MSK
Maneuvers / Diagnostics
Is the joint pain:
1. Articular or extraarticular?
2. Acute (<6 wks) or Chronic (>12
wks)?
3. Inflammatory or non-inflammatory?
4. Localized or diffuse?
-Inspect and palpate joints immediately above
and below the painful areas
-If no Sx, Active ROM testing can be done
bilaterally at the same time
-Examine unaffected side first to develop
sense of what is normal for pt.
Fernando Vélez
Taneil Gibson
Treatment
Shoulder pain
-Determine if pain is from shoulder or distant
site
● Shoulder mvmt → pain +/- stiffness
and Limited ROM = shoulder
●
disorder
Normal shoulder exam = referred
pain
-Is pain Periarticular or Intraarticular? Check
Passive and Active ROM
● Active ROM painful but no passive
ROM pain = Periarticular issue
○ tendonitis, bursitis
● Active and Passive ROM painful =
Intra-articular issue
○ arthritis of glenohumeral joint
○ *Exception ~ impingement
syndromes.
*Spurling maneuvers:
- Extends patient’s neck.
- Rotate head towards affected shoulder
- Place axial load on the cervical spine
- Test is positive if limb pain or
paresthesias are produced and the
test should be then stopped.
- Production of neck pain alone in
response to the Spurling maneuver is
nonspecific and constitutes a
negative test.
- The Spurling test has high specificity
for the presence of cervical
radiculopathy (nerve root
compression), but has a low to
moderate sensitivity.
-Referred pain from Cervical Spine:
- neck pain and stiffness
- decreased neck ROM (x6)
-Up, Down, Left, Right, Ear-toshoulder (left & right)
- pain → extending below the elbow
- **Conduct Spurling’s Test
Rotator Cuff Disorders
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●
●
●
Fernando Vélez
Taneil Gibson
Rotator Cuff tendonitis
Rotator Cuff tear
Subacromial bursitis
Impingement syndromes
○ From RC or subacromial
bursitis.
Special test to assess rotator cuff
(Impingement)
-
-
Painful arc test
- Active ROM triggers pain
between 60-120 degrees on
abduction.
Hawking’s test
- Pain when examiner internally
rotate the shoulder and elbow
Conservative treatment
- Ice
- Avoid repetitive overhead
activities.
- Lifting heavy objects
- NSAIDS & Acetaminophen.
Shoulder Steroid injection
- Single glucocorticoid
injection to those who fail a
-
flexed at 90 degrees.
- **most sensitive
Neer test
- Pain with a passive flexion of
the shoulder with fixed/stabled
scapula (arm pronated).
- 90 deg = mild
- 60-70 deg = moderate
- <45 deg = severe
Maneuvers for rotator cuff (Tear) ~ (Passive
Strength tests)
-
Drop arm test
- Supraspinatus tear
External rotation lag
- Weak → Unable to maintain
position
Supra/infraspinatus and teres
minor tear
Internal rotation lag
- Weak → Unable to maintain
-
-
-
position
Subscapularis tear
Maneuvers for rotator cuff (Composite:
Tear & Tendonitis) (Active against resistance)
- Empty can / Jobe’s test
- Supraspinatus
- Pain → Tendonopathy
-
- Weakness +/- pain → Tear
External rotation
- Infraspinatus, Teres minor
- Pain → Tendonopathy
-
Fernando Vélez
Taneil Gibson
Weakness +/- pain → Tear
4-6 weeks of conservative
measures or initially to those
whose pain is severe.
For Full Thickness tear
- Orthopedic referral and
immediate surgery for
healthy individuals.
- Conservatively in elderly
patients or with major
comorbidities.
- Partial tear that do not
respond to conservative
treatment therapy may need
surgery.
-
Internal rotation
- Subscapularis
- Pain → Tendonopathy
-
Weakness +/- pain → Tear
Imaging Tendinopathies
- MSK Ultrasound (Gold standard)
- MRI (If Dx: is uncleared)
Imaging RC Tears
- Pain radiograph
- Can show migration relative to
position.
- MSK Ultrasound
- Highly sensitive
- MRI
- Accurate for full thickness and
partial tears is less sensitive.
Bicep Pain
Hx:
Bicep Tendon Palpation
●
●
●
Pain on anterior shoulder with
radiation distally over the bicep
muscle.
Pain aggravated by lifting, pulling or
repetitive overhead activities.
May coexist with rotator cuff issues.
Yergason’s Test (Bicipital tendonitis)
- Pt’s elbow flexed to 90 deg. Thumb up
and elbow on the pr’s side.
- Examiner: place one hand on bicipital
groove, the other hand on patients
wrist.
- Examiner attempts to resist active
supination and elbow flexion by the
patient.
Speed’s test
- Pt’s forward flexes shoulder with elbow
in slight flexion and full supination.
- Examiners feels biceps long head.
- Pt’s actively flexes arm against
examiners downward resistance.
Fernando Vélez
Taneil Gibson
Initially
- NSAIDS x7d
- Physical therapy
- Activity modification
Subsequent (If no improvement)
- Conservative treatment for 6
weeks.
- Consider Ultrasound guided
glucocorticoid steroid
injection onto the sheath of
the long head of the biceps
tendon.
Patient education after glucocorticoid
injection.
- Must rest 72 hrs due to
rupture risk.
Elbow pain
**Epicondylitis and
Olecranon bursitis
= rarely affect
elbow ROM!
Hx
**Normal ROM
testing of elbow
RULES OUT
involvement of
elbow joint itself
Medial Epicondylitis
-Pain localized to the lateral epicondylar
process
-Aggravated by repetitive contraction of
the wrist extensors
-Pain localized to medial epicondyle
-Aggravated by actions that contract wrist
flexors
- Golf
- Repetitive shaking hands and use of
forearm/wrist
- Carpenters, Politicians, Gardeners,
Tennis players
PE
DDx
Fernando Vélez
Taneil Gibson
Lateral Epicondylitis
-Normal elbow ROM
-Pain at lateral epicondyle
-Pain with resisted wrist extension, or
wrist pronation/ supination with
elbow in full extension
-Pain with gripping
-Decreased grip strength
-Normal elbow ROM
-Pain at medial epicondyle
-Pain with resisted wrist flexion,
supination/ pronation with elbow in full
extension
-Pain with gripping
-Decreased grip strength
1. Cervical Radiculopathy
a. Referred pain from the
neck
b. No pain with elbow
mvmt but pain moving
shoulder or neck
2. Elbow arthritis
a. Elbow joint pain
b. May see joint effusion
c. ROM limited at elbow
3. Fracture
1. Ulnar neuritis
a. Ulnar nerve pain
b. Radiation into the ulnar
side of the hand with
sensory and motor Sx in
4th and 5th fingers
2. Cervical Radiculopathy
a. Referred pain from the
neck
b. No pain with elbow mvmt
but pain moving shoulder
or neck
3. Elbow arthritis
a. Elbow joint pain
Olecranon bursitis
-Elbow swelling with warmth and
redness.
Causes:
-Trauma
-Sepsis
-RA
-Gout
-Can fully extend the elbow since
elbow joint not involved
b. Joint effusion may be
seen
c. ROM limited in elbow
4. Fracture
Dx
and
Tx
Dx:
Dx:
●
●
Hx and PE
X ray only needed if fracture
suspected
●
●
●
●
Activity modification
Counter force bracing
Physical therapy
Topical and/or oral NSAIDS
Tx:
Wrist and Hand
pain
Hx:
●
Fernando Vélez
Taneil Gibson
Hx and PE
X ray only needed if fracture
suspected
●
●
●
●
Activity modification
Counter force bracing
Physical therapy
Topical and/or oral NSAIDS
Tx:
Carpal Tunnel Syndrome
- Median nerve compression within
the carpal tunnel
- Bilateral symptoms >50%
- Diseases/Risk factors:
- Obesity
- Female gender
- Pregnancy
- Hypothyroidism
- DM
- Connective tissue disease
●
●
●
Pain worse at night and with
repetitive actions
Pain and paresthesias limited to the
median-innervated fingers
○ Some pain/tingling in hand,
wrist
○ Some radiation to arm and
all 5 fingers
P.E:
●
●
●
Tx:
Hyperalgesia of median nerve
distribution and weakness of thumb
abduction and opposition
Thenar muscle atrophy- severe
disease
Phalen and Tinel’s test positive
●
●
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●
PROTECT the joint
Aspirate fluid
NSAIDS
Tx underlying condition
-
Avoid repetitive hand and
wrist movements
-
Neutral position wrist
splinting- used full time
-
Local steroid injection (10
wks) = short term relief
-
Oral steroids for 2 wks=
relief for 1 mo
-
NSAIDS
-
Surgery if:
- Nerve testing →
-
Severe disease
Muscle wasting
Failure to respond to
conservative tx
-
Knee pain
Hx:
Location of pain
Mechanism of Injury (MOI)
Duration of pain
Other sx:
●
●
●
●
●
●
Stiff joint
Swelling
Locking
Instability
Constitutional Sx (fever, weight, fatigue)
Joint redness
P.E.
-
-
●
Inspect
Palpate
Active ROM and Passive ROM (if
indicated)
Maneuvers for knee ligaments and
menisci:
- Anterior drawer/ Lachman
- Posterior drawer
- Valgus/ Varus stress
- Thessaly/Apley Grind/
McMurray/ Bounce/ SquatDuck walk
Effusions:
- Bulge
- Ballotment
- Balloon
Diagnostics:
- Arthrocentesis
- Septic knee
- NOT if ligament or meniscus
tear
- X-Ray
- Suspected trauma fracture
- OA signs
- Looking for foreign body
- MRI - if considering surgery or
persistent Sx
Fernando Vélez
Taneil Gibson
●
●
●
●
Intolerable pain
Due to another
disease; treat the
disease
Restrict weight-bearing
activities, use crutches
Knee brace
Ice, NSAIDS +/- Tylenol
Rehab- once pt has
painless, full ROM
Orthopedic referralarthroscopy
-
ACL tear
MOI
-Rapid deceleration +
pivot
-Knee hyperextension
-Popping sound, knee
instability, pain=
complete tear
Meniscal tear***
Plain Radiograph
- Acute injury
- Meniscal tear
PCL tear
-Posteriorly directed
force on the knee
MCL
-Direct valgus (medial)
force to an extended
knee
(e.g. motor accident
when knee is flexed and
strikes dashboard)
LCL
-Direct varus (lateral)
force to a extended leg
*less frequent than MCL
Meniscus
Acute tear:
Twisting knee when
foot is planted and
knee is flexed
Can continue to
participate in activity
Degenerative tear:
Can develop with
minimal/ no trauma
Hx
-Joint instability
-Medial knee pain
-Swelling
-Lateral knee pain and
swelling
-May lock, catch or giveout
- Small tear → insidious
onset of pain/swelling
(stiffness) over 24 hrs
- Severe tear → significant
pain, ↓ ROM, tearing and
pop at time of injury
Fernando Vélez
Taneil Gibson
- Weeks later→ popping,
locking, catching and giving
out
P.E
-Large effusion
-Lachman and
Anterior drawer= ↑
laxity
-Posterior drawer
test=↑ laxity
- POSITIVE Sag/
Godfrey sign
-Medial joint line
tenderness
-Valgus stress= ↑
-Lateral joint line
tenderness
-Varus stress= ↑ laxity
laxity
- Plain Radiograph followed
by Ottawa Knee Rule.
- MRI for patient with
persistent Sx despite the
initial treatment. (
Dx:
Low Back pain
Acute < 4 wks
Subacute 4-12 wks
Chronic >12 wks
-Spondylosis
●
Degenerative arthritis of spine
-Spondylolisthesis
●
Anterior displacement of a vertebral body
relative to the one below
-Spondylolysis
●
Fracture of the pars inter-articularis
-Spinal stenosis
●
Local, segmental or generalized narrowing of
vertebral canal by bone or soft tissue.
-Radiculopathy
●
Impaired nerve root → radiating pain,
numbness, tingling or muscle weakness
-Sciatica
Fernando Vélez
Taneil Gibson
-Joint line tenderness and
effusion
-Gait observation to assess
impact
-Loss of smooth passive/
active motion
-Inability to squat or kneel
-Palpable pain with
McMurray maneuver
-Pain elicited by Thessaly,
Bounce and Apley grind
tests
History
-Location
-Neurologic deficits?
-Acute vs Chronic Sx
-Character of pain
-Worse with or without activity?
-Psychosocial risk factors?
**Always ask Bowel or bladder issue when there is back
pain!
Imaging:
- Cancer or Vertebral infection- Plain film, MRI, ESR
- Cauda equina syndrome or Severe
Progressive neurologic deficits
Acute Lower Back Pain:
- NO prolonged bed rest
- Heat
- Tylenol, NSAIDS, Muscle
relaxants, Benzos,
Tramadol, opioids
(sparingly!)
- Spinal manipulation (*NOT
physical therapy)
- Follow up in 2-4 wks
Subacute/Chronic Back pain:
- Remain active
- Tylenol, NSAIDS, TCA’s,
Benzos, Tramadol, Opioids
(Sparingly!)
●
Pain, numbness, tingling in the distribution of
the sciatic nerve, radiating down the posterior
or lateral aspect of the leg.
-Cauda equina syndrome
●
Loss of bowel and bladder control
●
Numbness in groin and saddle area of
perineum
●
Associate with weakness of the lower ext
- MRI or EMG
Vertebral Fx
- Plain film
Ankylosing Spondylitis
- Plain film and ESR; Seronegative
**Cervical spine nerve roots- exit ABOVE the
vertebrae
Thoracic and Lumbar nerve roots exit
BELOW the like-named vertebrae
- Nerve exiting at level L4-L5 is L4
PE:
nerve but a disc protrusion→ L5
nerve root impingement syndromes.
Categories:
2.
3.
4.
Fernando Vélez
Taneil Gibson
Non specific pain (85%)
a. Lumbar strain
Pain with Radiculopathy or Spinal
Stenosis
a. Herniated disc
b. Nerve root impingement
Pain assc. With another specific spine
disorder
a. Cancer
b. Compression fx (fracture)
c. Infection
d. Ankylosing spondylitis
Pain referred from outside of the back
a. Pancreatitis
b. Nephrolithiasis
c. AAA
d. Pyelonephritis
-
spondyloarthropathy that initially targets
sacroiliac joints in young males (15 - 35 yrs).
●
●
Skin inspection
Inspection- symmetry, bulk, posture
●
●
●
Palpation/ ROM
Percussion
Lumbar disc herniation/ nerve root
impingement
Straight leg raise (SLR)
●
○
○
1.
-
-
Rules out disc radiculopathy and
indicates herniated disc
●
Crossed straight leg raise
●
Rectal exam- evaluates Cauda equina
syndrome
○
-
*hold pt at the hip when asking them
to rotate to prevent them from using
the knee/ankles to rotate.
Surgery candidates:
- Disk herniation causing
persistent radiculopathy =
Discectomy
-
Painful spinal stenosis=
decompressive laminectomy
-
Cauda equina syndrome=
decompression
Specific for radiculopathy
*If both SLR and C-SLR are positive it is indicative
of Disk Herniation
*0-5 for muscle grading (e.g. ⅗)
* 0-4 for reflex grading (2+ is normal)
Spinal manipulation,
massage, Physical therapy,
yoga, acupuncture, cognitive
behavioral therapy
Systemic glucocorticoids for
SHORT TERM pain relief,
not treatment
Trigger point injections of
local anesthetic
Epidural injections of
steroid- Chronic LBP +
Sciatica or Radiculopathy
**MUST KNOW:
Red Flags for serious conditions:
●
●
●
●
Hx or new diagnosis of
cancer (breast, lung, MM,
prostate, renal cell)
Unexplained weight loss
Failure to improve after 1
mo.
No relief with bed rest; pain
worse at night or when lying
down
Suggests→ Metastatic disease to the
spine
Fernando Vélez
Taneil Gibson
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●
Fever
Pain worse at night or
when lying down
●
Hx of IVDA
●
Hx of UTI
●
Hx of skin infection
Suggests → infection (osteomyelitis,
epidural abscess)
●
●
●
●
●
Morning stiffness
Pain not relieved when supine
Pain persistent for >3mo
Gradual onset
Involvement of other joints
Suggests → Inflammatory/ Rheumatologic
condition (Ankylosing spondylitis, RA etc)
●
Hx of Trauma
●
Hx of Glucocorticoid use
●
Hx of Osteoporosis
Suggests → Compression fracture
●
Severe leg pain, often
bilateral
●
Pain improved when seated
●
Pseudoclaudication
(worsened pain walking,
relief with sitting)
Suggests→ Spinal Stenosis
Fernando Vélez
Taneil Gibson
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●
Sciatica
Increased pain with cough,
sneeze or Valsalva
Suggests→ nerve root irritation
(radiculopathy) from herniated disc
●
●
●
Bowel or bladder dysfunction
Sexual dysfunction
Saddle anesthesia sensory loss
(S3-5)
●
Bilateral absence of ankle reflex
●
Rapidly progressive neurologic
deficits
Suggests → Cauda equina syndrome (aka
massive midline disc herniation)
Rheumatology
History
**GENERAL
CONCEPTS
P.E.
Terminology
Arthralgiasgeneralized joint
aches and pains
without evidence of
arthritis
Tenosynovitisinflammation of a
tendon or tendon
sheaths
Myositisinflammation of the
muscles
Arthritis - joint
pain, stiffness,
swelling, dec.
ROM, deformity,
warmth/erythema
Enthesitisinflammation at the
site of insertion of
tendons, ligaments
and synovium into
bone
Serositisinflammation of the
serous tissues of
the body
Synovitisinflammation of the
synovium
Myalgia- generalized
muscle aches and
pains
Gel phenomenonbrief periods of
daytime stiffness/
gelling following
inactivity; lasts 3060 mins (seen in
OA)
Stiffness- ≠ Pain !!
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●
●
Fernando Vélez
Taneil Gibson
Diagnosis/Labs
Joint patterna. Symmetric?
i.
Gout- asym
ii.
RA- sym
b. Inflammatory?
Joints involveda. Number
i.
Mono- Gout
ii.
Oligo (2-4)- Reactive arthritis
iii.
Poly (5+)- SLE, RA, Psoriatic symmetric
polyarthritis
b. Size
i.
Small- Rheumatoid arthritis (not DIP)
ii.
Large- Reactive arthritis
iii.
Spine- ankylosing spondylitis
Extra-articular manifestations?
●
Arthrocentesis results
a. Color
b. Transparency
c. Viscosity
d. Cell count
i.
ii.
iii.
●
Non-inflamm= OA
Inflamm- RA, Gout
Septic- Bacterial infxn
e. Crystals
f. Gram stain and culture
g. PCR- Lyme disease
Lab results
a. Inflammation- ESR, CRP,
Complement
b. AutoAb’s
i.
ii.
iii.
iv.
●
RF- RA and others
ANA- Lupus and others
Anti-CCP- RA
Anti-ds DNA- SLE
Imaging
a. Plain Xray- RA, OA
b. CT- Bony abnormalities
c. MRI- soft tissue abnormalities,
inflammation, fluid collection
d. US- soft tissue abnormalities
(bursitis, synovitis, tendonitis, joint
fluid)
Treatment
-Anti-inflammatory
- NSAIDS
- Glucocorticoids
- Colchicine
-Analgesics
- Acetaminophen
- Opiates
- Gabapentin, TCA,
SNRI
- Topicals→
Capsaicin,
Lidocaine
-DMARDS (disease
modifying anti-rheumatic
drugs)
- Nonbiologic:
-Methotrexate
-Hydroxychlororquine
-Sulfasalazine
-Leflunomide
-Azathioprine
-Cyclophosphamide
-Mycophenolate Mofetil
-Cyclosporine
-Apremilast
- Biologic:
-TNFa inhibitors
-Non TNF- Rituximab,
Anakinra
a. Constitutional Sx
i.
RA= low grade fever
b. Dermatologic
i.
Lupus= malar rash
c. Inflamm eye Dx
i.
Spondyloarthropathies = Uveitis
d. Internal Organs
i.
Lupus= carditis, nephritis
Rheumatoid arthritis
Presents as bilateral,
symmetric, inflammatory
polyarthritis
Tenderness and swelling
of joints
-
●
-Extra-articular
manifestations: soft tissues,
skin, vessels, heart, lung,
●
muscles
Symmetric joint
involvement
-
Anti-Cyclic citrullinated peptide
Ab’s (Anti CCP Ab)- 95% specific
Active signs of
inflammation for 6wks
-
↑ ESR and CRP
-Produces non-suppurative
synovitis
●
Mild fusiform soft-tissue
PIP swelling= early RA
-
CBC
-30-60 y/o; Female:
Male=3:1
●
●
Pain, swelling,
warmth in 3+ small
●
●
joints of hands/ feet
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●
Fernando Vélez
Taneil Gibson
Skin:
○
○
→ progress to larger
joints
○
Swan necking, ulnar
deviations, MCP
synovitis
●
DIP rarely
involved
Morning stiffness
●
>1 hr
Insidious onset
Fever, malaise,
depression, myalgia
Eyes:
○
Rheumatoid Factor- 70%
-
-
Pulmonary:
○ Pleuritis
○ Exudative pleural
effusion
○ DPLD
Normochromic, normocytic
anemia
Thrombocytosis
-
-
DMARDS
○
Imaging:
- Plain films
Pyoderma
gangrenosum
Rheumatoid
nodules
Keratoconjunctivi
tis sicca
●
sensitive
US
-
Bony erosions
Periarticular
osteopenia
Subluxations
Soft tissue swelling
Joint space narrowing
MCP and PIP
involvement on hand
radiograph
Synovitis
Erosions
Non-BiologicMethotrexate
■
○
Pregnancy
test first
Biologic-only if
inadequate
nonbiologic
response
●
Glucocorticoids - as
adjunctive tx
●
NSAIDS- adjunctive tx
●
Surgery
●
Infectious arthritis
Arises from hematogenous
spread, direct inoculation
or contiguous spread from
neighboring osteomyelitis,
cellulitis or septic bursitis
Cardiac:
○ Risk CAD and
HF
○ Pericarditis
●
●
Fever, chills, rigor
Warmth, erythema,
pain and swelling of
joint
Causes:
-Staph aureus- MC
-Disseminated Gonococcal
infection:
1. Vesiculopustular or
hemorrhagic
macular skin
lesions, fever, chills,
polyarthralgia
2. Purulent arthritis
-Lyme Arthritis
-
Arthrocentesis
CBC
Blood cultures
ESR, CRP
GU, rectal, pharyngeal cxs
- If suspect
disseminated GC
Lyme blood test (ELISA/
Western blot)
- If suspect Lyme
Imaging
- Non specific
- May reveal local
swelling or joint
destruction
-Bacterial septic joint=
- MRSA:
-Vancomycin/
Linezolid
-Clindamycin/
Daptomycin
- MSSA:
- Nafcillin
- Cefazolin
-Disseminated Gonococcal- IV ceftriaxone (714 d)
- Fluoroquinolones
- Azithro or Doxy
(treats for Chlamydia coinfection)
-Lyme arthritis=
- Oral doxycycline
or Amoxicillin (28 d)
-IV Ceftriaxone
(28d) if concurrent
neuro findings
Spondyloarthropathies
Fernando Vélez
Taneil Gibson
A group of 4 disorders:
1. Ankylosing
spondylitis
2. Psoriatic arthritis
3. IBD assoc. Arthritis
4. Reactive arthritis (
Reiter’s Syndrome)
...that share the following:
Psoriatic arthritis PE:
-Inflammatory articular dx +
3 or more of:
- Psoriasis
- Psoriatic nail
dystrophy
- Dactylitis/ swelling
of entire digit
- Negative RF
*No specific serologic tests
●
●
●
●
RF, Anti-CCP, ANA=
negative
↑ ESR and CRP
HLA-B27 - can’t confirm or
exclude any specific dx
Check for chlamydia- some
may have asymptomatic
-
Exercise
Steroid injections
NSAIDs → then non
biologic and
-
biologic DMARD’s
Surgery (if severe,
end stage joint/ soft
tissue damage)
●
●
●
●
Systemic Sclerosis
Inflammation of
axial skeleton,
tendons and
entheses
Tendone and
enthesis
calcification
HLA-B27 assoc
Mucocutaneous, GI
and ocular
inflammation
General Extracutaneous
features:
-Raynaud phenomenon
-Heart burn, dysphagia,
diarrhea
-HTN, Kidney disease
-Dyspnea on exertion
-Pulm.HTN, diffuse
parenchymal lung disease
-Mucocutaneous telangiectasia
- Radiologic
evidence of juxtaarticular new bone
formation
●
●
●
●
●
Reduced facial
wrinkles, small
mouth opening
Telangiectasia
Calcinosis cutis
Sclerodactyly
Digital ulcers and
pitting
●
-
Limited Cutaneous
Systemic sclerosis
(LcSSC)
- Thickened skin over
hands, face, neck
- Sclerodactyly
- CREST syndrome
features
-
-
Fernando Vélez
Taneil Gibson
Calcinosis
Raynauds
Esophageal
dysmotility
Sclerodactyly
Telangiectasia
No visceral organ
involvement
persistent infxn
Imaging:
○ Plain films of spine
and SI joints =
synovitis, axial
erosion, new bone
■ ankylosing
○ X-ray= erosive
changes
■ psoriatic
ANA
Anticentromere
- LcSSc
- CREST
Anti-Scl 70
- DcSSC
Anti-RNA polymerase III
- DcSSC
No biopsy because findings
are classic and characteristic
Therapy based on Organ
system:
Skin- Pruritus
● Emollients
● Antihistamines
MSK- Inflammatory arthritis
and Myositis
● MTX
● Glucocorticoids
● Leflunomide
Vascular- Raynaud’s
● Avoid cold
● CCB
● Anti-platelets
Diffuse cutaneous
systemic sclerosis
(DcSSc)
- Thick skin over
chest, abdomen,
forearms, upper
arms, shoulders +
hands, face, neck
- Visceral organ
involvement
Systemic sclerosis sine
scleroderma
- Fibrosing organ
involvement without
skin thickening
Systemic Vasculitis
Giant cell (Temporal)
arteritis
History:
- Scalp pain, HA or
tenderness over
temporal artery
- Weight loss,
malaise, low grade
fever
- Jaw claudication
- Blindness (sudden
or preceded by
amaurosis fugax)
GCA
●
●
Temporal artery
may be
erythematous,
swollen, tender
Diminished pulses
GCA
-
-
↑↑↑ ESR (>50)
- Marker of disease
activity
Temporal artery biopsy definitive diagnosis
- Skip lesions can
cause false negative
GCA
●
●
●
●
Polymyalgia Rheumatica
- Low grade fever,
Fernando Vélez
Taneil Gibson
PMR
PMR
PMR
●
Tx should never be
deferred pending
biopsy
Oral Prednisone
60mg or
1mg/kg/day for 1
month or until sx
resolve,
○ Taper 10%
every few
weeks
IV steroids if visual
loss
Duration 6-18
months
Low dose
-
-
Sjogren’s Syndrome
malaise, fever
Symmetric
proximal pain and
stiffness in
shoulder, neck and
hip
- Stiffness in arm
30-60 min;
better with
activity
- Pain worse
with activity
2-3x more common
than GCA
Immune mediated disease
-Infiltrative inflammation
damages exocrine glands
●
●
●
-↑ risk lymphoma
-Primary form= no
associations
-Secondary form- overlaps
with RA and SLE
-
↑ ESR/ CRP
Normal aldolase and CK
(muscle enzymes)
Normal muscle biopsy
CBC
- Normocytic anemia
- Thrombocytosis
MRI/ US:
- Bursitis
- Synovitis
●
●
●
Prednisone (10-20
mg/d)
Dramatic
improvement w/n 3
days (if not,
consider other dx)
Can have partial
relapse during taper
duration= years or
indefinitely
*inform pt’s of GC side effects:
osteoporosis, weight gain, fluid
retention, hyperglycemia,
myopathy
●
●
Keratoconjunctivitis
sicca
Xerostomia →
corneal damage
Females 9:1 , ~50y.o
-Skin, joints, lung, heart, Gi,
kidney, bladder, gyne,
heme, PNS/CNS affected
May have
decreased active
and passive ROM
(esp active
abduction of arms
above 90 degrees )
Strength and
muscle tone normal
No erythema,
warmth or swelling
and vision
●
●
●
impairment
Dental caries
Dry mucosal
membranes
Enlarged parotid
and lacrimal gland
-
RF
ANA
Anti-Ro/ SSA
Anti-La/ SSB
Lip biopsy for salivary gland
inflammation = GOLD
standard for Diagnosis
*Management depends on
Sx’s:
-Occular Sicca=
- Artificial tears
- Topical cyclosporine
-Oral Sicca=
- Artificial saliva
- Sugar free lozenges
- Pilocarpine
- Good dental hygiene
-Vaginal/Skin Sicca =
- Lubrication
-Arthralgia or rash=
- NSAIDs
- Hydroxychloroquine
- Glucocorticoids (low
dose po or Topical)
-Lung, Kidney, Nervous system
- Glucocorticoids (High
dose)
-Mtx
Fernando Vélez
Taneil Gibson
- Azathioprine
- Cyclophosphamide
Mixed Connective
Tissue Disease
Overlap syndrome that
includes features of:
- SLE
- Systemic sclerosis
- +/- Polymyositis
●
Anti-U1-Ribonucleoprotein
(RNP) antibodies
9:1 female predominance
Hx:
-
Hand edema and
synovitis
Myositis
↓ esophageal
motility and
-
Fernando Vélez
Taneil Gibson
fibrosing alveolitis
Pulmonary HTN
Starts similar to
SLE → MCTD
Sicca symptoms
Pleuropericarditis
Membranous
nephropathy
Trigeminal
neuralgia
0
●
●
●
●
Skin
○ Gottron rash
○ Malar rash
○ Photosensitivity
○ Telangiectasia
○ Calcinosis
○ Scleroderma
○ Sclerodactyly
Hand edema
Synovitis
Myositis
Trigeminal neuralgia
-
Anti- U1- RNP Ab =
DIAGNOSTIC
*Management depends on
Sx’s:
-
↑ ESR , Leukopenia,
-Arthritis and Myositis=
- GC
- Azathioprine
- Methotrexate
THrombocytopenia
-
ANA (speckled pattern)
-
No ds DNA or Anti-smith
Ab (only in SLE!)
-
Imaging:
- High resolution CT
of chest
- Echocardiography
- PFT’s
-Raynaud’s Phenomenon
Sx
- Ca2+ channel
blockers
-Esophageal dysmotility=
- PPI
-DPLD =
- Cyclophosphamide
-Pulmonary HTN=
- PDE inhibitors
- Enodthelin
Neuro Week
Cause
Motor Neuron
disease
Upper motor neuron
● “Pyramidal insufficiency”
Occur in:
● Neural pathway above
anterior horn
● Motor nuclei of cranial
nerves
● Brainstem or spinal cord
○ Due to either
Stroke, MS,
Cerebral palsy or
traumatic brain
injury
Lower motor neuron
Occurs in:
● Nerve fibers from the
anterior horn of spinal cord
● Cranial motor nuclei to the
relevant muscle
Amyotrophic Lateral Sclerosis
“Lou Gehrig disease”
-
Fernando Vélez
Taneil Gibson
Combined UMN and LMN
degeneration
Fatal
Signs/ Symptoms
Lab/Investigations
Treatment
Upper motor neuron
-
Weakness
Slowness
Hyperreflexia
Spasticity
Lower motor neuron
-
Weakness
Atrophy
Amyotrophy
Fasciculations
LMN sx: Dysarthria, dysphagia,
fasciculations, asymmetric limb
weakness, atrophy.
UMN sx: Spastic gait, clonus
*No sensory or bowel/bladder
deficits
Riluzole
Headaches
Types:
1. Migraine
○ Recurrent attacks
○ Primary neuronal dysfxn →
premonitory sx, aura,
headache, postdrome
Cortical spreading
depression:
i.
Causes aura
ii.
Activates CN5
afferents
iii.
Alters BBB
permeability
2. Tension
3. Cluster
4. Chronic daily
○
General Dx. is made by Hx, FHx & PE
- Imaging (MRI1 or CT2) if Hx, PE & presentation are inconsistent.
- LP required unless a benign etiology can be otherwise established.
- Psychological state of the pt should be evaluated (relationship between Depression and Pain)
Red Flags for 2ry (non migraine or tension) causes: HEADACHe
- Hx of worst headache of my life, Pain on Exertion, Age >50, Despite treatment headache
persist, Acute onset, CNS findings, HIV or immunosuppression, Fever.
Migraine
Dx Criteria:
2 or more of these:
●
Unilateral pain, throbbing/pulsatile,
aggravated by movement, moderate or
severe intensity.
Plus at least 1 of the following
●
N/V, photophobia, phonophobia
●
Avg= 4+ hrs
Comorbidities
○
○
*Cutaneous Allodynia
is the
perception of pain produced by the
innocuous stimulation (Brushing hair,
touching scalp, etc.) of normal skin and may
result from sensitization of central pain
pathways of migraine.
Variant: “Familial Hemiplegic Migraine”
●
Stroke like symptoms and paralysis on
one ½ of body
●
Lasts hours
*Medication-Overuse Headache
Evaluate for
TIA
Temporal Arteritis (Serum ESR &
Biopsy)
Meningitis (LP)
Hemorrhages (CT)
Neoplasms (CT)
Overuse of analgesic may aggravate
headache frequency, markedly reduce the
effect of preventive medicines and induce a
state of refractory daily or near-daily
headaches.
D/Dx:
1.
2.
3.
4.
Fernando Vélez
Taneil Gibson
Trigeminal Autonomic Cephalgia
(TAC)
Idiopathic Intracerebral HTN
a. Papilledema (inc CSF
pressure)
b. Tx: Spinal Tap
Medication Overuse Headache
a. Tx: preventative meds
Temporal arteritis
Insomnia, Depression
Anxiety
Migraine Disability Assessment Score (MIDAS)
https://migraine.com/wpcontent/uploads/2012/04/midas.pdf
Prophylaxis: Level A
NSAIDS - Ibuprofen
5-HT agonist 1B / 1D
Rizatriptan 10mg, Eletriptan 80mg, Almotriptan
12.5mg
Add Naproxen in patients with auras since
monotherapy with triptans are not effective
Add Anti-emetics to control N/V.
*Contraindicated in pt with Cardiovascular and
cerebrovascular problems.
Dopamine Antagonist (when above tx fail)
Metoclopramide
Patient education:
Avoid triggers www.achenet.org
Excess Caffeine/Alcohol
- Maintain diary
- Medication Side Effects
Non-Medical Tx:
●
Stress management
●
Acupuncture, massages
●
Aromatherapy, Herbs
Tension
-
Bilateral tight, band-like discomfort.
Pain builds slowly
Fluctuates in severity
Behavioral approach
Medications
5.
a. Biopsy: Giant cells
b. Tx: Prednisone
Sinus thrombosis
a. Diagnosis: MRV
-
Cluster
PE:
-
Palpate Temporal arteries
Fundoscopy
Diagnosis/ Labs:
●
LP
●
MRI, Angiography
○
Suspect aneurysm
○
Suspect AV
malformation
○
Add Gadolinium to
MRI- suspect BBB
crossing
Rare form of headaches (0.1%)
Deep retro-orbital pain unilateral.
- Core feature: Pain reoccurs at about the
same time each day and same duration
(short)
Excruciating intensity
Non-Fluctuating & explosive in quality.
*Associated with ipsilateral symptoms of cranial
parasympathetic autonomic activation:
conjunctival injection or lacrimation, rhinorrhea or
nasal congestion, or cranial sympathetic
dysfunction such as ptosis.
Chronic
daily
●
●
Fernando Vélez
Taneil Gibson
Not accompanied by N/V,
Photosensitivity or Phonophobia
Encompases a number of different
headaches syndromes, both primary
and secondary.
Chronic: 15+ days /month for more than
1 month
-
Acetaminophen
NSAIDS
100% Oxygen Inhalation 10-12L/min for 15-20 min
Medication
Sumatriptan 6mg nasal spray
Neurostimulation therapy
DBS of the posterior hypothalamic gray matter
Meningitis
Other Meningitis:
1. Lyme
2. Cryptococcal
meningitis
3. Syphilis (3⁰)
4. TB Meningitis
Bacterial
Community acquired
- Strep. Pneumo
- Neisseria meningitidis
- Listeria monocytogenes
- 50-60 y.o
immunocompromised
Healthcare associated
- Staph and Aerobic G(-)
bacilli
- Neurosurgery w/o
prophylaxis
- Internal or external
ventricular drains
- After trauma
Viral (Aseptic)
-
Fernando Vélez
Taneil Gibson
MCC = Enterovirus
Herpes Encephalitis
HIV
CMV
Infections: Mycobacteria, Fungi,
Spirochetes
Para meningeal infections
Bacterial
● Acute severe headache
● Fever
● Photophobia
● N/V
● Nuchal rigidity
● Altered mental status
● Accentuation of pain with
eye movement
Physical Examination Signs:
Bacterial
-CT before LP
- Rules out Obstructive
hydrocephalus
-LP
- Cell count- ↑ neutrophils
-
Protein ↑
Opening pressure (1315 Cm H2O)
Xanthochromia
(yellowing)
Prednisone (IV)- Empiric
- Minimizes chances of
morbidities
- Children and adults
Ceftriaxone- Tx
Meningitis Algorithm:
-Blood cultures
Viral (Aseptic)
● Fever (low grade)
● Headache
● Alt. mental status
● Stiff neck
● Photophobia
● Self limiting**
Viral (Aseptic)
- Meningeal
inflammation but
NEGATIVE bacterial
culture
- No CT or LP required
Viral (Aseptic):
Supportive or symptomatic
therapy is usually sufficient, and
hospitalization is not required
unless elderly patient or
immunocompromised.
-
Fungal
-
Encephalitis
Medications
Malignancies
HIV disease
Cryptococcal Meningitis (Indian
ink)
Encephalitis
1. Herpes simplex virus (HSV)
a.
b.
HSV1
HSV2
2. Other herpes viruses
a.
b.
EBV
Varicella-Zoster
3. Enterovirus
a.
b.
Poliovirus
Coxsackievirus
4. Mosquito-borne virus
a.
b.
c.
d.
West nile
La Crosse
St. Louis
Western/ Eastern equine
General SX:
- Fever
- Altered consciousness
- Behavioral changes
- Hallucinations;
- Seizures
- Local neurologic findings
such as aphasia,
hemiparesis, involuntary
movements, and cranial
nerve deficits.
a.
b.
c.
Seizures/
Epilepsy
Epilepsy= 2+
unprovoked
seizures; related
1. HSV
a. Acyclovir 14-21d
2. EBV and VZV
a. Acyclovir 14-21d
since no current
Tx is approved
3. LaCrosse and WNV
a. IV Ribavirin
mosquito exposure
Tick-borne virus
● Sx ~1 week after bite
*No therapy currently available
for enteroviral, mumps, or
measles encephalitis.
Measles (Rubeola)
Mumps
Rubella
Types of Seizure:
Focal seizure (Contained within
one hemisphere).
1. Retained awareness
2. Impaired awareness
3. **Temporal lobe is MC type
Fernando Vélez
Taneil Gibson
-
CSF PCR tests:
- HSV
- EBV
- VZV
- CMV
- HHV-6
- Enterovirus
CSF IgM-Ab
- West Nile
Virus
days → weeks after
Powassan virusMidwestern USA
6. Rabies virus
7. Childhood infections
-
Mosquito-borne virus
● Sx of infection appear
5. Tick-borne virus
a.
Viral Encephalitis:
Acute Symptomatic Seizure
-
Occur at time of insult
Within 24 hrs of Metabolic
changes
During drug/alcohol withdrawal
Within 1 week of stroke, brain
injury
Epilepsy Diagnosis:
● 2+ unprovoked (reflex)
seizures more than 24
hrs apart
● 1 unprovoked (reflex)
seizure + probability of
General Tonic-Clonic:
● Lorazepam/ Diazepam (IV)
● Phenytoin, Phenobarb
(maintenance)
Absence:
● Divalproex sodium (IV)
disorders
characterized by
seizure tendency
-
Generalized seizures (Engage
both cerebral hemispheres)
4. Typical Absence seizure
(Loss of consciousness but
no loss of postural control)
a. Age 7 → puberty
5. Atypical Absence seizure
Loss of both consciousness
and postural control).
During active phase of CNS
infection (encephalitis)
Unprovoked Seizure
-
Unknown etiology
Preexisting brain lesion
(“Remote symptomatic seizure”)
PNS disorder
Higher risk of future epilepsy (vs
Acute symptomatic seizure)
Fernando Vélez
Taneil Gibson
●
●
●
Generalized Tonic Clonic
6. Tonic contractions of the
muscle followed by clonic
phase (superimposed
periods of muscle
relaxation).
Causes of Seizures:
● Hypo/Hyperglycemia
● Hyponatremia
● Hypocalcemia
● Hypomagnesemia
● Disorders of porphyrin
metabolism
● Withdrawal states
● Uremia
● Drug intoxication
● Hyperthyroidism
more seizures
●
-
“3 spike and wave”
MRI- no contrast
EEG
○ Generalized
Epilepsy
○ Absence
○ Rolandic/
Localizationrelated
Epilepsy Monitoring
unit○ 3-7 d sleep
study
Metabolic work up (if
indicated)
●
Ethosuximide
Myoclonic:
● Divalproex sodium (IV)
Partial Seizures:
● Phenytoin (“Dilantin”)
● Carbamazepine (XR)
● Divalproex sodium (IV)
Others:
●
●
●
●
Clonazepam
Gabapentin
Lamotrigine
Felbatol
**Patient Education: Seizure
precaution, Driving
ADR
Divalproex: hepatotoxicity, spina bifida,
N/V, weight gain, hair loss, teratogenic
Carbamazepine:
Diplopia, Hyponatremia, Teratogenic
Phenobarb: brain function affected
Lamotrigine: Steven Johnson syndrome,
rash
-
MC
Due to brain scar tissue
“Focal epilepsy”
Cerebrovascular
disease
Ischemia
Types:
1. Thrombosis
2. Embolism
3. Systemic hypoperfusion
●
●
●
●
CT or MRI of brain
Cardiac monitoring
○ After ischemic
stroke onset
Monitor volume and
electrolytes
Serum glucose:
correct if low (<60
mg/dL)
-
Stabilize airway,
breathing and circulation
Prevent aspiration
Optimize bed head
position (30 degrees):
-
Acute Stroke
Sudden onset of neurologic deficit
of cerebrovascular origin in patients
with Hx of
- HTN
- DM
- Tobacco use
- A-Fib
- Atherosclerosis
Moyamoya Disease
Fernando Vélez
Taneil Gibson
Acute Stroke
- Neurological signs
reflects the region of the
brain involved
- Sensory, motor, speech
deficits
Moyamoya Disease
Acute Stroke
- Blood work is required
to determine the
source of the stroke.
(CBC, Serum Glucose,
Lipid panel, Blood
culture (if endocarditis
is suspected)).
- CT w/o contrast before
aspirin or
antithrombotic
administration.
- CT Angiography
Intracerebral
hemorrhage
↑ ICP
Aspiration
Cardiopulmonary
decompensation
O2 desaturation
Acute Stroke
● Antithrombotic: Aspirin or
Plavix
○ At First 48hrs
○ At Discharge
● Prophylaxis DVT and PE
● High intensity Statin (lipid
lowering)
○ ADR: myalgia
● BP reduction
● Behavioral and lifestyle
changes
Moyamoya Disease
Idiopathic vasculopathy that leads to
progressive occlusion of blood
vessels and proliferation of
capillaries at the base of the brain in
response to ischemia.
- Blocked arteries at basal
ganglia
- ICA intima thickens
- ACA, MCA, PCA = stenosis
or occlusion
Intracerebral Hemorrhages
1. Intraparenchymal
a. Systemic HTN
b. Contusion
c. Amyloid angiopathy
d. Vasculitis
e. Neoplasm
2. Subdural
a. Ruptured bridging
veins
b. Shaken baby
3. Epidural
a. Middle Meningeal
artery rupture
4. Subarachnoid
a. Acceleration/
deceleration injuries
b. Circle of Willis
Aneurysm rupture
c. AV malformation
Fernando Vélez
Taneil Gibson
●
Prone to strokes and
brain hemorrhages
Moyamoya Disease
- Angiography
Surgery (↑ blood flow):
- EDAS (encephalo-duro-
Intracerebral Hemorrhages
- Loss of consciousness in
50% of pts.
- N/V and headaches
- Focal Sx depending on
the site of the bleed.
Subdural:
- Altered mental status,
slow thinking
- Seizure
- Vague personality change
- Complication= Secondary
hydrocephalus
Epidural:
- Lucid interval: patient can
die suddenly
Subarachnoid:
- Xanthochromia
- “Worst headache of my
life”
- Complication= Secondary
stroke (from bv
vasoconstriction)
- MCC: Rupture of Berry
Intracerebral Hemorrhages
CT imaging:
- Intraparenchymal
-
Subdural
-
Epidural
-
Subarachnoid
arterio- synangiosis)
EC-IC (intracranial to
extracranial)
EMS (Encephalo-myosynangiosis)
Intracerebral Hemorrhages
- Surgery for
decompression to
prevent brain herniation.
- Conservative Neurologic
management
Aneurysm
Neuromuscular
disease
Myasthenia Gravis
-
-Autoimmune disorder: Anti-ACh
Receptor Ab in the postsynaptic
membrane of NMJ
-Monitor pt’s for:
- Hx of Myasthenic crisis
- MG therapy
- Thyroiditis, RA, SLE
*Assoc with Thymoma
-
Bulbar Sx:
- Dysphagia
- Dysarthria
- Nasal speech
- Low-intensity
speech
Ptosis
Diplopia
Progressive weakness
throughout the day
Dyspnea
SOB
*Nerve Conduction Study =
diagnosis
Edrophonium (Tensilon)
test= only if a Peripheral
neuron deficit
CT neck - look for Thymoma
(source of Antibodies)
AchE inhibitor (initial therapy)”
● Pyridostigmine
● Neostigmine
High-dose Glucocorticoids
- If contraindicated or
ineffective, use
Azathioprine,
Mycophenolate mofetil,
Cyclosporine
Surgical removal of Thymoma, if
present
Crisis:
● Intubation and
Mechanical ventilation
○ If Resp failure
○ Temporarily stop
Anti-AchE meds
● Plasma exchange
● IVIG (intravenous
immunoglobulin)
Peripheral Neuropathies
Damage to, or disease affecting
small nerves → impaired:
- Sensation
- Movement
- Gland/ organ function
Fernando Vélez
Taneil Gibson
Labs:
-Clinical test
-Monofilament testing- (Diabetic neuropathy)
-Reflexes
-EMG/ NCV
● NCV- Measures how fast/ well nerve functions
● EMG- needles placed on muscle to determine it’s behavior
with contraction
Types:
1. Polyneuropathy
a. DM
b. Guillain-Barre
2. Peripheral neuropathy
a. Radiculopathies
3. Neuropathy
a. CNS, PNS
4. Mononeuropathy
a. Carpal tunnel
Syndrome
5. Mononeruopathy multiplex
a. Leprosy
b. Diabetes
Causes:
● Diabetic
○
●
●
●
●
●
●
●
●
●
●
Inflammatory, metabolic
and ischemic events
Longstanding HIV
Critical illness
Amyloidosis
Vitamin deficiencies
Lyme disease
Autoimmune
Toxic
○ Alcoholic
Hereditary
Environmental
idiopathic
Guillain Barre Syndrome (AIDP)
AIDP
●
Autoimmune condition assoc. with
infections:
- Campylobacter jejunum
- Zika virus
-Schwann cell damage
Fernando Vélez
Taneil Gibson
●
●
●
●
Back and Extremity pain
○ GBS pt
○ Presenting Sx
Symmetric Weakness starts
in legs and ascends
↓ Reflexes- 90%
Dysautonomia - 70%
Severe resp muscle
Lab DX:
- LP:
- normal cell count
- ↑ Protein
Dx:
-
Electrophysiologic
studies may reveal
Disease-modifying Tx:
● IV IG
● Plasmapheresis
● Supportive therapy, ICU
*Majority recover completely
“Acute inflammatory demyelinating
polyneuropathy” = AIDP
●
●
●
●
●
weakness
Facial nerve palsy- 50%
Oropharyngeal weakness 50%
Oculomotor weakness -15%
Paresthesia
SIADH
○ GBS complication
-
-Sensory abnormality = rare
Muscular dystrophy
Group of diseases that cause
progressive weakness and loss of
muscle mass
Duchenne Muscular dystrophy
- < 5 yo boys (X-link rec.)
- Frameshift mutation
Duchenne Muscular dystrophy
-
-
abnormalities, which
do not necessarily
parallel the clinical
disorder in their
temporal course.
Pathologic
examination reveal
demyelination, or less
commonly, axonal
degeneration.
Duchenne Muscular dystrophy
Weak pelvic girdle
●
↑ Aldolase
muscles → progresses
●
●
↑ CK
Genetic testing
●
PE:
superiorly
Pseudohypertrophy of
calf muscles
Dilated cardiomyopathy
- MCC death
after weeks→ months
○
○
Gower’s Sign
Waddling gait
-Variants:
1. Becker dystrophy
2. Myotonic dystrophy
Prednisone (.75mg/kg OP/day)
- Improves muscle strength
and function.
- Monitor ADE.
Avoid prolonged bed rest or
inactivity
Physical therapy.
Multiple
Sclerosis
-
Fernando Vélez
Taneil Gibson
Demyelinating UMN
disease
●
●
Diplopia
Ataxia
MRI
-
GOLD standard
Acute Tx:
- IV Methylprednisolone
-
-
Environmental factors
- EBV
Neuromyelitis optica (
Devic’s disease is a
disorder related to MS.
●
●
●
●
●
●
MC affects Caucasian
Women, 20-30 y/o
●
Scanning speech
Intention tremor
INO/ nystagmus
Neurogenic bladder
Paraparesis
Hoffman & Babinski
Signs
Marcus Gunn Pupil
-
Periventricular plaques
Dawson fingers
-
(“Solumedrol”)
ACTH (if solumedrol fails)
Other Tx:
● Alemtuzumab
● Daclizumab
● Dimethyl Fumarate
● Fingolimod
● INF-b
Dx. Criteria:
Primary progressive disease
requires at least 1 year of
progressive disease, plus 2 or
3 of the following.
- At least 1 typical brain
lesion.
- At least 2 spinal
lesions
- IgG Oligoclonal
banding in the CSF.
PE: - Lhermitte Phenomenon
- Uhthoff phenomenon
Movement
disorders
Parkinson's Disease
- Decreased Dopamine
production in the substantia
nigra.
Sx:
-
*Extrapyramidal- so no babinski
-
Fernando Vélez
Taneil Gibson
Resting muscle tremors
Cogwheel Rigidity
Bradykinesia
Shuffling gait (Paralysis
agitans)
Loss of balance
Tremor is 3 cycles per
second and extinguishes
with movement.
Dopamine Agonist
- Bromocriptine
- Cabergoline
- Pergolide
- Pramipexole
- Ropinirole
Dopamine precursors
- L-Dopa / Carbidopa**
- Long acting LD/CD
- L-Dopa
Deep Brain Stimulationadvanced cases
Essential Tremors
- Movement disorder usually
on one side of the body.
Cognitive
impairment
Sx:
Timing tremors
- Intentional tremor of the
hand.
- Hands, head and voice
tremors
- Tremor is > 4 cycles per
second, intentional w/o
Cogwheel rigidity.
●
●
●
Mysoline (high dose250mg 4/day)
Alcohol
Propranolol
Deep Brain Stimulation
Memory Loss Testing
MMSE test - Includes simple questionnaire and problems in a number of areas.
-
Time and Place
Language Comprehension
Basic motor skills
Score > 24 is Nml (out of 30)
19 - 23 Mild
10 - 18 Moderate
< 9 Severe
*Score < 24= think dementia
Frontotemporal Dementia
- “Pick’s disease”
- Primary progressive
aphasia
- Semantic dementia
- Pick complex
- Corticobasal
degeneration +
Progressive
Supranuclear Palsy.
Behavioral Variant FTD
- Changes in social
behavior and conduct.
- Loss of social awareness.
- Poor impulse control.
Semantic Dementia
- Loss of semantic
understanding
- Impaired word
comprehension
- Speech remains fluent
Progressive Non-fluent aphasia
Fernando Vélez
Taneil Gibson
Alzheimer Disease
- Irreversible progressive
brain disorder
- Temporal AND Parietal
lobes
-
Progressive difficulty in
speech production
-
Memory and thinking
skill loss.
Inability to carry out
simple tasks
Lost in familiar places
Inability to differentiate
Right vs. Left
Sx:
-
Spinal Cord
Disorders
Neurofibrillary tangles
Plaques
NMDA Antagonist
- Memantine
Normal pressure hydrocephalus
- Enlargement of the
ventricular size with normal
opening pressure on LP.
-
TRIAD:
1. Dementia
2. Gait disturbances
(Magnetic Gait)
3. Urinary Incontinence
CT scan
Transverse Myelitis
- Segmental Spinal Cord
injury caused by acute
inflammation.
- Most cases are idiopathic.
Sx:
Transverse!!
- Corticospinal
- Spinothalamic
- Dorsal column
LP- ↑ WBC
Associated with:
- MS & SLE
- Mixed connective tissue
disease
- Sjogrens Synd.
- Antiphospholipid Ab Synd
- Ankylosing spondylitis
- RA
Subacute Combined Degeneration
- Vit. B-12 deficiency or
Chronic NO exposure
Fernando Vélez
Taneil Gibson
Cholinesterase Inhibitors
- Donepezil
- Rivastigmine
- Galantamine
Ventriculoperitoneal shunt
MRI- shows inflamed spinal
cord segment
Spinal Cord tracts
Sx:
-
Slowly progressive
weakness (Truncal and
Labs
-
Increase
homocysteine
Supplemental treatment with Vit.
B12.
-
(Interfere with methionine
synthetase)
Lead to dorsolateral white
matter degeneration in the
spinal cord.
Assoc. With Pernicious Anemia
Lyme Myelopathy
-rare
Fernando Vélez
Taneil Gibson
-
peripheral)
Peripheral neuropathy
Sensory ataxia (Vibration
and proprioception)
Paresthesia
Spasticity
Paraplegia
Incontinence
Decreased Visual acuity
MRI
-
Increase
Methylmalonic acid
T2 weighted signal of
posterior column.
Hematology
Anemias
Acute
-Usually due to blood loss
Acute
-
Chronic
Chronic
- Fatigue
- Exertional
dyspnea
- Exertional
palpitation
- Angina or CHF
- Pallor
- Splenomegaly ,
jaundice (=
hemolysis)
Chronic
● Fecal occult blood test
Microcytic anemia
(MCV <80)
Iron deficiency
- Restless legs
- Hair loss
- Pallor, cheilitis,
atrophic glossitis
- Koilonychia
Iron deficiency
● Serum iron ↓
Iron deficiency
Causes:
- Babies-RBC’s
made faster than
iron intake
- Menstrual blood
loss
- Chronic GI blood
loss
- Diet,
Malabsorption
Lead poisoning
Fernando Vélez
Taneil Gibson
Acute
SOB
Palpitation
Exercise
intolerance
Faintness
Hypotension,
tachycardia, pallor
●
TIBC ↑
●
●
Serum ferritin ↓
Fecal occult blood test
○ Adult male
○ Postmenopause
GI endoscopy
●
Lead poisoning
- Mental retardation
Iron deficiency
- Oral ferrous
sulfate/
gluconate
- IV iron Dextran/
sucrose
- Treat underlying
cause
Lead poisoning
- EDTA
- Succimer
-
Colicky abdominal
pain
Wrist drop
Skin lesions
Gingival lead line
Lead poisoning
● X ray- radiodense tibia
● Histo: nucleated RBC
with basophilic stippling
● Ringed sideroblasts
-
Dimercaprol
Thalassemia
Thalassemia
Thalassemia
𝛼 thalassemias- defect in
𝛼 chain production
Beta- spelnomegaly,
repeated infection
Thalassemia
𝛽 thalassemias- defect in
𝛽 chain production
Macrocytic anemia
(MCV >100)
B12 deficiency
- Autoimmune (Antiparietal cell Ab)
- Gastrectomy
Fernando Vélez
Taneil Gibson
B12 deficiency
- Impaired
cognition
- Disequilibrium
- Impaired position
and vibration
sense
- Gait disturbance
𝛽 Thal minor- Hb electrophoresis
𝛽 Thalassemia trait- target cells
*Bone marrow aspiration
B12 deficiency
Diet (meat, fish,
dairy, eggs)
- Oral B12- indefinitely
- Cobalamin 1000 µcg
monthly (parenteral)-
B12 deficiency
● Pancytopenia
● Rhomberg
● B12 serum levels
● Anti-parietal cell Ab
○ R/o autoimmune
indefinitely
-
Folate deficiency
Oral folic acid
●
●
●
Folate deficiency
- Poor diet (tea and
cookies diet)
- Alcoholic
- Intestinal
malabsorption
Myelodysplastic syndrome
- Elderly
- Impaired rbc
maturation
Drug- induced
- Antifolates
- Chemotherapy
- Anticonvulsants
Normocytic anemia
(MCV 80-100 fL)
*Blood loss w/o iron
deficiency
(a) Nonhemolytic
(b) Hemolytic
(a)Non hemolytic:
*(reticulocyte count ≤2%)
- Anemia of Chronic
Disease
-Iron deficiency
Fernando Vélez
Taneil Gibson
pernicious
anemia
Homocysteine ↑
MMA ↑
Upper endoscopy
surveillance (risk
stomach AdenoCa.)
Folate deficiency
● Pancytopenia
● Folate serum levels
● Anti-parietal cell Ab
○ R/o autoimmune
pernicious
anemia
● Homocysteine ↑
● Normal MMA
Myelodysplastic syndrome
● Pancytopenia
-Creatinine and eGFR
-Reticulocyte count
-Haptoglobin
-Bone marrow aspiration
-Aplastic anemia
-Chronic Kidney disease
(b) Hemolytic anemia
*(Reticulocyte count >2%)
Hereditary Spherocytosis
Gallstones (bilirubin)
●
●
●
-Hereditary Spherocytosis
-Autoimmune hemolytic
anemia
-G6PD deficiency
-Toxins and drugs
-Mechanical RBC damage
- Heart valve defect
- DIC, HUS, TTP
Bleeding Disorders
Labs:
●
●
CBC
PT
●
PTT
○
Drug/ toxin Hx
Recent viral infxn
Autoimmune dx?
HIV or HCV?
●
Thrombocytopenia
-Clopidogrel
-SSRI
Splenectomy
Vaccinate against Strep pneumo, HiB,
Neisseria meningitidis
Hx:
PE:
●
Labs:
●
●
●
○
(a) Acute ITP
-Post viral infection ; Ab’s
cross react with platelets
Acute ITP
● Sudden onset
purpura and
petechiae
●
(b) Chronic ITP
Fernando Vélez
Taneil Gibson
●
●
●
●
●
Test if on warfarin or
have liver dx
If pt on
Unfractionated
heparin
●
Factors 2, 7, 9, 10
○
Vit K
Special Tests:
●
Thrombin time
●
Factor assay
●
Ristocetin cofactor assay
●
PFA-100
●
Reticulocyte count
LDH
Haptoglobin
(intravascular hemolysis)
Coomb’s test (Ab to
RBC)
Osmotic fragility
○ Hereditary
spherocytosis
Ultrasound
Lymph, liver spleen, skin
WBC, RBC
ANA
Bone marrow
Acute ITP
- Normal WBC and RBC
(vs Acute leukemia)
Acute ITP
Chronic ITP
Chronic ITP
Corticosteroids
Self limited
DDx= Acute Leukemia
Chronic ITP
-Complicates Hep C and
HIV
-Drug induced
-SLE or autoimmune
association
DIC
●
●
●
-
Low platelet count
●
●
●
●
●
●
High PT and PTT
Low fibrinogen
High D-Dimer and FDP
Low platelet
Schistocytes
Microangiopathic
hemolytic anemia
Any bleeding or
bruising sx
Menorrhagia
Neonates:
- Umbilicus
bleed
- Postcircumcision
bleed
Post-Aspirin or
NSAID use
●
●
●
●
●
●
Platelet count normal
BT- prolonged
PT - normal
PTT- prolonged
Ristocetin cofactor assay
VWF Ag and Activity
Type 1:
- Desmopressin
Hemorrhage out of
proportion to
trauma
Hemarthrosis of
weight-bearing
joints
●
●
●
●
Hb normal or ↓
PTT prolonged
Factor VIII and IX assay
VWF Ag and activity
Desmopressin + Factor
(which is deficient)
Triggers:
-ObGyn catastrophe
-Trauma, burns
-Sepsis
-Hemolytic transfusion rxn
-Acute promyelocytic
leukemia
-Mucin secreting adenoCa.
Von Willebrand Disease
-
Type 1- 66-75%
● ↓#
● Normal function
-
Type 2- 20-25%
● Normal #
● ↓ Function
Asymptomatic
Purpura
petechiae
-
Corticosteroids
IVIG
Rituximab
Splenectomy
Type 2 and 3:
- Recombinant
VWF
Type 3● Absent VWF
Hemophilia
-
Hemophilia A- Factor VIII
deficiency
-
Hemophilia B- Factor IX
deficiency
Fernando Vélez
Taneil Gibson
X linked
Venous Thrombosis
Inherited
-Congenital deficiency or
dysfunction of natural
anticoagulant
Acquired
Myeloproliferative Disorders
Chronic Myelogenous
Leukemia (CML)
Inherited
Acquired
- Arterial and
venous
thrombosis
- PE
- Pregnancy loss
- +/- SLE or
autoimmune dx
-
Splenomegaly
Wells Criteria
Inherited
● Abnormal Factor V leiden
● Protein C or S deficiency
● Prothrombin gene mut.
● Antithrombin III
deficiency
Acquired
● Lupus anticoagulant
(anticardiolipin Ab)
● Antiphospholipid Ab
●
t(9;22)
Polycythemia Vera
-Red cells proliferate
autonomously
-High RBC, WBC, platelets
-
Dizzy
Headache
Angina
Claudication
Cyanosis
Splenomegaly
Pruritus
Warfarin - lifelong
●
●
●
●
CBC
○
-
Imatinib
(Tyrosine
Kinase inhibitor)
-
Regular
phlebotomy
Low dose
aspirin
Hydroxyurea,
Busulfan
(myelosuppressi
ve therapy)
Ruxolitinib
(JAK2 inhibitor)
Anemia
○
Thrombocytopenia
○
leukocytosis
EPO low
High red cell mass
JAK2 gene mutation
CBC
○ Leukocytosis
○ thrombocytosis
-
Essential
thrombocythemia
Clonal proliferation of
megakaryocytes (RBC,
WBC, Platelets)
Fernando Vélez
Taneil Gibson
-
RBC inc or dec. ⇒
headache, dizzy
●
●
●
JAK2 gene mut
Megakaryocytes
Thrombocytosis
Myelofibroblasts w/
Myeloid Metaplasia
Clonal proliferation of
marrow stem cells
-Fibrosis of bone marrow
Fernando Vélez
Taneil Gibson
-
Splenomegaly
●
●
Fibroblasts
Anemia,
thrombocytopenia,
leukocytosis
-
Ruxolitinib
(JAK inhibitor)
Oncology
Presentation
Cancer Staging
Signs
“B Symptoms”:
-Fever
-Night Sweats
-Weight loss
-Pruritus
Evaluation
●
T- size of primary Tumor (T1,
2, 3)
N- presence (1) or absence
(0) of lymph Node
involvement
M- presence (1) or absence
(0) of distant Metastasis
●
●
●
●
●
Hodgkin’s Disease
(Lymphoma)
Painless lymphadenopathy
Ages 15-35 and 55+ y/o
-
B symptoms
Atypical chest pain
Cough
SOB - if mediastinal
mass
Bone pain, painful
nodes (less common)
(a) Nodular Sclerosis
Age 15-30 y/o
- MC type F>M
Painless lymphadenopathy
Fernando Vélez
Taneil Gibson
-Palpable LN
- Neck>Axilla>Inguinal
-Check Epitrochlear nodes
-Check tonsils and oropharynx
-Hepato / Splenomegaly
TNM System:
●
●
●
●
Biopsy
Radionuclide bone
scanning
CXR, Chest CT, PET
Brain MRI
CT -Abdomen or pelvis
LN biopsy: ReedSternberg cell
CBC, CMP, ESR
Staging: CT, MRI, PET
Ann Arbor Staging
System
Treatment
Complete excision (+/regional LN excision)
Debulking surgery or
resection
Radiation therapy
Cytotoxic chemotherapy
Hormonal therapy
Growth factor inhibitors, Anticell surface marker Ab’s
Palliative Care
-
Radiation and
Combination Chemo
-
Death usually from
secondary
malignancy
-No physical findings if
disease is in a nonpalpable
node
●
●
●
Prominent fibro-sclerotic
bands of tissue
Reed Sternberg cells
Lacunar
Chemotherapy
Radiotherapy
*GOOD prognosis
(b) Mixed Cellularity
Age 40-50 y/o
- MC Male
●
Mixed cellular background
w/o bands of sclerosis
Reed- sternberg cells
Prognosis worse than
Nodular sclerosis
(c) Lymphocyte
Predominant type
●
Prognosis good
●
Nodal effacement with
small lymphocytes
Reed Sternberg cells
●
●
Retroperitoneal LN
Reed Sternberg cells
Poor prognosis
●
●
Lymph node biopsy
Immunophenotyping by
flow cytometry
Staging (Ann Arbor) with
CT, MRI, PET
Bone Marrow biopsy
CBC, CMP, HIV
Combination chemotherapy
+/- radiation
●
Uncommon
Male> Female
Age ~35 y/o
x
(d) Lymphocyte depletion
Uncommon
Most aggressive type
Mid→ Older age group
Non-Hodgkin
Lymphoma
Any age, avg 50 y/o
Involves LN, spleen and
marrow
HIV is a risk factor
-
Fernando Vélez
Taneil Gibson
Palpable node or B
-Abdominal or Testicular
mass
-Gastric lymphoma
-Pallor, Bruising, Petechiae
If thrombocytopenia
-Palpable LN
- Neck>Axilla>Inguinal
-Check Epitrochlear nodes
●
●
●
-Regimen based on type of
lymphoma, prognosis etc
-Rituximab
-
symptoms
Mass in GIT or
testicle
Bone marrow
involved: weak,
bruising
Recurrent infections
Acute Leukemias
-Check tonsils and oropharynx
-Hepato / Splenomegaly
-No physical findings if
disease is in a nonpalpable
node
-Bone marrow failure:
- Bruising, pallor, bleed,
fever, sepsis, lethargy
●
●
●
Acute
Lymphoblastic
Leukemia
ALL
-MC Children and curable
-Lethal in adults
ALL
Acute Myelogenous
Leukemia
AML
-Any age
-(~) curable in children
-Highly lethal in adults
AML
Chronic
Lymphocytic
Leukemia
-Clonal proliferation of
mature-appearing but
functionally impaired B cells
-Anemia
-Thrombocytopenia
-Neutropenia
-Infections (from Ig deficiency)
-Mid→ Elderly
-
Fernando Vélez
Taneil Gibson
Asymptomatic
Blood count= mature
CBC
○
Anemia,
thrombocytopenia
○ Leukocytosis with
blasts
Bone marrow aspiration
○ Stain, surface
markers,
cytogenetics
Flow cytometry
ALL
-
-
Frequent CNS
involvement
IV-IG = prophylaxis
●
●
●
NO Auer rods
Myeloperoxidase stain (-)
TdT (+)
AML
●
●
●
Some Auer rods
Myeloperoxidase stain (+)
TdT (-)
ALL
-2-3 yrs chemotherapy:
- Induction
- Consolidation
- CNS-directed
- Maintenance
-High cure rate if pt lacks
high-risk markers
AML
-2-3 years chemotherapy:
- Induction
- Consolidation
- Maintenance
-
Most require no Tx
-
10-20 year survival
-
Oral alkylating
agents-if dx is
progressive
Plasma Cell
MGUS
Multiple Myeloma
lymphocytes
LN and Spleen
involved
MGUS
-Elderly
-Asymptomatic
-Minority progress to
myeloma
Multiple Myeloma
->10% plasma cells in
marrow
-
Invasive Breast
Cancer
Risk factors:
-Age 50-70 y/o
-Delayed childbearing, early
menarche, late menopause
-Exogenous estrogen
-Obesity
-Radiation to chest
(mammography)
-Family Hx
Multiple Myeloma
-Anemia
-Thrombocytopenia
-Leukopenia
-Infections
-Bone invasion=
- Pain
- Pathologic fracture
- Hypercalcemia
- Mental status
- Nausea
- Dehydration
- polyuria
-Renal failure
-
Asymptomatic on
mammography
Lump in breast
Skin retraction,
dimpling, “peau
d’orange”
Axillary adenopathy
Nipple discharge
Possible Mets → bone,
-
Rituximab↑response and
survival
-
Surgery
Tamoxifen,
Anastrozole = if
Multiple Myeloma
●
●
●
●
Serum/ urine protein
Electrophoresis○ M spike
○ IgG or IgA
CBC
BMP- hyperCa, renal fxn
Bone marrow aspiration
and biopsy ↷
●
●
●
●
Diagnostic mammography
Biopsy
CXR, US, MRI
Staging
●
●
CXR
Chest CT
estrogen or progesteroneR’s seen on biopsy
- Trastuzumab= if
HER2-R seen on biopsy
Screening:
●
Mammography 40-49 y/o
●
Mamm /2years= 50-74 y/o
●
liver, lung, pleura,
brain
Lung Cancer
Fernando Vélez
Taneil Gibson
Risk factors:
● Smoking
Symptoms ←regional spread
NSCLC:
●
●
●
●
Occupational exposure
Environmental
carcinogens
Radiation
HIV
Paraneoplastic Syndrome in
NSCLC:
- Hypercalcemia
-from PTH-like
substance in SCC pt.
- → polyuria and
obtundation, nausea,
confusion,
dehydration
-Motor and Sensory
neuropathy
-from SCC and
AdenoCa.
Paraneoplastic Syndromes in
SCLC:
- SIADH
- Ectopic ACTH secretion
- Eaton Lambert Syndrome
- Acute sensory neuropathy
- Cerebellar degeneration
Prostate Cancer
Fernando Vélez
Taneil Gibson
-Predilection for bone
metastasis
->50 y/o male
-African American
or distant metastasis
-Paraneoplastic syndrome
-Supraclavicular or cervical
lymphadenopathy
-Dull percussion, ↓ breath
sounds= pleural effusion
Primary tumor:
- Cough, hemoptysis,
SOB
- (recurring) Pneumonia
- Atelectasis
●
●
●
●
●
●
Sputum cytology
○ If (+), no invasive
biopsy required
Bronchoscopy and biopsy
○ Central lesion
CT transthoracic biopsy
○ Peripheral lesion
Pleural fluid cytology
○ Metastatic lesion
Mediastinoscopy and
biopsy
○ Used to stage
Thoracotomy
Regional spread:
- Chest wall pain
- Arm pain or Horner’s
Syndrome
- Hoarseness
- SVC syndrome
- SOB
Early= asymptomatic
Frequency, urgency,
small void, poor
stream, dribbling,
retention, UTI
-
Surgery -lobectomy
or pneumonectomy
Radiotherapy
(palliative only)
Chemotherapy
(extend life by few
months)
Biologic agents
targeting oncogene
products
SCLC:
- Same as NSCLC
- Relapses occur
Screening:
● Chest CT (non contrast)
○ Annually in eversmoker 50-80 y/o
○ >30 pack year
○ Currently or quit
smoking <15
years ago
Metastasis:
- Bone pain, pathologic
fracture
- Seizure, impaired
cognitive,
disequilibrium
- Paraplegia,
bowel/bladder dysfxn
-
-
●
Prostate exam
○ Nodule or
induration
○ Screening starts
50-75 y.o
-
Watchful waiting
Radical
prostatectomy
Radiation with
curative intent
*Gleason Grade & Score
Grade: 1-5 (3-5= likely mets)
Score: 6-10 (higher=worse
prognosis)
-
Metastasis= Anemia
or pancytopenia, bone
pain
●
●
●
●
Colorectal Cancer
-Family Hx:
- FAP- APC gene
- Lynch Syndromemismatch repair gene
-Age: 68 y.o, younger ages
-Risk Factors:
- Red meat
- Animal fat intake
- Low fiber
- IBD
Early:
●
●
Late:
●
●
●
●
●
●
Rectal bleed
Pallor
-
PSA
Transrectal Ultrasound
Transrectal needle biopsy
○ If Palpable or
visible nodule
Blind needle biopsies
○ If PSA high but no
discrete nodule
Colonoscopy
Biopsy
CT (Staging)
CBC, CMP, CEA
Weight loss
Abdominal mass and
tenderness
Constipation
Cachexia
Ascites
hepatomegaly
3)
Endometrial Cancer
Fernando Vélez
Taneil Gibson
●
●
●
●
Surgery
Radiation
Adjuvant chemo for
stage 3
Biologics
Screening:
-Screen 50-75 y/o
- Choice at 76-85 y/o
-Annual FIT
-Colonoscopy- most effective
-Annual FIT +
Sigmoidoscopy
-Lesions:
1)
2)
If Advanced:
- Palliative radiation
- bone pain
- Surgical castration
- “Medical castration”
- Flutamide
- Leupromide
- Cytotoxic chemoDocetaxel
Hyperplastic polyp
Villous adenoma
Sessile polyp
-Middle age→ older women
-Precursor= Endometrial
hyperplasia
Risk factors:
- Obesity
- Unopposed estrogen
- Tamoxifen
OCP= protective
Painless vaginal bleed
●
●
●
●
Pelvic exam
Biopsy (in office)
Cytologic smear of cervix
Transvaginal sonography
(thickness
Hysterectomy
Ovarian Cancer
-
Abdominal discomfort
Bowel disturbances
Ascites
NO PELVIC MASS
●
Tumor marker CA-125,
CA-19.9
Pelvic ultrasound
CT of pelvis and abdomen
Cytologic analysis of
ascitic fluid
Mass biopsy
Remission:
Surgery, then Chemotherapy
●
CT scan, endoscopic
Ultrasound, MFRI, ERCP
-Pancreaticoduodenectomy
(Whipple Procedure)
-Chemotherapy
-Palliative care
●
Ultrasound
○ Cystic vs solid
○ Benign vs malig
Fine needle aspiration &
cytologic examination
*Most curable
●
●
●
●
Pancreatic Cancer
#4 cause of cancer mortality
in USA
75% at head of pancreas
*non specific:
- Weight loss
- Epigastric pain
radiates to back
- Depression
- New onset diabetes
- Pruritus
- Painless jaundice (if
cancer in head of pancreas)
Thyroid Cancer
Most <55 y/o
- Painless lump in thyroid
- Cervical lymphadenopathy
●
Uroepithelial
Cancer
(Bladder and Ureter)
Renal Cell Cancer
Risk factors:
- Smoking
- Environmental
carcinogens
-
Painless hematuria
Irritative void
-
Painless hematuria
Flank pain/ mass
-
Surgery
Radioactive iodine
Bladder Cancer: Transurethral removal
-Lifelong cystoscopic
surveillance
CT scan
*Poor prognosis
Chemotherapy= poor
response
Growth factor inhibitors=
Clear cell type of RCC
Fernando Vélez
Taneil Gibson