Blackbook 11 2018 PDF

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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