throat, ±arthralgias
★ Roseola: due to HHV-6; high-grade fever for 3 days, then diffuse maculopapular rash
Varicella (chickenpox): due to VZV; “dew drops on a rose petal” vesicular rash in an ill child
Viral gastroenteritis: rotavirus infx → fever, vomiting, severe watery diarrhea during the wintertime; Tx supportive care
Herpes keratoconjunctivitis: HSV infx → vesicular lesions on skin + dendritic corneal ulcers, ↑risk of blindness
Parasites
Cutaneous larva migrans: due to Toxocara canis/cati; presents as itchy lesion on bottom of foot after playing around barefoot; Tx ivermectin
Visceral larva migrans: due to Toxocara canis/cati; presents w/ fever + HSM + eosinophilia; Tx ivermectin
Malaria: due to Plasmodium spp; presents w/ cyclic fever/chills and hemolytic anemia; Dx Giemsa stain of blood smear, Tx mefloquine (+
primaquine for hypnozoites)
Pinworm: due to Enterobius vermicularis; causes perianal pruritus worse at night; Dx scotch tape test, Tx mebendazole
Ascariasis: due to Ascaris lumbricoides; presents w/ eosinophilia + intestinal obstruction
Trichinellosis: found in undercooked pork; triad of periorbital edema, myositis, eosinophilia; may have nonspecific splinter hemorrhages
Giardiasis: due to Giardia lamblii; presents w/ fever, foul-smelling fatty stools, abdominal pain; Tx metronidazole

––––––––––––––––––––––––––––––––––––––––––––––––––––––– ALLERGY/IMMUNOLOGY –––––––––––––––––––––––––––––––––––––––––––––––––––––––

Allergy
Urticaria (hives): pruritic “wheal and flare” rash; Tx PO benadryl + avoid exposure
Erythema multiforme: urticaria + target lesions, <10% BSA (body surface area)
Stevens-Johnson syndrome: EM + mucosal involvement, 10-30% BSA
Toxic epidermal necrolysis: severe SJS, >30% BSA
DRESS syndrome (drug rash, eosinophilia, systemic sx): EM w/ eosinophilia + systemic sx, usually due to anticonvulsants
Maternal ab: IgG via placenta (lasts 3-6 months), IgA via breast milk
★ Immunology
Chronic granulmatous disease: XR ∆NADPH oxidase → phagocytic defect → recurrent abscesses; Dx nitroblue tetrazolium (NBT) test
 Pediatrics – Shelf notes

Wiskott-Aldrich syndrome: XR, TIE – thrombocytopenia (petechiae), recurrent infx, eczema; Dx CBC (↓plt), ↓IgM, ↑IgA, ↑IgE
Bruton agammaglobulinemia: XR B-cell defect → lack of all Ig types → recurrent bacterial infx (OM, PNA, etc.) after 6 months since mom’s
Ig confers passive immunity; Dx ↓serum Ig levels, Tx repeated IVIG
T-cell defect: likely DiGeorge syndrome (CATCH-22); Dx intradermal Candida test
Combined variable immunodeficiency: acquired B-cell defect (>10 y/o) → lack of all Ig types but normal B-cell levels; ↑risk of lymphomas
SCID (“bubble boy disease”): XR or AR ∆adenosine deaminase → lymphocytes can’t make DNA to proliferate (both B- and T-cells) → severe
infx → death at young age; Tx bone marrow txp
Job syndrome: FATED – coarse Facies, Abscesses, retained primary Teeth, ↑↑IgE, Derm issues (eczema)
Asplenia: recurrent encapsulated bacterial infx (SHiN – Strep pneumo, H. influenza, Neisseria), common in SCD kids; Dx CBC w/ smear (Howell-
Jolly bodies)
Hereditary angioedema: AD ∆C1 esterase inhibitor → random activation of complement pathway → recurrent episodes of edema w/ positive
family hx
IgA deficiency: recurrent respiratory infx + diarrhea + anaphylatic transfusion rxns (reacts to donor serum IgA); Dx ↓IgA
Complement deficiency: C5-C9 deficiency predisposes to recurrent Neisseria infx; Dx CH50 test

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– HEM-ONC ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Juvenile rheumatoid arthritis (Still disease): RF (anti-IgG Fc domain) → type 3 HS; Tx NSAIDs > MTX > PO steroids
Polyarticular JRA: >5 joints
Pauciarticular JRA: 0-4 joints, can present w/ anterior uveitis (iridocyclitis); Dx slit-lamp eye exam, Tx PO/OU steroids
Systemic JRA: systemic sx prior to arthritis, rheumatoid rash, high spiking fevers
Juvenile dermatomyositis: presents w/ progressive muscle weakness, skin rash, fatigue; Dx ↑CPK
Neonatal lupus: skin lesions (maternal ab-ag complexes cross placenta) + 3° heart block (anti-SSA attacks fetal heart conduction)
Systemic lupus erythematosus (SLE): type 3 HS → flare-and-remission pattern of I’M DAMN SHARP – ↑IgG, Malar rash, Discoid rash, ANA, Mucositis
(throat ulcers), Neuro sx, Serositis (pleuritis/pericarditis), Hematologic d/o, Arthritis, Renal d/o (wire loops), Photosensitivity; Dx screen w/ ANA, confirm
w/ anti-dsDNA or anti-Smith, Tx low-dose aspirin
ITP: autoantibodies against gpIIb/IIIa → platelet sequestration in spleen → petechiae, purpura; Dx ↓plt/↑MKC, Tx RhoGAM (if Rh+), IVIG (if Rh-), steroids
(2nd line), splenectomy (if severe)
★ Anemia
Fanconi anemia: AR ∆DNA repair genes → aplastic anemia + short stature, hypopigmented areas, eye/ear deformities; Tx androgens +
hematopoietic drugs (EPO, neupogen, etc.)
Anemia of prematurity: MCC anemia in premature and SGA infants; Dx CBC shows profound anemia w/ ↓reticulocytes, Tx iron supplements
Transient erythroblastopenia of childhood: RBC aplasia in children following a viral infx; Dx CBC shows profound anemia w/ no reticulocytes,
Tx supportive care (lasts 1-2 months, may need pRBCs)
Blackfan-Diamond anemia: macrocytic RBC aplasia + short stature, webbed neck, cleft lip, shield chest, triphalangeal thumbs
Sickle cell anemia: Dx Hb electrophoresis shows ↑HbF, Tx folate supplements (for effective hematopoiesis) + hydroxyurea (↑HbF)
Sickle cell + sepsis: Strep pneumo
Sickle cell + osteomyelitis: Salmonella
Sickle cell + aplastic crisis: Parvo B19
Dactylitis: sickle cell anemia → vaso-occlusion → vascular necrosis of metacarpals/metatarsals → acute onset painful swelling of
hands and feet
Acute chest syndrome: PNA-like presentation; Dx CXR shows infiltrate, Tx azithromycin + ceftriaxone
Sickle cell trait: MC sx is painless gross hematuria; Dx Hb electrophoresis shows HbS of 35-40%
Thalassemias
Mechanism/presentation Management
β-thalassemia minor heterozygous ∆β-chain → mild anemia sx Dx screen w/ CBC (microcytic anemia + ↓RDW),
confirm w/ ↑HbA2; Tx reassurance
β-thalassemia major homozygous ∆β-chain → severe anemia sx Dx screen w/ CBC (microcytic anemia + ↓RDW),
confirm w/ ↑HbF; Tx frequent transfusions
Silent carrier 1-2 α-chain deletion → asx ---
HbH disease 3 α-chain deletion → severe anemia sx Dx screen w/ CBC (microcytic anemia + ↓RDW),
confirm w/ ↑HbH; Tx frequent transfusions
Barts disease 4 α-chain deletion → fetal hydrops Dx post-mortem autopsy

Kasabach-Merritt phenomenon: large vascular anomalies (kaposiform hemangioendothelioma, tufted angioma) sequester RBCs, platelets, and clotting
factors → anemia, thrombocytopenia, coagulopathy; Tx steroids + IFN-α
G6PD deficiency: XR ∆G6PD in African-American boys → RBCs can’t make enough NADPH to deal w/ oxidative stress (fava beans, sulfa drugs,
antimalarials, infx) → hemolytic anemia following exposure to oxidative stress
★ ALL: MC cancer in kids <15 y/o; pre-B-cell proliferation (CALLA+/TdT+) → infiltration of reticuloendothelial system (LAD, splenomegaly) and bone
marrow (pancytopenia); Dx bone marrow bx shows >25% lymphoblasts, Tx chemotherapy
ALL prognosis: good px w/ age 1-10, hyperdiploidy, WBC <50, and TEL/AML1 on t(12;21); poor px w/ Philadelphia chromosome on t(9;22)
Hodgkin lymphoma: B-cell proliferation into Reed-Sternberg cells → B-type sx (fever, weight loss, night sweats); Dx CXR to look for mediastinal mass
then LN bx, Tx chemotherapy
Langerhans cell histiocytosis: Langerhans cell proliferation → eosinophilic granuloma → painful, solitary lytic bone lesion (MC site is skull)
Hereditary spherocytosis: AR ∆spectrin → hemolytic anemia + jaundice in newborn; Dx CBC shows spherocytes + abnormal osmotic fragility test, Tx
splenectomy
Disseminated intravascular coagulation (DIC): systemic insult (MCC septic shock) → widespread microcoagulation → run out of clotting factors →
bleeding out; Dx ↑PT/INR + ↑PTT + ↑D-dimer + ↓platelets, Tx underlying cause
Von Willebrand disease: AD ∆vWF → MCC hemorrhagic diathesis; Dx vWF levels + activity (ristocetin cofactor activity), Tx DDAVP
 Pediatrics – Shelf notes

Tumor lysis syndrome: lysis of cancer cells → hyperkalemia + hyperuricemia + renal failure; Dx renal panel + ↑uric acid, Tx allopurinol

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ENDOCRINE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Sick euthyroid syndrome: ↑bodily stress (trauma, starvation, etc.) → ↑cortisol blocks TSH → ↓T4/T3, normal TSH, ↑rT3 (deiodinase 3 activated by stress)
Adrenal
Pheochromocytoma: episodic ↑catecholamine → 5 Ps – Pressure (BP), Pain (HA), Perspiration, Palpitations, Pallor; Dx 24 hr urinary
metanephrines, Tx α-blockers (phenoxybenzamine) then β-blockers then adrenalectomy
Cushing syndrome: ↑cortisol → truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, immunosuppression; Dx
ACTH/cortisol levels + dexamethasone suppression test (pituitary Cushing can be suppressed), Tx underlying cause
Hyperaldosteronism: ↑aldosterone → ↑Na, ↓K, ↓H (HTN, metabolic alkalosis)
Addison syndrome: ↓cortisol/↓aldosterone → fatigue, hypoglycemia, HTN, hyperpigmentation, weight loss; Tx prednisone + fludrocortisone
replacement
★ Congenital adrenal hyperplasia: ∆21α-hydroxylase → ↓aldosterone/↓sex hormones → ↓Na, ↑K, ↑H (metabolic acidosis), hirsutism,
virilization; Dx ↑17-OHP, Tx hydrocortisone + fludrocortisone replacement
Central DI: ↓ADH → can’t resorb water → polyuria, polydipsia, hemoconcentration (↑Na, ↑K); Tx DDAVP
Nephrogenic DI: end-organ resistance to ADH → polyuria, polydipsia, hemoconcentration (↑Na, ↑K); Tx HCTZ
SIADH: ↑ADH → fluid overload → hemodilution (↓Na, ↓K); Tx water restriction
Pancreatic
HbA1C: reflects 2-3 months of glucose control, normal <6.5%
DM type 2: presents as polyuria (bedwetting), polydipsia, polyphagia, acanthosis nigricans; Dx fasting glucose >126 x2, random >200 w/ sx,
or HbA1C >6.5%
Factitious hypoglycemia: mom’s giving baby insulin → hypoglycemia + hyperinsulinemia + low C-peptide levels (high C-peptide reflects
insulinoma); Munchhausen by proxy is a form of child abuse
Parathyroid
Hypercalcemia sx: stones (kidney, GB), bones (pain, osteitis fibrosa cystica), groans (PUD, pancreatitis), psychic overtones
Hypocalcemia sx: neuromuscular irritability (tingling, tetany), prolonged QT, arrhythmias
Hypercalcemia s/p fracture: due to extensive bone resorption; Dx urine calcium:creatinine ratio >0.2, Tx hydration, calcitonin if severe
Nutritional rickets: dietary ↓vitamin D → normal Ca, ↓P → decreased bone mineralization; increased risk in exclusively breast-fed babies, lack
of vitamin D supplements, African-Americans, limited sun exposure
X-linked hypophosphatemic rickets: XD ∆PHEX (renal phosphate resorption gene) → ↑urinary P, ↓serum P → decreased bone mineralization
resistant to vitamin D supplements
Pseudohypoparathyroidism: renal tubules unresponsive to PTH → ↓Ca, ↑P, ↑PTH → hypOcalcemia sx + 4th/5th finger bradydactyly (knuckle-
knuckle-dimple-dimple sign)
Hypoparathyroidism: lack of PTH → ↓Ca, ↑P, ↓PTH → hypOcalcemia sx
1° hyperparathyroidism: excessive PTH → ↑Ca, ↓P, ↑PTH → hypercalcemia sx

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ADOLESCENT ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

HEADSSS assessment: Home, Education, Activities, Drugs, Sex, Suicide, Safety

Eating disorders
Anorexia nervosa: fear of being fat → <85% ideal body weight, secondary amenorrhea, lanugo, hypothermia, osteoporosis, arrhythmias; Tx
TID sandwiches
Bulimia nervosa: binge-eating + behaviors intended to counteract weight gain (purging, diuretics, exercise, fasting), sialadenosis, dental
caries, Russell’s sign (dorsal knuckle callouses); Tx SSRIs + CBT
Anorexia vs. bulimia: both can have purging behavior, but anorexia has <85% ideal body weight
Refeeding syndrome: increased nutrition in starving pt → ↑synthesis of glycogen, fat, proteins uses up electrolytes (especially ↓K and
↓phosphate)
Sports contraindications: bleeding d/o (hemophilia), single eye, single kidney, unexplained syncope, infectious mononucleosis (to prevent splenic
rupture)
Sports concussions
Sx Management
Grade 1 (mild) no LOC, confusion <15 min can return to play
Grade 2 (moderate) no LOC, confusion >15 min must sit out for a week, go to hospital if >1 hr
Grade 3 (severe) LOC go to hospital

★ Tanner (SMR) staging

Males Females
Tanner 1 kid kid
Tanner 2 scrotal darkening, thin long pubic hair breast buds
Tanner 3 dark curly pubic hair breast elevation, peak growth velocity
Tanner 4 adult pubic hair but w/o full coverage, peak growth velocity areolar mound (look 4 big nipples)
Tanner 5 adult adult

Late-onset congenital adrenal hyperplasia: 21-hydroxylase deficiency → excess of sex steroids → precocious puberty in boys
McCune-Albright syndrome: precocious puberty in girls + café-au-lait spots + polyostotic fibrous dysplasia (bone zits that cause multiple fx)
Teenage pregnancy: complications include poor maternal weight gain, premature delivery, low birth weight, ↑risk of pre-eclampsia
★ Substance abuse: suspect w/ declining school performance, poor hygiene, exaggerated mood swings, hanging w/ the wrong crowd, frequent hostile
reactions
 Pediatrics – Shelf notes

Cocaine: euphoria, tachycardia, hypertension, nosebleeds, heart attacks, strokes

Marijuana: euphoria, paranoia, injected eyes, munchies
Anabolic steroids: muscles, hirsutism, acne, gynecomastia, testicular atrophy, roid rage; consider in football players
MDMA (Ecstasy): euphoria, stimulant, “sense of closeness with others”, death by hyperthermia or dehydration; consider in clubs/raves
Inhalants: brain damage, arrhythmias, death
Suicide: women attempt more but men are more successful; Tx admit + get full psych eval
Sleeping late w/ puberty: due to melatonin phase-delay in sleep-wake cycle
★ Acne vulgaris: not associated with food or caffeine intake; Tx topical benzoyl peroxide (1st line), topical retinoids or abx (2nd line), PO abx (3rd line),
isotretinoin (last line, teratogenic)
Dysfunctional uterine bleeding: abnormal menses w/o identifiable cause; Dx of exclusion, Tx OCPs to normalize cycle

★ = high-yield topics (review these before the shelf)