HEART

***APPROACH TO CV EXAM***
RF = smoking, HLD, HTN, DM
Common Sx
1) CP/Discomfort
Hx most imp!
Angina Pectoris = Dx based on hx alone!
Typical = substernal/retrosternal; dull/heavy/squeeze; ppt w/ exertion/emotion; relief
with rest or NTG
Atypical = R/L chest, ab, back, arm, jaw, NO SUBSTERNAL CP; sharp/fleeting, prolonged;
unrelated to ex; relief with ANTACIDS; epigastric/CP pp
MI = substernal pain may rad; heavy/P/burn/tight; sudden onset but > 30 min; NO
RELIEF rest or NTG; SOB, diaphoresis, N/V, weakness
Aortic dissection= ant chest may rad to back; tearing and knifelike; sudden and
unrelenting; with HTN; AI murmur, pulse/BP asym, cold extremity
PE = substernal/over PE; angina-like pain; sudden onset; dyspnea, tachycardia, hypotn,
hypoxia, hemoptysis, signs RHF
2) Dyspnea = SOB, Orthopnea (pillows), PND =(2-4 hrs afer sleep, gone 15-30 min)
3) Syncope
Cardiogenic = absence premonitory sx, us from brady or tachy rhythyms
Carotid sinus hypersensitivity = bradycardia with massage, can diff VT (slow down) from SVT
(same bc BBB)
Sev AS, HCM (us asym septum hypertrophy, SCD), Prolongede QT (FamHx QT, leads to vent
arrhythymmia or torsades de point)
4) Palpitations = with syncope maybe vent tachy, with CP maybe MI
Dx = HP, 12 lead, holter/event recorder, ECG
5) Fatigue = BB side fx
6) Edema
Unilateral = cellulitis, DVT, lymphatic blockage, pelvic/retroperitoneal tumors
Bilateral = CHF
Venous insuff, cardiac (rales), hepatic (cirrhosis, liver failure), renal (ac/chr, nephrotic
syndrome), endocrine (thyroid), meds (roids, CCBs)
CARDIAC exam
1) Gen app = diaphoresis, cold/clammy/pale skin, cachexia, cyanosis [central (art desat) and peripheral
(poor delivery sat)]
2) VS = HR <60 or >100, BP <90 or >140, tachypnea > 16 o cheyne-stokes
3) Skin and extremities = bronze, lose ax/pubic hair, venous stasis hyperpig, xanthoma, clubbing (central
cyanosis)
IE w/ oslers nodes (ow! Tender), Janeway lesions, splinter hemorrhages
Pulses dim in PVD, exag in AI/coarctation/PDA (L to R), delayed upstroke carotid in AI/AS, PP
(dec SBP > 10 in inspiration)
4) Neck veins = JVD (>5 bad), JVP, hepatojugular reflux (>1cm good)
5) Precordial exam = parasternal lift, displace PMI
6) Cardiac auscultation = S1 (louder MS), S2 (soft or gone or split AS), S3 (Kentucky, vent overload or
dilated LV), S4 (Tennessee, LV hypertrophy, always bad!), MVP clicks, murmurs (mr. astr mvp/ms arts pr
is sys/dia)
7) Lung sounds = cardiac (late inspire, fine, BL, > base), pul (ea-mid inspiration, coarse, all or local), wheeze
(asthma, COPD), dec breath sounds (pleural effusion, COPD bc more air moves)
8) Ab exam = hepatosplenomegaly, ascites, splenomegaly (sec IE), AAA (thin can see), coarctation of aorta
(no palp ab pulses, prominent neck and UE, LE Absent, narrow aorta!), RAS (periumbilical bruit)
Arteriosclerosis is systemic!


***ISCHEMIC HEART DIS***
Patho = fatty streak of lipids and macrophages from excess intake macro take up lipids foam cells. SMC
migrate here plaque
Stable with fibrous cap and ca/remodel; unstable with lg lipid core and thin cap
Ruptured plaque = turbulent flow and expose tissue factor so thrombosis-pt/fribrin; partial or complete
vessel occlusion, restabilize plaque with more stenosis
Plaques likely to rupture? Higher lipid, macro, Ca, and thin cap
AMI = us w/ new unstable plaques, emphasize stabile not prev
o Unmod = M, >55 M, > 65 F, Fam Hx premature < 45 M, < 55 F
o Mod = cigs, HLD, HTN, DM, phys inact, obesity
Metabolic X Syndrome = 3+ of waist > 40 M > 35 F, TG > 150, HDL < 40 M < 50 F, FG > 110, HTN, elev insulin
or insulin res
Acute Coronary Syndrome (ACS) = Unstable Angina (USA), NSTEMI (inner 1/3 myocardium, post-infarct),
STEMI (transmural)
Stable Angina = builds up in 30 sec rapidly, gone decrescendo 5-15 min
Unstable = unpredictable, more longer pain, crescendo
Prinzmetals = transient ST-seg elev with rest or AM, rep/intermittent, relief with NTG, occlusive spasm
causes
Dx?
o Resting ECG = transient ST depression when CP
o Exercise ECG/Treadmill stress test = best angina!
o Cardiac cath = best CAD
Invasive, sx angina
o PCI = PTCA (balloon, risk intimal dissection), intracoronary stent (us combo PTCA, drug elute helps),
laser atherectomy
o CABG
PCI > single-vessel, multi-vessel dis, hi-risk CABG
CABG > LAD, DM
COURAGE TRIAL = PCI + stent + meds is not def > meds alone
AMI = impending doom, crescendo pain, lightheadedness, 1/3 silent if older/BD/F, ea arrhythmias , v-fib
deadly
o VS = tachycardia, HTN or low if shock, elev RR, low-grade fever
o Labs = CK, CK-MB peak 1 day, troponin elev earlier and longer, myoglobin first (false + other mus
dam)
Normal CKMB w/ evelv troponin = microinfarct, non-transmural, non Qw, NONSTEMI
Xray = pul edema, pleural effusion, Kerley B lines
CBC = inc leukocytes, anemia or thrombocytopenia changes mgmt for PCI or thrombolytics
ECG = ST elev >1mm in 2+ leads
Peak T waves, tombstones ST elev, T inv, Q wave
o Mgmt STEMI = MOAN, BB, statins, Plavix (diadv delay sx 5 days), Unfrac heparin or LMWH + ASA,
reperfusion and cardiac cath TOC
o Prep pre-angiogram = Plavix, heparin, glycoprotein IIb/IIIa inhibitors
Arrythymia = vent most common after MI (use lidocaine, procainamide, amiodarone)
Myocardial dysfunction = BB, ACEI, ASA, statins
AMI = serial ECGs and serial cardiac enz! Myoglobin peaks 1
st
, CK-MB 2 days to see if another infarct
happened, troponin gold 7-10 days

***HTN***
Pre, stage 1, stage 2 = SBP + 20, DBP + 10
o Complications: CV ( LVH), Cerebrovascular Disease and Dementia, encephalopathy, intracranial
hemorrhage, kidney disease (nephrosclerosis), ocular compl (retinopathy), aortic dissection, PVD
RAAS = AG2 peripheral vconstrict, inc aldosterone so inc salt and H2O retention
Secondary = tx causes, in very young or new onset older, sudden onset sev/fluctuating HTN/target organ dam
o #1 cause parenchymal dis is renal HTN
Renal = bc excess vol and act RAS. Signs <20 or > 50, res 3 drugs combo, epigastric/renal artery bruits, pul
edema, ACEI dec kidney func, aorta or peri arteries artherosclerosis
o Dx: Doppler renal U/S, renal MRA, captopril renal scan
Primary hyperaldosteronism =
o #1 cause adrenal adenoma. Also BL cortical hyperplasia
o sx = H/A, paresthesias, polyuria, polydipsia, hypokalemia, alkalosis
o Dx = calc plasma aldosterone and renin ratio
Sleep Apnea = loud snoring, daytime fatigue, obese, bull neck, pickwickian,
o Dx = polysomnography
Coarctation of the aorta = narrow aortic arch distal to L subclavian artery, delayed/weak/no femoral pulses,
elev systolic btwn UE and LE
o Dx = LVH on ECG, rib notching CXR, Echo
o Tx = stent, resection narrowed, antiHTN meds
Cushing Syndrome = moon facies, central obesity, muscle wasting, purple striae, hirsutism, elev serum cortisol,
hyperglycemia, hypokalemia
Pheochromocytoma = triad H/A, facial flush, diaphoresis; anxiety/palpitations, elev urinary catecholamines
and metanephrines, pers or paroxysmal HTN
o Dx = CT, MRI, unilateral adrenal mass
Eval = 18-39 q2 yrs, 40+ q1 yr
o Target end organs = heart, brain, kidneys, eyes extremities
o Ask sx, FHx, HPI, meds, social, PMH, ROS (HA, blurry vision, fatigue, CP, palpitations), ethnic, obese, PE,
heart exam (displace PMI, L vent heave, murmur, S3 overload LV, S4, facies, PV exam exclude PAD and
aortic dissection also skin, fundoscopic (narrow arterial dia, copper wire cholesterol gold, exudate
fibrosis or chol, cotton wool patches edema, ret hemorrhages, papilledema severe emergency), ab
exam bruits or mass (US/CT), LVH on EKG (SV1 + R V5 > 35, LAD; L strain ST dep and hump up)
o US RADIO NOT NEEDED
o BP elev 3 diff days of >160/100
Home monitoring better outcomes, more likely med compliant and control BP
Red Na, keep K/Mg/Ca intake good
Stage 2 us needs 2 meds
DASH = dietary approaches to stop HTN
Tx:
o Diuretics is init DOC, ADR electrolyte abnorm (hypokalemia)
ACEI DOC DM, proteinuria, kidney disfunc, slows progression renal dis
Angioedema disadv, Contraindicated pregos and B/L RAS
o BB = labetalol and methyldopa safe in pregos
Higher elderly (SBP best predictor), F, prego, Af Am (diuretic, CCB 1
st
line)
Hypertensive emergency = severe elev >180/120 w/ target organ dysfunction; ischemic stroke dont lower,
aortic dissection lower immed, red to 160/110 next few hrs
Hypertensive urgency = W/O target organ dysfunction

***CHF***
Ischemic heart dis > , cardiomyopathy 2
nd
major cause, congenital/valvular/HTN 3
rd

Systolic HF = contractile state, preload, afterload, HR
Systolic HF = dec myocardial contractility so dec SV and CO, inadequate vent filling so chamber dilation. CAD
#1 cause
o Other causes are inf, valve d/o, septal defects, PHT cor pulmonale RHF, PE same
o Imp causes = anemia, hypo/hyperthyroidism, renal failure
Diastolic = abnorm filling, sec impaired relax ventricle, maybe bc stiff noncompliant chamber or excessive
hypertrophy
o Uncontrolled HTN #1 cause LVH and subsequent red vent relaxation
o Also hypoxia impairs dissoc crossbridges and contraction, tachycardia inhibits relaxation
Acute HF = AMI, sudden red CO and hypoperfusion WO peripheral edema, sudden rupture leaflet bc trauma, IE
Chronic = dilated cardiomyopathy or multivalvular dis, vas congestion common
LHF = overload sec AR, inc peripheral res bc HTN, weakened mus bc MI or hypothyroidism, AS, MR
o Sx = orthopnea, PND, oliguria, rales, S3 rapid vent filling/vent gallop, S4 gallop aka atrial
RHF = #1 cause L ventricular dysfunction, also PHT, PE, COPD, congenital and valvular dis like MS, PS, PR
o Sx = peripheral edema, JVD, hepatomegay, hepatojugular reflux, ascites, nocturia
o 10 ppt causes = inf, dysrhythmia, phy/diet/enviro/emo excess, MI, PE, anemia, thyrotoxicosis/prego,
HTN, myocarditis, IE
Cor pulmonale = enlg R ventricle, RVH primary change. Acute is PE or eacerbate chronic, chronic is COPD or loss
lung tissue
Preload = passive vent filling, measure EDV
Afterload = P ventricles to eject blood
ESV = amt left after systole, inc with AR
EDV = amt prior contraction, inc with AR
SV = vol blood ejected in 1 heartbeat; EDV-ESV
CO = L/min; SV * HR
EF = %blood ejected/beat, norm 50-55%, us from LV
Labs = CBC, CMP, thyroid, BNP, LFT, cardiac enz, ECG
o CXR = pul vas congestion, cephalization in apices, cardiomegaly, kerley b lines, pleural effusions BL or R,
fluid in fissures
o ABCDEFGH!
o Ex stress and scan = MI for L side, all chest sx esp angina
o Radionuclidee angiography = measures LV EF and wall motion
o Cardiac cath
Tx: diuretics #1!! Caution bc elec imbalance, dehydration, metabolic alkalosis
o ACEI cough, titrate 1-3 mos
o BB NOT in hypotensive! WATCH BP!
o Digoxin last resort AFIB! Dig tox ADR
o Anticoags prev thromboembolism: warfarin req cont INR; dabigatran doesnt
o Sx = revas, CABG, transplant, ICD, biventricular pacing
EF < 15% poor prognosis
Prev w/ BP control, lipid surveillance, ear tx valve d/o

***VALVULAR HEART DISEASE***
ARF decline bc PCN
o MVP and congenital aortic valve dis are most common valve lesions
GABHS, us after streptococcal pharyngitis, acute onset, febrile illness, Jones criteria!
Arthritis = poly, lg joints, lower 1
st
, tx w/ NSAIDs
Carditis = #1 imp to dx! Pancarditis all 3 layers (CP, friction rub, new or change murmurs)
#1 valve lesion is MR
AV delays common
Chorea = milking sign, Sydenham chorea
Skin = erythema marginatum (not itchy, centrifugally, with hot baths), us boney sur or
tendons, rheumatic nodules
o Tx = suppress inflame and min heart problems. Benzathine PCN, Pen V-K 10 days, anti-inflam
ASA/roids
Aortic Stenosis
o valvular/supra congenital/sub. Rheumatic with stiff, Ca, fever and congenital w/ murmur
o younger uni, older tricuspid
o compensate with LVH, usually asymp. Syncope and dizzy bc reduced cerebral perfusion,
DOE/PND/orthopnea bc pul HTN
o PE = narrowed PP, red pulses, thrill carotids and bases, mid-systolic ejection murmur, S4 gallop, S2
only
o Labs = ECG with LVH, ECG,
o A-fib convert NSR ASAP!!!
o Tx = mod avoid heavy activity, severe sx valve replacement
Aortic Regurge = aortic insufficiency, diastole
o Abnorm leaflets or roots (AAA, aortic dissection, syphilis, Marfan, annuloaortic ectasia)
o Acute = inc P so dyspnea and pul edema. Chronic = LV comp so dilatation and inc vol and P
overload so hypertrophy
o Sx = palpitations
o PE = bounding pulses, blowing early-diastolic murmur louder leaning fwd (tune in), Quinkes sign
o Tx = ACEI and CCB red afterload, severe sx
Mitral Regurge = systole
o IE = perf of leaflet or rupture chordae = MEDICAL EMERGENCY!
o Myxomatous degeneration MVP, redundant blow back. Also RF, ischemic heart dis, idiopathic
rupture, LVH
o Dec CO, in LA vol and P, vol-rel LV stress soo SV inc
o PE = holosystolic murmur best at apex rad L axilla if RF, LSB or aortic region if pap muscle
dysfunction, decrescendo, S3 bc inc LV vol
o Labs = CXR pul edema acute or enlgd L atria and ventricle chronic, ECG LAE and LVH, ECHO, cath pap
muscle dysfunction
o Tx = acute IV diuretics for pul edema and vasodilators to red peripheral res to CO; repair/replace in
chronic
Mitral Stenosis
o #1 cause is RF
o inc P LA, PHT, JVD, hepatomegaly, ascites, edema
o PE = ventricular tap, loud S1 (close MV), OS after S2 and decrescendo diastolic rumble after
o Mgmt = diuretics, if AF then BB or CCB with anticoag, valvuloplasty TOC
MVP = billowing, with MR sometimes, AD, Marfans or Ehlers-Danlos Syndrome
o Mid-systolic click, late systolic murmur at apex
o Dx ECHO
Tricuspid Stenosis = OS, diastolic, best heard at sternum with inspiration, JVD, Tx Sx
Tricuspid Regurge= systolic louder inspire, LSB, diuretics, sx repair
PS = congenital, balloon valvuloplasty, systolic
PR = pul HTN, dilate annulous, enlg pul artery, decrescendo high pitched LSB, tx underlying condition

***A-FIB***
Embolic not hemorrhagic stroke
Etiology:
o Hemodynamic stress =mitral or tricuspid, LV dysfunction most common
o Atrial ischemia
o Inflammation
o Non-cardiac respiratory causes = PE, pneumonia, lung CA, hypothermia
o Drug and ETOH = HOLIDAY HEART
o Endocrine = hyperthyroidism, pheochromocytoma, DM
o Neurologic = CVA, SAH
o Family Hx
o Adv age
Patho = 350-600 bpm, no p waves, irreg rhythym, undulating baselkine, pul veins most freq source of
automatic foci
No wavelets = refractory period, conduction velocity, atrial tissue mass
Dangerous bc rapid ventricular response compromise CO and stasis in atria thrombus
Types = paroxysmal, recurrent, persistent, permanent
Sx = asymp if controlled, dizzy, palpitations, TIA, CVA, syncope
Mgmt = hemo unstable then TFTs, ECG, CONTROL RATE!!! Hospitalize, cardioversion if shock, sev hypotn, pul
edema, ongoing MI or ischemia in 1
st
48 hrs bc inc risk embolization
o If thrombus then delay anticoag 3-4 wks
o Warfarin DOC, Target INR 2.0-3.0
Exception is lone a-fib = no underlying heart dis, HTN, atherosclerotic vas dis, DM, <65
CHADS2 Score
0-1 aspirin, 2+ anticog PO w/ warfarin or dabigatran
A-fib vs A-flutter = 350-600, irregular rhythm, vent 140-160, fibrillatory waves VS. 180-350, reg rhythm, var
vent, saw tooth

PULMONARY

***APPROACH TO RES DIS***
RR = norm 10-20, kids higher, infants 30s
Ox > 92%
Ox-Hgb dissoc curve = slippery slope at 60 mm, %O2 sat L, PO2 bottom
o Shift R if lower pH acidosis bc need more O2 rel from HgB to blood (rel means inc PO2)
Color = pink good, blue bad. Kids cap refill, adults nails/lips/face/cap refill
Diaphoresis = distress, forehead or back neck
Acc mus usage = neck, stridor
Lung exam = wheeze, crackles, silent and dull percuss, rubs, hamman crunch (pneumomediastinum)
Pneumothorax = honeycomb
Normal =
o pH = 7.4
o PO2 = 80-100 mm Hg
o O2 sat = 97-100% (3 mL, 197 mL most bound HgB)
o PCO2 = 40 mm Hg
o HCO3 = 24 mEq/L
PaCO2 = best ind alveolar ventilation. Elev if hypoventilate, low if hyperventilate and blow off
CO poison = 240x affinity O2, pink person still
Respiratory failure = need breathing tube, PO2 50-60 mm or 50 sea level (not in COPDers in hypoxic drive)
Hypoxemia = PaO2 fall w/ age and in smokers and res dis
V/Q Mismatch = ventilated lung underperfuse (PE, emboli artery) or perfused lung undervent (emphysematous
blebs)
Diffusion Capacity = red CHF, interstitial dis, anemia; inc polycythemia
A-a gradient = (alveolar, arterial) = 15-20 norm, 20-30 mild dysfunc, 50 sev
PFTs = FEV1 norm 75-80%, FVC norm; COPD and asthma red
TV and FVC red in restrictive dis (chest wall deform in kyphoscoliosis and sev obesity, weak chest mus in
neuromas d/o and paralyzed diaphragm, pleural dis)
Breathing patterns:
o Cheyne strokes = CNS damage, coma, CHF
o Kussmaul (rapid and deep)= metabolic acidosis and brain lesions
o Agonal gasp = dying, sev brainstem damage
Sleep Apnea = >M, postmenopausal women, loss pharyngeal mus tone so pharynx collapse. Obstructive or
central
o Sx = loud snore, irreg sleep, snort, sleep agitation, violent move, HA awaken, chr fatigue, mood do,
arrhythmia, cog impairment
o RF = micrognathia, macroglossia, tonsillar hypertrophy, cigs, hypothyroid, obese
o Dx = polysomnography (EEG, ECG, EOG, EMG, pulseox, breathing movements) w/ 6 hrs sleep has >5
obstructive or hypopneic episodes/hr
o Also multiple sleep latency test = falls asleep in 5 mins, avg adult is 10
o Also CXR and EKG for pul HTN, daytime ABG hypercapnia, TSH hypothyroid, ENT pharynx
o Tx = no ETOH and sedatives, wt loss, oral/dental, NCAP, sx (septoplasty, uvulopalatopharyngoplasty,
tracheostomy)
Obesity Hypoventilation Syndrome = aka Pickwickian; tx w/ wt loss, NPPV and pillows

***PUL MASSES AND INTERSTITIAL LUNG DISEASE***
pul nodule = <3 cm rounded, rare < 30, smokers and malignancy inc risk
1) image = rapid doubling time <30 days is inf, slow <465 is benign, HRCT all nodules!
2) Malignant if spiculations/peripheral halo, sparse stippled
3) Dx = bronchoscopy, TTNA, VATS
4) Tx = surgery via open thoracotomy or VATS
5) Mgmt = watch if low, resect if high; F/U CXR q3mos x 1 yr
Pul neoplasm = most are bronchogenic carcinoma and malignant from epi and mucosa cells of lower res tract
1) Main cause smoking, class by histologically type
Small cell carcinoma (oat cell)
Non-small
Epidermoid or sq
Lg cell carcinoma
Adenocarcinoma
Other = carcinoids, sarcomas, mesotheliomas
2) CXR = change or inc size preexisting nodule, persistent effusion/infiltrate, new lg effusions
SCC = metaplasia and dysplasia precede, from sur bronchial epithelium, us central (main stem) bronchi near
hilum, spread by dir extension to reg lymph nodes, mets late, cough and hemoptysis
Adenocarcinoma = can come from bronchial glands w/ mucus, originate peripheral segmental brochi, 1
st
mets,
invade blood and lymph vessels, NO SPUTUM DETECTION, not assoc w/ smoking
SVC syndrome, Horners (ptosis, miosis, anhidrosis from tumor paracervical symp nerves), hoarsenes
SCLC no sx bc downhill, NSCLC slower so can resect and do chemo
Dx = CXR, CT to diff, CBC, Chem 7, LFTs and alk phos, sputum cytology, effusion pleural fluid analysis and
cytology, bronchoscopy, lymph node bx, VATT
Mgmt = SCLC chemo and thoracic radiation, NSCLC sx resection and rad, chemo??
Interstitial pul dis = dyspnea, insidious onset, red lung vol (PSA!)
1) IPF = unknown etio, inflame fibrosis intralveolar septum and scarring so red gas diffusion, DOE most
common
PE = end-inspiratory rales at bases, clubbing, disable O2 dependency
2) Pneumoconiosis = CWP, alveolar macrophages, upper lobe, not worse with cigs, small macules CXR
3) Silicosis = glass workers, sm rounded opacities, TB episodes, patchy infiltrates, honeycombing, PPD 10
cm cutoff TB
4) Asbestosis = nodular interstitial fibrosis, pleural plaques, carcinogenic link to bronchogenic carcinoma
and malignant mesothelioma, nonprod cough
PE = inspiratory rales bases, red chest exp, cor pulmonale, do bronchoscopy to look for
carcinoma
5) Hypersensitivity Pneumonitis = tx steroids and inhalers, farmers lung and bird fanciers lung worse 2
most common
6) Sarcoidosis = granulomatous inflame, non-caseating granuloma, Af Am
TB mistaken us
Inc cytokines, TNF, fever, anorexia, arthralgia, looks like flu/pneumonia
Derm = erythema nodosum, cheek rash
Cardiac = heart failure or block
Rare neuro = CN palsy, lympocytic meningitis
Labs = CXR BL hilar lymphadenopathy, reticulonodular infiltrates, fibrosis, inc
Ca, elev ACE from NCGs
Stage 1 = potatoes at hilar, no sx
2 = enlgd l nodes and abnorm pattern lung fields, sx
3 = lung infiltrates
Dx = tissue bx NCG, endobronchial bx
Tx = no tx or NSAIDS (prednisone daily and taper)
Compl = ocular blindness, neuro, cardiac

***DO PUL CIRC***
PE = commonly forom prox and distal veins LE, UE, R atria and ventrical and venous
o Small = no sx or HR > 100, ox < 95%
o Mod = DOE and atypical CP, inc HR and low sat
o Lg CP = Hemoptysis, sev hypoxemia, circ collapse, tachycardia, syncope, RV failure
o PERC = <50, ox> 94%, no estrogen, <100 bpm, no DVT/hemoptysis/rec major/uni leg swell
o Tests = EKG (S1Q3T3), CXR (Hamptons hump, Westermarks sign), ABG (inc A-a grad, norm 10)
o Workup = D-dimer test (+ needs CT), leg Doppler, VQ scan to R/O or if cant do dye, spiral CT aka CTA us
stop here, pul arteriography gold standard
o Tx = heparin, Coumadin, LMWH (enoxaparin or lovenox), venal caval filer, Coumadin 3-6 mos INR 2-3,
thrombolytics only if stable and lg PE
o Beware False + D Dimer tests
o 3 factors PE = venous stasis, injury/inflame venous wall, hypercoagulable state
Primary Pul HTN = incpul art P and vas res, inc JVP, red carotid pulse, TR, peripheral edema, dx with cardiac cath
Pleural Effusion = lung compression, empyema, milky wt is chylous effusion, can be hemorrhagic or hemothorax
o Causes = transudative if inc hydrostatic or dec oncotic P. exudative if inc cap perm or dec lymphatic fluid,
empyema, bleed
Exudates have higher p/LDH/WBC and lower glucose, transudates (90% CHF) have glucose and
pH equal to serum [thoracentesis tx, tx underlying ocnd]
Bac pneumonia and CA are 2 biggest cause of exudates
o Sample for LDH, protein, glucose, cell count w/ diff
o Sx = dim chest movement on side of effusion, dullness to percuss over effusion, dec breath sounds,
dec vocal and tactile fremitus, egophony over compressed lung, tracheal deviation CXR, dec O2 sat
Parapneumonic pleural effusion = w/ pneumonia, uncomplicated resolve with ab, compl drain, empyema
routinely drained, comp with loculation
Malignant pleural effusion = most from lungs and breast CA, most exudative, tube thoracotomy and
pleurodesis common
2 ways image effusions = CXR and CT, lung floats on fluid bc less dense
Pleurodesis = reexp lung then use irritant to form adhesiosn btwn pleura to stop reaccum fluid here, insert
doxycycline and sterile talc, side FX pain and fever
Tx pleural effusions = thoracentesis us temp, chest tube, pleurodesis

***COPD***
Bronchitis = blue bloater, cough w/ sputum 2 mos/yr x 2 yrs
Emphysema = enlg air spaces and loss alveolar tissue, pink puffer
COPD = prev, treatable, not fully rev, progressive, abnorm inflame response, onset mid-life, prog sx, smoking hx,
DOE, irrev, proteases
Asthma = onset ear, at nt and ea morning sx, allergy, rhinitis, eczema triad, rev
Other RF are alpha 1 antitrypsin def
PE = cough, sputum, DOE, dec breath sound, prolonged expiration, wheeze forced, acc mus, barrel chest, distant
heart sounds, pursed lips, clubbing, cyanosis, tachycardia, LE edema
CXR = hyperinflation, flattened diaphragm, taper pul vessels twd periphery
EKG = low voltage, RAD, R atrial hypertrophy, P pulmonale, tachycardia, MAT
ABG = res acidosis
Spirometry = FEV1, FVC, FEV1/FVC norm > 80%
Pul cachexia, inc TNF and cytokines, res mus fatigued, mus wasting, undernut
GOLD staging
Tx = oral steroids, ab, home O2, smoking fcessation, pul rehab
LVRS (lung vol red sx) = imp survival emphysema, NETT fx LVRS vs meds. High be upper lobe dis, younger, low
PaCO2, hyperinflate, inc RV

***Pneumonia***
CASE = fever, myalgia, dry cough, malaise, elev T and HR, L base crackles, LLL airspace dis
o Dx = CAP
o Tx w/ Zpac
RF CAP = COPD, chr bronchitis, CV dis, DM, smoking, ETOH, neuro dis
o caused by microaspiration orgs that colonize oropharynx us during sleep or aspiration pneumonoia of
gastric contents
o us in elderly
o strep pneumo most common, H flu and M cat also common, enteric g neg in comorbidities, chronic
liver dis, and alcoholics; kleb pneumo in alchys; pseudo aeruginosa if chr lung dis, COPD, or long term
ICS
o think S aureus (CA-MRSA) if after influenza, cav no RF, IVDU, recent CA-MRSA skin or soft tissue higher
mortality and longer in hospital
o mycoplasma pneumo and chlamydophila pneumo outpt
o legionella ev CAP and travel hx
o also res viruses like influenza, parainfluenza, RSV, adenovirus
o Dx = cough, sputum, fever, chills, pleuritic CP, dyspnea nonspec elderly, confusion, exacerbate
underlying chronic cardiopul dis, tachypnea
o CXR in all! If norm then rep 24-48 hrs
o Legionella urine ag test if recent travel
o Microbio testing rec if hos and ab ineffective or if serious
o ICU = need blood culture before start ab!!, sputum gram stain and culture, pneumococcal and legionella
urine ag testing
CASE = fever, chills, cough, yellow sputum, dysnea, dec BP, inc HR and RR, dec Hgb, leukocyte, and pt,
consolidation and patchy airspace opacity CXR
Dx: lg pleural effusion
Tx: thoracentesis, blood in sputum cultures, pneumococcal and legionella sputum test
CASE= all above and L pleuritic CP, dim breath sounds dull to percuss, consolidation LLL, inc T/BP/HR/RR, dec O2,
lingual with pleural effusion L hemothoracic
Tx: thoracacentesis, delay is thoraseptic sx or open thoracotomy
CASE = dyspnea, cough, inc all vitals, crackles R lower, dec Hg, inc leuko and BUN and glucose, RLL airspace dis
Go to ICU!
ICU major = need vasopressin or mech vent
Sev ill = confusion, BUN > 20, RR > 30, SBP < 90, diastolic < 60, age > 65
CAP sev if initial ICU or ea transfer
RF drug res strep pneumo = >65, recent B-lactam, med comorbidities, immcompromise, ETOH, exp child daycare
Tx:
o Us 5-7 days
o Outpt = macrolide or doxycycline, if RF then FQ or B-lactam + macrolide or doxycycline
o Inpt = FQ or B-lactam + macrolide or doxycycline med ward; ICU B-lactam + azithromycin or FQ
CASE = nasal congestion, rhinorrhea, dry cough, fever, chills, myalgia, blood streaked yellow sputum, R side CP,
inc HR and RR, dec BP, crackles with egophony and inc fremitus, inc leukocyte, inc BUN, airspace dis w/
cavitation and blunt R costophrenic angle
o DX: S. aureus post influenza is classic
CASE = COPD, smoke, intubation, inc all vitals, dec breath sounds, scattered rhonchi, wheeze, longer expiratory,
hyperinflation, flat diaphragm, RLL consolidation with air bronchograms, g rods
o Tx: RF so cefepime, tobramycin, azithromycin for pseudomonas and R in 6 hrs
Can change IV PO if T <100, HR <100, RR < 24, SBP > 90, Osat >90 or PO2 >60, can tolerate PO, normal mental
status
Get neumo and influenza vax
Complications = persistent fever think parapneumonic effusion (1/3 get) or empyema [thoracentesis exclude],
also think drug fever or nosocomial inf
F/U to document clearance infiltrates and see if malignancy 6-8 wks after if >40 or smokers; 10-14 days
TB = primary prev with BCG vax, sec tx LTBI
o Patho = acid-fast bacillis, airborne expiratory droplets, macrophages ingest mycobac and mult, Ghon
complex (scar lung and lymph nodes)
o Clin = fever, nt sweats, cough, CP, wt loss, norexia, chronic cough varies, lymph nodes, bones, jts, pleura
o Dx = Mantoux TST (induration 48-72 hrs) or IGRA, CXR, acid-fast stain and culture
o CASE = active tuberculosis, no acute sx, TST (-), CXR normal
Tx: start isoniazid and pyridoxine
o CASE = bladder CA, annual scre
o Tx: interferon g rel assay
o High risk need CXR > 5 = recent contacts active TB, HIV, fibrotic changes, organ transplant, immunocomp
o > 10 = IVDU, immigrants, high risk setting employees/residents, clin cond, <4, kids exposed to adults
o False (-) = rec TB, < 6 mos, recent vax or viral inf, anergy. False (+) bc BCG, inf non-TB mycobacteria
o IGRA pref if pt BCG vax (avoid false +)
o Booser effect being pos wks later esp good for elderly with hx LTBI
o IGRA = ppl who dont FU. TST < 5.
o Always culture if active TB suspected! Rec nucleic acid amp, brnonchoscopy, lavage, bx
o Tx = latent 0 months isoniazid and pyridoxine (Vit B6)
o Active tx initial (2 mos isoniazid, rifampin, ethambutol, pyrazinamide) and then 4 mos isoniazid and
rifampin
o Drug res if prev tx TB and noncompliant, inf hi rate countries, not respond standard empiric therapy,
contact drug res TB
o Prev = BCG vax
o ARDS = noncardio pul edema, acute, persistent, diffuse lung inflame inj epi cells and pul cap endothelial
cells, sepsis, hypoxemia creates intrapulmonary shunt and rev with PEEP

***LUNG CA***
#1 CA, #1 cause tobacco. Also from malignant mesothelioma, radiation, radon, air pollution, FHx, antioxidants,
cruciferous veggies, phytoestrogens, fibrosis, COPD, oncogenic viruses
Patho = non-small or small mets bone, brain, liver. NSCLC grows and spreads slower but more common
1) SCC most bronchial, central loc, loc ea, hypercalcemia and hypercoag
2) Adenocarcinoma and lg cell us peripheral nodules, most common nonsmokers
Mesothelioma = smokers with asbestos, mets bone, brain, liver
Small cell aka oat = grows quicker, mets, pleural effusion common
Staging = lim and extensive
Sx related to:
1) primary lesion = cough, sputum prod, dyspnea, hemoptysis, CP, uni loc wheezing, wt loss
2) intrathoracic spread = pleural or pericardial effusion, hoarseness, SVC syndrome, brachial plexus
involved (pancoast syndrome with horners, rib destruction, hand mus atrophy, pain C8, T1, T2)
3) distant mets = bone, liver, brain
4) paraneoplastic syndromes = hypercalcemia PTH-rel peptide, hypertrophic pul osteoarthropathy, ectopic
hormone prod (SIADH, Cushing, HCG, neurologic (Lambert-Eaton myasthenic syndrome mus cell
weakness)
PE = l nodes, clubbing, hepatomegaly, neuro
Dx = sputum cytology, bronchoscopy with bx, FNA, thoracentesis, bx hard enlgd l nodes,
thoracotomy/mediastinoscopy
Stage by CT chest/ab/pelvis, MRI brain, bone scan, PET/CT
Tx small cell lim radio and chemo, ext palliative rad and chemo
Tx NSCLC chemo and inhibitors
SCLC EML4-ALK fusion gene

ENDOCRINE


***PITUITARY GLAND***
Aka hypophysis in sella tunica of sphenoid, reg homeostasis
AP = Pt Flag, PP = oxytocin and ADH, hypothalamus = CRH and ADH
Prolactin = target breasts for lactation, sexual gratification, proliff oligodendrocyte precursor cells for myelin
coating axons in CNS
GH = aka somatotropin, targets liver and adipose for gr and metabolism
ACTH = target cortex and inc glucocorticoids
LH = targets ovaries and testes for reprod, F ovulation, M leydig makes testosterone
FSH = syn and secreted by gonadotrophs, F stim graafian follicles, M stim androgen-binding p by sertoli cells for
spermatogenesis; inhibin shuts off
TSH = aka thyrotropin, neg feedback, T4 and T3 rel, target thyroid gland to make hormones
Oxytocin = distend cervix and vagina, rel in orgasm, maternal bonding, circadian rhythm, pos feedback, targets
ovaries and testes
ADH = aka vasopressin, reg body water, dereg in ETOH, conserve H2O and raise BP
HPA Axis = CRH and vasopressin stim ACTH to act adrenal cortex to prod glucocorticoids esp cortisol = excess
adipose, inc BP and glucose, neg feedback
DI = oxytocin def permanent
o Sx = very thirsty, crave ice water, polyuria, dehydrated
o Labs = 24 hr urine collection (<2L RO), hyperuricemia, BUN and Cr renal, electrolytes hydration
o Careful hydration and hypernatremia bc dilute out
o Tx = water, desmopressin central and pregos
SIADH = us CNS inj, excess rel ADH hyponatremia bc diluted
o Sx = dec osmolality, urine Na > 20, no cardiac, renal, hep, thyroid, adrenal dis, dec DTRs, cheyne-stokes,
asymp pupils, abnorm sensorium
o Tx = fluid restrict, correct hyponatremia
Acromegaly = middle aged, us from pituitary adenoma, frontal bossing, lg facial features, prominent mandible,
excess gr hands, ft, jaw, int organs, amenorrhea, hypogonadism, cephalgia, visual field loss, insulin res so DM
o Soft doughy sweaty hands, carpal tunnel macroglossia, OSA
o Dx = MRI enlgd sella or thicker skull, inc thickness heel pad
o Labs = CMP, LFTs, prolactin, Ca, inorganic phosphorus, TFTs
o Tx = endoscopic transnasal transsphenoidal pituitary microsurgery; also dopamine agonists,
somatostatin drugs, or both
Gigantism = childhood
Cushings = excess ACTH, us women reprod age, inc cortisol, #1 sx sudden wt gaincentral obesity, HTN, facial
plethora, menstrual do, dec libido, glucose intolerance
o Labs = 24 hr UFC, Dexa suppression test
o Tx = transsphenoid rem, glucocorticoid replacement or lifetime, irradiation recurrent tumors or BL
adrenalectomy if not imp
Panhypopituitarism = all ant gone, short, fail to grow, dec puberty, dry pale fine skin
1) Dx: MRI brain, L hand and wrist bone age delayed
2) Tx: HRT, sx
Pituitary tumors = pituitary adenomas are benign
Microadenoma <1 cm, macro more
Tx = sx, radiation, chemo, transnasal transphenoid pit tumor resection
2) ACTH prod = cushings
3) Prolactin prod = milk prod and amenorrhea women, impotence men
4) GH prod = gigantism and acromegaly
5) Non-func

**ADRENAL DISORDERS***
ZG aldosterone, ZF cortisol, ZR androgens
A. Med = NE and epi
Cortisol = from cortex by ACTH, neg feedback
Adrenal Insufficiency = def all, primary is fail adrenals, sec ACTH hyposecretion
o Primary = Addisons most common, inf then TB #1 cause ww, here is HIV
o Sec = #1 exo steroids
o Polyglandular automimmune I or II, many have antiadrenal ab, acute and chronic wks-mos
o Sx = inc pigmentation bc in cPOMC derived peptides, salt crave, anorexia, wt loss, fatigue, diarrhea,
vomiting
o Lab = hyponatremia and hyperkalemia, metabolic acidosis, azotemia, anemia, hypoglycemia,
hypercalcemia, fasting hypoglycemia, cant respond to stress, lack aldosterone so dehydrated, syncope,
and hypotn, lack androgen so masked men and women dec hair extremites/ax/pubic hair
o Acute adrenal crisis = unex hypotn esp if inc risk like immdef, prior glucocorticoids, autoimm dis, chr
fatigue and hyperpig hx, sev head trauma
o Dx = hyponatremia, hyperkalemia, metabolic acidosis, eosinophilia, cortisol and aldosterone levels,
ACTH/corticotropin stim test, CT/MRI adrenal image, adrenal autoab, corticotropin stim test most
common measure 0, 30, 60 min norm > 18 primary <12.>34 rO insuff, < 20 insuff, btwn partial
Long ACTH 48-72 hrs, measure urine and cortisol. primary dont bump, sec res 2
nd
or 3
rd
day
o Primary = dec cortisol and aldosterone, inc ACTH and renin, vol depletion and hypotn, hyperkalemia,
hyponatremia
o Sec = no aldosterone def, vol ok, hypokalemia, hypernatremia, no hyperpig
o AM plasma ACTH high primary, low sec
o Standing/Dehydration Test = NPO 12 hrs then rise to see if ACTH stim aldosterone to maintain bp,
failure rise is sec insuff
o Tx = fluids D5N5, solucortef, pressors
o Chronic mgmt = lifelong fluco and mineralocorticoids
o Cortisol func = gluconeogenesis, antiinflam, suppress imm response, upgrade catecholamine rec, mus
breakdown, inhibit bone formation and collagen synthesis, stress hormone, inc pigment
Cushings =
o Iatrogenic = exo, most common from excess glucocorticoids
o Spontaneous = endo, excess stim ACTH, disease from tumor
o Cortisol highest 4-5 AM
o Dx = 24 hr UFC, serum ACTH, dexa sup test, MRI gadolinium, MRI adrenals, CXR ectopic ACTH, DEXA
bone (hi ACTH lungs or pit tumor, high cortisol adrenals)
o Tx: exo lower roids, endo sx, rad, chemo, or unilateral adrenalectomy or rad
Aldosterone = keep Na in, spit out K, H, metabolic alkalosis
Hyperaldosteronism = aldosterone prod adenoma, BL adrenal hyperplasia primary; sec inc renin
o Clin = hypertn, hypokalemia (DTR absent, parasthesias, prox mus weak/fatigue)
o Dx = EKG, CT/MRI, measure aldosterone, low renin primary, high sec (RAS)
o Tx = electrolyte abnorm correct, sprinolactone, ACEI, sx, angioplasty RAS
Adrenal medullary hormones = epi and norepi 4:1, excess is pheochromocytoma
Pheochromocytoma = most adrenal medulla, MEN 2A (Marfinoid) and MEN2B, neurofibromatosis
o Tumor chromaffin so secrete catecholamines
o Benign if tx
o Sx = HTN, HA, palp, flushing, wt loss and inc appetite
o Dx = 24 hr urinary catecholamines or metabolites (metanephrines and VMAs), MRI or CT adrenals
o Tx = sx, alpha and beta blockade
PCOS = hirsutism, infertility, amenorrhea, obesity, enlg ovaries, Tx metformin
Adrenocortical/ovarian tumor = enlg clitoris and labial fusion in fetus, F pseudohermaphroditism
Congenital adrenal hyperplasia = def 21-hydroxylase, salt-losing w/ hyperkalemia and hyponatremia, comp inc
ACTH, precocious puberty
o PE = fusion labia and enlgd clitoris, males small phallus or hypospadias
o Dx = blood hormone levels, get steroid profile, best test 17 hydroxyprogestone test
o Tx = fluids, NS, steroid replacement 25 mg babies, 50 kids, 100 adolescents, DO NOT give insulin and
glucose for hyperkalemia in infants or else hypoglycemia

***DISORDERS OF THYROID GLAND***
Thyrotoxicosis = primary (graves most common, toxic multinodular goiter, toxic adenoma, iodine excess) and
thyroid destruction (subacute thyroiditis, silent thyroiditis, amiodarone, radiation)
o Sx = nervous, irritable, heat intolerance, sweating, palp, oligomenorrhea, diarrhea, wt loss, eye retract
and lidlag, systolic HTN, afib, systolic murmur, tachycardia, fine tremor, hyperreflexia, prox mus weak,
long then osteopenia. Elderly maybe only wt loss and fatigue, bruit/thrill, diffusely enlged,
ophthalmopathy, dermapathy pre-tib myxedema
o CASE = graves, proptosis
Tx = thyroidectomy
o Subacute thyroiditis = tender refer to jaw or ear, fever, URTI before, inc ESR
Tx = NSAIDs, BB, levothyroxine if hypothyroid phase prolonged
o Toxic adenoma/multinodular goiter = solitary or mult nodules, subclinical, us elderly, can have afib, palp,
tachycardia, nervous, tremor, wt loss, recent exp iodine
Dx = thyroid scan cold, barium swallow, dir vocal cord vis, spirometry, neck and chest CT w/o
contrast
Tx = RAI
o Thyroid storm = fever, delirium, seizure, arrhthymia, vomit, diarrhea, jaundice
CASE = anxious, inc all, NV, diarrhea, ab discomfort
Tx = PTU, propranolol, dexamethasone (CS), iodine soln, BB
o Silent/postpartum thyroiditis = BB thyrotoxic but levothyroxine in hypothyroid, withdraw 6-9 mos
o Sick Euthyroid Syndrome = abnorm TSH or thyroid hor in absences thyroid dis, norm in 8 wks
o CASE = dec all T3, norm T4 more ill then dec T4 too, inc TSH
o Amiodarone (hi iodine content)to tx suppress thyroid, hypopthyroid, or thyrotoxicosis
o RAI = high graves and nodular, low thyroid destruction, iodine excess, and extrathyroidal sources
o DONT do thyroid scan and RAI in pregos or BF!
o Tx = PTU and methimazole, check TFTs 3-4 wks. Side fx are rash, urticarial, fever, arthralgia, hepatitis,
agranulocytosis; propranolol/BB control adrenergic sx, anticoag and warfarin if a-fib, RI initial tx if no
remission with meds but NOT in pregos (PTU instead); artificial and tape shut when sleep if sev then
prednisone and orbital decompression
o Nontoxic goiter = enlgd thyroid can be diffuse or nodular, common in iodine def and replete, substernal
can obstruct thoracic inlet and be obstructive
o Do TFTs!
o Tx = iodine or thyroid hormone replacement in iodine deficiency, multinodular sx only, subtotal
thyroidectomy in goiter and thyrotoxicosis if euthyroid w/ drugs 1
st

o Toxic adenoma = solitary, mut TSH rec, thyroid scan hot, radioiodine ablation
o Thyroid Neoplasm
Carcinomas = papillary most common (multifocal, invade locally), follicular (diff dx FNA bc diff
benign vs malignant is inv vessels/nerves, bone/lung/CNS mets), anaplastic (very malignant and
fatal), thyroid lymphoma w/ hashimotos, MTC from parafollicular cells so inc calcitonin and
MEN2
Rapid growth nodule or mass, hx neck rad, l node inv, hoarseness, fixed to tissues, compress or
displace trachea or esophagus, obstructive
Dx w/ US, then FNA
Tx = monitor benign, TSH w/ levothyroxine; near total thyroidectomy for pap and follicular
maybe postop RIA remaining w/ FU scan and serum thyroglobulin levels; MTC sx; test RET mut
MEN2, follow calcitonin to see if residual or recurrent
Basically CA then tx combo thyroidectomy, RAI, levothyroxine
o CASE = nodule with microcal and inc vas
Dx: FNA and bx, esp if > 5 mm
Hypothyroidism = primary is thyroid failure, sec is pituitary hypothalamic dis
o Sx = lethargy, dry hair/skin, cold intolerance, hair loss, hard to conc and poor mem, constipation, wt
gain and poor appetite, mus cramping, menorrhagia, bradycardia, prolong DTRs, cool extremities,
goiter, carpal tunnel, cardiomegaly, periorbital puffiness, doughy skin
o can myxedema coma (cold exp, trauma, inf narcs); tx w/ thyroxine and hydrocortisone
o can look like fatigue and ill sx in mild
o Dx = dec free T4, inc TSH only in primary, inc TPO
o Tx = levothyroxine daily, monitor q6-8 wks
o Check in pregos! If not tx then fx fetal neural dev
Most T4 circ, T3 inactive. Both bound to TBG, transthyretin, and albumin
Inc T4 and T3 and normal free levels if inc carrier p like prego, estrogens, cirrhosis, hepatitis, inherited do
Dec T4 and T3 and normal free levels if sev systemic illness, chr liver dis, and nephrosis
Iodine suff = autoimm and iatrogenic most common causes
CASE = nonpainful swelling, no sx, min elg thyroid, elev TSH and TPO
o Dx = subclinical hypothyroidism
o Tx = levothyroxine if hi-risk overt
o RF = TSH > 10, FH, goiter, anti-TPO, and desire prego
CASE = rad neck to jaw, palp, fast HR, anxiety, fever, sore throat, enlg gland, BL hand tremor
o Dx: 24 hr RUI, Graves
Eval = TSH 1
st
then T4 free
Thyroid ab = anti-TPO, anti-thyroglobulin, anti-TSH rec (TSI, TBII)
Hashimoto elev anti-TPO and anti-thyroglobulin, Graves elev TS1 or TSII
Thyroglobulin elev hyperthyroidism and and destructive thyroiditis, dec fictitious thyrotoxicosis, tumor marker
after CA
Calcitonin = tumor marker MTC
RAIU high thyrotoxicosis, low subactue/silent/postpartum/exogenous hormones
Thyroid scan = diffuse graves, focal toxic adenoma and multinodular goiter NOT IN PREGOS
TSH TOC
Thyrotoxicosis any cause, hyperthyroidism overactive gland

***DB PART 1***
Type 1 aka juvenile, destroys betal cells so cant make insulin, us need insulin, younger, ketosis if uncontrolled,
lean at onset
o Present = polydipsia, polyuria, wt loss; also polyphagia, blurry vision, pruritis
Type 2 = NIDDM, begins as insulin res then beta cells lose ability to make, FHx, obese at onset
o Sx = many yrs till dx,
Chronic hyperglycemia main reason complications
Special inf = malignant Otis externa from pseudomonas, mucomycosis
DB2 w/ vulvagintis, candida intertrigo, pyogenic skin inf, necrotizing fasciitis, cellulitis, gangrene clostridium,
osteomyelitis, TB, UTIs, cystitis, emphysematous pyelonephritis (E.coli common, tx nerphrectomy, PC drain, IV
ab, stent and lithotripsy if stone)
Dx 3 tests and confirm with any next day = FBG > 126, OGTT > 200 gestational DM, random non fasting BG > 200,
HBA1C > 6.5 most common best measure 3 mos of glycosylation
Labs = C peptide > 1 is DM2, measure islet and anti-insulin ab DM1
Screen who? = overwt, 1
st
deg rel, HTN, after CV dis, pancreatitis
Hi risk NA, Hispanics, Pac, AA
>40 needs CBC, chem 7, fasting chol, PE
Initial workup fingerstick/accucheck random glucose > 200 then rep, UA, CBC, Chem7, HbA1C, return for fasting
lipids and EKG
Monitor w/ short term finger sticks BID or 4x/day and long term HgA1C
Brittle = wide fluctuations, prone rapid onset hypoglycemia
ADA goal HbA1c < 7
Hypoglycemia = 60-90
Wt loss 5-10% helps esp in DM2! Also orlistat helps wt loss, bariatric sx, exercise 60-90min/ day to sustain, diet
Sulfonylureas and meglitinides are hypoglycemic agents, dont use both at once
Sulfonylurea wt gain so best younger thinner BM < 5 yrs
Metformin wt neutral! NOT if Cr > 1.4
TZDs blackbox heart attacks
Symlin type 1 and 2, disadv is more inj
DM1 then rapid, short, inter, long, combo 70/30 best, us ppl do 1 long acting and 3 short acting. Adj dose takes
2-3 days
Goals = Short term relieve DKA and dehydration, inter euglycemia, longterm prev compl
Ea morning hyperglycemia = inadequate insulin. Dawn phenomenon = cortisol rel 3-5 AM and resting hepatic
glycogenolysis raises FBS
Somogyi effect = too much insulin PM so hypoglycemic 2-3 AM then rebound hyperglycemia so FBS high,
correct by dec PM Dose
HTN = start with ACEI or ARB, annual and ea EKGs esp for silent ischemia
DCCT = New guideline ASA = tight control slows retino, neuropathy, proteinuria but greater risk hypoglycemic
Microvas compl = retinopathy, neuropathy (#1 polyneuropathy glove and stocking dis, do neuro exam yrly),
dm foot compl like ulcers/cellulitis/osteomyelitis/charcot joint tarsal pt, glomerulopathy mesangial thickening
(kidney bv)
Diabetic nephropathy is #1 cause ESRD, starts with microalbuminuria, dialysis if GFR < 15
Macrovas compl = CAD, MI, stroke, PVD .. lipid and BP control imp!!!
Good dental care red risk CAD and nephropathy!
Soo lipids, ft exam, alb/cr ratio, eye, TSH exam annually, Hba1c q3 mos

***DB PART 2***
DKA EMERGENCY = dehydration, acidosis, hyperglycemia and electrolyte abnormal, feel sick and seek help, bc
dec glucose uptake or hyperglycemia from insulin insuff, insulin driving force
o Hyperglycemia > 250, academia bicarb < 15 and ph < 7.3, ketonemia breakdown TG FFA and
gluconeogenesis
o Patho = insulin def and glucagon excess .. adiposis does lipolysis to inc FFA, also this combo means
overprod ketones liver so not utilized and spills over
o Dx ketonuria on dipstick test
o Lg amt acid bc acetoacetate and B-hydroxybutyrate
o Severe dehydration and K, Na, and Cl urinated away; higher levels these if sev dehydration bc conc
o Epinephrine, glucoagon, and cortisol kick in to counterreg
o Sx = dehydration, thirst, polyuria, kussmaul respirations to dump acid, low BP, tachycardia, acetone
breath, vom, ab pain, diaphoresis, change mental status
o Tx = restore vol with IV!! Insulin, ICU, chem 7s q1-2 hrs esp bicarb and anion gaps
o Workup = troponins and EKG heart, prego test, CXR, ABG, culture if inf
HNKS = dehydration driving force, change in mental status more common, DM2,
o Older ppl , longer prodrome, BG higher > 60, us underlying renal dis
o Sx = higher mortality, higher serum osmolality > 320 big reason coma
Elev WBC bc excess catecholamines and elev HH bc dehydration so false
BUN elev, glucose too,
Dec DKA, CO2 and bicarb normal HNKS
Dec Na bc very dehydrated but norm or high HNKS bc severe
K varies but imp. DKA ECF shift K bc H enters. If low then replace but hi then Chem7 and wait to double check
that itt is ok
Dont give insulin until know K levels!! To avoid hypokalemia
Hypoglycemia = true <50, resolve w/ sx
o Neurogenic = sweat, pallor, tachy, HTN, tremor/shake, anxiety, irritable, tingle, hunger, NV
o Neuroglycopenic = CNS bc low BG, weak, HA, fatigue, drowsy, dysarthia, faint, blurr vision, amnesia,
confused, like seizure DAMAGE CAN OCCUR
o Counter hormones rel = epi, cortisol, GH, glucagon most imp
o Causes = too much insulin or change dosage, ETOH, sulfonyurea, sepsis, trauma, renal filure, uncomp ex,
ETOH/ASA overdose
o Nocturnal = 2-3 AM, nt sweats, sore, bad dreams
o Factitious = trick dx elev insulin w/o elev c=peptide
o Reactive/postprandial too much insulin or impaired glucose tolerance
o Alimentary = gastric sx bc sm area absorb food
o Idiopathic
o Tx = glucose IV or glucagon, good meal ASAP cake icing EMS

***OBESITY***
Quick measure = in cab girth to hip, >102 men, > 88 women
Central/visceral = ovoid, apple, hi risk, male pattern, metabolic syndrome
Gluteal-femoral = pear, lower risk
BMI > 30 4x risk DM2!
Liver steatosis
Goal dec TBW ~10% in 6 mos, then plateau. Calorie restriction causes, ex maintains wt loss
Rec intake = 40/30/30 cab > p > fat
Ex > 150 min/wk
Lets move = michelle obamo 4 concepts: healthy schools, access affordable and halthy food, raise phy activity,
fam make healthy choices
Meds = endocrinology 1
st
, only in conjuction otheries, BMI > 30 or 27 comorbidities, dangerous
o Phentermine short term. Monitor this and diethylpropion for elev BP
o Silbutramine higher rate MI and stroke
o Orlistat only one ok! But GI SIDE FX, interact w/ warfarin, intestinal leakage ADR
o Metformin ok
o Amlin sev hypoglycemia with insulin
o Exenetide aka byetta, slows gatric emptying and glucon
o Liraglutide aka victoza
o Leptin res theory in obese
sx = TLC only, > 40 BMI or > 35 comorbidities, must be commited! Helps DM2, HTN,
o restrictive = AGB, VBG NO MORE
o malabsorptive NOT REC nut def
o combine most common = RGB (most common and successful, gold standard) and BPD (highest wgt loss,
keeps pyloric valve and duodenum for absorp, stomach diverted)
o stom absorb water and ETOH, duodenum FE/Ca/fats/sugars/p/vitamins/mg/Na, jejunum more sugar
and p, ileum bile salts/b12/cl, colon water and electrolytes
o dumping syndrome = nausea, bloat, ab pain, weak, sweat, faint, diarrhea, dont eat foods high in sugar
o compl = B12 for RBC mat (paresthesia, mus weak, dec reflex, confused, dementia, macrocytic anemia),
intrinsic factor B6 def, B1 w/ vom/diarrhea (BeriBeri, fatigue, irritable, Wernicke-Korsakoff emergency
encephalopathy), Fe, Ca def
o avoid NSAIDs, ASA, med cause gerd, bisphosphonates, ETOH, ext rel/control sx, w/ sugars or gallstone
formation
o rec supplements = MVI folic acid and thiamine, Fe, Ca citrate w/ vit D, B12

***OSTEOPOROSIS***
most common metabolic bone disease in world!
Dec bone density, estrogen inc osteoblasts, testosterone inhibit PTH so inc bone density
Osteoclasts > blasts, esp after 50 and menopause
Type 1 = fx vert and forearm, us trabecular bone loss, estrogen def, postmenopausal F
Type 2 = fx femur, tibia, pelvis long bones, age rel cortical and trabecular bone loss
Secondary = from med cond and tx
Idiopathic = de calk phosphate
RF = F, menopause > 50, thin, FHx, low Ca and D, white, asain, lack ex, ea estrogen def, low bone mass, hx
fractures
Sedative and hypotn meds RF recurrent falls!
Osteoporosis us asymp, occasional back pain, us mid-thoracic or hi to mid-lumbar
Sx -= loss ht, back pain rad flank/ab, dorsal kyphosis and cervical lordosis, fx most concern hip!
Dx = DEXA best/gold stand BMD, bone loss already before xray! (fx darker, vert fx is wedge shaped), also
xrays
o T score = avg peak bone mass young adults same gender. Low bad! -1.0 - -2/4 osteopenia, -2/5
osteoporosis
o Z score = gender and age
o do if F > 65, M > 70, postmeno RF > 50 or inc fx, all ppl fx > 50, hjirisk
labs = serum and urine Ca, parathyroid hormone, 25-hydroxyvit D, alk phos, phosphorus
C-telopeptide = marker! Dec bisphonsphonate bc more to bone, inc anabolic therapy
FRAX = hip fx 10- yr and major osteo fx use femoral neck BMD predict (vert, hip, forearm, prox humerus). Disadv
incomplete assess! N oinc RF like fall risks, dis, meds
tx prev fx, Ca, vit D, wt bear ex
RDA rec 600 mcg vit D! toxic 3000. Kidney covnverts to active dose, sun to syn, helps absorb phosphorus too!
o Def = rickets children rosary rib beading, osteomalacia adults
o Overdose = NV, anorexia, constipation, wt loss, mental status
o 100 units daily! Def then 2000
Ca absorb 500-600 at once so must div dose!
Meds = bisphosphonates (ONJ osteonecrosis of jaw, atyp fx fem shaft), risedronate, SERM
o Rem estrogen bc risks, estrogen/est-prog inc MI and breast CA soo only if severe
o Calcitonin
o Forteo
o Dec estrogen RANK ligand in osteoclastic activity which med osteoclast induced bone loss so inc risk
fx
Denosumab inhibits
Tx ver fx w/ brace and PT and conservative, hip sx
Dont smoke!

***PARATHYROID***
From chief cells, act vit D33 in kidney for 2
nd
hydroxylation
Most in bones, 1% in blood
Func = neuro mus and sm mus func, p mem stability, perm
Norm 8.5-10.5
Corrected hypoalbunemia = 0.8 * (4- albumin) + serum Ca
Urgent if > 13.5, causes are hyperparathyroidism, #1 cause malignancy
Hyperparathyroidism = #1 cause hyperca outpt
o Primary = rare CA, 1 hyperfunc adenoma most common, us in parathyroid gland
o Sec = adv renal dis, renal osteodystrophy br expansile cysts
o Sx = bones, stones, ab groans, psycic moans, fatigue undertones = (bone pain, osteo fx, kidney stones,
ullcers, dep)
o Labs = elev Ca, norm or elev alk phos, then check PTH hormone and serum Cr, shortedned QT interval
ECG
o High Ca and high PTH = KUB or CT for stones, DEXA RO osteopenia/porosis, parathyroid scan, xray skull
hands long bones resorp suggest excess PTH esp inc trabecular pattern more on radial phalanges,
ostteitis fibrosa cystica
If high hor then check ser pho for renal, hx renal stones or dis
o Tx = avoid dehyrdration, bisphosphonate Cinacalcet, maybe sx if stones and young
Hypocalcemia = < 8.5, panic < 6.5
o Causes = shock, sepsis, renal fail, pancreatitis, post sx, less hyperparathyroidism
o Hereditary or acq, atoimm, misc metabolic acidosis
o Sx = tetany, mayalgia, mus spasm, dysmenorrhea, hair loss, mental retard, cataracts, short, dry skin, nail
split, depression, malform teeth, osteoporosis, chvosteks and trosseaus sign
o Lab dec Ca, dec PTH, dec mag can be cause, inc phos, long QT
o Acute tx = iv ca gluconoate, POI ca carbonate
o Maintain vit D and diet, avoid strong diuretics
Nephrolithiasis = dehydration and low urine, screen Ca level
MEN = facial angiofibroma, SC lipoma
MEN 1= Werners syndrome, hyperparathyroidism w/ parthyroid adenoma most common, 1
st
see
hyperparathy in 2/3, tumor can be pancreatic, pit, thyroid adenoma,
o Poke pit gland, grasp parathyoid gland, kick ab
MEN 2 = sipple syndrome
o 2A = hyperparathyroidism (so diff!),
Attack MTC, parathyoid gland so hyperparathyroidis, power form pheochoromcytoma
o 2B = ganglionoma mucosa and GI
Wolf attack MTC, power pheochromocytoma, dev neuroma

***THYROID CA AND MEN***
1) Papillary CA
o RF = rad, FAM hx, MAPK, ret/PTC, NTRK1, Ras, BRAF and VEGF prognostic
o Clin = rapid gr palp nodule fixated, hoarse, ipsilateral, l node inv, distant mets lung 2/3 and bone ,
unencapsulated, ground glass, holes, orphan annie eyes, psammoma bodies, soft tissue inv
2) Follicular
o Diff adenoma bc tumor extensure tru capsule and vas, cuboidal cells, RAS more aggressive CA, PAX8-
PPAR, iodine, cold nodule, FNA cant distinguish vs CA, dx after sx and id capsule/vas, uninodular too,
uncommon l nodes, mets, hurthle cell, insular CA
o Tx diff CA w/ total thyroidectomy if ext or mets, uni lobectomy and isthmusectomy if < 1cm and
combined, reg neck dissection if nodes involved. RAI 131, also levothyroxine, ext beam radiation if
refractory radioiodine, chemo, molecular targets
3) Anaplastic
o Very aggressive and mortal, mass, most mets lungs, rapidly enlging neck mass, BL enlg, erythematous
or ulcerated, spindle cell/pleomorphic giant/squamoid, num mitotic, ext necrosis
o Labs = TSH, T4, CBC, CMP, Ca, Phos
o Image = neck US, CT neck and mediastinum, PET, brain MRI, bone scan
o Local = sx, loc adv radio and chemo, mets
4) Medullary
o Parafollicular or C cells, calcitonin, MEN 2, solitary thyroid nodule most common upper lobe
o MEN2A = MTC, pheochromocytoma, prim parathyroid hyperplasia SHEEP
o MEN2B = MTC, pheochromocytoma, NO HYPERPARA, marfinoid w/ neuroma and int
ganglioneuromatosis WOLF
o Dx = FNA, immunochemical stain calcitonin, serum calcitonin, CEA, RET, serum Ca, plasma fractionated
metaephrines, 24urine frac metanephrines and catecholamines
o Mgmt = total thyroidectomy, thyroxine, surveil calcitonin and CEA 2x/yr x 2 yrs then yrly
o Tx = vandetanib, cabozanitib
Pheochromocytoma = MEN2, us after MTC, anxiety, diaphoresis, palp, triad HA, sweat, tachycardia, sustained
or paroxysmal HTN, Carney triad is hx gadstric stromal tumor or pul chondrma
o Dx = plasma frac metanephrine and urinary catecholamine
o Most in ab or intraadrenal (pheochromostytoma)
o Rad = CT or MRI ab and pelvis, MIBG, FDG-PET
o Incidentaloma measure 24 hr ur metanephrine and catecholamines
o Rem this tumor 1
st
!
o Mgmt = preop alpha adrenergic block then beta, lap adrenalectoma, BL MEN2
MEN 1 = 3 Ps parathyroid glands, AP, panc islet cells, mult parathyroid adenoma most common
o Dx = 2+ pth gland, AP, or panc islet cells
Pancreatic neuroendocrine tumors = gastrinoma, insulinoma, glucagonoma, VIPoma, Zollinger-ellison syndrome
us in duodenum tx PPI or sx if no mets, nonfun pancreatic tumor, carcinoid, gastric enterochromafin
o CT/MRI, EUS, chromogranin A most common secreted

OB

***REPROD CYCLE***
Age 15-45, range 21-35 days
Menses = days 0-5
Follicular phase = days 6-14, elev LH and estrogen,
Ovulation = day 14, LH surge
Luteal phase = dec LH and FSH, inc estrogen and progesterone (levels off)
Corpus = Day 20
Endometrial =
Basal body T highest at ovulation
Estrogen neg feedback FSH, progesterone LH
F 6-7 mil oogonia 20
th
wks, 1-2 mil at birth, 400k puberty, 500 ovulat
PE = BMI, palpate ab and inguinal l nodes, pelvic, CBC
Peds = vulvaaginitis most common, labial aglgut, vag bleed, FB, sex abuse, precocious puberty, malig, F circum
refugees
Adolescent 1
st
visit 13-15
Gardisil vax for HPV age 9-26
GPFPAL (full, pre < 37, abort eab/sab/ectopic, living)
Breast exam = tanner staging
Pap smear = 3 yrs after first sex, no later age 21
Update influenza, T-dap, HPV
Childbearing yrs Screen = bP, cervical CA, breast CA, osteoporosis, lipids
Peri/post menopausal = same above, FSH, UA, colorectal CA
Mammogram yrly start at 40
DEXA post men or >65 q 2 yrs
BRCA = gene ovarian and breast CA, check FHx
daily aspirin 55-79

***PRENATAL***
planning ask = immunization titers, dental cleaning, folic acid 1 mo prior, tobacco/ETOH/drugs, daily meds and
supplements, ex
dx prego = home urine hcg, missed cycle, tender breasts, nausea, serum hcg, fetal movement 15-18 wks,
chadwicks sign (blue), hegar aka ladens sign (soft)
validity LMP ask periods reg and birth control or depoprovera
grand-multigravid = 6+
threatened abortion vag bleeding 1
st
20 wks closed cervix vs inevitable open and no tissue vs incomplete same
w/ tissue
stillbirth = death after 20 wks
Nagles rule = LMP + 7 days 3 mos + 1 yr
12 wks/trimester
Initial labs = blood type and Rh, ab screen, CBC, rubella immunity, RPR, urine with culture and sensitivity, hep
profile, HIV, pap, gonorrhea/chlamydia
Optional = quad screen 14-20 wks, 1
st
trimester nuchal translucency and PAPP-A, CF carrier most common
Caucatian defect
Also = glucola 26-28 wks gestational DB or 14 wks if BMI, prior hx, FHx adult DM, deliver heavy child; group B
strep
Start prenatal vitamins 1 month before conception, also take folic acid, vit B complex, and Ca
New OB PE = breast exam, PAP, GC/chlamydia, pelvimetry and uterine size, transvag US measure crown rump
length correlates 7 days LMP or it changes EDC
Weight gain, exercise
Early formal US = if inadeq see IUP, uncertain dates
Anatomic scan 18-22 wks see fetal ana and growth 2
nd
trimester
Maternal changes
o GI = progesterone and E2 slows transit so GERD, const, hemorrhoids, GB
o Pul changes = inc TV, raises diaphragm and rib cage, engorge tissues, inc O2 consume, dec FRC and RV,
hypervent, dyspnea
o CV changes = inc BV, heart size inc, shift PMI left and upward, inc CO 1
st
half and SV 2
nd
half, dia dec
more
o Hematologic changes = rel anemia, need Fe prev Fe def, systolic eject murmur, arrhyth, PR dec
o Renal = bladder tone defc and pelves R> L dilate so asymp pylenephritis, inc GFT, glucose excretion inc
o metabolic acidosis, inc renin, hypervolemia
o skin = melisma, striae, linea alba to nigra
o endocrine = insulin res bc progesterone, cortisol, HPL
o MS = gravity alterled, lax jts
o Rerod = inc transudates, d/c, size uterus and vol, inc vag tissue stim
o Breast changes = enlg, inc blood flow, lgr and pigmented nipples, duct grow, alveolar hypertrophy
Ox Umb vein portal sys hep veins and IVC with LE 1/3 enters L atrium thru formaen ovale and mix with
pul return L ventricle aorta
Prox aorta sat brain and upper body, R vent receives from R atrium and is half sat, enters pul trunk, bypass
lungs ductus arteriosis and desc aorta to lower body but maj to umbilical arteries bring deox to placenta
Fetal
o Urine 2
nd
trimester, prim source amniotic fluid
o Give vit K newborn bc coag fac deficient
o Cross IgG passive immunity
Ea prenatal visit = review wt gain, measure maternal BP, measure fundal height accurate 20-36 wks within 2 cm,
FHT w/ ext Doppler, ask mom how feels
o No movement dont worry till 28 wks
o Preeclampsia = HA, blurry wt spots, RUQ pain, rash, nondep edema

***Intrapartum***
Contractions q3-5 min for 60 secs
Preterm labor < 37 wks with cervical change, preterm contractions without change
Lightening = baby head lower in pelvis so less P on diaphragm
True labor = painful over fundus, not gone with ambulate/rest/hydration/pain meds. False over ab/groin,
Braxton hicks, 2
nd
trimester, less intense, resolved with
Call OB if: gush fluid, vag bleed, contractions 4+/hr if not at term or reg, dec fetal movement, dont feel right
Mgmt = NPO but ice chips, CBC, IV access, monitor contractions and FHT, serial pelvic exams q2 hrs
Leopold maneuvers =
1) Fundal grip = which pole in upper part
2) Sides = spine and extremities
3) Thumb and fingers feel head
4) Deep to see how rot
Monitor FHR
1) External = q15 min 1
st
stage, after ea contration 2
nd
stage, freq and dur
2) Int with fetal scalp electrode, freq/dur/intensity, need mem ruptured
3) Accelerations = intact fetal mech when contract, squeeze, dec blood flow
4) Decel = grad dec and return to baseline
Ear = contraction, reassuring
late = start beg contraction, end after, w/ uteroplacental insuff, fetal hypoxia and academia, not
reassuring
5) Norm 110-170, brady < 100, tachy > 170
6) Can vary short term 5-25 beats or long term 3-10 cycles/min
7) Variable = anytime with or without contract, us means umbilical cord compression with body or dec
buoyancy if low or no amniotic fluid
Labor stages
1) 1
st

Latent = < 4 cm, maybe contract
Active = >5 cm, reg contractions
Assess progress by effacement, dilation, fetal station (0 at ischial spines), fetal pos, presenting
part
Friedman labor curve
2) 2
nd
= deliver baby
5 cardinal movements = engagement, flexion, descent and int rot, ext, ext rot
Ritgen maneuver
Episiotomy, suction and cord, shoulder del prev brachial plexus in
APGAR = HR, RR, muscle tone, reflex, color at 1 min and 5 min
3) 3
rd
= deliver placenta
<30 min
3 signs ready = gush blood, lengthen umbilical cord, uterine rising
Active mgmt = clamp cord, Pitocin, gentaal traction
4) 4
th
= postpartum
2 hrs post placenta delivery
Assess maternal circ, BF/bond, pain, inspect cervix and vag tissues, repair episiotomy and
lacerations
Pain mgmt = nubain, Demerol NOT in 2 hrs anticpated deliveray, interthecal think 2-4 hrs, pudendal under ischial
spine, epidural in active labor
Breech = inc risk premature, mult ges, polyhydram, hydro/anceph, uterine anomaly/tumor
o Frank (flex hips, ext4end knees), complete (both), footling (feet down inc risk cord prolapse)
o Mgmt by leopolds and US, concern hypertext head and entrap
Monitor =
o NST = > 32 wks, reactive if at least 2 accel >15 bpm from baseline, 15 secs, within 15 min. if not then do
BPP or CST
o CST = measure FHR in response to contration. Neg is unchanged or w/o decal after contraction good, + is
decal with contraction is bad!
o BPP = fetal breath 1 episode 30 sec in 30 min, fetal movement 3 body movements 30 mins, tone, 1+
amniotic fluid pockest, NST, 8-10 normal
Induction if post date 41 wks, AFI < 5, mater or fetal cond
C-section if
VBAC = 30 min decision to incision, 1 prev, no scars or prev rupture .. contra if
Abnormal labor patterns
o Dystocia
Power = 3 contractions/10 mins good MVU = # contractions/10 min * intensity, norm 200
Passenger = wt, lie, present, pos, flexion, head (asynclitic, ext, brow/face present, compound,
anomaly), pelvimetry, best predictor is progress descent
Cephalopelvic disproportion
Prolonged latent = > 20 primi, > 14 multi. Causes abnormal fetal pos, unripe cervix check bishops
score (dilate, efface, station, consistency, pos), excess anesthesia, ceph disprop, ineffecte
uterine contact
Mgmt = rest mom, AROM, ripening agents in canal
Protraction d/o = slower progress dilate
Prolonged active = >12 hrs primi, > 5 multi, causes ceph dis, malpos, sedation, inad contracture,
rupure prior labor inf, fetal comp, csec, op delivery
Cessation prog = arrest dilate (non e> 2 hrs active phase) or descent (>1 hrs 2
nd
stage), sec arrest
then check ceph dis or contractios
Mgmt = induct, augment, op delivery, csection
Meconium aspiration in prolonged labor

***POSTPARTUM***
2-3 days, pelvic rest 6 wks, no drive 1 wk, no lift 2 wks
Sitz bath, eval bladder func/inj, ice swell
Uterine wt 1000g, vol 5000 nL, 6 wks back to norm size
Lochia rubra few days, serosa 3-4, after 10-4 wks alba. Foul is endomyometritis. 3 wks reestablish lining
Cervix and vagina = drier, do kegals to regain tone
Ovarian = resume ovulation 3 months, suppress bc elev prolactin 6 wks
CV = 1000 mL plasma loss, norm wks, 5 kg wt loss diuresis and ECF shifts
GFR elev 1
st
few wks, uretal and renal pelvis norm 6-8 wks, leukocytosis common
Breast changes = drop estrogen, inc oxytocin when suckling rel prolactin so secrete fatty acids, lactose, casein
for milk
Mom eats 600 addl calories/day, 600-900 mL milk
1
st
3-5 days milk nut not voluminious, IgA protects baby, feed 1-4 hrs
Avoid some meds, pump and dump if cant .. HIV, HepB, lithium, oncology meds dont BF
Engorgement = BL, grad onset, gen pain/swell, no fever .. tx warm compress, cont BF, analgesis
Mastitis = unilat, sudden, localized pain, fever, staph aureus, tx dicloxacillin and thrush .. same tx
Plugged milk duct = grad onset, no fever, unilat, local pain and swell but overall well .. same tx
Contraception ask plans! Consider IUD, oral contraception minipill BF, depo provera or nuvaring at 6 wks
EPDS = new OB, 28 wks, 2 wk, 2 mo, 6 mo baby. Only Zoloft ok BF
Post partum psychosis = confused,distracted, inattn .. use antips or antidep

***INFERTILITY***
1 yr unprotected sex
Sperm 74 day journey
Epidydimus dev sperm, vas defere ns mature
Primary = no hx prego
sec = after prev conception
sterility = intrinsic inability prego
#1 causes are abnormal semen prod and pelvic dis
F = ov d/o, mech factors, hor do, uterine fac, cervical fac, unexplained
M = varicocele, prostate inf, hjor, obstruct, antisperm ab, testicular fail, unexplained
Enviro = toxins, smoke, pot, crack, drugs
F eval =- hx, PE, hor studies, ov assess, poistcotal, HSG, hysteroscopy and lapscopy, menstrual pattern, pelvic
pain, excess hair/acne/breast, prior contraceptive, prev prego, sx, sex, current and past health, obese, skin,
galactorrhea, clitoremegaly,cerv abnorm, nodes
F hormones = TSH < 5, prolactin < 16, testosterone, dHESO4, 17alphaOH progesterone, AM cortisol, FBG and
insulin, progesterone, estradiol
Day 3 FSH and estradiol < 75 norm!
Also BBT, follicle study
Luteal phase
PK test 2-12 sex before test, check mucus amt quality sperm no and activity .. poorly timed main reason, also
cervical issue, male, aantisperm ab, coital tech problem
HSG, sel tubal cath to check tubes, hysetoscopy and lap
Male complete semen analysis = count per cc, motility, morphology strit kruger criteria, vol and liq, culture
Male eval = testosterone, fsh, tsh, prolactin, ibt, spa, hza, fructose, urology
Tx = eds, ov induct, imp male fac, insemination, sx
Poor ov if abnorm thyroid, high prolactin, excess androgens
Thyroid = synthroid
Prolactin = mri, parlodel, dostinex
Androgen = prednisone, dexamethasone, ocps, Lupron, ov cryored
IR = FBS/fasting insulin < 4.5
ov induct = Clomid, gonadotropinhs, antagon, lupron
luteal phase sup = progesterone, prochieve gel, prometrium after ov until 12 wks gestation
tx male factor = tx prostate inf, hor eval and tx, stim sperm prod, varicoceletomy sx
IUI = husband insemination
IVF .. GIFT, ZIFT
Dont delay eval and tx!

***MED AND SX COND 1***
HTN leading cause mat morbidity
Changes = inc BV, HR, clotting factors, WBC, minute vent; hct same; dec SVR, pt, FRC, progesterone med sm mus
relax
Chronic before 20
th
week, >1 4-6 hrs apart, optimal measure before 12 wks bc Nader 16-18 can mask undx!
Tx with labetalol, methyldopa, hydralazine strong, avoid diuretics
Also can be from pheochromocytoma, prim aldos, cushing, sleep apnea, methamphetamine or crack, RAS
Preeclampsia = after 20 wks, 2 occasions 6 wks apart, proteinuria > 0.3 g, triad HTN, proteinuria, edema; before
20 wks think molar preg or choriocarcinoma
o Severe = oliguria < 500 mL in 24 hrs
o sx = CNS (hyperreflx, sezisures in ecclampsia, bblurry vis, scotoma, clonus, irritable), renal-glomerular
swell, hep, heme severe, vas, fetal-placental unit
o mgmt = delivery futus, stable preterm bedrest and betamethasone, mg sulfate
o seizure prophylaxis 12-24 podt deliver, avoid ACE and ARBs
HELLP = hemolysis elev liver enz and low pt, epigastric pain and prog nv
o Labs = hemolytic aneia (elev LDH and total bili, schistocytes), elv LFTs, thrombocytopenia
Eclampsia = tonic clonic seizure
o Tx ABCs, mg sulfate (dec BP), emergent delivery
Acute fatty liver of pregnancy = tonic clonic seizure
o Labs = elev ammonia, BG < 50, red fibrinogen and antithrombin III, may need liver transplant and supp tx
o Pruritis, bile salts, elve liv enz and bilirubin
Cholelithiasis
Gestational DM = hypogly, ca, hyperbili,polycythemia, birth inj, macrosomnia. Screen all women 24-28 wks,
glucose < 105, 1 hr <140/130,
o Target FG <90, 1 hr <135, 2 hr <120
o Tx = diet
Throid dis = graves, fetal goiter, thyroid storm
renal = prerenal hypoperfusion, renal, postrenal
obst lung asthma 3
rd
rule
epilepsy = AED and teratogenicity
GI
Hyperemesis gravidarum = 4-8 wks, gone 14-16 wks
Autoimm dis
Anemia FE def most common
Folate def = 2
nd
most common, tx folic acid
Coag do DVT, PE, superfic vein thrombosis
Inf dis
UTI dx, culture, ab 7 days
Bac vaginosis
Group b strep , tx IV pCN G
Herpes simplex, prophylax acyclovir
Parvovirus B19 (5
th
dis), CMV, rubella, gonorrhea tx ceftriaxone, chlamydia tx azithro or amox or emycin, HIV,
hep B, toxoplasmosis, syphilis

***MED AND SX COND 2***
1
st
trimester bleed = spon abort, ectopic, nonob
Embryonic demise = > 5 mm no cardiac activity
Anembryonic prego = blighted ovum, >18 mm no embryo
Sx spon abort = suprapubic pain, uterine cramp, back pain, vag bleed, pss tissue, cerv dilation, extrude
contraception prod
o dx = BHCG should inc q48 hrs, US
o complete tx = monitor bleed/inf, emo
o incomplete/inev/missed = d and c, prostaglandin
o threat = monitor bleed, pelvix rest, rhogam
ectopic prego = us fallopian tube, heterotopic prego is in tube and uterus
o sx = pelvic or ab pain, subdia and shoulder pain, spotting or amenorrhea, syncope, CMT, adnexal mass,
uterine changes, heme unstable
o dx = bhcg lower, US shows
o tx = stabilize, lap, salpingectomy/stomy, methotrexate if <4cm, no hearbeat, serial BHCG
3
rd
trimester bleed = placenta previa, abruption placenta, uterine rupture, non ob
Placenta previa = implant over cervical os, painless vag bleed after 28 wks, contra vag exam, deliver 36-27 c
section
o Tx = stabilize, iv, fetal monitor, HCT, type and cross, coag, rhogam, prep hemorrhage, preterm delivery,
betamethasone, tocolytics
Abruption placentae = hemorrhage btwn uterine wall and placenta
o Clin = vag bleeding, sev ab pain, strong contractions, fetal distress/emise
o Tx = potential hem/DIC/fetal hypoxia, stabilitze same!
o Immed devlier if unstable vitrals and coagulopathy

***MENSTRUAL***
Hypothalamus pulse generator, secretes GnRH from arc nuc
FSH and LH riuse for follicles dev, inner secrete estrogen and pro, ext capule .. enlg to antrum, dominant follicle,
LH rises in follicular stage
Corpus leuteum prog 3 mos until placenta takes over
Endometrium phases = prolif, secretory, menstrual
Menarche avg 12, anov 1-2 yrs
Menopause stop 1 yr or RSH > 30 = dec breast tissue, hair, skin elastic, sq fat, ovaries, uterus, pale and friable
cervix/vagina, osteoporosis, CV dis, vasomotor insability, urogenital atrophy
Amenorrhea =
o Primary fail by age 16, eval at 5 or if dont menstruate in 2 yrs sex char, causes are imperforate hymen
and androgen insen
o Sec = 3 cycles or 6 mos, causes are preg, ov/pit/hypo dysfunc, ashermans, pit tum, hypotpit dysfun
o Eval = bhcg, tsh, prolactin, progestin challenge bleed then RO, MRI pit, FSH and LH both low hypo/pit do,
both high ovarian fail
o Karyotype and test/FSH if nothing, uterus then FSH > or < 40 hyper/hypo gonadotropic hypogonadism,
boobs then mullergian agen or test fem, both gone 46XY
Dysmenorrhea = prev norm act, need meds
o Primary = 6-12 mo menarche, 1-2 dfays and 1
st
day peak, uterine contractions with ischemia so take
prosta inhibit before pain starts
o Sec = organ, pain not in menses or st day, later in lift, endometriosis, PID, fibroids, adenomysois, cerv
stenosis, polymps
o Eval = hx, PE, bhcg, CBC, pap, UA, US, hysteroscopy or HSG, laparoscopy
o Tx = primary nsaids, ocps, sx sec with gnRH agonists, progestin, doxyclcine, laparoscopy
DUB = btwn menarche and menopause, us bc hypo=pit-ov axis
o Eval < 35 hp, pap, pelvic us, culture, tsh, prog, bhcg older then add endometrial bx, dandc,
hysteroscopy
o Tx == younger BCP or progesterone , older then above with D&C, endo ablation, hysterectomy
o If on OCPs then culture and add premarin
Postmenopausal bleeding = after 12 mos amenorrhea, ENDOMETRIAL CA till proven
o Eval hp, us, endo bx
o Tx spon , add estrogen, hysterectomy
PCOS = obese, acne, hirsutism, oligomenorrhea, infertility +/- insulin res
o Sx = oligo or amenorrhea, DUB, infertility, hirsutism, acne, obesity, insulin res
o Dx = hormone assays, string of pearls
o Tx = lifestyle, hor, antiandrogenic, ov induce, antidb, correct lipids, sx
Endometriosis = 30s, nulliparous, infertile, CPP, triad dysmenorrhea, dyspareunia, dyschesia
o Dx laparoscopy/tomy
o Tx = TAH-BSO, laser ablation or electrocautery and excise/resect rest, gnrh agonists, danazol, OCPs,
levonorgesterol-rel IUD
Adenomyosis = 2.5 mm beneath basal layer, sym enlg uteru, boggy, tender
o Dx = US, sonohysterogram, MRI, def needs hysterectomy and patho confirm
o Tx = NSAIDs and hor control, ablation, hysterectomy
PMS/PMDD = luteal phase, gone after menses
o Dx =2 cycles
o Tx = herbal, meds

***MENOPAUSE***

Testosterone 2x premenopausal
Perimenopause 5-10 yrs
Hot flashes 1
st
sx ovarian failure and most common, 90 secs then cold so 3 min total
o 2-3 yrs disappear or tx HT
Sleep disturbance = inc latent phase, imp with HT
Vag dry and atrophy tx estrogen supplement
Mood swings = tx counsel, emo, meds
Skin hair nail changes
Osteoporosis, menopausal need 1500, pre need 1200 mg, dx DEXA, tx CA + bisphosphonates
CV changes
Premature ov failure
o Savages syndrome = follicles res FSH and LH so need exo estrogen
o Maybe bc part delete long arm X chr, total is turner syndrome
o Smoking 3-5 yrs earlier fail bc estrogen 2hydroxyestradiol
o Chemo
o Hysterectomy 3-5 yrs earlier
Low body wt, anorexia
NEVER GIVE UNOPPOSED ESTROGEN, causes CA
Hormonal options = estrogen, combine es/orog, cyclic/seq E2/P4, vag estrogen, transdermal patch, bioid horm,
SERMS
Pelvic floor sup defects, mus levator ani, urethral/anal sphinc, endopelvica fascia
o Sx = bulge, vag P, full, discomfort, low back pain, worse act, incomplete void, sui, thrust dyspareunia,
post BM, anal incontince
o Tx ob care, lifestyle changes, pessaries, coporrhapy, colpoplexy, TVT
o Prolapse ant = urethral hypermobilital uthrocele distal 4 cm, qtip>30 degrees test, SUI;
Cystocele thru hymen
o Apex
Uterine prolapse
Vault prolapse, us with enterocele
Enterocele
o Post
Rectocele
Perineal def
Perineal descent = diff defecate, anal sphincter denerv and fecal incont

***VULVOVAGINITIS***
Dc and/or itch and irritation +/- odor, us lactobacilli
Report chancroid, chlamydia, gonorrhea, syphilis, HIV/AIDS in 5 days!
Eval = hx, pe, vag ph, saline, KOH, wiff, culture/dna probes
Bac vaginosis = malodorous, profuse dc, fishy
o Dx 3: gr/wt, ph > 4.5, pos wiff test, >20% clud cells
o Tx: flagyl, clindamycin, metrogel
Vulvovaginal candiasis
o Us C. albicans
o Sx = itchy, irritate, burn, dysuria, dyspareunia, curdy cheeslike dc
o Tx = fluconazole PO or topical imidazole
Trichomons = protozaoan
o Sx = malodorous, yellow/gr, frothy, irritate, dc
o Dx = motile org on wet prep, strawberry cervix
o Tx = flagyl
Bartholins duct cyst and gland abscess
o Polymicrobial
o Tx = i&d, word catheter, excise, marsup

***SEXUAL ASSAULT***
Marital, acq, incest, date, statutory 14-18 yo
Child sexual abuse must report
know person
Young F, elderly, ment/phys disabled at risk
Underrep crime
Make sure safe, dont shower, ur/poop, brush teeth, eat/drink
Dont use word rape why or alleged, use sexual assault
Labs = fingernails, saliva, DSTI
Tx = inj, then sti prophylaxis is ceftriaxone, metro, doxycycline, hep B if high risk and bleed, emergency
contraception levonorgeter
FU 3 days, 1-2 wks .. HIV 3, 6, 12 mos, syphilis 1 month
RTS acute phase and integration
get PTSD
Dx = event, reexp, avoid/numb, inc arousal, >1 mo, distress social/job/etc

***CPP***
CPP = 3-6 mos, actue <1 month and life threatening
Splanchic organ sec tension or referred drmatones
Chr pain syn = > 6mos, 1 sign dep
PE = stand, sit, supine, lithotomy
Dx = labs, stool, us, radio, ct, mri, urodynamic, gi, eeg, nerve cond and emg, endoscopy
Adhesions = dx and tx lap
Pelvic caricosistes and pelvic congestion syndrome
o Sx = dull pain and ache, dub, gi, ur tract, nervous, ps, emo, blue cervis
o Dx -= lap, pelvicvenography, us, mri
o Tx -= hysterectomy, ovarian vein ligation, hor therapy, embolize ovarian veins
Vulvodynia
o Sx = itch, burn, pain, worse clothes/sewat/sit, hx sx or trauma
o Dx = wet prep and cultures, bx
o Tx = candidiasis, steroid reb derm, lichen sclerosus, vestibulitis, vangiismus, vulvar neuroma
Intersitital cystitis
o Dx absence
o GAG
o Sx freq, urgency, rec UTI neg cultures, nocturia
o Inc then plateau
o Dx = pe, cystouretrokscopy, k challenge, ua/culture/cytology, blader b, CT ab and pelvis, ivp, us,
urodynamic studies, void cystography
o Tx = diet mod, sx cystectomy ablate blader hydrodistension, elmiron, tca, k citrate, anti his
Ab wall and pelvic myofascial trigger pts
Sexual dysfunc do sex desire, emo, arousal, orgasmic, pain
PLISSIT = permission, lim info, spec suggstin, intensive therapy
Mononeuropathy and nerve entrap = single nerve vs p neuropathy
o Sx = sens loss, pare/dys/hyperesthesia, allodynia, hyperpathia, pain, motor loss, auto disturbance
o Tx = analgesic, tca, gabapentin, nerve boct, pt sx
Dyspareunia prim vs sec, entry vs deep
o Dyspareunia, fear pain, anxiety, vaginismus
o Tx cause

***BENIGN NEOPLASMS***
Vulvovag -= epidermal includiosn cyst, sebascoues cyst, bartholins gland cyst/abcess
Cervical = nabothian cysts, cerv polymps
Uterine = leioyomyoma, endo polyps or hyperplasia
Ovarian = cysts, solid tumors
Endometrial foci
Fibroids = benighn, estrogen dep
o Sx -= AUB, p, pain, reprod, palp
o Dx us most common, hsg, sonohystogram, hysteroscopy, mri
o Tx -= expectant, hor, uterine a embolize, mri guide, myomectomy, hysterectomy
Endometrial polyps = benighn, AUB, US/sonohysogram, excise
Endometrial hyperplasia = ea change glands, latee change cells
o Clin oligo/amenorrhea, pmb, enlg uterus
o Dx -= endometrial stripe, tissue dx needed
o tx = progesterone, d and c, hysterectomy
ovarian masses = cysts, solid masses
o dx = ab tender, peritoneal singn, palp adnexal mass, pelvic us best, ca 125
endometrial foci

***GESTATIONAL TROPHOBLASTIC DIS***
molar prego aka hydatidiform moles
o complete = enucleate egg, bunches of grapes
sx = vag bleed, pass molar, anemia, hyperemesis gravidarum, preecalam, hyper thy, uterine lgr,
absent featl heart sounds
dx = hi hcg, snowstorm, def see uterine onctents
tx = d&c, mg preecam, BB, rhogam, hysterectomy
FU hcg wkly till neg 3 wks, mo 6 mos, future prego monitor
o partial = 2 sperm, triploid, has fetus
sx -= delay menses, prego, mild or norm hcg, vag bleed
dx -= hcg, pelvic us, red amnn fluid, swiss cheese
tx = d and c
FU = hcgs , contraception
Malignant
o Pers/invasive = penetrate myometrium villi and trophoblast, AUB, plateau/rise hcg, dx hcg and pelvic us
and Doppler us
Tx = chemo
o Choriocarcinoma wks to yrs post prego, epi cell tumor
Sx late postpartum bleed, irreg, enlg uterine, signs mets
Dx = pelvic us/Doppler, hcg, mets eval
Tx = chemo
o Placental site trophoblastic tumor
No villi
Irreg bleed
Dx pelvic us
Tx hyserecomy then chemo

***GYN MALIGNANCIES***
o See chart

GI

***LIVER FAILURE CIRRHOSIS***
ALT (more spec) and AST (heart, skel mus, kidneys) =hepatocyte inflame or inj
Serum alk phos and bilirubin elev =biliary inj or abnormal bile flow, bone inj, prego
Conj = direct/dis liver, unconj = indir/nonliver dis (hemolysis, gilbert)
Serum albumin (nut state and renal/GI p losses fx albumin level) and PT (nut, esp vit K def bc coag fact) =
liver func
Acute < 6, chr > 6 mos
Test hep func = albumin, PT
Test hepatobiliary dis = bilirubin, alk phos
Test hepcell dam = AST, ALT
Viral hep
Autoimm hep = ANA, ASMA
Hemochromatosis = inc Fe and ferritin, dec TIBC
Wilson = ceruloplasmin
Fatty liver dis = liver bx
Acute viral hep = jaundice, hep and amino trans > 15x norm
Cirrhosis = regen nodules, dec liver func. sx = amenorrhea, impotence, infertitlity, vague RUQ pain, jaundice,
spider telangiectasias, palmer erythema, scleral icterus, parotid and lacrimal gland enlgd, clubbing,
dupuytrens contracture, gynecomastia, testicular atrophy, hepatosplenomegaly, ascites, GI bleed and varies,
hep encephalopathy
Labs = anemia, pancytopenia, prolonged PT, hyponatremia, glucose disturbances, hypoalbumemia
Complications:
1) Portal HTN and GE varices = #1 cause cirrhosis, ascites (most freq complication), hep encephalogpathy
Tx: endoscopic variceal ligation, prophlaxis variceal hemmorahge
Albumin grad >1.1 and total ascites p > 2.5 is cardiac dis like HF and constrictive pericarditis
2) Spon bac peritonitis = pos bac culture, elev PMN w/o sec cause peritonitis
Tx: IV albumin and ab therapy
3) Hepatic encephalopathy = coma, confusion, elev ammonia
Tx = red excess N in gut so dec absorb ammonia, lactulose therapy, rifaximin add
4) Hepatorenal syndrome = renal vasoconstrict so sev red glomerular func
Sx = serum Cr > 1.5 no improve w/ 2 days diuretic withdraw and vol exp
Tx: IV albumin and vol expansion, liver transplant most effective
5) Hepatopul syndrome = def art ox bc dilate pul vas, hypoxemia w/o other causes, clubbing, cyanosis,
transthoracic ECG with saline best see, dx microbubble L atrium 3-6 cardiac cycles
Dyspnea, cirrhosis, PO2<70
6) Fulminant hep failure = jaundice w/o preexist dis
Hyperacute 1 wk best prognosis, acte 1-4, subacute 4-12
#1 cause is acetaminophen overdose
Tx: immed refer liver transplant center
Transplants = FHF or decompensated cirrhosis (ascites, hep encephalopathy, jaundice, portal HTN) or
hepatocellular carcinoma
o Contra = old, extrahep malignancy, sub abuse
HC maintenance = bone mineral density testing, careful live vax (influenza, pneumococcus, hep a and b), careful
meds, app nut

***DO GB AND BILIARY TRACT***
Cholestatic liver dis
1) PBC = asymp 1
st
, within 10 yrs
Sx = dy eyes, mouth, pruritis, fatigue, cut hyperpig, xanthelasmas, jaundice, hepsllenmeg
Dx = in calk phos, AST, ALT, SMA > 1:40, liver bx florid duct lesion with granulomas
Tx = UDCA if not then liver transpant, tx dry eyes/mouth/pruritis
2) PSC = intra and extrahep ducts, most get IBD, pruritis, ab pain, jaudince
Dx = elev AST ALT alk phos, cholangiography gold standard, ANA, ASMA, beads on a string
fibrosis and dilation secular
Tx: transplant, risk cholangiocarcinoma
3) Asymptomatic gallstones
Observe unless > 3cm bc high risk GB CA
4) Biliary colic and acute cholecystitis
Biliary colic most common sx
Compl =cholecystitis (most gallstones fever, nausea, vom), cholangitis, pancreatitis
Dx = US, thick wall > 2 m, intramural gas, pericholecystic fluid, HIDA if US ?
Tx = lap cholecystectomy TOC
5) Acalculous cholecytitis
RF critical ill, burns, adv age, atherosclerotic vas dis, AIDs, inf salmonella or CMV, SLE
Unexplained fever, hyperamylassemia, bc chronic stasis underlying dis,
Dx = US thick wall
Tx = IV ab, cholecystectomy
6) CBD and cholangitis = charcot triad (fever, jaundice, RUQ pain), cholelithiasis, elev atrans, hyperbili
Dx = dilate extra and intra hep ducts US or CT, ERCP
Can become shock from PEEK
Tx: ab and decompress biliary
Cholestatic pattern = dilated ducts ab US, CT ab, ERCP, liver bx
PBC = AMA
PSC = ANCA, ANA, ASMA
Autoimm cholangitis = ANA

***PUD***
> 5 mm, <5 erosion
H Pylori and NSAIDs main causes
Sx = bleed, dyspepsia, epigastric burn/gnaw, us after meals
DU = long after meals, better food and antacids
Dx = upper endoscopy
Mult ulcers think gastrinoma
Gastric CA = irreg heaped up edges
Compl = giant ulcer, ulcers w/in 2 cm pylorus, prolonged ulcer hx, overt GI bleed #1 complaint
Penetration = deep ulcer, refer pain to back and longer
Perf w/ peritoneal signs
Gastric outlet = ea satiety, vom, wt loss, inflame, edema, pylorspasm
Mgmt = bx to RO malignancy GU!! Test all for hpylori
Noninvasive hpylori tests = serology suboptimal confirms past exp doesnt say if prev tx and erad or untx and
active, urea breath, fecal antigen toc
o PPI, H2, ab, bismuth dc sensitivity to all but serology
o If not on meds best is gastric bx and rapid urease test
Tx is Clairthromycin, amoxx, PPI x 14 days
Hi risk NSAID rel = hx PUD, and 2 + of > 65, hi NSAID, use with ASA anti coag or CS,
PPI tx NSAID rel 4-8 wks, GU heals slower. Discount NSAIDS! Use low aspirin when risk outweighs benefit
Bleeding ulcer = NG tube gastric decompress, hi dose IV PPI if ineff meds then dilate pylorus to 15 mm
endoscopic or surg vagotomy w/ pyloroplasty and anterectomy
NO upper endoscopy and barium studies in perfs!
Tx perf = fluids, ab peritontinits, sx

***HEPATITIS***
HAV = 2-6 wks get sx, jaundice and cholestasis 1-2 wks
o Dx = anti-HAV IgM, jaundice peak 2 wks gone 3 mos
o RF = travelers, MSM, spread fecal oral
o Contagious incubation per and 1 wk after jaundice
o Vax, wash hands and cook foods
HepB = blood, mucocut, perinatal, incubate 4-16 wks
o Dx = HBV ag, ab, DNA
o Mgmt = sup care, FHF needs transplant
o Tx = antiviral, oral nucleoside/nucleotide analogues if chr active
o Extrahep = polyarteritis nodosa and kidney dis like mem glomerulonephritis
o Hepatocellular CA risk if rel to cirrhosis and perinatal
o Prev w/ vas, lifestyle
o vert transmit min with vax and HBV Ig if mom has
HepC= precut exp, IVDU, blood
o RF = M, obese, ETOH, daily pot
o sx= arthralgia, extra hep mixed cryoglobulinemia, membranoproliferative glomerulonephritis,
porphyria cutanea tarda, NHL
o dx = HCV testing, RIBA
o tx = peginterferon, ribavirin, protease inhibitors
Hep D = need HBV complete
Hep E enteric, like HAV, acute
ETOH induced liver dis =
o simple steatosis (fatty liver) to cirrhosis, dose duration drinking pattern and type consider
o ALD dx hx ETOH, AST > ALT, liver bx confirm if superimposed
Prognosis score calc PT and total bilirubin, also bili, CR, and INR
Tx= no ETOH, imp nut, prednisolone or pentoxifylline
Drug and toxin induced = #1 cause acute liver failure needing liver transplant, us acetaminophen
o RF age and F
o Ab pain, jaundice, pruritis, fever, rash, eosinophilia , hyper sen, coagulopathy
o kidney disfunc, mental status change FHF
o dx further sup if gone with withdrawal
o N-acetylcysteine for idiosyncratic and acetaminophen tox
Autoimm hep = can lead to FHF, elev AST ALT alk phos, ANA, SMA, elev serum gammaglovulin, p-ANCA, liver bx
o Tx = cs, azathioprine,
NAFLD = insulin res and metabolic syndrome, many ppl have
o With inflame and fibrosis is NASH
o Dx = US, CT, MRI
o NASH infer meta syn and elev at w/o liver dis, liver bx confirms inflame and fibrosis
o RF = >50, BMI>28, TG > 150, ALT > 2x
o Tx = wt loss, mgmt comorbidities, monitor at q3-6 mos
Hereditary hemochromatosis = can lead to cirrhosis and hepatocellular c
o tx = phlebotomy
Alpha-1 antitrypsin def = can cause liver or pul dis, panacinar emphysema, cant excrete this p
o Tx = IV alpha-1 anti-tyrpsin
Wilson disease = inc hep uptake and ec biliary excrete copper, <45
o Dx = ceruloplasmin
o Tx = copper chelating agents and low copper diet

***DIVERTICULOSIS***
Patho = weakness where bv penetrate mus wall so int layers pen thru = diverticulo
Common W, not dev countries bc lower life exp and diet diff
West = sigmoid colon (highest P LLQ)
Asian = R sided more common, 40s
RF = inc age west, CT d/o, low fiber diet, less ex
Diverticulosis = us asymp, incidentally discovered
o Sx = us norm PE, mild LLQ discomfort, nonspec GI
o Dx = CT, colonoscopy, XR, barium enema
o Labs = CBC, CMP, amylase, lipase
o Tx = high sol fiber diet
o No relation to nuts!
Diverticulitis = micro or macro perf
o Old theory is obstruct diverticulum, new is erosion by food or P inflame and necrosis perfs
abscess and peritionitis
o Peritonitis if not walled off and macro perf, life threaten
o Sx = LLQ pain! Anemia, weak, arrhythmia, change mental status, syncope, sepsis, fever, distend, tender
mass, peritoneal signs, maybe rectal occult blood, NV
o Labs = neutron 1
st
, then lymphocytes. CBC, prego test, UA, LFT, amylase, lipase, pelvic exam w/ culture
o Imaging = CXR, ABD film eval perf or obstruct, CT BEST, barium enema but not in perfs, US
o Tx = oral meds and fluids,Must tx g orgs and anaerobes
Outpt = metronidazole (or clindamycin or moxifloxacin), ciprofloxacin, TMP/SMX combo [MCT]
Single = amox/clav
Inpt = NPO or cl liq, combo ceftriaxone + metronidazole OR clindamycin + AG
Single = 2
nd
gen ceph, combos pip/tazo, tic/clav, amp/sulbactam
Metro/clinda anaerobic, rest are g-
Sx = if recurrent, RF, emergency resection and primary anastomosis OR resection, colostomy,
delayered rev colostomy in emergencies (bowel obstruct, rev 6 mos later if stable)
Abscess w/ diverticulitis = PC route with CT or US
Diverticular bleeding = R more common, most common cause lower GI bleed, most need blood transfusions
o Signs = painless rectal bleeding, hematochezia L, maroon stools R side ascending, melanotic UGI above
ligament of treitz, us norm PE
o Tx = colonoscopy, technetium scan, angiography, colon resection with end to end anatotmosis