Disclaimer This material is for educational purposes only. It is not to be used to make medical decisions. Medical decisions should be made only with the guidance of a licensed medical professional. While efforts have been made to ensure the accuracy of the content within, the accuracy is not guaranteed. Blackbook Approaches to Medical Presentations Produced by The Cumming School of Medicine, University of Calgary Blackbook: Approaches to Medical Presentations Chief Editors Rebecca Phillips Ainna Preet Randhawa Vaneet Randhawa Consulting Editors Kea Archibold Sunny Fong Lucas Streith Faculty Editor Dr. Sylvain Coderre Editorial Board Dr. Henry Mandin Dr. Kevin McLaughlin Dr. Brett Poulin Incoming Editors Erin Kelly Tony Gu i Twelfth Edition (2019). First Printing. Copyright © 2007-2019. Faculty of Medicine, University of Calgary. All Rights Reserved. First Edition 2007 (Reprint 2008) Eighth Edition 2015 Second Edition 2009 (Reprints 2009, 2010) Ninth Edition 2016 Third Edition 2010 Tenth Edition 2017 Fourth Edition 2011 Eleventh Edition 2018 Seventh Edition 2014 Twelfth Edition 2019 ISBN Pending Assignment This material is covered by the following Creative Commons License: Creative Commons Attribution-NonCommercial 4.0 International License. This material is for educational purposes only. It is not to be used to make medical decisions. Medical decisions should be made only with the guidance of a licensed medical professional. While efforts have been made to ensure accuracy of the content within, the accuracy is not guaranteed. ii The Black Book Project may be contacted at: Design Undergraduate Medical Education Michael Cheshire Faculty of Medicine University of Calgary Illustrations Health Sciences Centre Gray’s Anatomy (Public Domain) 3330 Hospital Drive N.W. Vecteezy.com Calgary, Alberta, Canada T2N 4H1 blackbk@ucalgary.ca Medical presentation schemes conceived by Henry Mandin. The Calgary Black Book Project founded by Brett Poulin. Printed in Calgary, Alberta, Canada. iii iv A Message from the Editors Welcome to the Twelftth Edition of Blackbook! This ongoing project is the result of the hard work and dedication of medical students and faculty at the University of Calgary, Cumming School of Medicine. We are proud that healthcare practitioners and trainees across North America find Blackbook to be a useful tool. Blackbook continues to evolve and improve during each edition. In this newest print we have added and modified several schemes, including a new page for interpretation of pulmonary function tests, among numerous smaller edits and spelling corrections. We’re working on an open access, online version of Blackbook that will link to and integrate our other project, Calgary Cards (cards.ucalgary.ca). Cards is another study aid that employs student-authored patient scenarios in MCQ format. If students are struggling in a particular area (e.g., acid- base questions), cards is a great way to get some extra practice. Cards is free and in constant development - check it out! As always, we welcome feedback, suggestions, edits, or ideas for new schemes. Please e-mail us at blackbk@ucalgary.ca. v Thank you and happy learning! Rebecca Phillips, Ainna Preet Randhawa & Vaneet Randhawa vi Introduction to Schemes The material presented in this book is intended to assist learners in organizing their knowledge into information packets, which are more effective for the resolution of the patient problems they will encounter. There are three major factors that influence learning and the retrieval of medical knowledge from memory: meaning, encoding specificity (the context and sequence for learning), and practice on the task of remembering. Of the three, the strongest influence is the degree of meaning that can be imposed on information. To achieve success, experts organize and “chunk” information into meaningful configurations, thereby reducing the memory load. These meaningful configurations or systematically arranged networks of connected facts are termed schemata. As new information becomes available, it is integrated into schemes already in existence, thus permitting learning to take place. Knowledge organized into schemes (basic science and clinical information integrated into meaningful networks of concepts and facts) is useful for both information storage and retrieval. To become excellent in diagnosis, it is necessary to practice retrieving from memory information necessary for problem resolution, thus facilitating an organized approach to problem solving (scheme-driven problem solving). vii The domain of medicine can be broken down to 121 (+/- 5) clinical presentations, which represent a common or important way in which a patient, group of patients, community or population presents to a physician, and expects the physician to recommend a method for managing the situation. For a given clinical presentation, the number of possible diagnoses may be sufficiently large that it is not possible to consider them all at once, or even remember all the possibilities. By classifying diagnoses into schemes, for each clinical presentation, the myriad of possible diagnoses become more manageable ‘groups’ of diagnoses. This thus becomes a very powerful tool for both organization of knowledge memory (its primary role at the undergraduate medical education stage), as well as subsequent medical problem solving. There is no single right way to approach any given clinical presentation. Each of the schemes provided represents one approach that proved useful and meaningful to one experienced, expert author. A modified, personalized scheme may be better than someone else’s scheme, and certainly better than having no scheme at all. It is important to keep in mind, before creating a scheme, the five fundamentals of scheme creation that were used to develop this book. If a scheme is to be useful, the answers to the next five questions should be positive: viii 1. Is it simple and easy to remember? (Does it reduce memory load by “chunking” information into categories and subcategories?) 2. Does it provide an organizational structure that is easy to alter? 3. Does the organizing principle of the scheme enhance the meaning of the information? 4. Does the organizing principle of the scheme mirror encoding specificity (both context and process specificity)? 5. Does the scheme aid in problem solving? (E.g. does it differentiate between large categories initially, and subsequently progressively smaller ones until a single diagnosis is reached?) By adhering to these principles, the schemes presented in this book, or any modifications to them done by the reader, will enhance knowledge storage and long term retrieval from memory, while making the medical problem-solving task a more accurate and enjoyable endeavour. Dr. Henry Mandin Dr. Sylvain Coderre ix Table of Contents A Message from the Editors�������������������� v Shock�����������������������������������������������������������������������������������������13 Introduction to Schemes������������������������vii Systolic Murmur Benign & Stenotic��������������������15 Cardiovascular Diastolic Murmur���������������������������������������������������������������17 1 Syncope�����������������������������������������������������������������������������������14 Systolic Murmur Valvular & Other������������������������16 Abnormal Rhythm (1)�������������������������������������������������������� 3 x Abnormal Rhythm (2)������������������������������������������������������� 4 Respiratory 19 Chest Discomfort Cardiovascular��������������������������� 5 Pulmonary Function Tests Interpretation�������21 Chest Discomfort Pulmonary / Medistinal�����6 Acid-Base Disorder Pulmonary�����������������������������22 Chest Discomfort Other������������������������������������������������� 7 Chest Discomfort Cardiovascular������������������������ 23 Hypertension��������������������������������������������������������������������������8 Chest Discomfort Pulmonary��������������������������������� 24 Hypertension in Pregnancy�����������������������������������������9 Chest Discomfort Other���������������������������������������������� 25 Left-Sided Heart Failure����������������������������������������������10 Chest Trauma Complications���������������������������������� 26 Isolated Right-Sided Heart Failure������������������������11 Cough Chronic������������������������������������������������������������������� 27 Pulse Abnormalities��������������������������������������������������������12 Cough, Dyspnea & Fever������������������������������������������� 28 Dyspnea Acute������������������������������������������������������������������ 29 Anemia with Elevated MCV�������������������������������������� 43 Dyspnea Chronic Cardiac������������������������������������������30 Anemia with Normal MCV����������������������������������������� 44 Dyspnea Chronic Pulmonary / Other����������������31 Anemia with Low MCV������������������������������������������������� 45 Excessive Daytime Sleepiness������������������������������ 32 Approach to Bleeding / Bruising Platelets & Hemoptysis�������������������������������������������������������������������������� 33 Vascular System��������������������������������������������������������46 Hypoxemia���������������������������������������������������������������������������� 34 Approach to Bleeding / Bruising Coagulation Lung Nodule����������������������������������������������������������������������� 35 Mediastinal Mass��������������������������������������������������������������36 Proteins����������������������������������������������������������������������������� 47 Approach to Prolonged PT (INR), Prolonged Pleural Effusion������������������������������������������������������������������ 37 PTT���������������������������������������������������������������������������������������48 Pulmonary Hypertension�������������������������������������������38 Prolonged PT (INR), Normal PTT��������������������������49 Prolonged PTT, Normal PT (INR) Bleeding Hematologic 39 Tendency�������������������������������������������������������������������������50 Overall Approach to Anemia������������������������������������41 Prolonged PTT, Normal PT (INR) No Bleeding Approach to Anemia Mean Corpuscular Volume������������������������������������������������������������������������������ 42 Tendency��������������������������������������������������������������������������51 Approach to Splenomegaly������������������������������������� 52 xi Fever in the Immunocompromised Host������� 53 Abdominal Mass��������������������������������������������������������������� 72 Lymphadenopathy Diffuse��������������������������������������� 54 Abdominal Pain (Adult) Acute - Diffuse����������� 73 Lymphadenopathy Localized��������������������������������� 55 Abdominal Pain (Adult) Acute - Localized�����74 Neutrophilia��������������������������������������������������������������������������56 Abdominal Pain (Adult) Chronic - Constant� 75 Neutropenia Decreased Neutrophils Only��� 57 Abdominal Pain (Adult) Chronic - Crampy / Neutropenia Bicytopenia / Pancytopenia����58 Polycythemia����������������������������������������������������������������������59 Fleeting�����������������������������������������������������������������������������76 Abdominal Pain (Adult) Chronic - Post- Suspected Deep Vein Thrombosis (DVT)������60 Prandial����������������������������������������������������������������������������� 77 Suspected Pulmonary Embolism (PE)��������������61 Anorectal Pain��������������������������������������������������������������������78 Thrombocytopenia���������������������������������������������������������62 Acute Diarrhea�������������������������������������������������������������������79 Thrombocytosis����������������������������������������������������������������63 Chronic Diarrhea Small Bowel�������������������������������80 Hemolysis������������������������������������������������������������������������������64 Chronic Diarrhea Steatorrhea & Large Bowel ��������������������������������������������������������������������������������������������������81 Gastrointestinal xii 65 Constipation (Adult) Altered Bowel Function Abdominal Distention���������������������������������������������������69 & Idiopathic��������������������������������������������������������������������82 Abdominal Distention Ascites��������������������������������70 Constipation (Adult) Secondary Causes���������83 Abdominal Distention Other Causes������������������71 Constipation (Pediatric) ����������������������������������������������84 Dysphagia������������������������������������������������������������������������������85 Elevated Liver Enzymes���������������������������������������������86 Renal 99 Acute Kidney Injury������������������������������������������������������ 101 Hepatomegaly�������������������������������������������������������������������87 Chronic Kidney Disease��������������������������������������������102 Jaundice���������������������������������������������������������������������������������88 Dysuria�����������������������������������������������������������������������������������103 Liver Mass������������������������������������������������������������������������������89 Generalized Edema������������������������������������������������������104 Mouth Disorders (Adult & Elderly) ���������������������90 Hematuria����������������������������������������������������������������������������105 Nausea & Vomiting Gastrointestinal Disease Hyperkalemia Intercellular Shift������������������������ 106 ��������������������������������������������������������������������������������������������������91 Nausea & Vomiting Other Systemic Disease ������������������������������������������������������������������������������������������������� 92 Stool Incontinence����������������������������������������������������������93 Upper Gastronintestinal Bleed (Hematemesis / Melena)�������������������������������������������������������������������������94 Lower Gastrointestinal Bleed����������������������������������95 Weight Gain��������������������������������������������������������������������������96 Weight Loss������������������������������������������������������������������������� 97 Hyperkalemia Reduced Excretion��������������������107 Hypokalemia�������������������������������������������������������������������� 108 Hypernatremia���������������������������������������������������������������� 109 Hyponatremia������������������������������������������������������������������� 110 Hypertension���������������������������������������������������������������������� 111 Increased Urinary Frequency��������������������������������112 Nephrolithiasis������������������������������������������������������������������113 Polyuria�����������������������������������������������������������������������������������114 Proteinuria����������������������������������������������������������������������������115 xiii Renal Mass Solid������������������������������������������������������������ 116 Adrenal Mass Malignant�������������������������������������������133 Renal Mass Cystic�����������������������������������������������������������117 Amenorrhea�����������������������������������������������������������������������134 Scrotal Mass����������������������������������������������������������������������� 118 Breast Discharge������������������������������������������������������������135 Suspected Acid-Base Disturbance������������������ 119 Gynecomastia Increased Estrogen & Metabolic Acidosis Elevated Anion Gap������120 Metabolic Acidosis Normal Anion Gap�����������121 Increased HCG����������������������������������������������������������136 Gynecomastia Increased LH & Decreased Metabolic Alkalosis ����������������������������������������������������� 122 Testosterone���������������������������������������������������������������137 Urinary Incontinence���������������������������������������������������123 Hirsutism������������������������������������������������������������������������������138 Urinary Tract Obstruction�����������������������������������������124 Hirsutism & Virilization Androgen Excess����139 Hirsutism & Virilization Hypertrichosis�����������140 Endocrinology 125 Abnormal Lipid Profile Combined & Decreased HDL��������������������������������������������������������129 Abnormal Lipid Profile Increased LDL & xiv Hypercalcemia Low PTH����������������������������������������� 141 Hypercalcemia Normal / High PTH����������������142 Hypocalcemia High Phosphate��������������������������143 Hypocalcemia Low Phosphate���������������������������144 Increased Triglycerides���������������������������������������130 Hypocalcemia High / Low PTH��������������������������145 Abnormal Serum TSH�������������������������������������������������131 Hyperglycemia����������������������������������������������������������������146 Adrenal Mass Benign��������������������������������������������������132 Hypoglycemia������������������������������������������������������������������147 Hyperphosphatemia����������������������������������������������������148 Back Pain������������������������������������������������������������������������������167 Hypophosphatemia�����������������������������������������������������149 Cognitive Impairment������������������������������������������������ 168 Hyperthyroidism�������������������������������������������������������������150 Dysarthria���������������������������������������������������������������������������� 169 Hypothyroidism����������������������������������������������������������������151 Falls in the Elderly���������������������������������������������������������170 Hyperuricemia�����������������������������������������������������������������152 Gait Disturbance��������������������������������������������������������������171 Male Sexual Dysfunction�����������������������������������������153 Headache Primary�������������������������������������������������������� 172 Sellar / Pituitary Mass������������������������������������������������154 Headache Secondary, without Red Flag Sellar / Pituitary Mass Size�������������������������������������155 Symptoms��������������������������������������������������������������������� 173 Short Stature����������������������������������������������������������������������156 Hemiplegia������������������������������������������������������������������������� 174 Tall Stature��������������������������������������������������������������������������157 Mechanisms of Pain����������������������������������������������������� 175 Weight Gain / Obesity�����������������������������������������������158 Movement Disorder Hyperkinetic���������������������176 Movement Disorder Tremor����������������������������������� 177 Neurologic 159 Movement Disorder Bradykinetic����������������������178 Altered Level of Consciousness Approach163 Peripheral Weakness��������������������������������������������������179 Altered Level of Consciousness GCS ≤ 7�����164 Peripheral Weakness Sensory Changes����� 180 Aphasia Fluent�����������������������������������������������������������������165 Spell / Seizure Epileptic Seizure����������������������� 181 Aphasia Non-Fluent���������������������������������������������������� 166 Spell / Seizure Secondary Organic�����������������182 xv Spell / Seizure Other��������������������������������������������������183 Amenorrhea Secondary������������������������������������������ 199 Stroke Intracerebral Hemorrhage���������������������184 Antenatal Care����������������������������������������������������������������200 Stroke Ischemia���������������������������������������������������������������185 Bleeding in Pregnancy < 20 Weeks�����������������201 Stroke Subarachnoid Hemorrhage����������������� 186 Bleeding in Pregnancy 2nd & 3rd Trimester Syncope��������������������������������������������������������������������������������187 ���������������������������������������������������������������������������������������������� 202 Dizziness������������������������������������������������������������������������������ 188 Breast Disorder��������������������������������������������������������������� 203 Vertigo����������������������������������������������������������������������������������� 189 Growth Discrepancy Small for Gestational Age / Intrauterine Growth Restriction����204 Obstetrical & Gynecological 191 Intrapartum Abnormal Fetal HR Tracing Variability & Decelerations�������������������������������193 Intrapartum Abnormal Fetal HR Tracing Baseline��������������������������������������������������������������������������194 xvi Growth Discrepancy Large for Gestational Age������������������������������������������������������������������������������������205 Infertility (Female)���������������������������������������������������������206 Infertility (Male)��������������������������������������������������������������� 207 Intrapartum Factors that May Affect Fetal Abnormal Genital Bleeding������������������������������������195 Oxygenation���������������������������������������������������������������208 Acute Pelvic Pain���������������������������������������������������������� 196 Pelvic Mass������������������������������������������������������������������������209 Chronic Pelvic Pain�������������������������������������������������������197 Ovarian Mass���������������������������������������������������������������������210 Amenorrhea Primary�������������������������������������������������� 198 Pelvic Organ Prolapse�������������������������������������������������211 Post-Partum Fever�������������������������������������������������������� 212 Hair Loss (Alopecia) Localized���������������������������� 228 Post-Partum Hemorrhage�������������������������������������� 213 Morphology of Skin Lesions Primary Skin Recurrent Pregnancy Loss�������������������������������������214 Lesions��������������������������������������������������������������������������� 229 Vaginal Discharge����������������������������������������������������������215 Morphology of Skin Lesions Secondary Skin Dermatologic 217 Mucous Membrane Disorder Oral Cavity���� 231 Burns��������������������������������������������������������������������������������������� 221 Nail Disorders Primary Dermatologic Disease Lesions��������������������������������������������������������������������������� 230 Dermatoses in Pregnancy Physiologic Changes�������������������������������������������������������������������������222 Dematoses in Pregnancy Specific Skin Conditions���������������������������������������������������������������������223 Disorders of Pigmentations Hyperpigmentation�����������������������������������������������224 Disorders of Pigmentations �����������������������������������������������������������������������������������������������232 Nail Disorders Systemic Disease�����������������������233 Nail Disorders Systemic Disease - Clubbing ���������������������������������������������������������������������������������������������� 234 Pruritus No Primary Skin Lesion������������������������ 235 Pruritus Primary Skin Lesion��������������������������������� 236 Skin Rash Eczematous�����������������������������������������������237 Hypopigmentation�������������������������������������������������225 Skin Rash Papulosquamous��������������������������������� 238 Genital Lesion������������������������������������������������������������������ 226 Skin Rash Pustular�������������������������������������������������������� 239 Hair Loss (Alopecia) Diffuse�����������������������������������227 Skin Rash Reactive�������������������������������������������������������240 xvii Skin Rash Vesiculobullous��������������������������������������241 Vascular Joint Pain��������������������������������������������������������257 Skin Ulcer by Etiology������������������������������������������������242 Pathologic Fractures�������������������������������������������������� 258 Skin Ulcer by Location Genitals������������������������� 243 Soft Tissue�������������������������������������������������������������������������� 259 Skin Ulcer by Location Head & Neck������������� 244 Fracture Healing������������������������������������������������������������260 Skin Ulcer by Location Lower Legs / Feet245 Osteoporosis BMD Testing�������������������������������������261 Skin Ulcer by Location Oral Ulcers������������������ 246 Tumour���������������������������������������������������������������������������������� 262 Skin Ulcer by Location Trunk / Sacral Region Mytomes Segmental Innervation of Muscles �����������������������������������������������������������������������������������������������247 ���������������������������������������������������������������������������������������������� 263 Vascular Lesions������������������������������������������������������������ 248 Guide to Spinal Cord Injury������������������������������������ 264 Musculoskeletal Psychiatric 249 265 Acute Joint Pain Vitamin CD����������������������������������251 Anxiety Disorders Associated with Panic���� 267 Chronic Joint Pain����������������������������������������������������������252 Anxiety Disorders Recurrent Anxious Bone Lesion���������������������������������������������������������������������� 253 Thoughts ���������������������������������������������������������������������268 Deformity / Limp���������������������������������������������������������� 254 Trauma & Stressor Related Disorders�����������269 Infectious Joint Pain���������������������������������������������������� 255 Obsessive-Compulsive & Related Disorders Inflammatory Joint Pain�������������������������������������������� 256 xviii ���������������������������������������������������������������������������������������������� 270 Personality Disorder����������������������������������������������������� 271 Mood Disorders Depressed Mood�������������������272 Ophthalmologic 289 Cross Section of the Eye & Acronyms������������291 Mood Disorders Elevated Mood������������������������273 Approach to an Eye Exam�������������������������������������� 292 Psychotic Disorders ����������������������������������������������������274 Acute Vision Loss Bilateral������������������������������������� 293 Somatoform Disorders�����������������������������������������������275 Acute Vision Loss Unilateral��������������������������������� 294 Chronic Vision Loss Anatomic����������������������������� 295 Otolaryngologic 277 Amblyopia��������������������������������������������������������������������������296 Hearing Loss Conductive��������������������������������������� 279 Diplopia�������������������������������������������������������������������������������� 297 Hearing Loss Sensorineural����������������������������������280 Pupillary Abnormalities Isocoria������������������������298 Hoarseness Acute���������������������������������������������������������281 Pupillary Abnormalities Anisocoria������������������299 Hoarseness Non-Acute�������������������������������������������� 282 Red Eye Atraumatic�����������������������������������������������������300 Neck Mass�������������������������������������������������������������������������� 283 Red Eye Traumatic��������������������������������������������������������301 Otaligia���������������������������������������������������������������������������������� 284 Strabismus Ocular Misalignment��������������������� 302 Smell Dysfunction�������������������������������������������������������� 285 Neuro-Ophthalmology Visual Field Defects Tinnitus Objective���������������������������������������������������������286 ����������������������������������������������������������������������������������������������303 Tinnitus Subjective������������������������������������������������������ 287 xix Pediatric xx 305 Developmental Delay�������������������������������������������������������������������������������������� 311 School Difficulties�����������������������������������������������������������������������������������������������312 Small for Gestational Age�����������������������������������������������������������������������������313 Large for Gestational Age�����������������������������������������������������������������������������314 Congenital Anomalies�������������������������������������������������������������������������������������315 Headache.................................................................................................................316 Failure to Thrive Adequte Calorie Consumption�������������������������317 Failure to Thrive Inadequte Calorie Consumption���������������������318 Hypotonic Infant (Floppy Newborn)�����������������������������������������������������319 Acute Abdominal Pain������������������������������������������������������������������������������������320 Chronic Abdominal Pain……..…………….......................……………...........................321 Pediatric Vomiting………………………….................................…………….......................,,322 Neonatal Jaundice: Approach to Indirect Hyperbilirubinemia…………………….…….................…………….............................323 Neonatal Jaundice: Approach to Indirect Hyperbilirubinemia…………………………..................…………….............................324 Pediatric Diarrhea………….……….……………..........................………...……........................325 Constipation: Pediatric…………………………......................……………..........................326 Mouth disorder: Pediatric…………………........................…………….........................327 Depressed/Lethargic Newborn………............………………….......................,,.328 Cyanosis in the Newborn........................................……………..........................329 Noisy Breathing: Pediatric Stridor…….........……………............................……334 Pediatric Cough: Acute…………........……………..........................................……..……335 Pediatric Cough: Chronic……………………………......................................…….........336 Respiratory Distress in the Newborn: Tachypnea.......................337 Sudden Unexpected Death in Infancy……...........................................338 Enuresis…………………………………….................……………......................................................339 Apparent Life Threatening Event…………….....................................…….…..340 Pediatric Fractures………………………......……………..................................................….341 Salter Harris Classification………………………................................…….................342 Sudden Paroxysmal Event………........………...............................……................343 Non-Epileptic Paroxysmal Event………...............................…….................344 Pediatric Epilepsies….……..………………............................................…….................345 Pediatric Seizures………………….................……................................……................…346 Febrile Seizures………………….................……................................……................….....347 Pediatric Mood and Anxiety Disorders…....….............................……....348 Abdominal Mass…………………………………………................…................................……....349 Shock…………………………………………...…………………..........……….............................……...………….350 Hypoglycemia…………………………...................…………….............................……...………….351 Altered Level of Consciousness………........................................……......…..352 Bleeding/Bruising………………………………………….....................……........................…...353 Thrombocytopenia……………………….............………………….............................……...….354 Long PT (INR), Long PTT…………………….............................……...…........…………….355 Limp.......................................................................................……………...........................330 Respiratory Distress in the Newborn..…........…………….........................…331 Pediatric Dyspnea………………………………............................…………….........................332 Noisy Breathing: Pediatric wheezing…..........…………….........................…333 Long PT (INR), Normal PTT………………………….....….............................……..…….356 Normal PT (INR), Long PTT…………….............................……....……………....……….357 Dehydration……………………………………………...……………….............................……...…...………358 Hyponatremia………………………………...……………….………………….......................................359 Hypernatremia…………………………………...……………....……………......................................360 Global Developmental Delay/Intellectual Disability...............361 Fever (Age <1 Month)……………………………............……….....................................……362 Fever (Age 1-3 Months)……………………………….........……......................................…363 Fever (Age >3 Months)…………………………..........……………......................................364 Failure to Thrive………………………………..................……….....................................……….365 Short Stature………………………………….....................………....................................….……..366 Murmur in the Newborn (<48 Hours)…........…......................................367 Murmur in the Newborn Beyond Neonatal Period..................368 Preterm Infant Complications (<34 Weeks)....................................369 Preterm Infant Complications (34-36 Weeks)...............................370 Anemia by Mechanism……………………………..........….....................................………371 Anemia by MCV……………………………………….....................................................….……..372 Microcytic Anemia………………………….............……....................................……….………373 Paediatric Infectious Skin Rash………...............….....................................…374 Skin Lesion (Primary Skin)………………………………....….....................................….375 Skin Lesion (Secondary Skin)…………………….……....................................………376 Rash (Eczematous)………………………………………..................................................…….377 Rash (Papulosquamous)…………………………...........................................….…………378 Rash (Vesiculobullous)……………………………............................................….…………379 Rash (Pustular)………………………………………........................................................…………380 Rash (Reactive)……………………………...................…....................................…….…………..381 Proteinuria……………………………......………………….…………....................................….……………382 Hematuria…………………………………...…………………...……….....................................……………..383 Acute Renal Failure……………………………….................................................…………….384 Chronic Kidney Disease …………………………………...........................................……385 Edema ………………………………........…………………...………………….....................................….…..386 Dysuria ……………………………...………………….......………………................................................…387 Increased Urinary Frequency…….....................................................….………388 Scrotal Mass. ………………………………………........................................................…….……..389 Lymphadenopathy ………………………................................................…………………….390 Otalgia (Earache) …………………………...............…....................................…………….…..391 Sore Throat/Sore Mouth……………………………....................................….....…….…392 General Presentations������������� 393 Fatigue���������������������������������������������������������������������������������������������������395 Acute Fever���������������������������������������������������������������������������������������396 Fever of Unknown Origin / Chronic Fever����������������� 397 Hypothermia�������������������������������������������������������������������������������������398 Sore Throat / Rhinorrhea��������������������������������������������������������399 Historical Executive Student Editors�� 401 Scheme Creators���������������������������������� 402 Abbreviations ������������������������������������ 403 xxi Cardiovascular Abnormal Rhythm (1)����������������������������������������������������������3 Abnormal Rhythm (2)���������������������������������������������������������4 Chest Discomfort Cardiovascular�����������������������������5 Chest Discomfort Pulmonary / Medistinal������ 6 Chest Discomfort Other���������������������������������������������������7 Hypertension��������������������������������������������������������������������������� 8 Hypertension in Pregnancy������������������������������������������ 9 Left-Sided Heart Failure�����������������������������������������������10 Isolated Right-Sided Heart Failure�������������������������11 Pulse Abnormalities��������������������������������������������������������� 12 Cardiovascular 1 Shock������������������������������������������������������������������������������������������ 13 Syncope������������������������������������������������������������������������������������ 14 Systolic Murmur Benign & Stenotic��������������������� 15 Systolic Murmur Valvular & Other�������������������������16 Diastolic Murmur���������������������������������������������������������������� 17 Historical Editors Student Editors Katie Lin Azy Golian Payam Pournazari Harsimranjit Singh Marc Chretien Shaye Lafferty Tyrone Harrison Hamza Jalal Faculty Editor Geoff Lampard Dr. Sarah Weeks Luke Rannelli Connal Robertson-More Sarah Surette Lian Szabo Kathy Truong Vishal Varshney Cardiovascular Jeff Shrum 2 Abnormal Rhythm (1) ABNORMAL RHYTHM 1 Types of Arrhythmia Bradyarrhythmia (<60 bpm) • Sinus Bradycardia • Sick Sinus Syndrome • SA Block • AV Block (1st/2nd /3rd degree) • Junctional Escape Rhythm • Ventricular Escape Rhythm • Premature atrial contraction • Premature ventricular contraction Narrow QRS (<120 msec) SVT Cardiovascular 3 Tachyarrhythmia (>100 bpm) Abnormal Beats Regular Rhythm SVT (constant R-­‐R Interval) Irregular Rhythm SVT (variable R-­‐R interval) • Sinus Tachycardia • Monofocal Ectopic Atrial Tachycardia • Aflutter • AVNRT • AVRT (ie. WPW) • AFib • AFlutter with Variable AV Conduction • Multifocal Atrial Tachycardia Wide QRS (>120 msec) VT or SVT with aberrancy Regular Rhythm (constant R-­‐R Interval) • Monomorphic VT • Regular rhythm SVT with conduction aberrancy Irregular Rhythm (variable R-­‐R interval) • Polymorphic VT (including Tosades de Pointes if in a setting of long QT) • Irregular rhythm SVT with conduction aberrancy Abnormal Rhythm (2) ABNORMAL RHYTHM 2 Causes of Arrhythmia May present as: palpitations, dizziness, syncope, chest discomfort Cardiac • Valve disease • Cardiomyopathy High Output State • Anemia • Fever/infection • Pregnancy Electrical Conduction Abnormalities • Ectopic foci • Accessory pathway • Scar tissue (previous MI) Metabolic Drugs Psychiatric • Hypoglycemia • Thyrotoxicosis • Pheochromocytoma • Alcohol • Caffeine • Sympathomimetics •Anticholinergics •Cocaine • Panic Attack • Generalized Anxiety Disorder Cardiovascular Structural Non-­‐Cardiac 4 Chest Discomfort CHEST DISCOMFORT: Cardiovascular Cardiovascular Chest Discomfort Chest Discomfort Cardiovascular Cardiovascular 5 Outflow Obstruction • Aortic Stenosis Cardiovascular Pulmonary/Mediastinal Outflow Obstruction Ischemic • Aortic Stenosis • Myocardial Infarction* • Stable/Unstable Angina* Pulmonary/Mediastinal Other Ischemic Non-­‐Ischemic • Myocardial Infarction* • Stable/Unstable Angina* • Aortic Dissection* • Dilating Aneurysm* • Pericarditis • Myocarditis * Denotes acutely life-threatening causes •A •D •P •M Chest Discomfort CHEST DISCOMFORT: Pulmonary/Mediastinal Chest Discomfort Chest Discomfort Pulmonary/Mediastinal Cardiovascular Other Pulmonary/Mediastinal Chest Wall/Pleura Parenchymal Chest Wall/Pleura Vascular • Pneumothorax* • Pleural Effusion • Pulmonary Embolism* • Pleuritis/Serositis (chest pain often not present) • Pulmonary Hypertension * Denotes acutely life-threatening causes • Pneumonia with pleurisy* • Tuberculosis* • Pneumothorax* • Neoplasm* • Pleural Effusion • Sarcoidosis • Pleuritis/Serositis Other Parenchymal • Pneumonia with pleurisy* • Tuberculosis* • Neoplasm* • Sarcoidosis Cardiovascular cular Pulmonary / Medistinal 6 Chest Discomfort CHEST DISCOMFORT: Other Other Chest Discomfort Cardiovascular Cardiovascular 7 Gastrointestinal • Gastro-­‐Esophageal Reflux Disease • Biliary Disease • Peptic Ulcer Disease • Pancreatitis* • Esophageal Spasm • Esophageal Perforation* Cardiovascular Pulmonary/Mediastinal Gastrointestinal Musculoskeletal • Gastro-Esophageal Reflux • Costochondritis Disease • Muscular Injury • Biliary Disease • Trauma • Peptic Ulcer Disease • Pancreatitis* • Esophageal Spasm • Esophageal Perforation* Chest Discomfort Pulmonary/Mediastinal Other Musculoskeletal Neurologic/Psychiatric • Costochondritis • Anxiety/Panic • Muscular Injury • Herpes Simplex Virus/Post-­‐ • Trauma Herpetic Neuralgia • Somatoform Disorder • Spinal Radiculopathy * Denotes acutely life-threatening causes * Denotes acutely life-­‐threatening causes Hypertension HYPERTENSION HYPERTENSION HYPERTENSION Hypertension Hypertension Hypertension Primary (Essential) (95%) Primary Primary (Essential) (Essential) (95%) (95%) Secondary (5%) Secondary Secondary (5%)(5%) Onset etween 20 5a0. nd 50. Onset Onset between between abge 20 aage nd 2a0 5ge 0. and Positive family history. Positive Positive family fhamily istory. history. No of shecondary hypertension. No features No features of features secondary of secondary ypertension. hypertension. 2years. 0 50 years. Onset Onset age Onset < 2a0 ge o<r a ge >2 0 5<0 o r > o5r 0 >y ears. No family history. Hypertensive urgency. No family No fhamily istory. history. Hypertensive Hypertensive urgency. urgency. hypertension. Resistant Resistant hResistant ypertension. hypertension. Exogenous Exogenous Exogenous White-­‐ coat Hypertension • White-­‐ • White-­‐ c•oat H coat ypertension Hypertension • HMasked Hypertension • Masked • Masked ypertension Hypertension Renal Renal Renal Renal parenchymal • Renal • Renal p•arenchymal parenchymal disease disease disease •CKD •CKD•CKD •AKI •AKI•AKI •Glomerulonephritis •Glomerulonephritis •Glomerulonephritis • Renovascular disease • Renovascular • Renovascular disease disease (unilateral bilateral (unilateral (unilateral and bailateral nd abnd ilateral renal a rtery s tenosis) renal renal artery artery stenosis) stenosis) Mechanical Mechanical Mechanical Aortic coarctation • Aortic • Aortic c•oarctation coarctation •Obstructive Sleep •Obstructive •Obstructive Sleep Sleep Apnea Apnea Apnea Endocrine Endocrine Endocrine • Glucocorticoid excess (Cushing • Glucocorticoid • Glucocorticoid excess excess (Cushing (Cushing syndrome r disease) syndrome syndrome or disease) or doisease) •Catecholamine e xcess •Catecholamine •Catecholamine excess excess (pheochromocytoma) (pheochromocytoma) (pheochromocytoma) •Mineralocorticoid excess •Mineralocorticoid •Mineralocorticoid excess excess (primary aldosteronism) (primary (primary aldosteronism) aldosteronism) •Hyperthyroidism ( mainly •Hyperthyroidism •Hyperthyroidism (mainly (mainly hypertension) systolic systolic hsystolic ypertension) hypertension) •Hypothyroidism (mainly of hypertension: Hypertensive usually >180/110mmHg •Hypothyroidism •Hypothyroidism (mainly (mainly Definition Definition oDefinition f hypertension: of hypertension: Hypertensive Hypertensive Urgency: Urgency: BU P rgency: usually BP uB sually >P 180/110mmHg >180/110mmHg or or or ≥ 1o40mmHg oB r P Diastolic ≥ 90mmHg asymptomatic asymptomatic Diastolic BP >130mmHg ith target organ diastolic hypertension) Systolic Systolic BP Systolic ≥ 1B40mmHg P ≥ B1P 40mmHg r Diastolic or Diastolic ≥ 9B0mmHg P ≥ B9P 0mmHg asymptomatic Diastolic Diastolic BP >130mmHg BP >130mmHg with target with wtoarget rgan organ diastolic diastolic hypertension) hypertension) Isolated s ystolic h ypertension i n t he e lderly: ≥ 1 60mmHg damage u sually p resent b ut n ot a cutely c hanging •Hyperparathyroidism Isolated Isolated systolic systolic hypertension hypertension in the ien lderly: the elderly: ≥ 160mmHg ≥ 160mmHgdamage usually present but not acutely changing damage usually present but not acutely changing •Hyperparathyroidism •Hyperparathyroidism ellitus ≥ 130/80mmHg Hypertensive Emergency: usually >220/140mmHg Diabetes Diabetes mDiabetes ellitus mellitus ≥ m 130/80mmHg ≥ 130/80mmHg Hypertensive Emergency: BP usually >P 220/140mmHg Hypertensive Emergency: BP uB sually >220/140mmHg •Pregnancy (Gestational •Pregnancy •Pregnancy (Gestational (Gestational Note: In the children, he odf efinition of hypertension with evolving target organ damage Note: Note: In children, In children, definition the dtefinition hypertension of hypertension is is is with ewith volving target rgan amage evolving toarget odrgan damage hypertension) different (either systolic or diastolic BP >95%ile), but the hypertension) hypertension) • Corticosteroids • Corticosteroids • Corticosteroids • Oral Contraceptive • Oral • COral ontraceptive Contraceptive Pills PillsPills • Cocaine • Cocaine • Cocaine • Black l icorice • Black • Black licorice licorice • Medications • Medications • Medications different different (either (either systolic systolic or diastolic or diastolic BP >95%ile), BP >95%ile), but the but the is stame. he same. approach approach iapproach s the iss ame. the Cardiovascular • Long-­‐ standing • Long-­‐ • Long-­‐ standing standing • Uncontrolled • Uncontrolled • Uncontrolled • Drug W ithdrawal • Drug • Drug Withdrawal Withdrawal Mislabelled Mislabelled Mislabelled Repeatedly normal blood ressure when Repeatedly Repeatedly normal normal blood bplood ressure pressure wphen when taken aork t home, woork o r wau hen using taken taken at home, at hw ome, owr ork when r w using hen n sing an an ambulatory monitor. ambulatory ambulatory monitor. monitor. 8 Hypertension in Pregnancy HYPERTENSION IN PREGNANCY HYPERTENSION IN PREGNANCY Clinical Pearl: BP should always be in a sitting position for a Hypertension in PregnancyClinical Pearl: Bmeasured P should aplways pregnant atient.be HYPERTENSION IN PREGNANCY DBP ≥ 90mmHg, based on two measurements measured in a sitting position for a Hypertension in Pregnancy DBP ≥ 90mmHg, based on two measurements pregnant patient. Hypertension in Pregnancy DBP ≥ 90mmHg, based on two measurements Pre-­‐existing Hypertension Before Pregnancy OR Pre-­‐existing Hypertension <20 weeks gestational age Before Pregnancy OR Pre-­‐existing Hypertension <20 weeks gestational age Clinical Pearl: BP should always be measured in a sitting position for a pregnant patient. Gestational Hypertension Previously normotensive, Gestational Hypertension >20 weeks gestational age Previously normotensive, Gestational Hypertension >20 weeks gestational age Before Pregnancy OR <20 weeks gestational age Previously normotensive, >20 weeks gestational age No Proteinuria No Proteinuria Proteinuria (≥0.3g/24hr urine) Proteinuria (≥0.3g/24hr urine) Pre-­‐Eclampsia + one or umrine) ore Adverse one or umrine) ore Adverse • Gestational Proteinuria (OR No Proteinuria Proteinuria (OR ≥0.3g/24hr ≥0.3g/24hr Seizures/Coma Pre-­‐Eclampsia + HypertensionOR one or more A Conditions* OR one or more AConditions* dverse dverse • Gestational Seizures/Coma No Proteinuria No ProteinuriaConditions* Proteinuria (≥0.3g/24hr urine) Proteinuria (≥0.3g/24hr urine) • Eclampsia Hypertension Conditions* • Gestational H ypertension w ith • Pre-­‐existing Hypertension with Pre-­‐Eclampsia + one or more Adverse one or more A • dverse Eclampsia Chronic • Gestational Pre-­‐EOR clampsia Pre-­‐EOR clampsia Seizures/Coma • Gestational Hypertension with • Pre-­‐existing Hypertension with Hypertension Conditions* Conditions* Chronic Hypertension Pre-­‐Eclampsia No Proteinuria Cardiovascular 9 Pre-­‐Eclampsia Hypertension • Primary Chronic • Secondary • Primary Hypertension • Secondary • Primary • Secondary • Pre-­‐existing Hypertension with Pre-­‐Eclampsia Maternal • Gestational Hypertension with Pre-­‐Eclampsia Fetal • Eclampsia Maternal Fetal •Persistent or •Pulmonary Edema new/unusual headache • Suspected placental •Oligohydramnios •Persistent or • Visual disturbances *Adverse •Pulmonary Edema Maternal Fetal abruption •Intrauterine growth restriction new/unusual h• eadache Persistent • Suspected placental •Oligohydramnios • Elevated serum •Absent/reversed end-­‐diastolic flow in the *Adverse Conditions: • Visual disturbances abdominal/RUQ •Intrauterine growth restriction •Persistent oabruption r pain (SOGC, 2008) creatinine/AST/ALT/LDH umbilical artery • Persistent •Pulmonary E dema • Severe n ausea o r Conditions: • Elevated serum •Absent/reversed end-­‐diastolic flow in the new/unusual headache • Platelet <100x109/L •Intrauterine fetal death abdominal/RUQ pain • Suspected placental •Oligohydramnios vomiting (SOGC, 2008) *Adverse creatinine/AST/ALT/LDH • Visual disturbances • Serum albumin umbilical <20g/L artery •Intrauterine growth restriction • Severe nausea or pain/dyspnea abruption • Chest •Intrauterine fetal death • Persistent • Platelet <100x109/L Conditions: vomiting • Elevated s erum •Absent/reversed end-­‐diastolic flow in the • Severe hypertension • Serum albumin <20g/L abdominal/RUQ pain 008) •(SOGC, Chest p2ain/dyspnea creatinine/AST/ALT/LDH umbilical artery • Severe nausea or • Severe hypertension • Platelet <100x109/L •Intrauterine fetal death vomiting • Serum albumin <20g/L Left-Sided Heart Failure LEFT-­SIDED HEART FAILURE LEFT-­SIDED HEART FAILURE Left-­‐Sided Heart Failure SV = Stroke Volume EDV = End-­‐Diastolic Volume ESV = End-­‐Systolic Volume SV = Stroke Volume EDV = End-­‐Diastolic Volume ESV = End-­‐Systolic Volume Left-­‐Sided Heart Failure Ejection Fraction = SV = EDV -­‐ ESV EDV EDV Valvular Disease Ejection Fraction = SV = EDV -­‐ ESV EDV EDV Myocardial (Preserved Diastolic/Systolic Valvular Disease Function) Myocardial (Preserved D iastolic/Systolic • Mitral Stenosis Function) • Mitral Regurgitation Systolic Dysfunction Diastolic Dysfunction • Aortic Stenosis • Mitral Stenosis • Aortic Regurgitation • Mitral Regurgitation (Reduced Ejection Fraction) (Preserved Ejection Fraction) Systolic Dysfunction Diastolic Dysfunction • Aortic Stenosis • Aortic Regurgitation (Reduced Ejection Fraction) (Preserved Ejection Fraction) Impaired Contractility Increased Afterload Impaired Diastolic Filling • Uncontrolled Severe Impaired Contractility • Aortic Stenosis (Severe) Coronary Artery Disease Chronic Volume Dilated Overload Cardiomyopathies Coronary Artery Chronic Volume Dilated • Myocardial Infarction • Mitral Regurgitation • Infiltrative Overload Cardiomyopathies • Transient Myocardial •Disease Aortic Regurgitation • Infectious Ischemia • Myocardial Infarction • Transient Myocardial Ischemia •R Toxic (alcohol, • Mitral egurgitation cocaine) • Aortic Regurgitation • Genetic • Infiltrative • Infectious • Toxic (alcohol, cocaine) Cardiovascular • Transient Myocardial Ischemia Impaired Diastolic Filling Increased Afterload Hypertension • Left Ventricular Hypertrophy • Aortic Stenosis (Severe) • Uncontrolled Severe • Restrictive Cardiomyopathy • Transient Myocardial Ischemia • Pericardial Constriction Hypertension • Left Ventricular Hypertrophy • Restrictive Cardiomyopathy • Pericardial Constriction 9 10 Isolated Right-Sided Heart Failure URE ISOLATED RIGHT-­SIDED HEART FAILURE Note: all left-­‐sided heart failure can also lead to right-­‐sided heart failure (the most common cause of right heart failure is left heart failure) art Isolated Right-­‐Sided Heart Failure Note: all left-­‐sided heart failure can also lead to right-­‐sided heart failure (the most common cause of right heart failure is left heart failure) Cardiac Pulmonary Pulmonary Rule out Left-­‐Sided Heart Failure (Most Common) Cardiovascular Myocardium • Right Ventricle Parenchyma Infarction Valves • Pulmonary Stenosis Vasculature • Tricuspid Regurgitation • Restrictive Cardiomyopathy• Pulmonary Embolism • Chronic Obstructive Pulmonary Disease • Primary Pulmonary • Diffuse Lung Disease Arterial Hypertension • Acute Respiratory • Pulmonary Veno-­‐ 11 Distress Syndrome Occlusive Disease • Chronic Lung Pericardium • Constrictive Pericarditis • Pericardial Tamponade Parenchyma Vasculature • Chronic Obstructive Pulmonary Disease • Diffuse Lung Disease • Acute Respiratory Distress Syndrome • Chronic Lung Infection • Bronchiectasis • Pulmonary Embolism • Primary Pulmonary Arterial Hypertension • Pulmonary Veno-­‐ Occlusive Disease PULSE ABNORMALITIES Pulse Abnormalities Pulse Abnormalities • Obstructive arterial disease (ie. Atherosclerosis) • Aortic dissection • Aortic aneurysm • Aortic coarctation • Takayasu disease • Normal variant Pulsus Alternans Variation in pulse amplitude with alternate beats • Left heart failure Aortic Stenosis • Anacrotic • Pulsus parvus (small amplitude) • Pulsus tardus (delayed/slow upstroke) Pulsus Paradoxus Exaggerated inspiratory drop in arterial pressure >10mmHg • Cardiac tamponade • AECOPD/ Acute Exacerbation of Asthma • Hypovolemic shock • Constrictive Pericarditis • Restrictive Cardiomyopathy Water Hammer Pulse Rapid upstroke followed by rapid collapse • Aortic regurgitation • High output states (ie. Anemia, hypoglycemia, thyrotoxicosis, ) Cardiovascular Unequal/Delayed 12 Shock SHOCK Shock Warm Extremities Cold Extremities High JVP Cardiovascular 13 Distributive Shock Low JVP • Sepsis • Anaphylaxis • Burns • Neurogenic Cardiogenic Shock Bibasilar Lung Crackles • Myocardial Ischemia or Infarction • Left-­‐sided Valvular Disease • Arrhythmia • Cardiomyopathy (ie. HOCM) Low JVP Obstructive Shock Normal/Decreased Breath Sounds • Pulmonary Embolism • Tension Pneumothorax • Cardiac Tamponade Hypovolemic Shock (Rule out Decompensated Distributive Shock) • Hemorrhage • Dehydration • Vomiting • Diarrhea • Interstitial Fluid Redistribution Syncope SYNCOPE Rule out Seizure Syncope Respiratory Cardiac • Pulmonary Embolism • Hypoxia • Hypercapnia • Vasovagal • Orthostatic Hypotension • Autonomic Neuropathy • Situational (micturition, coughing, defecation) CO = SV x HR Stroke Volume Contractility • MI • DCM Afterload • Mitral/Aortic Stenosis • HCM (LVOT) Other • Hypoglycemia • Anemia • Medications (CCB, βB, Nitrates, Diuretics) • TIA • Psychiatric • Intoxication • Migraine Heart Rate/Rhythm Preload • Blood Loss/Hypotension • Mitral Stenosis • Cardiac Tamponade • Constrictive Pericarditis Tachyarrhythmia • VT/VFib • AFib/AFlutter • AVNRT/AVRT Bradyarrhythmia • Sick Sinus Syndrome (SA Node) • 2nd/3rd degree AV Block • Pacemaker Malfunction • Tachy-­‐Brady Syndrome Cardiovascular Neurocardiogenic 14 Systolic Murmur Benign & Stenotic SYSTOLIC MURMUR: Benign & Stenotic Systolic Murmur Benign/Flow/ Hyperdynamic Stenosis Incompetent Valve Other • Pregnancy • Fever • Anemia Subvalvular Supravalvular Cardiovascular 15 • Aortic Coarctation • Supravalvular Aortic Stenosis (rings, webs) Valvular • Hypertrophic Obstructive Cardiomyopathy • Subvalvular Aortic Stenosis (rings, webs) Aortic Stenosis* S1 S2 •Aortic Stenosis/ Pulmonary Stenosis • Uni-­‐/Bicuspid • Degenerative (Tricuspid) • Rheumatic Heart Disease Pulmonary Stenosis* Systolic Murmur Valvular & Other SYSTOLIC MURMUR: Valvular & Other Systolic Murmur Benign/Flow/ Hyperdynamic Stenotic Incompetent Valve Other • Ventricular Septal Defect Leaflet/Annulus • Prolapse* • Dilated cardiomyopathy • Endocarditis • Hypertrophic Cardiomyopathy • Rheumatic Fever • Marfan’s Disease Tricuspid Regurgitation* Papillary Muscle Dysfunction Chordae Tendinae • Rupture • Endocarditis • Rheumatic Fever • Trauma S1 Dilation of Right Ventricle/Annulus • Ischemia • Infarct • Rupture S2 •Mitral Regurgitation/ Tricuspid Regurgitation • Dilated cardiomyopathy • MI • Pulmonary Hypertension S1 OS Leaflet • Prolapse* • Endocarditis • Rheumatic Fever • Ebstein’s Anomaly • Carcinoid S2 * Mitral Valve Prolapse (OS – opening snap) 15 Cardiovascular Mitral Regurgitation* 16 Diastolic Murmur DIASTOLIC MURMUR Diastolic Murmur Cardiovascular 17 Early Diastolic Mid-­‐Diastolic • Aortic Regurgitation* • Pulmonary Regurgitation (Graham-­‐Steell Murmur)* • Mitral Stenosis* • Tricuspid Stenosis* • Severe Aortic Regurgitation (Austin Flint Murmur) • Atrial Myxoma Prolapse S1 S2 •Aortic Regurgitation/ Pulmonary Regurgitation Late Diastolic • Mitral Stenosis* • Tricuspid Stenosis* • Myxoma S1 S2 OS * Mitral Stenosis/Tricuspid Stenosis (OS – opening snap) S1 Respiratory Pulmonary Function Tests Interpretation�������21 Lung Nodule����������������������������������������������������������������������� 35 Acid-Base Disorder Pulmonary���������������������������� 22 Mediastinal Mass��������������������������������������������������������������36 Chest Discomfort Cardiovascular������������������������ 23 Pleural Effusion������������������������������������������������������������������ 37 Chest Discomfort Pulmonary��������������������������������� 24 Pulmonary Hypertension�������������������������������������������38 Chest Discomfort Other���������������������������������������������� 25 Chest Trauma Complications����������������������������������26 Cough Chronic������������������������������������������������������������������� 27 Cough, Dyspnea & Fever�������������������������������������������28 Dyspnea Acute������������������������������������������������������������������ 29 Dyspnea Chronic Cardiac������������������������������������������30 Respiratory 19 Dyspnea Chronic Pulmonary / Other����������������31 Excessive Daytime Sleepiness������������������������������ 32 Hemoptysis�������������������������������������������������������������������������� 33 Hypoxemia���������������������������������������������������������������������������� 34 Historical Editors Student Editors Calvin Loewen Amanda Comeau Yan Yu Shaye Lafferty Marc Chretien Vanessa Millar Faculty Editor Geoff Lampard Dr. Naushad Hirani Shaina Lee Dr. Daniel Miller Reena Pabari Katrina Rodrigues Lian Szabo Ying Wang Respiratory Eric Sy 20 Pulmonary Function Tests Interpretation Respiratory 21 Acid-Base Disorder Pulmonary ACID-­BASE DISORDER Acid-­‐Base Disorder pH < 7.35 pH 7.35-­‐7.45 Acidemia > Normal pH pH < 7.45 Alkalemia • Mixed Acid-­‐Base Disorder Metabolic Acidosis Respiratory Acidosis Metabolic Alkalosis Respiratory Alkalosis See “Metabolic• Decrease Alkalosis”EABV on page 122 • Hypokalemia* Normal Anion Gap Chronic Acute Chronic Acute • Diarrhea • Asthma* Hypervennlaaon • Pregnancy • Hypoxia • Methanol • COPD Hypovennlaaon See “Metabolic See “Metabolic Hypovennlaaon Hypervennlaaon • RTA • Uremia Acidosis Normal Disease Acidosis Elevated present for • Interstitial present for • Neuromuscular present for • Psychogenic present for • Salicylates • Interstitial N ephritis • Obstruction • Sepsis • DKA Anion Gap” on Anion Gap” on hours to days minutes to hours hours to days minutes to hours • Pulmonary • Paraldehyde page 120 page 121 Embolism* • Isoniazid • Lactic Acid * Denotes acutely life-­‐threatening causes • Ethylene Glycol • Salicylates Appropriate Compensation: Ratio (CO2:HCO3-­‐) Metabolic Acidosis 12:10 Metabolic Acidosis – Mixed Metabolic Disorder: Metabolic Alkalosis 7:10 Anion Gap Normal Normal AG Acidosis Alone Acute Respiratory Acidosis 10:1 -­‐ High AG Acidosis Alone ΔAnion Gap = ΔHCO3 Chronic Respiratory Acidosis 10:3 ΔAnion Gap < ΔHCO3-­‐ Mixed AG Acidosis + Normal AG Acute Respiratory Alkalosis 10:2 ΔAnion Gap > ΔHCO3-­‐ Mixed High AG Acidosis + Metabolic Alkalosis Chronic Respiratory Alkalosis 10:4 Respiratory Elevated High Anion Gap Anion Gap 22 Chest Discomfort Cardiovascular Pulmonary Respiratory 23 Aorrc Disseccon* * Potentially acutely life-threatening Chest Discomfort Pulmonary Pulmonary • Pneumothorax (Tension*) • Pleuriis/Serosiis • Pleural Effusion • Malignant Mesothelioma * Potentially acutely life-threatening Processes that can affect the Pleura • Pneumonia* • Pulmonary Embolism* • Malignancy • Sarcoidosis • Acute Chest Syndrome Respiratory Pleural Processes 24 Chest Discomfort Other Respiratory 25 EST TRAUMA Chest Trauma Complications Chest Trauma Cardiac • Rib Fractures • Flail Chest* • Diaphragm Injury Lung • Pulmonary Contusion • Pneumothorax (Tension*) • Hemothorax Respiratory • Cardiac Tamponade* • Pericarditis • Myocardial Contusion • Acute Aortic Rupture* Chest Wall * Potentially acutely life-threatening 26 Cough Chronic COUGH: Chronic Cough Chronic Cough ( > 3 wks ) Normal Chest X-­‐Ray Normal Spirometry Abnormal Chest X-­‐Ray Obstructive Disease (FEV1/FVC <75%) • Asthma • COPD Respiratory 27 Upper Airway • Post-­‐Nasal Drip / Rhinosinusitis • Neuromusclar Swallowing Disorder • Thyroiditis • Mediastinal Mass • Elongated Uvula Cough & Dyspnea & Fever Lower Airway • Asthma • GERD • Post-­‐Infectious • Smoker’s Cough • Non-­‐Asthmatic Eosinophilic Bronchitis • Foreign Body • COPD • Chronic Infection (Eg. Fungal, Tuberculosis) • Neoplasm • CHF • Interstitial Disease • Foreign Body Other • ACE Inhibitor Cough, Dyspnea & Fever COUGH: Dyspnea & Fever * Denotes acutely life-­‐threatening causes Cough Chronic Cough ( > 3 wks ) Cough & Dyspnea & Fever Normal CXR Abnormal CXR • Acute Bronchitis • AECOPD • Pulmonary Embolism* • Cryptogenic Organizing Pneumonia • Wegener’s Granulomatosis Hospital-­‐Acquired Pneumonia in the Immunocompetent Host Pneumonia in the Immunocompromised Host New/Changed Murmur • Bacterial (often non-­‐pathogenic with immune competence) • Fungal (e.g. Pneumocystic jirovecii) • Viral Community-­‐ Acquired • Aerobic Gram-­‐ • S. pneumoniae *Negative Potentially Bacilli acutely life-threatening • H. influenzae • Gram-­‐Positive Cocci • Viral (Eg. Influenza) Tuberculosis Peripheral Stigmata of Subacute Endocarditis • Left-­‐Sided Intravenous Drug User • Right-­‐Sided Respiratory Non-­‐Infectious 28 Dyspnea Acute Respiratory 29 Dyspnea Chronic Respiratory Cardiac * Potentially acutely life-threatening 30 Dyspnea Chronic Pulmonary / Other Respiratory 31 Excessive Daytime Sleepiness Obesity Hypovennlaaon Syndrome Respiratory Differennate Faague from Sleepiness 32 Hemoptysis Hematemesis Epistaxis Bronchiis Respiratory 33 Pulmonary Vasculiis Pulmonary Vasculiis Granulomatosis with polyangiiis /microscopic polyangiiis Hypoxemia Normal < (Age/4) + 4 Normal < (Age/4) + 4 Obesity Hypovennlaaon Syndrome ** Neuromascular Weakness Severe Pneumonia Pleural Abnormaliies Chest Wall Abnormaliies Atelectasis Obesity Hypovennlaaon Syndrome Neuromascular Weakness Pleural Abnormaliies Chest Wall Abnormaliies Respiratory Pulmonary Arterial Hypertension 34 Lung Nodule Respiratory 35 Metastases Granulomatosis with polyangiiis (GPA)/microscopic polyangiiis (MPA) * Potentially acutely life-threatening Mediastinal Mass Mediastinal Mass • Thyroid • Thymoma • Teratoma • “Terrible” Lymphoma Middle • Aneurysm • Lymphadenopathy • Cystic (Bronchial, Pericardial, Esophageal) Posterior • Neurogenic Tumour • Esophageal Lesion • Diaphragmatic Hernia Respiratory Anterior 36 Pleural Effusion Thoracic Thoracic Ultrasound should be used to perform perform Diagnossc Thoracentesis Use Use Light’s Light’s Criteria Criteria Increased Hydrostaac Hydrostaac Pressure Respiratory Congessve Heart Failure Renal Failure with with Hypervolemia (Early) Pulmonary Pulmonary Embolus 37 SerumLDH LDHUpper Upper Limit Limit of of Normal Normal Serum * Potentially acutely life-threatening Decreased DecreasedOncooc Oncooc Pressure Pressure Cirrhosis Cirrhosis Nephrooc NephroocSyndrome Syndrome Pulmonary Hypertension Sleep-Disordered Breathing Miscellaneous Hematologic Disorders Metabolic Disorders Respiratory Associated with: - Conneccve Tissue Disease - Portal Hypertension - Congenital Heart Disease - HIV 38 Hematologic Overall Approach to Anemia������������������������������������41 Approach to Anemia Mean Corpuscular Hematologic 39 Prolonged PTT, Normal PT (INR) No Bleeding Tendency��������������������������������������������������������������������������51 Volume������������������������������������������������������������������������������ 42 Approach to Splenomegaly������������������������������������� 52 Anemia with Elevated MCV�������������������������������������� 43 Fever in the Immunocompromised Host������� 53 Anemia with Normal MCV����������������������������������������� 44 Lymphadenopathy Diffuse��������������������������������������� 54 Anemia with Low MCV������������������������������������������������� 45 Lymphadenopathy Localized��������������������������������� 55 Approach to Bleeding / Bruising Platelets & Neutrophilia��������������������������������������������������������������������������56 Vascular System��������������������������������������������������������46 Neutropenia Decreased Neutrophils Only��� 57 Approach to Bleeding / Bruising Coagulation Neutropenia Bicytopenia / Pancytopenia����58 Proteins����������������������������������������������������������������������������� 47 Polycythemia����������������������������������������������������������������������59 Approach to Prolonged PT (INR), Prolonged Suspected Deep Vein Thrombosis (DVT)������60 PTT���������������������������������������������������������������������������������������48 Suspected Pulmonary Embolism (PE)��������������61 Prolonged PT (INR), Normal PTT��������������������������49 Thrombocytopenia���������������������������������������������������������62 Prolonged PTT, Normal PT (INR) Bleeding Thrombocytosis����������������������������������������������������������������63 Tendency�������������������������������������������������������������������������50 Hemolysis������������������������������������������������������������������������������64 Historical Editors Lian Szabo Soreya Dhanji Evan Woldrum Jen Corrigan Ying Wang Jennifer Mikhayel Yang (Steven) Liu Student Editors Megan Barber Andrea Letourneau Lorie Kwong Victoria David Aravind Ganesh Faculty Editor Jesse Heyland Dr. Lynn Savoie Tyrone Harrison Nancy Nixon Nahbeel Premji Connal Robertson-More Hematologic Khaled Ahmed 40 Overall Approach to Anemia Hematologic 41 Approach to Anemia Hematologic Mean Corpuscular Volume 42 Anemia with Elevated MCV Hematologic 43 Hematologic Anemia with Normal MCV 44 Anemia with Low MCV Hematologic 45 Approach to Bleeding / Bruising Hematologic Platelets & Vascular System 46 Approach to Bleeding / Bruising APPROACH TO BLEEDING/BRUISING: Coagulation Proteins Coagulation Proteins Bleeding/Bruising Platelets Vascular System Congenital Hematologic 47 • Factor VIII Deficiency • Factor IX Deficiency • Von Willebrand’s Disease • Other deficiencies Coagulation Proteins Acquired • Anticoagulation (Iatrogenic) • Liver Disease • Vitamin K Deficiency • Disseminated Intravascular LCoagulation Hematologic Approach to Prolonged PT (INR), Prolonged PTT 48 Prolonged PT (INR), Normal PTT PROLONGED PT (INR), NORMAL PTT Normal PTT/Long PT Sufficient Vitamin K Insufficient Vitamin K • Congenital Clotting Factor Deficiency – Extrinsic Factor (Factor VII Deficiency) Vitamin K Deficiency Vitamin K Antagonist • Coumadin (Warfarin) use Hematologic 49 Child/Adult • Antibiotics and Poor Nutrition • Fat Malabsorption Newborn • Hemorrhagic Disease of the Newborn Prolonged PTT, Normal PT (INR) Hematologic Bleeding Tendency 50 Prolonged PTT, Normal PT (INR) No Bleeding Tendency Hematologic 51 Hematologic Approach to Splenomegaly 52 Fever in the Immunocompromised Host Hematologic 53 Lymphadenopathy Diffuse LYMPHADENOPATHY: Diffuse Diffuse Lymphadenopathy Systemic Inflammatory • Systemic Lupus Erythematosus • Sarcoidosis • Rheumatoid Arthritis • Pseudotumor Infectious •EBV •CMV •HIV •Tuberculosis • Hepatitis Neoplastic Other Leukemia Monoclonal Lymphocytes on Biopsy • Non-­‐Hodgkin’s Lymphoma • Acne • Allergy • Insect Bites • Young age History of Bleeding, Infection, Fatigue • Acute Lymphoblastic Leukemia (Pancytopenia, WBC differential includes Blasts) Asymptomatic, Age > 50 • Chronic Lymphocytic Leukemia (CBC with Lymphocytes) Reed-­‐ Sternberg Cells on Biopsy • Hodgkin’s Lymphoma Hematologic Reactive 54 Lymphadenopathy Localized Hematologic 55 Hematologic Neutrophilia 56 Neutropenia Decreased Neutrophils Only Hematologic 57 Neutropenia NEUTROPENIA: Bicytopenia/Pancytopenia Bicytopenia / Pancytopenia Neutropenia Isolated Neutrophil Decrease Bicytopenia/Pancytopenia (Neutrophils and Other Cell Lines Decreased) Decreased Production Sequestration Marrow Infiltration • Hematologic and non-­‐hematologic malignancies • Infection • Primary Myelofibrosis Stem cell damage or suppression • Chemotherapy • Radiation • Drugs • Toxins • Aplastic Anemia • Myelodysplasia Nutritional deficiency • B12/folate/combined deficiencies Hematologic • Splenomegaly 58 Polycythemia Hematologic 59 Hematologic Suspected Deep Vein Thrombosis (DVT) 60 Suspected Pulmonary Embolism (PE) SUSPECTED PULMONARY EMBOLISM (PE) Suspected PE Calculate Clinical Probability Score Low: ≤ 4 Points Negative D-­‐Dimer High: > 4 Points Positive D-­‐Dimer CT-­‐PA or Compression U/S STOP Well’s Criteria for PE Clinical Signs and Symptoms of DVT (3.0) Negative CT-­‐PE Non-­‐ Diagnostic High Clinical Suspicion Compression U/S Positive CT-­‐PA (leg swelling and pain with palpation of the deep veins) Alternative diagnosis less likely than PE (3.0) Heart rate >100bpm (1.5) Hematologic 61 TREAT Low Clinical Suspicion STOP Immobilization or surgery in last 4 weeks (1.5) Previous DVT or PE (1.5) Hemoptysis (1.0) Positive Negative TREAT • Repeat U/S in 1 Week Malignancy (ongoing or previous 6 months) (1.0) Wells P.S, et al. (2000). Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-­‐dimer. Thromb Haemost 2003; 83: 416-­‐20. Writing Group for the Christopher Study Investigators. (2006). Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-­‐Dimer testing, and computer tomography. JAMA;295: 172-­‐179. Hematologic Thrombocytopenia 62 Thrombocytosis THROMBOCYTOSIS Thrombocytosis Reactive Spurious • Artifact (redo CBC) Hematologic 63 Infectious • Acute or Chronic Inflammatory • IBD • Rheumatic disorders • Celiac disease Tissue Damage • Post-­‐op surgery • Trauma • Burns Autonomous • • • • Essential thrombocytosis Polycythemia Vera Chronic Myelogenous Leukemia Primary Myelofibrosis Non malignant hematologic conditions • Rebound effect following treatment of ITP • Rebound effect following ETOH induced thrombocytopenia Other • Post-­‐splenectomy or hyposplenic states • Non-­‐hematologic malignancy • Iron deficiency anemia Hemolysis Hemolysis Hemolysis Intravascular Hemolysis within circulation Extrinsic to RBC Intrinsic to RBC • Malaria • Babesiosis • C. perfringens Immune-­‐ Mediated • Warm AIHA • Cold AIHA • Alloimmune delayed HTR • Drug-­‐induced AIHA Infections Abnormal Hgb & Hgb Defects • Thalassemia • Sickle cell • Unstable Hgb Membrane Defects • Hereditary spherocytosis • Hereditary elliptocytosis RBC Enzyme Defects • G6PD deficiency • PK deficiency Complement-­‐ Mediated • Cold AIHA • PCH • PNH • Drug-­‐induced immune-­‐complex hemolytic anemia • Acute HTR Mechanical Shearing • MAHA (TTP, DIC, HUS) • Prosthetic heart valves • Atriovenous malformations Hematologic Extravascular Spleen and RES-­‐ mediated hemolysis 64 Gastrointestinal Abdominal Distention���������������������������������������������������69 Abdominal Distention Ascites��������������������������������70 Abdominal Distention Other Causes������������������71 ��������������������������������������������������������������������������������������������������81 Constipation (Adult) Altered Bowel Function Abdominal Mass��������������������������������������������������������������� 72 & Idiopathic��������������������������������������������������������������������82 Abdominal Pain (Adult) Acute - Diffuse����������� 73 Constipation (Adult) Secondary Causes���������83 Abdominal Pain (Adult) Acute - Localized�����74 Constipation (Pediatric) ����������������������������������������������84 Abdominal Pain (Adult) Chronic - Constant� 75 Dysphagia������������������������������������������������������������������������������85 Abdominal Pain (Adult) Chronic - Crampy / Elevated Liver Enzymes���������������������������������������������86 Fleeting�����������������������������������������������������������������������������76 Gastrointestinal 65 Chronic Diarrhea Steatorrhea & Large Bowel Abdominal Pain (Adult) Chronic - Post- Hepatomegaly�������������������������������������������������������������������87 Jaundice���������������������������������������������������������������������������������88 Prandial����������������������������������������������������������������������������� 77 Liver Mass������������������������������������������������������������������������������89 Anorectal Pain��������������������������������������������������������������������78 Mouth Disorders (Adult & Elderly) ���������������������90 Acute Diarrhea�������������������������������������������������������������������79 Nausea & Vomiting Gastrointestinal Disease Chronic Diarrhea Small Bowel�������������������������������80 ��������������������������������������������������������������������������������������������������91 Nausea & Vomiting Other Systemic Disease�������������������������������������������������������������������92 Stool Incontinence�����������������������������������������������93 Upper Gastronintestinal Bleed (Hematemesis / Melena)�������������������������94 Lower Gastrointestinal Bleed�����������������������95 Weight Gain���������������������������������������������������������������96 Gastrointestinal Weight Loss�������������������������������������������������������������� 97 66 Historical Editors Shabaz Syed Dr. Chris Andrews Ying Wang Khaled Ahmed Jennifer Amyotte Student Editors Stacy Cormack Scott Assen Beata Komierowski Jonathan Seto James Lee Jacob Charette Shaina Lee Gastrointestinal 67 Matt Linton Faculty Editor Michael Prystajecky Dr. Sylvain Coderre Daniel Shafran Dr. Kelly Burak Robbie Sidhu Mia Steiner 68 Gastrointestinal Abdominal Distention Gastrointestinal 69 Abdominal Distention Ascites ABDOMINAL DISTENTION: Ascites Abdominal Distention Ascites Other Causes Bowel Dilatation Portal Hypertension • Cirrhosis • Alcoholic Hepatitis • Portal vein thrombus • Budd-­‐Chiari Syndrome Low Albumin Gradient (SAAG)* <11 g /L serum-­‐albumin gradient Cardiac • Congestive Heart Failure • Constrictive Pericarditis Peritoneal • Carcinomatosis • Infection (Neutrophils > 250/cc) Other Causes • Pancreatitis • Serositis • Nephrotic Syndrome Clinical pearl: “rule of 97”: SAAG 97% accurate. If high SAAG, 97% of time it is cirrhosis/portal hypertension. If low SAAG, 97% time carcinomatosis (and cytology 97% sensitive) *Serum Ascites Albumin Gradient (SAAG) = [Serum albumin] – [Peritoneal fluid albumin] Gastrointestinal High Albumin Gradient (SAAG)* >11 g /L serum-­‐fluid albumin 70 Abdominal Distention Other Causes ABDOMINAL DISTENTION: Other Causes Abdominal Distention Ascites Pelvic Mass Gastrointestinal 71 • Pregnancy • Fibroids • Ovarian Mass • Bladder Mass • Malignancy • Obesity 6 Fs of Abdominal Distention • Fluid • Feces • Flatus • Fetus • Fibroids and benign masses • Fatal tumour Bowel Dilatation Feces/Flatus • Constipation • Irritable Bowel Syndrome • Carbohydrate Malabsorption • Diet (Lactose Intolerance) • Chronic Obstruction Other Causes Organomegaly • Hepatomegaly • Splenomegaly • Hydronephrosis • Renal Cysts • Aortic Aneurysm Abdominal Mass ABDOMINAL MASS Abdominal Mass Exclude pregnancy/hernia/abdominal wall mass • Liver • Spleen • Kidneys (e.g. Cysts, Cystic Renal Cell Carcinoma, Hydronephrosis) Feces Neoplastic Other Causes • Gastrointestinal Tumours (e.g. Colonic, Gastric, Pancreatic) • Gynecologic Tumors (e.g. Ovarian, Uterine) • Lymphoma/Sarcoma Pulsatile • Vascular (Abdominal Aortic Aneurysm) Pseudoneoplastic • Pancreatic Pseudocyst Gastrointestinal Organomegaly 72 Abdominal Pain (Adult) Acute - Diffuse ABDOMINAL PAIN (ADULT): Acute -­‐ Diffuse Acute Abdominal Pain (<72 hours) Look For Surgical Abdomen Upper Quadrant: R/O Cardiac, Pulmonary, Renal, Musculoskeletal Causes Lower Quadrant: R/O Genitourinary Causes Diffuse Gastrointestinal 73 Peritonitic • Pancreatitis • Bowel Obstruction • Viscus Perforation • Intraperitoneal Hemorrhage (ruptured AAA) Localized Non-­‐Peritonitic • Gastroenteritis • Irritable Bowel Syndrome • Constipation • Metabolic Disease (e.g. Diabetic Ketoacidosis) • Mesenteric Ischemia • Mesenteric Thrombus • Sickle Cell Anemia • Musculoskeletal • Trauma • Peptic Ulcer Disease Abdominal Pain (Adult) Gastrointestinal Acute - Localized 74 Abdominal Pain (Adult) ABDOMINAL PAIN (ADULT): Chronic -­‐ Constant Chronic - Constant Chronic Abdominal Pain Recurrent abdominal pain? Consider tumor Upper Quadrant/Epigastric? Consider cardiac causes Lower quadrant? Consider genitourinary causes Gastrointestinal 75 Constant Cramping/Fleeting Post-­‐Prandial Upper Quadrant Lower Quadrant Any Location/Diffuse • Gastroesophageal Reflux Disease • Peptic Ulcer Disease •Chronic Pancreatitis • Pancreatic Tumor • Gastric Cancer • Liver Distention (e.g. Hepatomegaly, Tumor, Fat) • Splenic (e.g. Abscess, Splenomegaly) – very rare • Crohn’s Disease • Gynecologic (e.g. Tumor, Endometriosis) • Ascites • Muscle Wall • Neuropathic pain • Somatization Abdominal Pain (Adult) ABDOMINAL PAIN (ADULT): Chronic – Crampy/Fleeting Chronic - Crampy / Fleeting Chronic Abdominal Pain Constant Cramping/Fleeting Post-­‐Prandial Upper Quadrant Lower Quadrant Any Location/Diffuse • Biliary Colic/Cholelithiasis • Choledocholithiasis • Sphincter of Oddi Dysfunction • Renal Colic • Bloating (e.g. Celiac Disease, Lactose Intolerance) • Renal colic • Irritable Bowel Syndrome • Bowel Obstruction (e.g. Adhesions, Crohn’s, Volvulus, Neoplasm, Hernia) • Irritable Bowel Syndrome Gastrointestinal Recurrent abdominal pain? Consider tumor Upper Quadrant/Epigastric? Consider cardiac causes Lower quadrant? Consider genitourinary causes 76 Abdominal Pain (Adult) ABDOMINAL PAIN (ADULT): Chronic – Post-­‐Prandial Chronic - Post-Prandial Chronic Abdominal Pain Recurrent abdominal pain? Consider tumor Upper Quadrant/Epigastric? Consider cardiac causes Lower quadrant? Consider genitourinary causes Gastrointestinal 77 Constant Cramping/Fleeting Post-­‐Prandial Upper Quadrant Lower Quadrant Any Location/Diffuse • Biliary Colic/Cholelithiasis • Gastroesophageal Reflux Disease • Peptic Ulcer Disease/Dyspepsia • Gastric Cancer • Chronic Pancreatitis • Obstructing Colon Cancer • Obstructing Colon Cancer • Bowel Obstruction (e.g. Adhesions, Crohn’s, Volvulus, Neoplasm, Hernia) • Mesenteric Angina Anorectal Pain ANORECTAL PAIN Anorectal Pain Exclude: Poor Hygiene, Dietary, Anal Trauma Internal Lesion Diagnosis of Exclusion External Lesion Proctitis • Inflammation • Infection (Including Sexually Transmitted) Other • Malignancy • Solitary Rectal Ulcer Dermatologic • Dermatitis • Psoriasis Anorectal Disease • Fissure • Fistula/Abscess (Crohn’s) • Hemorrhoid Gastrointestinal • Proctalgia 78 Acute Diarrhea ACUTE DIARRHEA Acute Diarrhea > 2-­‐3 loose stools/day, >175-­‐235 g /day; > 48 hours, <14 days Infectious Ischemic Inflammatory Dietary Diarrhea Predominant Nausea/Vomiting Predominant Non-­‐Bloody Bloody • Bacillus cereus •Staphylococcus aureus Gastrointestinal 79 Watery/Large Volume (Small Bowel) • Viral • Bacterial (e.g. C. perfringens, V. cholerae, E. coli, Salmonella, Yersinia) • Parasitic (e.g. Giardia) • Drugs (Antibiotics, Laxatives, Antacids) • Toxins Bloody/Pain/Small Volume/Urgency (Large Bowel) • Bacterial (e.g. E. coli, C. difficile, Salmonella, Campylobacter, Shigella) • Parasitic (e.g. E. histolytica) • Crohn’s Ileitis • Crohn’s Colitis • Ulcerative Colitis • Crohn’s Colitis **C. difficile is under “large bowel” but presents with non-­‐bloody diarrhea usually. Ischemic colitis is a self-­‐limiting illness in most (due to vascular network from SMA, IMA, iliacs) whereas small bowel ischemia is an abdominal catastrophe (only one supply, SMA). Chronic Diarrhea Small Bowel CHRONIC DIARRHEA: Small Bowel Chronic Diarrhea >3 Loose Stools/Day, > 14 days Exclude Chronic Inflammation Secretory Large Bowel Small Volume/Bloody/Painful/ Tenesmus/Urgency Disordered Motility • Irritable Bowel Syndrome (diagnosis of exclusion) • Diabetic Neuropathy • Hyperthyroidism Mucosal • Crohn’s Disease (Screen with CBC, albumin, ESR, endoscopy) • Celiac Disease (screen with TTG) • Chronic Inflammation • Whipple’s Disease Small Bowel Large Volume/Watery Osmotic • Magnesium, Phosphate, Sulfate • Carbohydrate Malabsorption • Lactose Intolerance Tumors Mucosal • Gastrinoma • Carcinoid Syndrome • Mastocystosis Neoplastic • Adenocarcinoma • Lymphoma Gastrointestinal Steatorrhea Oily/Foul/Hard to Flush 80 Chronic Diarrhea Steatorrhea & Large Bowel CHRONIC DIARRHEA: Steatorrhea & Large Bowel Chronic Diarrhea >3 Loose Stools/Day, > 14 days Exclude Chronic Inflammation Large Bowel Steatorrhea Oily/Foul/Hard to Flush Maldigestive Gastrointestinal 81 Malabsorptive Small Volume/Bloody/Painful/ Tenesmus/Urgency Motility Small Bowel Large Volume/Watery Inflammatory • Irritable Bowel Syndrome • Inflammatory Bowel Disease • Hyperthyroid • Radiation Colitis • Ischemic Colitis • Pancreatic Insufficiency Primary Malabsorption • Celiac Disease • Mucosal Disease • Ileal Crohn’s Disease Secondary Malabsorption • Bacterial Overgrowth • Liver Cholestasis • Mesenteric Ischemia • Short Bowel/ Resection Secretory • Villous Adenoma • Colon Cancer • Microscopic Colitis Constipation (Adult) Altered Bowel Function & Idiopathic CONSTIPATION (ADULT): Altered Bowel Function & Idiopathic Constipation Infrequency (< 3 bowel movements/week)? Sensation of Blockage or incomplete evacuation? Straining? Diet/Lifestyle • Fibre • Calories • Fluid • Exercise • Psychosocial Medications • Neurally Active Medications (e.g. Opiates, Anti-­‐ Hypertensives) • Cation Related (e.g. Iron, Aluminum, Calcium, Potassium) • Anticholinergic (e.g. Antispasmodics, Antidepressants, Antipsychotics) Severe Idiopathic Colonic Inertia Secondary Causes Outlet Delay • Pelvic Floor Dyssyngergia Irritable Bowel Gastrointestinal Altered Bowel Function 82 Constipation (Adult) Secondary Causes CONSTIPATION (ADULT): Secondary Causes Constipation Infrequency (< 3 bowel movements/week)? Sensation of Blockage or incomplete evacuation? Straining? Altered Bowel Function Severe Idiopathic Secondary Causes Neurogenic Gastrointestinal 83 Peripheral • Hirschsprung’s Disease • Autonomic Neuropathy • Pseudo-­‐obstruction Non-­‐Neurogenic Central • Multiple Sclerosis • Parkinson’s Disease • Spinal Cord/Sacral/Cauda Equina Injury Metabolic • Hypothyroidism • Hypokalemia • Hypercalcemia Colorectal Disease • Colon Cancer • Colonic Stricture (Inflammatory Bowel Disease and Diverticular Disease) Constipation (Pediatric) CONSTIPATION (PEDIATRIC) Constipation Infrequent Bowel Movements? Hard, Small stools? Painful evacuation? Encopresis? Dietary/Functional • Insufficient Volume/ Bulk Older Child Neurologic Dietary/Functional • Hirschsprung’s Disease • Imperforate Anus • Anal Atresia • Intestinal Stenosis • Intestinal Atresia • Insufficient Bulk/Fluid • Withholding • Painful (e.g. Fissures) Anatomic • Bowel Obstruction • Pseudo-­‐obstruction Neurologic • Hirschsprung’s Disease • Spinal Cord Lesions • Myotonia Congenita • Guillain-­‐Barré Syndrome Gastrointestinal Neonate/Infant 84 Dysphagia DYSPHAGIA Dysphagia If heartburn present: Consider GERD Oropharyngeal Dysphagia Immediate Difficulty Esophageal Dysphagia Delayed Difficulty Difficulty initiating swallowing? Choking? Nasal Regurgitation? Structural • Tumors • Zenker’s Diverticulum • Foreign Body Gastrointestinal 85 Intermittent Symptoms • Esophageal Spasm Neuromuscular/Toxi c/Metabolic • Myasthenia Gravis • CNS Tumors • Cerebrovascular Accident • Multiple Sclerosis • Amyotrophic Lateral Sclerosis • Polymyositis Progressive Symptoms • Scleroderma • Achalasia • Diabetic Neuropathy Food sticks seconds later/ Further down? Functional Motor Disorder Solids and/or Liquids Mechanical Obstruction Solids only Intermittent Symptoms Progressive Symptoms • Reflux Stricture • Schatzki Ring • Esophageal Cancer • Esophageal Web • Eosinophilic Esophagitis Elevated Liver Enzymes ELEVATED LIVER ENZYMES ELEVATED LIVER ENZYMES ELEVATED LIVER EENZYMES ELEVATED ELEVATED ELEVATED LLLIVER IVER IVER EENZYMES NZYMES NZYMES Elevated Liver Enzymes Elevated Liver Enzymes Elevated Liver Enzymes LLiver EEnzymes Elevated Elevated Liver iver Enzymes nzymes Hepatocellular Elevated Cholestatic (does not always cause • •• • • Drugs/Toxins • Viral • •• •Autoimmune Viral •Ischemia Viral Viral • Drugs/Toxins •• •• •Wilson’s Drugs/Toxins •Autoimmune Drugs/Toxins Drugs/Toxins Ischemia •• •• •Pregnancy Ischemia •Wilson’s Ischemia Ischemia Autoimmune • AFLP • Autoimmune • Pregnancy • Autoimmune Autoimmune • •Wilson’s ••Wilson’s HELLP AFLP •Wilson’s Wilson’s • • •Pregnancy • ••Pregnancy HELLP Pregnancy • •Pregnancy AFLP •AFLP • AFLP AFLP • •HELLP • •HELLP • HELLP HELLP Dx ALF if Dx ALF if ↑INR and hepatic ↑INR Dx aAnd LF hifepatic encephalopathy Dx AALF ififif Dx A LF encephalopathy ↑INR aDx nd hLF epatic ↑INR a nd hhepatic ↑INR ↑INR aand nd hepatic epatic encephalopathy encephalopathy encephalopathy encephalopathy Drugs • •Viral • •AIH Wilson’s Viral •Viral Viral • ••Drugs Hemochromatosis Drugs •Wilson’s •Drugs Drugs • •••AIH NAFLD • AIH • Hemochromatosis • • AIH AIH • Wilson’s Others Wilson’s •NAFLD •Wilson’s Wilson’s • ••Hemochromatosis • Hemochromatosis • Others • • Hemochromatosis Hemochromatosis • NAFLD •NAFLD •NAFLD NAFLD • •Others • •Others •Others Others ETOH hepatitis ETOH hepatitis usually cholestatic, usually holestatic, ETOH hcepatitis and huhepatitis sually ETOH ETOH ETOH hepatitis epatitis and usually usually cholestatic, ALT <cholestatic, 300 usually c usually usually ALT <cholestatic, holestatic, 300 and usually and u sually and and u u sually sually ALT < 300 ALT << <3 3 00 ALT ALT 300 00 Jaundice) LT or cAause ST Cholestatic (does AnLP ot >a A lways Jaundice) ALP > AaLT or AST Cholestatic (does not lways cause Cholestatic (does aalways Cholestatic Cholestatic (A (does not ot lways cause ause US – Dilated Bile Jaundice) LP >n not A LT oalways ASTccause US –does Normal Br ile Mild Jaundice) AALP >> >A A oor or Ar AST Jaundice) Jaundice) ADucts LP LP LT ALT LT AST ST Ducts ALT < 5x ULN US – Normal Bile US – Dilated Bile Mild • PBC Ducts Bile DuctsBB ALT Mild < 5x ULN US – Normal US – Dilated ile • NAFLD • Common ile Duct US – Normal B ile US – Dilated BBile Mild • PSC US US –Ducts –Normal Normal BBile ile US US –Ducts –Dilated Dilated Bile ile Mild • PBC ALT < 5Mild x ULN Alcohol Stone • •NAFLD • Common Bile Duct • Alcoholic hepatitis Ducts Ducts ALT < 5 x U LN Ducts Ducts Ducts Ducts ALT ALT < < 5 5 x x U U LN LN • PSC Viral • Biliary stricture • PBC • •Alcohol • NAFLD ••Viral NAFLD •Hemochromatosis NAFLD NAFLD • ••Alcohol ••Hemochromatosis Alcohol •Drugs Alcohol Alcohol • ••Viral ••Drugs Viral •AIH Viral Viral • ••Hemochromatosis • A1AT deficiency • Hemochromatosis • AIH • • Hemochromatosis Hemochromatosis • Drugs •A1AT Drugs deficiency •Wilson’s Drugs Drugs • ••AIH • AIH • Others • Wilson’s •AIH AIHdeficiency • A1AT A1AT ddeficiency •Others disease •Cholestatic A1AT A1AT deficiency eficiency • ••Wilson’s Wilson’s •Cholestatic •Wilson’s Wilson’s disease • ••Others •Others •Others Others disease • •Cholestatic • •Cholestatic ddisease •Cholestatic Cholestatic disease isease NAFLD NAFLD 10% population 10% NAFLD population NAFLD NAFLD 10% pNAFLD opulation 10% ppopulation 10% 10% population opulation • Stone Common Bile Duct Drugs hepatitis PBC •Alcoholic ••PBC PBC • PSCstricture • ••PSC Common BBile DDuct •• •Biliary •Common Common Bile ile Duct uct Stone TPN hepatitis PSC •Drugs ••PSC PSC • ••Alcoholic • Worms/flukes Stone • PSC Stone Stone • Biliary stricture Sepsis hhepatitis Alcoholic •TPN ••Alcoholic Alcoholic hepatitis epatitis • ••Drugs • Cholangiocarcinoma Biliary stricture ••PSC Worms/flukes • • Biliary Biliary s s tricture tricture • Infiltrative Drugs •Sepsis ••Drugs Drugs • ••TPN • Pancreatic cancer PSC •Cholangiocarcinoma •PSC PSC • ••Worms/flukes TPN •Infiltrative •TPN TPN • Sarcoid • ••Sepsis • Others cancer Worms/flukes •Pancreatic •Worms/flukes Worms/flukes • ••Cholangiocarcinoma • Amyloid • Sarcoid •Sepsis •Sepsis Sepsis • •Infiltrative • Cholangiocarcinoma • Others ••Cholangiocarcinoma Cholangiocarcinoma • Pancreatic cancer • •Infiltrative Amyloid • Malignancy •Infiltrative Infiltrative • •Sarcoid •Others cancer •Pancreatic •Pancreatic Pancreatic ccancer ancer • Sarcoid Infection •Malignancy ••Sarcoid Sarcoid • ••Amyloid • •Others •Others Others • Amyloid • Infection ••Amyloid Amyloid • Cirrhosis (any) • Malignancy • Cirrhosis (any) •Malignancy •Malignancy Malignancy •Congenital • •Infection • •Infection •Infection Infection • •Congenital Cirrhosis (•Biliary any) Atresia • Cirrhosis •Biliary Atresia • • Cirrhosis Cirrhosis ((any) any) •Alagille Syndrome •Congenital (any) •Congenital •Alagille Syndrome •Congenital •Congenital •Biliary Atresia •Progressive Familial •Biliary A tresia •Progressive Familial •Biliary •Biliary A A tresia tresia •Alagille Syndrome Intracholestasis •Alagille Syndrome Intracholestasis •Alagille •Alagille Syndrome Syndrome •Progressive F amilial ERCP for dx Dx by biopsy •Progressive FFamilial amilial ERCP for dx Intracholestasis Dx •Progressive b•Progressive y biopsy Familial and therapy ± MRI/MRCP Intracholestasis and tfherapy ± MRI/MRCP ERCP or dx Dx by Intracholestasis bIntracholestasis iopsy bby bbiopsy Dx Dx by y biopsy iopsy ±Dx MRI/MRCP ±±±MRI/MRCP MRI/MRCP MRI/MRCP ERCP for ddxdxx ERCP ERCP ffor or and therapy and therapy and and ttherapy herapy Gastrointestinal Severe ALT >Severe 15x ULN ALT Severe > 15x ULN Viral Severe ALT > Severe 1Severe 5x ULN Drugs/Toxins Viral ALT >> >1 1 5x UULN ALT ALT 15x 5x ULN LN Ischemia ALT or AST > ALP Hepatocellular ALT or AST > ALP Hepatocellular Hepatocellular Hepatocellular Hepatocellular ALT or AST > ALP Moderate ALT oor or Ar AST >> >A A ALT ALT AST ST LP ALP LP ALT 5–15x ULN Moderate ALT 5 –15x U LN Moderate • ViralModerate Moderate ALT 5Moderate –15x ULN Drugs •• Viral ALT 55–15x UULN ALT ALT 5–15x –15x ULN LN • AIH 86 Hepatomegaly HEPATOMEGALY Hepatomegaly Rule out concurrent splenomegaly and jaundice Infiltrative Congestive • Right Heart Failure • Budd-­‐Chiari Syndrome • Constrictive Pericarditis Gastrointestinal 87 Malignant • Primary Carcinoma • Metastases • Lymphoma • Leukemia • Polycythemia • Multiple Myeloma Non-­‐Malignant • Fatty Liver • Cysts • Hemochromatosis • Wilson’s Disease • Amyloidosis • Myelofibrosis Infectious • Hepatitis A, B, C • Mononucleosis • Tuberculosis • Bacterial Cholangitis • Abscess • Schistosomiasis Inflammatory • Alcoholic Hepatitis • Autoimmune Hepatitis • Drug Induced Hepatitis • Sarcoidosis • Histiocytosis X • Primary Sclerosing Cholangitis • Primary Biliary Cirrhosis Jaundice JAUNDICE Jaundice Pre-­‐Hepatic Unconjugated Hyperbilirubinemia Post-­‐Hepatic Usually has Duct Dilatation on Ultrasound Hepatic Conjugated Hyperbilirubinemia • Hepatocellular • Cholestatic • Dubin Johnson Increased Production • Hemolysis • Ineffective Erythropoiesis • Hematoma Decreased Hepatic Uptake • Sepsis • Drugs (e.g. Rifampin) Decreased Conjugation • Gilbert’s Syndrome • Crigler-­‐Najjar Syndromes (I and II) Biliary Duct Compression • Malignancy • Metastases • Pancreatitis Intraductal Obstruction • Gallstones • Biliary Stricture • Cholangiocarcinoma • Primary Sclerosing Cholangitis Gastrointestinal See Elevated Liver Enzymes scheme 88 Liver Mass LIVER MASS Liver Mass Cystic Benign Solid Malignant Benign Malignant • Cystadenocarcinoma Simple Gastrointestinal 89 Complex •Cyst •Polycystic Liver Disease •Caroli’s Proliferative Infectious Proliferative •Cystadenoma •Hydatid Cyst • Hemangioma • Focal Nodular Hyperplasia • Adenoma Infectious • Abscess Primary Malignancy • Hepatocellular Carcinoma • Cholangiocarcinoma Secondary Malignancy • Metastases (e.g. Lung, Colon, Breast) Mouth Disorders (Adult & Elderly) MOUTH DISORDERS: Adult and Elderly Mouth Disorders Consider oral manifestations of systemic disease Teeth Mucous Membrane • GERD (Dissolves enamel) • Sjögren’s Syndrome (Dental Caries) Gastrointestinal • Crohn’s Disease • Ulcerative Colitis • NSAIDs Other • Canker Sore • Cold Sore • Anemia • Langerhan’s Cell Histiocytosis • Wegener’s Disease • Sarcoidosis • Drug Induced • Sexually Transmitted Infection Non-­‐Ulcerating Lighter (White) Darker (Red) • Gingivitis • Kawasaki Disease (Strawberry Tongue) • Other Gum Disease • Mucocele • Allergic Reaction Non-­‐Neoplastic • Candidiasis • Lichen Planus • Anemia Neoplastic • Leukoplakia • Squamous Cell Carcinoma No Colour Change • Chronic Liver Disease • Sjögren’s Syndrome • Acromegaly • Amyloidosis • Psoriasis • Gingival Hyperplasia • Dry Mouth Gastrointestinal Ulcerating 90 Nausea & Vomiting NAUSEA AND VOMITING: Gastrointestinal Disease Gastrointestinal Disease Nausea and Vomiting Gastrointestinal Disease Other Systemic Disease Upper Gastrointestinal Gastrointestinal 91 Hepatobiliary Lower Gastrointestinal • Acute Hepatitis • Acute Cholecystitis • Cholelithiasis • Choledocholithiasis • Acute Pancreatitis Acute • Infectious Gastroenteritis • Gastric/Duodenal Obstruction • Gastric Volvulus Chronic • Gastroesophageal Reflux Disease • Peptic Ulcer Disease • Gastroparesis Acute • Infectious Gastroenteritis • Small/Large Bowel Obstruction • Acute Appendicitis • Mesenteric Ischemia • Acute Diverticulitis Chronic • Inflammatory Bowel Disease • Colonic Neoplasm Nausea & Vomiting NAUSEA AND VOMITING: Other Systemic Disease Other Systemic Disease Nausea and Vomiting Endocrine/Metabolic • Pregnancy • Diabetes/ DKA • Uremia • Hypercalcemia • Addison’s Disease • Thyroid Disease Other • Sepsis (e.g. Pyelonephritis, Pneumonia) • Radiation Sickness • Acute Myocardial Infarction High Intracranial Pressure • Hemorrhage • Meningitis • Infarction • Malignancy • Head Trauma Other Systemic Disease Drugs/Toxins Central Nervous System • Chemotherapy • Antibiotics • Ethanol • Carbon Monoxide • Heavy Metal • Nicotine Vestibular (Inner Ear) • Ear Infection • Motion Sickness • Vestibular Migraine • Ménière’s Disease Psychiatric • Self-­‐Induced (Bulimia) • Cyclic Vomiting • Psychogenic Gastrointestinal Gastrointestinal Disease 92 Stool Incontinence STOOL INCONTINENCE Stool Incontinence Intact Pelvic Floor Trauma/Surgery • Surgery: Anorectal, Prostate, Bowel • Pelvic Fracture • Pelvic Inflammation Gastrointestinal 93 Chronic Constipation • Stool Impaction with overflow • Encopresis Affected Pelvic Floor Nerve/Sphincter Damage Congenital Anorectal Malformation • Vaginal Delivery • Rectal Prolapse • Severe Hemorrhoid Neurological Conditions Diarrheal Conditions • Age-­‐Related (e.g. Dementia, Strokes) • Neuropathy (e.g. Diabetes, Congenital Megacolon, Hirschsprung’s Disease) • Multiple Sclerosis • Tumors/Trauma (e.g. Brain, Spinal Cord, Cauda Equina) • Inflammatory Bowel Disease • Irritable Bowel Syndrome • Chronic Laxative Use Stress and Emotional Problems Upper Gastronintestinal Bleed UPPER GASTROINTESTINAL BLEED (HEMATEMESIS/MELENA) (Hematemesis / Melena) Acute Hematemesis/Melena Blood in vomitus?/black, tarry stools If Melena, 5-­‐10% colorectal/small bowel. Exclude bleeding disorder. Peptic Ulcer Disease (55%) Portal Hypertension (15%) Other Gastric Acid Hypersecretion • Zollinger-­‐Ellison Syndrome Non-­‐Steroidal Anti-­‐ Inflammatory Drugs Stress (ICU Setting) Helicobacter Pylori Retching? Mallory Weiss Tear Tumors • Benign • Malignancy Esophagitis/ Gastritis Gastrointestinal • Gastro-­‐esophageal varices 94 Lower Gastrointestinal Bleed LOWER GASTROINTESTINAL BLEED Lower Gastrointestinal Bleed Occult (Stool + Occult blood and/or iron deficiency anemia) Overt Bleeding In Patient Gastrointestinal 95 • • • • Colorectal cancer Angiodysplasia (colon or small bowel) Occult UGI bleeding (ulcer, esophagitis, gastritis, cancer) Other: small bowel tumors, asymptomatic IBD • RULE OUT BRISK Upper GI bleed, Diverticular bleed, • Acute colitis (ischemia, infectious, inflammatory), • Small bowel source (e.g. Meckel's, tumor), • Angiodysplasia Out Patient • Perianal Disease (most common) • Inflammatory Bowel Disease • Colorectal Cancer Weight Gain WEIGHT GAIN Weight Gain Increased Intake • Dietary • Social/Behavioural • Iatrogenic • Depression • Dementia Hypothalamic/Pituitary Gonadic • Hypothalamic Syndrome • Growth Hormone Deficiency • Polycystic Ovarian Syndrome • Hypogonadism Other Causes • Cushing’s Disease • Hypothyroidism Gastrointestinal Neurogenic/Genetic Decreased Expenditure • Sedentary Lifestyle • Smoking Cessation 96 Weight Loss WEIGHT LOSS Weight Loss Decreased Intake • GI illness (upper and lower) • Psychiatric (Depression, eating disorders) • Poverty •Abuse • Dementia • Anorexia as an Adverse Drug Effect Gastrointestinal 97 Malabsorption • Small Bowel Disease (e.g. Crohn’s Disease, Celiac Disease) • Pancreatic Insufficiency • Cholestatic Liver Disease • Protein-­‐losing Enteropathy (e.g. Inflammatory Bowel Disease) Increased Expenditure • Increased Protein/Energy Requirements (e.g. Post-­‐Surgical, Infections, Trauma, Burns) • Cancer • Hyperthyroidism • Chronic Cardiac/Respiratory distress (e.g. COPD) • Chronic Renal Failure • Adrenal Insufficiency • Poorly Controlled Diabetes Mellitus • HIV Renal Acute Kidney Injury������������������������������������������������������ 101 Proteinuria����������������������������������������������������������������������������115 Chronic Kidney Disease��������������������������������������������102 Renal Mass Solid������������������������������������������������������������ 116 Dysuria�����������������������������������������������������������������������������������103 Renal Mass Cystic�����������������������������������������������������������117 Generalized Edema������������������������������������������������������104 Scrotal Mass����������������������������������������������������������������������� 118 Hematuria����������������������������������������������������������������������������105 Suspected Acid-Base Disturbance������������������ 119 Hyperkalemia Intercellular Shift������������������������ 106 Metabolic Acidosis Elevated Anion Gap������120 Hyperkalemia Reduced Excretion��������������������107 Metabolic Acidosis Normal Anion Gap�����������121 Hypokalemia�������������������������������������������������������������������� 108 Metabolic Alkalosis ����������������������������������������������������� 122 Hypernatremia���������������������������������������������������������������� 109 Urinary Incontinence��������������������������������������������������� 123 Hyponatremia������������������������������������������������������������������� 110 Urinary Tract Obstruction�����������������������������������������124 Hypertension���������������������������������������������������������������������� 111 Increased Urinary Frequency��������������������������������112 Renal 99 Nephrolithiasis������������������������������������������������������������������113 Polyuria�����������������������������������������������������������������������������������114 Historical Editors Student Editors Dr. Andrew Wade Colin Roscher (Co-editor) Dr. Sophia Chou Mark Elliot (Co-editor) Dave Campbell Derrick Chan Faculty Editor Marc Chretien Dr. Kevin McLaughlin Mollie Ferris Kody Johnson Becky Kennedy Vera Krejcik Keith Lawson Eric Sy Maria Wu Renal Vanessa Millar 100 Acute Kidney Injury ACUTE KIDNEY INJURY ACUTE KIDNEY INJURY Acute Kidney Injury Acute Kidney Injury Acute increase in creatinine by at least 50% Pre-­‐Renal (FeNa < 1%, bland urine sediment) Acute increase in creatinine by at least 50% Renal Pre-­‐Renal (FeNa < 1%, bland urine sediment) Renal Systemic Hypoperfusion • Hepatorenal syndromes • Drugs Renal • Emboli Hypoperfusion Hypotension • Shock Systemic Hypotension Tubular • Hepatorenal • Shock Acute Tubular syndromes Necrosis • Drugs (Epithelial cell casts) • Emboli Renal 101 • Ischemia (severe hypotension) • Toxins (contrast, Acute aminoglycosides, Tubular Necrosis chemotherapy) • Pigments (Epithelial cell casts) • Ischemia (severe Tubular Obstruction Tubular • Cast nephropathy (multiple myeloma) • Urate crystals •Tubular Calcium Oxalate (Ethylene glycol) Obstruction • Cast nephropathy (FeNa > 2%) Urinalysis Renal and CBC (FeNa > 2%) Urinalysis and CBC Vascular (Thrombocytopenia and schistocytosis on CBC) TTP/HUS Vascular (Thrombocytopenia and schistocytosis on (E. CBC) • Shiga-­‐like toxin coli) • Drugs • HIV • Malignancy TTP/HUS • Shiga-­‐like toxin (E. coli) Post-­‐Renal (Obstruction/hydronephrosis on U/S) • Benign Prostatic Hyperplasia • Constipation Post-­‐Renal • Prostate Cancer (Obstruction/hydronephrosis on U/S) • Urolithiasis • Benign Prostatic Hyperplasia • Constipation Glomerular • Prostate CancerInterstitial (RBC casts, (Sterile pyuria, • Urolithiasis dysmorphic RBCs) Rapidly Progressive Glomerular Glomerulonephritis (RBC casts, • Anti-­‐dysmorphic GBM antibodies RBCs) eosinophiluria) Acute Interstitial Interstitial Nephritis (Sterile pyuria, • Drugs (NSAIDs, Abx, eosinophiluria) • Immune-­‐complex allopurinol, PPI) deposition (IgA, post-­‐ • Infections (CMV, strep, strep, lupus) Progressive legionella) Acute Interstitial Rapidly • Pauci-­‐immune • Immune (lupus, sarcoid, Nephritis GlomerulonephritisSjögren) (Wegener's) • Anti-­‐GBM antibodies • Drugs (NSAIDs, Abx, Chronic Kidney Disease CHRONIC KIDNEY DISEASE Chronic Kidney Disease Decreased kidney function (eGFR < 60ml/min/1.73m2) persistent over at least 3 months Renal (Abnormal urinalysis: proteinuria/pyuria) • Reflux nephropathy • Benign prostatic hyperplasia • Constipation • Prostate cancer • Atheroemboli • Renal artery stenosis • Drugs • Chronic hypoperfusion Tubular Post-­‐Renal (Obstruction/hydronephrosis on U/S) Vascular (Family history, ultrasound) (Other small vessel disease) • Polycystic kidney disease • Medullary cystic disease • Nephronophthisis • Atherosclerosis Glomerular (Proteinuria) • Diabetes • Hypertension Interstitial (Sterile pyuria, WBC casts, eosinophiluria) • Drugs (NSAIDs, analgesics) • Infections (chronic pyelonephritis) • Immune (sarcoid, Sjögren) • Multiple myeloma • Hyperoxaluria • Hypercalcemia • Hyperphosphatemia Renal Pre-­‐Renal (Evidence of Renovascular disease) 102 Dysuria DYSURIA Dysuria Pyuria No Pyuria Leukocytes on Dipstick/Microscopy Bacteriuria & Hematuria Dipstick positive for nitrites (if infected with enterobacteria). No Leukocytes on Dipstick/Microscopy No Bacteriuria & No Hematuria • Gonococcal • Non-­‐Gonococcal (e.g. Chlamydia, Trichomonas) Renal 103 Upper Urinary Tract Infection/Pyelonephritis WBC Casts Urethritis Dipstick negative for nitrites. • Candida • Herpes Simplex Virus Lower Urinary Tract Infection/Cystitis WBC Clumps Vaginitis • Candida • Gardnerella • Neoplasm Non-­‐Pathogenic • Estrogen deficiency • Interstitial cystitis • Radiation cystitis Generalized Edema GENERALIZED EDEMA Generalized Edema Increased blood pressure Overfill Underfill (Increased renal sodium retention, Urine Na > 40meq/L) (Urine Na < 20meq/L) • NSAIDs • AKI/CKD • Nephrotic Syndrome Signs of left ventricular failure Increased Interstitial Oncotic Pressure • Myxedema (Hypothyroid) Increased Capillary Hydrostatic Pressure • Right heart failure • Constrictive pericarditis • Portal hypertension • Pregnancy Congestive Heart Failure “forward failure” (Relative decrease in EABV) Low serum albumin due to loss or impaired synthesis Severely ill (e.g. in ICU) Decreased Capillary Oncotic Pressure Increased Capillary Permeability • Nephrotic syndrome • Cirrhosis • Inflammation • Sepsis • Acute Respiratory Distress Syndrome • Allergies • Burns/Trauma Renal Altered Startling Forces (Absolute decrease in EABV) 104 Hematuria Renal 105 (Granulomatosis with polyangiiis/microscopic polyangiiis) Hyperkalemia Intercellular Shift HYPERKALEMIA: Transcellular Shift Hyperkalemia TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine) Hyperkalemia Serum Potassium > 5.5 mmol/L Serum Potassium > 5.5 mmol/L Reduced Excretion Reduced Excretion TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine) Exclude pseudohyperkalemia Leukocytosis, thrombocytosis, Exclude pseudohyperkalemia hemolysis Increased Intake (IV potassium with reduced excretion) Increased Intake (IV potassium with reduced excretion) Increased Release Increased Serum Osmoles, Increased Urate, Phosphate, Creatinine Kinase Increased Release • Non-­‐Anion Gap Metabolic Acidosis Increased Serum Osmoles, Increased • Hyperosmolarity Phosphate, Creatinine Kinase • Cell Urate, Lysis (e.g. Tumor Lysis Syndrome, rhabdomyolysis) • Non-­‐Anion Gap Metabolic Acidosis • Hyperosmolarity Leukocytosis, thrombocytosis, hemolysis Transcellular Shift Appropriate renal excretion (GFR, TTKG, distal flow adequate) Transcellular Shift Appropriate renal excretion (GFR, TTKG, distal flow adequate) Decreased Entry Decreased Na+-­‐H+ Exchanger Decreased Na+-­‐K+-­‐ATPase Decreased Entry • Insulin Deficiency/Resistance Decreased Na+-­‐H+ Exchanger • β2 antagonism + + • α1 agonism Decreased Na -­‐K -­‐ATPase • Digoxin • Insulin Deficiency/Resistance • β2 antagonism Renal HYPERKALEMIA: Transcellular Shift 106 HYPERKALEMIA: Reduced Excretion Hyperkalemia Reduced Excretion Hyperkalemia HYPERKALEMIA: Reduced Excretion Exclude pseudohyperkalemia Leukocytosis, thrombocytosis, hemolysis Serum potassium > 5.5 mmol/L Hyperkalemia Serum potassium > 5.5 m mol/L Increased Intake (IV potassium with reduced excretion) Reduced Excretion Reduced Excretion Principal Cell Problem TTKG < 7 Principal Cell Problem TTKG < 7 High Renin High Aldosterone Renal 107 • ENaC blockers •High AIN/CIN Renin • Obstruction High Aldosterone • ENaC blockers • AIN/CIN • Obstruction Increased Intake (IV potassium with reduced excretion) Reduced flow through distal nephron TTKG > 7, Urine Na < 20meq/L • Low EABV (e.g., CHF, cirrhosis, hypotension) Reduced flow through distal nephron TTKG > 7, Urine Na < 20meq/L • Low EABV e.g., CHF, cirrhosis, Low Renin High R(enin hypotension) Low Aldosterone Low Aldosterone • ACEi/ARB • Adrenal insufficiency Renin •High Heparin Low Aldosterone • ACEi/ARB • Adrenal insufficiency • Heparin Exclude pseudohyperkalemia Leukocytosis, thrombocytosis, Transcellular Shift hemolysis Transcellular Shift Decreased Glomerular Filtration Rate Increased Creatinine • Chronic renal failure • AKI Decreased Glomerular Filtration Rate Increased Creatinine • Chronic renal failure • AKI • Diabetic nephropathy • β2 antagonism Renin • Low NSAIDs Low Aldosterone • Diabetic nephropathy • β2 antagonism • NSAIDs TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine) Hypokalemia HYPOKALEMIA Hypokalemia Serum Potassium <3.5 mmol/L Decreased intake Increased Loss Renal Loss GI loss Urine loss >20mmol/d High distal [K] Urine loss <20mmol/d High distal flow TTKG > 4 Transcellular shift (rare cause in isolation) TTKG < 4 •Polyuria • Diarrhea • Vomiting • NG suction • Laxatives • Insulin • β2 agonists • alkalemia • Refeeding syndrome • Rapid hematopoiesis • Hypothermia • Thyrotoxic periodic paralysis/familial hypokalemic periodic paralysis EABV contracted Normal or expanded EABV • Loop diuretics/ Bartter’s syndrome • Thiazide diuretics/ Gittelman’s syndrome • Magnesium depletion High renin High aldosterone •Renal artery stenosis Low renin High aldosterone •Hyperaldosteronism Low renin Low aldosterone •Licorice intake •Liddle’s syndrome Renal Volume Status Assessment 108 Hypernatremia HYPERNATREMIA Hypernatremia Excess free water loss Serum Sodium >145 mmol/L High Urine Volume Low Urine Volume >3L/24 hours Renal water loss High Urine Osmolality Low Urine Osmolality • Hypertonic saline administration • Osmotic diuresis (see Polyuria scheme) e.g., mannitol, glucosuria •Diabetes Insipidus > 300 mmol/kg Renal 109 <3L/24 hours < 300 mmol/kg Non-­‐renal losses Hypodipsia Decreased intake of water • Decreased level of consciousness • No access to water GI loss • Watery Diarrhea Insensible loss • Burns • ICU patients • Fever • Inadequate intake for exercise-­‐related loss • Hyperventilation Hyponatremia Artifactual Normal Posm Artifactual High Posm Hyponatremia Hyponatremia Serum Sodium <135 mmol/L Serum Sodium <135 mmol/L Posm < 280 mmol/kg Impaired H20 Excretion Intact H20 Excretion Intact H20 Excretion Hyper-­‐osmolar urine Uosm > 100 Hyper-­‐osmolar mmol/kg urine Hypo-­‐osmolar urine Uosm < 100 m mol/kg Hypo-­‐ osmolar urine 280-­‐295mmol/kg >295mmol/kg High Posm Normal Posm • Reduced GFR Impaired H20 Excretion 280-­‐295mmol/kg >295mmol/kg • Hyperglycemia* •Hypertriglyceridemia • Diuretics • Reduced GFR • Mannitol • Hyperglycemia* • Paraproteinemia •Hypertriglyceridemia • Diuretics • Mannitol • Paraproteinemia ADH expression Uosm > 100 mmol/kg ADH expression Syndrome of Inappropriate ADH Hypo-­‐osmolar plasma Posm < 280 Hypo-­‐ mmol/kg osmolar plasma ADH suppression Uosm < 100 mmol/kg • Primary polydipsia ADH suppression • Insufficient o•smole intake Primary polydipsia • Insufficient osmole intake Reduced EABV Euvolemic; no physiologic stimulus to ADH Urine [Na+] < 20mmol/L Syndrome of Inappropriate ADH Reduced EABV Euvolemic; no physiologic stimulus to ADH Urine [Na+] < 20mmol/L • Pain/Post-­‐op • Neurologic trauma • Pain/Post-­‐op True hypovolemia With edema Hormonal changes • Drugs • Neurologic trauma True hypovolemia With edema Hormonal changes • Pulmonary p•athology Drugs • Congestive heart failure • Bleeding • Hypothyroidism • Malignancy • Pulmonary pathology • Cirrhosis • GI losses • Bleeding • Adrenal • Congestive heart failureinsufficiency • Hypothyroidism • Malignancy • Nephrotic syndrome • Renal losses • GI losses • Pregnancy • Adrenal insufficiency • Cirrhosis (especially • Renal losses • Reduced GFR• Nephrotic syndrome • Pregnancy AKI/CRF thiazide diuretics) • Reduced GFR (especially *serum sodium correction in hyperglycemia: AKI/CRF thiazide d iuretics) [Na+]corrected = [*serum Na+] + (s0.3 * ( [glucose] – 5)) odium correction in hyperglycemia: [Na+]corrected = [Na+] + (0.3 * ( [glucose] – 5)) Renal HYPONATREMIA HYPONATREMIA 110 Hypertension HYPERTENSION HYPERTENSION Hypertension BP > 140/90 (>130/80 for DM) Hypertension Consider secondary HTN •Onset <20yo, >50yo secondary HTN Consider •No FHx BP >o 1r 40/90 (>130/80 DM) Hypertensive urgency emergency (any for visit) •Hypertensive urgency •Onset <20yo, >50yo Hypertension with end-­‐organ damage or DM (visit 2) •Refractory hypertension •No FHx Diagnosis based Hypertensive on repeat clinic visits, oAr mbulatory urgency emergency b(lood any visit) (multi-­‐ d rug r esistance) •Hypertensive urgency pressure monitor, Self/Home pressure monitoring (visit +)(visit 2) Hypertension with end-­‐organ damage or D3M •Refractory hypertension Diagnosis based on repeat clinic visits, Ambulatory blood (multi-­‐drug resistance) pressure monitor, Self/Home pressure monitoring (visit 3+) Essential (Primary) Hypertension Essential (Primary) Hypertension Cardiac Output (Volume dependent) Cardiac Output (Volume dependent) Renal 111 Secondary Hypertension Secondary Hypertension Systemic Vascular Resistance (Vasoconstrictive) Systemic Vascular Resistance (Vasoconstrictive) Renal Parenchymal Mineralocorticoid Vasoconstrictors Anatomic Causes Metabolic Causes Diseases Excess Renal Parenchymal Mineralocorticoid Anatomic Causes Metabolic Causes • Sympathetic nVasoconstrictors ervous system • Aortic coarctation • Conn’s syndrome • Hyperthyroidism • Glomerulonephritis Diseases • NSAIDs Excess (ie. cocaine, • Hypercalcemia • Nephritic syndrome • Unilateral RAS • Licorice • Conn’s syndrome pheochromocytoma) • Pheochromocytoma • AKI/CKD • Glomerulonephritis • Sympathetic nervous system • Aortic coarctation • Hyperthyroidism • Steroids ((ie. Cushing’s, exogenous • Liddle’s syndrome cocaine, • Hypercalcemia • NSAIDs • Nephritic syndrome • Unilateral RAS steroids) • Bilateral R AS pheochromocytoma) • Licorice • Pheochromocytoma • AKI/CKD • Steroids s(timulation Cushing’s, exogenous • Liddle’s syndrome• Renin-­‐Angiotensin (OCP) steroids) • Bilateral RAS • Alcohol a•buse/ wAithdrawal Renin-­‐ ngiotensin stimulation •Unilateral (OCP) RAS • Alcohol abuse/ withdrawal Increased Urinary Frequency INCREASED URINARY FREQUENCY Increased Urinary Frequency Non-­‐increased urine volume (<2mL/min) Rule out polyuria Intrinsic to Urinary Tract Extrinsic to Urinary Tract Urinary Tract Infection Urinary Obstruction (See Dysuria scheme) • Benign prostatic hyperplasia • Prostatitis • Prostate cancer • Nephrolithiasis Small volume bladder Detrusor Hyperactivity • Overactive Bladder •Diabetes • MS • Irritant drugs: Diuretics, caffeine, alcohol Renal • Vulvovaginitis • Bladder compression/Pregnancy 112 Nephrolithiasis NEPHROLITHIASIS Nephrolithiasis Radio-­‐opaque Radiolucent Calcium-­‐containing 90% of stones Non-­‐calcium 10% of stones Hard Stones Calcium oxalate/phosphate 80% of stones Renal 113 Hypercalciuria • Increased PTH • High salt intake • High protein intake Soft Stones Struvite Stones Cysteine Stones 10% of stones • Urinary tract infection Hyperoxaluria • Enteric overproduction • Low calcium intake • Dietary • Ethylene glycol ingestion Non Calcium containing, but opaque • Cystinuria Stones with decreased solubility • Low urine volume • Hypocitraturia • RTA type I • High protein intake Uric Acid Stones • Hyperuricosuria • High protein intake Anatomical problem • Medullary sponge kidney Polyuria POLYURIA Polyuria Urine Output > 3L/day Increased Urine Volume (>2ml/min) Osmotic Diuresis Water Diuresis • Hyperglycemia (uncontrolled Diabetes Mellitus) • Mannitol administration • Increased urea concentration (e.g. Recovery from Acute Renal Failure, increased protein feeds, Hypercatabolism [Burns, Steroids], GI Bleed) • NaCl administration Urine Osmolality < Serum Osmolality Hypotonic Urine Following Water Deprivation Test Excessive Loss Give DDAVP Uosm Increased by >50% Proper kidney response • Central Diabetes Insipidus Hypertonic Urine Following Water Deprivation Test • Primary polydipsia Uosm unchanged or increased by <50% Renal Urine Osmolality > Serum Osmolality Unresponsive Kidney • Nephrogenic Diabetes Insipidus 114 Proteinuria Renal 115 Granulomatosis with polyangiiis (GPA)/microscopic polyangiiis (MPA) RENAL MASS: Solid Renal Mass Solid Renal Mass Benign <3 cm in size Presence of fat on CT • Angiomyolipoma (hamartoma) • Oncocytoma • Tuberous Sclerosis Cystic Suspicious >3 cm in size • Renal Cell Carcinoma • Wilm’s tumor (nephroblastoma) • Metastatic spread to kidneys Renal Solid 116 Renal Mass RENAL MASS: Cystic Cystic Renal Mass Solid Cystic Benign Suspicious Anechoic on ultrasound Well-­‐demarcated on ultrasound/CT Non-­‐enhancing with CT contrast Simple Cysts Renal 117 No family history of ADPKD Normal sized kidneys No cysts in other organs Septated/Loculated on ultrasound Irregular border on ultrasound/CT Enhancing with CT contrast Polycystic Multiple bilateral cysts Positive family history Enlarged kidneys Cysts in other organs • Polycystic Kidney Disease • Tuberous Sclerosis • Von Hippel-­‐Lindau Syndrome Carcinoma No signs of infection • Renal Cell Carcinoma Abscess Fever and leukocytosis Positive Gallium scan Scrotal Mass SCROTAL MASS Scrotal Mass Gradual Onset Sudden Onset • Testicular Torsion • Torsion of the Testicular Appendix • Trauma • Incarcerated Hernia Epididymal • Epididymal Cyst • Spermatocele Painless If with Dysuria see Dysuria scheme • Acute Epididymitis • Epididymo-­‐orchitis Spermatic Cord Hydrocele • Communicating hydrocele • Communicating/non-­‐ • Indirect hernia communicating • Traumatic/Reactive Trans-­‐illuminates Tumor Does Not Trans-­‐ illuminate Varicocele Solid = Tumor until Soft/”Bag of Worms” proven otherwise • Germ cell Seminoma, Teratoma, Mixed • Non-­‐germ cell Leydig, Sertoli Renal Painful 118 Suspected Acid-Base Disturbance ASE DISORDER Acid-­‐Base Disorder H < 7.35 pH 7.35-­‐7.45 cidemia pH < 7.45 Normal pH Alkalemia • Mixed Acid-­‐Base Disorder Respiratory Acidosis idosis Metabolic Alkalosis Respiratory Alkalosis • Decrease EABV • Hypokalemia* Normal Anion Gap • Diarrhea • RTA • Interstitial Nephritis Chronic • COPD • Interstitial Disease Acute • Asthma* • Neuromuscular • Obstruction Chronic • Pregnancy • Psychogenic Acute • Hypoxia • Salicylates • Sepsis • Pulmonary Embolism* * Denotes acutely life-­‐threatening causes Renal osis – Mixed Metabolic Disorder: mal Normal AG Acidosis Alone High AG Acidosis Alone ΔHCO3-­‐ ΔHCO3-­‐ Mixed AG Acidosis + Normal AG ΔHCO3-­‐ Mixed High AG Acidosis + Metabolic Alkalosis 119 Appropriate Compensation: Metabolic Acidosis Metabolic Alkalosis Acute Respiratory Acidosis Chronic Respiratory Acidosis Acute Respiratory Alkalosis Chronic Respiratory Alkalosis Ratio (CO2:HCO3-­‐) 12:10 7:10 10:1 10:3 10:2 10:4 Metabolic Acidosis Elevated Anion Gap METABOLIC ACIDOSIS: Elevated Anion Gap Metabolic Acidosis Need to correct anion gap for albumin: For every drop of 10 for albumin (from 40) add 2.5 to the anion gap Elevated Anion Gap (>12) Normal Anion Gap (≤12) (Gain of H+) (loss of HCO3) Elevated serum creatinine Decreased NH4 production and anion secretion Excess acid addition Positive serum salicylate level Elevated serum lactate Positive serum ketones Elevated osmolar gap Salicylate poisoning Lactic acidosis Ketosis Toxic alcohol ingestion • Shock • Drugs • Inborn errors • Diabetic ketoacidosis • Starvation/alcoholic ketosis • Ethylene/Propylene glycol • Methanol Other ingestion • Paraldehyde, Iron, Isoniazid, Toluene, Cyanide Renal • AKI/CKD 120 Metabolic Acidosis Normal Anion Gap METABOLIC ACIDOSIS: Normal Anion Gap Metabolic Acidosis METABOLIC ACIDOSIS: Normal Anion Gap Need to correct anion gap for albumin: For every drop Metabolic cidosis of 10 for albumin (from 40) add A 2.5 to the anion gap Elevated Anion Gap (>14) (Acid Gain) Need to correct anion gap for albumin: For every drop of 10 for albumin (from 40) add 2.5 to the anion gap Elevated Anion Gap (>14) (Acid GI GTain) ract Loss (Negative urine net charge) • Diarrhea • Fistula GI Tract Loss (Negative urine net charge) • Diarrhea • Fistula Renal 121 TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine) Urine net charge = UNa + UK -­‐ UCl TTKG = (KUrine x OsmSerum)/(KSerum x OsmUrine) Urine net charge = UNa + UK -­‐ UCl History of diarrhea? Normal Anion Gap (≤14) (Loss of Bicarbonate) Normal Anion Gap (≤14) (Loss of Bicarbonate) Renal Loss History of diarrhea? Renal Loss Indirect Loss Direct Loss Negative U net charge High FEHCO3 • RTA Type II • Carbonic Direct anhydrase Lossinhibitor Positive U net charge Negative U net charge High FEHCO3 • RTA Type II Principal Cell • Carbonic anhydrase inhibitor Problem Low TTKG • RTA Type IV Principal Cell Indirect Loss Positive U net charge α-­‐ Intercalated Cell Problem High TTKG • RTA Type I α-­‐ Intercalated Cell Metabolic Alkalosis METABOLIC ALKALOSIS Transient Sustained Metabolic Alkalosis • IV Bicarbonate • Acute correction of hypercapnia Rule Out Renal Failure with Ingestion Volume Status Assessment Expanded Effective Arterial Blood Volume Signs of volume depletion Gastrointestinal Loss Renal Loss Low U Cl-­‐ Gastric • Vomiting • NG suction • Malignant Hypertension • Renovascular Hypertension • Renin-­‐Secreting Tumor Lower Bowel • Villous adenoma • Laxative abuse • Chloridorrhea High U Cl-­‐ Non-­‐reabsorbed anions • Penicillins Low Renin High Aldosterone • Aldosterone-­‐secreting mass • Adrenal hyperplasia • Glucocorticoid remediable aldosteronism Impaired tubular transport • Diuretics (loop/thiazide) • Hypomagnesemia • Barrter’s/Gitelman’s Low Renin Low Aldosterone • Licorice • Liddle’s Syndrome • Enzyme deficiency Renal No signs of volume depletion High Renin High Aldosterone • Milk-­‐Alkali syndrome • Bicarbonate ingestion Contracted Effective Arterial Blood Volume 122 Urinary Incontinence URINARY INCONTINENCE Urinary Incontinence Transient Established Easily reversible cause Not easily reversible cause • Delirium/confusional states • Infection (UTI) • Atrophic urethritis/vaginitis • Pharmaceuticals • Psychological/psychiatric • Excessive urine output • Restricted mobility • Stool impaction Stress Incontinence Failure of urethral sphincter to remain closed Small Volume Precipitated by stress maneuvers More common in multiparous women Renal 123 Overflow Incontinence Distended bladder with high post-­‐void residual volume Continuous small volume leakage +/-­‐ Precipitated by stress maneuvers Impaired Detrusor Contraction Signs of autonomic neuropathy or spinal cord disease, cauda equina syndrome, anticholinergic medications Urge Incontinence Detrusor overactivity Abrupt urgency Moderate to large leakage of urine Precipitated by cold temperature & running water Bladder Outlet Obstruction Urinary Tract Obstruction URINARY TRACT OBSTRUCTION Urinary Tract Obstruction Upper Tract Lower Tract Bladder NOT distended on ultrasound Hematuria, flank pain, +/-­‐ N/V Distended bladder on ultrasound Urgency, frequency, hesitancy, nocturia Intraluminal Extraluminal • Retroperitoneal Fibrosis • Cancer Mass • Urothelial cell carcinoma • Squamous cell carcinoma Stone • Calcium oxalate • Calcium phosphate • Uric acid [radiolucent on x-­‐ray] • Struvite • Cysteine Intramural • Ureteropelvic junction obstruction Bladder Outflow Tract • Carcinoma (until proven otherwise) • Bladder stone • Thrombus (frank hematuria) • BPH • Prostate cancer • Urethral stricture • Posterior Urethral valves Renal CT KUB 124 Endocrinology Abnormal Lipid Profile Combined & Decreased HDL��������������������������������������������������������129 Abnormal Lipid Profile Increased LDL & Endocrinology 125 Hirsutism & Virilization Androgen Excess����139 Hirsutism & Virilization Hypertrichosis�����������140 Hypercalcemia Low PTH������������������������������������������141 Increased Triglycerides���������������������������������������130 Hypercalcemia Normal / High PTH����������������142 Abnormal Serum TSH�������������������������������������������������131 Hypocalcemia High Phosphate��������������������������143 Adrenal Mass Benign�������������������������������������������������� 132 Hypocalcemia Low Phosphate���������������������������144 Adrenal Mass Malignant�������������������������������������������133 Hypocalcemia High / Low PTH��������������������������145 Amenorrhea�����������������������������������������������������������������������134 Hyperglycemia����������������������������������������������������������������146 Breast Discharge������������������������������������������������������������135 Hypoglycemia������������������������������������������������������������������147 Gynecomastia Increased Estrogen & Hyperphosphatemia����������������������������������������������������148 Increased HCG����������������������������������������������������������136 Gynecomastia Increased LH & Decreased Hypophosphatemia�����������������������������������������������������149 Hyperthyroidism�������������������������������������������������������������150 Testosterone��������������������������������������������������������������� 137 Hypothyroidism����������������������������������������������������������������151 Hirsutism������������������������������������������������������������������������������138 Hyperuricemia�����������������������������������������������������������������152 Male Sexual Dysfunction��������������������������������153 Sellar / Pituitary Mass���������������������������������������154 Sellar / Pituitary Mass Size����������������������������155 Short Stature������������������������������������������������������������ 156 Tall Stature�����������������������������������������������������������������157 Endocrinology Weight Gain / Obesity������������������������������������� 158 126 Historical Editors Student Editors Dr. Andrew Wade Parul Khanna (Co-editor) Dr. Sophia Chou Patricia Wong (Co-editor) Dave Campbell Soreya Dhanji Derrick Chan Marc Chretien Faculty Editor Mollie Ferris Dr. Kevin McLaughlin Kody Johnson Becky Kennedy Vera Krejcik Endocrinology 127 Keith Lawson Vanessa Millar Eric Sy Maria Wu 128 Endocrinology Abnormal Lipid Profile Combined & Decreased HDL Endocrinology 129 Abnormal Lipid Profile Endocrinology Increased LDL & Increased Triglycerides 130 Abnormal Serum TSH * Endocrinology 131 *Refer to Hyperthyroidism (1) on page 150 **Refer to Hyperthyroidism (2) on page 151 ** Adrenal Mass Benign ADRENAL MASS: Benign Benign Adrenal Mass Most common neoplasm is Benign Non-­‐Functioning Adenoma No Signs of Hormone Excess Hyperplasia Often Bilateral •Congenital Adrenal Hyperplasia •ACTH Dependent •ACTH Independent •Macronodular Hyperplasia Androgen Excess Virilization/ Hirsutism Estrogen Excess Feminization, Early Puberty, Heavy Menses •Estrogen Releasing Adenoma (High Plasma E2 + Clinical Picture) High DHEAS •Androgen Releasing Adenoma Normal DHEAS •Other Source (e.g. Polycystic Ovarian Syndrome, Congenital Adrenal Hyperplasia) Glucocorticoid Excess Cushingoid Features •Glucocorticoid Releasing Adenoma (Positive Dexa-­‐ methasone Suppression Test) Aldosterone Excess Hypertension +/-­‐ Hypokalemia/Alkalosis •Aldosterone Releasing Adenoma (High Aldosterone: Renin Ratio) Positive 24-­‐ Hour Metanephrines + Nor-­‐ Metanephrines Silent/Non-­‐ Functioning Mass •Pheochromocytoma (Paroxysmal Hypertension, Headache, Diaphoresis, Palpitations, Anxiety) Rule of 10’s For Pheochromocytoma: Normal DHEAS Other 10% are Malignant 10% are Bilateral 10% are Extra-­‐Adrenal 10% are Familial 10% are not Associated with Hypertension •Non-­‐functioning Adenoma •Lipoma •Myelolipoma •Ganglioneuroma •Cyst •Pseudocyst •Hematoma •Infection (TB, Fungal) Amyloidosis Endocrinology Signs of Hormone Excess 132 Adrenal Mass Malignant ADRENAL MASS: Malignant ADRENAL MASS: Malignant Malignant Adrenal Mass Malignant Adrenal Mass Suggestive of Malignancy: Inhomogenous Density, Delay in CT Contrast Washout of Malignancy: Inhomogenous ensity, Delay in CHT Contrast ashout (<50% in 10 mSuggestive inutes), Irregular Shape, Diameter >4cm, CDalcification, >20 ounsfeld UW nits on CT, Vascularity of Mass, (<50% in 10 minutes), Irregular Shape, Diameter 4cm, Calcification, >20 Hounsfeld Units on CT, Vascularity of Mass, Hypointense to >Liver on T1 Weighted MRI – DO NOT Biopsy Hypointense to Liver on T1 Weighted MRI – DO NOT Biopsy Signs of Hormone Excess Signs of Hormone Excess No Signs of No Signs of Hormone Excess Hormone Excess Positive 24-­‐Hour Aldosterone Positive Estrogen Excess 24-­‐Hour Glucocorticoid Aldosterone Androgen Estrogen Silent/Non-­‐ Metanephrines Excess Glucocorticoid Androgen Silent/Non-­‐ Excess Feminization, Metanephrines Excess Functioning Excess + Nor-­‐ Excess Feminization, Hypertension +/-­‐ Excess Functioning Early Puberty, Excess + N or-­‐ Virilization/ Hirsutism Cushingoid F eatures Hypertension + /-­‐ Early Heavy Puberty, Mass Metanephrines Menses Hypokalemia/Alkalosis Metanephrines Virilization/ Hirsutism Cushingoid Features Mass Heavy Menses Hypokalemia/Alkalosis Endocrinology 133 •Glucocorticoid •Aldosterone •Pheo-­‐ •Glucocorticoid •Aldosterone •Pheo-­‐ Releasing Releasing chromocytoma Releasing Releasing chromocytoma Carcinoma Carcinoma ( High (Paroxysmal Carcinoma Carcinoma ( High (Paroxysmal (Positive Aldosterone: Renin Hypertension, (Positive Aldosterone: R enin Hypertension, Dexamethasone Ratio) Headache, Dexamethasone Headache, Suppression Test) Ratio) Diaphoresis, Suppression Test) Diaphoresis, Palpitations, Palpitations, Normal DHEAS High DHEAS Normal Anxiety) DHEAS High DHEAS Anxiety) •Androgen Releasing •Other Source (e.g. •Androgen Releasing Source (Oe.g. Carcinoma (e.g. •Other Polycystic varian Carcinoma (e.g. Polycystic Ovarian Adrenocortical Syndrome, Adrenocortical Syndrome, Carcinoma) Congenital Adrenal Carcinoma) Congenital A drenal Hyperplasia) Hyperplasia) •Estrogen •Estrogen Releasing Releasing Carcinoma (High Carcinoma (High Plasma E + Plasma E2 + 2 Clinical Picture) Clinical Picture) •Lymphoma •Lymphoma Metastases (Often Metastases (Often Bilateral) Adrenal Bilateral) Adrenal Carcinoma Carcinoma Rule of 10’s For Rule oPheochromocytoma: f 10’s For Pheochromocytoma: 10% are Malignant 10% a10% re Maalignant re Bilateral 10% a10% re Bilateral are Extra-­‐Adrenal 10% a10% re Extra-­‐ drenal are FAamilial 10% a10% re Familial are not Associated 10% awith re not A ssociated Hypertension with Hypertension Amenorrhea AMENORRHEA AMENORRHEA Amenorrhea Amenorrhea Rule Out Pregnancy Rule Out Pregnancy Elevated FSH Elevated FSH Bleed With Progestin Bleed With Progestin Challenge ChallengeOvarian •Polycystic Hypothalamic-­‐ Hypothalamic-­‐ Pituitary Axis Pituitary Axis High Prolactin High Prolactin Organic Cause Organic Cause •Polycystic Ovarian Syndrome Syndrome •Hyperprolactinemia •Hyperprolactinemia No Bleed With No B leed With Challenge Progestin Progestin Challenge •Hypothyroidism •Hypothyroidism •Hyperthyroidism •Hyperthyroidism •Diabetes Mellitus •Diabetes Mellitus Androgen Use •Exogenous •Exogenous Androgen Use •Congenital Structural •Congenital Structural Abnormalities Abnormalities Failed Progestin Failed Progestin Challenge Challenge •Functional •Congenital GnRH Deficiency •Functional •Congenital GnRH Deficiency •Hypothalamic •Infiltrative or Inflammatory •Hypothalamic •Infiltrative or Inflammatory •Amenorrhea Lesion •Amenorrhea (e.g. (e.g. Lesion •Weight Loss, Eating •Tumors •Weight Loss, Eating •Tumors Disorders, Exercise, •Infarction Disorders, Exercise, •Infarction Prolonged •Empty ella Syndrome Stress, PStress, rolonged •Empty Sella SSyndrome Illness) •Apoplexy Illness) •Apoplexy If bleed ith progestin challenge = estrogenized If bleed with w progestin challenge = estrogenized o bleed ith progestin challenge on-­‐estrogenized If no If bnleed with w progestin challenge = non-­‐=e n strogenized •Premature Ovarian Failure •Premature Ovarian F•Menopause ailure •Menopause •Spontaneous •Spontaneous Endocrinology Low/Normal FSH Low/Normal FSH 134 Breast Discharge BREAST DISCHARGE Breast Discharge Other Breast Discharge True Galactorrhea (on microscopy) Abnormal TSH/ Prolactin Normal TSH/ Prolactin •Neoplasm (usually blood) •Other Internal Breast Discharge •Idiopathic Endocrinology 135 High Prolactin + Normal TSH High Prolactin + Normal/ Low TSH •Microprolactinoma •Steroid Hormone Intake •Chronic Renal Failure •Stress (e.g. Pregnancy, Breast Stimulation, Trauma/Surgery) •Pituitary Macroadenoma •Dopamine Inhibition •Pituitary Stalk Compression/Lesion Autonomous Production •Renal Cancer or Failure •Lactotroph Adenoma •Bronchogenic Tumor •Contraceptive Pill/Patch/Ring High Prolactin + High TSH •Primary Hypothyroidism Gynecomastia Endocrinology Increased Estrogen & Increased HCG 136 Gynecomastia Increased LH & Decreased Testosterone Endocrinology 137 Endocrinology Hirsutism 138 Hirsutism & Virilization Androgen Excess Endocrinology 139 Hirsutism & Virilization Endocrinology Hypertrichosis 140 Hypercalcemia Low PTH Endocrinology 141 Hypercalcemia Endocrinology Normal / High PTH 142 Hypocalcemia High Phosphate Endocrinology 143 Hypocalcemia Endocrinology Low Phosphate 144 Hypocalcemia High / Low PTH Endocrinology 145 Endocrinology Hyperglycemia 146 HYPOGLYCEMIA HYPOGLYCEMIA Hypoglycemia Hypoglycemia Hypoglycemia 4 mmol/L) (< 4 m(< mol/L) Fasting Hypoglycemia Fasting Hypoglycemia •Excess •Excess InsulinInsulin •Medications (e.g. Insulin •Medications (e.g. Insulin Secretagogues, β-­‐Adrenergic Secretagogues, β-­‐Adrenergic Antagonists, Quinine, Salicylates, Antagonists, Quinine, Salicylates, Pentamidine) Pentamidine) •Alcohol •Alcohol Endocrinology 147 Post-­‐Post-­‐Prandial Prandial Other Causes Other Causes (Reactive) (Reactive) •Alimentary (e.g. the setting •Alimentary (e.g. in the isn etting of of Gastric Surgery) Gastric Surgery) •Congenital Enzyme Deficiencies •Congenital Enzyme Deficiencies •Idiopathic •Idiopathic •Critical e.g. Hepatic Failure, •Critical Illness Illness (e.g. H(epatic Failure, Failure, Cardiac Failure) Renal Renal Failure, Cardiac Failure) •Sepsis •Sepsis •Hypopituitarism •Hypopituitarism •Adrenal Insufficiency •Adrenal Insufficiency •Hyperinsulinemic •Hyperinsulinemic States S(tates e.g. (e.g. Glucagon, Catecholamine Deficiency, Glucagon, Catecholamine Deficiency, Insulinoma) Insulinoma) •Malnutrition/Anorexia Nervosa •Malnutrition/Anorexia Nervosa Signs/Symptoms of Hypoglycemia: Signs/Symptoms of Hypoglycemia: Neurogenic: irritability, tremor, anxiety, palpitations, tachycardia, sweating, paresthesias Neurogenic: irritability, tremor, anxiety, palpitations, tachycardia, sweating, pallor, ppallor, aresthesias Neuroglycopenia: confusion, lethargy, abnormal behaviour, amnesia, weakness, blurred seizures Neuroglycopenia: confusion, lethargy, abnormal behaviour, amnesia, weakness, blurred vision, vsision, eizures HYPERPHOSPHATEMIA Hyperphosphatemia Hyperphosphatemia (> 1.46 mmol/L) •Rhabdomyolysis •Tumor Lysis •Metabolic or Respiratory Acidosis •Insulin Deficiency Decreased Excretion FEPO4 < 20% •Renal Disease •Hypoparathyroidism •Pseudo-­‐hypoparathyroidism •Acromegaly •Bisphosphonate Therapy Increased Intake/ Absorption Normally in Context of Impaired Renal Function •Hypervitaminosis D •Phosphate Supplementation •Phosphate Containing Enemas/Laxatives Pseudo-­‐ hyperphosphatemia •Multiple Myeloma Hyperbilirubinemia •Hemolysis •Hyperlipidemia •Tumor Lysis Endocrinology Transcellular Shift 148 HYPOPHOSPHATEMIA Hypophosphatemia Hypophosphatemia (< 0.8 mmol/L) Transcellular Shift •Recovery From DKA •Refeeding Syndrome •Acute Respiratory Alkalosis •Hypokalemia •Hypomagnesemia •Burns Endocrinology 149 Increased Excretion GI •Small bowel diarrhea •Enteric Fistula Renal FePO4 > 5% Decreased Intake Dietary deficiency Malabsorption •Anorexia •Chronic Alcoholism •Aluminum/Magnesium Containing Antacids •Inflammatory Bowel Disease •Steatorrhea •Chronic Diarrhea •Hyperparathyroidism •Vitamin D Deficiency/Resistance •Hypophosphatemic Rickets •Oncogenic Osteomalacia •Fanconi Syndrome •Osmotic Diuresis •Acute Volume Expansion •Acetazolamide and Thiazide Diuretics Hyperthyroidism HYPERTHYROIDISM Hyperthyroidism Low Radioiodine Uptake Autoimmune Thyroid Disease •Grave’s Disease •Positive anti-­‐TSH Receptor Antibody Autonomous Thyroid Tissue •Toxic Adenoma •Toxic Multinodular Goiter TSH/HCG Excess •TSH-­‐Secreting Pituitary Adenoma •Gestational Trophoblastic Neoplasm Subacute Thyroiditis •Granulomatous •Lymphocytic •Postpartum •Amiodarone •Radiation Exogenous/Ectopic Hormone •Excessive Thyroid Drug •Struma Ovarii Endocrinology High/Normal Radioiodine Uptake 150 Hypothyroidism HYPOTHYROIDISM Hypothyroidism Central Hypothyroidism Primary Hypothyroidism Thyroid Hormone Resistance Iatrogenic •Isolated TSH Deficiency •Panhypopituitarism Chronic Transient •Subacute Lymphocytic/ Granulomatous •Thyroiditis •Post-­‐Partum Thyroiditis •Subtotal Thyroidectomy Endocrinology 151 Infiltrative Disease •Fibrous Thyroiditis •Hemosiderosis Congenital Thyroid Agenesis/ Degenesis •Severe Iodine Deficiency Medications •Thionamides •Lithium •Amiodarone •Interferon Central Hypothyroidism •Hashimoto’s Thyroiditis Hyperuricemia HYPERURICEMIA Hyperuricemia Hyperuricemia Primary Secondary • • • Increased turnover of nucleotides • Hemolytic Anemia Lymphoproliferative Disorders Acute lymphoblastic leukemia (ALL) Acute myeloid leukemia (AML) Chronic myeloid leukemia (CML) • Under-­‐excretion Lower uric acid clearance Starvation See hemolysis scheme Psoriasis Chemotherapy Drug-­‐induced High purine diet Renal Endocrine Others • • • • • • Hyperparathyroidism Diabetic acidosis • • • Chronic renal failure Sarcoidosis Hypercalcemia Drug-­‐Induced • • • • • • • Antiuricosuric drugs ACE inhibitors Cyclosporine Diuretics Organic acids Ethambutol Alcohol Endocrinology • Over-­‐production Under-­‐excretion Over-­‐production • 152 Male Sexual Dysfunction MALE SEXUAL DYSFUNCTION Sexual Dysfunction Establish Dysfunction in Context: Partner Showing Less Desire is not Necessarily Impaired Global Dysfunction is likely Organic Cause Situational Impairment Most Likely Psychological Desire Erectile Dysfunction Psychological Endocrinology 153 Physiological •Performance Anxiety •Lack of Sensate •Focus •Mood Disorder •Anxiety Disorder •Stress •Guilt •Interpersonal Issues Chronic Disease •Diabetes •Cardiovascular Disease •Peyronie’s •Connective Tissue Disease Neurological •Stroke •Spinal Cord Injury •Multiple Sclerosis •Dementia •Polyneuropathy Reduced/Absent Pharmacological Physiological •Anti-­‐hypertensives •Anti-­‐depressants •Diuretics •Benzodiazepines •Alcohol •Sympathomimetic Drugs (e.g. Cocaine, Amphetamines) •Hypo-­‐ testosteronism •Prolactinemia •Hyper-­‐estrogenism •Hypothyroidism •Hyperthyroidism •Chronic Pain Physiological •Hypo-­‐ testosteronism •Prolactinemia •Hypothyroidism •Hyperthyroidism Pelvis •Trauma •Pelvic Surgery •Prostate Surgery •Priapism •Infection •Bicycling Pharmacological •Anti-­‐depressants •Narcotics •Anti-­‐psychotics •Anti-­‐androgens •Alcohol •Benzodiazepines •Hallucinogens Other •Hypertension •Dyspareunia •Dialysis Psychological •Mood Disorders •Anxiety Disorders •Guilt •Stress •Interpersonal Issues (e.g. Lack of trust in partner) •Psychosis/Delusions •Previous psycho-­‐social trauma •(e.g. Abuse) SELLAR/PITUITARY MASS Sellar / Pituitary Mass Sellar/Pituitary Mass Hyperplasia Non-­‐Adenomatous •Infectious •Autoimmune •Giant Cell Granuloma •Langerhan’s Cell •Histiocytosis •Sarcoidosis •Physiological (e.g. Pregnancy) •Compensation (e.g. Hypothyroidism) •Stimulatory (e.g. Ectopic GNRH, CRH) Secreting •Prolactin •GH •ACTH •TSH •LH/FSH •Mixed Non-­‐ Functioning •Oncocytoma •Null Cell Adenoma Vascular •Aneurysm •Infarction Inflammatory Hamartoma Neoplasm •Craniopharyngioma •Meningioma •Cyst •Glioma •Ependymoma Metastatic Endocrinology Adenoma Primarily Anterior Pituitary 154 SELLAR/PITUITARY MASS: Size Sellar / Pituitary Mass Size Sellar/Pituitary Mass Small (<1cm) Endocrinology 155 •Hypersecretion Large (>1cm) •Hypersecretion •Hyposectretion Other Short Stature SHORT STATURE Short Stature <3rd Percentile Detailed History, Physical Exam, and Mid-­‐Parental Target Height Normal Variant Pathological/Abnormal •Skeletal Dysplasias •(e.g. Achondroplasia) •Rickets Normal Puberty Onset (BA=CA) Proportionate •Familial Short Stature No Dysmorphic Features Delayed Puberty Onset (BA<CA) •Constitutional Short Stature (Late Bloomer) Dysmorphic Features •Trisomy 21 •Noonan Syndrome •Prader-­‐Willi Syndrome •Russell-­‐Silver Syndrome •Turner Syndrome Deprivation •Primary Malnutrition •Psychosocial •Deprivation Endrocrine •Cushing’s Disease •GH Deficiency •IGF-­‐1 Deficiency (e.g. Laron Dwarfism) •Hypothyroidism •Congenital Adrenal Hyperplasia •Panhypopituitarism Treatment •Glucocorticoids •Radiation •Chemotherapy •Bone Marrow Transplant Chronic Disease •GI (e.g. Celiac, IBD) •Renal (e.g. CRF) •Infection (e.g. Chronic UTI) •Cardiopulmonary (e.g. Cystic Fibrosis, CHF) •Inborn Metabolism Error •Immunologic •Hematologic Other •Intrauterine Growth Retardation •Bulimia Nervosa •Anorexia Nervosa •CNS Tumors (e.g. Craniopharyngioma) Endocrinology Disproportionate 156 Tall Stature TALL STATURE Tall Stature > 97th Percentile Detailed History, Physical Exam, and Mid-­‐Parental Target Height No Other Obvious Abnormalities/Stigmata Normal Growth (BA=CA) Accelerated Growth (BA>CA) •Familial Tall Stature •XYY Syndrome Non-­‐Obese BMI Obese BMI •Exogenous Obesity Endocrinology 157 Early Puberty Onset Normal Puberty Onset •GH Excess •Hyperthyroidism Precocious Puberty •Adrenal Tumor •Ovarian Tumor •Testotoxicosis •Congenital Adrenal Hyperplasia Constitutional •Constitutional Tall Stature (Early Bloomer) Other Obvious Abnormalities/Stigmata Disproportionate •Klinefelter’s Syndrome (XXY) •Soto’s Syndrome/ Cerebral Gigantism •Marfan’s Syndrome •Homocystinuria •Sex Steroid Deficiency/ Resistance •Acromegaly (Rare in Children) Proportionate •Bechwith-­‐Weidmann Syndrome (Normalizing growth after birth) •Weaver Syndrome •XYY Syndrome •Neurofibromatosis 1 •Hyperthyroidism (Untreated/Severe) WEIGHT GAIN/OBESITY Weight Gain / Obesity Weight Gain/Obesity Energy Related Secondary Increased Intake Decreased Expenditure •Sedentary Lifestyle •Smoking Cessation Dietary •Progressive •Polyphagia •High-­‐Fat Diet Social/Behavioural •Socioeconomic •Ethnicity •Psychological Neuroendocrine •Polycystic Ovarian Syndrome •Hypothyroid •Cushing’s Syndrome •Hypogonadism •GH Deficiency •Hypothalamic Obesity Iatrogenic •Drugs/Hormones •Tube Feeding Hypothalamic Surgery Genetic •Autosomal Dominant •Autosomal Recessive •X-­‐Linked •Chromosomal Abnormality Endocrinology (Primary) 158 Neurologic Neurologic 159 Altered Level of Consciousness Approach163 Movement Disorder Hyperkinetic���������������������176 Altered Level of Consciousness GCS ≤ 7�����164 Movement Disorder Tremor����������������������������������� 177 Aphasia Fluent�����������������������������������������������������������������165 Movement Disorder Bradykinetic����������������������178 Aphasia Non-Fluent���������������������������������������������������� 166 Peripheral Weakness��������������������������������������������������179 Back Pain������������������������������������������������������������������������������167 Peripheral Weakness Sensory Changes����� 180 Cognitive Impairment������������������������������������������������ 168 Spell / Seizure Epileptic Seizure����������������������� 181 Dysarthria���������������������������������������������������������������������������� 169 Spell / Seizure Secondary Organic�����������������182 Falls in the Elderly���������������������������������������������������������170 Spell / Seizure Other��������������������������������������������������183 Gait Disturbance��������������������������������������������������������������171 Stroke Intracerebral Hemorrhage���������������������184 Headache Primary�������������������������������������������������������� 172 Stroke Ischemia���������������������������������������������������������������185 Headache Secondary, without Red Flag Stroke Subarachnoid Hemorrhage����������������� 186 Symptoms��������������������������������������������������������������������� 173 Syncope��������������������������������������������������������������������������������187 Hemiplegia������������������������������������������������������������������������� 174 Dizziness������������������������������������������������������������������������������ 188 Mechanisms of Pain����������������������������������������������������� 175 Vertigo����������������������������������������������������������������������������������� 189 160 Neurologic Student Editors Historical Editors Neurologic 161 Dr. Darren Burback Kaitlin Chivers-Wilson Jared McCormick Dr. Brian Klassen Lindsay Connolly Dilip Koshy Dr. Gary Klein Nichelle Desilets Aleksandra Ivanovic Dr. Dawn Pearson Jonathan Dykeman Dr. Oksana Suchowersky Vikram Lekhi Faculty Editor Erin Butler Chris Ma Dr. Kevin Busche Aaron Wong Sandeep Saran Sophie Flor-Henry Jeff Shrum Ted Hoyda Siddhartha Srivastava Andrew Jun Stephanie Yang Khaled Ahmed Anastasia Aristarkhova John Booth 162 Neurologic Altered Level of Consciousness ApproachLEVEL OF CONSCIOUSNESS: Approach ALTERED Altered Level of Consciousness Glasgow Coma Scale Score: 12-­‐15 = Investigate 8-­‐12 = Urgent Investigation ≤ 7 = Resuscitate + Investigate Rapidly Deteriorating = Resuscitate + Investigate Clinical Exam Focal Neurologic 163 • Trauma • Stroke • Tumor • Hemorrhage • See Imaging Section Non-­‐Focal • Refer to Blood Work and Imaging Sections Blood Work Metabolic Abnormality • Hypoxia • Hypercapnea • Hyper/HypoNa • Hyper/HypoCa • Hyper/HypoK • Sepsis No Metabolic Abnormality • Postictal • Concussion • Meningitis • Encephalitis Imaging Structural Abnormality • Epidural Hemorrhage • Subdural Hemorrhage • Intracranial Hemorrhage • Ischemia • Tumor Non-­‐ Structural • Post-­‐Ictal • Concussion • Encephalitis Altered Level of Consciousness GCS ≤ 7 ALTERED LEVEL OF CONSCIOUSNESS: GCS ≤ 7 ALTERED LEVEL OF CONSCIOUSNESS: GCS ≤ 7 LOC GCS ≤ 7 Altered LOC GCS Altered ≤ 7 Coma • Locked-­‐in Syndrome •Stupor •Persistent Vegetative State Brain Involvement Brain Involvement Focal Lesions Hemispheric • Hemorrhage • Traumatic • Ischemia/ Infarction • Neoplastic Abscess • Skull fracture • Subdural hematoma • Intracranial Bleeding *NB – must be direct or indirect bi-­‐hemispheric involvement Focal Diffuse Lesions Lesions Hemispheric Brain Stem • Hemorrhage • Hemorrhage • Traumatic • Traumatic • Ischemia/ • Ischemia/ Infarction Infarction • Neoplastic • Neoplastic Abscess Abscess • Skull fracture • Herniation • Subdural • Brain stem hematoma Lesion • Intracranial Bleeding Brain Stem Vascular • Hemorrhage • Hypertensive • Traumatic encephalopathy • Ischemia/ • Vasculitis Infarction • TTP • Neoplastic • DIC Abscess • Hypoxemia • Herniation • Multiple • Brain stem emboli Lesion *NB – must be direct or indirect bi-­‐hemispheric involvement Diffuse Lesions Vascular Infection Other Infection Other Other • Locked-­‐in Syndrome •Stupor •Persistent Vegetative State Systemic Involvement OtherInvolvement Systemic • Meningitis • Trauma/ • Hypertensive • Meningitis • Trauma/ • Encephalitis Concussion encephalopathy • Encephalitis Concussion • Post-­‐ictal • Vasculitis • Post-­‐ictal • TTP • DIC Excesses Deficiencies • Hypoxemia Excesses Deficiencies Drugs/Toxins • Multiple • Liver/Renal Failure • Hypoxemia • Alcohols • Liver/Renal Failure • Hypoxemia emboli • Carbon Dioxide • Hypoglycemia • Barbituates • Carbon Dioxide • Hypoglycemia Narcosis • B12/Thiamine • Tranquilizers Narcosis • B12/Thiamine • Metabolic Acidosis deficiency • Other • Metabolic Acidosis deficiency • Hypernatremia • Hyponatremia • Hypernatremia • Hyponatremia • Hypercalcemia • Hypocalcemia • Hypercalcemia • Hypocalcemia • Hypermagnesemia • Hypomagnesemia • Hypermagnesemia • Hypomagnesemia • Hyperthermia • Hypothermia • Hyperthermia • Hypothermia • Thyroid Storm • Myxedema Coma • Thyroid Storm • Myxedema Coma Drugs/Toxin • Alcohols • Barbituates • Tranquilizers • Other Neurologic Coma 164 Aphasia APHASIA: Fluent Fluent Aphasia Fluent Grammatically correct, but nonsensical, tangential. Phonemic & semantic paraphasias Impaired Repetition Neurologic 165 Impaired Comprehension Intact Comprehension • Wernicke’s Aphasia • Conduction Aphasia Non-­‐Fluent Agrammatic, hesitant, but substantive communication Intact Repetition Impaired Comprehension • Transcortical Sensory Aphasia Intact Comprehension • Anomic Aphasia Aphasia APHASIA: Non-­‐Fluent Non-Fluent Aphasia Impaired Repetition Impaired Comprehension • Global Aphasia Intact Comprehension • Broca’s Aphasia Non-­‐Fluent Agrammatic, hesitant, but substantive communication Intact Repetition Impaired Comprehension Intact Comprehension • Mixed Transcortical Aphasia • Transcortical Motor Aphasia Neurologic Fluent Grammatically correct, but nonsensical, tangential. Phonemic & semantic paraphasias 166 Back Pain BACK PAIN Back Pain BACK PAIN Always assess for red flags. Painafter 6 weeks If no red fBack lags, assess Red Flags: bowel or bladder dysfunction, saddle paresthesia, constitutional symptoms, parasthesis, age >50, <18, IV drug use, neuromotor deficits, nocturnal pain, ohr igh energy Red Flags: bowel bladder trauma, past history of neoplasm dysfunction, saddle paresthesia, constitutional symptoms, parasthesis, age >50, <18, IV drug use, neuromotor deficits, nocturnal pain, high energy trauma, past history of neoplasm Always assess for red flags. If no red flags, assess after 6 weeks Acute/Subacute + Chronic/Acute After 6 Red Flags weeks + No Red Flags < 6 weeks > 6 weeks Fracture Neurologic 167 Fracture Acute/Subacute + Red Flags Tumor/Infection < 6 weeks Cauda Equina Syndrome Chronic/Acute After 6 weeks + No Red Flags > 6 weeks Unresolved Radicular Cauda Equina Tumor/Infection Syndrome Myelopathic Symptoms Unresolved Radicular Spondyloarthropathies or Osteoarthritis Spondyloarthropathies Cognitive Impairment COGNITIVE IMPAIRMENT Cognitive Impairment Decline in Instrumental Activities of Daily Living Affecting Multiple Domains • Amnestic Mild Cognitive Impairment • Non-­‐Amnestic Mild Cognitive Impairment • Depression • Delirium Subcortical Dementia Treatable Cause • Normal Pressure Hydrocephalus • Chronic Meningitis • Chronic Drug Abuse • Tumor • Subdural Hematoma • B12 deficiency • Hypothyroidism • Hypoglycemia Cortical Dementia Early Extrapyramidal Features Rapidly Progressive • Parkinson’s Disease with Dementia • Huntington’s Disease • Creutzfeldt-­‐Jakob Disease • Paraneoplastic disorder Early Language and Behavioral Dysfunction • Fronto-­‐temporal Dementia Abrupt Onset, Stepwise Progression • Vascular Dementia Early Impairment of Recent Memory • Alzheimer’s Dementia Early Extrapyramidal Features • Dementia with Lewy Bodies Neurologic Dementia 168 Dysarthria DYSARTHRIA Dysarthria Lower Motor Neuron Slow, Low Volume, Breathy Speech Tongue and Facial Atrophy Fasciculations •Motor Neuron Disease •Lesions of Cranial Nerves VII, IX, X, XII •Myasthenia Gravis •Muscular Dystrophy Neurologic 169 Upper Motor Neuron Slow, strangulated, harsh voice Positive jaw jerk, hyperactive gag reflex. Emotional lability •Bilateral Lacunar Internal Capsule Strokes •Multiple Sclerosis •Amyotrophic Lateral Sclerosis Ataxic (Cerebellar) Irregular Rhythm and Pitch •Spinal-­‐Cerebellar Ataxia •Multiple Sclerosis •Alcohol •Tumour •Paraneoplastic Disorder Extra-­‐Pyramidal Rapid, Low Volume, Monotone Speech •Parkinson’s Disease Falls in the Elderly FALLS IN THE ELDERLY Fall Normally is a combination of multiple factors Intrinsic Factors Extrinsic Factors Sensory Impairments Neurological Psychiatric Performance Measures • Cardiac • Non-­‐Cardiac • Vision • Vestibular • Neuropathy • Proprioception • Stroke • Parkinsonism • Cognition • Depression • Other • Weakness • Decreased Balance • Gait Abnormalities Musculo-­‐ skeletal • Arthritis Drugs • Polypharmacy – esp. >4 medications • Psychotropics Environment • Rugs • Stairs • Lighting Neurologic Presyncope/ Syncope 170 Gait Disturbance GAIT DISTURBANCE Gait Disturbance Movement Disorder Sensory Ataxia Cerebellar Ataxia • Vestibular • Visual • Proprioceptive Neurologic 171 X-­‐Linked/ Mitochondrial • Fragile X Sporadic Hereditary See Movement Disorder schemes Progressive/ Degenerative Dominant • Spinocerebellar Ataxia Recessive • Friedrich’s Ataxia • Telangiectasia • Vascular • Infection • Toxic • Nutrition • Metabolic • Inflammation • Neoplasm • Degenerative Catalytic Deficiency (Childhood) Intermittent • Hyperammonemia • Aminoaciduria • Pyruvate/Lactic Acid Chronic Progressive • Tay-­‐Sachs Disease • Niemann-­‐Pick Disease Headache Primary HEADACHE: Primary Headache Primary Secondary Usually episodic Usually constant No pattern Other In Clusters Autonomic Cephalgias Unilateral • Migraine (Throbbing/Pulsating) Bilateral Last for minutes to hours. Separated by hours. Sudden onset. • Tension/Stress Headache (Tightening, Band-­‐Like, Dull) • Cluster Headache (Orbital, Sharp, Autonomic Dysfunction) • Hemicranial Continua Other Last for seconds, separated by minutes to hours • Trigeminal Neuralgia (Shooting, stabbing) Neurologic • Primary Cough Headache • Primary Exertional Headache • Primary Stabbing Headache 172 Headache HEADACHE: Secondary, without Red Flag Symptoms Secondary, without Red Flag Symptoms Headache Primary Secondary Usually episodic Usually constant With Red Flag Symptoms No Red Flag Symptoms Systemic symptoms, focal neurological signs, sudden onset, old age, progressive signs of increased intracranial pressure Neurologic 173 Acute • Sinusitis • Dental Abscess • Glaucoma • Traumatic Brain Injury • Acute Mountain Sickness Chronic Drugs • Analgesic Induced Headache • Substance Withdrawal Hemiplegia HEMIPLEGIA Upper Motor Neuron Weakness Tone: Spastic with clasp-­‐knife resistance Reflexes: Hyperactive +/-­‐ Clonus Pathological Reflexes: Babinski/Hoffman • Aphasia • Apraxia • Agnosia • Agraphia • Acalculia • Alexia • Anomia • Anosognosia • Asterognosia • Seizures • Personality Changes •Cognition/Confusion, Dementia • +/-­‐ Sensory Loss Contralateral/Sub-­‐ Cortical (Corona radiata, Internal Capsule) • May be without sensory loss • May be combined with contralateral sensory loss Brain Stem • Diplopia • Dysarthria • Dysphagia • Ptosis • Decreased Level of Consciousness • Cranial Nerve Palsies • ‘Crossed’ Sensory Findings: ipsilateral facial and contralateral extremity findings Unilateral Spinal Cord Lesions Above ~C5 • Brown-­‐Sequard Syndrome (sensory loss to pain and temperature contralateral to weakness, vibration and proprioception loss ipsilateral to weakness) Neurologic Cerebral Hemisphere (Contralateral motor cortex) 174 Mechanisms of Pain MECHANISMS OF PAIN Pain Nociceptive Tissue Damage Visceral Somatic Neuropathic Mixed Nociceptive/Neuropathic (From organ/cavity lining) Poorly localized, crampy, diffuse, deep sensation Central Nervous System Burning, shooting, gnawing, aching, lancinating Peripheral Nervous System • Post-­‐Herpetic Neuralgia • Neuroma • Neuropathy Neurologic 175 Deep Less well-­‐localized, dull, longer duration Superficial Well-­‐localized, sharp, short duration Deafferentation Loss of sensory input • Phantom Limb • Post-­‐stroke • Spinal injury Sympathetic • Complex regional pain syndrome Movement Disorder MOVEMENT DISORDER: Hyperkinetic Hyperkinetic Movement Disorder Tremor Tics • Tourette’s Syndrome • Attention Deficit Hyperactivity Disorder • Obsessive Compulsive Disorder Dystonia • Generalized dystonia • Writer’s cramp • Blepharospasm • Cervical Dystonia Stereotypies Myoclonus • Epilepsy • Toxic/ metabolic Bradykinetic Chorea Athetosis Ballism • Huntington’s Disease Neurologic Hyperkinetic Examples listed not exhaustive for all causes 176 Movement Disorder MOVEMENT DISORDER: Tremor Tremor Movement Disorder Hyperkinetic Action Tremor Occurs During Voluntary Muscle Movement • Cerebellar Disease (e.g. spinocerebellar ataxia, Vitamin E deficiency, stroke, multiple sclerosis) Neurologic 177 Tremor Resting Tremor Occurs at Rest • Parkinson’s Disease • Midbrain Tremor • Wilson’s Disease • Progressive supranuclear palsy • Multiple System Atrophy • Drug-­‐Induced Parkinsonism Bradykinetic Postural Tremor Occurs While Held Motionless Against Gravity • Enhanced Physiologic Change • Essential tremor • Dystonia • Metabolic Etiology (Thyroid, Liver, Kidney) • Drugs (Lithium, Amiodarone, Valproate) MOVEMENT DISORDER: Bradykinetic Movement Disorder Bradykinetic Movement Disorder Parkinson’s Disease (TRAP) • Resting Tremor • Cogwheel Rigidity • Akinesia/Bradykinesia • Postural Instability Tremor Drug-­‐Induced Parkinsonism • Neuroleptics • Haloperidol • Metoclopramide • Prochlorperazine • Amiodarone • Verapamil Bradykinetic Progressive Supranuclear Palsy Characteristics: • Vertical Gaze Palsy • Axial rigidity > limb rigidity • +/-­‐ Tremor • Bradykinesia • Falling backwards Multiple System Atrophy Characteristics: • Bradykinesia • +/-­‐ tremor • Cerebellar signs • Postural Hypotension Neurologic Hyperkinetic 178 Peripheral Weakness PERIPHERAL WEAKNESS Weakness Objective Weakness Upper Motor Neuron Increased tone and reflexes Babinski Reflex No Objective Weakness Lower Motor Neuron Decreased tone and reflexes No Babinski reflex Sensory Changes No Sensory Changes Upper and Lower Motor Neuron • Amyotrophic Lateral Sclerosis • Cervical myelo-­‐ radiculopathy • Syrinx • Cardio-­‐pulmonary disease • Anemia • Chronic Infection • Malignancy • Depression • Deconditioning • Arthritis • Fibromyalgia • Endocrine Disease See Peripheral Weakness: Sensory Changes scheme Neurologic 179 Motor Neuron and Motor Neuropathy Atrophy, Fasciculations, Hyperreflexia • Lead toxicity • Progressive muscular atrophy • Hodgkin’s lymphoma • Polio • Multifocal Motor Neuropathy • Spinal Muscular Atrophy Neuromuscular Junction Fatigability, Variability, Oculomotor • Myasthenia Gravis • Lambert-­‐Eaton Myasthenic Syndrome • Botulism • Congenital Myopathy Proximal muscle involvement, elevated CK • Polymyositis • Duchenne Muscular Dystrophy • Statin Toxicity • Dermatomyositis • Viral infection Peripheral Weakness Neurologic Sensory Changes 180 Spell / Seizure Epileptic Seizure SPELL/SEIZURE: Epileptic Seizure SPELL/SEIZURE: Epileptic Seizure Spell/Seizure Spell/Seizure Unprovoked Recurrence Provoked Recurrence Epileptic Seizure Unprovoked Recurrence Non-­‐epileptic organic seizure/other Provoked Recurrence Epileptic Seizure Focal Seizure1 Non-­‐epileptic organic seizure/other Neurologic 181 Generalized Unclassified Focal Seizure1 Non-­‐Dyscognitive1 2 1 Dyscognitive Non-­‐Dyscognitive Features of Features of • Aura • Aura • Motor • Motor • Autonomic • Autonomic Generalized Unclassified Dyscognitive2 Non-­‐Convulsive Convulsive Non-­‐Convulsive Convulsive • Absence • Absence • Atonic • Atonic Evolving to Bilateral Evolving to Bilateral 3,4 Convulsive Seizure3,4 Convulsive Seizure 1 2 3 4 • Myoclonic • Myoclonic • Clonic • Clonic • Tonic • Tonic • Tonic-­‐Clonic • Tonic-­‐Clonic Previously named Simple Partial Seizure Previously 1named Simple Partial Seizure 2 Previously named Complex Partial Seizure Previously 3named Complex Partial Seizure Previously named Secondary Generalized Tonic-­‐Clonic Seizure Previously 4named Secondary Generalized Tonic-­‐tC Seizure A focal seizure may evolve so rapidly o lonic a bilateral convulsive A focal seizure seizure may etvolve rapidly to a bilateral convulsive hat no sio nitial distinguishing features are apparent. seizure that no initial distinguishing features are apparent. Spell / Seizure Secondary Organic SPELL/SEIZURE: Secondary Organic Spell/Seizure Unprovoked Recurrence (Primary) Provoked Recurrence (Secondary) Other Secondary Organic Non-­‐epileptic organic seizure/other Febrile Infection • Sepsis • Encephalitis • Meningitis Metabolic • Hypoglycemia • Hyperglycemia • Hypocalcemia • Hyponatremia • Uremia • Alcohol/drug withdrawal • Drug overdose • Liver Failure Vascular • Intracerebral hemorrhage • Subarachnoid hemorrhage • Subdural hemorrhage • Epidural hemorrhage • Ischemic Degenerative • Dementia Structural • Congenital abnormality • Neoplasm • Arteriovenous malformation Pregnancy • Eclampsia Neurologic Epileptic Seizure 182 Spell / Seizure Other SPELL/SEIZURE: Other Spell/Seizure Unprovoked Recurrence (Primary) Provoked Recurrence (Secondary) Other Secondary Organic Non-­‐epileptic organic seizure/other Epileptic Seizure Neurological Neurologic 183 • Migraine/Auras • Movement disorders (Dystonia, Dyskinesia, Chorea) Cardiovascular • Syncope Psychogenic • Panic Disorder • Conversion Disorder • Pseudoseizures STROKE: Intracerebral Hemorrhage Stroke Intracerebral Hemorrhage Stroke Hypertension • Essential Hypertension (Aneurysm) • Drugs (Cocaine, Amphetamines) Ischemia Vessel Disease • Amyloid Angiopathy • Vascular Malformation • Aneurysm • Vasculitis Subarachnoid Hemorrhage Other • Trauma • Bleeding diathesis • Hemorrhage into tumors • Hemorrhage into infarct Neurologic Intracerebral Hemorrhage 184 Stroke Ischemia STROKE: Ischemia Stroke Intracerebral Hemorrhage Ischemia Subarachnoid Hemorrhage Embolus Systemic Hypoperfusion Thrombosis Atherosclerosis, Arterial Dissection, Fibromuscular Dysplasia Large Vessel Neurologic 185 Small Vessel • Lacunar Unknown Heart • Left Ventricle • Left Atrium • Valvular • Atrial fibrillation • Bacterial endocarditis • Myocardial infarction Ascending Aorta Pump Failure •Cardiac arrest • Arrhythmias Cardiac Output Reduction • Myocardial infarction • Pulmonary embolus • Pericardial effusion • Shock STROKE: Subarachnoid Hemorrhage Stroke Subarachnoid Hemorrhage Stroke Ischemia Vessel Disease • Aneurysm • Vascular Malformation Subarachnoid Hemorrhage Other • Bleeding Diathesis • Trauma • Drug Use Neurologic Intracerebral Hemorrhage 186 Syncope SYNCOPE Syncope Non-­‐Cardiac Cardiac Arrhythmia • Tachyarrhythmia • Bradyarrhythmia • Supraventricular Tachycardia • Sick-­‐Sinus Syndrome • Second/Third Degree Atrioventricular Block Outflow Obstruction Vasovagal/Autonomic • Aortic Stenosis • Hypertrophic Obstructive Cardiomyopathy • Pulmonary Embolus • Other • Dehydration • Hypovolemia • Medications Central • Emotional Neurologic 187 Orthostatic Peripheral/Situational • Bladder Emptying • Pain • Reduced Effective Arterial Blood Volume • Carotid Sinus Syncope • Tussive • Defecation Dizziness VERTIGO/DIZZINESS: Dizziness Vertigo/Dizziness Dizziness Lightheaded, unsteady, disoriented Organic Disease Psychiatric Disease • Presyncope/Vasodepressor Syncope • Cardiac Arrhythmia • Orthostatic Hypotension • Hyperventilation • Anemia • Peripheral neuropathy • Visual Impairment • Musculoskeletal Problem • Drugs • Depression • Anxiety • Panic Disorder • Phobic Dizziness • Somatization Neurologic True Vertigo Illusion of Rotary Movement 188 Vertigo VERTIGO/DIZZINESS: Vertigo Vertigo/Dizziness True Vertigo Illusion of Rotary Movement Dizziness Lightheaded, unsteady, disoriented Central Vestibular Dysfunction Peripheral Vestibular Dysfunction Imbalance, neurologic symptoms/signs, bidirectional nystagmus Neurologic 189 Infection Trauma • Meningitis • Cerebellar/ Brainstem Abscess • Cerebellar Contusion Inflammatory • Multiple sclerosis Intoxication • Barbiturates • Ethanol Nausea and vomiting, auditory symptoms, unidirectonal nystagmus Space-­‐ Occupying Lesion • Infratentorial Tumors • Cerebellopontine Angle Tumors • Glomus Tumors Vascular • Vertebrobasilar Insufficiency • Basilar Artery Migraine • Transient Ischemic Attack • Cerebellar/ Brainstem Infarction • Cerebellar Hemorrhage • Benign Paroxysmal Positional Vertigo • Labrynthitis/Vestibular Neuronitis • Menière’s Disease • Acoustic Neuroma • Ototoxicity (usually imbalance and oscillopsia) • Otitis Media • Temporal Bone Fracture Obstetrical & Gynecological Intrapartum Abnormal Fetal HR Tracing Variability & Decelerations�������������������������������193 Intrapartum Abnormal Fetal HR Tracing Obstetrical 191 Growth Discrepancy Small for Gestational Age / Intrauterine Growth Restriction����204 Growth Discrepancy Large for Gestational Baseline��������������������������������������������������������������������������194 Age������������������������������������������������������������������������������������205 Abnormal Genital Bleeding������������������������������������195 Infertility (Female)���������������������������������������������������������206 Acute Pelvic Pain���������������������������������������������������������� 196 Infertility (Male)��������������������������������������������������������������� 207 Chronic Pelvic Pain�������������������������������������������������������197 Intrapartum Factors that May Affect Fetal Amenorrhea Primary�������������������������������������������������� 198 Oxygenation���������������������������������������������������������������208 Amenorrhea Secondary������������������������������������������ 199 Pelvic Mass������������������������������������������������������������������������209 Antenatal Care����������������������������������������������������������������200 Ovarian Mass���������������������������������������������������������������������210 Bleeding in Pregnancy < 20 Weeks�����������������201 Pelvic Organ Prolapse�������������������������������������������������211 Bleeding in Pregnancy 2nd & 3rd Trimester Post-Partum Fever�������������������������������������������������������� 212 ���������������������������������������������������������������������������������������������� 202 Post-Partum Hemorrhage�������������������������������������� 213 Breast Disorder��������������������������������������������������������������� 203 Recurrent Pregnancy Loss�������������������������������������214 Vaginal Discharge��������������������������������������������������������� 215 Historical Editors Student Editors Dr. Heather Baxter Neha Chadha (Co-editor) Dr. Dorothy Igras Angela Deane (Co-editor) Dr. Clinton Chow Dr. Calvin Greene Faculty Editor Dr. Magali Robert Dr. Ronald Cusano Dr. Maire Duggan Dr. Barbara Walley Vera Krejcik Shaina Lee Maria Wu Danny Chao Neha Sarna Obstetrical Mia Steiner 192 Intrapartum Abnormal Fetal HR Tracing Variability & Decelerations INTRAPARTUM ABNORMAL Decelerations FETAL HEART RATE TRACING: Variability & Abnormal Fetal Heart Rate Tracing Abnormal Variability Minimal/Absent Variability ≤ 5 bpm • Fetal sleep • Prematurity • Medications (analgesia, sedatives) • Hypoxic acidemia •Congenital anomalies Obstetrical 193 Baseline Abnormality Marked Variability ≥ 25 bpm • Mild hypoxia Sinusoidal Pattern • Severe fetal anemia (Hgb < 70) • Tissue hypoxia in fetal brain stem Decelerations Absent Accelerations • Hypoxic acidemia • Fetal abnormality Early decelerations Variable decelerations Late decelerations • Fetal head compression (mirror contractions) • Cord compression • Fetal acidemia if complicated variable decelerations • Uteroplacental insufficiency • Maternal hypotension • Reduced maternal arterial oxygen saturation • Hypertonic uterus • Fetal acidemia Prolonged deceleration • Hypertonic uterus • Unresolving umbilical cord compression • Maternal hypotension • Maternal seizure • Rapid fetal descent Intrapartum Abnormal Fetal HR Tracing INTRAPARTUM ABNORMAL FETAL HEART RATE TRACING: BaselineBaseline Abnormal Fetal Heart Rate Tracing Abnormal Variability Baseline Abnormality Bradycardia Tachycardia • Hypotension • Drug response • Maternal position • Connective tissue disease with congenital heart block (e.g. SLE) > 160 bpm Fetal • Umbilical cord occlusion • Fetal hypoxia/acidosis • Vagal stimulation (e.g. chronic head compression) • Fetal cardiac conduction or structural defect Maternal • Fever • Infection • Dehydration • Hyperthyroidism • Endogenous adrenaline or anxiety • Drug response • Anemia Fetal • Infection • Prolonged fetal activity or stimulation • Chronic hypoxemia • Cardiac abnormalities • Congenital anomalies • Anemia Obstetrical < 110 bpm Maternal Decelerations 194 Abnormal Genital Bleeding ABNORMAL GENITAL BLEEDING Abnormal Genital Bleeding Pregnant Non Pregnant See Bleeding in Pregnancy Scheme Gynecologic Non-­‐Gynecologic • Medical (e.g. coagulopathy, liver disease, renal disease) • Drugs Uterus Obstetrical 195 • Anovulatory • Atrophy • Fibroid • Polyp • Exogenous estrogen • Neoplasm • Infection • Endometrial Hyperplasia Cervix • Polyp • Ectropion • Dysplasia • Neoplasm • Infection • Trauma Vagina • Atrophy • Vulvovaginitis • Neoplasm • Infection • Trauma Vulva • Vulvar dystrophy • Vulvar Atrophy • Vulvovaginitis • Neoplasm • Infection • Trauma Acute Pelvic Pain ACUTE PELVIC PAIN ACUTE PELVIC PAIN Acute Pelvic Pain Acute Pelvic Pain Gynecologic Non-­‐Gynecologic Gynecologic Non-­‐Gynecologic • Genitourinary (Infection, Stone) • Gastrointestinal (Appendicitis, Gastroenteritis, • Genitourinary (Infection, Stone)IBD) Diverticulitis, • Gastrointestinal (Appendicitis, Gastroenteritis, • Musculoskeletal Diverticulitis, IBD) • Musculoskeletal Extrauterine Extrauterine Intrauterine Intrauterine Non-­‐Pregnant Uterus Uterus Ovary Non-­‐Pregnant Fallopian Tube Ovary Fallopian Tube • Tubo-­‐ovarian abscess** • Ectopic pregnancy** • Placental bruption**abruption** • Fibroid • Tubo-­‐ovarian abscess** • Tubo-­‐ovarian abscess** • Ectopic pregnancy** • aPlacental • Fibroid • Tubo-­‐ovarian abscess** • Pelvic inflammatory • Spontaneous abortion • Endometriosis • Torsion** • Pelvic inflammatory • Spontaneous a bortion • Endometriosis • Torsion** disease • Labour • Adenomyosis • Ovarian cyst disease • Labour cyst •Molar pregnancy • Pyometrium • Adenomyosis • Endometriosis • Ovarian •Torsion •Torsion •Molar pregnancy• Hematometra • Pyometrium• Ovulation pain • Endometriosis • Endometriosis • Endometriosis Hematometra • Hydrosalpinx • Congenital A•nomaly • Ovulation pain • Dysmenorrhea • Hydrosalpinx • Congenital Anomaly **Obstetrical Emergencies **Obstetrical Emergencies • Dysmenorrhea Obstetrical Pregnant Pregnant 196 Chronic Pelvic Pain CHRONIC PELVIC PAIN Chronic Pelvic Pain > 6 months in duration Gynecologic Non-­‐Gynecologic • Endometriosis • Chronic pelvic inflammatory disease • Dysmenorrhea • Adenomyosis • Ovarian cyst • Adhesions Obstetrical 197 Gastrointestinal • Irritable bowel syndrome • Inflammatory bowel disease • Constipation • Neoplasm Co-­‐morbidities • Somatization • Sexual/physical/psychological abuse • Depression/anxiety • Abdominal wall pain Genitourinary • Interstitial cystitis • Urinary retention • Neoplasm Musculoskeletal • Pelvic floor myalgia • Myofascial pain (trigger points) • Injury Amenorrhea Primary AMENORRHEA: Primary Amenorrhea Primary Ovarian Etiology High FSH Low Estrogen • 46, XX Gonadal Dysgenesis (e.g. Fragile X, Balanced Translocations, Turner’s mosaic) • 46, XY Gonadal Dysgenesis (e.g. Swyer’s Syndrome) • 45, XO Turner syndrome • Savage syndrome (ovarian resistance) • Premature Ovarian Failure (Autoimmune, Iatrogenic) Receptor Abnormalities and Enzyme Deficiencies Secondary Absence of menses for 3 cycles or 6 months Central Low FSH Low Estrogen • Androgen insensitivity • 5-­‐α Reductase deficiency • 17-­‐ α Hydroxylase deficiency • Vanishing Testes Syndrome • Absent Testes Determining Factor Hypothalamic • Functional (e.g. eating disorder, weight loss, stress, excessive exercise, illness) • Congenital GnRH deficiency (Kallmann syndrome) • Constitutional delay of puberty Congenital Outflow Tract Anomalies • Imperforate hymen • Transverse vaginal septum • Vaginal agenesis (Mayer-­‐ Rokitansky-­‐Küster-­‐Hauser syndrome) • Cervical stenosis Pituitary • Surgery • Irradiation • Tumor, Infiltration • Hyperprolactinemia • Hypothyroidism Obstetrical No onset of menarche by age 16 with secondary sexual characteristics Or, No onset of menarche by age 14 without secondary sexual characteristics 198 Amenorrhea Secondary AMENORRHEA: Secondary Amenorrhea Secondary Primary No onset of menarche by age 16 Absence of menses for more than 3 cycles or 6 months in women who were previously menstruating Rule out pregnancy (β-­‐hCG) Ovarian Obstetrical 199 Hypothalamic Negative progesterone challenge, Low FSH, Low estrogen • Functional (e.g. eating disorder, weight loss, stress, excessive exercise, illness) • Infiltrative lesions (e.g. lymphoma, Langerhans cell histiocytosis, sarcoidosis) Normal FSH • Polycystic ovarian syndrome (positive progesterone challenge, normal prolactin, chaotic menstruation history) High FSH • Menopause • Premature ovarian failure (<35 years old, e.g. autoimmune, chromosomal, iatrogenic) Pituitary Outflow Tract Obstruction • Asherman’s syndrome • Cervical stenosis High Prolactin • Pituitary Adenoma • Prolactinoma • Chest wall irritation • Hypothalamic-­‐Pituitary Stalk Damage (e.g. Tumors, trauma, compression) • Hypothyroidism Other • Sheehan’s Syndrome • Radiation • Infection • Infiltrative Lesions; hemochromatosis Antenatal Care ANTENATAL CARE Antenatal Care At Every Visit Weight, Blood pressure, Psychosocial screening, Counseling re. Indications to go to hospital (0-­‐12 weeks) • Detailed history and physical exam • Estimated date of delivery • Dating ultrasound • Prenatal labs (CBC, ABO/Rh type & screen, Antibody screen, HBsAg, Syphilis serology, Rubella IgG, Varicella, HIV) • Chlamydia/Gonorrhea screen • Urine culture & sensitivity Second Trimester (12-­‐28 weeks) • Fetal heart rate tones (starting at 12 weeks) • Prenatal genetic screening • First trimester screen (nuchal translucency, β-­‐hCG , PAPP-­‐A; 11-­‐14 weeks) • Maternal serum screen (AFP, uE3, β-­‐ hCG; 15-­‐22 weeks) • ± Prenatal diagnosis • Chorionic villus sampling (11-­‐13 weeks) • Amniocentesis (15-­‐17 weeks) • Detailed 18-­‐20 week Ultrasound (dating, number of fetuses, placental location, anatomic survey) • Gestational diabetic screen (50g oral glucose challenge; 24-­‐28 weeks) • Rh antibody screen and Rh immunoglobulin if indicated (28 weeks) Third Trimester (28-­‐40 weeks) • Fetal surveillance • Fetal movement counts (>6 movements in 2 hours) • Symphysis fundal height •Leopold maneuvers • Group B Streptococcus screen (35-­‐37 weeks) • ± Ultrasound for growth, presentation, biophysical profile • ± Non-­‐stress test Obstetrical First Trimester 200 Bleeding in Pregnancy < 20 Weeks BLEEDING IN PREGNANCY: <20 Weeks Bleeding in Pregnancy Hemodynamically Unstable – Do ABCDEs < 20 Weeks Second / Third Trimester Bleeding from the Os Not Bleeding from the Os • Cervical polyp/Ectropion • Cervical/Vaginal neoplasm • Vaginal laceration • Infection Cervix Open Obstetrical Passing Tissue and Clots Not Passing Tissue and Clots • Complete abortion • Incomplete abortion • Ectopic pregnancy • Missed abortion • Inevitable abortion • Cervical insufficiency Cervix Closed No IUP on Transvaginal U/S IUP on Transvaginal U/S Ectopic Pregnancy on U/S No Ectopic Pregnancy on U/S β-­‐hCG < 1500 β -­‐hCG > 1500 β-­‐hCG doubled in 72h 201 Viable pregnancy – monitor for ectopic or IUP (implantation bleed) Ectopic likely β-­‐hCG not doubled in 72h Ectopic pregnancy or failed pregnancy Bleeding in Pregnancy 2nd & 3rd Trimester BLEEDING IN PREGNANCY: 2nd and 3rd Trimesters Bleeding in Pregnancy Hemodynamically Unstable – Do ABCDEs < 20 Weeks Second / Third Trimester Do NOT perform digital examination until the placental location is known Not Bleeding from the Os • Cervical polyp/Ectropion • Cervical/Vaginal neoplasm • Vaginal laceration • Infection Painful • Placental abruption • Uterine rupture • Labour (bloody show) Painless • Placenta previa • Vasa previa Obstetrical Bleeding from the Os 202 Breast Disorder Obstetrical 203 Growth Discrepancy Gestational Age A / Intrauterine Growth Restriction GROWTH DISCREPANCY: SSmall mall for For Gestational ge/ Intrauterine Growth Restriction Growth Discrepancy Large for Gestational Age Small for Gestational Age (Growth > 90th percentile for GA) Maternal Factors TORCH Infections (Growth < 10th percentile for GA) Fetal Factors Multiple Gestation Placental Factors Chromosomal Abnormalities • Trisomy 13, 18, 21 • Turner syndrome, 45X Placental Abruption • Placenta previa • Chronic insufficiency Decreased Uteroplacental Flow • Gestational hypertension/ Pre-­‐eclampsia • Renal insufficiency • Diabetes mellitus • Autoimmune disorders Maternal Lifestyle • Malnutrition • Smoking • Alcohol • Drugs Placental Malformations Confined Placental Mosaicism (Rare) • Vasa previa Maternal Hypoxemia • Pulmonary diseases • Chronic anemia • High altitude Iatrogenic • Folic acid antagonists • Anticonvulsants Obstetrical Placental Ischemia/ Infarction 204 Growth Discrepancy Large for Gestational Age GROWTH DISCREPANCY: Large for Gestational Age Growth Discrepancy Large for Gestational Age (Growth > 90th percentile for GA) Maternal Factors • Multiparity • Previous history of large for gestational age fetus • Aboriginal, Hispanic, and Caucasian races • Maternal co-­‐morbidities (e.g. diabetes, obesity) • Excessive weight gain over course of pregnancy (>40 lbs) Obstetrical 205 MATERNAL COMPLICATIONS • Prolonged labour • Operative vaginal delivery • Caesarean section • Genital tract lacerations • Post-­‐partum hemorrhage • Uterine rupture Small for Gestational Age (Growth < 10th percentile for GA) Fetal factors • Male infant • Prolonged gestation (>41 weeks) • Genetic disorder (e.g. Sotos syndrome, Beckwith-­‐Wiedemann syndrome, Weaver’s syndrome) FETAL COMPLICATIONS • Shoulder dystocia • Birth injury (brachial plexus injury, clavicular fracture) • Cerebral palsy secondary to hypoxia • Hypoglycemia • Polycythemia • Perinatal asphyxia • Hyperbilirubinemia Infertility (Female) INFERTILITY: Female Infertility Failure to conceive following > 1 year of Unprotected sexual intercourse Uterus HSG or SHG or hysteroscopy • Fibroids/polyps • Asherman’s syndrome • Congenital anomalies • Adenomyosis • Unfavourable cervical mucous • Cervical stenosis Decreased FSH Unexplained (15%) Fallopian Tube HSG or SHG or laparoscopy Hypothalamic Ovary Ovulation confirmation: mid-­‐luteal serum progesterone Ovarian reserve: Day 3 FSH +/-­‐ Estradiol • Pelvic inflammatory disease • Endometriosis • Adhesions • Previous tubal pregnancy • Congenital Anomalies Normal FSH • Polycystic ovarian syndrome • Obesity • Weight loss/malnutrition • Excessive exercise • Stress/psychosis • Systemic disease Female (50%) Hypopituitarism • Hypothyroidism • Hyperprolactinemia • Tumors (e.g. Prolactinoma) Increased FSH • Premature ovarian failure • Premenopausal changes • Turner’s syndrome Obstetrical Male (35%) 206 Infertility (Male) INFERTILITY: Male Infertility Failure to conceive following > 1 year of unprotected sexual intercourse Male (35%) Unexplained (15%) Sperm Production Sperm Motility (Non-­‐obstructive azoospermia) • Antibodies from infection Obstetrical 207 Sperm Transport Abnormal semen analysis Low testosterone Pre-­‐Testicular (Hypogonadotrophic hypogonadism) Low FSH/LH • Kallmann syndrome • Suppression of gonadotropins (e.g. hyperprolactinemia, hypothyroidism, drugs, tumor, infection, trauma) • Anabolic steroids • Vasectomy • Cystic fibrosis gene mutation • Post-­‐infectious obstruction • Ejaculatory duct cysts (e.g. prostate) • Kartagener syndrome Testicular (Sperm production problem) High FSH/LH • Genetic abnormality (e.g. Klinefelter’s) • Cryptorchidism • Varicocele • Mumps orchitis • Radiation, Infection, drugs, trauma, torsion Female (50%) Sexual Dysfunction See Sexual Dysfunction Scheme Intrapartum Factors that May Affect Fetal Oxygenation INTRAPARTUM Factors that may affect fetal oxygenation Factors affecting fetal oxygenation Excessive Uterine Activity • Hyperstimulation • Placental abruption Decreased Maternal Arterial O2 Tension • Smoking • Hypoventilation • Respiratory disease • Seizure • Trauma Maternal Factors Uteroplacental Dysfunction • Placental abruption • Placental infarction • Chorioamnionitis • Post-­‐dates pregnancy Decreased Maternal O2 Carrying Capacity • Maternal anemia • Carboxyhemoglobin Fetal Factors Cord Compression • Oligohydramnios • Cord prolapse • Cord entanglement Decreased Uterine Blood Flow • Hypotension • Anesthesia • Maternal positioning Decreased Fetal O2 Carrying Capacity • Fetal anemia • Carboxyhemoglobin • Intrauterine growth restriction • Prematurity • Fetal sepsis Maternal Medical Conditions • Fever • Vasculopathy (SLE, Type 1 diabetes mellitus, HTN) • Hyperthyroidism • Antiphospholipid syndrome Obstetrical Uteroplacental Factors 208 Pelvic Mass PELVIC MASS Pelvic Mass Do Pelvic U/S Gynecologic Non-­‐Gynecologic Gastrointestinal • Appendiceal abscess • Diverticular abscess • Diverticulosis • Rectal/Colon cancer Non-­‐Pregnant Obstetrical 209 Uterus • Fibroid • Adenomyosis • Neoplasm • Pyometra • Hematometra Fallopian Tube • Tubo-­‐ovarian abscess • Paratubal cyst • Neoplasm • Pyosalpinx • Hydrosalpinx Genitourinary • Distended bladder • Bladder cancer • Pelvic kidney • Peritoneal Cyst Pregnant Ovary See Ovarian Mass scheme Uterus • Intrauterine pregnancy Fallopian Tube • Tubal ectopic pregnancy Ovary • Ovarian ectopic pregnancy Ovarian Mass OVARIAN MASS Ovarian Mass Hyperplastic • Polycystic ovary • Endometrioid cyst Epithelial • Serous cystadenoma • Mucinous cystadenoma Epithelial • Serous cystadenocarcinoma • Mucinous cystadenocarcinoma • Endometrioid • Clear Cell Germ Cell • Mature teratoma (may be cystic) • Gonadoblastoma (can become malignant) Germ Cell • Dysgerminoma • Immature teratoma • Yolk Sac Functional Malignant Neoplasms • Follicular cyst • Corpus lutein cyst • Theca lutein cyst Sex Cord Stromal • Fibroma • Thecoma • Granulosa cell tumor Sex Cord Stromal • Granulosa cell tumor • Sertoli Cell • Sertoli -­‐ Leydig Metastases • Krukenberg tumor (gastrointestinal metastasis) • Breast Obstetrical Benign Neoplasms 210 Pelvic Organ Prolapse PELVIC ORGAN PROLAPSE Pelvic Organ Prolapse Herniation of one or more pelvic organs Risk factors: genetics, multiparity, operative vaginal delivery, obesity, increasing age, estrogen deficiency, pelvic floor neurogenic damage (i.e. surgical), strenuous activity (i.e. weight bearing) Uterus Sensation of object “falling out of vagina,” possible lower back pain • Uterine prolapse • Cervical prolapse Obstetrical 211 Vaginal Apex Pelvic pressure, urinary retention, stress incontinence • Vaginal vault prolapse Bladder Slow urinary stream, stress incontinence, bladder neck hypermobility • Cystocele (anterior prolapse) • Cystourethrocele Bowel/Rectum Defecatory symptoms • Enterocele • Rectocele (posterior prolapse) Obstetrical Post-Partum Fever 212 Post-Partum Hemorrhage POST-­‐PARTUM HEMORRHAGE Post-­‐Partum Hemorrhage Blood Loss: >500mL post vaginal delivery OR >1000mL post Caesarean section Uterine Atony (70%) Obstetrical 213 • Uterine fatigue (e.g. prolonged/induced labor, rapid labor, grand multiparity) •Overdistension of uterus (e.g. multiple gestation, polyhydramnios, fetal macrosomia) • Bladder distension • Uterine infection (e.g. chorioamnionitis) • Functional/anatomic distortion of uterus • Drugs – Uterine relaxants (e.g. nifedipine, magnesium sulfate, NSAIDs) Trauma (20%) • Perineal laceration (e.g. episiotomy) • Vaginal laceration/ hematoma • Cervical laceration (e.g. forceps/vacuum delivery) • Uterine rupture • Uterine inversion Remnant Tissue (10%) • Retained blood clots • Retained cotyledon or succenturiate lobe • Abnormal placentation (placenta accreta, increta, or percreta) Thrombin (1%) • Thrombocytopenia • Idiopathic thrombocytopenic purpura (ITP) • Thrombotic thrombocytopenic purpura (TTP) • HELLP syndrome • Disseminated intravascular coagulation (DIC) • Anti-­‐coagulation agents (e.g. heparin) • Pre-­‐existing coagulopathy (e.g. von Willebrand’s disease, Hemophilia A) Recurrent Pregnancy Loss RECURRENT PREGNANCY LOSS POST-­‐PARTUM HEMORRHAGE Recurrent Pregnancy Loss Post-­‐Partum Hemorrhage ≥ 3 consecutive spontaneous abortions Blood Loss: >500mL post vaginal delivery OR >1000mL post Caesarean section Maternal Fetal • Genetic abnormalities Trauma (20%) MedicalRemnant Tissue (10%) Thrombin (1%) Anatomic Obstetrical Uterine AEnvironmental tony (70%) Toxin (organic • Thrombocytopenia • Retained blood clots •• Uterine fatigue s(olvents, e.g. mercury, lead) • Perineal laceration (e.g. • Smoking • Idiopathic thrombocytopenic • Retained cotyledon or prolonged/induced labor, episiotomy) • Alcohol succenturiate lobe rapid labor, grand multiparity) • Vaginal laceration/ Cervixpurpura (ITP) Uterus • Drugs • Thrombotic • Abnormal placentation •Overdistension of uterus (e.g. hematoma • Ionizing radiation • oCervical • Fibroids thrombocytopenic purpura (placenta accreta, increta, r multiple gestation, • Cervical laceration (e.g. insufficiency(TTP) • Congenital percreta) polyhydramnios, fetal forceps/vacuum delivery) anomaly • HELLP syndrome macrosomia) • Uterine rupture • Polyps • Disseminated intravascular • Bladder distension • Uterine inversion • Asherman’s coagulation (DIC) • Uterine infection (e.g. Other Autoimmune Endocrine Genetic syndrome • Anti-­‐coagulation agents (e.g. chorioamnionitis) heparin) Functional/anatomic • Antiphospholipid • Diabetes mellitus • Maternal age •• Maternal infection of uterus syndrome • Hypo/hyperthyroidism • Maternal/paternal • Pre-­‐existing coagulopathy •distortion Thrombophilia (e.g. von Willebrand’s disease, • Drugs – Uterine relaxants • Lupus anticoagulant • PCOS chromosomal Hemophilia A) (e.g. nifedipine, magnesium • Luteal phase deficiency abnormality sulfate, NSAIDs) 214 Vaginal Discharge VAGINAL DISCHARGE Vaginal Discharge Infectious Inflammatory Systemic • Crohn’s disease • Collagen vascular disease • Dermatologic Obstetrical 215 Sexually Transmitted Infection • Chlamydia trachomatis • Neisseria gonorrhoeae Toxic Shock Syndrome Neoplastic Local • Chemical irritant • Douching • Atrophic vaginitis • Foreign body • Lichen planus Vulvovaginitis • Vulvovaginal candidiasis • Bacterial vaginosis • Trichomonas vaginalis • Endometrium • Cervix • Vulva • Vagina Dermatologic Burns��������������������������������������������������������������������������������������� 221 Dermatoses in Pregnancy Physiologic Changes�������������������������������������������������������������������������222 Dematoses in Pregnancy Specific Skin Conditions���������������������������������������������������������������������223 Disorders of Pigmentations Hyperpigmentation�����������������������������������������������224 Disorders of Pigmentations Dermatologic 217 Morphology of Skin Lesions Secondary Skin Lesions��������������������������������������������������������������������������� 230 Mucous Membrane Disorder Oral Cavity���� 231 Nail Disorders Primary Dermatologic Disease �����������������������������������������������������������������������������������������������232 Nail Disorders Systemic Disease�����������������������233 Nail Disorders Systemic Disease - Clubbing ���������������������������������������������������������������������������������������������� 234 Hypopigmentation�������������������������������������������������225 Pruritus No Primary Skin Lesion������������������������ 235 Genital Lesion������������������������������������������������������������������ 226 Pruritus Primary Skin Lesion��������������������������������� 236 Hair Loss (Alopecia) Diffuse�����������������������������������227 Skin Rash Eczematous�����������������������������������������������237 Hair Loss (Alopecia) Localized���������������������������� 228 Skin Rash Papulosquamous��������������������������������� 238 Morphology of Skin Lesions Primary Skin Skin Rash Pustular�������������������������������������������������������� 239 Lesions��������������������������������������������������������������������������� 229 Skin Rash Reactive�������������������������������������������������������240 Skin Rash Vesiculobullous���������������������������� 241 Skin Ulcer by Etiology��������������������������������������242 Skin Ulcer by Location Genitals����������������243 Skin Ulcer by Location Head & Neck����244 Skin Ulcer by Location Lower Legs / Feet��������������������������������������������������������������������������245 Skin Ulcer by Location Oral Ulcers�������� 246 Skin Ulcer by Location Trunk / Sacral Region��������������������������������������������������������������������247 Dermatologic Vascular Lesions�������������������������������������������������� 248 218 Historical Editors Student Editors Danny Guo Noelle Wong (Co-editor) Rachel Lim Heena Singh (Co-editor) Dave Campbell Joanna Debosz Faculty Editor Safiya Karim Dr. Laurie Parsons Beata Komierowski Natalia Liston Arjun Rash Jennifer Rodrigues Dermatologic 219 Sarah Surette Yang Zhan 220 Dermatologic URNS Burns BURNS Burns Burns Physical Agents Dermatologic 221 • • • • Thermal Burn Cold Burn Electrical Burn Sun Burn Chemical Agents Physical Agents • Acid • Alkali • Thermal Burn • Cold pBeroxides, urn • Oxidants (Bleaches, • Electrical Burn chromates, manganates) • Sun Burn • Vesicants (sulfur and nitrogen, mustards, arsenicals, phosgene oxime) • Others (white phosphorus, metals, persulfates, sodium azide) Chemical Age • Acid • Alkali • Oxidants (Bleaches, perox chromates, manganates) • Vesicants (sulfur and nitro arsenicals, phosgene oxime • Others (white phosphorus persulfates, sodium azide) Parkland formula for fluid resuscitation: 4cc x Weight (kg) x %TBSA burn Dermatoses in Pregnancy DERMATOSES IN PREGNANCY: Physiologic Changes Physiologic Changes Dermatoses in Pregnancy Physiologic Skin Changes Pigmented Specific Skin Conditions Other Vascular Face • Melasma Abdomen • Linea Nigra Hormone induced • Hyperpigmentation of areolae, axillae & genitalia • Increase in mole size & number (probable) Skin • Palmar erythema • Spider Nevi • Cherry Hemangioma (Campbell de Morgan spot) • Pyogenic granuloma Mucous Membranes • Chadwick’s sign (bluish discoloration of cervix/vagina/vulva) Dermatologic • Striae Distensae (striae gravidarum) • Distal Onycholysis • Subungual Keratosis • Hyperhidrosis • Miliaria • Dyshidrotic Eczema • Hirsutism (face, limbs, and back) 222 Dematoses in Pregnancy Specific Skin Conditions DERMATOSES IN PREGNANCY: Specific Skin Conditions Dermatoses in Pregnancy Physiologic Skin Changes Specific Skin Conditions Non-­‐Pruritic Pruritic • Pustular psoriasis of pregnancy • Impetigo Herpetiformis Dermatologic 223 Non-­‐Primary Skin Lesion • Intrahepatic cholestasis of pregnancy (pruritis worse at night , 3rd trimester) Primary Skin Lesion • Pemphigoid gestationis • Pruritic urticarial plaques & papules of pregnancy (PUPPP) Disorders of Pigmentations DISORDERS OF PIGMENTATION: Hyperpigmentation Hyperpigmentation Disorder of Pigmentation Hypopigmentation Hyperpigmentation Diffuse Localized Discrete Areas Congenital • Café au lait macules (neurofibromatosis or McCune Albright syndrome) • Congenital melanocytic nevi Acquired • Freckles (ephelides) • Lentigines • Melasma • Tinea versicolor (more commonly hypopigmented) • Post-­‐Inflammatory hyperpigmentation Dermatologic • Tanning • Adverse cutaneous drug eruption • Addison’s disease • Hemochromatosis • Porphyria cutanea tarda 224 Disorders of Pigmentations Hypopigmentation DISORDERS OF PIGMENTATION: Hypopigmentation Disorder of Pigmentation Hypopigmentation Hyperpigmentation Localized Diffuse Congenital Dermatologic 225 Acquired • Tuberous sclerosis (white “ash leaf” macules) Congenital • Phenylketonuria • Albinism • Piebaldism Scale • Tinea versicolor (can also be hyperpigmented) • Pityriasis alba Acquired Generalized hypopigmentation of hair, eyes, skin • Vitiligo Acquired • Vitiligo • Post-­‐Inflammatory hypopigmentation Genital Lesion GENITAL LESION Genital Lesion Elevated Vesicles Depressed Papules/Plaques Erosions/Ulcers • Herpes simplex Excoriations • Scabies • Pubic lice Non-­‐Infectious • Molluscum contagiousum • Human papilloma virus warts (condyloma acuminata) • Secondary Syphilis (condyloma lata) • Reiter’s syndrome (circinate balanitis) Inflammatory • Lichen planus • Psoriasis Painful Painless • Herpes simplex • Haemophilus ducreyi (chancroid) • Behçet’s syndrome • Pemphigus vulgaris • Lichen Sclerosis • Erosive Lichen Planus • Primary syphilis (chancre) • Granuloma Inguinale • Lymphogranuloma venereum Non-­‐Infectious • Squamous cell carcinoma (can be in situ) • Melanoma Dermatologic Infectious 226 Hair Loss (Alopecia) Diffuse HAIR LOSS (ALOPECIA): Diffuse Hair Loss Localized (focal) Diffuse Scarring Irreversible-­‐biopsy required Non-­‐Scarring Reversible • Lupus erythematosus • Lichen planopilaris Pattern • Androgenetic alopecia Dermatologic 227 Endocrine • Hypothyroidism • Hyperthyroidism • Hypopituitarism • Post-­‐Partum Anagen Effluvium • Chemotherapy • Loose anagen syndrome Dietary • Iron deficiency • Zinc deficiency • Copper deficiency • Vitamin A Excess Discrete Patches Telogen Effluvium • Alopecia totalis (all scalp and facial hair) • Alopecia universalis (all body hair) Drugs • Oral contraceptives • Hyperthyroid drugs • Anticoagulants • Lithium Stress Related • Post-­‐infectious • Post-­‐operative • Psychological stress Hair Loss (Alopecia) HAIR LOSS (ALOPECIA): Localized Localized Localized (focal) Diffuse Scarring Irreversible-­‐biopsy required Non-­‐Scarring Reversible Infectious • Tinea capitis with kerion • Folliculitis decalvans Secondary to Skin Disease • Discoid lupus erythematosus • Lichen planopilaris • Pseudopelade of Brocq • Alopecia Mucinosa • Keratosis Follicularis • Aplasia cutis Broken Hair Shafts • Tinea capitis • Trichotillomania • Traction alopecia • Congenital hair shaft abnormalities Hair Shafts Intact or Absent • Alopecia areata • Secondary syphilis Dermatologic Hair Loss 228 Morphology of Skin Lesions Primary Skin Lesions MORPHOLOGY OF SKIN LESIONS: Primary Skin Lesions Skin Lesion Primary Skin Lesion Secondary Skin Lesion Initial lesion not altered by trauma, manipulation (rubbing, scratching), complication (infection), or natural regression over time. Lesion that develops from trauma, manipulation (rubbing, scratching), complication (infection) of initial lesion, or develops naturally over time Flat Elevated • Macule (≤ 1 cm diameter) • Patch (> 1 cm diameter) Solid Fluid-­‐Filled OR Semi-­‐Solid-­‐Filled Fluid-­‐Filled • Cyst Dermatologic 229 No Deep Component • Papule (≤ 1 cm diameter) • Plaque (> 1 cm diameter) Deep Component • Nodule (1-­‐3 cm diameter) • Tumor (> 3 cm diameter) Firm/Edematous Transient/Itchy • Wheals/Hives Purulent • Pustule Non-­‐Purulent Fluid • Vesicle (≤ 1 cm diameter) • Bulla (> 1 cm diameter) Morphology of Skin Lesions Secondary Skin Lesions MORPHOLOGY OF SKIN LESIONS: Secondary Skin Lesions Skin Lesion Secondary Skin Lesion Lesion that develops from trauma, manipulation (rubbing, scratching), complication (infection) of initial lesion, or develops naturally over time Elevated Depressed • Crust/Scab (dried serum, blood, or pus overlying the lesion) • Scale (dry, thin or thick flakes of skin overlying the lesion) • Lichenification (thickened skin with accentuation of normal skin lines) • Hypertrophic Scar (within boundary of injury) • Keloid Scar (extend beyond boundary of injury) • Atrophic Scar (fibrotic replacement of tissue at site of injury) • Ulcer (complete loss of epidermis extending into dermis or deeper; heals with scar) • Erosion (partial loss of epidermis only; heals without scar) • Fissure (linear slit-­‐like cleavage of skin) • Excoriation/Scratch (linear erosion induced by scratching) Dermatologic Primary Skin Lesion Initial lesion not altered by trauma, manipulation (rubbing, scratching), complication (infection), or natural regression over time. 230 Mucous Membrane Disorder MUCOUS MEMBRANE DISORDER (Oral Cavity) Oral Cavity Mucous Membrane Disorder Erosions/Ulcers/Blisters Primary Dermatologic Diseases Dermatologic 231 • Aphthous Stomatitis (recurrent, punched out ulcers, often preceded by trauma/emotional stress) • Herpetic gingivostomatitis • Pemphigus vulgaris • Bullous pemphigoid • Erythema multiforme • Stevens-­‐Johnson Syndrome • Toxic epidermal necrolysis Systemic Disease • Systemic lupus erythematosus • Inflammatory bowel disease (ulcerative colitis more than Crohn’s disease) • Behçet’s syndrome White Lesions Non-­‐neoplastic Neoplastic • Leukoplakia • Squamous cell carcinoma Candidiasis White/cottage cheese like plaques/scrape off easily Lichen Planus Reticular (lace-­‐like) white lines & papules Nail Disorders NAIL DISORDERS: Primary Dermatologic DiseasePrimary Dermatologic Disease Nail Disorder Oil Drop Sign Systemic Disease Nail Plate Abnormality Nail Fold Abnormality Pitting Thickening Onycholysis • Psoriasis • Alopecia Areata • Psoriasis • Onychomycosis • Onychogryphosis • Psoriasis • Onychomycosis Brown/Black Linear Streak Fungal Culture • Psoriasis White/Yellow-­‐ Brown • Onychomycosis Green • Pseudomonas infection •Junctional/ Melanocytic Nevus • Malignant Melanoma Under Nails • Drug-­‐Induced Inflammation Erythema, Swelling, Pain Proximal & Lateral Telangiectasia • SLE • Scleroderma • Dermatomyositis Lateral Only • Ingrown Nail Acute Trauma/Infection • Acute Paronychia Chronic • Chronic Paronychia Dermatologic Discolouration Primary Dermatologic Disease 232 Nail Disorders Systemic Disease NAIL DISORDERS: Systemic Disease Nail Disorder Primary Dermatologic Disease Nail Plate Abnormality Systemic Disease Nail Fold Abnormality Nail Bed Abnormality • SLE • Scleroderma • Dermatomyositis Koilonychia Spoon-­‐Shaped • Iron deficiency anemia Dermatologic 233 Onycholysis Plate Separating from Bed • Hyperthyroidism Blue Discoloration • Medications • Wilson’s disease • Silver poisoning • Cyanosis Beau’s Lines Horizontal Grooves Clubbing • Any systemic disease severe enough to transiently halt nail growth (e.g.. shock, malnutrition) White Discoloration Red Discoloration Splinter hemorrhages (dark red, thin lines, usually painful) • Bacterial endocarditis • Trauma Terry’s Nails Proximal 90% • Liver cirrhosis • Congestive heart failure • Diabetes Mellitus Half-­‐and-­‐Half Nails 50% • Chronic renal failure • Uremia Muehrcke’s Lines Transverse lines • Nephrotic syndrome Nail Disorders NAIL DISORDERS: Systemic Disease -­‐ Clubbing Systemic Disease - Clubbing Nail Disorder Nail Plate Abnormality Koilonychia Onycholysis Systemic Disease Nail Fold Abnormality Beau’s Lines Spoon-­‐Shaped Plate Separating from Bed Horizontal Grooves Bronchopulmonary Disease Cardiovascular Disease Gastrointestinal Disease • Bronchiectasis • Chronic Lung Infection • Lung Cancer • Asbestosis • Cystic Fibrosis • Chronic Hypoxia • Cyanotic Heart Disease • Inflammatory Bowel Disease (Crohn’s Disease, Ulcerative Colitis) • Gastrointestinal Cancer Nail Bed Abnormality Clubbing Endocrine Disease • Hyperthyroidism (Grave’s Disease) Other • Human Immunodeficiency Virus • Congenital Defect Dermatologic Primary Dermatologic Disease 234 Pruritus PRURITUS: No Primary Skin Lesion No Primary Skin Lesion Pruritus Primary Skin Lesion No Primary skin Lesion Primary Abnormal Finding Dermatologic 235 Blood Glucose Liver Function Tests/Enzymes • Diabetes Mellitus • Cholestatic liver disease Creatinine & BUN • Chronic renal failure/uremia TSH & T4 • Hypothyroidism • Hyperthyroidism CBC & Differential • Lymphoma • Leukemia • Polycythemia rubra vera • Essential Throbocythemia • Myelodisplastic syndrome Psychiatric Disease • Delusions of parasitosis Pruritus PRURITUS: Primary Skin Lesion Primary Skin Lesion Pruritus Macules/Papules/Plaques • Xerosis (dry skin) • Atopic dermatitis • Nummular dermatitis • Seborrheic dermatitis • Stasis dermatitis • Psoriasis • Lichen Planus • Infestations (scabies, lice) • Arthropod bites No Primary skin Lesion Vesicles/Bullae • Varicella zoster (chickenpox) • Dermatitis herpetiformis • Bullous pemphigoid Wheals/Hives • Urticaria Dermatologic Primary Skin Lesion 236 Skin Rash SKIN RASH: Eczematous Eczematous Skin Rash Eczematous Pruritic/Scaly/Erythematous lesions. Usually poorly demarcated Atopic Dermatitis Dermatologic 237 (Eczema) Erythematous papules and vesicles (acute) or lichenification (chronic) Age dependent distribution: Infants: scalp, face, extensor extremities Children: flexural areas Adults: flexural areas/hands/face/ nipples Papulosquamous Erythrematous or violaceous papules & plaques with overlying scale Nummular Dermatits (Discoid Eczema) Coin shaped (discoid) erythematous plaques. Usually on lower legs Vesiculobullous Blisters containing non-­‐ purulent fluid Seborrheic Dermatitis Yellowish-­‐red plaques with greasy distinct margins on scalp/face/central chest folds Stasis Dermatitis Pustular Blisters containing purulent fluid Erythematous eruption on lower legs. Secondary to venous insufficiency. +/-­‐ pigmentation, edema, varicose veins, venous ulcers Dyshidrotic Eczema (pompholyx) Deep-­‐Seated tapioca-­‐like vesicles on hands/feet/sides of digits. Irritant Rapid onset, requires high doses of the agent. May occur in anyone Reactive Reactive erythematous with various morphology Contact Dermatitis Well-­‐demarcated erythema, papules, vesicles, erosions scaling confined to area of contact Allergic Delayed onset (12-­‐ 72 hrs). Very low concentrations sufficient. Occurs only in those sensitized Skin Rash SKIN RASH: Papulosquamous Papulosquamous Skin Rash Psoriasis Well demarcated plaques, thick silvery scale on elbows & knees. Auspitz sign Koebner’s phenomenon Papulosquamous Erythrematous or violaceous papules & plaques with overlying scale Lichen Planus Purple, pruritic, polygonal, planar (flat-­‐topped) papules on wrists/ankles/genital s (especially penis) Wickham’s striae Koebner’s phenomenon Vesiculobullous Blisters containing non-­‐ purulent fluid Pityriasis Rosea Oval, tannish-­‐pink or salmon-­‐coloured patches, plaques with scaling border in Christmas tree pattern on trunk, begins with a large lesion patch (Herald’s patch) Tinea Pustular Blisters containing purulent fluid (Ring Worm) Annular (Ring-­‐ shaped) lesion with elevated scaling, red border, central clearing Secondary Syphilis Red brown or copper coloured scaling papules and plaques on palms and soles Reactive Reactive erythematous with various morphology Discoid Lupus Erythematous Scarring and/or atrophic red/purple plaques with white adherent scales on sun-­‐exposed area Dermatologic Eczematous Pruritic/Scaly/Erythematous lesions Usually poorly demarcated 238 Skin Rash SKIN RASH: Pustular Pustular Skin Rash Eczematous Pruritic/Scaly/Erythematous lesions Usually poorly demarcated Papulosquamous Erythrematous or violaceous papules & plaques with overlying scale Vesiculobullous Blisters containing non-­‐ purulent fluid Acneiform Acne Vulgaris Dermatologic 239 Comedones Absent Acne Rosacea Telangiectasia, episodic flushing after sunlight, alcohol, hot or spicy food & drinks Reactive Reactive erythematous with various morphology Infectious Erythematous papules and pustules on face Comedones +/-­‐ nodules, cysts, scars on face & trunk Pustular Blisters containing purulent fluid Folliculitis Pustules centered around hair follicles Perioral Dermatitis Perioral, periorbital & nasolabial distribution, sparing vermillion borders of lips Impetigo Pustules with overlying thick honey-­‐yellow crusts Candidiasis “Beefy red” erythematous patches in body folds with satellite pustules at periphery Skin Rash SKIN RASH: Reactive Reactive Skin Rash Papulosquamous Erythrematous or violaceous papules & plaques with overlying scale Vesiculobullous Blisters containing non-­‐ purulent fluid Urticaria Firm,/edematous papules & plaques that are transient & itchy. Usually lasts <24hrs Pustular Reactive Blisters containing purulent fluid Reactive erythematous with various morphology Erythema Nodosum Erythema Multiforme Tender or painful red nodules on shins Target lesions possibly with macules, papules, vesicles &/or bullae on palms soles and mucous membranes Dermatologic Eczematous Pruritic/Scaly/Erythematous lesions Usually poorly demarcated 240 Skin Rash Vesiculobullous SKIN RASH: Vesiculobullous Skin Rash Eczematous Pruritic/Scaly/Erythematous lesions Usually poorly demarcated Papulosquamous Erythrematous or violaceous papules & plaques with overlying scale Vesicles Fragile/Easily Ruptured Intraepidermal blisters, possibly crusts/erosions Dermatologic 241 Inflammatory • Pemphigus vulgaris • Pemphigus foliaceus Infectious • Varicella zoster (chickenpox) • Herpes zoster (shingles) • Herpes simplex • Bullous impetigo Reaction to Agent • Contact dermatitis Pustular Vesiculobullous Blisters containing purulent fluid Blisters containing non-­‐ purulent fluid Reactive Reactive erythematous with various morphology Vesicles NOT Fragile/NOT Easily Ruptured Subepidermal blisters, tense intact blisters Inflammatory • Bullous pemphigoid • Mucous membrane pemphigoid • Dermatitis herpetiformis • Bullous systemic lupus erythematous Metabolic • Porphyria cutanea tarda • Diabetic bullae (bullous diabeticorum) Reaction to Agent • Phototoxic drug eruption Skin Ulcer by Etiology SKIN ULCER BY ETIOLOGY Skin Ulcer Vascular Hemoglobino-­‐ pathy • Sickle cell anemia •Thalessemia Hematologic • Arterial Insufficiency • Venous insufficiency • Vasculitis Other • Cryog-­‐ lobulinemia Neoplastic Neurological • Squamous cell carcinoma •Basal cell carcinoma • Melanoma • Mycosis fungoides (cutaneous t-­‐ cell lymphoma) • Diabetic neuropathy • Tabes dorsalis (syphilis) • Factitious disorder • Delusions of parasitosis Protozoan • Leishmaniasis Viral • Herpes simplex Infectious Metabolic • Pyoderma gangrenosum • Diabetic dermopathy • Necrobiosis lipoidica Bacterial • Tuberculosis •Syphilis • Chlamydia trachomatis • Klebsiella granulomatis Drugs • Coumadin • Heparin • Bleomycin Fungal • Histoplasmosis • Coccidioido-­‐ mycosis • Cryptococcosis Dermatologic Physical • Trauma • Pressure • Radiation 242 SkinULCER Ulcer Location SKIN BY by LOCATION: Genitals Genitals Skin Ulcer Oral Head/Neck Painful Dermatologic 243 • Herpes simplex • Haemophilus ducreyi (chancroid) • Behçet’s syndrome • Pemphigus vulgaris • Lichen sclerosis • Erosive lichen planus Trunk/Sacral Region Genitals Painless • Primary syphilis (chancre) • Granuloma inguinale • Lymphogranuloma venereum Lower Legs/Feet Skin Ulcer by Location SKIN ULCER BY LOCATION: Head and Neck Head & Neck Skin Ulcer Neoplastic • Squamous cell carcinoma • Basal cell carcinoma • Melanoma Head/Neck Trunk/Sacral Region Metabolic • Pyoderma gangrenosum Genitals Vascular Lower Legs/Feet Other • Wegner’s granulomatosis • Radiation Dermatologic Oral 244 SkinULCER Ulcer Location SKIN BY by LOCATION: Lower Legs / Feet Lower Legs / Feet Skin Ulcer Oral Physical • Pressure • Trauma • Radiation Dermatologic 245 Head/Neck Vascular • Arterial insufficiency • Vascular insufficiency • Vasculitis Trunk/Sacral Region Neurological • Diabetic neuropathy • Tabes dorsalis (syphilis) Metabolic • Pyoderma gangrenosum • Diabetic dermopathy • Necrobiosis lipoidica Genitals Neoplastic • Squamous cell carcinoma • Basal cell carcinoma • Melanoma Lower Legs/Feet Other SKIN ULCER BY LOCATION: Oral Ulcers Skin Ulcer by Location Oral Ulcers Skin Ulcer Single Ulcer • Traumatic ulcer • Angular ulcer • Aphthous ulcer • Herpes simplex Head/Neck Trunk/Sacral Region Multiple Acute Ulcers • Viral stomatitis • Erythema multiforme • Acute necrotizing ulcerative gingivitis Genitals Multiple Recurrent Ulcers • Aphthous stomatitis • Herpes simplex infection Lower Legs/Feet Multiple Chronic Ulcers • Pemphigus vulgaris • Lichen planus • Lupus erythematosus • Bullous pemphigoid Dermatologic Oral 246 SkinULCER Ulcer Location SKIN BY by LOCATION: Trunk / Sacral Region Trunk / Sacral Region Skin Ulcer Oral Head/Neck Trunk/Sacral Region Neoplastic Dermatologic 247 • Squamous cell carcinoma • Basal cell carcinoma • Melanoma • Mycosis fungoides (cutaneous t-­‐cell lymphoma) Physical • Physical • Trauma • Radiation Genitals Lower Legs/Feet Other VASCULAR LESIONS Vascular Lesions Vascular Lesions Blanches with Pressure Small, dilated superficial blood vessels Does not blanche with pressure Erythematous or violaceous discolorations of skin due to extravasation of RBCs in dermis • Telangiectasia Congenital • Hemangioma Acquired • Vasculitis Dermatologic Petechiae < 0.2 cm diameter Purpura 0.2 -­‐ 1.0 cm diameter Ecchymosis > 1 cm diameter 248 Musculoskeletal Acute Joint Pain Vitamin CD����������������������������������251 Chronic Joint Pain����������������������������������������������������������252 Bone Lesion���������������������������������������������������������������������� 253 Deformity / Limp���������������������������������������������������������� 254 Infectious Joint Pain���������������������������������������������������� 255 Inflammatory Joint Pain�������������������������������������������� 256 Vascular Joint Pain��������������������������������������������������������257 Pathologic Fractures�������������������������������������������������� 258 Soft Tissue�������������������������������������������������������������������������� 259 Musculoskeletal 249 Fracture Healing������������������������������������������������������������260 Osteoporosis BMD Testing�������������������������������������261 Tumour���������������������������������������������������������������������������������� 262 Mytomes Segmental Innervation of Muscles ���������������������������������������������������������������������������������������������� 263 Guide to Spinal Cord Injury������������������������������������ 264 Historical Editors Student Editors Dr. Marcia Clark Angie Karlos (Co-editor) Dr. Sylvain Coderre Ryan Iverach (Co-editor) Dr. Mort Doran Dr. Henry Mandin Faculty Editor Graeme Matthewson Dr. Carol Hutchison Katy Anderson Tara Daley Kate Elzinga Bikram Sidhu Musculoskeletal Jonathan Dykeman 250 Acute Joint Pain Vitamin CD ACUTE JOINT PAIN-­‐ VITAMIN CD Vascular -­‐ See vascular joint pain Infectious -­‐ See infectious joint pain Trauma Autoimmune Musculoskeletal 251 -­‐ Multiple injury sites, Open Fracture, Infectious joint pain -­‐ See inflammatory joint pain Metabolic -­‐ See pathologic fractures Iatrogenic -­‐ Hx of prior surgery Neoplastic -­‐ See Tumour Congenital -­‐ Scoliosis, Talipes Equinovarus, Meta tarsus adductus, Bow leg, Knock-­‐ Knee’d Degenerative -­‐ Degenerative Disc Disease, Osteoarthritis, Osteoporosis Musculoskeletal Chronic Joint Pain 252 Bone Lesion BONE LESION Bone Lesion on X-­‐ray Rule Out Osteomyelitis & Secondary Metastases Non-­‐aggressive Exostotic Aggressive Narrow, <1mm margin Reactive bone formation Broad or Indistinct Margin &/or Soft Tissue Invasion • Osteochondroma Multiple Lytic Lesions • Multiple Myeloma Malignant Asymptomatic &/or Non-­‐ Active Bone Scam Musculoskeletal 253 Symptomatic &/or Active Bone Scan • Unicameral Bone Cysts • Aneurysmal Bone Cysts •Non-­‐ossifying Fibroma Inflammatory Appearance • Osteoid Osteoma (“Nidus” appearance) • Osteoblastoma (may be malignant or sclerotic in appearance) Benign No Bone Mineralization • Enchondroma (can calcify &/or turn malignant) • Giant Cell Tumor (“Soap Bubble” appearance) Not Inflammatory Appearance • Chondroblastoma • Chondromyxoid Fibroma Bone Mineralization, Constitutional Symptoms, Codman’s Triangle, Excessive Scalloping & Destruction of Cortical Bone • Osteosarcoma (Codman’s Triangle) • Chondrosarcoma (“Popcorn” appearance) • Ewing’s Sarcoma Deformity / Limp DEFORMITY/LIMP Deformity/Limp Infection • Septic Arthritis • Cortical Hypertrophy • Osteomyelitis Inflammation • Rheumatoid Arthritis • Toxic Synovitis • Reactive Arthritis Other Causes • Osteoarthritis • Osteomalacia • Rickets Hip Joint Knee Joint Spine/Stature • Hip Dysplasia • Slipped Capital Femoral Epiphysis • Legg-­‐Calve-­‐ Perthes Disease • Patellofemoral Syndrome (Chondromalacia Patellae) • Osgood-­‐ Schlatter Disease • Patella (e.g., Tendon Rupture, Dislocation, Subluxation) • Osteoporosis • Scoliosis/Spinal Curvature • Dwarfism Musculoskeletal Always check neurological and vascular status one joint below the injury 254 Infectious Joint Pain INFECTIOUS JOINT PAIN Infectious Joint Pain Fever/Chills/Myalgia Constant Pain Increased Heat and Swelling Signs & Symptoms of Viral Infection 9E.g., Rhinitis/Cough) Polyarticular Musculoskeletal 255 • Viral Myalgia • Viral Arthritis • Disseminated Gonoccocal Infection (Dermatitis, Migratory Arthralgia & Tenosynovitis) • Secondary Syphilis (Red/Copper Papules & Mucosal Lesions) • Fifth Disease (Erythema Infectiousum & Symmetrical Rash) • Rubella (Measles-­‐ like rash) • Primary HIV Infection • Endocarditis Monoarticular Articular Peri-­‐Articular • Cellulitis • Necrotizing Fasciitis • Septic Bursitis • Abscess • Osteomyelitis • Lymphadenitis • Warts Acute Onset • Septic Arthritis Insidious Onset • Fungal tuberculosis • Lyme Disease (Erythema Migrans) Inflammatory Joint Pain INFLAMMATORY JOINT PAIN Inflammatory Joint Pain Monoarticular Oligoarticular (1-­‐4 joints) • Gout • Psoriatic (Nail Changes, Plaques) • Enteropathic (e.g. Inflammatory Bowel Disease) • Reactive • Rheumatic Fever (recent Pharyngitis, Carditis) • Lyme Disease (Tick bite, Migratory red Macules) Peripheral Only Subacute & Symmetrical • Rheumatoid Arthritis • Systemic Lupus Erythematosus • Sjögren’s (a.k.a. Sicca) Syndrome • Scleroderma • Henoch-­‐Schonlein Purpura • Polymyalgia Rheumatica • Wegener’s Granulomatosis Insidious Monoarticular • Symmetric (Polymyositis/Dermato myositis) • Asymmetric (Psoriatic Arthritis) Peripheral & Axial Migratory • Rheumatic Fever Acute Onset • Reactive Insidious Onset • Ankylosing Spondylitis • Enteropathic (e.g. Inflammatory Bowel Disease) • Psoriatic Arthritis Musculoskeletal • Gout (Podagra, Tophi) • Pseudogout • Early Rheumatic Disease • Reactive (e.g. Genitourinary Infection) Polyarticular (>4 joints) 256 Vascular Joint Pain VASCULAR JOINT PAIN Vascular Joint Pain Constant Pain (Ischemia) Acute Onset Increased Pain with Activity (Claudication) Cold Extremity or Hyperemia Spasm • Vasculitis Musculoskeletal 257 Occlusion Disruption • Sickle Cell Anemia • Peripheral Vascular Disease • Atherosclerosis • Deep Vein Thrombosis • Septic Embolism (e.g. Infective Endocarditis) • Fat Embolism (e.g. fractured long bone) • Air Embolism • Vasculitis • Trauma to Vessel (dislocation/fracture) • Hemarthrosis (Hemophilia or Trauma) • Peripheral/Mycotic Aneurysm (e.g. Marfan’s Syndrome, Infective Endocarditis, Atherosclerosis) Compression • Any structure compressing the blood vessels • Abscess • Cyst • Neoplasm • Dislocated Bone gility Fractures PATHOLOGIC FRACTURES Pathologic/Fragility Fractures Low Energy/No Exercise/Repeated Use Always Check neurological and vascular status one joint below the injury Metabolic Bone Disease Tumours See Bone Lesions Scheme Renal Osteodystrophy Metabolic Bone Disease Osteomalacia/Ricketts Secondary to Chronic Renal Diffuse Pain/Proximal MDuscle Paget’s isease Osteoporosis Failure Weakness Skull/Spine/Pelvis Vertebrae/Hip/Distal Radius Positive Alkaline Phosphatase • Vitamin D Deficiency • Mineralization Defect • Phosphate Deficiency Primary • Post-­‐Menopausal • Elderly Renal Osteodystrophy Secondary to Chronic Renal Failure Osteomalacia/Ricketts Diffuse Pain/Proximal Muscle Weakness • Vitamin D Deficiency • Mineralization Defect • Phosphate Deficiency Secondary • Gastrointestinal Disease • Bone Marrow Disorder • Endocrinopathy • Malignancy • Drugs (e.g. corticosteroids) • Rheumatoid Disease • Renal Disease • Poor Nutrition • Immobilization Toronto Notes for Medical Students, Inc. (2009). Toronto Notes 209: Comprehensive Medical Reference and Review for MCCQE I & USMLE II. McGraw-­‐Hill: Toronto, Ontario. Toronto Notes for Medical Students, Inc. (2009). Toronto Notes 209: Comprehensive Medical Reference and Review for MCCQE I & USMLE II. McGraw-­‐Hill: Toronto, Ontario. Musculoskeletal rcise/Repeated Use cal and vascular status ow the injury Pathologic Fractures 258 Soft Tissue Musculoskeletal 259 Fracture Healing FRACTURE HEALING FRACTURE HEALING Fracture Healing Fracture Healing Delayed Union (3 – 6 months) Delayed Union (3 – 6 months) Fracture Healing Non-­‐Union (after 6 months) Non-­‐Union (after 6 months) Fracture Healing Malunion Malunion • Tobacco / nicotine / nicotine • NSAIDS• Tobacco Delayed Union (3 – 6 months) Non-­‐Union (after 6 months) Malunion • NSAIDS D deficiency • Ca2+ /Vitamin 2+ /Vitamin D deficiency • Ca Delayed Union (3 – 6 months) Non-­‐Union (after 6 months) Malunion • Tobacco / nicotine Septic Aseptic Non Functional Functional • NSAIDS (R/O First)Septic Aseptic Non Functional Functional • Tobacco icotine D deficiency • Ca/2+ n/Vitamin (R/O First) RED F LAGS ( life t hreatening) • NSAIDS • Inadequate • Small deviations RED F LAGS ( life t hreatening) • • CaMulti-­‐ traumaD deficiency 2+ /Vitamin Septic • Inadequate • Small axisdeviations immobilization/ Aseptic from normal Non Functional • Fracture Multi-­‐trauma Functional • Pelvic immobilization/ from normal axis reduction (R/O First) • Fracture Pelvic Fracture Atrophic Hypertrophic Septic • Femur RED F LAGS (life threatening) reduction •Misalignment Aseptic Non F unctional Functional Atrophic Hypertrophic • Femur Fracture (inadequate blood (adequate b(R/O lood First) • Inadequate • Small deviations • High Spine Fracture •Misalignment • Cervical Multi-­‐trauma before immobilization/ casting (inadequate blood flow) High Cervical Spine Fracture flow)(adequate blood from normal axis RED •F•LAGS threatening) before Pelvic (Flife racture flow) •Premature cast casting flow) • Inadequate • Small deviations reduction • Multi-­‐ raumaFracture • Mechanical failure) Hypertrophic •Tobacco /Atrophic nicotine •Premature cast • tFemur removal immobilization/ from normal axis •Misalignment • Mechanical failure) •NSAIDS •Tobacco / n icotine • Excessive m otion (inadequate b lood • Pelvic F racture (adequate b lood removal • High Cervical Spine Fracture reduction before casting • Excessive Atrophic •NSAIDS Hypertrophic flow) flow) •Excessive bone gapmotion •Medications • Femur Fracture •Misalignment •Premature cast •Excessive blood (adequate blood bone gap (inadequate •Medications • High Cervical Spine Fracture •Allergies •flow) Mechanical failure) •Tobacco / n icotine before casting removal flow) •Allergies •Biologic Failure • Excessive motion •NSAIDS •Premature cast •Biologic Failure • Mechanical f ailure) •Tobacco / n icotine •Excessive bone gap •Medications removal • Excessive motion •NSAIDS •Allergies •Excessive bone gap •Medications Non-­‐Operative Operative •Biologic Failure Operative •Allergies FracturesNon-­‐Operative Inflammation Fractures: Soft Callus Hard Callus Remodelling Inflammation •Biologic Soft FC allus Hard Callus Remodelling ailure • ClosedFractures • Open Fractures: Hours-­‐ Days Days-­‐ Weeks Weeks-­‐ Months Years • Open • Stable• Closed • Unstable Hours-­‐ Days Days-­‐ Weeks Weeks-­‐ Months Years Non-­‐ O perative Operative • Stable • Unstable • Undisplaced • Displaced Fractures Fractures: Inflammation Soft Callus Hard Callus Remodelling • Undisplaced • Displaced • Extra-­‐ •Operative Intra-­‐ Non-­‐ O perative • Closed • Open • Extra-­‐ • Intra-­‐Fractures Hours-­‐ Days Days-­‐ Weeks Weeks-­‐ Months Years articular articular Fractures: Inflammation Soft Callus Hard Callus Remodelling • Stable • Unstable articular articular • Closed • Open • Undisplaced • Displaced Hours-­‐ Days Days-­‐ Weeks Weeks-­‐ Months Years Musculoskeletal FRACTURE HEALING FRACTURE HEALING 260 OSTEOPOROSIS-­‐ BMD testing Osteoporosis BMD Testing OSTEOPOROSIS-­‐ BMD testing T-­‐Scores: Osteoporosis T-­‐Scores: Osteoporosis Normal > -­‐1 -­‐2.49 < Osteopenia < -­‐1 Osteoporosis -­‐ < -­‐ 2.5 Normal > -­‐1 -­‐2.49 < Osteopenia < -­‐1 Osteoporosis -­‐ < -­‐ 2.5 Age > 50 years • Age < 50 years • • All men and women >65 fragility fracture Age >• 50 Prior years Musculoskeletal 261 • • • • • • • • • • • • Prolonged glucocorticoid use • Rheumatoid Arthritis All men and women >65 in past 12 months • Falls Prior fragility fracture • Parental Hip Fracture Prolonged glucocorticoid • Other umseedications Rheumatoid Arthritis • Vertebral fracture Falls in past 12 •months Osteopenia on X ray Parental Hip Fracture • Smoking/ETOH Other medications • Low body weight (<60kg) or major loss (>10% of Vertebral fracture when 25) Osteopenia on X ray Smoking/ETOH Low body weight (<60kg) or major loss (>10% of when 25) Fragility Fracture Prolonged Glucocorticoid use Age < •50 yUse earsof other high risk medicatio • • • • • • • • Aromatase Inhibitors Fragility Fracture • Androgen Deprivation Prolonged Glucocorticoid uTherapy se Use of other high r isk m edications • Hypogonadism/Premature • Aromatase Inhibitors Menopause • Androgen • Deprivation Malabsorption Syndrome Therapy• Primary Hyperparathyroidism Hypogonadism/Premature • Other disorders strongly associa Menopause with rapid bone loss and/or frac Malabsorption Syndrome Primary Hyperparathyroidism Other disorders strongly associated with rapid bone loss and/or fracture 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada Tumour TUMOUR Tumour Metastatic-­‐ Primary Most common tumour in adults Breast Prostate Thyroid Lung Renal Benign •Osteochondroma •Osteoid osteoma •Chondroblastoma •Friboxanthoma •Fibrous Dysplasia •Non-­‐ossifying fibroma •Chondromyxoid Fibroma •Periosteal Chondroma Aggressive, Non-­‐Malignant •Giant Cell Tumour •Enchondroma •Aneurysmal Bone Cyst Malignant 66% of adult tumours •Multiple Myeloma-­‐ most common •Osteosarcoma •Chondrosarcoma •Ewing’s Sarcoma •Fibrosarcoma •Liposarcoma •Rhabdomyosarcoma •Leiomyosarcoma •Malignant Fibrous Histiocytoma Musculoskeletal • • • • • 262 Mytomes MYOTOMES: Segmental Innervation of Muscles Segmental Innervation of Muscles MYOTOMES: Segmental Innervation of Muscles Muscle Group Shoulder Elbow Wrist Fingers Hip Knee Musculoskeletal Ankle Action Muscle Group Abduction Shoulder Adduction Flexion Extension Elbow Extension Flexion Wrist Fingers Abduction Flexion Extension Hip Abduction Flexion Extension Knee Dorsiflexion Plantarflexion Ankle Myotome Action C5 AbductionC6-­‐C8 AdductionC5 Flexion C7 Extension C6 Extension C8 Flexion T1 AbductionL2 Flexion S1 Extension L5 AbductionL5 Flexion L3 Extension L4 S1 Dorsiflexion Plantarflexion Peripheral Nerve Myotome Peripheral Nerve Axillary Nerve Thoracodorsal Nerve Axillary Nerve C5 Nerve Thoracodorsal Nerve C6-­‐C8 Musculocutaneous Radial N erve Musculocutaneous N C5 Radial Nerve Radial Nerve C7 Median Nerve Radial Nerve C6 Ulnar Nerve Median Nerve C8 Nerve to Psoas Ulnar Nerve T1 Inferior Gluteal NNerve erve to Psoas L2 Superior G luteal N erve Gluteal Nerve Inferior S1 Tibial Nerve Superior Gluteal Nerv L5 Femoral Nerve Tibial Nerve L5 Deep Peroneal Nerve Femoral Nerve L3 Tibial Nerve Deep Peroneal Nerve L4 Tibial Nerve S1 N.B. There is considerable overlap between myotomes for some actions. The myotomes listed are the dominant segments involved. 263 N.B. There is considerable overlap between myotomes for some actions. The myotomes listed are the dominant segments involved. Guide to Spinal Cord Injury Spinal RRoot oot Spinal Sensory Sensory Motor Motor Reflex Reflex C4 C4 C5 C5 C6 C6 C7 C7 C8 C8 T1 T1 T7-­‐12 T7-­‐12 L2 L2 L3 L3 L4 L4 L5 L5 S1 S1 S2 S2 S3/S4 S3/S4 Acromioclavicular JJoint oint Acromioclavicular Radial AAntecubital ntecubital FFossa ossa Radial Dorsal TThumb humb Dorsal Dorsal M Middle iddle FFinger inger Dorsal Dorsal LLittle ittle FFinger inger Dorsal Ulnar AAntecubital ntecubital FFossa ossa Ulnar See DDermatomes ermatomes See Anterior M Medial edial TThigh high Anterior Medial FFemoral emoral CCondyle ondyle Medial Medial M Malleolus alleolus Medial nd MTP) First W Web eb SSpace pace ((11stst/2 /2nd First MTP) Lateral CCalcaneus alcaneus Lateral Popliteal FFossa ossa Popliteal Perianal RRegion egion Perianal Respiration Respiration Elbow FFlexion lexion Elbow Wrist EExtension xtension Wrist Elbow EExtension xtension Elbow Finger FFlexion lexion Finger Finger AAbduction bduction Finger Abdominal M Muscles uscles Abdominal Hip FFlexion lexion Hip Knee EExtension xtension Knee Ankle DDorsiflexion orsiflexion Ankle Big TToe oe EExtension xtension Big Ankle PPlantarflexion lantarflexion Ankle Anal SSphincter phincter Anal Anal SSphincter phincter Anal None None Biceps RReflex eflex Biceps Brachioradialis RReflex eflex Brachioradialis Triceps RReflex eflex Triceps None None None None Abdominal RReflex eflex Abdominal Cremasteric RReflex eflex Cremasteric None None Knee JJerk erk RReflex eflex Knee Hamstring RReflex eflex Hamstring Ankle JJerk erk RReflex eflex Ankle Bulbocavernosus Bulbocavernosus None None N.B. TThere here iis s cconsiderable onsiderable vvariability ariability iin n sspinal pinal ccord ord llevels evels ffor or m motor otor aand nd rreflex eflex ttesting. esting. AAlways lways ttest est tthe he llevel evel aabove bove aand nd bbelow elowthe the ssuspected uspected iinjury njury N.B. Musculoskeletal GUIDE TO SPINAL CORD INJURY 264 Psychiatric Anxiety Disorders Associated with Panic���� 267 Anxiety Disorders Recurrent Anxious Thoughts ���������������������������������������������������������������������268 Trauma & Stressor Related Disorders�����������269 Obsessive-Compulsive & Related Disorders ���������������������������������������������������������������������������������������������� 270 Personality Disorder����������������������������������������������������� 271 Mood Disorders Depressed Mood�������������������272 Mood Disorders Elevated Mood������������������������273 Psychotic Disorders ����������������������������������������������������274 Somatoform Disorders�����������������������������������������������275 Psychiatric 265 Historical Editors Student Editors Dr. Jason Taggart Lundy Day (Co-editor) Dr. Lauren Zanussi Michael Martyna (Co-editor) Dr. Lara Nixon Emily Donaldson Haley Abrams Daniel Bai Faculty Editor Kaitlin Chivers-Wilson Dr. Aaron Mackie Carmen Fong Leanne Foust Aravind Ganesh Qasim Hirani Psychiatric Leena Desai 266 Anxiety Disorders Associated with Panic Psychiatric 267 Anxiety Disorders Psychiatric Recurrent Anxious Thoughts 268 Trauma & Stressor Related Disorders Psychiatric 269 Psychiatric Obsessive-Compulsive & Related Disorders 270 Personality DisorderDISORDER PERSONALITY PERSONALITY DISORDER PERSONALITY DISORDER Personality Personality Disorder Disorder Personality Disorder • Enduring • Enduring pattern pattern of experience of experience and baehaviour nd behaviour that d that eviates deviates from fcrom ultural cultural expectations, expectations, manifest manifest in two in otwo r more or m the following the following areas: areas: cognition, cognition, affectivity, affectivity, interpersonal interpersonal functioning, functioning, and iampulse nd impulse control control • Enduring pattern of experience and behaviour that deviates from cultural expectations, manifest in two or more of • The •pThe attern pattern is inflexible is inflexible and paervasive nd pervasive across across many msany ocial social and paersonal nd personal situations situations the following areas: cognition, affectivity, interpersonal functioning, and impulse control • aThe attern pattern laeads leads tm o any distress to distress oar impairment r impairment in important in important areas ao reas f functioning of functioning • The pattern is inflexible nd •ppThe ervasive cross social nd poersonal situations • The •opThe pattern is stable iis table and oaf nd long of ldong duration, with w an ith onset an onset that cthat an bce an traced be traced back bto ack childhood to childhood or adolescence or adolescence • The pattern leads to distress r attern impairment n simportant areas ouration, f functioning • The pattern is stable and of • long duration, wis ith an tdue oo nset that can be m traced back hildhood r am dolescence • The pThe attern pattern is not due not another to another mental ental illness, illness, ato gceneral a general moedical edical condition, condition, or substance or substance use use • The pattern is not due to another mental illness, a general medical condition, or substance use Cluster Cluster B: DB ramatic, : Dramatic, Emotional, Emotional, or or Cluster C: Anxious or Fearful Social Social : Dramatic, Emotional, or Cluster Cluster A: OAdd : OoCluster dd r Eccentric or EBccentric Cluster A: Odd or Eccentric Social • Antisocial • Antisocial -­‐ disregard disregard for -­‐ssocial ocial for social orms, norms, Antisocial -­‐ disregard norms, •-­‐Avoidant innhibition, Paranoid • Paranoid -­‐ irrational s•uspicion suspicion or or for social • Paranoid -­‐ irrational s•uspicion or -­‐ irrational the law, and rights of others the law, ypersensitivity the alaw, nd raights nd inadequacy, rights of others of ohthers mistrust mistrust mistrust Psychiatric 271 Cluster Cluster C: Anxious C: Anxiou o • Avoidant • Avoidant -­‐ social -­‐ social inhibition inhib inadequacy, inadequacy, hypersensitivity hypersensit •detachment, Borderline -­‐ instability • Dependent -­‐ o psychological • Schizoid -­‐ emotional d•etachment, • Borderline • Borderline -­‐ instability -­‐ instability of identity, f identity, dependence • Dependent • Dependent -­‐ psychological -­‐ psycholo Schizoid • Schizoid -­‐lack emotional -­‐ emotional detachment, lack lack of identity, relationships, and behaviour relationships, on baoehaviour thers) of interest in social relationships relationships, and nd behaviour on others) on others) of interest of interest in social in social relationships relationships • Histrionic -­‐ attention-­‐seeking, • Schizotypal -­‐ Odd beliefs • Obsessive-­‐Compulsive -­‐ rigid, inflexible • Histrionic • Histrionic -­‐ attention-­‐ -­‐ attention-­‐ seeking, • Obsessive-­‐ Compulsive Compulsiv -­‐ rig • Schizotypal • Schizotypal -­‐ Odd -­‐ b Odd eliefs beliefs emotional expression exaggerated conformity to sreeking, ules, order, and codes)• Obsessive-­‐ exaggerated exaggerated emotional emotional expression expression conformity conformity to rules, to rules, order, ord an • Narcissistic -­‐ grandiosity, need for • Narcissistic -­‐ grandiosity, -­‐ grandiosity, need nfeed or for admiration, lack of empathy • Narcissistic 1. admiration, admiration, lack olack f empathy of empathy Black, D.W., and N.C. Andreasen (2011). Introductory Textbook of Psychiatry, 5th Ed. Washington: American Psychiatric Publishing, Inc. pp. 285-­‐317 1. 1. Black, DBlack, .W., aD nd .W., N.C. and Andreasen N.C. Andreasen (2011). (I2011). ntroductory Introductory Textbook Textbook of Psychiatry, of Psychiatry, 5th Ed. 5W th ashington: Ed. Washington: American American Psychiatric Psychiatric Publishing, Publishing, Inc. pp. Inc. 285-­‐317 pp. 285-­‐317 Mood Disorders Psychiatric Depressed Mood 272 Mood Disorders Elevated Mood Psychiatric 273 Psychotic Disorders Medical Conditions: PSYCHOTIC DISORDERS Para/Neoplastic Parkinson's Infectious Degenerative Brain tumour AIDS, syphilis Cushing's Endocrine Psychotic Disorder Stroke Epilepsy MS, SLE Vascular Medications: Amphetamines Dopamine Agonist Methylphenidate Anticholinergic PCP Steroids L-­‐Dopa ood syndromes absent (or brief lative to duration of psychotic symptoms ymptoms ted to ons Psychotic symptoms limited to non-­‐bizarre delusions only Non-­‐bizarre delusions ≥ 1 month, no decline in functioning, behaviour is not odd • Delusional disorder Prominent mood syndrome (major depression, mania) present for significant portion of illness Psychotic symptoms present exclusively during major mood syndrome Delusions developed in context of close relationship with a person with already established similar delusion Stroke Epilepsy MS, SLE Vascular Cocaine Cocaine es and/or Brain tumour AIDS, syphilis Cushing's Endocrine Drugs of Abuse: Psychosis Rule out psychotic disorder due to substances and/or general medical condition Drugs of Abuse: Alcohol (rare) Cannabis Amphetamines Opiates (rare) Hallucinogens Para/Neoplastic Parkinson's Infectious Degenerative • Mood disorder with psychotic features Duration of illness ≤ 1 month • Brief psychotic disorder • Shared psychotic disorder (Folie a Deux) 1 or more: 1) Delusions 2) Hallucinations 3) Disorganized speech 4) Grossly disorganized or catatonic behaviour Alcohol (rare) Cannabis Amphetamines Opiates (rare) Hallucinogens Medications: Amphetamines Dopamine Agonist Methylphenidate Anticholinergic PCP Steroids L-­‐Dopa Mood syndromes absent (or brief relative to duration of psychotic symptoms Psychotic symptoms also present outside of mood episodes Psychotic symptoms not limited to delusions Psychotic symptoms limited to non-­‐bizarre delusions only • Schizoaffective disorder (bipolar & depressive) Duration of illness 1-­‐6 months • Schizophreniform disorder 2 or more (1 must be 1-­‐3): 1) Delusions 2) Hallucinations 3) Disorganized speech 4) Grossly disorganized or catatonic behaviour 5) Negative sx (affective flattening, alogia, avolition) Duration of illness ≥ 6 months • Schizophrenia Criteria: see schizophreniform disorder Suicide = 10% Neuroleptic Malignant Syndrome: Side effects of anti-­‐psychotics Sx: Hyperpyrexia (>38.5°C), muscle rigidity and mental status changes 20% mortality Non-­‐bizarre delusions ≥ 1 month, no decline in functioning, behaviour is not odd • Delusional disorder Delusions developed in context of close relationship with a person with already established similar delusion • Shared psychotic disorder (Folie a Deux) Psychiatric Medical Conditions: 274 Somatoform Disorders SOMATOFORM DISORDERS Somatoform Disorder Patient presents with complex medical problem or symptoms that cannot be explained medically Symptoms Consciously Produced Psychiatric 275 Symptoms Not Consciously Produced Motivation is primary gain (to assume the sick role) Motivation is secondary gain • Factitious Disorder • Malingering Pain; psychological factors important • Pain Disorder Focus is the sick role; not accepting reassurance Focus is a physical symptom • Illness Anxiety Disorder Multiple symptoms; long history • Somatization Disorder Criteria -­‐4 pain sx -­‐ 2 GI sx -­‐ 1 sexual sx -­‐ 1 pseudo-­‐neuro sx Neurologic • Conversion Disorder Must have symptoms affecting movement or sensation (non-­‐ anatomic and unexplainable) Focus is appearance; exhibit significant distress • Body Dysmorphic Disorder One or more symptoms for at least six months • Undifferentiated Somatoform Disorder Otolaryngologic Hearing Loss Conductive��������������������������������������� 279 Hearing Loss Sensorineural����������������������������������280 Hoarseness Acute���������������������������������������������������������281 Hoarseness Non-Acute�������������������������������������������� 282 Neck Mass�������������������������������������������������������������������������� 283 Otaligia���������������������������������������������������������������������������������� 284 Smell Dysfunction�������������������������������������������������������� 285 Tinnitus Objective���������������������������������������������������������286 Tinnitus Subjective������������������������������������������������������ 287 Otolaryngologic 277 Historical Editors Student Editors Justin Lui Dilip V. Koshy Andrew Jun Wesley Chan Dave Campbell Joanna Debosz Faculty Editors Sarah Hajjar Dr. Doug Bosch Dr. James Brookes Otolaryngologic Dr. Justin Chau 278 Hearing Loss Conductive Otolaryngologic 279 Hearing Loss Otolaryngologic Sensorineural 280 Hoarseness Acute HOARSENESS: Acute Hoarseness If Hoarseness persists > 3 months, Refer to ENT Acute Non-­‐Acute Constant Variable > 3 weeks < 3 weeks Otolaryngologic 281 Infectious • Viral Laryngitis • Fungal Laryngitis (Monilia) • Bacterial Laryngitis • Bacterial Tracheitis Inflammatory • Acute Nonspecific Laryngitis (GERD, Smoking, Allergies, Vocal Abuse) • Inhaled Steroids Trauma • External Laryngeal Trauma • Iatrogenic -­‐ Endoscopy -­‐ Endotracheal intubation Inflammatory Hyperfunction • Voice Overuse • Muscle Tension Dysphonia Hoarseness Non-Acute HOARSENESS: Non-­‐Acute Hoarseness If Hoarseness persists > 3 months, Refer to ENT Acute Non-­‐Acute Constant Variable > 3 weeks < 3 weeks Infectious • Bacterial Infection • Fungal Infection (Monilia) Inflammatory • Chronic Laryngitis • GERD • Smoking Trauma • External • Internal (Surgery, Intubation) Benign Mucosal Changes • • • • Nodules Polyps Granuloma Cysts Reinke’s Edema Neoplastic • Malignancy: Squamous Cell Carcinoma • Benign: Papilloma (HPV 6 & 11) • Dysplasia: Leukoplakia Neurological • Vocal Cord Paralysis • Spasmodic Dysphonia • Tremor Otolaryngologic • Functional 282 Neck Mass NECK MASS Neck Mass Congenital Inflammatory • • • • • • Otolaryngologic 283 Neoplasms Thyroglossal Duct Cyst Branchial Cleft Anomalies Dermoid Cyst Teratoma Lymphatic Malformation Hemangioma Lymphadenitis Sialadenitis Primary • Bacterial • Viral • Granulomatous Disease • Tuberculosis • Atypical Mycobacterium • Actinomycosis • Cat-­‐Scratch Disease • Parotid Salivary Gland • Submandibular Salivary Gland • Lymphoma • Thyroid Neoplasm • Neoplasm of Salivary Glands • Neurogenic Neoplasm • Schwannoma • Neuroblastoma • Ganglioneuroma • Paragangliomas • Carotid Body Tumors Metastatic • Squamous Cell Carcinoma • Thyroid (Spread to Cervical Lymph Nodes) • Melanoma • Distant site (Stomach, etc.) Otaligia OTALGIA Otalgia Referred Periauricular • Via Vagus or Glossopharyngeal Nerves • Nasopharyngeal, Oropharyngeal, Laryngeal, Hypopharyngeal Pain • Thyroiditis • Aerodigestive Tract Malignancy • Post-­‐tonsillectomy Increased Pain With Pinna Manipulation External Auditory Canal • Otitis Externa • Osteomyelitis of Temporal Bone Herpes Simplex Zoster (Ramsay Hung Syndrome if Facial Nerve Paralysis) • Furunculosis Mastoid • Mastoiditis • TMJ Pathology • Parotiditis Pain Unchanged With Pinna Manipulation Auricle • Cellulitis/Perichondri tis • Trauma (Frostbite, Auricular Hematoma) • Autoimmune (Relapsing Polychondritis) Abnormal Tympanic Membrane Ulceration/ Abnormal Tissue Growth • Acute Otitis Media • Barotrauma • Traumatic Perforation • Squamous Cell Carcinoma • Sarcoma • Cholesteatoma (Typically Otorrhea) Otolaryngologic Otologic 284 Smell Dysfunction SMELL DYSFUNCTION Smell Dysfunction ENT History, Physical Exam, Anterior Rhinoscopy Sensory Testing, CT/MRI to Rule Out Neoplasms, Fractures & Congenital abnormalities Nasal Obstruction/ URTI Otolaryngologic 285 • Septal Deviation • Allergic Rhinitis • Bacterial/ Viral Infection (Influenza) Trauma • • • • Foreign Body Nasal Surgery Base of Skull Fracture Nasal Fracture Endocrine/ Metabolic • Alcoholism • Diabetes Mellitus • Adrenal Hypofunction • Adrenal Hyperfunction • Vitamin B12 Deficiency • Zinc Deficiency • Malnutrition Toxins and other Factors Neoplastic • Nasal Polyps • Juvenile Nasopharyngeal Angiofibroma • • • • Smoking Drugs Radiation Toxin Exposure Tinnitus Objective TINNITUS: Objective Tinnitus Subjective Objective (90%) Pulsatile or Rhythmic (10%) Vascular Venous Arterial • Atherosclerosis • Idiopathic Intracranial Hypertension • Acute Exacerbation of Systemic Hypertension • Developmental Anomaly • Blood flow in normal artery near ear • Persistent Stapedial Artery • Glomus Tympanicum • • • • AV Shunt High Jugular Bulb Glomus Jugulare Hyperthyroidism • Myoclonus of Stapedius/Tensor Tympani/Palatal Muscles • Degenerative Disease of the Head and Neck • Eustachian Tube Dysfunction Otolaryngologic Muscular Potentially Auscultated 286 Tinnitus Subjective TINNITUS: Subjective Tinnitus Subjective Objective Heard only by patient (Common) Heard by others (Rare) Unilateral Bilateral On Audiogram Perform MRI to rule out RC Lesion Otolaryngologic 287 • Acoustic Neuroma • Lesion of Cochlear or Auditory Nerve • Brainstem Lesion • Multiple Sclerosis • Infarction • Ménière's Disease On Audiogram Hearing Loss No Hearing Loss • Metabolic Causes: Thyroid Dysfunction, Vitamin A, B, Zinc Deficiency. • Psychogenic, Anxiety, Depression • Drugs (Salicyclates, Quinidine, Indomethacin) • Idiopathic Sensorineural Hearing Loss Conductive Hearing Loss • Lesion of External or Middle Ear • Impacted Cerumen • Otitis Media • Otosclerosis • • • • Noise Induced Ototoxicity Presbycusis Drugs (Propranolol, Levodopa, Loop Diuretics) • Congenital Somatic • • • • • TMJ Bruxism Whiplash Skull Fracture Closed Head Injury Ophthalmologic Cross Section of the Eye & Acronyms������������291 Approach to an Eye Exam�������������������������������������� 292 Acute Vision Loss Bilateral������������������������������������� 293 Acute Vision Loss Unilateral��������������������������������� 294 Chronic Vision Loss Anatomic����������������������������� 295 Amblyopia��������������������������������������������������������������������������296 Diplopia�������������������������������������������������������������������������������� 297 Pupillary Abnormalities Isocoria������������������������298 Pupillary Abnormalities Anisocoria������������������299 Ophthalmologic 289 Red Eye Atraumatic�����������������������������������������������������300 Red Eye Traumatic��������������������������������������������������������301 Strabismus Ocular Misalignment��������������������� 302 Neuro-Ophthalmology Visual Field Defects ����������������������������������������������������������������������������������������������303 Historical Editors Student Editors Dr. John Huang Prima Moinul Dr. Ying Lu Jessica Ruzicki Anastasia Aristakhova Jagdeep Doulla Senior Editor Kathleen Moncrieff Dr. Monique Munro Nazia Panjwani Faculty Editor Stephanie Yang Dr. Patrick Mitchell Vikram Lekhi Ophthalmologic Micah Luong 290 Cross Section of the Eye & Acronyms Ophthalmology Acronyms EOM Extra ocular movements IOL Intraocular Lens IOP Intraocular Pressure OD Oculus Dexter (right eye) OS Oculus Sinister (left eye) OU Oculus Uterque (both eyes) PERRLA Pupils Equal, Round, Reactive to Light & Accommodation Ophthalmologic 291 RAPD Relative Afferent pupillary defect SLE Slit Lamp Exam VA Visual Acuity Approach to an Eye Exam 2 History 3 Obvious Physical Trauma 4 Initial Assessment A. Visual Acuity B. Pupils a. Light Reflex, 5 Slit Lamp Exam A. Lids / Lashes/ Lacrimal B. Sclera/ Conjunctiva Fundoscopy A. Retina B. Optic Nerve/ Disc/ Cup: Disc Ratio Accommodation, C. Cornea C. Macula RAPD D. Anterior Chamber D. Fovea E. Iris E. Blood Vessels C. Ocular Movements (CN 3, 4, 6) D. Visual Fields by Confrontation F. Lens G. Vitreous Humor Ophthalmologic 1 292 Acute Vision Loss Bilateral ACUTE VISION LOSS: Bilateral Clinical Pearl: • Patients with bilateral acute vision loss should have a CT. Vision Loss ACUTE VISION LOSS: Bilateral Clinical Pearl: • Patients with bilateral acute vision loss should have a CT. Vision Loss Acute Chronic Acute Ophthalmologic 293 Chronic Bilateral Unilateral Unilateral Complete/ Partial Homonymous Hemianopia • Infarct • Intracranial Hemorrhage Complete/ Partial Homonymous • Tumor Hemianopia Bilateral Other • Migraine • Systemic Hypoperfusion Other ACUTE VISION LOSS: Unilateral Acute Vision Loss Clinical Pearls: • Optic neuritis causes pain with EOM • Temporal arteritis causes temporalis pain and pain with mastication • Acute angle closure glaucoma causes high intraocular pressure, unilateral eye pain, mid-­dilated pupil and n/v • Retinal detachment can present as a veil over the vision and with flashes and floaters. • TIA, vein or artery occlusion requires stroke work-­up Unilateral Acute Vision Loss Bilateral Unilateral Painless Painful Cornea • Keratopathy No Abnormalities of the Optic Nerve Clinical Pearls: • Optic neuritis causes pain with EOM • Temporal arteritis causes temporalis pain and pain with mastication • Acute angle closure glaucoma causes high intraocular pressure, unilateral eye pain, mid-­dilated pupil and n/v • Retinal detachment can present as a veil over the vision and with flashes and floaters. • TIA, vein or artery occlusion requires stroke work-­up • Acute Angle Closure Glaucoma (fixed dilated pupil) Abnormalities of the Optic Nerve • Temporal Arteritis • Demyelination • MS • Idiopathic • Glaucoma Retina Transient Ischemic Attack Vitreous • Retinal Detachment • Retinal Artery Occlusion • Retinal Vein Occlusion • Ischemic Optic Neuropathy Retina Visible • Visual Cortex Infarction Retina Not Visible • Retinal Hemorrhage • Vitreous Hemorrhage Ophthalmologic Optic Nerve 294 Chronic Vision Loss Anatomic CHRONIC VISION LOSS: Anatomic Clinical Pearls: • Edema can cause halos in the vision. • Bilateral disc swelling and any suspected mass require imaging. Chronic Vision Loss Perform slit-­‐lamp exam to localize: Left →Right on Scheme Cornea Ophthalmologic 295 • Keratoconus • Stromal Scaring • Neovascularization • Edema • Pterygium Lens Obscure Red Reflex, Poor fundus Visibility Macula Drusen or Edema Retina Cotton wool spots, Micro-­‐aneurysms, Hemorrhage and Macular Edema • Cataract (Nuclear, • Age Related Macular • Diabetic Subcapsular, Cortical) Degeneration (Wet, Dry) Retinopathy (Background, Pre-­‐ Proliferative, Proliferative) • Retinitis Pigmentosa (Decreased night vision, loss of peripheral vision) • Systemic inflammatory conditions CHRONIC VISION LOSS: Anatomic Chronic Vision Loss Optic Nerve Pallor, Papilledema, Irregular Disc Large Cup:Disc • Glaucoma (Open-­‐ Angle) Optic Track Visual field defects, decrease in color vision • Optic Nerve Compression • Pituitary Lesion • Meningioma • Craniopharyngioma Clinical Pearls: • Edema can cause halos in the vision. • Bilateral disc swelling and any suspected mass require imaging. Amblyopia AMBLYOPIA Clinical Pearl: • Congenital cataracts and retinoblastoma’s cause leukocoria and a decreased red reflex AMBLYOPIA Amblyopia Clinical Pearl: • Congenital cataracts and retinoblastoma’s cause leukocoria and a decreased red reflex Amblyopia Deprivational* Refractive Error Deprivational* Obstruction of Visual Axis Refractive Error Obstruction of Visual Axis • Severe Anisometripia (Unequal • Severe Anisometripia (Unequal Refractive Error) Refractive Error) • Hyperopia • Hyperopia • Astigmatism • Astigmatism Clinical Pearl: • Congenital cataracts and retinoblastoma’s cause leukocoria and a decreased red reflex * Can cause permanent visual impairment if not treated urgently in infancy See Strabismus scheme See Strabismus scheme Ophthalmologic • Ptosis • Ptosis • Congenital Cataracts • Congenital Cataracts Congenital Corneal Opacities • •Congenital Corneal Opacities Hemangioma • •Hemangioma • •Retinal Disease/Damage (undiagnosed Retinal Disease/Damage (undiagnosed not responsive to treatment) not responsive to treatment) Strabismic Strabismic Abnormal Binocular Interaction Abnormal Binocular Interaction 296 Diplopia DIPLOPIA Monocular • Refractive Error • Cataract/Lens Dislocation • Functional • Corneal Distortion/Scarring • Vitreous Abnormalities Diplopia Clinical Pearls: • Diplopia is almost always binocular. • CN VI palsy is a red flag for intracranial masses. • Look for ptosis with CN III palsy. • Examine both eyes to determine which is affected. • Neurologic symptoms suggest a mass as the cause. • Myasthenia Gravis is fatiguable. • Migraine is a diagnosis of exclusion. Extraocular Muscle Restriction/Entrapment Neuronal Neuromuscular Junction (Non-­‐Comitant) • Myasthenia Gravis Strictly Horizontal Ophthalmologic 297 (Cranial Nerve VI problem) Cannot Abduct • Ischemia • Diabetes Mellitus • Aneurysm • Tumor • Trauma Binocular • Orbital Inflammation • Orbital Tumor • Orbital Floor Fracture Horizontal and/or Vertical Cranial Nerve III Cranial Nerve IV Eye depressed, abducted, ptosis, large/unreactive pupil Eye cannot depress when looking medially • Ischemia • Diabetes Mellitus • Aneurysm • Trauma • Ischemia • Diabetes Mellitus • Aneurysm • Trauma • Subdural Hemorrhage Grave’s Ophthalmopathy • Hyperthyroidism Pupillary Abnormalities Isocoria PUPILLARY ABNORMALITES: Isocoria Pupillary Abnormality Equal (Isocoria) Bilateral Impairment • Optic Neuritis • Ischemic Optic Neuropathies • Optic Nerve Tumor • Retinal detachment • Traumatic/Compressive Optic Neuropathy Dorsal Midbrain (Parinaud’s Syndrome) • Tumor • Hemorrhage • Hydrocephalus Dilated Pupils (Mydriasis) Constricted Pupils (Miotic) • Syphilis (light-­‐near dissociation) • Pharmacologic (e.g Opioids, Alcohol) Neuromuscular Junction Dysfunction • Botulism Pharmacologic • Atropine • LSD • Cocaine • Amphetamines Ophthalmologic Relative Afferent Pupil Defect Unequal (Anisocoria) 298 Pupillary Abnormalities Anisocoria PUPILLARY ABNORMALITIES: Anisocoria Clinical Pearl: • Pupils should be examined in both a light and dark setting to determine whether the big pupil or the small pupil is abnormal. Pupillary Abnormality Equal Unequal (Isocoria) (Anisocoria) Physiological Pathological Anisocoria equal in light and dark, 10%cocaine: pupils dilate symmetrically • Simple Anisocoria ( <0.5mm) Impaired Dilation Impaired Constriction Parasympathetic dysfunction Anisocoria greater in light Large pupil abnormal Ophthalmologic • Angle Closure Glaucoma (mid-­‐fixed) • Iritis/Synechiae (not complete fixation) • Trauma (not complete fixation) Preganglionic Ptosis, opthalmoplegia Constriction with 0.1% pilocarpine • Oculomotor Nerve/Fascicle (Other CN III Findings) Postganglionic Constriction with 0.1% pilocarpine • Tonic (Adie’s) Pupil (Ciliary Ganglion Lesion) LLARY ABNORMALITIES: Anisocoria 299 Sympathetic dysfunction/Horner’s Syndrome: miosis, anyhydrosis, ptosis Anisocoria greater in dark Small pupil abnormality Fixed Pupil Pupillary Abnormality Neuromuscular Junction No constriction with 0.1% pilocarpine • Pharmacologic • Factitious Clinical Pearl: • Pupils should be examined in both a light and dark setting to determine whether the big pupil or the small pupil is abnormal. Preganglionic No dilation with 0.125% adrenaline • Idiopathic • Trauma • Tumor (Lung, Breast, Thyroid) Postganglionic Dilation with 0.125% adrenaline • Cluster Headache • Carotid Dissection • Trauma • Idiopathic Red Eye Atraumatic RED EYE: Atraumatic Clinical Pearl: • Orbital cellulitis can present with pain on EOM and orbital signs of involvement Red Eye Lids/Orbit/ Lacrimal System • Blepharitis • Stye/ Chalazion • Dacrocystitis • Pre-­‐septal cellulitis • Orbital Cellulitis Clinical Pearl: • Orbital cellulitis can present with pain on EOM and orbital signs of involvement Atraumatic Ocular Surface • Subconjunctival Hemorrhage • Conjunctivitis • Corneal Abrasion/ Erosion • Keratitis/Corneal Ulcer • HSV Keratitis Intermediate Layers • Episcleritis • Scleritis • Uveitis • Iritis Intraocular • Acute Angle Closure Glaucoma • Endophthalmitis Ophthalmologic Traumatic 300 Traumatic RED EYE: Traumatic Red Eye Clinical Pearls: • With chemical burns, it is important to determine if the burn was caused by acid or worse, alkali. • With a globe-­penetrating injury, call ophthalmology, shield the eye, and do not touch the eye. Traumatic Surface Injury • Corneal Abrasion • Ultraviolet Keratitis • Chemical (Acid, alkali) Ophthalmologic Red Eye 301 Atraumatic Blunt Trauma Hyphema, diplopia, periorbital ecchymosis, subcutaneous emphysema of lid Globe Penetrating Injury Hyphema, history of trauma/high velocity impact, reduced visual acuity • Orbital Rim/Mid-­‐facial Fracture • Orbital Floor Fracture • Orbital Apex Injury/ Retrobulbar Fracture** ** Urgent lateral canthotomy Red Eye Clinical Pearls: • With chemical burns, it is important to determine if the burn was caused by acid or worse, alkali. • With a globe-­penetrating injury, call ophthalmology, shield the eye, and do not touch the eye. Associated Injury • Lids: Swelling, Laceration • Conjunctiva: Subconjunctival hemorrhage • Cornea: Abrasion • Iris: Laceration, iritis, iridodialysis • Pupil: Traumatic mydriasis • Lens: Cataract, dislocation • Vitreous hemorrhage • Retina: Tear, hemorrhage, choroidal rupture • Glaucoma • Optic Neuropathy Strabismus STRABISMUS: Ocular Misalignment Ocular Misalignment Clinical Peal: • Strabismus is most often seen in pediatrics. Strabismus Rule Out Amblyopia Phoria Tropia • Latent deviation • Symmetrical corneal light reflex, • Negative cover test positive cover/uncover test Horizontal (eso/exotropia) • CN VI problem (eye cannot abduct) Clinical Pearl: Clinical Peal: • Orbital cellulitis can present with pain on Strabismus is most often seen EOM and orbital signs of involvement in pediatrics. Paretic Non-­‐comitant Angle of misalignment changes with direction of gaze Horizontal and/or vertical (Eso/exotropia, hyper/hypotopia, mixed) • CN III Problem (eye is depressed and abducted, ptosis, large/unreactive pupil) • CN IV Problem (eye cannot depress when looking medially) Non-­‐Paretic Comitant Angle of misalignment unchanged with direction of gaze • Accommodative Esotropia (onset 2-­‐4yrs, hyperopic) • Congenital Esotropia (contralateral eye deviates medial à straight when ipsilateral covered) • Exotropia (contralateral eye deviates lateral à straight when ipsilateral covered) Ophthalmologic • Esophoria (eye moves medial à centre when uncovered) • Exophoria (eye moves lateral à centre when uncovered) • Manifest deviation • Asymmetrical light reflex, • Positive cover test 302 Neuro-Ophthalmology Visual Field Defects Neuro-­Ophthalmology: Visual Field Defects Optic Nerve Lesion (Monocular vision loss) Optic Chiasm Lesion (bitemporal hemianopia) ! Optic Tract Lesion (Incongruous right homonymous hemianopia) Ophthalmologic 303 Lateral Geniculate Nucleus Lesion (Right homonymous horizontal sectroanopia) • Pituitary/metastatic tumor • Craniopharyngioma • Meningioma • Optic nerve glioma • Aneurysm • Infection • MS • Sarcoidosis Meyer’s Loop Lesion (Incongruous superior homonymous quadrantanopia) Right Parietal Lobe Lesion (Inferior homonymous hemianopia) ! Pediatric Developmental Delay��������������������������������������������������311 School Difficulties���������������������������������������������������������� 312 Small for Gestational Age����������������������������������������313 Hyperbilirubinemia…………………….…….......................323 Neonatal Jaundice: Approach to Indirect Large for Gestational Age����������������������������������������314 Hyperbilirubinemia…………………………........................324 Congenital Anomalies������������������������������������������������315 Pediatric Diarrhea………….……….……………...........................325 Headache............................................................................316 Constipation: Pediatric………………………….......................326 Failure to Thrive Adequte Calorie Mouth disorder: Pediatric…………………........................327 Consumption�������������������������������������������������������������� 317 Failure to Thrive Inadequte Calorie Pediatric 305 Neonatal Jaundice: Approach to Indirect Depressed/Lethargic Newborn………............…….328 Cyanosis in the Newborn.........................................329 Consumption��������������������������������������������������������������318 Limp.........................................................................................330 Hypotonic Infant (Floppy Newborn)����������������319 Respiratory Distress in the Newborn..…........…331 Acute Abdominal Pain����������������������������������������������� 320 Pediatric Dyspnea……………………………….............................332 Chronic Abdominal Pain……..……………........................321 Noisy Breathing: Pediatric wheezing…..........…333 Pediatric Vomiting………………………….................................322 Noisy Breathing: Pediatric Stridor…….............……334 Pediatric Cough: Acute…………............……..……335 Pediatric Cough: Chronic…………………….........336 Respiratory Distress in the Newborn: Tachypnea……………………………............……............337 Sudden Unexpected Death in Infancy................................................................338 Enuresis……………………………………..................................339 Apparent Life Threatening Event…….…..340 Pediatric Fractures………………………..................….341 Salter Harris Classification………….........……..342 Non-Epileptic Paroxysmal Event………...344 Pediatric Epilepsies….……..………………................345 Pediatric Seizures………………….................……...…346 Pediatric Sudden Paroxysmal Event………........………..343 306 Pediatric Febrile Seizures……………………………...…………………................347 Pediatric Mood and Anxiety Disorders…....….348 Disability…………………………………....................……………………..361 Abdominal Mass…………………………………………................…....349 Fever (Age <1 Month)……………………………............……………362 Shock…………………………………………...…………………..........………………….350 Fever (Age 1-3 Months)……………………………….........………363 Hypoglycemia…………………………...................……………………….351 Fever (Age >3 Months)…………………………..........…………….364 Altered Level of Consciousness………..............…..352 Failure to Thrive………………………………..................……………….365 Bleeding/Bruising…………………………………………............…...353 Short Stature………………………………….....................………………..366 Thrombocytopenia……………………….............…………………….354 Murmur in the Newborn (<48 Hours)…........….367 Long PT (INR), Long PTT………………………........…………….355 Murmur in the Newborn Beyond Neonatal Long PT (INR), Normal PTT………………………….....……….356 Normal PT (INR), Long PTT…………………………....……….357 Pediatric 307 Global Developmental Delay/Intellectual Dehydration……………………………………………...…………………...………358 Hyponatremia………………………………...……………….…………………..359 Hypernatremia…………………………………...……………....……………..360 Period….…………………………………………………...…………………....…..368 Preterm Infant Complications (<34 Weks)…………………..……………...…………………...........……369 Preterm Infant Complications (34-36 Weeks)……………………...........………………...............370 Anemia by Mechanism……………………………..........…………371 Chronic Kidney Disease …………………………………......……385 Anemia by MCV……………………………………….................………..372 Edema ………………………………........…………………...…………………….…..386 Microcytic Anemia………………………….............……………………373 Dysuria ……………………………...………………….......………………...........…387 Paediatric Infectious Skin Rash………...............….…374 Increased Urinary Frequency…….................…………388 Skin Lesion (Primary Skin)………………………………....…….375 Scrotal Mass. ………………………………………....................…………..389 Skin Lesion (Secondary Skin)…………………….……………376 Lymphadenopathy ………………………............…………………….390 Rash (Eczematous)……………………………………….............…….377 Otalgia (Earache) …………………………...............…………………..391 Rash (Papulosquamous)………………………….......……………378 Sore Throat/Sore Mouth……………………………….....………392 Rash (Vesiculobullous)……………………………........……………379 Rash (Pustular)………………………………………...................…………380 Proteinuria……………………………......………………….…………………………382 Hematuria…………………………………...…………………...……………………..383 Acute Renal Failure………………………………............…………….384 Pediatric Rash (Reactive)……………………………...................…………………..381 308 Historical Editors Debanjana Das Elbert Jeffrey Manalo Dr. Susan Bannister Cody Flexhaug David Cook Dr. Kelly Millar Carmen Fong Dr. Mary Ann Thomas Carly Hagel Faculty Editor Dr. Andrei Harabor Rebekah Jobling Dr. Marielena Dibartolo Dr. Jean Mah Beata Komierowski Dr. Henry Mandin Anuradha Surendra Dr. Leanna McKenzie Shahbaz Syed Dr. Ian Mitchell Gilbert Yuen Dr. Katherine Smart Dr. Sylvain Coderre Pediatric 309 Student Editors Dr. Pamela Veale Jaskaran Singh Christopher Skappak 310 Pediatric Developmental Delay Pediatric 311 Pediatric School Difficulties 312 Small for Gestational Age Pediatric 313 Pediatric Large for Gestational Age 314 Congenital Anomalies CONGENITAL ANOMALIES Congenital Anomalies Isolated Malformation • Embryonic development failure or inadequacy (often multifactorial) Pediatric 315 Multiple Deformation Disruption Association of A (Syndrom • Abnormal mechanical forces distorting otherwise normal structures (e.g.exoligohydramnios) • Destruction/ Breakdown of previously normal tissue (e.g. ischemia) • Chromosomal • Single Gene • Teratogenic • Association (e.g. V Things to Consider: History – Prenatal: maternal health, exposures, screening, ultrasounds; delivery; neonatal Family History – Three Generations: prior malformations, stillbirths, recurrent miscarriages, consanguinity Physical Exam – Variants, minor anomalies, major malformation Diagnostic Procedures – Chromosomes, molecular/DNA, radiology, photography, metabolic Diagnostic Evaluations – Prognosis, recurrence, prenatal diagnosis, surveillance, treatment Pediatric Headache 316 Failure to Thrive Adequte Calorie Consumption Pediatric 317 Failure to Thrive Pediatric Inadequte Calorie Consumption 318 Hypotonic Infant (Floppy Newborn) Pediatric 319 Pediatric Acute Abdominal Pain 320 Chronic Abdominal Pain Pediatric 321 Pediatric Pediatric Vomiting 322 Neonatal Jaundice Approach To Indirect Hyperbilirubinemia Pediatric 323 Neonatal Jaundice Pediatric Approach To Direct Hyperbilirubinemia 324 Diarrhea (Pediatric) Pediatric 325 Pediatric Constipation (Pediatric) 326 Mouth Disorders (Pediatric) Pediatric 327 Pediatric Depressed /Lethargic Newborn 328 Cyanosis in the Newborn Pediatric 329 Pediatric Limp 330 Respiratory Distress In The Newborn Pediatric 331 Pediatric Pediatric Dyspnea 332 Noisy Breathing Pediatric Wheezing Pediatric 333 Noisy Breathing Pediatric Pediatric Stridor 334 Pediatric Cough Acute Pediatric 335 Pediatric Cough Pediatric Chronic 336 Respiratory Distress In The Newborn Tachypnea Pediatric 337 Pediatric Sudden Unexpected Death In Infancy (SUDI 338 Pediatric Fractures Pediatric 339 SALTER HARRIS PHYSEAL INJURY CLASSIFICATION SYSTEM Salter Harris Physeal Injury Classification Population Features Younger Children II Older Children (75%) Fracture through a portion of the physis that extends through the metaphyses III Separation through the physis Older Children (75%) Fracture line goes below the physis through the epiphysis, and into the joint IV Fracture Line through the metaphysis, physis and epiphysis V Compression fracture of the growth plate http://www.jaaos.org/content/10/5/345/F1.large.jpg S Straight through A Above L Lower T Through R Crush Pediatric Type I 340 Enuresis Pediatric 341 Pediatric Apparent Life Threatening Event 342 Sudden Paroxysmal Event Pediatric 343 Pediatric Non-Epileptic Paroxysmal Event 344 Pediatric Epilepsies Pediatric 345 Pediatric Pediatric Seizures 346 Febrile Seizures Pediatric 347 Pediatric Pediatric Mood And Anxiety Disorders 348 Abdominal Mass Pediatric 349 Pediatric Shock 350 Hypoglycemia Pediatric 351 Pediatric Altered Level Of Consciousness 352 Bleeding/Bruising Pediatric 353 Pediatric Thrombocytopenia 354 Long PT (INR), Long PTT Pediatric 355 Pediatric Long PT (INR), Normal PTT 356 Normal PT (INR), Long PTT Pediatric 357 Pediatric Dehydration 358 Hyponatremia Pediatric 359 Pediatric Hypernatremia 360 Global Developmental Delay/Intellectual Disability Pediatric 361 Pediatric Fever (Age <1 Month) 362 Fever (Age 1-3 Months) Pediatric 363 Pediatric Fever (Age >3 Months) 364 Failure To Thrive Pediatric 365 Pediatric Short Stature 366 Murmur In The Newborn (<48 Hours) Pediatric 367 Pediatric Murmur In The Newborn Beyond Neonatal Period 368 Preterm Infant Complications (<34 Weeks) Pediatric 369 Pediatric Preterm Infant Complications (34-36 Weeks) 370 Anemia By Mechanism Pediatric 371 Pediatric Anemia By MCV 372 Microcytic Anemia Pediatric 373 Pediatric Paediatric Infectious Skin Rash 374 Skin Lesion (Primary Skin) Pediatric 375 Pediatric Skin Lesion (Secondary Skin) 376 Rash (Eczematous) Pediatric 377 Pediatric Rash (Papulosquamous) 378 Rash (Vesiculobullous) Pediatric 379 Pediatric Rash (Pustular) 380 Rash (Reactive) Pediatric 381 Pediatric Proteinuria 382 Hematuria Pediatric 383 Pediatric Acute Renal Failure 384 Chronic Kidney Disease Pediatric 385 Pediatric Edema 386 Dysuria Pediatric 387 Pediatric Increased Urinary Frequency 388 Scrotal Mass Pediatric 389 Pediatric Lymphadenopathy 390 Otalgia (Earache) Pediatric 391 Pediatric Sore Throat/Sore Mouth 392 General Presentations Fatigue����������������������������������������������������������������������������������� 395 Acute Fever�����������������������������������������������������������������������396 Fever of Unknown Origin / Chronic Fever� 397 Hypothermia���������������������������������������������������������������������398 Sore Throat / Rhinorrhea����������������������������������������399 General Presentations 393 Historical Editors Student Editors Dr. Heather Baxter Adrianna Woolsey Dr. Harvey Rabin Fatima Pirani Dr. Ian Wishart Brittany Weaver Senior Editor Geoff Lampard Dr. Monique Munro Kathy Truong Faculty Editor Dr. Sylvain Coderre General Presentations Harinee Surendra 394 Fatigue FATIGUE Fatigue Exclude Sleep Disturbance/Lifestyle Issues/Pregnancy Organic Etiologies Endocrine/ Metabolic Neoplastic/ Hematologic • Anemia • Malignancy General Presentations 395 Endocrine • Hypo/Hyper-­‐ thyroidism • Diabetes • Pituitary Insufficiency • Adrenal Insufficiency No Organic Etiologies Infectious Chronic Disease • Endocarditis • Tuberculosis • Epstein-­‐Barr Virus • Hepatitis • HIV Pharmacologic Psychogenic Idiopathic • Hypnotics • Anti-­‐ hypertensives • Anti-­‐Depressants • Drug Abuse (e.g. Alcohol) • Drug Withdrawal • Anxiety • Somatization Disorder •Malnutrition/ Drug Addiction • Chronic Fatigue Syndrome Metabolic • Renal Failure • Liver Failure • Hypercalcemia Autoimmune/ Inflammatory • Rheumatoid Arthritis • Celiac Disease • SLE • Polymyalgia Rheumatica Cardio-­‐ pulmonary • Congestive Heart Failure • Chronic Obstructive Pulmonary Disease Neurologic • Depression • Multiple Sclerosis • Stroke • Parkinson’s • Myasthenia Gravis Acute Fever ACUTE FEVER Fever (acute onset) Infectious Bacterial • Rhinovirus • Influenza Virus • Parainfluenza Virus • Adenovirus • Enterovirus • Coronavirus • HIV Bacteremia • Intermittent Bacteremia • Continuous Bacteremia Other • Fungal • Protozoa (eg. malaria) • Other parasites Septic Shock Inflammatory Iatrogenic • PE • Transfusion • Thrombophlebitis reaction • DVT • Malignant • Pancreatitis Hyperthermia • Neuroleptic malignant syndrome Acute Organ Specific Infection • Upper Respiratory Tract Infection • Urinary Tract Infection • Pneumonia • Pyelonephritis • Meningitis • Skin Infection Endocrine • Thyroid storm • Acute Adrenal Insufficiency Abscess •Head and neck • Thoracic • Abdominal • Pelvic • Extremity Other • Heat stroke • Sickle Cell disease • Drug fever • MI General Presentations Viral Non-­‐infectious 396 Fever of Unknown Origin / Chronic Fever FEVER OF UNKNOWN ORIGIN/CHRONIC FEVER Fever of unknown origin/chronic fever Infection Neoplasm Autoimmune • NHL • Hodgkin’s lymphoma • Leukemia • Solid tumors General Presentations 397 Bacterial Organ Specific Infection • Infectious endocarditis • Osteomyelitis • Occult abscess • Sinusitis • Cholangitis • UTI • Meningitis • SLE • RA • Polyarteritis nodosum • Giant cell arteritis • Sarcoidosis Viral Non-­‐organ specific •Brucellosis • Q-­‐fever • Salmonella • Yersinia • Tuleremia • Septic Phlebitis • Rheumatic fever • Lyme disease • TB • Whipple’s disease • HIV • EBV • CMV • Viral hepatitis • Enterovirus Other • Fungal • Protozoa (eg. malaria) • other parasites Other •Drug fever • Factitious fever • Trauma Non-­‐ infectious hepatitis • Recurrent PE Hypothermia HYPOTHERMIA Hypothermia Environmental Acute Illness Body Heat Loss • Drugs/Toxins • Iatrogenic • Burns Lack of Body Heat Generation • Hypothyroidism • Adrenal Insufficiency • Hypoglycemia • Malnutrition Improper Thermoregulation • Cerebrovascular Accident • Central Nervous System Trauma • Multiple Sclerosis • Drugs/Toxins Other • Trauma • Sepsis • Vascular Insufficiency • Uremia General Presentations • Immersion • Non-­‐Immersion 398 Sore Throat / Rhinorrhea SORE THROAT / RHINORRHEA Sore Throat / Rhinorrhea Common viral pathogens: Rhinovirus, Coronavirus, Influenza virus, Parainfluenza Virus, Adenovirus, Herpes Simplex Virus, Enterovirus (Coxsackie, Echo), Epstein Barr Virus, Cytomegalovirus, HIV Most common bacterial pathogen: Group A Beta Hemolytic Streptococcus pyogenes (GABHS) Predominantly Rhinorrhea General Presentations 399 Acute • Acute Viral Sinusitis • Acute Bacterial Sinusitis • Acute Head Cold Syndrome Predominantly Sore Throat Chronic • Allergic/Vasomotor/Drug Rhinitis • Nasal Polyposis • Chronic Sinusitis • Nasopharyngeal Cancer Acute Viral • Acute viral Pharyngitis • Acute Influenza • Acute Viral Laryngotracheitis • Acute Viral Tracheobronchitis • Acute Infectious Mononucleosis • Herpangina Bacterial • Streptococcal Tonsillopharyngitis • Peritonsillar Abscess • Ludwig’s Angina Chronic • GERD • Environmental • Trauma • Foreign Body • Neoplasm Historical Executive Student Editors 401 2016-2017 Joshua Nicholas, Peter Rogers & Scott Belyea 2015-2016 Jared McCormick & Hai (Carlos) Yu 2014-2015 Jared McCormick & Hai (Carlos) Yu 2013-2014 Yang (Steven) Liu & Brian Glezerson 2012-2013 Neha Sarna & Sarah Sy 2011-2012 Katrina Kelly & Harinee Surendra 2010-2011 Jonathan Dykeman & Kathy Truong 2009-2010 Lucas Gursky & Ting Li 2008-2009 Linnea Duke & Mustafa Hirji 2007-2008 Brett Poulin (Founder of the Calgary Black Book Project) Scheme Creators Students M. Abouassaly A. Aristarkhova M. Broniewska P. Chen M. Chow R. Cormack P. Davis L. Duke J. Evinu A. Geist F. Girgis A. Hicks J. Hodges G. Ibrahim C. Johannes D. Joo S. Khan L. Kimmet M. Klassen J. Lawrence J. Laxton K. Leifso J. McCormick Faculty V. Lekhi S. Lipkewich C. Lu L. Luft A. Lys D. McDougall B. McLane J. McMann J. Nadeau B. Poulin V. Prajapati N. Ramji K. Sahi R. Schachar P. Schneider R. Simms A. Skinn U. Unligil C. Verenka H. Waymouth P. Zareba K. Swicker V. David K. Burak D. Burback K. Busche S. Casha M. Clark S. Coderre M. Doran P. Federico K. Fraser S. Furtado N. Hagen J. Huang N. Jette A. Jones G. Klein S. Kraft A. Mahalingham H. Mandin J. Mannerfeldt K. McLaughlin D. Miller L. Parsons D. Patry A. Peets G. Pineo M-C. Poon H. Rabin T. Remington B. Ruether A. Smithee O. Suchowersky P. Veale B. Walley L. Welikovitch R.C. Woodman L. Zanussi Missing a credit? If you are the creator of a scheme currently used in the Blackbook and believe you have not been credited appropriately, please contact us at blackbk@ucalgary.ca 402 Abbreviations AAA ACE ACTH ADPKD ADH AIN ALS ARB ARF ARPKD BPH CCD CHF CIN CLL CNS COPD CRF CRH CT DCIS DHEA DHEA-S DIC 403 Abdominal Aortic Aneurysm Angiotensin-Converting Enzyme Adrenocorticotropic Hormone Autosomal Dominant Polycystic Kidney Disease Antidiuretic Hormone Acute Interstitial Nephritis Amyotrophic Lateral Sclerosis Angiotensin Receptor Blocker Acute Renal Faliure Autosomal Recessive Polycystic Kidney Disease Benign Prostatic Hypertrophy Cortical Collecting Duct Congestive Heart Failure Chronic Interstitial Nephritis Chronic Lymphocytic Leukemia Central Nervous System Chronic Obstructive Pulmonary Disease Chronic Renal Failure Corticotrophic Releasing Hormone Computed Tomography Ductal Carcinoma In Situ Dehydroepiandrosterone Dehydroepiandrosterone Sulfate Disseminated Intravascular Coagulation DKA DRE DVT EABV ECF ENaC FEV1 FJN FSGS FSH FVC GBM GERD GFR GHRH GH GI GN GnRH GPA GRA GTN H+ HCG Diabetic Ketoacidosis Digital Rectal Exam Deep Vein Thrombosis Effective Arterial Blood Volume Extracellular Fluid Epithelial Sodium Channel Forced Expiratory Volume in One Second Familial Juvenile Nephronophthisis Focal Segmental Glomerulosclerosis Follicle Stimulating Hormone Forced Vital Capacity Glomerular Basement Membrane Gastrointestinal Esophageal Reflux Disease Glomerular Filtration Rate Growth Hormone Releasing Hormone Growth Hormone Gastrointestinal Glomerulonephritis Gonadotropin Releasing Hormone Granulomatosis with Polyangiitis Glucocorticoid Gestational Trophoblastic Neoplasm Hydrogen Human Chorionic Gonadatropin HDL HELLP HIV HPL-1a HRT HSP HSV HUS IBD IBS ICP ICU IGF INR ITP IUGR High Density Lipoprotein Hemolysis, Elevated Liver Enzymes, Low Platelets Human Immunodeficiency Virus Human Peripheral Lung Epithelial Cell Line 1a Hormone Replacement Therapy Henoch-Schönlein Purpura Herpes Simplex Virus Hemolytic-Uremic Syndrome Irritable Bowel Disease Irritable Bowel Syndrome Increased Intracranial Pressure Intensive Care Unit Insulin-like Growth Factor International Normalized Ratio Idiopathic Thrombocytopenic Purpura Intrauterine Growth Restriction LPL MCD MCH MCHC MCV MEN MI MPA MPGN MS MSK Na+ NSAIDs OCP OSM PE Lipoprotein Lipase Minimal Change Disease Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentration Mean Corpuscular Volume Multiple Endocrine Neoplasma Myocardian Infarction Microscopic Polyangiitis Membranoproliferative Glomerulonephritis Multiple Sclerosis Musculoskeletal Sodium Non-Steroidal Anti-Inflammatories Oral Contraceptive Pill Osmolality Pulmonary Embolism IV IVP JVP K+ KUB LCIS LDL LGA LH LLN LOC Intravenous Intravenous Pyelogram Jugular Venous Pyelogram Potassium Kidney, Ureter, Bladder Lobular Carcinoma In Situ Low Density Lipoprotein Large for Gestational Age Luteinizing Hormone Lower Limit of Normal Level of Consciousness PID PMN POSM PPROM PROM PT PTH PTT PUD PUJ RAPD Pelvic Inflamatory Disease Polymorphic Neutrophils Plasma Osmolality Preterm Premature Rupture of Membranes Premature Rupture of Membranes Prothrombin Time Parathyroid Hormone Partial Thromboplastin Time Peptic Ulcer Disease Pelviureteric Junction Right Afferent Pupillary Defect 404 RAS RBC RTA SGA SLE TORCH TSH TSHR TTKG TTP UTI US VACTERL VSD VUJ 405 Renal Artery Stenosis Red Blood Cell Renal Tubular Acidosis Small for Gestational Age Systemic Lupus Erythematosus Toxoplasmosis, Other (Hepatitis B, Syphilis, Varicella-Zoster virus, HIV, Parvovirus B19), Rubella, Cytomegalovirus, Herpes Simplex Virus Thyroid Stimulating Hormone Thyroid Stimulating Hormone Receptor Transtubular Potassium Gradient Thrombotic Thrombocytopenic Purpura Urinary Tract Infection Ultrasound Vertebral Anomalies, Anal Atresia, Cardiovascular Anomalies, Tracheoesophageal Fistula, Esphageal Atresia, Renal Anomalies, Limb Anomalies Ventricular Septal Defect Vesicoureteral Junction Notes