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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
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