Disclaimer This material is for educational purposes only. It is not to be used to make medical decisions. Medical decis
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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 Eleventh Edition (2018) Produced by The Cumming School of Medicine, University of Calgary
Blackbook: Approaches to Medical Presentations Eleventh Edition (2018) Chief Editors
Kea Archibold Sunny Fong Lucas Streith Consulting Editors
Alec Campbell Jinghui Hu Taryn Ludwig
Faculty Editor
Dr. Sylvain Coderre Editorial Board
Dr. Henry Mandin Dr. Kevin McLaughlin Dr. Brett Poulin
Incoming Editors
Rebecca Phillips Ainna Preet Randhawa Vaneet Randhawa i
Eleventh Edition (2018). First Printing. Copyright © 2007-2018. Faculty of Medicine, University of Calgary. All Rights Reserved. First Edition
2007 (Reprint 2008)
Seventh Edition
2014
Second Edition
2009 (Reprints 2009, 2010)
Eighth Edition
2015
Third Edition
2010
Ninth Edition
2016
Fourth Edition
2011
Tenth Edition
2017
ISBN
Pending Assignment
Eleventh Edition
2018
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.
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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 [email protected] Medical presentation schemes conceived by Henry Mandin. The Calgary Black Book Project founded by Brett Poulin. Printed in Calgary, Alberta, Canada.
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A Message from the Editors Welcome to the eleventh edition of the Blackbook! This evolving project is the result of collaboration between medical students and faculty at the University of Calgary. The Blackbook schemes have been incorporated into medical education at the University of Calgary for several years, and more recently at several other institutions across Canada and the United States. We are proud that health care institutions across North America find it to be a useful tool. For the first time in the Blackbook’s history, we are offering this resource as a free online PDF. It is our hope that these schemes will assist learners in structuring their clinical reasoning and will promote discussions about approaches to many different presentations. As the Blackbook continues to grow and develop, we are always interested in collaboration with users. If you have feedback or suggestions to improve the Blackbook, please direct these communications to: [email protected]. Thank-you for your interest in the Blackbook, we hope you will find it a useful addition to your clinical repertoire. Kea Archibold, Sunny Fong and Lucas Streith
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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).
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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:
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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
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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
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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
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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
Thrombocyopenia�����������������������������������������������������������62
Acute Diarrhea�������������������������������������������������������������������79
Thrombocytosis����������������������������������������������������������������63
Chronic Diarrhea Small Bowel�������������������������������80
Hemolysis������������������������������������������������������������������������������64
Chronic Diarrhea Steatorrhea & Large Bowel ��������������������������������������������������������������������������������������������������81
Gastrointestinal
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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
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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 &
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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
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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
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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 Hemorrhage�������������������������������������� 212 Recurrent Pregnancy Loss������������������������������������� 213 Vaginal Discharge����������������������������������������������������������214
Morphology of Skin Lesions Primary Skin Lesions����������������������������������������������������������������������������227 Morphology of Skin Lesions Secondary Skin Lesions��������������������������������������������������������������������������� 228
Dermatologic
215
Mucous Membrane Disorder Oral Cavity��� 229
Burns���������������������������������������������������������������������������������������219
Nail Disorders Primary Dermatologic Disease
Dermatoses in Pregnancy Physiologic Changes������������������������������������������������������������������������ 220 Dematoses in Pregnancy Specific Skin Conditions��������������������������������������������������������������������� 221 Disorders of Pigmentations Hyperpigmentation�����������������������������������������������222 Disorders of Pigmentations
���������������������������������������������������������������������������������������������� 230 Nail Disorders Systemic Disease����������������������� 231 Nail Disorders Systemic Disease - Clubbing �����������������������������������������������������������������������������������������������232 Pruritus No Primary Skin Lesion�������������������������233 Pruritus Primary Skin Lesion��������������������������������� 234 Skin Rash Eczematous���������������������������������������������� 235
Hypopigmentation�������������������������������������������������223
Skin Rash Papulosquamous��������������������������������� 236
Genital Lesion�������������������������������������������������������������������224
Skin Rash Pustular���������������������������������������������������������237
Hair Loss (Alopecia) Diffuse�����������������������������������225
Skin Rash Reactive������������������������������������������������������� 238
Hair Loss (Alopecia) Localized���������������������������� 226
Skin Rash Vesiculobullous������������������������������������� 239
xvii
Skin Ulcer by Etiology�����������������������������������������������240
Pathologic Fractures�������������������������������������������������� 256
Skin Ulcer by Location Genitals��������������������������241
Soft Tissue���������������������������������������������������������������������������257
Skin Ulcer by Location Head & Neck��������������242
Fracture Healing������������������������������������������������������������ 258
Skin Ulcer by Location Lower Legs / Feet243
Osteoporosis BMD Testing������������������������������������ 259
Skin Ulcer by Location Oral Ulcers������������������ 244
Tumour����������������������������������������������������������������������������������260
Skin Ulcer by Location Trunk / Sacral Region
Mytomes Segmental Innervation of Muscles
���������������������������������������������������������������������������������������������� 245
�����������������������������������������������������������������������������������������������261
Vascular Lesions������������������������������������������������������������ 246
Guide to Spinal Cord Injury������������������������������������ 262
Musculoskeletal
Psychiatric
247
263
Acute Joint Pain Vitamin CD��������������������������������� 249
Anxiety Disorders Associated with Panic���� 265
Chronic Joint Pain���������������������������������������������������������250
Anxiety Disorders Recurrent Anxious
Bone Lesion�����������������������������������������������������������������������251
Thoughts ���������������������������������������������������������������������266
Deformity / Limp�����������������������������������������������������������252
Trauma & Stressor Related Disorders����������� 267
Infectious Joint Pain���������������������������������������������������� 253
Obsessive-Compulsive & Related Disorders
Inflammatory Joint Pain�������������������������������������������� 254
����������������������������������������������������������������������������������������������268
Vascular Joint Pain������������������������������������������������������� 255
Personality Disorder����������������������������������������������������269
xviii
Mood Disorders Depressed Mood������������������ 270
Ophthalmologic
287
Mood Disorders Elevated Mood������������������������ 271
Cross Section of the Eye & Acronyms�����������289
Psychotic Disorders ����������������������������������������������������272
Approach to an Eye Exam��������������������������������������290
Somatoform Disorders�����������������������������������������������273
Acute Vision Loss Bilateral��������������������������������������291 Acute Vision Loss Unilateral��������������������������������� 292
Otolaryngologic
275
Chronic Vision Loss Anatomic����������������������������� 293
Hearing Loss Conductive����������������������������������������277
Amblyopia�������������������������������������������������������������������������� 294
Hearing Loss Sensorineural���������������������������������� 278
Diplopia�������������������������������������������������������������������������������� 295
Hoarseness Acute�������������������������������������������������������� 279
Pupillary Abnormalities Isocoria������������������������296
Hoarseness Non-Acute��������������������������������������������280
Pupillary Abnormalities Anisocoria������������������ 297
Neck Mass���������������������������������������������������������������������������281
Red Eye Atraumatic�����������������������������������������������������298
Otaligia���������������������������������������������������������������������������������� 282
Red Eye Traumatic�������������������������������������������������������299
Smell Dysfunction�������������������������������������������������������� 283
Strabismus Ocular Misalignment���������������������300
Tinnitus Objective��������������������������������������������������������� 284
Neuro-Ophthalmology Visual Field Defects
Tinnitus Subjective������������������������������������������������������ 285
�����������������������������������������������������������������������������������������������301
xix
Pediatric
303
Constipation (Pediatric)��������������������������������������������� 321
Developmental Delay������������������������������������������������ 307
Mouth Disorder (Pediatric)��������������������������������������322
School Difficulties���������������������������������������������������������308
Depressed / Lethargic Newborn����������������������323
Small for Gestational Age���������������������������������������309
Cyanosis in the Newborn Non-Respiratory
Large for Gestational Age����������������������������������������310
���������������������������������������������������������������������������������������������� 324
Congenital Anomalies�������������������������������������������������311
Cyanosis in the Newborn Respiratory����������� 325
Preterm Infant Complications������������������������������ 312
Pediatric Dyspnea�������������������������������������������������������� 326
Failure to Thrive Adequte Calorie
Noisy Breathing Pediatric Wheezing��������������327
Consumption��������������������������������������������������������������313 Failure to Thrive Inadequte Calorie
xx
Noisy Breathing Pediatric Stridor���������������������� 328 Pediatric Cough Acute���������������������������������������������� 329
Consumption��������������������������������������������������������������314
Pediatric Cough Chronic�����������������������������������������330
Hypotonic Infant (Floppy Newborn)����������������315
Respiratory Distress in the Newborn��������������331
Acute Abdominal Pain������������������������������������������������316
Sudden Unexpected Death in Infancy����������332
Pediatric Vomiting Gastrointestinal Causes317
Enuresis�������������������������������������������������������������������������������� 333
Pediatric Vomiting System Causes�������������������318
Acute Life Threatening Event������������������������������ 334
Neonatal Jaundice��������������������������������������������������������319
Pediatric Fractures������������������������������������������������������� 335
Pediatric Diarrhea��������������������������������������������������������� 320
Salter Harris Physeal Injury Classification��� 336
Pediatric Seizure Unprovoked�����������������������������337 Pediatric Seizure Provoked����������������������������������� 338 Pediatric Seizure Spells������������������������������������������� 339 Pediatric Mood & Anxiety Disorder������������������340
General Presentations
341
Fatigue����������������������������������������������������������������������������������� 343 Acute Fever����������������������������������������������������������������������� 344 Fever of Unknown Origin / Chronic Fever� 345 Hypothermia���������������������������������������������������������������������346 Sore Throat / Rhinorrhea�����������������������������������������347
Historical Executive Student Editors�� 349 Scheme Creators���������������������������������� 350 Abbreviations ������������������������������������ 351
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 (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 o2 0 5 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 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 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
Thrombocyopenia
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)* 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 ( 2-‐3 loose stools/day, >175-‐235 g /day; > 48 hours, 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 LLIVER IVER ENZYMES NZYMES ELEVATED ELEVATED LIVER EENZYMES
Elevated Liver Enzymes Elevated Liver Enzymes Elevated Liver Enzymes Elevated LLiver iver EEnzymes nzymes Elevated Hepatocellular Cholestatic (does not always cause
Alcohol Stone • AIH •• Drugs/Toxins •• NAFLD • Common Bile Duct • Drugs Viral • Drugs Viral ••PBC Alcoholic hepatitis • •PBC • Hemochromatosis •uct PSC PSC • Autoimmune •••Viral Common ile DDuct ••NAFLD Viral •Stone Biliary stricture Viral • Wilson’s Ischemia • •NAFLD • •Common BBile • ••• Viral Alcohol Drugs/Toxins • Viral • TPN • AIH Drugs ••PSC Drugs • •PSC Alcoholic hepatitis • Drugs • Wilson’s • Alcohol Stone • Hemochromatosis •• PSC Drugs/Toxins Autoimmune • Alcohol • Hemochromatosis Stone • ••• Drugs/Toxins • Viral Biliary stricture• Worms/flukes ••Drugs Wilson’s Ischemia • •Drugs • Sepsis AIH • Alcoholic h epatitis • TPN • Alcoholic h epatitis • Drugs • AIH • Pregnancy • •AIH •••Biliary stricture• Cholangiocarcinoma ••Viral Drugs Worms/flukes Ischemia Wilson’s • •Viral • ••• Ischemia Hemochromatosis PSC stricture ••AIH Hemochromatosis Autoimmune • Infiltrative• Biliary Wilson’s • NAFLD ••Drugs Sepsis • •Drugs TPN • A1AT deficiency • AFLP ••Hemochromatosis AIH ••PSC Cholangiocarcinoma Autoimmune Pregnancy • •Hemochromatosis • •PSC • ••• Autoimmune • Others Drugs Worms/flukes• Pancreatic cancer Wilson’s ••Wilson’s NAFLD • •Wilson’s Hemochromatosis • Sarcoid ••TPN Infiltrative • •TPN Sepsis • Wilson’s • Others ••Drugs A1AT deficiency • HELLP •Worms/flukes Pancreatic cancer Wilson’s • AFLP • •Drugs • •Worms/flukes • •• Wilson’s AIH • Cholangiocarcinoma ••Hemochromatosis Others Pregnancy • •Hemochromatosis NAFLD • Amyloid • Sarcoid • •Sepsis •Sepsis Infiltrative • Others ••AIH Wilson’s ••Cholangiocarcinoma Others Pregnancy •• HELLP • •AIH • •Cholangiocarcinoma • • Pregnancy A1AT deficiency Pancreatic cancer AFLP • •NAFLD •NAFLD Others •Infiltrative Infiltrative •• Amyloid • Malignancy •isease Sarcoid • A1AT d eficiency • Pancreatic c ancer • Others • Cholestatic d AFLP • A1AT d eficiency • Pancreatic c ancer • ••AFLP • Wilson’s • Others • Others HELLP • Others ••Sarcoid Malignancy • Infection • •Sarcoid Amyloid Others ••Wilson’s Cholestatic disease HELLP • •Wilson’s • •Others • •HELLP Others ••Amyloid Infection • •Amyloid • Cirrhosis (any) Malignancy • •Others •Others Cholestatic disease •Malignancy Malignancy • Cirrhosis ( any) • •Congenital • Infection Cholestatic ddisease isease • •Cholestatic Infection •Congenital • •Infection •Biliary Atresia • Cirrhosis (any) Cirrhosis (any)Atresia•Alagille Syndrome •Biliary • •Cirrhosis (any) •Congenital •Congenital •Alagille •Congenital •Biliary ASyndrome tresia•Progressive Familial •Biliary tresia •Progressive Familial •Biliary AAtresia •Alagille Syndrome Intracholestasis •Alagille Syndrome Intracholestasis •Alagille Syndrome •Progressive Familial Dx ALF if ETOH hepatitis ERCP for dx Dx by biopsy NAFLD •Progressive F amilial Dx ALF if •Progressive Familial ETOH hepatitis ERCP for dx bIntracholestasis y biopsy ↑INR and hepatic usually cholestatic, NAFLD10% populationDx Intracholestasis and therapy ± MRI/MRCP Intracholestasis ↑INR and hepatic Dx ALF if usually ETOH chholestatic, epatitis and therapy
population NAFLD encephalopathy and usually 10% NAFLD Dx aAA LF f ETOH epatitis Dx LF ihfiepatic ETOH hh encephalopathy NAFLD ↑INR nd and uholestatic, sually usually cepatitis 10% population ALT < 300 10% ↑INR nd hhepatic epatic usually holestatic, ↑INR aand usually ccholestatic, 10% ppopulation opulation encephalopathy ALT 300 and u ALP Hepatocellular Jaundice) A LP > A LT o r A ST Cholestatic ( does n ot a lways c ause Hepatocellular Hepatocellular Cholestatic (does ot always lways cause ause Cholestatic (does nnot aUS ALT or AST > AModerate LP Jaundice) ALP > A LT AcST US – Dilated Bile –or Normal Bile Mild Severe ALT ALT oor r AAST ST >> A ALP LP Jaundice) AALP LP >> A ALT LT oor r AAST ST Jaundice) ALT > 15x ULN Moderate ALT 5–15x ULN US – Normal Bile Ducts US – Dilated Bile Ducts Mild ALT < 5x ULN Severe Ducts• PBC Ducts• Common ALT 1• 5x ULN US – Normal Bile US – Dilated Bile ALT 5–15x ULN Moderate Bile Duct Viral • Viral Normal Bile ile US ––Dilated Dilated ile Mild Severe Moderate US ––Normal US BBile Mild Severe Moderate •US PBC Ducts•BPSC Ducts ALT < 5x •UAlcohol LN ALT > 1• 5x ULN ALT 5–15x ULN Stone Drugs/Toxins • Drugs • NAFLD • Common Bile D uct • Viral • ALT Viral • Alcoholic hepatitis Ducts Ducts ALT < 5 x U LN ALT >> 1 15x 5x U LN ALT 5 –15x U LN Ducts Ducts ALT < 5 x U LN ALT U LN 5 –15x U LN • PSC • Viral • Biliary stricture • Ischemia • PBC
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)
Granulomatosis with polyangiiis (GPA)/microscopic polyangiiis (MPA)
Gastrointestinal
Mouth Disorders (Adult & Elderly)
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 (
FeNa = 100 × (Serum Creaanine × Urine Na) (Serum Na × Urine Creaanine)
(
)
FeNa = 100 × (Serum Creaanine × Urine Na) (Serum Na × Urine Creaanine)
Renal
101
(Granulomatosis with polyangiiis /microscopic polyangiiis)
)
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 20mmol/d
High distal [K]
Urine loss 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
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 50yo secondary HTN Consider
•No FHx BP >o 1r 40/90 (>130/80 DM) Hypertensive urgency emergency (any for visit) •Hypertensive urgency •Onset 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 ( 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 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 • 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 (4cm, CDalcification, >20 ounsfeld UW nits on CT, Vascularity of Mass, (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) •Hypersecretion •Hyposectretion
Other
Short Stature SHORT STATURE Short Stature 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, 50, 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 Hemorrhage�������������������������������������� 212
���������������������������������������������������������������������������������������������� 202
Recurrent Pregnancy Loss������������������������������������� 213
Breast Disorder��������������������������������������������������������������� 203
Vaginal Discharge����������������������������������������������������������214
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 (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: 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 BREAST DISORDERS Breast Disorders
Breast Infection
Lactational • Mastitis • Abscess
Obstetrical
203
Non Lactational
Breast Mass
Malignant
Gynecomastia
Benign
• Subareolar abscess • Acute mastitis
Non-‐Invasive • Ductal carcinoma in situ • Lobular carcinoma in situ
Physiologic • Newborn • Adolescence • Aging
Invasive • Ductal carcinoma • Lobular carcinoma • Tubular carcinoma • Medullary carcinoma • Papillary carcinoma • Mucinous carcinoma
Nodular • Fibrocystic change
Benign • Gross cyst • Galactocele • Fibroadenoma
Pathologic • Drugs • Decreased testosterone • Increased estrogen • Idiopathic
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)
Post-Partum Hemorrhage POST-‐PARTUM HEMORRHAGE Post-‐Partum Hemorrhage
Blood Loss: >500mL post vaginal delivery OR >1000mL post Caesarean section
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)
Obstetrical
Uterine Atony (70%) • 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)
212
Recurrent Pregnancy Loss RECURRENT PREGNANCY LOSS Recurrent Pregnancy Loss ≥ 3 consecutive spontaneous abortions
Maternal
Fetal • Genetic abnormalities
Environmental
Medical
• Toxin (organic solvents, mercury, lead) • Smoking • Alcohol • Drugs • Ionizing radiation
Obstetrical
213
Other • Maternal infection • Thrombophilia
Autoimmune • Antiphospholipid syndrome • Lupus anticoagulant
Anatomic
Cervix • Cervical insufficiency
Endocrine • Diabetes mellitus • Hypo/hyperthyroidism • PCOS • Luteal phase deficiency
Genetic • Maternal age • Maternal/paternal chromosomal abnormality
Uterus • Fibroids • Congenital anomaly • Polyps • Asherman’s syndrome
Vaginal Discharge VAGINAL DISCHARGE Vaginal Discharge
Inflammatory
Systemic • Crohn’s disease • Collagen vascular disease • Dermatologic
Sexually Transmitted Infection • Chlamydia trachomatis • Neisseria gonorrhoeae
Toxic Shock Syndrome
Neoplastic
Local
• Endometrium • Cervix • Vulva • Vagina
• Chemical irritant • Douching • Atrophic vaginitis • Foreign body • Lichen planus
Vulvovaginitis • Vulvovaginal candidiasis • Bacterial vaginosis • Trichomonas vaginalis
Obstetrical
Infectious
214
Dermatologic Burns���������������������������������������������������������������������������������������219 Dermatoses in Pregnancy Physiologic Changes������������������������������������������������������������������������ 220 Dematoses in Pregnancy Specific Skin Conditions��������������������������������������������������������������������� 221 Disorders of Pigmentations Hyperpigmentation�����������������������������������������������222 Disorders of Pigmentations
Dermatologic
215
Morphology of Skin Lesions Secondary Skin Lesions��������������������������������������������������������������������������� 228 Mucous Membrane Disorder Oral Cavity��� 229 Nail Disorders Primary Dermatologic Disease ���������������������������������������������������������������������������������������������� 230 Nail Disorders Systemic Disease����������������������� 231 Nail Disorders Systemic Disease - Clubbing �����������������������������������������������������������������������������������������������232
Hypopigmentation�������������������������������������������������223
Pruritus No Primary Skin Lesion�������������������������233
Genital Lesion�������������������������������������������������������������������224
Pruritus Primary Skin Lesion��������������������������������� 234
Hair Loss (Alopecia) Diffuse�����������������������������������225
Skin Rash Eczematous���������������������������������������������� 235
Hair Loss (Alopecia) Localized���������������������������� 226
Skin Rash Papulosquamous��������������������������������� 236
Morphology of Skin Lesions Primary Skin
Skin Rash Pustular���������������������������������������������������������237
Lesions����������������������������������������������������������������������������227
Skin Rash Reactive������������������������������������������������������� 238
Skin Rash Vesiculobullous��������������������������� 239 Skin Ulcer by Etiology������������������������������������� 240 Skin Ulcer by Location Genitals���������������� 241 Skin Ulcer by Location Head & Neck����242 Skin Ulcer by Location Lower Legs / Feet��������������������������������������������������������������������������243 Skin Ulcer by Location Oral Ulcers���������244 Skin Ulcer by Location Trunk / Sacral Region��������������������������������������������������������������������245 Dermatologic
Vascular Lesions�������������������������������������������������� 246
216
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
217
Sarah Surette Yang Zhan
218
Dermatologic
URNS
Burns BURNS
Burns
Burns
Physical Agents
Dermatologic
219
• • • •
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)
220
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
221
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
222
Disorders of Pigmentations Hypopigmentation
DISORDERS OF PIGMENTATION: Hypopigmentation Disorder of Pigmentation
Hypopigmentation
Hyperpigmentation
Localized
Diffuse
Congenital
Dermatologic
223
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
224
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
225
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
226
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
227
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.
228
Mucous Membrane Disorder
MUCOUS MEMBRANE DISORDER (Oral Cavity)
Oral Cavity
Mucous Membrane Disorder
Erosions/Ulcers/Blisters
Primary Dermatologic Diseases
Dermatologic
229
• 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
230
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
231
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
232
Pruritus
PRURITUS: No Primary Skin Lesion No Primary Skin Lesion Pruritus
Primary Skin Lesion
No Primary skin Lesion
Primary Abnormal Finding
Dermatologic
233
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
234
Skin Rash
SKIN RASH: Eczematous Eczematous Skin Rash
Eczematous
Pruritic/Scaly/Erythematous lesions. Usually poorly demarcated
Atopic Dermatitis
Dermatologic
235
(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
236
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
237
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 1 cm diameter
246
Musculoskeletal Acute Joint Pain Vitamin CD��������������������������������� 249 Chronic Joint Pain���������������������������������������������������������250 Bone Lesion�����������������������������������������������������������������������251 Deformity / Limp�����������������������������������������������������������252 Infectious Joint Pain���������������������������������������������������� 253 Inflammatory Joint Pain�������������������������������������������� 254 Vascular Joint Pain������������������������������������������������������� 255 Pathologic Fractures�������������������������������������������������� 256 Soft Tissue���������������������������������������������������������������������������257 Musculoskeletal
247
Fracture Healing������������������������������������������������������������ 258 Osteoporosis BMD Testing������������������������������������ 259 Tumour����������������������������������������������������������������������������������260 Mytomes Segmental Innervation of Muscles �����������������������������������������������������������������������������������������������261
Guide to Spinal Cord Injury������������������������������������ 262
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
248
Acute Joint Pain Vitamin CD
ACUTE JOINT PAIN-‐ VITAMIN CD Vascular
-‐ See vascular joint pain
Infectious
-‐ See infectious joint pain
Trauma Autoimmune
Musculoskeletal
249
-‐ 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
250
Bone Lesion BONE LESION
Bone Lesion on X-‐ray Rule Out Osteomyelitis & Secondary Metastases
Non-‐aggressive
Exostotic
Aggressive
Narrow, -‐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
259
• • • • • • • • • • •
• 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 (10% of Vertebral fracture when 25) Osteopenia on X ray Smoking/ETOH Low body weight (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
• • • • •
260
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.
261
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
262
Psychiatric Anxiety Disorders Associated with Panic���� 265 Anxiety Disorders Recurrent Anxious Thoughts ���������������������������������������������������������������������266 Trauma & Stressor Related Disorders����������� 267 Obsessive-Compulsive & Related Disorders ����������������������������������������������������������������������������������������������268 Personality Disorder����������������������������������������������������269 Mood Disorders Depressed Mood������������������ 270 Mood Disorders Elevated Mood������������������������ 271 Psychotic Disorders ����������������������������������������������������272 Somatoform Disorders�����������������������������������������������273 Psychiatric
263
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
264
Anxiety Disorders Associated with Panic
Psychiatric
265
Anxiety Disorders
Psychiatric
Recurrent Anxious Thoughts
266
Trauma & Stressor Related Disorders
Psychiatric
267
Psychiatric
Obsessive-Compulsive & Related Disorders
268
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
269
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
270
Mood Disorders Elevated Mood
Psychiatric
271
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:
272
Somatoform Disorders SOMATOFORM DISORDERS Somatoform Disorder Patient presents with complex medical problem or symptoms that cannot be explained medically
Symptoms Consciously Produced
Psychiatric
273
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����������������������������������������277 Hearing Loss Sensorineural���������������������������������� 278 Hoarseness Acute�������������������������������������������������������� 279 Hoarseness Non-Acute��������������������������������������������280 Neck Mass���������������������������������������������������������������������������281 Otaligia���������������������������������������������������������������������������������� 282 Smell Dysfunction�������������������������������������������������������� 283 Tinnitus Objective��������������������������������������������������������� 284 Tinnitus Subjective������������������������������������������������������ 285 Otolaryngologic
275
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
276
Hearing Loss Conductive
Otolaryngologic
277
Hearing Loss
Otolaryngologic
Sensorineural
278
Hoarseness Acute
HOARSENESS: Acute Hoarseness If Hoarseness persists > 3 months, Refer to ENT
Acute
Non-‐Acute
Constant
Variable
> 3 weeks
< 3 weeks
Otolaryngologic
279
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
280
Neck Mass NECK MASS Neck Mass
Congenital
Inflammatory • • • • • •
Otolaryngologic
281
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
282
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
283
• 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
284
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
285
• 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�����������289 Approach to an Eye Exam��������������������������������������290 Acute Vision Loss Bilateral��������������������������������������291 Acute Vision Loss Unilateral��������������������������������� 292 Chronic Vision Loss Anatomic����������������������������� 293 Amblyopia�������������������������������������������������������������������������� 294 Diplopia�������������������������������������������������������������������������������� 295 Pupillary Abnormalities Isocoria������������������������296 Pupillary Abnormalities Anisocoria������������������ 297 Ophthalmologic
287
Red Eye Atraumatic�����������������������������������������������������298 Red Eye Traumatic�������������������������������������������������������299 Strabismus Ocular Misalignment���������������������300 Neuro-Ophthalmology Visual Field Defects �����������������������������������������������������������������������������������������������301
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
288
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
289
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
Slit Lamp Exam
A. Lids / Lashes/
B. Pupils a. Light Reflex,
5
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
290
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
291
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
292
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
293
• 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
294
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
295
(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)
296
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 ( 90th Percentile
Rule Out: • Wrong Dates, Twins, Polyhydramnios, Fibroids and Pelvic Mass
Maternal Factors • Familial • Diabetes Mellitus (Macrosomia) • Maternal Obesity
Fetal • Syndromes • Constitutionally Large
Pediatric
True LGA
310
Congenital Anomalies CONGENITAL ANOMALIES CONGENITAL ANOMALIES
Congenital Anomalies Congenital Anomalies Isolated
Multiple
Isolated Malformation
Multiple Deformation
Disruption
Association of A (Syndrom
Association • Chromosomal • Destruction/ Breakdown oof f Anomalies • Single Gene (Syndromic) failure or inadequacy (often distorting otherwise normal previously normal tissue (e.g. • Teratogenic multifactorial) structures ischemia) • Chromosomal • Embryonic development • Abnormal mechanical f(e.g.exoligohydramnios) orces • Destruction/ Breakdown of • Association (e.g. V • Single Gene failure or inadequacy (often distorting otherwise normal previously normal tissue (e.g. • Teratogenic multifactorial) structures ischemia) • Association (e.g. VACTERL) (e.g.exoligohydramnios) forces Malformation • Embryonic development Deformation • Abnormal mechanical Disruption
Pediatric
311
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 Things to Consider: Procedures – Chromosomes, mdolecular/DNA, radiology, photography, metabolic History – Prenatal: maternal hDiagnostic ealth, exposures, screening, ultrasounds; elivery; neonatal Diagnostic Evaluations – Prognosis, recurrence, renatal diagnosis, surveillance, treatment Family History – Three Generations: prior malformations, stillbirths, recurrent pm iscarriages, consanguinity Physical Exam – Variants, minor anomalies, major malformation
Preterm Infant Complications PRETERM INFANT COMPLICATIONS Preterm Infant Complications
• Transient Tachypnea of the Newborn (TTN) • Respiratory Distress Syndrome (RDS) • Chronic Lung Disease (CLD) • Bronchopulmonary Dysplasia (BPD) • Apnea of Prematurity (AOP)
Hemodynamics • Persistent Ductus Arteriosis (PDA)
Gastrointestinal • Necrotizing Enterocolitis (NEC)
Neurologic • Intraventricular Hemorrhage (IVH) • Neurodevelopmental Impairments (NDI)
Ophthalmology • Retinopathy of Prematurity (ROP)
Pediatric
Respiratory
312
Failure to Thrive
Adequte Calorie Consumption FAILURE TO THRIVE: Adequate Calorie Consumption
Failure to Thrive
Adequate Calorie Consumption
Increased Losses • Vomiting • Gastroesophageal Reflux • Renal Tubular Acidosis
Pediatric
313
Malabsorption • Pancreatic Insufficiency (Cystic Fibrosis) • Celiac Disease • Liver Disease
Inadequate Calorie Consumption
Increased Demands • Congestive Heart Failure • Chronic Respiratory Failure
Failure to Utilize • Metabolic Disorders • Syndromes
Failure to Thrive Inadequte Calorie Consumption FAILURE TO THRIVE: Inadequate Calorie Consumption Failure to Thrive
Organic Illness • Chronic Renal Failure • Esophagitis • Congenital Heart Defect • Structural Dystrophies
Inadequate Calorie Consumption
Protein-‐Energy Malnutrition • Kwashiokor (inadequate protein intake) • Marasmus (inadequate protein and energy intake)
Psychosocial Illness • Oral Aversion • Neglect • Poverty • Disturbed Parent-‐Child Relationship
Pediatric
Adequate Calorie Consumption
314
Hypotonic Infant (Floppy Newborn) Hypotonic Infant (Floppy Newborn) Hypotonic Infant (Floppy Newborn)
Hypotonic Infant
Hypotonic Infant Decreased LOC, Axial Weakness, Normal Strength, Normal Reflexes Decreased LOC, Axial Weakness, Normal Strength, Normal Reflexes
Central Nervous System
Central Nervous System Brain
Alert, Responding to Surroundings, Profound Peripheral Weakness Peripheral Nervous
System
Peripheral Nervous System Neuromuscular Nerves Junction
Musc
• Congenital • Hypoxic-‐Ischemic • Spinal Muscular Atrophy Neuromuscular • Congenital and Transient • Congenital Spinal Cord Nerves Hypomyelinating Dystrophies Encephalopathy* • Trauma Myasthenia GMuscle ravis Junction Neuropathy • Metabolic •Trisomy 21* • Hematoma • Infantile Botulism • Infantile Neuroaxonal • Abscess • Congenital • Magnesium Toxicity • Congenital Myotonic • Central Co • Hypoxic-‐Ischemic • Intracranial • Spinal Muscular Atrophy • Congenital and Transient Degeneration • Other Cong Hemorrhage • Arteriovenous Fistula • Aminoglycoside Toxicity Hypomyelinating Dystrophies Encephalopathy* • Trauma Myasthenia Gravis • CNS •Infection • Infantile Neuropathy Neuronal • Metabolic MyopathiesMyopathies •Trisomy 21* Hematoma • Infantile Botulism • Metabolic Diseases Degeneration • Infantile Neuroaxonal • Magnesium Toxicity • Central Core Disease • Intracranial • Abscess • Prader-‐ Willi Degeneration • Other Congenital Hemorrhage • Arteriovenous Fistula • Poliomyelitis • Aminoglycoside Toxicity • Intracranial Mass/lesion Myopathies • CNS Infection • Infantile Neuronal • Other C ongenital • Metabolic Diseases Degeneration Syndromes • Prader-‐Willi • Poliomyelitis • Intracranial Mass/lesion • Other Congenital Syndromes * Indicates most common causes of hypotonia
Brain
Pediatric
315
Spinal Cord
Alert, Responding to Surroundings, Profound Peripheral Weakness
Acute Abdominal Pain ACUTE ABDOMINAL PAIN Acute Abdominal Pain
Focal
Generalized/Migratory
Epigastric • Gastritis • Peptic Ulcer Disease • Pancreatitis • Gastroesophageal Reflux Disease
Right Upper Quadrant • Hepatitis • Cholelithiasis • Cholecystitis • Pyelonephritis • Right Lower Lobe Pneumonia
Left Upper Quadrant • Viral Illness with Splenic Enlargement/Rupture • Pyelonephritis • Left Lower Lobe Pneumonia
Right Lower Quadrant • Appendicitis • Ovarian Cyst • Ovarian Torsion • Ectopic Pregnancy • Pelvic Inflammatory Disease • Nephrolithiasis • Dysmenorrhea
Left Lower Quadrant • Ovarian Cyst • Ovarian Torsion • Ectopic Pregnancy • Pelvic Inflammatory Disease • Nephrolithiasis
Pediatric
• Intussusception • Gastroenteritis • Viral Illness • Diabetic Ketoacidosis • Bowel Obstruction • Henoch-‐Schonlein Purpura • Malrotation/Volvulus • Urinary Tract Infection • Peritonitis • Somatization • Sickle Cell Crisis • Ileus • Infantile Colic
316
Pediatric Vomiting
Gastrointestinal PEDIATRIC VCauses OMITING: Gastrointestinal causes
Vomiting
Gastrointestinal Disease
Other Systemic Disease
Upper Gastrointestinal
Hepatobiliary
Lower Gastrointestinal
• Acute Hepatitis • Acute Pancreatitis
Pediatric
317
Acute • Infectious Gastroenteritis • Gastric/Duodenal Obstruction • Pyloric Stenosis • Intussusception • Gastric Volvulus • Necrotizing Enterocolitis
Chronic • Gastroesophageal Reflux Disease • Peptic Ulcer Disease • Gastroparesis • Gastritis
Acute • Infectious Gastroenteritis • Small/Large Bowel Obstruction • Intussusception • Acute Appendicitis • Incarcerated Hernia
Chronic • Intestinal Atresia • Midgut malrotation
PEDIATRIC VOMITING: Systemic causes
Pediatric Vomiting System Causes
Vomiting
Endocrine/Metabolic • Pregnancy • Diabetes/ DKA • Uremia • Hypercalcemia • Addison’s Disease • Thyroid Disease
Other • Sepsis (e.g. Pyelonephritis, Pneumonia) • Radiation Sickness • Poisoning • Food Allergy • Urinary Tract Infection
High Intracranial Pressure • Hemorrhage • Meningitis • Head Trauma • Brain Tumour • Hydrocephalus
Other Systemic Disease
Drugs/Toxins
Central Nervous System
• Chemotherapy • Antibiotics • Carbon Monoxide
Vestibular (Inner Ear)
• Ear Infection (Otitis Media) • Motion Sickness • Vestibular Migraine • Ménière’s Disease • Labrynthitis
Psychiatric • Self-‐Induced (Bulimia) • Cyclic Vomiting • Psychogenic
Pediatric
Gastrointestinal Disease
318
Neonatal Jaundice NEONATAL JAUNDICE Neonatal Jaundice
< 1 Week Old
> 1 Week Old Measure TSB and Conjugated Bilirubin
Pre-‐Hepatic
Hepatic
Post-‐Hepatic
Measure TSB or TcB
Physiologic
Pediatric
319
Pathologic
(Jaundice before 24 hours of age, rapid elevation of serum bilirubin greater that 80uM and peak bilirubin greater than 350 uM)
Increased Production
Decreased Metabolism
RBC Intrinsic
RBC Extrinsic
Increased Re-‐Absorption
Pediatric Diarrhea
PEDIATRIC DIARRHEA Pediatric Diarrhea
• Viral • Bacterial • Parasitic
Malabsorption • Lactase Deficiency •Cystic Fibrosis • Celiac Disease • Primary Immuno-‐Deficiency • Dissacharidase Deficiency
Other • Toddler’s Diarrhea • Constipation/Overflow Diarrhea • Drugs • Laxative Abuse • Inflammatory Bowel Disease • Overfeeding • Short Bowel Syndrome • Food Poisoning • Irritable Bowel Syndrome
Pediatric
Infectious
320
Constipation (Pediatric) CONSTIPATION: PEDIATRIC Constipation Infrequent Bowel Movements? Hard, Small stools? Painful evacuation? Encopresis?
Neonate/Infant
Dietary/Functional
Pediatric
321
• Insufficient Volume/ Bulk
Older Child
Neurologic
Dietary/Functional
• Hirschsprung’s Disease • Imperforate Anus • Anal Atresia • Intestinal Stenosis • Intestinal Atresia • Cystic Fibrosis
• Insufficient Bulk/Fluid • Withholding • Painful (e.g. Fissures) • Drugs (Narcotics, Psychotropics)
Anatomic • Bowel Obstruction • Pseudo-‐obstruction
Neurologic • Hirschsprung’s Disease • Spinal Cord Lesions • Myotonia Congenita • Guillain-‐Barré Syndrome • Muscular Dystrophy • Sexual Abuse
MOUTH DISORDERS: PEDIATRIC
Mouth Disorder (Pediatric)
Mouth Disorders
Teeth
Mucous Membranes
Painful
Non-‐Painful
• Teething
• Crohn’s Disease • Ulcerative Colitis
Other • Gum Disease (e.g. Gingivitis) • Hand, Foot and Mouth Disease (Coxsackie Virus) • Streptococcal Throat Infection • Canker Sore • Herpes Simplex Virus • Inflamed Papillae (e.g. Burn)
Non-‐Inflammatory • Impetigo • Mucocele • Candidiasis
Inflammation • Allergic Reaction
Pediatric
Gastrointestinal
322
Depressed / Lethargic Newborn Depressed/Lethargic Newborn Depressed/Lethargic Newborn
Child Related
Maternal Related • Drugs (Ex. SSRI) • Diabetes Mellitus • Gestational Hypertension
Pediatric
323
Congenital • Birth Injury • Congenital Malformation • TORCH Infection • Congenital Heart Defect
Respiratory • Respiratory Distress Syndrome • Birth Asphyxia • Pneumothorax • Meconium Aspiration • Sepsis
Other • Anemia • Shock • Hypothermia • Hypoglycemia
Cyanosis in the Newborn Non-Respiratory
CYANOSIS IN THE NEWBORN: Non-‐Respiratory Cyanosis
Central and Peripheral
Peripheral Only • Poor Perfusion • Acrocyanosis
Cardiovascular
Hemoglobinopathy
Respiratory
• Congenital • Acquired • Sulfhemoglobin
• Patent Ductus Arteriosus • Ventricular Septal Defect • Atrioventricular Septal Defect • Truncus Arteriosus • Atrial Septal Defect • Total Anomalous Pulmonary Venous Return
Right-‐to-‐Left Shunt • Transposition of the Great Arteries • Tetralogy of Fallot • Obstructive/Hypoplastic Lesions • Aortic Atresia/Stenosis • Interruption of the Aortic Arch • Aortic Coarctation
Pediatric
Left-‐to-‐Right Shunt
324
Cyanosis in the Newborn Respiratory
CYANOSIS IN THE NEWBORN: Respiratory Cyanosis
Central and/or Peripheral
Peripheral Only • Poor Perfusion • Acrocyanosis
Cardiovascular
Reduced Respiratory Drive
Pediatric
325
• CNS Malformations • Seizures • CNS Hemorrhage • CNS Infections • Asphyxia • Metabolic Disease • Narcotics/Sedatives • Sepsis
Hemoglobinopathy
Airway Obstruction • Atresia • Laryngomalacia • Tracheomalacia • Extrinsic Compression • Anatomic Compression • Meconium Aspiration
Lung Parenchyma • Bronchopulmonary Dyspnea • Pulmonary Edema • Pneumothorax • Malformation with Infection • Aspiration
Respiratory
Other • Persistent Pulmonary Hypoplasia of the Newborn •Transient Tachypnea of the Newborn • Diaphragmatic Hernia • Infection (RSV)
Pediatric Dyspnea PEDIATRIC DYSPNEA Pediatric Dyspnea
• Croup • Foreign Body • Tracheitis • Epiglottitis • Laryngospasm
Wheeze • Asthma • Bronchiolitis • Foreign Body • Viral Induced Wheeze
Crackles • Pneumonia • Congestive Heart Failure • Bronchiolitis • Foreign Body
Decreased Air Entry • Pneumonia • Asthma • Bronchiolitis • Foreign Body • Pleural Effusion • Atelectasis • Pneumothorax
Normal Breath Sounds • Pneumonia • Foreign Body • Heart Disease • Diabetic Ketoacidosis • Pulmonary Embolism
Pediatric
Stridor
326
Noisy Breathing
NOISY BREATHING: Pediatric Wheezing
NOISY BREATHING: Pediatric Wheezing Pediatric Wheezing
Wheezing in a Child Wheezing in a Child CXR Non Specific CXR Non Specific
Relief With Beta-‐Agonist Relief With Beta-‐Agonist • Asthma*
Pediatric
327
• Pulm • Cong • Bronc • Neur • Terat • Medi
CXR Abnormal
• Pulmonary Sequestration • Congenital Adenoid Cystic Malformation • Bronchogenic Cyst • Neuroblastoma • Teratoma R/O Endobronch Wheeze MassWith Positive Sweat • Mediastinal
Chloride
Feeding
Fibrosis • Aspiration Endobronchial Wheeze With • Cystic R/O Positive Sweat • Asthma* Disease • GE Reflux Feeding Chloride • H-‐Type Esophageal • Vascular Compression Syndrome Fistula • Cystic Fibrosis • Aspiration • Foreign Body Aspiration* • GE Reflux • Endobronchitis • H-‐Type Esophageal • Structural Anomaly Fistula
Disease
• Vascular Compress • Foreign Body Aspir • Endobronchitis • Structural Anomal
* Denotes acutely life-‐threatening causes
Pediatric Wheezing NOISY BREATHING: Pediatric Stridor Stridor in a Child CXR Abnormal Present Since Infancy • Pulmonary Sequestration
No Respiratory Distress •Laryngomalacia
Wheeze With Feeding
• Aspiration • GE Reflux • H-‐Type Esophageal Fistula
Not Present Since Infancy
• Congenital Adenoid Cystic Malformation • Bronchogenic Cyst • Neuroblastoma • Teratoma Non-‐Acute Onset Respiratory Distress • Mediastinal Mass
• Laryngomalacia
Web R/O •• ELaryngeal ndobronchial Hemangioma Disease • Vocal Cord Dysfunction • Subglottic Stenosis
• Hemangioma • Vocal Cord Dysfunction • Subglottic Stenosis • Laryngeal Papillomatosis
• Vascular Compression Syndrome • Foreign Body Aspiration* • Endobronchitis • Structural Anomaly
* Denotes acutely life-‐threatening causes
Afebrile
Febrile
• Peritonsillar/Retropharyn geal Abscess* • Epiglottitis* • Mononucleosis • Bacterial Tracheitis*
Acute Onset
Barking Cough • Croup • Atypical Croup
Partially-‐Treated Bacterial Tracheitis
Pediatric
brosis
Pediatric Stridor
Wheezing in a Child
CXR Non Specific
e Sweat ride
Noisy Breathing
328
Pediatric Cough
NOISY BREATHING: Pediatric Wheezing
PEDIATRIC COUGH: Acute Acute
Wheezing in a Child Acute Cough in Children ( < 3 wks )
CXR Non Specific
No Fever, No Tachypnea
URTI Symptoms
Normal Chest Auscultation • Post-‐nasal drip
Pediatric
329
No URTI Symptoms
Fever, Tachypnea
Normal CXR
CXR Shows Consolidation
CXR Shows Diffuse Changes
• Pulm • Cong • Bronc • Neur • Terat • Medi
• History oRelief r body Sweat • Bacterial Wheeze W•ith Atypical or vR/O iral Endobronch With • Foreign Positive suspicion of aspiration* pneumonia pneumonia Disease Feeding Beta-‐ A gonist Chloride foreign body? • Bronchitis/Bron chiolitis • Vascular Compress • Asthma* • Cystic Fibrosis • Aspiration Wheeze and/or • Foreign Body Aspir • GE Reflux • Endobronchitis Crackles • H-‐Type Esophageal • Structural Anomal Fistula • Asthma* • Bronchiolitis/Bron chitis
* Denotes acutely life-‐threatening causes
Pediatric Cough
PEDIATRIC COUGH: Chronic
Chronic
Chronic Cough In Children ( > 3 wks ) Poor Growth
Normal Growth
Exacerbated by Exertion/URTI
Abnormal CXR
• Asthma
Abnormal CXR
CT Scan • Structural Abnormality • Tumor
Non-‐Specific CXR • Immunodeficiency • Chronic Aspiration • Environmental Exposure • Poorly Controlled Asthma • Infection
CT Scan
Normal CXR • Chronic Sinusitis • Post Nasal Drip • GERD +/-‐ Aspiration • Habit Cough • Environmental Exposure
• Tumors • Congenital Anomaly
Pediatric
Sweat Chloride Test to R/O Cystic Fibrosis
330
NOISY BREATHING: Pediatric Wheezing
Respiratory Distress in the Newborn
RESPIRATORY DISTRESS IN THE NEWBORN
Wheezing in a Child Respiratory Distress In The Newborn
CXR Non Specific
Premature
Normal CXR
Pediatric
331
• Apnea of Prematurity • Sepsis* • Intraventricular Hemorrhage* • Hypoglycemia* • Hypothermia* • Narcosis
• Pulm • Cong • Bronc • Neur • Terat • Medi
Not Premature
R/O Endobronch Wheeze With Relief With Meconium Positive Sweat Abnormal CXR Beta-‐Agonist Aspiration Chloride Infectious Feeding Non-‐Infectious Disease • Asthma* • Respiratory Distress Syndrome (RDS)* • Transient Tachypnea of the Newborn (TTNB) • Pneumonia • Pneumothorax* • Congenital Abnormality
• Cystic istress Compress • Meconium in Fibrosis • Sepsis* • Aspiration • Respiratory •DVascular Foreign Body Aspir • GE Reflux Syndrome (•RDS)* • Pneumonia Amniotic Fluid • Endobronchitis • H-‐Type Esophageal • Transient Tachypnea • Structural Anomal Fistula of the Newborn (TTNB) • Pneumothorax* • Congenital Abnormality
* Denotes acutely life-‐threatening causes
Sudden Unexpected Death in Infancy
UDDEN UNEXPECTED DEATH IN INFANCY (SUDI)
Sudden nexpected eath SUDDEN UNEXPECTED DUEATH IN IDNFANCY (SUDI) in Infancy Sudden Unexpected Death Must be Reported in to Infancy Medical Examiner
Must be Reported to Medical Examiner
Infection
Injury
Other
Sudden Infant Death Syndrome (SIDS)
Sudden Infant Death • Acute Illness • Autopsy negative • Deliberate (abuse) • Severe Pneumonia Cardiac Anomaly Congenital Other Infection Injury • 80% of SUDI • Accidental* Sepsis Cardiac Arrhythmia Syndrome (SIDS) Anomaly/ D•isorder • Risk Factors: • Gastrointestinal Neurologic Anomaly • Acute Illness Autopsy negative • Prone •Sleeping • Deliberate (abuse) • Severe Pneumonia • Cardiac Anomaly infection Pulmonary Anomaly position• 80% of SUDI • Accidental* • Sepsis • Cardiac Arrhythmia Metabolic Disorders • Risk Factors: • Tobacco • Gastrointestinal • Neurologic Anomaly • Prone Sleeping exposure infection • Pulmonary Anomaly position • Sharing a • Metabolic Disorders • Tobacco Sleeping exposure Surface • Prematurity • Sharing a Sleeping Surface * SUDI with negative investigations and infant found in prone position or in bed with parent may be called either • Prematurity SIDS or injury (new ideas evolving)
Pediatric
Congenital Anomaly/ Disorder
332
Enuresis ENURESIS Enuresis Rule in/out age-‐appropriate enuresis Age 2 2.5 3
Dry during day 25% 85% 98%
Nocturnal Enuresis
Primary
(Urinary Control Never Achieved)
Pediatric
333
• Delayed Maturation (Familial) • Idiopathic • Sleep Disorders (Obstructive Sleep Apnea) • Anatomic Abnormality
Secondary (Red Flag) (> 6 Month Continence Prior)
• Urinary Tract Infection • Idiopathic • Behavioural/Psychogenic (Child Abuse) • Cystitis • Diabetes Mellitus • Other (Diabetes Insipidus, Urethral Obstruction, Cerebral Palsy, Neurogenic Bladder, Seizure Disorder)
Dry during night 10% 48% 78%
Diurnal Enuresis • Pediatric Unstable Bladder • Infrequent Voiding (Urinary Tract Infection) • Cystitis • Behavioural/Psychogenic • Idiopathic • Non-‐neurogenic (Hinman Syndrome) • Vaginal Voiding (Labial Adhesion)
Acute Life Threatening Event APPARENT LIFE THREATENING EVENT Apparent Life Threatening Event Based on History from Parent (Extent of investigations based on initial examination)
Witnessed Choking Spell
Injury • Non-‐Accidental • Unnoticed • Factitious by Proxy
Cardiac
Metabolic
• Congenital Heart Disease • Arrhythmia • Cardiomyopathy • Myocarditis
• Inborn Errors of Metabolism • Reye’s Syndrome • Electrolyte Disturbances
Neurologic • Seizure • Malignancy • Neuromuscular • Disorders • Central Apnea
Respiratory • Anatomical Foreign Body Aspiration • Breath-‐holding spell (age-‐ dependent)
Apnea • Periodic Breathing • Apnea of Infancy
Infectious
Gastrointestinal
• Pneumonia • Sepsis • Upper Respiratory Tract Infection • Empyema • Urinary Tract Infection
• Gastroesophageal Reflux • Volvulus • Gastroenteritis • Incarcerated Hernia
Pediatric
Acute Illness
334
Pediatric Fractures PEDIATRIC FRACTURES Pediatric Fractures
Non-‐Accidental Trauma (indication of child abuse)
Distal Radius
Accidental Trauma
Clavicle Fracture
Tibia Fibular Fracture
• Torus (junction of metaphysis) • Green stick (bone bent at convex side •Complete (spiral, oblique, transverse)
Pediatric
335
Femur # < 1 y.o.
Scapular # Without Traumatize Hx
Elbow •Supra condylar •Lateral supracondylar
Transverse Fractures